Can supplementation of tryptophan in parenteral nutrition increase melatonin and alleviate inflammatory response?

OBJECTIVE: Endogenous melatonin is produced from tryptophan which is an essential amino acid. Besides its role in the regulation of sleep patterns, melatonin has anti-inflammatory effects. In this case-control study, we aimed to compare tryptophan and melatonin levels and their relationship with the inflammatory response, specifically serum interleukin-1, interleukin-6, and c-reactive protein levels following major abdominal surgery in patients with food restriction and who receive parenteral nutritional therapy. METHODS: We enrolled 40 patients between the ages of 18 and 65 years in the study. We collected blood and urine samples 48 h before the operation and on postoperative days 1, 3, and 5. RESULTS AND CONCLUSION: The tryptophan levels in the experimental group were higher than in the control group but failed to reach any statistical difference. Melatonin levels were increased in both groups following the surgery compared with preoperative levels. The increase in the experimental group was statistically different 3 days after the surgery. The difference in the level of interleukin-1 between the control and the experimental groups was greatest on postoperative day 3. On postoperative day 3, the interleukin-6 level in the treatment group was slightly higher than in the control group. We did not find any difference in the levels of c-reactive protein between the groups. As a result, the levels of tryptophan and melatonin were increased in the parenteral nutrition group, irrespective of the postoperative inflammatory response.

Can 3D radiological calculations predict operational difficulties for rectal cancer?: A single center retrospective analysis.

Low anterior resection, performing total mesorectal excision with appropriate pelvic dissection to prevent local recurrence, is probably the most challenging type of surgery in colorectal surgery, especially in a narrow pelvis. In this study, we aimed to predict the operation difficulty of rectal cancer by comparing the operation time with 2D and 3D pelvimetry. Sixty-six patients who underwent total mesorectal excision after neoadjuvant chemoradiotherapy due to primary rectal cancer located in the middle and lower rectum (10 cm from the anus) were included in the study. Surgery notes were reviewed and data on demographic factors, tumor stage, duration of surgery, and types of surgery were collected, as well as pelvimetric parameters. All protocols had 2D T2-weighted sequences in 3 planes (axial, sagittal, and coronal). Pelvimetric measurements were made by measuring 8 pelvic lengths and 2 angles. Pelvis and tumor volume were measured by manual margin monitoring. In each slice, both pelvis and tumor boundaries were manually drawn individually in the sagittal plane. Pelvis and tumor volumes were calculated from the set of adjacent images by summing slice thickness and products of area measurements within the pelvis and tumor boundaries. In our results, no correlation was observed with operation time, including pelvic volume. Exception for this were interacetabular distance and tumor volume. In the regression test, the only parameter that correlated with the operation time was tumor volume. In conclusion, we believe that tumor volumetric calculations may be useful in predicting difficult distal rectal carcinoma surgeries.

Acute appendicitis during coronavirus disease 2019 in Türkiye: Changes in clinical approach, treatment, and diagnosis modalities: A retrospective and cohort study.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) has resulted in major changes in health-care systems and emer-gency surgical interventions. Here, we examined patients with acute appendicitis who presented to emergency departments and com-pared diagnosis, treatment, and post-treatment processes before and during the pandemic period and investigated how the pandemic affected management of acute appendicitis. METHODS: A national, multicenter, and cohort study model was designed that included patients older than 18 years of age diag-nosed with acute appendicitis clinically and/or radiologically, with patients compared before (pre-pandemic period: January 1-April 30, 2019) and after (pandemic period: January 1-April 30, 2020) the pandemic. Our investigation included comparisons of pre-operative imaging methods, presence of plastron appendicitis/abscess, conservative/surgical approach, type of anesthesia given, laparoscopic/open surgical approach, bowel resection rates, drain insertion rates, and presence of post-operative complications RESULTS: For the two study groups, 8972 patients from 69 centers were examined, with 4582 patients operated in the pre-pan-demic period and 4234 patients operated in the pandemic period. During the pandemic period, 63.6% of patients underwent open surgery, whereas 34.4% had laparoscopic surgery. Although 60 patients (1.3%) requested non-operative follow-up in the pre-pandemic period, 94 patients (2.2%) requested this in the pandemic period. When conditions of patients were evaluated regardless of their own wishes, 114 patients (2.4%) before and 163 patients (3.8%) during the pandemic received non-operative follow-up. CONCLUSION: Our study did not show the direct correlation between the application of COVID-19-related restrictions and the severity of acute appendicitis. Although non-operative management rates have been increased during the COVID-19 period, the incidences of both complicated and the uncomplicated appendicitis were similar during the COVID-19 crisis period. Given this infor-mation non-operative management can be employed for patients diagnosed with appendicitis.

