Is the increased incidence of pathologically proven acute appendicitis more likely seen in elderly patients? A retrospective cohort study.

AIM: Although appendicitis is a disease of the young, it has been speculated that its incidence has increased among the elderly people. In this study, it was aimed to evaluate annual changes of appendicitis seen in older patients (≥60 years) throughout a 10-year period. METHODS: All adult patients who were surgically treated for acute appendicitis were retrospectively analyzed with respect to pathological analysis, gender, age and proportion of the patients aged 60 or over in an annual base. Variability in the mean age and proportion of the older patients aged 60 or over throughout the study years were regarded as the main outcomes. RESULTS: There were 3296 patients with a mean age of 30.42 ± 12 years. Distribution of gender was similar (p = 0.636). There was a significant positive correlation in the mean age of the patients throughout the study years (p = 0.043). Stratification by the age of 60 yielded a significant increase in percent of the older patients, from 0.93% at 2007 to 4.28% at 2016 (p = 0.019). CONCLUSIONS: The mean age of the patients with acute appendicitis is going to increase. Therefore, it is expected that all surgeons are more likely to be confronted with elderly patients with appendicitis in the near-future.

Prospective multi-center study of surgeon's assessment of the gallbladder compared to histopathological examination to detect incidental malignancy.

PURPOSE: Routine histopathological examination after cholecystectomy for gallstones is performed despite the low rates of incidental findings of malignancy. The aim of this study was to assess predictive values of macroscopic examination of cholecystectomy specimens by surgeons in gallstone disease. METHODS: A prospective multi-center diagnostic study was carried out between December 2015 and March 2017 at four different centers. All patients undergoing cholecystectomy for gallstone disease were consecutively screened for eligibility. Patients whose ages are 18 to 80 years, and preoperative imaging findings without any pathology except cholelithiasis were included. The gallbladder was first evaluated macroscopically ex situ by two operating surgeons and rated as macroscopically benign (group S1), suspicious for a benign diagnosis (group S2), and suspicious for malignancy (group S3). Thereafter, a pathologist made a final histopathological examination whose results are grouped as chronic cholecystitis (group P1), benign or precancerous lesions in which only cholecystectomy is the adequate treatment modality (group P2), and carcinoma (group P3). Diagnostic accuracy of the surgeon's assessment to the histopathological examination was evaluated using sensitivity, specificity, positive and negative predictive values, and accuracy, and correlated by a kappa agreement coefficient. RESULTS: A total of 1112 patients were included in this trial. The specificity rates were 96.5%, 100%, and 98.7% for group S1-group S2, group S1-group S3, and group S2-group S3, respectively. Accuracy rates to detect malignancy were 100% and 95. 2% for group S1 and group S2, respectively. Kappa coefficient values were 1.0 and 0.64 for group S1-group S3 and group S2-group S3, respectively (p < 0.001 for both). CONCLUSION: Assessment of the gallbladder specimen and selective histopathological examination may be adequate after cholecystectomy for gallstone diseases. Such a procedure would have the potential to reduce costs and prevent unnecessary loss of labor productivity without affecting patients' safety. However, higher number of patients in more centers is needed to confirm this hypothesis.

The impact of a percutaneous cholecystostomy catheter in situ until the time of cholecystectomy on the development of recurrent acute cholecystitis: a historical cohort study.

BACKGROUND: the optimal duration of percutaneous cholecystostomy in patients with acute cholecystitis is unknown. METHODS: this study was a retrospective analysis of patients (age ≥ 18 years) who underwent percutaneous cholecystostomy due to acute calculous cholecystitis. Patients were grouped according to treatment modality: percutaneous cholecystostomy as a definitive treatment (group 1), subsequent surgical treatment after the removal of the catheter (group 2) and those remaining in situ (group 3). The development of gallstone-related complications was the main outcome. RESULTS: there were 24 females (43.6%) and 31 males (56.4%) included in the study with a mean age of 64.8 ± 15.9 years. There were 16 (29.1%), 19 (34.5%) and 20 (36.4%) patients in groups 1, 2, and 3, respectively. The catheter withdrawal time for group 1 and group 2 was 18.2 ± 6.9 and 20.7 ± 13.4 days, respectively. Surgical treatment was performed after a mean of 85.4 ± 93.5 days following catheter removal in group 2 and a mean of 64 ± 32.5 days while the PC tube was in place in group 3. There were one (6.3%) and two cases of a recurrence (10.5%) in groups 1 and 2, respectively. Two patients developed choledocholithiasis (10%) in group 3. CONCLUSION: maintaining percutaneous cholecystostomy tubes in place until the time of surgery in surgically fit patients may help to prevent a recurrence after acute calculous cholecystitis.

Analysis of reporting quality for oral presentations of observational studies at 19th National Surgical Congress: Proposal for a national evaluation system.

