Classification of Hartmann's procedure reversal complications according to the Clavien-Dindo System.

BACKGROUND: Hartmann's Procedure (HP) is performed for cancer, trauma or benign diseases of the left colon. It is regarded as a solution to avoid a risky anastomosis with the intent to reverse after the diseased colon is given time to recover. This reversal has been associated with a potential morbidity and mortality. OBJECTIVES: Our objective was to investigate the complications and morbidities associated with HP reversal. METHODS: The Hartmann reversal operations performed in the general surgery department were reviewed between January 2014 and January 2018 in the Istanbul Haseki Training and Research Hospital. RESULTS: During the evaluation period, 41 patients underwent a HP reversal with the mean age of 57.45 ± 15.75 The majority of the patients were male (73%; n = 30). The overall complication rate was 44%. There were seven (17%) cases of reoperation with high-grade complications, and four (9.8%) of the patients were re-hospitalized due to complications. CONCLUSIONS: HP reversal can be considered a relatively safe operation for a selected group of patients including those with preoperative comorbidities, yielding an anastomotic leakage rate of 7.3% and a hospital readmission rate of less than 10%. The repair of an incisional hernia at the same time does not increase the complication rate. KEY WORDS: Complications, Colostomy, Clavien-Dindo classification, Hartmann's procedure reversal, Hartmann's system procedure reversal.

Rat Model Investigation on the Role of Biomarkers in Hepatic Ischemia-Reperfusion Injury.

OBJECTIVES: Liver function is affected by ischemiareperfusion. Ischemia-reperfusion injury to the liver often follows hepatobiliary surgery. Here, we investigated biomarkers of liver ischemia-reperfusion injury using an animal model. MATERIALS AND METHODS: For this study, 24 male Sprague Dawley rats (146-188 g) were divided into 4 groups: group A was the control group, group B was the partial hepatic ischemia-reperfusion group, group C was the total hepatic ischemia-reperfusion group, and group D was the intermittent total hepatic ischemiareperfusion group. Laboratory liver function levels were measured before ischemia, after ischemia, and after reperfusion. We used liver and renal biopsies for histopathological examination at the end of the study. RESULTS: After clamping and reperfusion, alanine aminotransferase and cystatin C levels in groups B, C, and D were significantly higher than levels in group A. In group B, after clamping, neutrophil gelatinaseassociated lipocalin levels were higher than in groups A and D, with significantly higher level than in group D after reperfusion. Neutrophil gelatinase-associated lipocalin levels decreased significantly in groups B, C, and D after reperfusion. There was significantly greater hepatic damage in groups B, C, and D compared with group A but no significant differences in renal injury scores among the groups. There was a significant positive correlation between hepatic damage and renal injury. With regard to histopathological examination versus laboratory results, a statistically significant positive correlation was shown between grade of hepatic damage and serum alanine aminotransferase and cystatin C levels. Similarly, there was a positive correlation between renal damage score and alanine aminotransferase level. CONCLUSIONS: In our animal model, alanine amino - transferase and cystatin C levels tended to increase with ischemia-reperfusion injury levels but neutrophil gelatinase-associated lipocalin decreased during reperfusion. In liver ischemia, we suggest that neutrophil gelatinase-associated lipocalin may be an important biomarker for distinguishing the reperfusion phase.

A Fast and Reliable Method to Interpret Short-Term Mortality in Perforated Peptic Ulcer: Red Cell Distribution Width is Sensitive and Specific.

INTRODUCTION: Peptic ulcer is an important health problem worldwide with a prevalence of around 5%. Peptic ulcer perforation is a potentially mortal complication of peptic ulcer disease. We aimed to investigate the potential use of red cell distribution width as a prognostic marker in peptic ulcer perforation. METHODS: The files, operation notes, biochemical and hematological parameters, and prognosis of patients who were operated for a peptic ulcer perforation were reviewed in a retrospective cohort study. The relation of red cell distribution width (RDW) to main outcome in-hospital mortality was assessed. RESULTS: The mean age of the 172 patients was 40 ± 17.89. There were 158 (92%) males and 14 (8%) females. The in-hospital mortality was 8.7% (15/172). The median RDW in the group with mortality was 15.00 (interquartile range (IQR): 14.30-17.20) compared with the median RDW in the group with no mortality as 13.2 (IQR: 12.80-14.00, p ≤ 0.001). Receiver operator characteristic curves were plotted for RDW to identify nonsurvivors and yielded a significant area under the curve as 0.812 (95% confidence interval: 0.682-0.942). The sensitivity and specificity of RDW at a cutoff value of 14.25% were calculated with an accuracy of 81.98 (95% confidence interval: 75.40-87.41) as 80.00 (51.91-95.67) and 82.17 (75.27-87.81), respectively. CONCLUSION: Increased RDW may be of use to interpret mortality in patients with peptic ulcer perforation.

