Neutrophil-to-lymphocyte ratio: could it be used in the clinic as prognostic marker for gastrointestinal stromal tumor?

BACKGROUND/AIMS: The association between systemic inflammatory response and tumor biology has been well documented over the last decade. The aim of this study is to investigate the prognostic role of neutrophilto- lymphocyte ratio (NLR) in gastrointestinal stromal tumors (GISTs). METHODOLOGY: A prospectively recorded database of 67 patients who underwent surgical resection for GIST was reviewed. High and low NLR were defined with respect to the sample median, which was 1.92. Demographical, clinicopathological, and surgical characteristics were analyzed as well as disease free survival (DFS) rates according to NLR classification. RESULTS: We observed better disease free survival rates in patients with low NLR compared to patients with high NLR (85.7% and 69%, respectively; p=0.037). Estimated five-year overall and disease free survival rates were 95.1% and 78.7%, respectively. In univariate analysis synchronous sarcomatosis, tumor size, mitotic rate, presence of necrosis, lymph node metastasis, surgical margin status, risk category and NLR were associated with DFS. On multivariate analysis sarcomatosis (HR: 30.455), surgical margin status (HR: 4.228) and necrosis (HR: 4.415) were found as independent prognostic factors for DFS. CONCLUSIONS: NLR can give information about inflammatory status, tumor aggressivity and prognosis in GIST patients. It could be a new prognostic factor for GIST patients.

Surgical management of rectal foreign bodies: A single-center experience.

BACKGROUND: Rectal foreign bodies (RFBs) are one of the rare clinical presentations in colorectal surgical practice, with an increasing incidence over the recent years. Due to the lack of standardized treatment options, the management of RFBs can be chal-lenging. This study aimed to evaluate our diagnostic and therapeutic approach to RFBs and to suggest a management algorithm. METHODS: All patients with RFBs who hospitalized between January 2010 and December 2020 were retrospectively reviewed. Patient demographics, RFB insertion mechanism, inserted objects, diagnostic findings, management, complications, and outcomes were all evaluated. An algorithm for clinical management was developed depending on the center's experience. RESULTS: The cohort consisted of 21 patients, 17 (81%) were males. The median age was 33 years (ranging, 19-71). Sexual prefer-ences were the reason for RFB in 15 (71.4%) patients. In 17 (81%) patients, the RFB size over 10 cm. In 4 (19%) patients, RFBs were removed transanally without anesthesia in the emergency department; in the remaining 17 (81%), they were removed under anesthesia. Among these, RFBs were removed transanally under general anesthesia in 2 (9.5%) patients; with the assistance of a colonoscope under anesthesia in 8 (38%) patients; by milking towards the transanal route during laparotomy in 3 (14.2%) patients; and with the Hartmann procedure without restoration of bowel continuity in 4 (19%) patients. The median hospital stay was 6 days (ranging, 1-34 days). The Clavien-Dindo grade III-IV complication rate was 9.5%, and no post-operative mortality was observed. CONCLUSION: RFBs can usually be successfully removed transanally in the operating room with appropriate anesthetic technique and proper surgical instrument selection.

Unusual case of severe late-onset cytomegalovirus-induced hemorrhagic cystitis and ureteritis in a renal transplant patient.

Cytomegalovirus (CMV) infection is common in solid organ transplant recipients and accounts for the majority of graft compromise. Major risk factors include primary exposure to CMV infection at the time of transplantation and the use of antilymphocyte agents such as OKT3 (the monoclonal antibody muromonab-CD3) and antithymocyte globulin. It most often develops during the first 6 months after transplantation. Although current prophylactic strategies and antiviral agents have led to decreased occurrence of CMV disease in early posttransplant period, the incidence of late-onset CMV disease ranges from 2% to 7% even in the patients receiving prophylaxis with oral ganciclovir. The most common presentation of CMV disease in transplant patients is CMV pneumonitis followed by gastrointestinal disease. Hemorrhagic cystitis is a common complication following hematopoietic stem cell transplantation. The condition is usually due to cyclophosphamide-based myeloablative regimens and infectious agents. Even in these settings, CMV-induced cases occur only sporadically. Ureteritis and hemorrhagic cystitis due to CMV infection after kidney transplantation is reported very rarely on a case basis in the literature so far. We report here a case of late-onset CMV-induced hemorrhagic cystitis and ureteritis presenting with painful macroscopic hematuria and ureteral obstruction after 4 years of renal transplantation. The diagnosis is pathologically confirmed by the demonstration of immunohistochemical staining specific for CMV in a resected ureteral section. We draw attention to this very particular presentation of CMV hemorrhagic cystitis with ureteral obstruction in order to emphasize atypical presentation of tissue-invasive CMV disease far beyond the timetable for posttransplant CMV infection.