Are the conventional scoring systems efficient in predicting mortality of acute mesenteric ischemia?: Mortality estimation in patients with AMI.

Acute mesenteric ischemia is a surgical emergency with high morbidity and mortality rates. Therefore, it is important to determine the prognosis for this disease. In the present study, we aimed to compare the prediction accuracy of 3 scoring systems: Acute physiology and chronic health evaluation II, sequential organ failure assessment score and simplified acute physiology score II (SAPS II). The retrospective cohort study was conducted in a university hospital. Eighty-two acute mesenteric ischemia patients were evaluated retrospectively. The mortality prediction abilities of the scoring systems were evaluated by comparing the prediction rates of > 10%, 30% and 50% and the actual mortality among survivors and non-survivors in pairs. Predicted mortality rates among survivors and non-survivors differed among the 3 classification systems. The mortality estimates of the SAPS II were closer to the actual mortality rates. Analysis of the estimated mortality rates as mortality risk limits showed that acute physiology and chronic health evaluation II was superior to sequential organ failure assessment score and SAPS II in estimating mortality rates, whereas SAPS II was more successful in detecting survivors. The estimated mortality rates of the 3 rating systems, the estimated mortality rates were higher in the non-survivor group than in the survivor group. The accuracy of the SAPS II in determining prognosis was relatively better.

The role of anakinra in the modulation of intestinal cell apoptosis and inflammatory response during ischemia/reperfusion

Background/aim: Even though interleukin-1 receptor antagonist, IL-1Ra, is used in certain inflammatory diseases, its effect on ischemia-reperfusion injury is a current research topic. We aimed to investigate the protective effects of anakinra, an IL-1Ra, on the I/R induced intestinal injury. Materials and methods: The rat model of intestinal ischemia-reperfusion was induced. Rats were randomized into 4 groups: (group 1) control group, (group 2) I/R group, (group 3 and 4) treatment groups (50 mg/kg and 100 mg/kg, respectively). Gene expressions of caspase-3, TNF-α, IL-1α, IL-6, and apoptotic cells in tissue samples were evaluated by PCR and TUNEL methods, respectively. Plasma levels of superoxide dismutase (SOD), catalase (CAT), and malondialdehyde (MDA) were studied by the ELISA method and tissue samples were examined histopathologically as well. Results: Anakinra inhibited the expression of IL-1α, IL-6, and TNF-α and decreased the SOD, CAT, and MDA caused by ischemia- reperfusion injury in both treatment groups. Caspase-3 expression and TUNEL-positive cell number in treatment groups were also less. Histopathologically, anakinra better preserved the villous structure of the small intestine at a dose of 100 mg/kg than 50 mg/kg. Conclusion: Anakinra decreased the intestinal damage caused by ischemia-reperfusion and a dose of 100 mg/kg was found to be histopathologically more effective.

Pancreatic extragastrointestinal stromal tumor invading the duodenum.

Extragastrointestinal stromal tumors that arise in the pancreas are extremely rare and managing them can be difficult, particularly if located in the head of pancreas. This case report aims to contribute to the existing data in the literature regarding extragastrointestinal stromal tumors with rare and unusual locations. We present a 56-year-old man who presented with recurrent mild right upper quadrant abdominal pain. Abdominal computed tomography and magnetic resonance imaging revealed a mass lesion with a diameter of 10 cm localized in the head of pancreas. Pancreaticoduodenectomy with complete tumor excision was performed. He was discharged on the postoperative day 14. Only 15 extragastrointestinal stromal tumors cases have been reported. Of these 15 cases, tumors were located in the head of pancreas in six cases. Here we report the seventh case of pancreatic extragastrointestinal stromal tumor arising in the head of pancreas and also the largest of these seven tumors.

