A new prognostic marker in patients undergoing Hartmann's procedure for acute tumoral obstruction of the left colon.

BACKGROUND: In acute obstructive left-sided colorectal cancers (AOLCRC), damage to the colon wall may occur as a result of distension of the colon segments proximal to the tumor. In this study, we aimed to evaluate the relationship between the ratio of dilated colon diameter (CD) to lumbar vertebral corpus diameter on preoperative abdominal computed tomography (CT) scan in patients undergoing Hartmann's Procedure (HP) and post-operative complications. METHODS: The tumor group consisted of 49 patients who underwent HP for AOLCRC under emergency conditions. The control group consisted of 49 age-and gender-matched individuals (compatible with tumor group) that had an abdominal CT due to pathologies outside the gastrointestinal tract and without a history of abdominal surgery. In both group, the ratios of the CD to the diameter of the first lumbar vertebra corpus (L1-VD) measured on axial CT images of each patient. These ratios were compared between groups. In the tumor group, the relationship between post-operative complications (Clavien-Dindo classification-major (grade ≥III), minor (grade

Histopathological examination of the impact of sodium hypochlorite on the hepatobiliary system. An experimental study.

BACKGROUND: The liver is the most common organ for settlement of hydatic cyst disease. All acknowledged protoscolicidals that are used for echinococcus degeneration have a risk of caustic secondary sclerosing cholangitis. The sodium hypochlorite is an effective protoscolicidal agent for treatment of hydatid liver cysts in vitro. OBJECTIVE: This study aimed to investigate the safe usability of sodium hypochlorite for the treatment of hydatid cyst in the hepatobiliary system in an experimental rat model. METHODS: This experimental study designed as one side blinded animal study. Study was carried out between October 2017 and August 2018. Rats were randomly allocated to the study (n=7), control (n=7), and sham (n=7) groups. A duodenotomy was performed, and a catheter was inserted through the ampulla. The tip of the catheter was placed to instill 0.15 ml sodium hypochlorite (0,25%) solution, and 0.15 ml isotonic saline solution were into the common bile duct in the study and control groups, respectively. After three months, all rats were sacrificed. Livers, biliary tracts, pancreas, and duodenum were investigated for histopathological changes by blinded two pathologists. RESULTS: No significant difference was found between groups for periductal portal inflammation (p=0.077), parenchymal inflammation, and focal necrosis (p=0.119). There was not any histopathological change in 71.4 % of the subjects in control and experimental groups. CONCLUSION: Sodium hypochlorite (0,25%) did not cause any unfavorable changes in the hepatobiliary system, and this reminds that sodium hypochlorite can be a safe alternative in percutaneous drainage, laparoscopic, and open surgery in the treatment of hydatid cyst. KEY WORDS: Hepatobiliary system, Hydatid disease, Sodium hypochlorite, Treatment.

Assessment of prophylactic antibiotic usage habits of the general surgeons in Turkey.

INTRODUCTION: One of the most important aspects of inappropriate antibiotic use among general surgeons in Turkey is the use of surgical antibiotic prophylaxis (SP). In order to shed light on the current situation, we conducted a survey of general surgeons in our country. Our aim was to evaluate the approach taken by our general surgeons in prescribing SP, while providing data pertinent to the effectiveness of the 'Rational Drug Use' (AIK) national action plan. METHODOLOGY: A questionnaire on the subject of personal SP usage and compliance with guidelines was distributed amongst general surgeons between 2018-2019. The questions related to individual approaches taken by surgeons when treating patients with either clean or clean-contaminated wounds. Results of the questionnaires were collated and compliance with ASHP guidelines was evaluated. RESULTS: A total of 317 completed questionnaires were evaluated. According to the questionnaire results, the rate of total compliance with ASHP guidelines was 26.8%. The compliance rate for preoperative SP was 69.7% in the clean wound group and 54.6% in the clean-contaminated wound group. Although 96.5% of the participants reported correct timing for the first dose of SP, this number dropped to 79.5% apropos the adminstration of further doses of prophylaxis. The percentage of surgeons prescribing continued antibiotics at discharge for clean and clean-contaminated cases was 22.7% and 38.5%, respectively. CONCLUSIONS: The results of this study indicate that inappropriate use of SP is widespread in our country, and that antibiotics continue to be prescribed at discharge.

