Comparison of clinical outcomes of robotic-assisted and video-assisted esophagectomy for esophageal cancer.

INTRODUCTION: Robotic-assisted minimally invasive esophagectomy (RAMIE) is a recently developed technique for the treatment of resectable esophageal cancer. The present study compares the outcomes of RAMIE and video-assisted thoracoscopic esophagectomy (VATE). METHOD: Patients undergoing minimally invasive esophageal surgery between December 2020 and September 2022 were included in the study, while those undergoing conventional surgery were excluded. The patients were divided into two groups, as those undergoing RAMIE (Group 1) and those undergoing VATE (Group 2). The demographic and clinical characteristics, intraoperative parameters, pathological data, and postoperative parameters of the groups were compared. RESULTS: A total of 28 patients were included in the study, with 13 patients in Group 1 and 15 patients in Group 2. The gender distribution was similar (P = 0.488), and the mean age was 64.7 and 59.0 years in Groups 1 and 2, respectively (P = 0.068). The majority of the sample was in the ASA2 category (46.2% vs. 66.7%, P = 0.341); Ca19.9 levels were higher in Group 1 than in Group 2 (25.7 vs. 13.7, P = 0.027); preoperative Hb was lower in Group 1 than in Group 2 (10.9 g/dL vs. 12.2 g/dL, P = 0.043); the most commonly performed surgery was the McKeown procedure (69.2% vs. 66.7%, P = 0.492); an intraoperative feeding jejunostomy was placed only in Group 2; the operation time was similar between the groups (338.5 min vs. 340 min, P = 0.916); and the distribution of tumor localizations was similar between the groups (P = 0.407). In terms of tumor histology, squamous cell carcinoma (SCC) was the most common tumor type in the two groups (84.6% vs. 80%, P = 0.636); the tumor diameter was similar between the groups (14.9 vs. 18.1, P = 0.652); the number of removed lymph nodes was similar between the groups (24.9 vs. 22.5, P = 0.419); and the number of metastatic lymph nodes was higher in Group 2 (0.08 vs. 1.07, P = 0.27). One patient in Group 2 underwent repeat surgery due to suspected ischemic anastomosis; the distribution of postoperative complications according to the Clavien-Dindo classification system was similar in the two groups (P = 0.650); there was no early mortality within the first 30 days in either group; one patient in Group 2 was re-admitted within 90 days of discharge with decreased oral intake; the length of hospital stay was shorter in Group 1 (9 days vs. 16.5 days, P = 0.006); and the patients in Group 2 more often received neoadjuvant therapy in proportion to the disease stage (15.4% vs. 60%, P = 0.016). CONCLUSION: Robotic procedures can be safely performed in esophageal cancers with complication rates and oncological radicality similar to those of other minimally invasive techniques.

Synchronous and metachronous neoplasms of different histogenesis with gastrointestinal stromal tumor (GIST): 10 years experience of a single institution.

AIM: Gastrointestinal stromal tumors (GISTs) are the most common primary mesenchymal neoplasms of the gastrointestinal tract. Significant advances have been made in its pathogenesis, diagnosis, and treatment over the past few decades. However, little is known about the occurrence of synchronous or methacronous tumors with other histogenesis in addition to GISTs. The aim of this study was to present a series of 15 patients diagnosed with a second primary neoplasm in addition to GIST. MATERIAL AND METHODS: Patients who were diagnosed with both GIST and other primary neoplasm between January 2010 and December 2019 were included in the study. Demographic, clinicopathologic and immunohistochemical parameters of the patients were analyzed along with the follow-up results RESULTS: This study included 12 men and 3 women with a median age of 68 years (range: 57-83 years). Of the GISTs, 93.3% were localized in the stomach and 73.3% were at very low / low risk category. Of the second primary tumors, 66.6% were in the gastrointestinal tract. Detection of the GIST was synchronous in 9 cases, metachronous in 2 cases and preceded the GIST diagnosis in 4 cases. GIST was incidentally found intra-operatively in 3 of the cases. The mean size of the synchronous GISTs was 20 mm while the most common GIST-associated malignancy was gastric adenocarcinoma. The median follow-up times was 62 months (range: 13-129 months). CONCLUSIONS: The prevalence of secondary malignancies in GIST patients is significantly higher than the healthy population. The high occurrence rate of additional primary tumors in GIST patients has focused the attention of surgeons on this problem. While it is not yet clear if there is a causal association or a common genetic mechanism for the concomitant occurrence of GIST with other malignancies, a closer surveillance of GIST patients is needed due to their proved increased prevalence of a second primary tumor especially during the first year after diagnosis. KEY WORDS: Gastrointestinal stromal tumor, Coexistence, Synchronous malignancy, Second neoplasm, Gastric adenocarcinoma.