A grey zone of hyperamylasemia following endoscopic retrograde cholangiopancreatography: follow-up and differential diagnosis from acute pancreatitis.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is a tool often used for treating and diagnosing pancreaticobiliary diseases. One of the important complications of ERCP is pancreatitis. Even though transient hyperamylasemia is a more common and benign situation, it must be distinguished from post-ERCP pancreatitis. AIM: To define the risk factors associated with post-ERCP pancreatitis (PEP) and tried to identify a cutoff about laboratory findings for positive or negative prediction. MATERIAL AND METHODS: We reviewed the medical files of patients who underwent ERCP for choledocholithiasis in a retrospective cohort study. The primary outcome is the risk factors associated with PEP. Receiver operator characteristics analysis was carried out for determination of cut-offs for laboratory parameters. RESULTS: The presence of cholangitis (p = 0.018), Wirsung cannulation (p = 0.008), presence of abdominal pain at 12th and 24th h (p < 0.001), amylase level at 12th h (p < 0.001), C-reactive protein (CRP) levels at 6th and 12th h (p = 0.001 and p < 0.001), white blood cells (WBC) levels at 6th and 12th h (p = 0.001 and p < 0.001) were significant for development of PEP. CRP levels above 8 mg/l and WBC above 10 × 103 had negative predictive values over 70% and 90% respectively. CONCLUSIONS: Physical examination and inflammatory parameters are important in diagnosis of PEP. CRP and WBC have high negative predictivity and sensitivity. Amylase level increase was most apparent 12 h after ERCP and significantly higher (p < 0.001) for the development of PEP. The first abdominal pain evaluation is meaningful at the 12th h timepoint because insufflation during the procedure and other causes of abdominal pain may result in misinterpretation.

Red Cell Distribution Width as a Predictor of Malignancy in Patients Who Underwent Upper Gastrointestinal System Endoscopy.

INTRODUCTION: Red cell distribution width (RDW) has predictive properties in different benign and malignant diseases. AIM: Our aim was to evaluate the predictive value of RDW for malignant gastric lesions by upper gastrointestinal screening. MATERIALS AND METHODS: Data of 91 male patients (Group A) who underwent upper gastrointestinal endoscopy and subsequent surgery for gastric malignancy and age-matched 91 healthy male patients (Group B) with benign disorders were reviewed in this retrospective cohort study. The pathology reports, laboratory parameters, and demographics of the patients were recorded for comparison. Receiver operating characteristic curves were plotted for RDW, and a threshold for prediction of malignancy was calculated. RESULTS: The average age of the patients with gastric cancer was 62 (interquartile range [IQR]: 53-70) years. The difference in RDW levels between Group A and Group B was found to be significant: 14.40% (IQR: 13.40-16.40) versus 13.10% (IQR: 12.55-13.50) for the malignant and benign groups, respectively, P = 0.000. The area under the curve was 0.81 (95% confidence interval [CI]: 0.76-0.86), P = 0.000. For the threshold of 13.45%, the positive predictive value (PPV) for malignancy was found to be 69.15 (95% CI: 61.77-75.67) and negative predictive value (NPV) was 70.45 (95% CI: 62.60-77.26). CONCLUSION: RDW was found to have a PPV for malignancy in nearly two-thirds of the patients and had a similar NPV.

Delayed Gastric Emptying as a Complication of Whipple's Procedure: Could it be Much Less Frequent than Anticipated? Could the Definition Be Revised? A Single Center Experience.