Evaluation of Antibiotic Prophylaxis and Discharge Prescriptions in the General Surgery Department.

Introduction Although there are international guidelines for surgical antibiotic prophylaxis (SP), the use of inappropriate SP is still a common problem. Most studies investigated SP applications in clean and clean-contaminated cases. However, antibiotics in the discharge prescriptions of these cases have not been adequately investigated. In this study, we aimed to examine the antibiotics in SP applications and discharged prescriptions together and to find out the causes of inappropriate use. Materials and methods We retrospectively evaluated the data of patients admitted to our general surgery wards between 2014 and 2015. Patients with clean or clean-contaminated wound category operations were included. The patients were evaluated in terms of convenience of SP (choice of antibiotics, compliance with an indication for SP, timing of the first dose, SP>24 hours, and discharge prescription). In addition, to interpret the results, a questionnaire has been performed for the surgeons in the same clinics. Results A total of 1205 patients with clean and clean-contaminated wound class operation were enrolled in this study. The total accuracy rate of SP was 7.1%. SP application with the correct indication and timing of the first dose was compatible with guidelines: 55.6% and 81.9%, respectively. SP was applied >24 hours at 60.2% and antibiotic prescribing carried out after discharge at 80.6% of patients. According to questionnaire results, the use of SP over 24 hours and the prescription of antibiotics during discharge were: drain usage, hyperthermia, leukocytosis, surgeons feeling of comfort, avoidance of patients, and their relatives' reactions. Conclusion The total accuracy rate of SP rate was low in the present study and in surgeons prescribing the SP after discharge. In light of the present study, we suggest that discharge prescriptions should also be reviewed in clinics who have a high inappropriate surgical antibiotic prophylaxis rate.

Correction: Evaluation of Antibiotic Prophylaxis and Discharge Prescriptions in the General Surgery Department.

[This corrects the article DOI: 10.7759/cureus.4793.].

Intussusception Can Be the First Sign of Post-transplant Lymphoproliferative Disease.

Intussusception is usually seen in the pediatric age group and rarely seen in adults. It results in the progression of the proximal segment of the intestine into the distal intestine. A 50-year-old immunosuppressive male patient presented with the complaints of abdominal pain, nausea, vomiting, and no gas or stool discharge for 2 days. He was hospitalized with the presumptive diagnosis of acute abdomen. He has a history of renal transplantation due to chronic renal insufficiency. An explorative laparotomy was performed. The operative findings were compatible with jejunojejunal intussusception, and a segmental small bowel resection and end-to-end anastomosis were performed. The patient was uncomplicated postoperatively and discharged on the fifth postoperative day. The pathology was reported as Epstein-Barr virus negative with diffuse large-cell B lymphoma. In this case report, we aim to report on a jejunojejunal intussusception that was presented as the first sign of post-transplant lymphoproliferative disease.

First step toward a better trauma management: Initial results of the Northern Izmir Trauma Registry System for children.

BACKGROUND: Trauma is an important health problem in children, and improvement in national trauma care is only possible through the knowledge gathered from trauma registry systems. This information is not available in our country, because there is no current trauma registry system at the hospitals. Our aim is to explain the trauma registry system we have developed and present the first year's data. METHODS: The planned trauma registry system was integrated into the emergency department registry system of 14 hospitals in Izmir province. The data of pediatric multiple trauma patients have been recorded automatically through the registry system. Demographics, vital signs, mechanism, type of trauma, anatomical region, ISS, PTS, GCS, length of hospital stay and need for blood transfusion/endotracheal intubation/surgery/hospitalization were evaluated by patient transfer status and outcome. RESULTS: At the end of one year, a total of 356 pediatric major trauma patients were included in the study. The most common type of trauma was blunt trauma (91.9%) and the mechanism was vehicle-related traffic accidents (28.1%). In the group with the worse outcome than the Glasgow outcome score, age was greater, ISS was higher and PTS was lower. Motorcycle accidents, sports injuries, and penetrating injuries were more frequent in this group. All the scales were significantly different between direct and transferred patients. The referral time to the hospital of the transferred patients were longer than directly admitted patients, but the results were not different. CONCLUSION: Pediatric major trauma is an important cause of mortality and morbidity, and our trauma registry system, which is a successful example abroad, is not enough in the country. We hope that the trauma registry system we planned and started the pilot application will be expanded to include other hospitals throughout the country with the aim of developing a national registry system.