Short-term surgical outcomes of robotic gastrectomy. A single center/single surgeon experience.

AIM: Surgical resection is considered the optimum approach to the treatment of gastric cancer. The present study evaluates the efficacy of robotic surgery for the treatment of gastric cancer. METHOD: Included in the study were 30 patients who underwent robotic surgery for gastric cancer at the General Surgery Clinic between July 2021 and 2022. The demographic and clinical properties of the patients,intraoperative and postoperative results, tumor Characteristics, and early morbidity and mortality values were evaluated. RESULTS: The mean age of the 30 (F/M:8/22) patients was 63.9 (42-83) years, among which 20 (66.7%) had undergone neoadjuvant treatment. The mean surgery duration was 252.82 (110-380) minutes. A subtotal gastrectomy was performed in 10 patients (33%), while the remaining 20 patients (67%) underwent a total gastrectomy. The operation was converted to open surgery in four patients (13.2%). No intraoperative complications were seen, although one patient (3%) underwent re-anastomosis on postoperative day 3 due to an obstruction in the gastroenterostomy anastomosis. The mean largest diameter of the tumor was 4.6 (0-9) cm; the mean number of resected lymph nodes was 30.8 (11-58); and the mean duration of hospital stay was 5.9 (3-12) days. Early mortality within the first 30 days was seen in one patient with a cardiac cause. The rate of re-admission to hospital within the first 90 days was 11% (3 patients). CONCLUSION: Robotic surgery in patients with gastric cancer can be applied efficiently considering the successful clinicopathological results, short hospital stay, and low morbidity and mortality rates. KEY WORDS: Cancer, Morbidity, Mortality, Robotic Surgery, Stomach.

An early experience with the Da Vinci Xi surgical system in colorectal surgery. A single-center study.

AIM: Surgery is the optimum treatment approach in cases of colorectal cancer, with open or minimally invasive surgery options applied to patients in general surgery clinics. We present here an assessment of our use of robotic colorectal surgery for the treatment of colorectal cancer. METHOD: The outcomes of robotic colorectal surgeries performed in the General Surgery Clinic of Basaksehir Cam and Sakura City Hospital were evaluated. The demographic data, indications, type of surgery, complications, duration of postoperative stay and pathology results of the patients were recorded, and the surgical results were evaluated retrospectively. RESULTS: Of the 50 patients who underwent robotic colorectal surgery selected for the study, 19 were female and 31 were male, with a mean age of 60.9 years. Among the patients, 48% received neoadjuvant treatment and the most common tumor localization was the rectosigmoid region (40%), the most frequently performed operation was low anterior resection (44%). An ostomy was created in 50% of the patients, and two patients were converted. The mean duration of surgery was 191 minutes, the mean tumor diameter was 36 mm, the mean total number of lymph nodes dissected was 22.2 and the rate of complications of Clavien Dindo grade 3 or higher was 10%, namely anastomotic leak, anastomotic bleeding and chylous fistula. The mean length of hospital stay was 5 days, and one patient was reoperated due to the development of stomal necrosis. The rate of 90-day unplanned readmission was 10% and the most frequent cause was sub-ileus. One patient died in the postoperative period. CONCLUSION: Robotic surgery is a minimally invasive surgical approach that can be successfully applied in centers where perioperative and postoperative complications can be managed. KEY WORDS: Colorectal Cancer, Minimally Invasive Surgery, Robotic Surgery.

Management of choledochal cysts in adults: a retrospective analysis of 23 patients.

BACKGROUND/AIMS: Choledochal cysts are rare congenital anomalies of the pancreaticobiliary system, whose etiology remains unknown. We aimed to review patients with choledochal cysts and to compare our results with current literature. METHODOLOGY: Twenty-three patients diagnosed as having choledochal cysts between January 2004 and July 2010 were evaluated retrospectively. RESULTS: Thirteen patients had type I (56.5%), 3 patients type II (13%), 3 patients type III (13%), 1 patient type IV-A (8.3%) and the remaining 3 patients had type V (13%) choledochal cysts. All patients with type I cysts underwent cyst excision with Roux-en-Y hepaticojejunostomy. Two patients with type II cysts underwent cyst excision with choledochoduodenostomy, whereas cyst excision with T-tube drainage was applied to the other. Endoscopic unroofing was performed type III cysts. The patient with type IV-A cyst was not eligible for surgery due to low cardiopulmonary performance status but ERCP was applied successfully more than 3 times for the extraction of the stones which fell from the intrahepatic ducts into the common bile duct. Patients with Type V cysts underwent left hepatectomy, choledocoduodenostomy and cadaveric liver transplantation, respectively. Wound infection developed in 5 patients and anastomotic leakage occurred in 3; one died from sepsis. CONCLUSIONS: Choledochal cysts are rare congenital malformations. Although treatment varies depending on the type of the cysts, complete excision of the cysts should be performed if possible.

