Accuracy of the ACS NSQIP Surgical Risk Calculator for Predicting Postoperative Complications in Gastric Cancer Following Open Gastrectomy.

INTRODUCTION: The prediction of complications before gastric surgery is of utmost importance in shared decision making and proper counseling of the patient in order to minimize postoperative complications. Our aim was to evaluate the predictive validity of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator in gastric cancer patients who underwent gastrectomy. METHODS: Preoperative assessment data of 432 patients were retrospectively reviewed and manually entered into the calculator. The accuracy of the calculator was evaluated using Pearson's chi-squared test, C-statistic, Brier score, and Hosmer-Lemeshow test. RESULTS: The lowest Brier scores were observed in urinary tract infection, renal failure, venous thromboembolism, pneumonia, and cardiac complications. Best results were obtained for predicting sepsis, discharge to rehabilitation facility, and death (low Brier scores, C-statistic >.7, and Hosmer-Lemeshow P > .05). CONCLUSION: The calculator had a strong performance in predicting sepsis, discharge to the rehabilitation facility, and death. However, it performed poor in predicting the most commonly observed events (any or serious complication and surgical site infection).

Rare case of bilateral incarcerated obturator hernia: a case report.

Here, we report the case of an 84-year-old woman with acute mechanical intestinal obstruction (AMIO) who was admitted to our Emergency Department. Computed tomography (CT) scan revealed an incarcerated bilateral obturator hernia, and the defect was resolved using transabdominal preperitoneal (TAPP) technique with polypropylene mesh. The patient was administered an oral regimen two days after the operation. The patient stayed in the intensive care unit for 4 days and was uneventfully discharged on the 9th postoperative day. Follow-up was scheduled at the 6th month, during which no adverse events were detected and the patient did not report any complaints. Obturator hernia is among the differential diagnoses of intestinal obstruction requiring early diagnosis and prompt surgical intervention. Laparoscopic approach is less invasive compared with open surgery, and it can be attempted in cases presenting with no sign of ischemia or peritonitis. TAPP technique should be preferred since it allows the control of all intraabdominal pathologies and the viability of the intestines.

Predicting Value of Serum Procalcitonin, C-Reactive Protein, Drain Fluid Culture, Drain Fluid Interleukin-6, and Tumor Necrosis Factor-α Levels in Anastomotic Leakage after Rectal Resection.

BACKGROUND: Anastomotic leak is the most dreaded septic complication of colorectal surgical procedures. Death is proportional to the time between occurrence and diagnosis of the leakage. Biomarkers, which may help to predict anastomotic leakage before appearance of its clinical features, may be beneficial in preventing adverse outcomes. This study investigates a biomarker that might be useful to predict rectal anastomotic leakage before its clinical presentation. PATIENTS AND METHODS: Serum procalcitonin and C-reactive protein (CRP) levels, bacterial proliferation, interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) levels of drain fluid were evaluated in 50 consecutive patients who underwent low anterior resection without diverting ostomy for rectal carcinoma. RESULTS: Anastomotic leakage occurred in seven of 50 (14%) patients. Serum CRP and procalcitonin levels at post-operative day three were higher in patients with anastomotic leakage (p = 0.01, p = 0.02 respectively). Drain TNF-α values were increased 63.2% on post-operative day five when compared with post-operative day three in patients with anastomotic leakage, but were decreased in patients without leakage. There was no statistical difference for drain IL-6 levels between groups. The bacterial proliferation rate of drain fluid culture in the leakage group was 42.9% at post-operative day three and 85.7% at post-operative day five (p = 0.29 and p = 0.0001, respectively). CONCLUSIONS: High serum CRP and procalcitonin values on post-operative day three are alarming, and assessment of anastomotic leakage by abdominal imaging with rectal contrast is suggested. In addition, increasing levels of TNF-α and bacterial proliferation in drain fluid are predictive, whereas IL-6 is not.

Extended pancreaticoduodenectomy for a huge cystic-cavernous lymphangioma: a case report.

CONTEXT: Cystic-cavernous lymphangioma is a rare cystic tumor especially for adults and pancreas. CASE REPORT: We reported a case of a 33-year-old woman who presented with a visible and palpable abdominal mass found to be a huge lymphangioma of the pancreas. An abdominal magnetic resonance imaging (MRI) showed a multiloculated, lobulated T1 hypo/hyper, T2 hyperintense cystic mass extending from right subhepatic space to the pelvis measuring 155x167x100 mm. A pancreaticoduodenectomy was performed encompassing the distal stomach and a segment of the transverse colon, because of their close, inseparable relationship to the mass. The cystic mass was histopathologically diagnosed as partly cavernous and partly cystic lymphangioma. CONCLUSION: To our knowledge this is the first case of pancreatic lymphangioma requiring additional organ resection besides a standard pancreaticoduodenectomy. To reduce recurrences, we recommend a complete resection for this pathology, even though its benign nature.

