Comparison of emergency surgeries for obstructed colonic cancer with elective surgeries: A retrospective study.

OBJECTIVE: Colon cancer patients presented with obstruction were known to have worse postoperative morbidity and mortality rates, but conflicting data has been reported in recent years. We aimed to investigate postoperative complication rates, and short and long-term oncological outcomes in patients with colon cancer treated with either emergency surgery due to obstruction or elective surgery. METHODS: Two hundred fifty two patients were analyzed. Patients presented with obstruction and underwent an emergency surgery, and patients operated under elective circumstances were compared according to their demographic variables, tumor characteristics, and short and long term treatment outcomes. RESULTS: Distribution of age, gender and comorbidities were similar between both the groups. Need for an end colostomy was significantly higher in obstructed patients (22.7% vs 1.6%, respectively). Obstructed patients were tending to be at an advanced stage. Postoperative morbidity and mortality, and prognosis of colon cancer patients presented with obstruction is worse than patients operated under elective circumstances. CONCLUSIONS: Colon cancer patients presented with obstruction constitutes more than one quarter of all patients. These patients have significantly higher morbidity and mortality rates. Obstructed colon cancer usually appears at advanced stage. Primary resection and anastomosis is safe in most of the cases.

Can horizontal diameter of colorectal tumor help predict prognosis?

OBJECTIVE: We aimed to investigate the relationship between the horizontal tumor diameter and prognosis. MATERIAL AND METHODS: Patients' records were analyzed retrospectively. Patient data, including age, gender, vertical penetration, anatomic location, differentiation of the tumor, tumor node metastasis (TNM) stage, survival rate, and disease-free survival, were analyzed to find out if there was any correlation with horizontal tumor diameter. RESULTS: A total of 439 colorectal cancer patients were enrolled. Patients were stratified into two groups according to the horizontal tumor diameter (≤4.5 cm vs. >4.5 cm). Poorly differentiated tumors were significantly larger than other differentiation groups (p=0.003). The horizontal diameter increased with increase in T-stage (p<0.001). Similarly, the number of positive lymph nodes increased significantly as the size of the horizontal tumor diameter increased (p<0.001). The relationship between TNM staging and the horizontal diameter of tumors in both groups was examined, and it was found that the progression of tumor stage was accompanied by increased horizontal diameter (p<0.001). It was also found that the horizontal tumor diameter was not correlated with local recurrence (p=0.063). However, distant metastasis was higher in patients with a tumor larger than 4.5 cm (p=0.02). Although the disease-free survival was shorter in patients with a horizontal tumor diameter more than 4.5 cm, the difference was not statistically significant. CONCLUSION: There is a significant relation between horizontal diameter of the tumor and depth of the tumor, lymph node involvement, overall survival, and distant metastasis. Horizontal diameter of the tumor can possibly be used as a prognostic factor in colorectal cancer patients.

A rare clinical manifestation of rectal adenocarcinoma and synchronous scalp metastasis: A case report.

In this case report, our aim was to emphasize that cutaneous involvement can be seen at the time of diagnosis or during the clinical course of visceral organ cancers in general and in colorectal cancers particularly. We also aimed to demonstrate that cutaneous lesions occurring in patients under follow up for visceral organ cancers could be metastases. A rapid progressing scalp lesion was detected in a newly diagnosed rectal cancer patient and the tru-cut biopsy revealed adenocarcinoma metastasis. This patient died due to a myocardial infarction during neoadjuvant chemotherapy. Cutaneous metastatic lesions in colorectal cancers must be evaluated as a sign of advanced disease and treatment protocols should be determined accordingly.

Appendiceal mucocele mimicking urolithiasis.