Complete mesocolic malposition of the gallbladder: An unusual case report with literature's review.

Anatomic variations and congenital anomalies involving the gallbladder position, shape, and number are frequently encountered on routine abdominal imagings and at surgery. However, most have no clinical significance, but their recognition is important because they may predispose to gallbladder diseases, serve as a potential source of confusion and diagnostic pitfalls for radiologists and surgeons, and increase the risk of inadvertent injury during biliary tract surgery or intervention. We observed an intra-mesocolic gallbladder found unexpectedly during the cholecystectomy in a 65-year-old male patient who was being operated on for acute calculous cholecystitis. An abdominal ultrasonography and computed tomography scan reported no anomalous or malpositioned gallbladder pre-operatively. As the location of this organ could not be definitely clarified in his previous operation elsewhere, we performed an explorative lapa-rotomy. There was no gallbladder at the normal position. The organ was found embedded deeply within the proximal portion of the transverse mesocolon, and then it was successfully excised. We established the diagnosis of an ectopic gallbladder in mesocolic position.

Diagnostic Value of Preoperative Haemoglobin, Albumin, Lymphocyte and Platelet (HALP) Score in Predicting Tumour Budding in Colorectal Cancer.

OBJECTIVE: To investigate the value of preoperative haemoglobin, albumin, lymphocyte, and platelet (HALP) score in predicting tumour budding in colorectal carcinoma. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: University of Health Sciences, Basaksehir Çam and Sakura City Hospital Istanbul/Turkey, between May 2020 and May 2021. METHODOLOGY: The colorectal cancer patients who underwent surgery were divided into two groups according to the presence or absence of tumour budding. A total of 110 patients were included in the study, and there were 31 patients in group 1 and 79 patients in group 2. The predictive value of the HALP score in predicting tumour budding at the determined cut-off point was evaluated. RESULTS: The mean HALP score was similar in both groups (p=0.459). The rate of lymphovascular invasion was higher in group 2 (p=0.002), and T3 and T4 tumours were more common in group 2 (p<0.001). The number of metastatic lymph nodes was higher in group 2 (p=0.049). When the patients in group 2 were divided into subgroups according to the degree of tumour budding, the HALP score differed between intermediate and high budding groups (p=0.032). A HALP value of >31.6 predicted the presence of tumour budding with a sensitivity of 70.89% and a specificity of 48.39%. CONCLUSION: The presence of tumour budding is associated with aggressive phenotypic features in colorectal carcinoma. The preoperative prediction of tumour budding can serve as a guide in the development of individualised therapy plans. The HALP score was associated with the presence of intermediate or high degree of tumour budding. KEY WORDS: Colorectal cancer, Tumor, Pathology, Hemoglobin, Albumin.

Clinicopathologic characteristics and surgical management of schwannomas of the upper digestive tract.

AIM: Schwannoma is a peripheral nervous system tumor arising from Schwann cells of the neural sheath, and they are very rarely seen in the upper digestive tract. In this study, we aimed to present the clinicopathologic characteristics and surgical management of patients who underwent surgical treatment for esophageal or gastric schwannoma. MATERIAL AND METHODS: Patients who were diagnosed with esophageal or gastric schwannoma between January 2013 and January 2020 were included in the study. Demographic, clinicopathological and immunohistochemical parameters of the patients were analyzed along with the follow-up results. RESULTS: There were 13 patients in our study. Nine patients had gastric schwannoma and 4 patients had esophageal schwannoma. Female gender was dominant (61.5%). The mean age was 56 years. Esophageal tumors were all enucleated. Minimal invasive approach was preferred in 3 patients. Gastric tumors were most commonly localized in the lesser curvature. Three patients underwent laparoscopic wedge resection, 3 patients open wedge resection, 2 patients subtotal gastrectomy, and one patient proximal gastrectomy. Intraoperative or postoperative complications did not develop in any patient. No patient required reoperation, and there were no deaths within 90 days postoperatively. In the postoperative 90-day period, there was no unplanned re-admission to the hospital. The mean follow-up period was 53.4 months (range: 23-93 months). No recurrence was detected in any patients. CONCLUSIONS: Definitive diagnosis of schwannomas is made only by histopathologic examination postoperatively. S-100 expression has diagnostic significance. The preferred treatment is complete surgical excision with negative margins, and the long-term outcome is excellent as these lesions are mostly benign. KEY WORDS: Esophagus, Enucleation, Schwannoma, Stomach, Wedge resection.

