Factors influencing cost, length of hospital stay and mortality in colorectal cancer.

PURPOSE: Colorectal cancers (CRCs) are the most common cancers in the world after lung and prostate cancer in men and breast and lung cancer in women, and usually occur in the recto-sigmoid region. There are many factors that affect their morbidity and mortality. Some markers have been evaluated to predict disease prognosis. However, a gold standard prognostic biomarker has not yet been found for CRC. In the present study, we aimed to evaluate the factors associated with the duration and cost of hospital stay and mortality. METHODS: Patients who were admitted to the emergency service and general surgery clinic with abdominal pain, rectal bleeding, weight loss, diminished stool discharge, and ileus were included in this study. Recorded were patient age, gender, comorbid factors, family history, surgical treatment procedure, elective or urgent surgical intervention, bowel cleansing before surgery, pathological stage, neutrophil/lymphocyte ratio (NLR), red cell distribution width (RDW), mean platelet volume (MPV) and CEA, CA 19.9 and hemoglobin levels. RESULTS: The mean patient age was 61.2±12.4 years. The male/female ratio was 0.596(81/136). Emergency surgery was an independent factor increasing the cost and length of hospital stay (p=0.007 and p=0.018). Additionally, patients >65 years of age had increased length of hospital stay and mortality (p=0.008 and p=0.024, respectively). Anemic patients had 50% higher mortality risk compared with patients with normal hemoglobin levels (p=0.030). CONCLUSION: Based on our results, anemic patients in the geriatric population who underwent emergency CRC surgery may have higher costs, longer hospital stay and greater mortality rates than other CRC patients.

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.

Peptic ulcer complications requiring surgery: what has changed in the last 50 years in Turkey.

BACKGROUND/AIMS: The incidence and prevalence of peptic ulcer disease has decreased in recent years, but it is not so easy to make the same conclusion when complications of peptic ulcer are taken into consideration. The aim of this study is to determine the time trends in complicated peptic ulcer disease and to state the effects of H2 receptor blockers, proton pump inhibitors (PPI), and H. pylori eradication therapies on these complications. MATERIALS AND METHODS: This study retrospectively evaluated the patients who were operated on for complications (perforation, bleeding, and obstruction) of peptic ulcer for the last 50 years. Patients were grouped into four groups (G1-G4) according to the dates in which H2 receptor blockers, PPIs, and eradication regimens for H. pylori were introduced The time periods that were studied were: (G1) 1962-1980, (G2) 1981-1990, (G3) 1991-1997, and (G4) 1998-2012. RESULTS: In total, 2953 patients were operated on for complications of peptic ulcer disease, of which 86% of the patients were male. In G1, perforation and obstruction were significantly the most frequent complications (p<0.001), followed by bleeding. In groups G2 and G3, obstruction was still the most frequent complication requiring surgery (p<0.001). In G2 and G3, obstruction was followed by perforation and bleeding, respectively. In G4, perforation was significantly the most frequent complication (p<0.001). CONCLUSION: From 1962 to 1990 obstruction was the most common complication requiring surgery. In the last decade, perforation became the most common complication. In contrast to reports in the literature, bleeding was the least common complication requiring surgery in Turkey.

Are neutrophil-lymphocyte ratio and platelet-lymphocyte ratio as effective as Fournier's gangrene severity index for predicting the number of debridements in Fourner's gangrene?

BACKGROUND: Fournier's gangrene (FG) is a rapidly progressive and necrotizing infection of the subcutaneous and fascial tissues with a high mortality rate. In the present study, we aimed to investigate prognostic factors and analyze the outcomes of 68 patients in a tertiary reference hospital. METHODS: Patients admitted to the emergency department were investigated retrospectively between January 2006 and January 2013 and divided into two groups. The patients in Group I (G1) required one debridement, and Group II (G2) patients required more than one. Patient demographic and clinical characteristics were encoded. Fournier's Gangrene Severity Index (FGSI) scores, neutrophil-lymphocyte ratios (NLR), and platelet-lymphocyte ratios (PLR) were calculated. Prognostic factors were compared between the groups. RESULTS: There were no statistically significant differences between the groups in terms of mean age, female-male ratio, or duration of symptoms on admission; however, there were more infection sources, predisposal factors, and positive culture results in G2. Additionally, hospital stay, total cost, and mortality rate values were high in G2. We found statistically higher NLR and PLR ratios in G2, but there was no significant difference in FGSI scores between the groups. CONCLUSION: The FGSI scoring system was not found to be valuable in determining prognosis. However, NLR and PLR were valuable, and previous use of NLR and PLR for determining Fournier's gangrene prognosis could not be found in the English literature.