Appendiceal mucocele is a rare clinical condition that results from distension of the appendix lumen with mucus. It is only found in 0.1-0.3% of all appendectomy specimens. Twenty-five per cent of these cases are asymptomatic and are incidentally discovered either during surgery or upon radiological examination. The treatment of appendiceal mucocele is surgical, and while appendectomy is usually sufficient in some cases right hemicolectomy may be considered as a treatment option. Mucoceles are histologically subdivided into four types: retention cysts, mucosal hyperplasia, cystadenomas and cystadenocarcinomas. Herein, we present a case of appendiceal mucocele clinically mimicking urolithiasis in a 62-year-old female patient with a complaint of colicky right flank pain and a single episode of macroscopic hematuria. The patient's abdominal ultrasonography and abdominal CT scan showed a mass consistent with mucocele in the right lower quadrant of the abdomen. Colonoscopy gave the impression of a mass lesion exerting pressure from the outside. The patient was electively operated. Histopathological diagnosis was reported as mucinous cystadenoma. Appendiceal mucocele or mucinous cystadenomas are usually seen in patients undergoing surgery with a diagnosis of appendicitis but, as in our case, these lesions may rarely occur with a clinical picture that mimics urological disease.

Time course of collagen peak in bile duct-ligated rats.

BACKGROUND: One of the most useful experimental fibrogenesis models is the "bile duct-ligated rats". Our aim was to investigate the quantitative hepatic collagen content by two different methods during the different stages of hepatic fibrosis in bile duct-ligated rats on a weekly basis. We questioned whether the 1-wk or 4-wk bile duct-ligated model is suitable in animal fibrogenesis trials. METHODS: Of the 53 male Wistar rats, 8 (Group 0) were used as a healthy control group. Bile duct ligation (BDL) had been performed in the rest. Bile duct-ligated rates were sacrificed 7 days later in group 1 (10 rats), 14 days later in group 2 (9 rats), 21 days later in group 3(9 rats) and 28 days later in group 4 (9 rats). Eight rats underwent sham-operation (Sham). Hepatic collagen measurements as well as serum levels of liver enzymes and function tests were all analysed. RESULTS: The peak level of collagen was observed biochemically and histomorphometricly at the end of third week (P < 0.001 and P < 0.05). Suprisingly, collagen levels had decreased with the course of time such as at the end of fourth week (P < 0.01 and P < 0.05). CONCLUSION: We have shown that fibrosis in bile duct-ligated rats is transient, i.e. reverses spontaneously after 3 weeks. This contrasts any situation in patients where hepatic fibrosis is progressive and irreversible as countless studies performed by many investigators in the same animal model.

A comparison of dexmedetomidine versus midazolam for sedation, pain and hemodynamic control, during colonoscopy under conscious sedation.

OBJECTIVE: The intent of our study was to compare the effects of dexmedetomidine versus midazolam on perioperative hemodynamics, sedation, pain, satisfaction and recovery scores during colonoscopy. MATERIAL AND METHODS: A total of 60 ASA I-II patients, between 20 and 80 years of age were included in the study. Patients were randomly assigned to two groups. Midazolam 0.05 mg kg(-1) and fentanyl citrate 1 microg kg(-1) were administered intravenously to cases in Group I (n = 30). An initial loading dose of 1 microg kg(-1) dexmedetomidine was administered intravenously in 10 min to cases in Group II (n = 30) before the procedure and as a continuous infusion dose of 0.5 microg kg(-1) h(-1) just before the procedure started. Also 1 microg kg(-1) fentanyl citrate was administered intravenously immediately before the procedure. Peripheral oxygen saturation (S(pO2)), mean arterial pressure (MAP), heart rate (HR), Ramsay Sedation Scale (RSS), Numeric Rating Scale (NRS) scores and colonoscopist satisfaction scores of the cases were recorded. RESULTS: Although statistically significant values were not detected between the two groups with regard to mean arterial pressure, in Group I heart rates were higher and S(pO2) scores were lower in a statistically significant manner. When the groups were compared with regard to RSS, the RSS scores of Group I at the 10th and 15th minutes were significantly lower than Group II. There was no statistically significant difference between the two groups when compared with regard to NRS scores. Satisfaction scores were significantly lower in Group II. CONCLUSION: Dexmedetomidine provides more efficient hemodynamic stability, higher Ramsay sedation scale scores, higher satisfaction scores and lower NRS scores in colonoscopies. According to our results we believe that dexmedetomidine can be used safely as a sedoanalgesic agent in colonoscopies.

The effects of gabapentin on acute and chronic pain after inguinal herniorrhaphy.