The effect of phlebotomy and mannitol on acute renal injury induced by ischemia/reperfusion of lower limbs in rats.

BACKGROUND: Abdominal aortic surgery can cause ischemic/reperfusion (I/R) injury not only in the lower limbs but also in remote organs such as kidneys. Venous blood volume exclusion from the inferior vena cava (phlebotomy) or/and mannitol are used as a treatment for I/R injury of kidney in humans, despite the fact that the effectiveness of these treatments is still debated. The aim of this study was to evaluate the effects of phlebotomy or/and mannitol on rat kidneys in a model of lower limbs I/R-induced acute renal injury (ARI). MATERIAL AND METHODS: Thirty male Wistar albino rats were used and divided into five groups: (I) sham-operated group, laparotomy without I/R injury (group [S], n = 6); (II) I/R group, infrarenal aortic cross-clamp was used for lower limbs I/R, 3 hours of ischemia followed by 2 hours of reperfusion (group [I/R], n = 6); (III) I/R + phlebotomy group, identical to group [I/R] except for 1 mL of blood aspiration from the inferior caval vein just after ischemia (group [P], n = 6); (IV) I/R + mannitol-treated group, these rats were subjected to I/R and received a bolus injection of mannitol (group [M], n = 6); and (V) I/R + phlebotomy + mannitol-treated group (group [P + M], n = 6), the same procedures were performed as those described for previous groups. At the end of 2-hour reperfusion, all rats were sacrificed. Both kidneys were harvested for biochemical assay (myeloperoxidase [MPO] and superoxide dismutase [SOD] activities, and malondialdehyde [MDA] and reduced glutathione levels) and for histopathological examination (tubular necrosis and acute inflammation on kidney [ARI score]). RESULTS: Aortic I/R significantly increased the level of MDA (reflecting lipid peroxidation), SOD (enzymatic endogenous antioxidant), and MPO (reflecting neutrophil infiltration) activity (p < 0.05). Phlebotomy or/and mannitol treatments significantly decreased the level of MDA, SOD, and MPO activity and increased glutathione level (nonenzymatic antioxidant in the kidney tissues) (p < 0.05). Histological evaluation of ARI score showed that aortic I/R significantly increased (p value for group [S] versus group [I/R] was 0.012), whereas phlebotomy or/and mannitol treatments significantly decreased tubular necrosis and inflammatory infiltration (p values for group [I/R] versus group [P], [M], and [P + M] were 0.043, 0.043, and 0.003, respectively). CONCLUSION: This experiment clearly indicated that the lower limbs I/R-induced ARI attenuated significantly by phlebotomy or/and mannitol treatments. Phlebotomy plus mannitol is more effective treatment than phlebotomy or mannitol alone in preventing lower limbs I/R-induced ARI in rats. Further clinical studies are required to clarify whether phlebotomy or/and mannitol treatments are beneficial in alleviating of ARI during abdominal aortic surgery.

Giant hemorrhagic adrenal pseudocyst in a primiparous pregnancy: report of a case.

Adrenal cysts are rare and are usually discovered incidentally during diagnostic imaging, surgery, or autopsy. Most cystic lesions of the adrenal gland are nonfunctioning and become symptomatic when complicated by rupture, hemorrhage, or infection. A 40-year-old woman presented with a history of gradual-onset pain in her left flank region at 20 weeks' gestation. Ultrasound showed a 20-cm cystic mass in her left abdominal cavity. Pertinent laboratory tests were within normal limits. The patient underwent exploratory laparotomy, which revealed a 20 × 15-cm left adrenal cyst; thus, we performed left adrenalectomy with complete excision of the cyst. Histological examination confirmed a hemorrhagic adrenal pseudocyst. The patient had an uneventful postoperative course, and subsequent routine obstetric ultrasound examinations showed normal fetal activity and development until the pregnancy terminated with a stillbirth caused by pre-eclampsia at 34 weeks' gestation. To the best of our knowledge, this is only the 12th reported case of adrenal pseudocyst discovered during pregnancy. We analyze the clinicopathologic findings and discuss the possible association of pregnancy, with special reference to etiopathogenesis, presentation, diagnosis, and treatment.

Mannitol attenuates acute lung injury induced by infrarenal aortic occlusion-reperfusion in rats.