Tuberculosis in renal transplant recipients.

BACKGROUND: Renal transplant recipients should be considered at high risk for development of Mycobacterium tuberculosis infection (tuberculosis, TB). TB is relatively more frequent among transplant recipients than general population, depending on its epidemicity in the geographic region. Clinical manifestations in this group of patients may be atypical and deserve aggressive investigations for diagnosis. Tuberculin skin test has several limitations regarding diagnosis in chronic renal failure patients. In this retrospective study, we aimed to explore the prevalence and clinical manifestations of TB in renal transplant patients. MATERIALS AND METHODS: We retrospectively analyzed the data for TB prevalence, clinical presentations, and patient and graft survivals of total 320 pediatric and adult renal transplant recipients in our center between 1992 and 2010. RESULTS: The prevalence of TB was 2.8%. Five patients received kidney from living-donor related and four from cadaveric donors. Cadaveric-donor patients received antithymocyte globulin for induction, and four patients received pulse steroid for acute rejection. The median duration of time between transplantation and TB was 21 (1-150) months, and between induction/pulse therapy and infection was 5 (1-100) months. The immunosuppressive protocols included prednisolone and cyclosporine/rapamycin with or without mycophenolate mofetil/azathioprine. The major symptoms were fever (77%), cough (66%), and abdominal pain (22%). Extrapulmonary TB with intestinal (2/9), pericardial (1/9), lymph node (1/9), and cerebral (1/9) involvements developed in five patients. One patient had both pulmonary and testicular involvements. All patients received quartet of anti-TB therapy for a median duration of 9 months. One patient died at the second month of therapy because of dissemination of TB, and one patient returned to hemodialysis because of chronic allograft nephropathy. CONCLUSION: The prevalence of TB was 2.8% in our renal transplant patients. The quartet of anti-TB treatment including rifampicin resulted in success in a majority of patients.

Results of 4-year analysis of conversion from calcineurin inhibitors to mTOR inhibitors in renal transplant patients: single-center experience.

In this retrospective study, 83 patients were accepted. Mammalian target of rapamycin (mTOR) group consisting of 37 patients were converted from calcineurin inhibitors (CNI), and the control group included 46 patients (initially CNI-receiving patients). As a control-match of each mTOR inhibitor patient, the succeeding patient with transplantation who continued CNI therapy was chosen. All patients received CNI, MMF, and prednisolone as an immunosuppressive therapy initially. In comparison of two groups, there was no significant difference between sex, donor organ source, donor organ ischemia time, or mismatches. However, mean age between groups was significantly different (mTOR group: 48.3 ± 12, CNI group: 38.6 ± 11, p < 0.001). Decision of conversion to mTOR inhibitors in 30 patients was made by biopsy. The reasons for conversion were determined as CNI nephrotoxicity in 15 patients, chronic allograft nephropathy in 15 patients, malignancy in 6 patients, and renal artery stenosis in 1 patient. Basal glomerular filtration rates (GFRs) were markedly lower in mTOR group than in CNI group (38.8 mL/min vs. 72.7 mL/min). At the end of 48-month follow-ups, GFR increased from 38 mL/min to 54 mL/min in mTOR group; however, it decreased to 53 mL/min from 72 mL/min in CNI group. There was no difference left between the two groups in GFR after 4-year follow-up. Hyperlipidemia was higher in mTOR group. Acute rejection rates were similar. Cytomegalovirus (CMV) disease was more prevalent in CNI group. Graft failure developed due to secondary reasons, causing mortality in both groups. We suggest that conversion to mTOR inhibitors maintains and improves graft functions well.

