Determination of risk factors for conversion from laparoscopic to open appendectomy in patients with acute appendicitis.

BACKGROUND: Acute appendicitis is the most common cause of surgical emergencies. It can be difficult to distinguish cases of acute appendicitis that should be managed by laparoscopic appendectomy (LA) from those that should be managed by open surgery. This study aimed to prevent the inappropriate choice of technique and associated complications by identifying potential risk factors for conversion from laparoscopic to open appendectomy (OA) at the time of initial surgical assessment. METHODS: This is a retrospective analysis of patients who underwent laparoscopic exploration for acute appendicitis. The study included patients over 18 years of age between January 2016 and July 2021. Patients were divided into two groups according to the surgical approach: those who underwent a LA and those who initially underwent laparoscopic exploration first and then converted to OA. Demographics, perioperative factors, and outcomes were compared between groups. RESULTS: The study included 634 adults undergoing laparoscopic exploration for an appendectomy. About 80.8% had LA, and 19.2% (n=122) required COA. COA patients' average age was significantly higher than LA patients' (48.5 years vs. 37.8 years, P<0.001). The conversion rate for patients over 65 was 63.8%, compared to 15.6% for those under 65 (P<0.001). COA patients had higher bilirubin levels (36.1% vs. 13.5%, P<0.001), higher American Society of Anesthesiologists (ASA) scores (ASA >2, COA 52.5% vs. LA 7.8%, P<0.001), and a higher need for CT imaging (84.4% vs. 67.6%, P<0.001) than LA patients. An Alvarado score >6 significantly differenti-ated LA from COA (62.6% vs. 39.4%, P< p<0.001). COA patients experienced significantly increased periods until starting oral intake (31.6 vs. 9.9 h, P<0.001) and higher rates of complicated appendicitis (40.9% vs. 0.6%, P<0.001). After surgery, COA had higher rates of complications compared to LA: surgical site infections (8.2% vs. 2.7%, P=0.004), reoperation (13.1% vs. 0%, P<0.001), hospital re-admission (14.7% vs. 2.3%, P<0.001), and mortality (1.6% vs. 0%, P<0.004). CONCLUSION: Advanced age, especially over 65 years, elevated bilirubin levels, an ASA >2 score, and an increased need for pre-operative diagnostics using CT scans were found to be significant predictors of conversion to OA. In the conversion group, operative time, time to oral intake, and the incidence of complicated appendicitis were significantly higher. The conversion group had significantly higher rates of postoperative complications, surgical site infections, hospital readmissions, and mortality. To avoid the increased rate of complications associated with conversion to open surgery, the initial evaluation of a patient with prospective risk factors may be beneficial.

Preoperative ALBI grade predicts mortality in patients undergoing curative surgery for pancreatic head cancer.

The clinical significance of the albumin-bilirubin (ALBI) grade in patients with pancreatic head cancer (PHC) undergoing surgery is unknown. Preoperative ALBI grade is believed to be influenced by tumor burden. This study aimed to develop and validate the ALBI grade as a preoperative prognostic model for predicting the survival of patients with PHC. This is a retrospective study of Whipple procedures performed on PHC patients between January 2013 and December 2022. ALBI grade was compared to age, gender, type of operation, presence of complications, type of complications, Clavien-Dindo classification, total bilirubin levels, and albumin levels. Of the series, 46 (41.1%) of the 112 patients were female, while 66 (58.9%) were male. The rate of complications following Whipple procedures was 36.6% (n = 41). The overall mortality hazard ratio increased significantly with increasing ALBI grades (HR: 1538, hazard ratio mean: -1602). Hospital mortality increased 2.84 times as the ALBI grade increased. The model's accuracy of 88.4% showed that the ALBI grade directly affected both the overall mortality rate and the hospital rate. But there was no statistically significant difference between the ALBI grade and other variables. Multivariate regression analysis identified the preoperative ALBI grade as an independent predictor of mortality (P = .006). To the best of our knowledge, this is the first study to identify preoperative ALBI grade as an independent predictor of survival in PHC. It was found that the ALBI grade of -1602 was a new grading system that would be more predictive of mortality in PHC.