Neutrophil-to-lymphocyte ratio as a predictor of acute appendicitis.

BACKGROUND: Accurately diagnosing appendicitis can be difficult. This retrospective study aimed to evaluate the ability of the neutrophil-to-lymphocyte ratio (NLR) to predict acute appendicitis pre-operatively and to differentiate between simple and complicated appendicitis. METHODS: A database of 1067 patients who underwent surgery was evaluated. Based on postoperative histopathological examination, the patients were divided into two groups: acute appendicitis (G1) and normal appendix (G2). Patients in the acute appendicitis group were further divided into two subgroups: simple appendicitis (G1a) and complicated (gangrenous and perforated) appendicitis (G1b). RESULTS: G1 included 897 patients and G2 included 170 patients. Among the 897 G1 patients, there were 753 G1a patients and 144 G1b patients. A NLR of 4.68 was associated with acute appendicitis (G1 vs G2, p<0.001). The sensitivity and specificity were 65.3% and 54.7%, respectively. A NLR of 5.74 was associated with complicated appendicitis (G1a vs G1b, p<0.001). The sensitivity and specificity of the two clinical features were 70.8% and 48.5%, respectively. CONCLUSION: We suggest that preoperative NLR is a useful parameter to aid in the diagnosis of acute appendicitis and differentiate between simple and complicated appendicitis, and can be used as an adjunct to the clinical examination.

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.

Neutrophil-lymphocyte ratio as a predictive factor for tumor staging in colorectal cancer.

BACKGROUND/AIM: In the preoperative period, simple methods to identify the tumor stage of colorectal cancer patients are needed. In recent years, the neutrophil-lymphocyte ratio (NLR) has been used as a predictive parameter for systemic inflammatory response in many different clinical entities. This study aims to determine if the NLR predicts the tumor stage in colorectal cancer patients in the preoperative period. MATERIALS AND METHODS: A total of 206 patients diagnosed with colorectal cancer and admitted for surgical treatment over a 6-year period were identified from a retrospectively maintained database. NLR was calculated from preoperative full blood counts. NLRs were compared with the tumor stages as determined in histopathological reports and scanning tests to determine the extent of metastasis. RESULTS: We found NLRs to be statistically higher in patients with T3 and T4 tumors than in patients with T1 and T2 tumors (mean: 5.261 vs. 4.499, respectively, P = 0.010). Similarly, we found statistically higher NLR values in the N1 and N2 groups than in the NO group (mean: 6.597 vs. 4.501, respectively, P < 0.001). Additionally, NLRs were statistically higher in M1 patients than in MO patients (mean: 8.261 vs. 5.158, respectively, P = 0.004). CONCLUSION: In the preoperative period, NLR was found to be a valuable predictive parameter for tumor staging in patients with colorectal cancer, thus informing us as to the kind of tumor we will meet when we open the abdomen.

Comparison of 3D imaging and 2D imaging for performance time of laparoscopic cholecystectomy.

OBJECTIVE: The aim of this study is to evaluate the effect of the Viking 3-dimensional (3D) system on performance time of laparoscopic cholecystectomy. METHODS: Twenty-two patients were included in the study. The groups were standardized using a multiparameters filter (MPF) depending on preoperative ultrasonography and perioperative exploration findings. The 11 patients operated with the Viking 3D system (group A) were compared with 11 patients operated with the Olympus 2D/HD system (group B). RESULTS: The mean performance time was 20.63 ± 5.66 and 30.0 ± 6.03 minutes in the group A (3D) and group B (2D), respectively (P<0.01). CONCLUSIONS: The 3D imaging systems may cause a significant reduction in the performance time of laparoscopic cholecystectomy.

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.

The association between thyroid malignancy and chronic lymphocytic thyroiditis: should it alter the surgical approach?