An unusual cause of small bowel perforation: apricot pit.

Ingestion of foreign bodies can be a common problem, especially among children, alcoholics, and psychiatric and senile patients. Foreign bodies with smooth edges usually do not pose significant problems, but a sharp foreign object that is not retrieved immediately may penetrate the wall and cause complications. Ingested foreign bodies usually pass the intestinal tract uneventfully, and perforation occurs in less than 1%. In this study, we report a case of small bowel obstruction with perforation in a 73-year-old female due to the accidental swallowing of an apricot pit.

Carnitine protects the intestine against reperfusion injury in rats.

BACKGROUND: Although the negative effects of ischemia on anastomotic healing have been shown in many studies, there is no adequate information on the effects of reperfusion injury. Therefore, in this study, we investigated the effect of ischemia-reperfusion (IR) injury on intestinal anastomosis and the protective efficiency of carnitine in an experimental relatively short intestinal ischemia and long duration reperfusion model. METHODS: Animals were divided into three groups (n=14). Each group was separated into two subgroups. In subgroups A, morphologic injury and the number of perfused intestinal muscular microvessels were analyzed to show "no-reflow phenomenon." Intestinal resection and anastomosis were performed in subgroups B. Carnitine group (IRCarG) received 200 mg/kg intravenous carnitine 2 min prior to reperfusion. Malonyldialdehyde, nitric oxide levels in tissue and blood, collagen levels, bursting pressures, and histopathologic evaluation of anastomosis were measured in subgroups B. RESULTS: Morphologic damage was statistically lower, number of perfused microvessels and epithelial regeneration were statistically higher in IRCarG, compared with ischemia-reperfusion group (P=0.03, P=0.008, P=0.05, respectively). CONCLUSION: Carnitine application prior to reperfusion may reduce the severity of the reperfusion injury by preventing the occurrence of no-reflow phenomenon, increase the number of perfused microvessels in the ischemic intestine, and may improve epithelial regeneration in intestinal anastomosis.

Prosthetic repair of acutely incarcerated groin hernias: a prospective clinical observational cohort study.

BACKGROUND AND AIM: Mesh usage in repair of acutely incarcerated hernia is still a concern owing to infectious complications. The aim of this prospective clinical observational cohort study was to evaluate factors that increase the risk of bowel necrosis and to document the clinical outcome of the patients with acutely incarcerated groin hernias treated by non-absorbable mesh. MATERIALS AND METHODS: Ninety-five adult patients with acutely incarcerated groin hernias who underwent prosthetic herniorrhaphy from 1997 to 2005 were prospectively included. The patients were evaluated in two groups, which were based on whether the bowel resection was required (group 1) or not (group 2). Demographics and characteristics of patients in each group were compared. Chi-square, Fisher's exact, and Mann-Whitney U test were used to determine the statistical significance (p < 0.05). RESULTS: Bowel resection was required in 14 (14.7%) and not required in 81 (85.3%) patients. Duration of symptoms longer than 6 h was an important factor for determining the need for resection (p = 0.026). No significant difference was noted concerning the development of wound infection, postoperative recurrence, morbidity, and mortality rates between the two groups. CONCLUSIONS: Our results suggest that duration of symptoms longer than 6 h was an important factor for determining the need for resection. The use of non-absorbable mesh for acutely incarcerated groin hernia repair is effective and may be used with an acceptable incidence of wound infection and recurrence even when intestinal necrosis was present.

Benign solitary cecal ulcer: a condition that mimics plastron appendicitis.