BACKGROUND AND OBJECTIVE: To find out whether preoperative gabapentin use had a favourable effect on long-term postoperative pain in patients undergoing inguinal herniorrhaphy. METHODS: Sixty male patients--aged 20-40 years--who were scheduled for unilateral inguinal herniorrhaphy under spinal anaesthesia were included in this prospective, randomized, double-blind study. The patients were randomly allocated to two groups: the gabapentin group (n=30) received single-dose 1.2 g oral gabapentin 1 h before surgery, and the placebo group received a placebo capsule instead. Spinal anaesthesia was performed with heavy bupivacaine, and all operations were performed by the same surgeon with the same technique. Postoperative analgesia was evaluated during sitting and lying with a visual analogue scale. Assessment of postoperative pain at 1, 3 and 6 months was carried out with an 11-point numerical rating scale; 0 indicating 'no pain' and 10 indicating 'worst pain imaginable'. Patients who had numerical rating scale scores of more than 0 were further evaluated with regard to the impact of pain on their daily activities. RESULTS: When compared with the placebo group, the gabapentin group displayed significantly lower visual analogue scale scores (lying and sitting) and total tramadol consumption at 8, 12, 16, 20 and 24 h after surgery (P<0.05) and higher postoperative patient satisfaction scores (P<0.05). Numerical rating scale scores at 1, 3 and 6 months after surgery were lower in the gabapentin group than in the placebo group (P<0.05). The number of patients whose daily activities were adversely affected by pain was smaller in the gabapentin group at the first month; however, the two groups were found to be similar at 3 and 6 months. CONCLUSION: We conclude that preoperative single-dose gabapentin decreases the intensity of acute postoperative pain, tramadol consumption and the incidence and intensity of pain in the first 6 months after inguinal herniorrhaphy.

Pulmonary echinococcosis mimicking multiple lung metastasis of breast cancer: the role of fluoro-deoxy-glucose positron emission tomography.

BACKGROUND: Echinococcosis is still a serious problem particularly in endemic areas such as South and Central America, Mediterranean countries, and Russia. Furthermore, hydatid cysts of the lung are often indistinguishable from a variety of other pulmonary lesions such as lung tumors CASE PRESENTATION: We herein present a 56 year old woman with breast cancer who presented with bilateral pulmonary nodules due to echinococcosis granulosis that mimicked metastatic breast cancer to the lung. CONCLUSION: During the evaluation of the malignancies which could metastasize to the lung, it must be kept in mind that the appearance of bilateral multiple pulmonary masses can also be the sign of a pulmonary echinococcosis especially in endemic areas. FDG-PET with its known high negative predictive value in characterizing indeterminate pulmonary nodules >1 cm is very helpful to characterize this kind of lesions.

Overlapping repair in patients with anal sphincter injury.

OBJECTIVE: The aim of this study was to demonstrate the improvement of anal canal function after overlap sphincter repair and confirm that this treatment option is superior in patients with nonobstetric sphincter damage. SUBJECTS AND METHODS: From 1998 to 2003, 44 women who underwent overlapping sphincter repair were enrolled in this study. The women were allocated to one of two groups, obstetric trauma (n = 31) and nonobstetric (perineal) trauma (n = 13). Both groups were compared in terms of age, operation time, number of deliveries, hospital stay, need for analgesics, complication rate, pre- and postoperative outcomes of anal manometry and quality of life, using the fecal incontinence severity index and a questionnaire for fecal disorders. RESULTS: Anal canal length was significantly extended postoperatively in both groups compared to preoperative length. Eight-week postoperative resting and squeeze pressures were significantly higher than preoperative pressures in both patients with nonobstetric and obstetric sphincter injury. Although significant increase was seen in both groups, the mean postoperative resting and squeeze pressures at 1 year were rather high in patients with nonobstetric sphincter injury. At the end of a year of follow-up, overall satisfaction of the repair was about 82%. CONCLUSION: Overlap sphincter repair was feasible, although patient satisfaction was slightly less in the obstetric than in the nonobstetric trauma group. The improvement of anal function at 20- to 24-month follow-up is attributed to both high squeeze pressure and broad anal canal.

Incidental gastrointestinal stromal tumor at a gastroscopic polypectomy specimen: A case report and review of literature.