Can combined use of tumor markers in pancreatic cancer be a solution to short- and long-term consequences?: A retrospective study.

As in other types of cancer, tumor markers are used in pancreatic ductal adenocarcinoma (PDAC) for disease follow-up, especially after surgery. There has been shown to be a significant correlation between the tumor marker levels and poor prognosis in locally or systemic advanced stage PDAC patients. However, there is no significant correlation between prognosis and marker levels in patients with early stage PDAC patients. This study aimed to examine the effect of the carbohydrate antigen 19-9 (Ca19-9)/carcinoembryogenic antigen (CEA) ratio in ductal adenocarcinoma of the pancreatic head on disease prognosis and mean survival. This retrospective study was conducted with 129 pancreatic head adenocarcinoma patients who were treated with whipple procedure at the Ankara University Surgical Oncology Clinic between 2010 and 2020. All patients' demographics, stage of the disease, CEA, CA 19-9 levels, and CEA/Ca 19-9 ratio were enrolled and compared statistically. A new cutoff value was calculated for the Ca19-9/CEA ratio. A Ca19-9/CEA ratio >29.77 showed 69.9% sensitivity and 70.9% specificity for the probability of the T3 and T4 stages. The cutoff value for the Ca19-9/CEA ratio was 27.18. This cutoff value had a sensitivity of 79.4% and a specificity of 80.3% for lymph node metastasis. Patients with a Ca19-9/CEA ratio below the cutoff value of 28.475 had a mean survival of 93.161 months and those with a value higher than the cutoff value had a mean survival of 28.541 months (P < .001). A simple combination of tumor markers was determined to have higher accuracy rates in predicting tumor prognosis and in determining mean survival, which are particularly needed in early stage cancers.

Effect of thyroid nodule size on cytology reliability and incidence of malignancy: A large cohort of 1205 patients from a single center.

OBJECTIVE: There is controversy about whether the rates of malignancy and of false-negative malignancy are greater in large nodules. The aim of this study was to determine the reliability of cytology in ≥4cm nodules and to compare malignancy rates between ≥4cm and<4cm nodules. METHODS: The study included 1205 patients who underwent biopsy and subsequent thyroidectomy with the diagnosis of nodular thyroid disease between 2014 and 2019. The patients were separated into two groups, ≥4cm and<4cm, according to the size of the index nodule on ultrasonography. RESULTS: Two hundred and eleven index nodules (17.5%) were ≥4cm. Malignancy rate on definitive pathology was 51% in<4cm nodules and 30% in ≥4cm nodules. Malignancy risk was significantly lower in ≥4cm nodules than <4cm nodules (P<0.001). When<1cm nodules were excluded and 1-4cm and ≥4cm nodules were compared, malignancy risk was also significantly lower in ≥4cm nodules (P=0.001). On definitive pathology, there were 45 false-negative results among cytologically benign nodules. There was no difference in false-negative cytology rate between<4cm and ≥4cm nodules (P=0.209). CONCLUSION: The present study found no decrease in the reliability of cytology in ≥4cm nodules, and there may not be a linear relationship between nodule size and malignancy risk. Therefore, in asymptomatic cytologically benign ≥4cm nodules, surgery may not be recommended based on nodule size alone.

Liver Dysfunction After Use of Nathanson Retractor During Laparoscopic Gastrectomy for Gastric Cancer.