The benign solitary cecal ulcer is a rare clinical entity that is not usually included in the differential diagnosis of the cecal diseases. The etiology is unknown, and there are no pathognomonic lesions or symptoms. Pre-operative and intra-operative diagnosis is difficult. Definitive diagnosis is generally obtained by histologic evaluation of the surgical specimen after a right hemicolectomy performed for a suspected neoplasm of the cecum. We herein describe a 70-year-old woman with solitary cecal ulcer presenting with abdominal pain, palpable mass on the right lower quadrant and leukocytosis, mimicking plastron appendicitis on initial evaluation.

Delayed complete gastric outlet obstruction due to a dinner fork: report of a case.

Ingestion of foreign bodies can be a common problem especially among children, alcoholics, psychiatric patients, and senile patients, but ingestion of a metallic dinner fork is uncommon. Foreign bodies with smooth edges usually do not pose significant problems, but a sharp foreign object that is not retrieved at the earliest may penetrate the wall and cause complications. Ingested foreign bodies usually pass the intestinal tract without problems, and perforation occurs in less than 1%. In this paper, a case of rare gastric outlet obstruction due to a dinner fork, which was ingested 25 days before, is reported.

Partially hydrolyzed guar gum attenuates the severity of pouchitis in a rat model of ileal J pouch-anal anastomosis.

We aimed to evaluate the efficacy of treatment with partially hydrolyzed guar gum (PHGG) using a rat model of ileal pouch-anal anastomosis and pouchitis. In the J pouch groups, tissue myeloperoxidase activities were significantly higher than native myeloperoxidase activities (P = 0.020; P = 0.015; P = 0.004, respectively). A statistically significant difference in total histological score was detected in the J pouch + 5% dextran sulfate sodium (DSS) group, compared to the J pouch control and the J pouch + 5% DSS + PHGG groups (P < 0.01 and P < 0.01, respectively). There was a significant overgrowth of aerobes and anaerobes in the J pouch + 5% DSS group. This study demonstrated that rectal administration of PHGG attenuates the severity of pouchitis in a rat model. In conclusion, PHGG may be an additional therapeutic strategy for the treatment of pouchitis.

What is the role of the abdominal perfusion pressure for subclinical hepatic dysfunction in laparoscopic cholecystectomy?

BACKGROUND: Subclinical hepatic dysfunction after laparoscopic cholecystectomy (LC) has been described in the literature. However, this alteration is not encountered in all patients. In order to address this situation, a prospective study was conducted to investigate the effect of abdominal perfusion pressure (APP) on liver function tests after LC performed under constant intra-abdominal pressure (IAP). PATIENTS AND METHODS: Of 78 patients who underwent LC between May 2007 and October 2007, 40 patients were eligible for the study. In all the patients, six parameters of liver function (aspartate aminotransferase, alanine aminotransferase, direct bilirubin, indirect bilirubin, alkaline phosphatase, and gamma-glutamyltransferase) were assessed before and 24 hours after surgery. Patients who showed more than a 100% increase in at least one parameter (group 1) were compared to those who did not (group 2) regarding age, sex, body weight, body height, operation time, pneumoperitoneum time, IAP, preoperative, and intraoperative APP. RESULTS: Of the patients, 37.5% showed more than a 100% increase in at least one parameter of liver function. No significant difference was found between the two groups with regard to age, sex, body weight, body height, operation time, pneumoperitoneum time, and IAP. There were significant increase in AST and ALT at 24 hours postoperatively in group 1, as compared with group 2 (P = 0.000, P = 0.001). In comparison of preoperative APP with intraoperative APP values, group 1 showed a statistically significant decrease (P = 0.000), while no difference was found in group 2. CONCLUSION: Subclinical hepatic dysfunction after LC could mostly be attributed to the negative effects of the pneumoperitoneum on hepatic blood flow. For the evaluation of hepatic hypoperfusion, APP may be a new criterion as a determinant of interaction with mean arterial pressure (MAP) and IAP.

Adult morgagni hernia: a single center experience of 5 cases and review of literature.