A new antibiotic stewardship program approach is effective on inappropriate surgical prophylaxis and discharge prescription.

INTRODUCTION: This study aims to evaluate the efficacy of a new antimicrobial stewardship program (ASP) on surgical antibiotic prophylaxis (SP) and antibiotics in discharge prescriptions used as a continuation of SP. METHODOLOGY: The study included elective patients with clean and clean-contaminated wounds. The accuracy of the assigned SP was evaluated according to international guidelines. Primary outcome measures comprised appropriateness of prophylactic antibiotic indication, correct timing of initial dose, discontinuation of SP within 24 hours, and antibiotic prescription at discharge. A secondary outcome measure was to determine whether the effect of ASP was sustained long-term. RESULTS: The total compliance rate for all stages of SP increased from 8% to 52.1% after the intervention (p < 0.05). When analyzed according to individual SP components, it was found that although ASP did not change first dose timing rates, it did affect the rates of prophylactic antibiotic indication, discontinuation of SP within 24 hours and antibiotic prescription at discharge, with statistical significance (p < 0.05). In addition, ASP continued to increase its effectiveness throughout the 3rd year. CONCLUSIONS: Based on the findings of our study, it seems clear that the modified ASP introduced in our general surgery clinic can be used effectively and simply; in addition, this ASP increases its efficacy with time.

Robotic-Assisted Transthoracic Esophageal Diverticulectomy.

INTRODUCTION: Esophageal diverticulum is a rare entity with symptoms that include dysphagia, halitosis, chest pain, and regurgitation. Indications for surgery include the presence of any of these symptoms and a diverticulum larger than 3 cm because of the increased risk of malignancy and aspiration. Treatment is open or minimally invasive surgery performed from the transhiatal or transthoracic approach. CASE DESCRIPTION: Three patients were investigated by esophagogastroduodenoscopy, esophageal manometry, and computed tomography and were given the diagnosis of epiphrenic diverticulum of the esophagus. MANAGEMENT AND OUTCOME: The patients underwent robot-assisted surgery by a transthoracic approach for esophageal diverticulectomy. The mean operative time was 211 min, with no significant blood loss or intraoperative complications. DISCUSSION: This report of robot-assisted surgery for esophageal diverticulectomy from a transthoracic approach adds to the literature regarding surgical treatment of epiphrenic esophageal diverticulum. It is a feasible method that can be used in selected patients with esophageal diverticulum.

Retroperitoneal paraganglioma presenting with pancytopenia: A rare case with rare manifestation.

INTRODUCTION: Paragangliomas are tumors that arise from extraadrenal chromaffin cells and most of them are asymptomatic presenting with painless mass. Retroperitoneal paragangliomas are mostly benign with good prognosis; however, they can present with abdominal pain, palpable mass, or hypertensive episodes. Surgical resection is still the main treatment and necessary for histological assessment. CASE REPORT: A 41 year old female patient presented with 6 months of loss of appetite, weight loss, weakness and breathlessness on exertion.. The patient's initial blood examination showed marked anemia, reduced leukocyte count with neutropenia and lymphopenia and a marked reduction in the platelet count. The patient was admitted for evaluation of her pancytopenia. Magnetic resonance imaging revealed a 8×7×8cm sized mass closed to the pancreatic tail invading splenic hilum. A large mass was identified retroperitoneally, closed to the tail of pancreas with a splenic hilum invasion. Total mass resection and splenectomy was performed. DISCUSSION: Complete surgical excision is the treatment of choice for extra-adrenal paragangliomas as well as for recurrent or metastatic neoplasms. Reactive thrombocytosis is a common cause of thrombocytosis. Splenectomy was found to be one of the main causes of extreme reactive thrombocytosis. Reactive thrombocytosis is a predictable finding after splenectomy and management of the thrombocytosis and prevention of complications should be initiated.