OBJECTIVE: Whipple's procedure for periampullary tumors has significant risks and complications. Delayed gastric emptying has the highest rate. Although the International Study Group of Pancreatic Surgery defined (ISGPS) this entity, multiple definitions still exist among authors. This study aims to revise the definition. METHOD: Seventy-three consecutive patients were analyzed for complications, particularly delayed gastric emptying. All patients underwent a standardized surgery. Procedures used for total pancreatectomies and benign diseases were excluded. RESULTS: A total of 73 patients were included in the study. Intra-abdominal complications were observed in 15 (20.6%) patients. Grade C delayed gastric emptying was observed in only one (1.4%) patient. Grade A and B disease were observed in three (4.1%) patients. However, they responded well to conservative methods, causing no extra morbidity. CONCLUSION: Grade A and B delayed gastric emptying can be observed after any gastrointestinal surgery. These patients respond well to simple conservative methods with nasogastric intubation. Drainage of the intra-abdominal collection resolves the emptying problem (if any). Only grade C disease without other intra-abdominal complications can be accepted as a complication of this procedure. ISGPS definition does not include the cause. Thus, the definition and grading can be revised.

Elevated serum bilirubin levels may predict perforation of the appendix.

AIM: Acute appendicitis is one of the most common pathology requiring emergency operations, and if perforated, can cause morbidity and mortality. The serum bilirubin levels were studied to see whether an elevation predicted perforation. MATERIAL AND METHODS: In a retrospective cohort study the medical files of 221 patients who were operated for acute appendicitis were reviewed. RESULTS: Total and indirect bilirubin levels were significantly higher in patients with a perforated appendicitis compared with patients with simple appendicitis. Elevated serum bilirubin had a sensitivity of 50.00 (95% CI 29.93 to 70.07) and a specificity of 80.73 (95% CI 74.43 to 86.05) when predicting a perforated appendicitis. CONCLUSIONS: Appendiceal perforation may be accompanied with elevated serum bilirubin level. Assessment of bilirubin levels must be a part of the initial evaluation of a suspected appendicitis in the emergency room. KEY WORDS: Acute appendicitis, Gangrenous appendicitis, Perforated appendicitis, Serum bilirubin, Total Hyperbilirubinemia.

In the Experimental Model of Acute Mesenteric Ischemia, The Correlation of Blood Diagnostic Parameters with the Duration of Ischemia and their Effects on Choice of Treatment.

Purpose/Aim: Acute mesenteric ischemia is a syndrome characterized by sudden onset abdominal pain followed by intestinal necrosis. Morbidity and mortality increase with delayed diagnosis. Even with the latest radiological diagnostic methods, early diagnosis and initiation of treatment can be delayed. Using an experimental model, here we aim to determine the relationship between the laboratory parameters used to detect acute mesenteric ischemia and the duration of irreversible ischemia. Materials and Methods: A total of 30 male Wistar albino rats were divided into five groups, all of which underwent general anesthesia: (i) Superior mesenteric artery (SMA) dissection with laparotomy was performed, and blood samples and intestinal segment samples were taken after 2 hr (Sham group); (ii) volvulus of one-third of the small intestines was performed manually by laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (Volvulus group); (iii) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 2 hr (SMA+ligated 2-hr group); (iv) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 4 hr (SMA+ligated 4-hr group); and (v) SMA was ligated with laparotomy, and blood samples and intestinal segment samples were taken after 6 hr (SMA+ligated 6-hr group). Results: The mean lactate dehydrogenase (LDH) activities of the SMA+ligated 2-hr and SMA+ligated 6-hr groups were statistically higher than the control group (p = .004). Compared to the Sham and Volvulus groups, the mean lactate level of the SMA+ligated 6-hr group was significantly higher (p = .004). Compared to the Sham and Volvulus groups, the mean D-dimer levels of the SMA+ligated 4-hr and SMA+ligated 6-hr groups were significantly higher (p = .004 and .003, respectively). By histopathological evaluation, we found that pathological damage increased as the ischemia lengthened. Conclusions: Mesenteric ischemia leads to an irreversible loss of intestinal perfusion and an increase in parameters of ischemia. Irreversible tissue damage occurs after 4 hr of ischemia and peaks after 6 hr, whereas parameters of ischemia (D-dimer, LDH, and L-Lactate levels) are highest at 2 hr after the onset of ischemia.