PURPOSE: Mannitol is used as a treatment for ischemia/reperfusion (IR) injury of various organs in humans, despite the fact that its effectiveness in vivo is still disputed. The purpose of this study was to determine the effects of mannitol on acute lung injury (ALI) induced by infrarenal aortic occlusion. METHODS: Male Wistar-albino rats were allocated into five groups: (i) sham-operated group, which received a laparotomy without IR injury (n = 12); (ii) IR group, which received 3 h of ischemia followed by 2 h of reperfusion (n = 12); (iii) IR + inferior caval phlebotomy (ICP) group, which was identical to group 2 except for 1 ml of blood aspiration from the inferior caval vein (n = 12); (iv) IR + mannitol-treated group, for which rats were subjected to IR and received a bolus injection of mannitol (n = 12); and (v) IR + ICP + mannitol-treated group, which underwent the same procedures as described for the previous groups. Arterial blood gas parameters were studied and bronchoalveolar lavage (BAL) was performed. Evans blue dye was injected into half of the rats. We biochemically assessed the degree of pulmonary tissue injury by investigating oxidative stress markers and enzymatic and nonenzymatic antioxidant markers, and evaluated ALI by establishing pulmonary leukosequestration and ALI scoring, histopathologically. Pulmonary edema was estimated by using Evans blue dye extravasation and wet/dry weight ratios. RESULTS: Hypertonic mannitol treatment significantly reduced oxidative stress markers, and significantly increased enzymatic and nonenzymatic antioxidant markers in the lung tissues (P < 0.05). Arterial blood gas parameters were significantly ameliorated (P < 0.05), the BAL cytology was significantly better (P < 0.05), pulmonary leukosequestration and ALI scores were significantly decreased (P < 0.05), and pulmonary edema was significantly alleviated (P < 0.05) by mannitol administration. CONCLUSION: This study clearly showed that mannitol treatment significantly attenuated the aortic IR-induced ALI. Further clinical studies are required to clarify whether mannitol has a useful role in ALI during surgeries in which IR-induced organ injury occurs.

Hepar lobatum carcinomatosum associated with metastatic rectal carcinoma: an unusual cause of liver dysmorphy.

OBJECTIVE: The aim of this study was to present a case of hepar lobatum resulting from metastatic rectal carcinoma. CLINICAL PRESENTATION AND INTERVENTION: A 50-year-old man presented with a 2-year history of bleeding per anum, tenesmus, malaise and weakness. Initially, the patient received neoadjuvant chemoradiotherapy followed by abdominoperineal resection of the rectum. Abdominal computed tomography showed lobar enlargement and lobulated contour, mainly in the left lobe of the liver, but no primary or metastatic lesions were detected. Laparotomy revealed an irregularly lobulated hepatic deformity. Liver biopsy showed a necrotic tumor growth from adenocarcinoma of the rectum in subcapsular localizationof the liver. CONCLUSION: This case showed a patient with hepar lobatum carcinomatosum caused by metastatic rectal carcinoma. The report further highlights the need for clinicians and surgeons to keep in mind the possibility of hepar lobatum carcinomatosum while caring for rectal carcinoma patients, especially when the lobulated contour of the liver is detected at preoperative imaging studies or when the coarsely lobated liver is encountered during surgery for carcinoma of the rectum.

Laparoscopic versus open complete meso-colic excision for right-sided colon cancer. Analysis of short-term outcomes.