Although gastrointestinal stromal tumors (GISTs) comprise less than 1% of all gastrointestinal (GI) tract tumors, they are the most common mesenchymal tumors of the GI tract. Gastrointestinal stromal tumors can occur anywhere along the GI tract, but the stomach and small intestine are the most frequently involved sites. Gastrointestinal stromal tumors are frequently asymptomatic, and one-third of all cases are found incidentally. Endoscopy, endoscopic ultrasonography, and computed tomography are useful tools in the diagnosis. Endoscopic mucosal resection, endoscopic submucosal dissection, laparoscopic endoscopic cooperative surgery, and surgery with either laparoscopic or open approaches are treatment modalities for GISTs. An R0 resection is the principle surgery. Imatinib is the main medical agent used in the adjuvant or neoadjuvant treatment of GIST. We present a 65-year-old woman with an asymptomatic GIST that arose from a gastric polyp treated via endoscopic polypectomy.

Influence of the c-erb B-2, nm23, bcl-2 and p53 protein markers on colorectal cancer.

BACKGROUND/AIMS: Under stringent intra-laboratory conditions we evaluated the relationship between the expression of four protein markers and clinicopathologic characteristics of colorectal tumors. METHODS: 124 patients with colorectal cancer from 1999 to 2002 were assessed. RESULTS: The expression of cerb B-2, nm23 and p53 was mostly determined in tumors located in the rectum. However, about 20% of the rectal lesions had bcl-2 expression. p53 and c-erb B-2 expression was significantly demonstrated in the lesions with vascular and lymph node involvement. However, the difference between the markers and staging was not statistically significant (p=0.388, p=0.301). Cerb B-2 and p53 were more frequently expressed in the patients with large tumors (more than 5 cm) with moderate and poor differentiation grade. About half of the tumors expressing c- erb B- 2 and p53 had vascular invasion and more than 70% had N1 and N2 lymphatic invasion as well. In the patients with tumors expressing c-erb B-2 and p53, recurrences often occurred and both disease-free survival (DFS) and overall survival (OS) in the first two years after surgery were shorter than of the patients with tumors expressing nm23 and bcl-2. CONCLUSION: In this study, c-erb B-2 and p53 were frequently expressed in the Astler- Coller stage C large tumors located in the rectum and a high degree of vascular and lymphatic invasion was observed. In the patients with tumors expressing c-erb B-2 and p53, recurrences were determined more frequently and DFS and OS were shorter than in patients with tumors expressing nm23 and bcl-2. Thus, two different protein markers should be taken into consideration when evaluating the clinical outcome of patients with colorectal cancer.

Long-term Results of Hemorrhoidal Artery Ligation.

Aim of this study is to assess the efficacy, safety, and long-term results of doppler-guided hemorrhoidal artery ligation procedure with a 7-year follow-up period for treatment of grade II and III degree hemorrhoidal diseases. The procedure was performed by a specially designed proctoscope to locate and ligate all terminal branches of superior rectal artery. Patients were followed up at postoperative 1st week and 3rd, 12th, and 24th months by physical examination and 7th year by phone questionnaire using Short Form-36. Between November 2006 and May 2007, 50 patients (29 females, mean age = 38.2) underwent this procedure. All patients discharged at operation day and mean return to work was 2.5 days. There were no major complications and mean postoperative Visual Analogous Scale at first week was 1.72. At 24th month, 44 (88%) and 38 (76%) patients at 7th year were symptom free. Doppler-guided hemorrhoidal artery ligation is a safe, effective, and outpatient procedure, which can be the treatment of choice for second- and third-degree hemorrhoidal diseases with satisfactory long-term results.

MicroRNA expression profile in patients with stage II colorectal cancer: a Turkish referral center study.