Visceral organ resection during femoral hernia surgery is a predictor of morbidity.

Reports on the outcomes of emergency and elective femoral hernia surgery are scarce. Most studies do not distinguish femoral hernia from other types of groin hernia; studies of femoral hernia alone are few in number. The main objective of the present study was to identify factors affecting morbidity of femoral hernia patients. We retrospectively analyzed data on 80 patients who underwent femoral hernia surgery between June 2009 and June 2013. Patients who did and did not experience morbidity were compared in terms of age, sex, hernia location, the presence of any comorbid disease, the type of anesthesia employed, the operative technique used, the type of surgical intervention, and performance of small bowel resection. Forty-three patients (53.8%) underwent emergency surgery because of incarceration. Of these, 18 (41.9%) experienced strangulation and underwent resection. Postoperative complications developed in 11 patients (13.8%). Upon multiple logistic regression analysis, visceral organ resection (of the small bowel and/or omentum) was the only independent predictor of significant morbidity (P < 0.05; odds ratio [OR]: 14.010, 95% confidence interval [CI]: 1.001-196.143). When diagnosed, femoral hernias should be electively repaired as soon as possible. The cumulative probability of strangulation rises over time. A requirement for bowel resection seems to significantly increase morbidity.

Comparision of the Limberg flap with the V-Y flap technique in the treatment of pilonidal disease.

PURPOSE: In this study, we investigated whether there is a factor that can aid determi nation of the preferred technique by comparing the early and late results of two different surgical techniques for the treatment of pilonidal sinus. METHODS: The medical records of 176 patients in whom the Limberg flap (LF) or V-Y flap techniques were applied for reconstruction after the excision were evaluated retrospectively. RESULTS: The development rates of postoperative hematoma, wound separation, wound infection, and seroma were 2.8%, 5.1%, 5.6%, and 6.3%, respectively, while total flap necrosis was not observed in any patient. Return to daily activities was achieved after a mean of 17.1 days (13 to 21 days) days in the LF group and 32.7 days (18 to 47 days) in the V-Y flap group. During the average follow-up of 65 months (36 to 110 months), nine patients (5.1%) developed recurrent disease. There was no difference between the two groups with respect to early surgical complications (P = 0.286) or disease recurrence (P = 0.094), whereas the resumption of daily activities was longer in patients with a V-Y flap (P < 0.001). CONCLUSION: The early postoperative and long-term results of the LF and V-Y flap techniques for the treatment of pilonidal sinus were similar. Because the resumption of daily activities at work is achieved later in patients undergoing the V-Y flap compared with the LF technique, patients' employment (or position in working life) must be considered when determining the most appropriate surgical technique.

CT findings of patients with small bowel obstruction due to bezoar: a descriptive study.

PURPOSE. The aim of this study was to present the computed tomography (CT) findings of bezoars that cause obstruction in the small bowel and to emphasize that some CT findings can be considered specific to some bezoar types. MATERIALS AND METHODS. The records of 39 patients who underwent preoperative abdominal CT and subsequent operation with a diagnosis of intestinal obstruction due to bezoars were retrospectively analyzed. RESULTS. In total, 56 bezoars were surgically removed from 39 patients. Bezoars were most commonly located in the jejunum (n = 26/56, 46.4%). Sixteen (41.0%) patients had multiple bezoar locations in the gastrointestinal tract. Common CT findings in all patients were a mottled gas pattern and a focal ovoid or round intraluminal mass with regular margins and a heterogeneous internal structure. Furthermore, some CT findings were determined to be specific to bezoars caused by persimmons. CONCLUSIONS. Preoperative CT is valuable in patients admitted with signs of intestinal obstruction in geographic regions with a high bezoar prevalence. We believe that the correct diagnosis of bezoars and the identification of their number and location provide a great advantage for all physicians and surgeons. In addition, some types of bezoars have unique CT findings, and we believe that these findings may help to establish a diagnosis.

A case of achalasia presented with cardiopulmonary arrest.