SCOPO DELLO STUDIO: L'emicolectomia destra per escissione mesocolica completa (EMC) laparoscopica mostrerebbe benefici comparabili a breve termine, nonché esiti patologici e oncologici per la chirurgia a cielo aperto. Lo scopo di questo studio era di confrontare la tecnica laparoscopica e la EMC aperta per i tumori del colon sul lato destro in termini di campioni patologici e risultati a breve termine. MATERIALE E METODI: I dati dei pazienti sottoposti a EMC laparoscopica (n=31) e EMC aperto (n=35) per adenocarcinoma del colon destro tra gennaio 2016 e giugno 2019 sono stati analizzati retrospettivamente. Sono stati confrontati dati demografici, parametri preoperatori, peroperatori e postoperatori e campioni di patologia dei due gruppi. RISULTATI: Non ci sono state differenze statistiche tra il gruppo laparoscopico di EMC e il gruppo aperto di EMC in termini di età, sesso, indice di massa corporea, posizione del tumore, punteggio dell'American Society of Anesthesiologists (ASA), presenza di comorbidità, storia di altre neoplasie e precedente chirurgia addominale (p>0,05). I pazienti nel gruppo EMC laparoscopico presentavano lunghezze d'incisione più brevi, tempi operativi più lunghi, minore perdita di sangue operativa, tempi di mobilizzazione più brevi, recupero precoce del movimento intestinale, tempo più breve per dieta leggera, durata ridotta della degenza e dimensioni del tumore più piccole (p<0,05). Il numero medio di linfonodi raccolti in gruppi laparoscopici e di EMC aperti non era statisticamente significativo (29,83+8,90 e 31,34+13,10, rispettivamente). Non ci sono state differenze statistiche in termini di lunghezza del campione tra i gruppi laparoscopici e aperti di EMC (35,19+9,8 cm e 32,71+11,12 cm, rispettivamente). Il tasso di complicanze postoperatorie di 30 giorni era più elevato nel gruppo EMC aperto (35,5% contro 42,9%, rispettivamente), ma non statisticamente significativo (p>0,05). CONCLUSIONI: Patologici (lunghezze dei campioni, lunghezze dei margini di resezione, numero di linfonodi e resezione R0) e risultati a breve termine del gruppo laparoscopico di EMC erano comparabili. Inoltre, la EMC laparoscopica ha conferito benefici a breve termine in termini di lunghezze di incisione più brevi, minore perdita di sangue operativa, riduzione dei tempi di mobilizzazione, recupero precoce dei movimenti intestinali, minor tempo di dieta leggera e riduzione della durata della degenza ospedaliera. Sulla base di questi risultati, la EMC laparoscopica può essere considerata come un approccio elettivo di routine per il carcinoma del colon destro.

Laparoscopic revisional surgery for failed anti-reflux procedures.

AIM: Failure ratio of an anti-reflux surgery is 2-17% in adults. After unsuccessful fundoplications, if necessary, revisional surgeries can be performed. Revisional surgeries are technically difficult to perform and require professionally advanced experience. On the other hand, it is still controversial which technique should be used in revisional surgery. The aim of this study is to present our experience with revisional surgical procedures for complications or recurrences after anti-reflux surgeries. MATERIAL AND METODS: A total of 18 patients, 16 of whom were referred to our clinic from other centers, and who underwent revisional surgery for failed fundoplication between 2014 and 2019 were retrospectively analyzed RESULTS: Five patients were male and 13 were female. The mean age was 40.3±11.7 years. The most common symptom was the persistence of reflux symptoms (61.2%). Indications for revisional surgery were recurrent hiatal hernia in 10 patients, thightness in 4 patients, mesh migration in 2 patients, mesh migration with recurrent hiatal hernia in 1 patient, and mesh migration with thightness in 1 patient. The mean operative time was 107.2+29.2 minutes. The median hospital stay was 2.9 days (range: 1-6 days). The most common surgical procedure performed was the repair of hiatal crura with mesh, and reconstruction of fundoplication and fixation of neo-fundoplication to the right crus (44.4%). In addition, other surgical procedures performed were takedown of the previous fundoplication (16.6%), takedown of the previous fundoplication and reconstruction of fundoplication (11.1%), cruroplasty and fundoplication with gastric wedge resection (11.1%), removal of the mesh and takedown of the previous fundoplication (5.6%), removal of sutures from the hiatal crura (5.6%), and gastric wedge resection (5.6%). Four patients (27.8%) developed morbidity due to gastric perforation and pleural opening during these procedures. The median follow-up period was 29 months (range: 6-69 months). Two cases (11.1%) who underwent revisional surgery failed, and re-revisional surgery was performed. CONCLUSIONS: Revisionary surgical procedures performed for failed anti-reflux surgery are not limited to re-fundoplication. Different procedures such as takedown of the previous fundoplication, reconstruction of fundoplication, removal of the mesh, removal of the sutures or wedge resection may be necessary. These procedures can successfully be performed laparoscopically by experienced surgeons in well-equipped centers. KEY WORDS: Fundoplication, Gastroesophageal reflux, Laparoscopy, Revisional Surgery, Antireflux surgery.

Timing of elective laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreaticography with sphincterotomy: a prospective observational study of 308 patients.