OBJECTIVE: To compare the quality of oral presentations presented at the 19th National Surgical Congress with a national evaluation system with respect to the applicability of systems, and consistency between systems and reviewers. MATERIAL AND METHODS: Fifty randomly selected observational studies, which were blinded for author and institute information, were evaluated by using the Strengthening the Reporting of Observational Studies (STROBE), Timmer Score, and National Evaluation System by two reviewers. Abstract scores, evaluation periods, and compatibility between reviewers were compared for each evaluation system. Abstract scores by three different evaluation systems were regarded as the main outcome. Wilcoxon matched-pairs signed rank and Friedman tests for comparison of scores and times, kappa analysis for compatibility between reviewers, and Spearman correlation for analysis of reviewers based on pairs of evaluation systems were used. RESULTS: There was no significant difference between abstract scores for each system (p>0.05). A significant difference for evaluation period of reviewers was detected for each system (p<0.05). Compatibility between reviewers was the highest for the Timmer Score (medium, κ=0.523), and the compatibility for STROBE and National Evaluation System was regarded as acceptable (κ=0.394 and κ=0.354, respectively). Assessment of reviewers for pairs of evaluation systems revealed that scores increased in the same direction with each other significantly (p<0.05). CONCLUSION: The National Evaluation System is an appropriate method for evaluation of conference abstracts due to the consistent results between the referees similarly with the current international evaluation systems and ease of applicability with regard to evaluation period.

Intraoperative diagnosis of cecal diverticulitis during surgery for acute appendicitis: Case series.

OBJECTIVE: Cecal diverticulum is a rare entity, and can cause acute abdomen by the way of diverticulitis and perforation of diverticulitis. In this study, we aimed to perform an analysis of patients that have cecal diverticulitis, and presented with acute abdomen. MATERIAL AND METHODS: Patients who were admitted to emergency clinic between 2009-2012 and had acute abdomen due to cecal diverticulitis were included into study retrospectively. RESULTS: Six patients were included in the study with a mean age of 34 years (range 24-43). Four patients were male and two were female (male/female: 2). All six patients presented with abdominal pain, additional symptoms were nausea in five patients, and vomiting in one patient. The mean white blood cell count was 11.900/mm(3) (5850-17.400/mm(3)), while the remaining laboratory results were normal. There were no specific findings on abdominal X-ray or ultrasonography. The surgical exploration revealed an inflamed cecal diverticulitis and normal appendix in all patients. Five patients underwent appendectomy and diverticulectomy. Right hemicolectomy was performed in one patient due to suspicion of malignancy. The early postoperative period was uneventful in all patients. The mean length of hospital stay was 4.5 days with a range of 2-6 days. Histopathological examination showed acute perforated diverticulitis with underlying true diverticulum in three patients, and true diverticulum with acute diverticulitis in the remaining three patients. CONCLUSION: Pre-operative diagnosis of cecal diverticulitis is challenging due to symptoms and signs that resemble acute appendicitis. Diverticulectomy and incidental appendectomy is the treatment of choice in uncomplicated cases.

Interposition of the hernia sac as a protective layer in repair of giant incisional hernia with polypropylene mesh.

BACKGROUND AND PURPOSE: Repair of giant incisional hernia is still associated with high postoperative morbidity and recurrence rates. We evaluated the effectiveness of placing the hernia sac between the viscera and the polypropylene mesh in the repair. METHODS: The subjects of this study were patients with an incisional hernia at least 15 cm in diameter, diagnosed between June 2004 and October 2010 and treated with on-lay polypropylene mesh at least 25 cm in length. We operated using a simplified method of placing the hernia sac between the viscera and the mesh, and fixing the mesh with interrupted trans-fascial U sutures. We evaluated the patient demographics and postoperative complications retrospectively. RESULTS: A total of 25 patients (mean age 57.1 ± 10 years) were included. The mean length of hospital stay was 1.8 ± 1.2 days. Seroma developed in four patients (16 %), but only two with cystic seroma required excision of the cyst wall with preservation of the mesh. Twenty-two patients (88 %) were followed up for a mean period of 42.6 ± 23 months. There was no incidence of chronic pain, hospitalization for intestinal obstruction, or enterocutaneous fistulization. There was only one recurrence (4.55 %). CONCLUSION: The hernia sac can be interposed in all patients undergoing giant incisional hernia repair if direct contact between the polypropylene mesh and intestine is unavoidable.

Evaluation of reporting quality of the 2010 and 2012 National Surgical Congress oral presentations by CONSORT, STROBE and Timmer criteria.