Background: Cardiopulmonary complications and liver dysfunction are also specific complications and problems associated with laparoscopic surgery. The main causes of postoperative liver dysfunction, which may often occur after laparoscopic surgery, include carbon dioxide pneumoperitoneum and ligation of the aberrant left hepatic artery. Hepatic steatosis may develop as a natural consequence of neoadjuvant therapy, although rarely, owing to chemotherapy. Nathanson retractor may cause a prolonged elevation in liver enzymes of these patients compared with those who do not receive neoadjuvant therapy. Materials and Methods: The data of 151 patients who underwent laparoscopic radical gastrectomy between January 2017 and January 2022 for histologically proven primary gastric cancer in our clinic were retrospectively reviewed. Results: The mean length of hospital stay was 6.21 days. The mean time normalization of the aspartate aminotransferase (AST) value was 2.45 ± 1.83 (range, 0-12) days postoperatively. The analysis of the correlation between the preoperative and postoperative 1-day values of alanine aminotransferase (ALT) and AST revealed a significant difference between the preoperative and postoperative 1-day median values of both parameters (P < .001). Each one unit increase in ALT led to an increase of 0.338 days in the length of intensive care stay and an increase of 0.345 days in the overall length of hospital stay. As the time to normalization of the AST value increased, the length of both intensive care stay and hospital stay increased. Each one unit increase in AST resulted in an increase of 0.316 days in the length of intensive care stay and an increase of 0.376 days in the overall length of hospital stay. Conclusion: Alternative retraction methods can be used safely in laparoscopic surgery for gastric cancer patients receiving neoadjuvant therapy. We are of the opinion that the Nathanson retractor should be used only during dissection of the relevant regions to shorten the intraoperative intermittent release or the time of use.

Role of Intraoperative Nerve Monitoring in Postoperative Muscle and Nerve Function of Patients Undergoing Modified Radical Mastectomy.

This study aimed to postoperatively evaluate the effects of intraoperative neural monitoring (IONM) on muscles and nerves in patients who underwent modified radical mastectomy (MRM). In the 11 patients included in the study, nerves were determined and protected by nerve monitoring during the axillary dissection (IONM group). In another 11 patients, nerve monitoring was not performed; however, protection of the same nerves was attempted through careful nerve dissection (cautious nerve dissection [CND] group). The control group consisted of 22 healthy subjects. Muscle and nerve functions were blindly evaluated by an experienced physical therapy and rehabilitation specialist using electromyography (EMG) and ultrasonography (US) methods. The EMG values of the pectoralis major muscle were similar in the IONM and control groups (1.97 mV/1.98 mV, p = 0.97) but significantly lower in the CND group (1.57 mV, p < 0.05). Significant differences were found in the US values of the pectoralis major and minor muscles between the IONM and CND groups. No significant difference was found between the IONM and control groups in terms of EMG values of the serratus anterior muscle. This is the first prospective randomized study to objectively evaluate preservation of the nerve through nerve monitoring and its functional results. Monitoring of nerves during MRM is of great importance in terms of demonstrating the positive effects on muscle and nerve functions.

New Findings on Autoimmune Etiology of Idiopathic Granulomatous Mastitis: Serum IL-17, IL-22 and IL-23 Levels of Patients.

BACKGROUND: Idiopathic Granulomatous Mastitis (IGM) is a benign chronic inflammatory breast disease that mimics breast cancer, and the etiopathogenesis has not yet been fully evaluated. Autoimmunity has received the most focus as a possible etiology. Our aim in this prospective clinical study was to investigate the possible association between the cytokines, interleukin IL-17, IL-22, IL-23 and IGM. MATERIALS AND METHODS: The current study was conducted in 26 women with histopathologically diagnosed IGM, and 15 control women of reproductive age having no breast disease history. Blood samples were collected, and serum concentrations of IL-17, IL-22, and IL-23 were determined. RESULTS: In the analysis of variables, the patients with IGM and the control group had statistically significant differences between serum IL-22 titers (p = 0.0378) and IL-23 titers (p = 0.0469. No statistically significant difference was found between IGM patients and the control group in serum IL-17 titers (p = 0.9724). CONCLUSION: The results of the current study, especially pertaining to serum IL-22 and IL-23 levels, support the etiopathogenesis of IGM in favor of the autoinflammatory thesis. Nevertheless, this thesis should be supported by a large case number and prospective clinical studies.