PURPOSE: Endoscopic retrograde cholangiopancreaticography (ERCP) with sphincterotomy is associated with higher rates of conversion to open surgery during subsequent laparoscopic cholecystectomy (LC). The mechanisms of this association are unclear. The aim of this study was to investigate whether the time interval between the two procedures can affect the course of LC in terms of conversion rate or complications. METHODS: In this prospective observational study, 308 consecutive patients underwent ERCP with sphincterotomy followed at various intervals by elective LC. According to these intervals, the patients' data were assigned to one of three groups: short-interval (2 days or less), medium-interval (3-42 days), or long-interval (43 days or more). Groups were also defined in terms of whether gallstones were extracted during ERCP and in terms of the number of ERCPs performed (single or multiple) prior to LC. The main outcome measures for all groups were the frequency of complications during or after LC and the frequency of conversions to open surgery. RESULTS: Of the 308 patients, 43 required conversion to open cholecystectomy (14%). The short-interval (95 patients), medium-interval (100 patients), and long-interval (113 patients) groups did not differ significantly in terms of intraoperative complications, postoperative complications, or conversion to open surgery (p = 0.985, 0.340, and 0.472, respectively). The conversion rate also did not differ significantly according to the presence or absence of gallstones on ERCP (14.7% versus 12.8%, respectively, p = 0.392). However, compared with patients who underwent single ERCP (n = 290), those who underwent multiple ERCPs (n = 18) experienced significantly more conversion to open surgery (p = 0.026). CONCLUSIONS: The length of time between endoscopic sphincterotomy and LC did not affect the latter procedure in terms of complications or conversion to open surgery. However, the lack of an association between conversion rate and gallstone presence on ERCP and the higher conversion rate among patients who underwent multiple ERCPs, suggest that ERCP with sphincterotomy itself may be a factor in the higher conversion rates that have been observed after this procedure.

Effects of carbon dioxide pneumoperitoneum on hepatic function in obstructive jaundice: an experimental study in a rat model.

BACKGROUND AND AIMS: The physiology of the patient during laparoscopy differs from that of open surgery. Both pneumoperitoneum and obstructive jaundice impair the hepatic function, but the combined insult has not been previously examined. In this study, we aimed to investigate the effects of carbon dioxide (CO(2)) pneumoperitoneum on hepatic function in a rat model of obstructive jaundice. METHODS: Forty-four male Sprague-Dawley rats were divided into four groups: group 1 (n = 10), sham-operated group; group 2 (n = 12), obstructive jaundice group; group 3 (n = 10), CO(2) pneumoperitoneum group; and group 4 (n = 12), obstructive jaundice and CO(2) pneumoperitoneum group. Common bile duct was ligated and divided in the obstructive jaundice groups. After 6 days, a 12-mmHg pneumoperitoneum was induced, maintained for 60 min, and released for 120 min. Blood samples were drawn for the measurement of white blood cell and platelet counts, serum liver enzymes (aspartate aminotransferase [AST], alanine aminotransferase [ALT], total bilirubin). Tissue samples were obtained for analyses of malondialdehyde (MDA), glutathione (GSH), and superoxide dismutase (SOD) levels. We evaluated the degree of liver injury on a grading scale from 0 to 4, histopathologically. RESULTS: Pneumoperitoneum after biliary obstruction resulted in an increase in AST and ALT levels and a decrease in white blood cell and platelet counts. However, changes in liver tissue MDA, GSH, and SOD levels did not correlate with the changes in AST and ALT levels and white blood cell and platelet counts. After sham operation with pneumoperitoneum, the GSH levels in liver homogenate were significantly decreased in the group 3 when compared to the group 2. On the other hand, obstructive jaundice itself caused significant reduction in the SOD activity of liver homogenate in comparison to the group 3. Histopathologically, sinusoidal congestion and vacuolization were more severe in the group 3. CONCLUSIONS: Alterations in hepatic function occur in pneumoperitoneum applied jaundiced subjects. However, there were no statistically significant differences between the groups 2 and 4 with regard to white blood cell and platelet counts, serum liver enzymes including AST, ALT, and total bilirubin values, MDA and GSH levels and SOD activity of liver homogenate, and histologic damage. These results indicate that there is no additional risk on liver function associated with pneumoperitoneum performed in obstructive jaundice.

Postoperative hemorrhagic complications after elective laparoscopic cholecystectomy in patients receiving long-term anticoagulant therapy.

BACKGROUND AND AIMS: Among patients on long-term anticoagulant therapy who undergo laparoscopic cholecystectomy (LC), bleeding complications have not been extensively investigated. The objective of this study was therefore to investigate postoperative bleeding complications prospectively in patients on chronic oral anticoagulation. MATERIALS AND METHODS: In the period of January 2002 to December 2007, 44 patients on long-term anticoagulation with warfarin, an oral anticoagulant (OAC), underwent LC in our center. Oral anticoagulant was discontinued 5 days before the planned date of surgery, and patients were admitted to the hospital 3 days before. Upon admission, bridging anticoagulation with enoxaparin, a low molecular weight heparin (LMWH), was started. When their international normalized ratio (INR) decreased to <1.5, patients underwent LC. In the absence of postoperative bleeding complications, OAC and LMWH were resumed on the evening of the day of surgery, and LMWH was continued until each patient's target INR was reached. A comparison group was comprised by 1,421 consecutively enrolled patients with no comorbid disease who underwent LC during the same period. RESULTS: In the comparison group, postoperative bleeding was encountered in 21 patients (1.5%). In the anticoagulation group, postoperative bleeding was encountered in 11 patients (25%) and ranged from minor oozing from a port incision in one patient to hemorrhage, sepsis, and fatality in one patient. In the anticoagulation group, no significant differences were found between patients with and without postoperative bleeding in terms of age, gender, body mass index, American Society of Anesthesiologists score, INR, or other hemostasis parameters. CONCLUSIONS: In patients who underwent LC with bridging anticoagulation, postoperative bleeding was markedly more frequent than expected and was not predicted by the usual coagulation parameters. This suggests a need for methods that can indicate which patients on long-term anticoagulation are at risk for postoperative bleeding.