Comparison of slit mesh versus nonslit mesh in laparoscopic extraperitoneal hernia repair.

INTRODUCTION: Endoscopic hernia repair integrates the advantages of tension-free preperitoneal mesh support of the groin with the advantages of minimally invasive surgery procedures. AIM: To compare outcomes between slit mesh (SM) and nonslit mesh (NSM) placement in laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. MATERIAL AND METHODS: This is a retrospective study of 353 patients who underwent TEP inguinal hernia repair between January 2010 and December 2011. One hundred forty-nine and 154 hernias were operated on in the SM and NSM groups, respectively. Postoperative complications, recurrence, early postoperative pain, and chronic pain levels were evaluated. RESULTS: In a total of 303 patients, hernia repair was performed as 395 direct and indirect hernias. Nonslit mesh was converted from TEP to transabdominal preperitoneal patch plasty (TAPP) in 4 patients in the group and 6 patients in the slit mesh group. The average operation time of the SM group was significantly higher than that of the NSM group (p < 0.001). In the evaluation of early postoperative pain, VAS levels of the NSM group were statistically significantly lower than those of the SR group in all evaluations (p = 0.001). The pain rate of the SM group after 3 months of chronic pain was significantly higher than that of the NSM group (p = 0.004). There was no difference in recurrence rate, 6th month chronic pain, wound infection or wound hematoma. CONCLUSIONS: The use of SM and NSM in TEP operations is not different in terms of recurrence and complications. However, the use of NSM gives better results in terms of early postoperative pain and chronic pain.

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.

Two pseudotumor cases mimicking liver malignancy.

Inflammatory pseudotumor of the liver is a rare benign tumor that can be confused with malignant tumors of the liver. It is usually diagnosed after pathologic evaluation of the resected lesion. If a mass lesion in the liver is suspicious for malignancy on radiologic evaluation then surgical resection is planned for suitable patients rather than a biopsy. Inflammatory pseudotumors are similar to malignant tumors on macroscopic assessment, but microscopically they are characterized by the presence of inflammatory cells. In case of clinical or radiologic suspicion, the lesion is biopsied and once the diagnosis of inflammatory pseudotumor is made the lesion is managed by conservative-medical treatment. It must be kept in mind as part of differential diagnosis to avoid unnecessary surgery.

Spinal anesthesia is safe in laparoscopic total extraperitoneal inguinal hernia repair. A retrospective clinical trial.

INTRODUCTION: Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is an effective and safe method for the treatment of inguinal hernia. There are very few studies on regional anesthesia methods in TEP surgery. AIM: To compare TEP inguinal hernia repair performed when the patient was treated under spinal anesthesia (SA) with that performed under general anesthesia (GA). MATERIAL AND METHODS: All total of 80 patients were studied between December 2015 and March 2017. Hyperbaric bupivacaine and fentanyl were used for SA, to achieve a sensorial level of T3. Propofol, sevoflurane, rocuronium, fentanyl, and tracheal intubation were used for GA. Intraoperative events related to SA, surgical times, intra- and postoperative complications, and pain scores were recorded. RESULTS: The mean operative time in the SA TEP group was 70.2 ±6.7 min, which was significantly longer than the mean operative time in the GA TEP group of 67.2 ±6.2 min (p < 0.038). The mean pain scores in the SA TEP group were 0.23 ±0.42 at the first hour, 1.83 ±0.64 at 6 h and 1.28 ±0.45 at 24 h. These scores were significantly lower than the corresponding scores of 5.18 ±0.84 (p < 0.001), 2.50 ±0.55 (p < 0.001) and 1.58 ±0.55 in the GA TEP group. Generally, patients were more satisfied with SA than GA (p < 0.004). CONCLUSIONS: Spinal anesthesia TEP is significantly less painful in the early postoperative period, leading to earlier ambulation than GA TEP. Additionally, SA TEP results in significantly less need for analgesics and better patient satisfaction results. SA TEP seems to be a better alternative than the existing GA TEP.