Achalasia is a rare disorder characterised by obstruction of the distal oesophagus and subsequent dilation of the proximal oesophagus. Patients generally complain of gastrointestinal symptoms; however, pulmonary symptoms and complications may also occur. A 35-year-old woman was brought to our emergency service complaining of sudden-onset dyspnea that started 15 minutes earlier during dinner. She suffered a cardiopulmonary arrest due to aspiration 5 minutes after being admitted to the emergency room and was intubated. Thoracic computed tomography examination showed that her oesophagus was filled with undigested food. Heller cardiomyotomy and Dor fundoplication was performed via laparotomy with the diagnosis of primary achalasia, and she was discharged as uneventful on the 5th postoperative day.

Renal cytokine and histopathologic changes following acutely increased intra-abdominal pressure: an animal study.

BACKGROUND: The reason for acute renal failure (ARF) in abdominal compartment syndrome (ACS) is thought to be due to the increase in renal venous pressure. In this study, the changes in plasma and renal tissue cytokine levels and histopathologic changes in renal tubular and glomerular cells were evaluated and compared in a model of acute elevation in abdominal tension with different pressures. METHODS: Eighteen Sprague-Dawley rats were randomly assigned into three groups: Sham-operated rats and rats in Groups 1 and 2, in which 20 and 30 mmHg of intra-abdominal pressure (IAP) was applied for 60 minutes, respectively. Left kidneys of the animals and intracardiac blood samples were taken at the end of the procedures. Tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) levels were investigated in plasma and renal tissue samples. Renal tissues were also evaluated for histopathologic changes. RESULTS: Renal tissue and plasma TNF-alpha and IL-6 levels were found to be significantly increased when the sham-operated group was compared to the study groups (p<0.05). Renal tissue changes showed that the total histopathologic scores were significantly increased in study groups compared to the sham-operated group (p<0.05); tubular changes were more prominent than glomerular changes. CONCLUSION: Abdominal tension linearly can cause renal tubular histopathologic changes. Cytokines may play a role in ARF due to ACS.

ß-Catenin and its relation to VEGF and cyclin D1 expression in pT3 rectosigmoid cancers.

BACKGROUND/AIMS: ß-Catenin is a critical component of the Wnt signaling pathway that regulates cell proliferation and differentiation. Wnt signaling leads to the stabilization of cytosolic ß-catenin and to translocation to the nucleus, where it binds with T-cell factor and promotes the transcription and changes in target gene expression, including vascular endothelial growth factor and cyclin D1. The aim of this study was to assess the expression of cyclin D1 and vascular endothelial growth factor and to correlate them with ß-catenin expression and some clinicopathologic parameters. METHODS: In this study, we analyzed paraffin-embedded specimens from 42 patients with pT3 rectosigmoid cancer for ß-catenin, vascular endothelial growth factor and cyclin D1 expression using immunohistochemistry. RESULTS: Thirty-six (85.7%) and 24 (57.1%) tumors expressed vascular endothelial growth factor and cyclin D1, respectively. Nuclear expression of ß-catenin was detected in only 26.1% of tumors. It was revealed that cytoplasmic ß-catenin expression was significantly related to vascular endothelial growth factor expression (p=0.011). No association was found between nuclear or cytoplasmic ß-catenin and cyclin D1 expression. No significant association was seen between ß-catenin, vascular endothelial growth factor or cyclin D1 expression and some investigated clinicopathologic features. CONCLUSIONS: Our results may contribute to knowledge regarding the functional interaction between ß-catenin and vascular endothelial growth factor. We suggest that the overexpression of cyclin D1 in rectosigmoid cancers may be more complicated than purely upregulation by ß-catenin. Further larger studies on Wnt/ß-catenin and target gene activity and protein expression are necessary to better understand and define their roles in the pathogenesis of colorectal carcinoma.

Surgery for acute abdomen and MEFV mutations in patients with FMF.