A tumor-like lesion mimicking mucinous (colloid) carcinoma in heterotopic pancreas of the prepyloric antrum: a formidable challenge for frozen examination.

CONTEXT: Heterotopic pancreas is defined as the presence of pancreatic tissue, outside its usual location, which lacks anatomical and vascular continuity with the pancreas proper. Despite the development of modern diagnostic procedures, it is still difficult to differentiate heterotopic pancreas from benign or malignant tumors and other tumor-like lesions. Frozen examination of mucinous lesions arising from heterotopic pancreas may represent a diagnostic problem. A decision may be very difficult and it is sometimes impossible to decide on the basis of the frozen sections whether a lesion is benign or malignant. CASE REPORT: We report a tumor-like lesion mimicking a mucinous (colloid) carcinoma arising in heterotopic pancreatic tissue in the prepyloric antrum of a 56-year-old woman which was found incidentally during an elective laparoscopic cholecystectomy for cholelithiasis. The tumor was treated by wedge resection and, in the frozen section examination, there were pancreatic ducts in the proper muscle layer, pancreatic acini with islets of Langerhans under the serosal surface and mucinous lakes close to the heterotopic pancreatic tissue and to a peripheral nerve. CONCLUSION: The significance of this unusual lesion is its potential confusion with mucinous (colloid) carcinoma or other mucous tumors. Such confusion is more likely to occur if the tissue sample is selective or limited, and the presence of pancreatic tissue cannot be verified. Therefore, we believe that a choice of local excision, wedge resection or more extensive eradication be determined only after intraoperative, pathological confirmation of the complete and accurate diagnosis.

Spilled gallstones found incidentally in a direct inguinal hernia sac: Report of a case.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is the preferred surgical treatment for symptomatic gallstones. Iatrogenic gallbladder perforation and spillage of gallstones during LC is a frequent occurrence. There are many different clinical presentations of complications resulting from dropped gallstones. We herein present a case of scattered gallstones after LC encountered incidentally during a direct inguinal hernia repair. PRESENTATION OF CASE: A 62-year-old male presented with a 4-year history of swelling of both right and left groins. He had undergone LC for acute calculous cholecystitis at another hospital 5 months earlier. Physical examination revealed reducible both right and left direct inguinal hernias. Surgical exploration of the right side revealed foreign bodies at the fundus of the sac attached to the inner wall, with a fibrotic reaction around it. On closer inspection these foreign bodies were macroscopically consistent with gallstones. The gallstones were removed, and bilateral herniotomies and Lichtenstein's prolene mesh repair were performed. Pathologic evaluation confirmed 10 foreign bodies of 5-mm in size to be cholesterol gallstones. DISCUSSION: Gallstones have been very rarely reported previously within a hernia sac after LC. Most of the spilled gallstones are clinically silent and rarely become symptomatic. Complications may occur from the immediately postoperative period to a long time interval of 20 years. Treatment of complications is based on its type and location. CONCLUSION: This case presents a very rare entity resulting from leaving spilled gallstones behind. We recommend that every effort should be made to retrieve any scattered stones during LC in order to avoid complications.

Free perforation of primary small bowel lymphoma in a patient with celiac sprue and dermatitis herpetiformis.

Small bowel lymphomas are rare and constitute approximately 1% of the malignant gastrointestinal tumors. However, the risk of malignant disease in adult celiac disease is about 8-10%, and non-Hodgkin lymphoma is the most common. In the literature, cases with celiac disease and small bowel lymphoma have been reported, but the emphasis on emergency surgery is extremely rare. We herein present a case of primary small intestinal lymphoma diagnosed after surgery in a 55-year-old male patient who presented to our emergency department with findings of gastrointestinal perforation and had a history of celiac disease and dermatitis herpetiformis. The purpose of this report is to review this situation briefly and discuss it in the light of literature.