Are fibrinogen and complete blood count parameters predictive in incarcerated abdominal hernia repair?

Therapeutic delays in cases of external incarcerated hernias typically result in increasing morbidity, mortality, and health expenditures. We investigated the diagnostic role of blood fibrinogen level, white blood count (WBC), mean platelet volume (MPV), and platelet distribution width (PDW) in patients with incarcerated hernia. Two groups, each containing 100 patients, were studied. Group A underwent elective, and group B underwent incarcerated and urgent external hernia repair. We observed high fibrinogen and WBC levels but low MPV and PDW values for patients in group B. Contrary to our expectations, we found lower MPV and PDW values in the complicated group than in the elective group. The morbidity rate and cost burden were higher in group B, and the results were statistically significant. Early operation should be recommended for patients with incarcerated external hernias if their fibrinogen and WBC levels are high.

Effects of intraabdominal pressure on mean platelet volume during laparoscopic cholecystectomy.

BACKGROUND/AIM: Intraabdominal hypertension is a common occurrence, especially in intensive care unit patients, and it has high mortality and morbidity rates. The onset is commonly insidious and the poor prognosis is attributed to the long delay in diagnosis. Unfortunately, diagnosis is often delayed until loss of function in the affected tissues has already occurred. The aim of this study was to determine the predictive value of mean platelet volume (MPV) in assessing the risk of intraabdominal hypertension. MATERIALS AND METHODS: Pneumoperitoneum during elective laparoscopic cholecystectomy was used as a model for intraabdominal hypertension. The study included 103 patients who met the inclusion criteria. MPV evaluations were made at 3 distinct times during laparoscopic cholecystectomy based on the actual intraabdominal pressure. RESULTS: MPV values during preinsufflation, insufflation, and desufflation were 8.483 fL (range: 6.7 to 11.1), 8.901 fL (range: 6.8 to 11.9), and 8.538 fl (range: 5.8 to 10.9), respectively. A statistically significant increase in MPV values was found during high intraabdominal pressures (P < 0.001). A significant decrease in MPV values was also detected with desufflation (P < 0.001). CONCLUSION: Increasing MPV values may reflect increased intraabdominal pressures, which may have a clinical implementation in intraabdominal hypertension.

The role of general surgery consultations in patient management.

OBJECTIVE: Consultation results of patients who were thought to require a surgical intervention and were evaluated in the General Surgery Department for diagnostic support and treatment, upon detection of pathology in clinical and/or laboratory tests. MATERIAL AND METHODS: In a six-months period, 221 patients were retrospectively analyzed. There were 121 male (54.75%) and 100 female (45.25%) patients and the mean age was 46 years (15-102). The departments which requested consultation, the reason for consultation, test and physical examination findings before consultation, required additional tests after consultation and results of consultations were recorded as well as performed interventions. RESULTS: The majority of consultations were from the emergency department (91.9%) and the most frequent reason was abdominal pain (29.9%). No tests were performed before consultation in 21% of cases. Physical examination was completely fulfilled in 100% of judicial cases, but this ratio was 35% in perianal diseases and 30% in patients with bowel obstruction. Additional tests were required in 54.3% of the patients after consults. Out of the whole group with surgical consultation, 21% were operated under general anesthesia, 9% under local anesthesia, while an elective operation was suggested in 3%. CONCLUSION: Currently, it is mandatory that patient management is carried out with a multidisciplinary approach; however, we believe that consultations should be asked in a more selective manner.

Does topical rifampicin reduce the risk of surgical field infection in hernia repair?