OBJECTIVES: Familial Mediterranean Fever (FMF) is an autosomal recessive disease characterized by recurrent fever, peritonitis, arthritis, pleuritis, and secondary amyloidosis. In the current study, we sought to determine the frequency of acute surgical abdominal intervention and MEFV gene mutations in FMF patients. PATIENTS AND METHODS: A total of 159 patients were referred to our department with a diagnosis of FMF. Twenty-six patients (16.4%) had a history of surgical intervention. Of these, 17 (10.7%) were operated on due to appendicitis, and 9 (5.7%) were operated on due to other acute abdomen reasons. Genomic DNA was isolated from the blood samples, and in the isolated DNA samples, 12 MEFV gene mutations were studied. RESULTS: Mutation frequency was detected to be 80.8% in the patients with acute abdomen surgery intervention and 56.4% in the patients without acute abdomen surgical intervention. Upon mutational evaluation of these patients, we noted that the M694V (40.5%) and E148Q (21.4%) mutations occurred most frequently. CONCLUSIONS: The MEFV gene mutation frequency in FMF patients with acute abdomen surgical intervention was significantly higher than that in patients without such intervention. Increased mutation scanning in FMF patients will significantly decrease unnecessary surgical interventions in this patient group.

Stepwise rising CO2 insufflation as an ischemic preconditioning method.

BACKGROUND: The pneumoperitoneum (Pp) is associated with ischemia and reperfusion (I/R) injury and oxidative stress. Various ischemic-preconditioning (IP) methods were used to reduce ischemic injury in intra-abdominal organs. In this experimental, randomized, controlled trial with a blind assessment of the outcome, we evaluated the effects of a new IP method, stepwise rising CO(2) insufflation, on oxidative stress and inflammatory cytokine response. METHODS: Twenty-one rats were divided into three groups. Rats in the control group were subjected to general anesthesia for only 60 minutes. The stepwise group was subjected to 5 mm Hg for 10 minutes, 10 mm Hg for 10 minutes, and 15 mm Hg of CO(2) insufflation for 60 minutes without deflation. In the Pp15 group, the pressure of CO(2) insufflation was fixed at 15 mm Hg for 60 minutes without deflation. Liver and blood samples were examined to determine malondialdehyde (MDA), the antioxidant, superoxide dismutase (SOD), and inflammatory cytokine (tumor necrosis factor-alpha [TNF-alpha], interleukin-6 [IL-6]) levels. Histopathologic scores of liver tissue were examined in all groups. RESULTS: The highest plasma and liver MDA, TNF-alpha, and IL-6 values were in the Pp15 group, followed by the stepwise and control groups. However, plasma and liver SOD levels determined in the control group were significantly higher, compared to stepwise and Pp15 groups. The lowest plasma and liver levels of SOD were in the Pp15 group, followed by the stepwise and control groups. Significantly higher histopathologic scores were found in the Pp15 group, followed by the stepwise and control groups, as well as MDA and inflammatory cytokine (TNF-alpha, IL-6) levels. CONCLUSIONS: We concluded that the stepwise rising CO(2) insufflation method may be an alternative IP method that may lead to a reduction in I/R injury.

Effects of octenidine HCl on liver tissue: could it be an alternative scolicidal for Hidatid disease?

Octenidine HCl is new topical antiseptic solution for wounds and abdominal washing that has been found to be highly effective for inactivating scolices in an in vitro study. However, the effects of octenidine HCl on the liver are not yet known. The aim of this study was to determine if there are any histopathologic changes after injecting octenidine HCl into the liver. A group of 50 male Sprague-Dawley rats were included in the study and randomly divided into five groups of 10 rats each, as follows: sham group; 0.09% NaCl group; 20% NaCl group; undiluted octenidine HCl group; 1% octenidine HCl group. The scolicidal agents (0.3 ml) were directly injected into the left lobe of the liver (except in the sham group). At 3 and 7 days after the injection, the rats were sacrificed, and the left lobe of the liver was harvested. Liver tissue was scored for degree of necrosis and the diameter of the necrosis examined under light microscopy. The highest scores were found in the undiluted octenidine HCl group, although a similar effect was observed in the 20% NaCl group. There was no necrosis in the sham group, the 0.09% NaCl group, or the 1% octenidine HCl group. All of the injury was coagulation-type necrosis. No mortality was observed throughout the study. The 1% octenidine HCl solution could thus be used as a scolicidal agent in liver tissue, whereas the undiluted form of octenidine and 20% NaCl solutions were shown to cause necrosis when directly injected into liver tissue in our animal model.