OBJECTIVE: This study aimed to evaluate the abstracts of oral presentations that were accepted to the National Surgical Congress by CONSORT, STROBE and Timmer criteria and to recommend development of a national abstract assessment system. MATERIAL AND METHODS: Presentation scores were calculated for oral presentations that have been accepted to the 2010 and 2012 National Surgical Congresses and have been included in the digital congress abstract booklets by two independent reviewers who were blinded to information regarding both the author and the institution. The CONSORT and Timmer criteria were used for randomized controlled trials, and for observational studies the STROBE and Timmer criteria were used. The presentation score that was obtained by three different evaluation systems was accepted as the main variable. The score changes according to the two congresses, the influence of the reviewers on the presentation scores, and compatibility between the two reviewers were evaluated. Comparisons regarding study types and total presentation number were made by using the chi-square test, the compatibility between the total score of the presentations were made by the Mann-Whitney U test and the compatibility between the reviewers were evaluated by the Wilcoxon signed ranks test. RESULTS: There was no difference between the two Congresses in terms of study type distribution and total number of accepted presentations (p=0.844). The total scores of randomized controlled trials and observational studies from the 2010 and 2012 National Surgical Congresses that were evaluated by two independent reviewers with different assessment tools did not show any significant difference (p>0.05). A significant difference was observed between the reviewers in their evaluation by CONSORT, STROBE and Timmer criteria (p<0.05). CONCLUSION: Implementation of standard criteria for the evaluation of abstracts that are sent to congresses is important in terms of presentation reporting quality. The existing criteria should be revised according to national factors, in order to reduce the significant differences between reviewers. It is believed that discussions on a new evaluation system will be beneficial in terms of the development of a national assessment system.

Effect of surgeon's judgement on the diagnosis of acute appendicitis.

OBJECTIVE: The accuracy of a surgeon's judgement still remains to be controversial in the diagnosis of acute appendicitis, which is a diagnosis usually based on laboratory data and imaging tests. MATERIAL AND METHODS: Patients with a possible diagnosis of acute appendicitis were reviewed retrospectively with regard to demographic variables, laboratory and imaging results, and treatment modalities. RESULTS: There were 128 patients with a mean age of 31.2±14 years. The mean white blood cell count and the proportion of polymorphonuclear leukocytes were 11403±4669/mm(3) and 75±11%, respectively. Appendectomy was performed on 66 (51.6%) patients. Conservative management was applied to 62 (48.4%) patients. Statistical analysis showed that patients with appendicitis have a higher white blood cell count (p=0.015) and a higher proportion of polymorphonuclear leukocytes (p=0.023). Sensitivity, specificity and accuracy rates were 84.6%, 63.7% and 74.3% for ultrasound and 100%, 86.7% and 92.2% for computed tomography, respectively. CONCLUSION: Diagnosis based on patients' laboratory and imaging data, in combination with, the surgeon's judgement appears to yield the best outcomes in patients with suspicion of acute appendicitis.

Routine use of positron-emission tomography/computed tomography for staging of primary colorectal cancer: does it affect clinical management?

BACKGROUND: The use of positron emission tomography-computed tomography (PET/CT) for the preoperative staging of patients with colon and rectal cancer has increased steadily over the last decade. The aim of this study was to evaluate the effect of PET/CT on the preoperative staging and clinical management of patients with colorectal cancer. METHODS: Between December 2010 and February 2012, 64 consecutive patients with colorectal cancer were evaluated with both PET/CT scans and conventional preoperative imaging studies. We prospectively recorded the medical reports of these patients. The PET/CT findings were compared with conventional imaging studies and the rate of over-staging or down-staging and changes in clinical management were evaluated. The correlation of the PET/CT with the conventional imaging was compared by a kappa agreement coefficient. Differences in the accuracy for N and T staging were assessed by χ2 and related-samples marginal homogeneity tests. RESULTS: Thirty-nine (60.9%) patients had rectal cancer and 25 (39.1%) had colon cancer. Based on PET/CT, additional lesions were found in 6 (9.4%) of the patients: hilar and paratracheal lesions in 4 patients, hepatic in 1 and supraclavicular in 1 patient. In four of six patients, detailed imaging studies or biopsies revealed chronic inflammatory changes. Hepatic and supraclavicular involvement was confirmed in two patients. Therefore, the false positivity rate of PET/CT was 6.25%. Based on the additional PET/CT, 2 (3.2%) patients had a change in surgical management. A chemotherapy regimen was administered to the patient with a 1.5 cm hepatic metastasis near the right hepatic vein; for another patient with an identified supraclavicular lymph node metastasis, a simultaneous excision was performed. CONCLUSIONS: Routine use of PET/CT for preoperative staging did not impact disease management for 96.8% of our patients. The results of our study conclude that PET/CT should not be routinely used for primary staging of colorectal cancer. More studies are required for identifying the subgroup of patients who might benefit from a PET/CT in their initial staging.

Standard laparoscopic cholecystectomy for malposition of the gallbladder caused by right-sided ligamentum teres.

Atypical localization of the gallbladder associated with right-sided ligamentum teres is a rare anomaly of the biliary system. Although the conventional nomenclature as being a left-sided gallbladder is usually used, this definition may be incomprehensive because of lacking the anatomical detail. This report describes atypical localization of the gallbladder associated with right-sided ligamentum teres and abnormal intrahepatic portal venous branching, surgically removed laparoscopically.