Spontaneous intramural hematoma of the small intestine.

BACKGROUND: Spontaneous intramural hematoma of the small intestine is a rare clinical condition that may result in potentially serious complications. The purpose of this study was to present our experience with the diagnosis and management of spontaneous intramural hematoma of the small intestine. METHODS: The medical records of the patients with spontaneous intramural hematoma of the small intestine were retrospectively reviewed. Six patients were included in this study. RESULTS: Anticoagulation therapy and factor VIII deficiency were found to be responsible for the intramural hemorrhage in five patients (83%) and one patient, respectively. Acute abdominal pain followed by nausea and vomiting were the most common presenting symptoms. Abdominal computed tomography scan was diagnostic in five of the six patients. Four patients were followed up with conservative therapy. Surgical intervention was required in two patients due to acute abdomen. All patients were discharged from the hospital uneventfully. CONCLUSION: The patient's medical history, physical examination and radiological evaluation proved adequate for the diagnosis. Conservative therapy provides regression of the hematoma in most patients. Surgery should be reserved only for the complicated cases.

Use of "house" advancement flap in anorectal diseases.

BACKGROUND: A retrospective review of 28 patients who had "house flap" anoplasty was carried out to evaluate the therapeutic effectiveness of the procedure. METHODS: House flap anoplasty was performed at Istanbul University Cerrahpasa Medical School, General Surgery Department, in 28 patients over 4 years. Indications were chronic anal fissure, anal stenosis, high transsphincteric fistula, low rectovaginal fistula, anal neoplasia, and obstetric third-degree perineal tear and incontinence. After rectangular excision of the anal or perianal lesion, the "walls" and "roof" of the house flap were incised to the depth of ischiorectal fat. The "base" of this house-shaped flap was then fixed to the top of the excised area. RESULTS: Median postoperative hospital stay was 4.86 (range = 2-12) days. Postoperative complications included three patients with minimal wound dehiscence and one with rectovaginal fistula recurrence. At a median follow-up of 26.4 (range = 1-46) months, excluding the patient with recurrence, all patients were satisfied with house flap anoplasty. CONCLUSION: House advancement flap anoplasty is a relatively simple procedure, combining the beneficial features of rectangular flaps and V-Y plasties. It can be used in nearly all types of anoderm deficiencies with a high rate of success and patient satisfaction.

Primary umbilical adenocarcinoma: case report and review of the literature.

Primary adenocarcinoma arising at the umbilicus is a very rare condition. The umbilicus has been found to show a wide variety of tumors and is predisposed to metastases from visceral tumors because of its relationships and generous vascular and embryologic connections. Herein, we describe a case of a primary umbilical adenocarcinoma with short time survival related to local recurrence and multiple hepatic metastases 6 months after her surgical treatment.

Passage of "colonic cast" after colorectal surgery: report of four cases and review of the literature.

Anal passage of a full-thickness infarcted colonic segment (so-called "cast") not accompanied by any features of acute peritonitis is a very rare occurrence and may be the main advertising manifestation of acute colonic ischemia. Most of the reported cases of acute colonic ischemia are secondary to abdominal aortic aneurysms and ensuing inferior mesenteric artery thrombosis or to the repair of these aneurysms. The preceding events causing ischemia in other cases are Hartmann reversal, rectal resection and colonic J-pouch construction, and acute pancreatitis. In this article we present our experience on four cases of colonic cast passage, all of which developed subsequent to colorectal resection. Three of these casts are supposed to be mucosal and one is transmural. Generally, surgery is the rule and consists of the resection of the concerned ischemic segment. Every clinician should be aware of this form of presentation of bowel ischemia, not only following aneurysm surgery but also in the postoperative course of colorectal surgery.

Laparoscopic repair of Morgagni hernia.