BACKGROUND: There are increasing data about microRNAs (miRNA) in the literature, providing abundant evidence that they play important roles in pathogenesis and development of colorectal cancer. In this study, we aimed to investigate the miRNA expression profiles in surgically resected specimens of patients with recurrent and non-recurrent colorectal cancer. MATERIALS AND METHODS: The study population included 40 patients with stage II colorectal cancer (20 patients with recurrent tumors, and 20 sex and age matched patients without recurrence), who underwent curative colectomy between 2004 and 2011 without adjuvant therapy. Expression of 16 miRNAs (miRNA-9, 21, 30d, 31, 106a, 127, 133a, 133b, 135b, 143, 145, 155, 182, 200a, 200c, 362) was verified by quantitative real-time polymerase chain reaction (qRT-PCR) in all resected colon cancer tissue samples and in corresponding normal colonic tissues. Data analyses were carried out using SPSS 15 software. Values were statistically significantly changed in 40 cancer tissues when compared to the corresponding 40 normal colonic tissues (p<0.001). MiR-30d, miR-133a, miR-143, miR-145 and miR-362 expression was statistically significantly downregulated in 40 resected colorectal cancer tissue samples (p<0.001). When we compared subgroups, miRNA expression profiles of 20 recurrent cancer tissues were similar to all 40 cancer tissues. However in 20 non-recurrent cancer tissues, miR-133a expression was not significantly downregulated, moreover miR-133b expression was significantly upregulated (p<0.05). CONCLUSIONS: Our study revealed dysregulation of expression of ten miRNAs in Turkish colon cancer patients. These miRNAs may be used as potential biomarkers for early detection, screening and surveillance of colorectal cancer, with functional effects on tumor cell behavior.

The effect of early warm plastic bag application on postoperative pain after hemorrhoidectomy: a prospective randomized controlled trial.

Hemorrhoidectomy is used for the surgical treatment of high-grade hemorrhoids. The most prominent complaint after hemorrhoidectomy is pain. Postoperative pain management is still a big problem after surgery in patients with hemorrhoidectomy. The aim of the study was to assess the effect of early application of warm bag on postoperative pain after hemorrhoidectomy. All patients were randomly divided into warm plastic bag and control groups by using sealed envelopes, which were prepared preoperatively. After standard spinal anesthesia, all patients underwent standard Milligan-Morgan hemorrhoidectomy using Ligasure™. Although the study group received the warm bag application, the control group did not receive such a treatment. Two separate visual analog scale (VAS) measurements were performed for postoperative pain assessments on postoperative days, one during the resting state and the other one during the straining phase after the onset of peristaltic bowel movement. Postoperative VAS scores were significantly lower among the warm plastic bag group as compared with the control group on Days 1 and 3 for the resting state and on Day 3 for defecation. Additionally, a significant difference existed between the two groups in terms of the need for additional anesthesia. Local thermal application appears to be a safe and effective method for pain relief after hemorrhoidectomy.

Pretreatment neutrophil/lymphocyte ratio as a prognostic aid in colorectal cancer.

BACKGROUND: Colorectal cancers(CRC) are the third most common cancer in the western world, with surgery preferred for management of non-metastatic disease and post surgical treatment usually arranged according to the TNM staging system. However, there is still prognostic variation between patients who have the same stage. It is increasingly recognized that variations within disease course and clinical outcome in colorectal cancer patients are influenced by not only oncological characteristics of the tumor itself but also host response factors. Recent studies have shown correlation between the inflammatory response and clinical outcomes in various cancers. The neutrophil/lymphocyte ratio (NLR) has been described as a marker for immune response to various stimuli including cancer. MATERIAL-METHODS: Two hundred eighty-one CRC patients were included in our retrospective analysis, separated into two groups according to a cut-off value for the NLR. Patient data including age, gender, vertical penetration, anatomic location, and differentiation of the tumor, TNM stage, survival rate, and disease-free survival were analyzed for correlations with the NLR. RESULTS: Using ROC curve analysis, we determined a cut-off value of 2.2 for NLR to be best to discriminate between patient survival in the whole group. In univariate analysis, high pretreatment NLR (p=0.001, 95%CI 1.483-4.846), pathologic nodal stage (p<0.001, 95%CI 1.082- 3.289) and advanced pathologic TNM stage (p<0.001, 95%CI 1.462-4.213) were predictive of shorter survival. In multivariate analysis, advanced pathologic TNM stage (p=0.001, 95%CI 1.303-26.542) and high pretreatment NLR (p=0.005, 95%CI 1.713-6.378) remained independently associated with poor survival. CONCLUSIONS: High pre-treatment NLR is a significant independent predictor of shorter survival in patients with colorectal cancer. This parameter is a simple, easily accessible laboratory value for identifying patients with poorer prognosis.

Single-incision laparoscopic cholecystectomy versus laparoscopic cholecystectomy: a prospective randomized study.