High nucleostemin expression has a favorable prognostic effect on gastric carcinomas

Background/aim: Nucleostemin is a nuclear protein that maintains stem cell features and plays a role as a cell proliferation marker. It also participates in cell cycle regulation by interfering with other intracellular proteins. Recent reports have indicated that this protein plays a role in ribosomal biogenesis and genome protection. High expression level of nucleostemin has been reported in some cancer patients. However, the importance of nucleostemin in gastric cancer needs to be addressed. The aim of this study was to investigate nucleostemin expression in gastric cancer and the effects of this expression on prognosis. Materials and methods: Nucleostemin expression was assessed in 103 patients with gastric carcinomas via immunohistochemistry. Subsequently, relationships between nucleostemin expression and clinicopathological features and prognosis were evaluated. Results: In this study, there were 33 and 70 cases involving high and low nucleostemin expression, respectively. Nucleostemin expression was negatively correlated with lymphovascular invasion, the number of metastatic lymph nodes, extracapsular extension, and T stage. Disease-free survival and overall survival were markedly longer in patients with high nucleostemin expression. Conclusion: We suggest that nucleostemin is a favorable prognostic marker for gastric cancer patients. Our results are in conflict with prior studies. The prognostic effect of nucleostemin in gastric cancer remains to be solved.

Effects of melatonin on colonic anastomosis healing following chemotherapy in rats.

INTRODUCTION: This study aimed to investigate the effects of melatonin on the healing of colon anastomosis following chemotherapy. METHODS: 32 rats were randomised into four groups: (a) control group, which underwent sigmoid colon transection and primary anastomosis; (b) melatonin group, which received melatonin daily following anastomosis; (c) 5-fluorouracil (5-FU) group, which received 5-FU for five days prior to anastomosis; and (d) 5-FU+melatonin group, which received 5-FU for five days prior to anastomosis and melatonin daily following anastomosis. The rats were sacrificed on Postoperative Day 7 and anastomotic bursting pressures were measured. The anastomotic segment was extracted for hydroxyproline, luminol and lucigenin measurement and histopathological examination. Blood samples were obtained from the vena cava for measurement of tumour necrosis factor-alpha (TNF-α) and interleukin-1 beta (IL-1ß) plasma levels. RESULTS: Compared to the 5-FU group, bursting pressures of anastomosis and hydroxyproline levels were significantly higher, while luminol and lucigenin levels were significantly lower, in the control and 5-FU+melatonin groups. In addition, TNF-α and IL-1ß plasma levels were significantly lower in the control and 5-FU+melatonin groups than in the 5-FU group. Histopathological examination showed a significant decrease in inflammation and necrosis formation in the melatonin group when compared to the control group. The positive effect of melatonin was also seen in the rats that received 5-FU. CONCLUSION: Our study results showed that the adverse effects of chemotherapy on the mechanical, biochemical and histopathological parameters of anastomosis healing were attenuated through melatonin treatment.

Preoperative immunonutrition regulates tumor infiltrative lymphocytes and increases tumor angiogenesis in gastric cancer patients.

INTRODUCTION: An increased number of tumor infiltrative lymphocytes (TILs) is considered a favorable prognostic factor in various cancers because it is a marker of antitumoral activity of the immune system. In this prospective, non-randomized clinical trial, we evaluated the impact of preoperative immunonutrition on tumor infiltrative lymphocytes and neoangiogenesis in cancerous tissue in patients with locoregional and resectable gastric adenocarcinoma. MATERIAL AND METHODS: Patients with locoregional and resectable gastric adenocarcinoma were divided non-randomly into two study groups. The first (control) group included patients who had standard nutrition, and the second group included those who had immunonutrition for 7 days before surgery. The biopsy samples taken endoscopically in the preoperative period, as well as the gastrectomy samples, were subjected to immunohistochemical staining for quantitative analysis of CD4, CD8, CD16, CD56, CD31 and CD105 antibodies. Main outcome measures were CD4-to-CD8 ratio and CD105 levels. RESULTS: Fifty patients were included in the study between January 2013 and December 2014. Twenty-five patients were assigned to each of the first and second group. The CD4-to-CD8 ratio and CD105 levels determined in endoscopic biopsy samples were similar in both groups. The CD4-to-CD8 ratio in gastrectomy samples was significantly higher in the first group (p = 0.0001). The CD105 levels in gastrectomy samples were significantly lower in the first group (p = 0.01). CONCLUSIONS: Seven-day preoperative immunonutrition use regulates TILs in gastric cancer patients, but prolonged use increases tumor angiogenesis.