Morgagni hernia is a rare congenital anomaly arising through the fusion defect between the septum transversum and sternum. Diagnosis is usually confusing as the presentation may be asymptomatic as well as with respiratory symptoms, abdominal and/or retrosternal pain, abdominal fullness or gastrointestinal obstruction. In this paper, we discussed the clinical presentation and management of this rare situation with five consecutive cases. Between 2009 and 2015, five cases underwent surgery for Morgagni hernia (3 laparoscopic and 2 open repair); one patient had recurrent hernia after 7 months from laparoscopic surgery. This case is the first recurrence in the literature after laparoscopic repair in an adult group. In Morgagni hernias, the only treatment is surgery, which can be performed by transthoracic, transabdominal, laparoscopic or thoracoscopic approaches. The issues of using mesh and reducing the hernia sac are still controversial.

Exposure of surgical staff in surgical probe applications in radioguided parathyroidectomy.

The aim of this study is to calculate the exposure of surgical staff during radioguided parathyroidectomy. Two parathyroidectomy operations on patients with parathyroid adenoma were selected. Fifty-centimeter spaced circles were drawn surrounding the operation bed on the floor of the operation room. During the operation, radiation dose was measured according to the drawn circles at distances of 50-200 cm from the side of patient's head, bilateral neck and abdomen while the patient lied on the operation bed. All the operations were recorded throughout with a video camera. Three physicians watched all records. The time spent at each distance for every staff during the operation was recorded. Whole body dose to senior surgeon was calculated as 8.78-11.00 microSv which means that a senior surgeon can perform 91-114 procedures per year to reach the annual International Commission on Radiological Protection (ICRP) radiation dose limit for a member of the public. We concluded that radiation risk to the surgical staff is low from radioguided parathyroidectomy.

Cytomegalovirus disease in renal transplant recipients: a single-center experience.

UNLABELLED: Cytomegalovirus (CMV) disease is an important complication and an independent risk factor for acute rejection and recipient morbidity-mortality. The aim of this study was to review the results of CMV disease in renal transplant recipients. METHOD: We have retrospectively analyzed CMV disease in 120 renal transplant recipients and recorded the demographic features, clinical manifestations, and immunosuppressive regimens. RESULTS: Twenty-nine recipients (24.1%) developed CMV disease after a median interval of 2.8 +/- 2,6 months from transplantation. CMV disease developed in 36.3% of recipients who received basiliximab as induction therapy and 21.4% of recipients who were treated with anti-thymocyte globulin (ATG). The most commonly used immunosuppressive regimen was cyclosporine-A (CsA)-based (79.3%). The mean cumulative steroid dose until the diagnosis was 3,600 mg methyl prednisolone per patient. Malaise, fever, and diarrhea were the most common symptoms. Gastritis, pneumonia, and transaminitis were the most commonly seen end-organ involvements. Frequent laboratory findings were leukopenia (34.5%), increased serum creatinine level (34.5%), and leukocytosis (20.7%). We performed renal biopsy to seven patients and detected acute rejection in four patients. In 25 patients, immunosuppressive treatment was modified. Relapsing CMV disease was seen in seven patients. CONCLUSION: In our study, CMV disease was seen in recipients who were treated with basiliximab, a finding similar to recipients who were treated with ATG.

The Effect of the Cartridge Used in Laparoscopic Sleeve Gastrectomy on the Development of a Staple-Line Leak.