BACKGROUND: Morgagni hernia is a rare type of diaphragmatic hernia which represents less than 5% of all congenital diaphragmatic hernias. Patients are generally asymptomatic and are diagnosed incidentally. When symptomatic, it generates symptoms due to the compression of thoracic organs or compression of herniated intraabdominal organs. Once diagnosed, the condition requires prompt surgical correction. The defect is repaired either by primary suture or by the use of a prosthetic mesh. In adults, prosthetic mesh repair is preferred. Recently, laparoscopic repair of Morgagni hernia has been introduced and gained wide acceptance. MATERIALS AND METHODS: Between 2002 and 2004, 5 patients with Morgagni hernia were treated laparoscopically at our department. Female/male ratio was 3/2. Mean age was 56 years (range 41 to 69 y). Diagnosis were made by chest x-ray and CT scan. Herniation was on the left in 2 patients, and on the right in 3. The content of hernial sac was transverse colon and stomach. There were 2 separate defects in a patient with left-sided hernia. All cases were laparoscopically treated using prosthetic material. RESULTS: All operations were completed laparoscopically. The postoperative hospital stay was 3 to 5 days with a mean of 4 days. None of the patients developed any complication in the early postoperative period. The mean follow-up period is 7 months (range 3 to 24 mo). All patients are actually in good health and without recurrence. CONCLUSION: Laparoscopic repair of Morgagni hernia is a safe, simple, and reliable procedure which presents all the advantages of the minimally invasive surgery.

Detection of an inguinal ovary at controlled ovarian stimulation that was successfully treated by repositioning.

OBJECTIVE: To report a rare case of an ectopic ovary placed in the inguinal canal that was detected while performing a controlled ovarian hyperstimulation (COH). DESIGN: Case report. SETTING: A university hospital. PATIENT(S): A couple with primary infertility for 4 years was referred to our infertility clinic. The woman's medical history revealed a left inguinal operation at age 7. On vaginal ultrasound, only the right ovary could be seen. An infertility workup conducted for the man revealed teratospermia. The couple was subsequently admitted to the in vitro fertilization (IVF) program. While having a COH, the woman experienced a painful swelling in the inguinal area, and an ovarian image with follicular growth on the left inguinal region was observed with ultrasound. Afterward, surgery was performed, and the ectopic ovary in the left inguinal region was detected. INTERVENTION(S): Detection of an inguinal ovary with a controlled ovarian hyperstimulation procedure and surgical repositioning of the ectopic ovary. MAIN OUTCOME MEASURE(S): Controlled ovarian hyperstimulation, transabdominal ultrasound, transvaginal ultrasound. RESULT(S): The ectopic ovary was successfully repositioned with surgery. CONCLUSION(S): Patients must be closely monitored while performing COH. In patients who do not have a unilateral ovary, a painful inguinal mass should alert the physician to the possible presence of an ectopic ovary in the inguinal canal.

Enteroliths developed in a chronically obstructed afferent loop coexisting with gastric remnant carcinoma: Case report and review of the literature.

A case of gastric remnant carcinoma coexisting with a chronic afferent loop syndrome harboring multiple enteroliths in a grossly dilated and elongated afferent loop is presented herein. The patient had undergone a Polya type antecolic Billroth II reconstruction for a stenosing duodenal ulcer 40 years previously. A concise review of the relevant literature is also presented.

Laparoscopic repair of ventral and incisional hernias: our experience in 150 patients.

BACKGROUND: Incisional hernias develop in 2 to 20% of laparotomy incisions. Approximately 100,000 ventral hernias are operated on each year in the United States. The reported recurrence rates for open repair are 25-52% for primary and 12.5-19% for mesh repair. Compared to the open technique, laparoscopic repair has low rates of complications and recurrence, greater patient acceptance, and shorter hospital stay. MATERIALS AND METHODS: Between April 1999 and April 2004, we treated 150 patients (111 female, 39 male) with ventral and incisional hernias laparoscopically. Data concerning the age and sex of patients, the location, number, and size of fascial defects, the type of hernias and their contents, the size and type of meshes used in repair, operative time, length of hospital stay, and postoperative complications were collected. RESULTS: Of the 150 patients, 92 had incisional hernias and 58 had umbilical hernias. Polypropylene was used in 85 cases, dual mesh in 40 cases, and composite mesh in 25 cases. The mean age of the patients was 56.0 years (range, 33-81 years). Mean operative time was 63 minutes (range, 30-125 minutes). Mean postoperative hospital stay was 2.5 days (range, 1-15 days). The postoperative complication rate was 8.6% (seroma, paralytic ileus, small bowel injury, and suture-site neuralgia). The mean follow-up period was 32 months (range, 4-60 months). There was a 3% recurrence rate. Three subileus cases were detected during follow-up. CONCLUSION: The laparoscopic approach to ventral and incisional hernias is safe, feasible, and a good alternative to the open approach. Our results are comparable with those of other reports in the literature.

Thoracoscopic enucleation of a giant submucosal tumor of the esophagus.