Can we predict mortality in patients with necrotizing fasciitis using conventional scoring systems?

BACKGROUND: This study compared the predictive accuracy of four scoring systems, namely Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score II (SAPS II), and Mortality in Emergency Department (MEDS), for estimating prognosis in patients with necrotizing fasciitis. METHODS: Seventy-four patients who presented with necrotizing fasciitis were retrospectively examined. The ability of the scoring systems to predict mortality was assessed by comparing the estimated mortality rates in mortality groups (survivors/non-survivors), and mortality rates among survivors and non-survivors with an estimated mortality of >10%, 30%, and 50% in the scoring systems were compared in pairs. RESULTS: Estimated mortality rates in the survivor and non-survivor groups were different for all the scoring systems. The estimated mortality rates of APACHE II and SAPS II were much closer to the actual mortality rates than the other two scoring systems. When the predicted mortality rates were analyzed as limits for a mortality risk, the predicted mortality rate by APACHE II was superior to that by SAPS II. CONCLUSION: The studied scoring systems had significantly higher predicted mortality rates in non-survivors than in survivors; however, they all underestimated the mortality rate. APACHE II and SAPS II were relatively superior for estimating mortality in patients with necrotizing fasciitis. APACHE II rather than the other scoring systems should be currently used.

Effects of Sleep Quality on Melatonin Levels and Inflammatory Response after Major Abdominal Surgery in an Intensive Care Unit.

Disruption of nocturnal sleep in an intensive care unit may remarkably affect production of melatonin, which is also known to have anti-inflammatory properties. In the present study, we aimed to investigate the effect of sleep quality on melatonin levels and inflammation after surgery. Thus, we compared the patients, who were screened in the side-rooms where the lights were dimmed and noise levels were reduced, with the patients who received usual care. Preoperative and postoperative urine 6-sulphatoxymelatonin, serum interleukin-1 (IL-1), interleukin-6 (IL-6), and c-reactive protein (CRP) levels were measured and data on sleep quality was collected using the Richards-Campbell Sleep Questionnaire. Postoperative CRP and IL-6 levels were greater in the control group than in the experimental group, whereas postoperative 24 h melatonin levels were greater than preoperative levels and the difference was steeper in the experimental group in concordance with sleep quality scores. Thus, the regulation of light and noise in ICUs may help the recovery after major surgeries in patients, potentially by increasing melatonin production, which has anti-inflammatory properties.

Evaluating the Use of Hematological Parameters in Staging Hidradenitis Suppurativa.

INTRODUCTION: Recently, it has been shown that hematological parameters may be used as markers of inflammatory response. In this study, the authors aimed to identify the potential roles of the neutrophil-lymphocyte ratio (NLR) and other hematological markers in the evaluation of hidradenitis suppurativa (HS), a chronic, recurrent inflammatory disease. MATERIALS AND METHODS: A total of 35 patients, diagnosed with HS between January 1, 2012 and December 31, 2014, were categorized into 3 groups according to the Hurley staging system. The basic patient demographics, the anatomic regions involved, and the hematological parameters including NLRs were evaluated in the present retrospective chart review. RESULTS: Hemoglobin, mean corpuscular volume, and mean corpuscular hemoglobin levels were greater in stage I than stage III, while hematocrit, red cell distribution width (RDW), mean platelet volume, mean corpuscular hemoglobin concentration levels, and platelet counts did not differ between the stages. White blood cell and neu- trophil counts were higher in stage III than stage II, while lympho- cyte counts were lower in stage III than stage II. The NLR of stage I was detected as being significantly higher than stage II and lower than stage III. CONCLUSION: The present study shows hematological markers, and NLR in particular may be related to the severity of HS. Further studies are required to demonstrate the significance of NLR in the evaluation of HS.

In vitro effects of rabeprazole on human pylorus tone.