BACKGROUND: The relation between thyroid neoplasms and chronic lymphocytic thyroiditis (CLT) is controversial. While it is accepted that focal lymphocytic thyroiditis develops secondarily to malignancy, it is not clear whether diffuse lymphocytic thyroiditis has a tendency to develop into thyroid cancer. The aim of this study was to investigate the relation between CLT and malignant tumours of the thyroid and evaluate the surgical approach to CLT cases. MATERIAL AND METHODS: In this study, 917 patients operated on for thyroid diseases were investigated retrospectively. Seventy-seven (8.4%) patients histopathologically diagnosed as having CLT (either non-specific or Hashimoto's thyroiditis) were investigated for any concurrent malignant neoplasm. Fifteen patients in whom CLT and thyroid malignancy were coexisting were included in the study. RESULTS: In the pathological evaluation of 917 cases, malignancy in the thyroid was found in 97 (10.6%) cases. Seventy-seven cases were categorised as CLT. Of these 77, 16 (20.8%) were Hashimoto's thyroiditis (specific CLT) and the other 61 (79.2%) were non-specific CLT. In 15 cases, thyroid malignancy was found to be concurrent with CLT. Of the malignities, nine (60%) were papillary carcinoma, three (20%) medullar carcinoma, one (6.6%) follicular carcinoma, one (6.6%) Hurthle cell carcinoma, and one (6.6%) lymphoma. In our series, the rate of the development of malignancy against the background of CLT was 19.48%, while the rate in the groups without CLT was 9.76%, with a statistically significant difference between the groups (p = 0.008). CONCLUSIONS: CLT cases should be evaluated more carefully in terms of malignancy. If a nodule is detected on thyroiditis, the minimal surgical intervention should be lobectomy. Total thyroidectomy should be considered as preferable to subtotal thyroidectomy because of its many advantages such as controlling thyroiditis, removing the probability of reoperation, and hormonal stability.

Sexual dysfunction after curative radical resection of rectal cancer in men: the role of extended systematic lymph-node dissection.

BACKGROUND: This study was designed to determine the incidence and patterns of sexual dysfunction after curative radical resections (CRR) with or without extended systematic lymph-node dissection (ESLND) for rectal cancer Material/Methods: A total of 91 patients with rectal cancer were reviewed with respect to surgical procedures and postoperative sexual functions using the International Index of Erectile Function (IIEF), a 15-item self-administered questionnaire. CCR (abdomino-perineal resections or sphincter-saving anterior resections) was performed in 78 patients (Group I) and ESLND plus CRR in 13 patients (Group II), and sexual functions were also evaluated in the colostomy and non-colostomy subgroups. RESULTS: In the postoperative period, the five domains of IIEF scoring decreased significantly from the preoperative scores in both groups (p<0.05), but the postoperative decreases were not significant between groups I and II (p>0.05). Having a permanent colostomy decreases IIEF scores in all colostomized patients. CONCLUSIONS: CRR and CRR+ESLND both decrease sexual function and lymph-node dissection is not considered to have any additive effect on this decrease. In addition to standard surgery, anxiety about having a malignant disease and permanent colostomy may play an important role in male sexual dysfunction.

Local recurrence and survival rates after extended systematic lymph-node dissection for surgical treatment of rectal cancer.

BACKGROUND/AIMS: Extended systematic lymph-node dissection (ESLND) is a surgical procedure aimed at decreasing the local recurrence rate of rectal cancer and increasing the survival rate. However, it is criticized because it has not shown the expected effects on survival, and it has been shown to increase the proportion of complications in rectal cancer surgery. This study was designed to determine incidence and patterns of recurrence after curative resection with or without ESLND for rectal cancer. METHODOLOGY: A total of 184 patients with rectal cancer were reviewed with respect to surgical procedures, local recurrence and survival rates. RESULTS: 170 of 184 patients with rectal cancer were administered curative surgical resection. ESLND was added to the surgical procedure of 24 of these 170 patients. The local recurrence rate of the patients who did not receive lymph-node dissection was 15%, and the survival rate over 5 years was 58.9%. The local recurrence rate of the patients receiving ESLND was 12.5%, and the survival rate over 5 years was found to be 55.7% (p>0.05). CONCLUSIONS: Because ESLND is a procedure added on to curative resection in the surgical treatment of rectal cancer, it increases the general anesthesia and length of surgery, and it is possible that some complications due to the operation itself may arise. In the current study and in a large amount of research in the literature, a statistically significant effect on the survival rate has not been found. In conclusion, the opinion has been reached that ESLND does not have an important benefit in the curative surgical treatment of rectal cancer.