Morbid obesity surgery has increased by 450 per cent in the past decade. Preferred surgical techniques have also changed, and since 2014, the most common surgical procedure worldwide has been laparoscopic sleeve gastrectomy (LSG). The most serious complication of this surgery is staple-line leaks, which leads to significant increases in cost and a considerable rate of mortality. This study aimed to investigate the effects of staples used in LSG on the development of staple-line leaks. The sample of the study comprised 70 patients that consecutively underwent surgery at Dokuz Eylül University Hospital between March 2014 and June 2015. The patients were divided into two equal groups. For the first group, resection was performed using blue-green EndoGIA™ cartridges (BGC) (Medtronic, Norwalk, CT). In the other group, purple Tri-Staple™ cartridges (TSC) (Medtronic) were used. To examine the effect of the cartridge type, the point and pressure of leak was determined from fresh specimens following saline infusion. No statistically significant difference was found between the two groups in terms of mean age, body mass index, gender distribution or comorbidity. The median number of cartridges used was five in both groups. The resistance of the staple line to intragastric pressure was found to be significantly higher in the TSC group compared with the BGC group [51.94 (±18.34) mmHg and 39.77 (±17.09) mmHg, respectively, P = 0.005]. Most applications undertaken to reduce the risk of leak development in LSG aim to reinforce the staple line. There are very few studies that investigated the quality of staple line, and none examined the effect of staple cartridges on the development of leaks. Therefore, we conducted this study to fill this gap in the literature. The results revealed that tissue thickness cartridge compatibility had a role in the development of leaks during the resection of gastric tissue in which the thickness is reduced from the distal to the proximal portion. We conclude that during vertical sleeve gastrectomy, using TSC that are compatible with a wider range of tissue thickness results in more durable staple lines than EndoGIA™ cartridges.

Adult morgagni hernia: A single-center experience of five cases and a review of literature.

Morgagni hernia is a rare congenital anomaly arising from the fusion defect between the septum transversum and sternum. The diagnosis is usually difficult since the presentation may be asymptomatic or with respiratory symptoms, abdominal and/or retrosternal pain, abdominal fullness, or gastrointestinal obstruction. In this report, we discuss the clinical presentation and management of this rare condition in five consecutive cases. Between 2009 and 2015, five cases underwent surgery for Morgagni hernia (three laparoscopic and two open repair surgeries); one patient developed recurrent hernia 7 months after the laparoscopic surgery. This case is the first reported recurrence in literature following laparoscopic repair in adults. Surgery is the only treatment option for Morgagni hernias, which can be performed through transthoracic, transabdominal, laparoscopic, or thoracoscopic approach. The issues of using mesh and reducing the hernial sac remain controversial.

Symptomatic intestinal lipomas requiring surgical interventions secondary to ileal intussusception and colonic obstruction: report of two cases.

Lipomas are rare but well-recognized tumours of the small and large intestines. They usually arise from the submucosa and may occasionally protrude into the lumen, thus causing abdominal pain resulting from obstruction or intussusception or they may become evident through haemorrhage. Intestinal lipomas should be removed either endoscopically or surgically because they can cause severe symptoms and usually a tissue diagnosis is indicated in intestinal tumours to exclude a malignancy. We describe two cases of symptomatic intestinal lipoma and review some aspects of diagnosis and treatment.

A rare clinical entity misdiagnosed as a tumor: peliosis hepatis.

Peliosis hepatis (PH) is a rare condition characterized by the presence of cystic, blood filled cavities within the hepatic parenchyma. Regardless of the reason, surgery should be performed under meticulous control of hemorrhage, if it is thought to be unavoidable. In this case report, ominous results of clinically misdiagnosed PH have been presented. PH should be kept on mind in all patients with hepatic mass, especially presented by sudden onset distention of the abdomen. Every effort should be done for the differential diagnosis with other cystic conditions like hydatid cyst in endemic areas.

Simple, Safe, and Cost-Effective Technique for Resected Stomach Extraction in Laparoscopic Sleeve Gastrectomy.

Background. Laparoscopic sleeve gastrectomy (LSG) has become a popular operation during the recent years. This procedure requires resection of 80-90% of the stomach. Extraction of gastric specimen is known to be a challenging and costly stage of the operation. In this paper, we report results of a simple and cost-effective specimen extraction technique which was applied to 137 consecutive LSG patients. Methods. Between October 2013 and October 2015, 137 laparoscopic sleeve gastrectomy surgeries were performed at Dokuz Eylul University General Surgery Department, Upper Gastrointestinal Surgery Unit. All specimens were extracted through a 15 mm trocar site without using any special device. Results. We noticed one superficial incisional surgical site infection and treated this patient with oral antibiotics. No cases of trocar site hernia were observed. Conclusion. Different techniques have been described for specimen extraction. This simple technique allows extraction of specimen safely in a short time and does not require any special device.