BACKGROUND/AIMS: It has been reported that proton pump inhibitors induce relaxation in different types of smooth muscles. The aim of this study is to investigate in vitro effects of proton pump inhibitors on human pylorus muscle. METHODS: Pyloric sphincters were studied in 10 patients who were operated for stomach cancer. In isolated organ bath, control and re-sponse to rabeprazole were recorded following contraction with carbachol. During the treatment experiment, while distilled wa-ter was applied during the control experiment in every 5 minutes, rabeprazole was administered in every 5 minutes at doses of 10(-6), 10(-5), 10(-4), and 10(-3) M respectively. Contraction frequencies, maximum contraction values and muscle tones were measured. RESULTS: The contraction frequencies in the control group were greater than the rabeprazole group in the second, third and fourth in-tervals while the maximum contraction values in the rabeprazole group were lower in the fourth interval. Even though muscles tones were not different in both groups during all intervals, it was remarkable that the muscle tone was significantly decreased in the rabeprazole group during the fourth interval compared to the first and second intervals. CONCLUSIONS: In the present study, high doses of rabeprazole reduced contraction frequencies, maximum contraction values, and muscle tone of human pylorus.

The effect of rabeprazole on LES tone in experimental rat model.

INTRODUCTION: Despite adequate treatment with proton pump inhibitors (PPIs), symptoms of gastroesophageal reflux disease (GERD) may remain persistent as well as Barrett's esophagus may emerge. It may be proposed that the relaxant effect of PPIs on the smooth muscles may lead to resistance of symptoms. The aim of this study is to investigate effects of rabeprazole on the lower esophageal sphincter (LES) pressure with a rat model. MATERIALS AND METHODS: Sixteen rats were grouped as control and treatment groups. After obtaining LES tissues followed by a 60 min equilibration period for stabilization, contractile response to carbachol was obtained by application of single dose of carbachol to have a final concentration of 10(-6) M in the organ bath. After the contractions reached a plateau, concentration-response relationships for rabeprazole were obtained in a cumulative manner in the treatment group. RESULTS: In the carbachol contracted LES preparations; 1.5 × 10(-6) and 1.5×10(-5) M of rabeprazole caused 6.08% and 11.34% relaxations respectively which were not statistically significant. However, mean integral relaxation value for 4.5 × 10(-5) M of rabeprazole was 17.34% and this relaxation was significant compared with controls. CONCLUSIONS: In the present study, rabeprazole caused no direct significant change in LES tone in the therapeutic dose range applied to the organ bath. However, rabeprazole at the high dose caused a significant decrease in the LES tone.

Pneumomediastinum and subcutaneous emphysema caused by sigmoid diverticulum perforation secondary to blunt abdominal trauma: report of a case.

Pneumomediastinum and subcutaneous emphysema are very rare reported signs of colonic perforation most often associated with diverticulitis, toxic megacolon and colonoscopy. We report a case of a 60-year-old man with subcutaneous emphysema and pneumomediastinum, which developed three days after a car accident without pneumothorax. A computed tomography scan demonstrated perforation of a sigmoid diverticulum in conjunction with air. A laparotomy was performed and revealed a perforated sigmoid diverticulum, fistulized into the retroperitoneal cavity. We suspect that this diverticular perforation was caused by the deterioration of the sigmoid mesocolon secondary to the blunt abdominal trauma. To our knowledge, this is the first report in the literature about pneumomediastinum and subcutaneous emphysema caused by sigmoid diverticular rupture following mesosigmoid trauma.

Colonic perforation during barium enema in a patient without known colonic disease: a case report.

The barium enema is a safe and accurate diagnostic study of the colon but, in rare cases, causes complications, such as colonic perforation. A colon weakened by iatrogenic trauma due to the enema tip and/or retention balloon, or by disease is more likely to perforate during an enema than is a normal healthy bowel. Rarely the colon may burst due to excessive transmural pressure alone. We report a case of colonic perforation during barium enema in a 72-year-old female patient, due to excessive barium applied into the rectum.

Spontaneous common bile duct perforation due to chronic pancreatitis, presenting as a huge cystic retroperitoneal mass: a case report.

Spontaneous perforation of the bile duct, is a disease in which spontaneous perforation occurs in the wall of the extrahepatic or intrahepatic duct without any traumatic or iatrogenic injury and more often described in neonates. In this report, we present a 38-year-old female patient who underwent surgery due to an intraabdominal cystic mass. The diagnosis of spontaneous rupture of the common bile duct and huge retroperitoneal biloma was made by intraoperative abdominal exploration. The biloma was drained, ruptured portion of the common bile duct was primarily repaired over a T-tube.