OBJECTIVE: Inguinal hernia operations are common procedures in general surgery. There have been many approaches in the historical development of hernia repair; tension free repair with mesh being the most commonly used technique today. Although it is a clean wound, antibiotic use is still controversial due to concerns about infection related to synthetic mesh. We aimed to determine the probable role of topical rifampicin in patients with tension-free hernia repair and mesh support. MATERIAL AND METHODS: The charts of patients who underwent tension-free inguinal hernia repair were retrospectively analyzed. Information and operative notes on patients, in whom synthetic materials were used, were identified. The patients were divided into two groups, placebo group (G1) and patients with application of topical rifampicin on the mesh (G2). Infection rates between the groups in the early postoperative period were compared. RESULTS: The mean age of the 278 patients who were included in the study was 49.6±15.39 and the female/male ratio was 10/268. There were recurrent hernias in four patients and superficial wound infections in 22 patients in the early period. One patient had testicle torsion and underwent an orchiectomy. There were no significant differences between the groups in terms of age and gender. The types of hernia and body mass index were homogenous between the two groups. In the early postoperative period the infection rates were 16/144 (11.1%) and 6/134 (4.48%) in the groups, respectively, with the difference being statistically significant (p=0.041). CONCLUSION: We suggest that applying rifampicin locally can decrease surgical site infection in hernia operations where meshes are used.

Efficacy of radical surgery in preventing early local recurrence and cavity-related complications in hydatic liver disease.

BACKGROUND: Hydatic disease of the liver remains to be a complex worldwide problem especially in rural areas. Early local recurrence and cavity-related complications are still a matter of conflict in the management of hydatic liver disease. The aim of this study is to investigate efficacy of the type of surgical treatment in preventing early local recurrence and cavity-related complications of this disease. Here, we present the preliminary results of our study. METHODS: This study was performed prospectively including 32 patients who were operated for hydatic liver disease between January 2001 and January 2005. Patients were randomized into radical and conservative surgery groups. Recurrences at the primary surgical site in the first 2 years were considered as early local recurrence and biliary leakage, biliary fistula, cavity abscess, etc. were considered as cavity-related complications. RESULTS: Early local recurrences were observed only after conservative surgical procedures (p=0.045). Recurrent cysts were found to be due to satellite cysts or pericystic disease. Cavity-related complications were seen in six patients in the conservative surgery group (p=0.011). CONCLUSIONS: In suitable patients, radical surgical resection provides an effective surgical management option in preventing early local recurrence and cavity-related complications when compared to conservative surgical approaches.

The effect of platelet activating factor antagonist BN 52021 on bacterial translocation and ICAM-I expression in experimental obstructive jaundice.

Expression of intracellular adhesion molecule-1 (ICAM-1) in an obstructive jaundice model and the potential protective role of platelet activating factor antagonist over small intestine and liver together with its effects on bacterial translocation are examined in this study. Forty-eight male Wistar albino rats were assigned into four equal groups of 12. In groups I and II, animals were sham operated. In groups III and IV, common bile duct ligation and division were performed. In group I and group III, 0.5 ml/day normal saline was applied intraperitoneally daily from day 2 to 6 of the study; in group II and group IV, 1 mg/kg/day BN 52021 was applied intraperitoneally daily from day 2 to 6 of the study. All animals were sacrificed on postoperative day 7. ICAM-1 expression (CD54 positivity) was analyzed in the liver and ileum tissue by immunohistochemical method. Samples from blood, liver mesenteric lymph nodes, and spleen were cultured under aerobic conditions. It is revealed that ICAM-1 expression was statistically higher in group III, with highest bacterial translocation and liver and spleen injury when compared to other groups. Serum alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), gamma-glutamyltranspeptidase (GGT), bilirubin, tumor necrosis factor alpha (TNFalpha), and interleukin 1beta(IL-1beta) values were at the highest level in group III, and there was a statistical decrease in group IV compared to group III. The administration of BN52021 in experimental obstructive jaundice is a useful way to reduce liver and intestinal mucosal villi damage by inhibiting bacterial translocation and systemic inflammatory response.