This prospective randomized study compared single-incision laparoscopic cholecystectomy (SILC) and laparoscopic cholecystectomy (LC) with respect to estimated blood loss, operative time, postoperative pain levels, and complications. Thirty-four study patients were divided into 2 groups: 17 patients underwent SILC and 17 underwent LC. Operative time was longer for SILC than for LC, and the difference was statistically significant (P<0.001). There was no statistically significant difference in the relationship of body mass index with operative time between SILC and LC (P=0.613, P=0.983, respectively). The 2 groups had no statistically significant differences with respect to visual analog scale scores, estimated blood loss, shoulder pain, or complications (P>0.05). SILC can be the treatment of choice for gallbladder disease. Although the surgeon's first several attempts at SILC require a longer operative time compared with LC, there are no differences in hospital length of stay, blood loss, complication rates, or pain scores between SILC and LC.

Doppler-guided hemorrhoidal artery ligation: experience with 2 years follow-up.

Doppler-guided hemorrhoidal artery ligation (DGHAL) is a nonexcisional surgical technique for the treatment of hemorrhoidal disease, consisting of the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of hemorrhoidal plexus resulting in fibrosis. The aim of the study was to assess the efficacy and safety of DGHAL, define its indications, and identify its possible advantages and limitations for the treatment of second- and third-degree hemorrhoids. The procedure was performed using a specially designed proctoscope. The Doppler probe was used to locate all the terminal branches of hemorrhoidal arteries, which were then sutured. Patients were followed up for 2 years. From November 2006 to May 2009, 50 patients (29 female, mean age 38.2 years) underwent this procedure. The procedure was performed under local anesthesia. An average of five ligatures was placed. Average length of hospital stay was 2 hours and return to work was 2.5 days. The mean postoperative pain score was 1.72. There were no intra- or immediate postoperative major complications. In 44 patients (88%), surgery resolved the symptoms completely in a 2-year follow-up period. DGHAL is a safe and effective procedure. DGHAL can be the choice for second- and third-degree hemorrhoids with minimal postoperative pain and quick recovery.

The role of d-lactate in differential diagnosis of acute appendicitis.

INTRODUCTION: Early diagnosis of acute appendicitis, known as the most frequent cause of acute surgical abdominal pathologies, dramatically decreases the related complications. D-lactate, produced by intestinal bacteria as a fermentation product, may be useful in diagnosing acute abdominal pathologies. The aim of this study was to investigate whether the presence of d-lactate would be a significant indicator in the early diagnosis of acute appendicitis. METHODS: Eighty consecutive patients were prospectively included in this study. The patients were divided into four groups: acute appendicitis (group 1), perforated acute appendicitis (group 2), nonspecific abdominal pain (group 3), and acute abdomen other than acute appendicitis (group 4). For the control group, blood samples were taken in the same manner from 20 healthy subjects. RESULTS: There was no significant difference in blood d-lactate levels between the simple acute appendicitis and acute perforated appendicitis groups (p > .05). The blood d-lactate levels in groups 1 and 2 were significantly higher than those in groups 3 and 4, and the control group (p < .001). The reliability of d-lactate was determined as 97% sensitivity, 93% specificity, 90% positive predictive and 95% negative predictive values, and 95% accuracy. CONCLUSIONS: Based on findings in this study, blood d-lactate level may be a valuable diagnostic marker for the diagnosis of acute appendicitis.

The effects of LigaSure on the laparoscopic management of acute appendicitis: "LigaSure assisted laparoscopic appendectomy".

A very important step in laparoscopic appendectomy is dissection of the appendiceal mesenteric pedicle. The aim of this study was to investigate the effect of LigaSure in laparoscopic appendectomy. Between August 2007 and June 2008, a total of 32 patients were included in the study. Patients were randomized into 2 groups. The first group's dissection of the mesoappendix was performed with LigaSure (5 to 10 mm), whereas the second group's with endodissector and endoclip. The surgical time, postoperative complications, additional analgesics use and hospital stay were compared. There were no significant differences in complication rates, use of analgesics and hospital stay between the groups. The operation time (49.06+/-14.73 min vs. 59.69+/-12.54 min, P=0.036) was significantly lower in the LigaSure group. This study demonstrates that dissection of the mesoappendix with LigaSure reduces the operation time and could be used safely. However, more experiences are needed to attain reliable scientific results.