Since the introduction of thoracoscopy in the surgical field, many thoracic interventions have been considered feasible via thoracoscopic route. The authors reported a case of thoracoscopic enucleation of a giant esophageal submucosal tumor (8.5 cm in diameter) situated along the left side of the midesophagus. Histopathologic evaluation revealed a gastrointestinal stromal tumor (GIST). Postoperative period was uneventful and the patient was discharged on the eighth postoperative day. Given the well-known advantages of minimally invasive surgery, we assume that the removal of esophageal submucosal tumors can first be attempted by thoracoscopic approach, even if the tumor is of a big size. In cases of histopathologically unknown tumors preoperatively, definitive examination of the complete specimen provides the basis for further therapeutic decisions.

The effects of the immunomodulators on the colonic anastomosis in an experimental model of intraperitoneal sepsis.

BACKGROUND/AIMS: The present study examined the effects of G-CSF and Levamisole used as immunomodulators on the colonic anastomosis healing in the presence of an intraabdominal infection. METHODOLOGY: 40 male Spraque-Dawley rats were randomly allocated to 4 groups each consisting of 10 animals. Standard colonic anastomosis, peritonitis and colonic anastomosis, peritonitis and colonic anastomosis and G-CSF, peritonitis and colonic anastomosis and Levamisole were applied to groups I, II, III and IV, respectively. The cecum of the rats in groups II, III and IV was ligated and perforated to create an intraabdominal sepsis model. G-CSF 50 microg/kg/day were given subcutaneously to group III and Levamisole 5 mg/kg/day were given perorally to group IV in the postoperative period until sacrifice. The rats were sacrificed on the fourth postoperative day. Bursting pressure and hydroxyproline level measurements of the anastomosis were evaluated. RESULTS: Bursting pressures of all groups were lower than the control group (p<0.001). The mean bursting pressure of group III was significantly higher than group II (p<0.05). The mean level of hydroxyproline in group III was significantly higher than group II (p<0.05) however; overall, it was lower in all groups than the control (p<0.05). CONCLUSIONS: This study demonstrated that intraabdominal sepsis adversely affects healing of colonic anastomosis, and healing of the anastomosis becomes better and the mortality rate decreases by the use of G-CSF.

Percutaneous drainage for treatment of infected pancreatic pseudocysts.

BACKGROUND: Infection of pancreatic pseudocysts is a potentially fatal complication that must be treated immediately. Despite numerous published reports about percutaneous treatment, the effectiveness of percutaneous catheter drainage (PCD) of infected pancreatic pseudocysts is still under discussion. METHODS: In this study, 30 patients (17 women) with 30 infected pancreatic pseudocysts were administered local anesthesia and underwent PCD performed with the use of a single-step trocar technique with computed tomographic guidance. The patients' ages varied from 27 to 74 years (mean age, 45 yr). The etiology was acute pancreatitis in 18 patients, chronic pancreatitis in 11 patients, and surgical trauma in 1 patient. RESULTS: No complications related to the procedure occurred in our series. The success rate was 96% (29 of 30 patients), with no recurrence during follow-up, which ranged from 2 to 58 months (mean follow-up, 27.2 mo). One patient had unsuccessful PCD and was subsequently treated surgically. CONCLUSION: Our findings indicate that PCD is a safe and effective front-line treatment for patients with infected pancreatic pseudocysts.

Laparoscopically treated liver hydatid cysts.

HYPOTHESIS: Laparoscopy is effective and reliable in treating hepatic hydatid disease. DESIGN: Case series of patients with hepatic hydatid disease who underwent laparoscopic treatment within 7 years. SETTING: Department of General Surgery, Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey. PATIENTS: Forty-eight patients with hydatid disease who met our criteria for laparoscopic surgery and were aged 17 years or older. INTERVENTIONS: Cystotomy and partial cystectomy with drainage were performed in 33 patients. Omentoplasty was simultaneously performed in 15 patients to obliterate the cystic cavity. MAIN OUTCOME MEASURES: Clinicopathologic features, morbidity, mortality, operative time, length of hospital stay, conversion to laparotomy, and recurrences were reviewed retrospectively. RESULTS: The mean operative time was 82 minutes (range, 45-170 minutes). The conversion rate to open surgery was 4%. The mean postoperative length of hospital stay was 4.2 days. Morbidity was 6% (3 patients). There was no mortality. The mean follow-up was 34.2 months. No recurrences were observed during this period. CONCLUSIONS: Laparoscopic hepatic hydatid surgery is a safe and effective method in selected patients. Further studies should be encouraged in this field because there is no universally accepted standard technique.