Comparison of transanal and transvaginal specimen extraction in laparoscopic colorectal surgery.

AIM: This study aimed to compare the outcomes of transanal and transvaginal NOSES in patients undergoing laparoscopic colorectal surgery. MATERIAL AND METHODS: This study included 45 patients who were scheduled for NOSES after undergoing laparoscopic colorectal resection in our clinic between January 2019 and March 2020. To ensure homogeneity between the groups, the data of 22 female patients were analyzed in this study. Patients were divided into two groups according to the specimen extraction technique used. Demographic data, preoperative and postoperative findings, as well as the pathology and sizes of the specimens were examined in both the groups. RESULTS: The demographic characteristics and preoperative and early postoperative outcomes were similar in both the groups. The size of the lesion was larger in the transvaginal group than that in the transanal group [4.58 ± 1.28 and 2.71 ± 1.55, respectively (P = 0.039)]. Two complications associated with extraction were observed (%9.09). A patient who underwent transanal extraction developed transient anal incontinence, which spontaneously resolved, and a patient who underwent transvaginal extraction developed anastomotic leakage and rectovaginal fistula associated with anastomotic leakage; a colonic stent was inserted for the management of this condition following which the patient recovered. CONCLUSION: Only the lesion size was statistically significantly different between the transanal and transvaginal routes. Further, avoiding secondary organ injury is essential; therefore, the transanal route is primarily preferred. However, if the diameter of the lesion is large and the patient is female, the transvaginal route can be a useful alternative. KEY WORDS: Natural orifice specimen extraction surgery, Laparoscopic colorectal surgery, Minimally invasive surgery.

Factors affecting mortality in patients with traumatic diaphragmatic injury: An analysis of 92 cases.

BACKGROUND: This study aims to investigate the factors associated with mortality in patients with traumatic diaphragmatic rupture (TDR). METHODS: The records of patients who were operated on at a single hospital with the indication of blunt or penetrating thoracoabdominal injuries between January 2010 and June 2018 and who were perioperatively diagnosed with a diaphragmatic injury were evaluated retrospectively. The details of demographic characteristics, the type and localization of the trauma, presence and number of associated organ injuries, vital signs at admission, time from admission until surgery, type of operation, type of diaphragmatic repair, therapeutic approach, complications and Injury Severity Score (ISS) were analyzed. RESULTS: A total of 92 patients were included in this study. The mortality rate throughout the postoperative period was 15.2%. A penetrating injury was detected in 77.2% of the patients. Associated organ injury was most frequently in the liver, which was significant as a factor that increased mortality (p=0.020). The mortality rate was significantly lower among patients who underwent repair of diaphragmatic rupture when compared with untreated patients (p=0.003). Atelectasis was the most common complication. An ISS ≥24 points in patients with TDR was found to be an independent risk factor associated with mortality (p=0.003). CONCLUSION: Other organs are frequently involved in cases of TDR, and mortality increased significantly in cases with associated liver injury. An ISS of ≥24 was determined to be an independent risk factor associated with mortality. Since the main determinant of mortality was the presence or absence of additional organ injuries, it is important that this should be taken into consideration in these patients.

Successful Application of the Ventriculo-Gallbladder Shunt: A Salvage Procedure.

Ventriculo-gallblader shunt is very rarely used in the treatment of hydrocephalus. A 44-year-old male with ventriculoatrial shunt dysfunction was evaluated. His ventriculoatrial shunt was not working. His medical history revealed that his hydrocephalus was treated five times by venrtriculoperitoneal shunt, and four times by ventriculoatrial shunt. Another trial for ventriculoperitoneal or ventriculoatrial shunting was not considered feasible. A ventriculo-gallbladder shunt was placed to the patient as a potential salvage procedure. Remarkably, the patient benefited from the ventriculo-gallbladder shunt and was discharged from the hospital. We think that ventriculo-gallbladder shunting is a safe and effective treatment for hydrocephalus as the last resort in complicated cases of shunt dysfunction.

Evaluation of current therapeutic approach to obstructive and perforated colorectal cancers.

BACKGROUND: Late diagnosis continues to be a significant problem in the treatment of colorectal cancer (CRC). Most cases require emergency surgical intervention due to acute intestinal obstruction or perforation. This retrospective study was formed from an assessment of the clinical presentation, treatment, early results, and survival of patients with CRC undergoing emergency surgery for acute obstruction or perforation. METHODS: Between 2012 and 2017, 612 patients underwent surgery for CRC. In all, 179 patients who required emergency treatment were retrospectively evaluated according to age, gender, significant comorbidities, physiological status, surgical indications, tumor location, tumor stage, perioperative blood transfusion rate, type of surgery, and the length of the operation and hospitalization. RESULTS: In total, 152 (85%) patients had a complete obstruction and 27 (15%) patients had a perforation. A major postoperative complication was identified nearly in half of the patients. The overall mortality rate was 12% (22 patients). Mortality was seen in 12% (18 patients) cases received surgery due to obstruction and in 15% (four patients) cases received surgery due to perforation. Perioperative blood transfusion and a high Acute Physiology and Chronic Health Evaluation II score were independent factors that predicted a major complication. Advanced age and perioperative blood transfusion were statistically independent prognostic factors for mortality. CONCLUSION: Consisted with the findings of studies in the literature, the results of this study also revealed a high perioperative morbidity and mortality rate in patients with CRC who required urgent surgery. Our findings suggest that early detection and treatment of CRC with screening programs can be life-saving.

Laparoscopic treatment of hepatic hydatid cysts. Our approach.

AIM: In this study, we aimed to evaluate the clinical characteristics and outcome of patients with hydatid cyst (HC) of the liver who were laparoscopically operated at our clinic and to define a new technique and technical details to present our experience in the field of laparoscopic treatment of hepatic hydatid cysts. METHODS: Between January 2014 and October 2016, 18 patients with hydatid disease of the liver were considered for laparoscopic surgery in Dr. Lutfi Kirdar Education and Research Hospital, Department of General Surgery. All patients were evaluated based on history, physical examination, ultrasound (US), and computed tomography (CT) scan. All ultrasound examinations were classified according to Gharbi. All cases received laparoscopic surgical interventions. Demographic data, clinical presentation, cyst location, operative data, postoperative complications and follow-up results were recorded retrospectively. RESULTS: Eighteen patients underwent laparoscopic surgery for hydatid cysts of the liver. here were 14 female (78%) and 4 male (22%) patients with a mean age of 42.9 years (range, 19-57). The hydatid cysts were solitary in 11 patients, and multiple in 7 patients had 2 or more cysts (4 patients had 2 cysts, 3 patients had 3 cysts). Most of the cysts on USG were Gharbi type III (8 cysts), 4 of Type II, and 3 of Type I. The average operating time was 75 minutes (range 50 - 135 minutes). Conversion to open surgery was necessary in one patients due to cyst in difficult location. CONCLUSION: Laparoscopic management of hydatid cysts of the liver can be performed safely and successfully. This technique can be used in patients with unique, small sized, superficially located cysts, and also has the advantages of other abdominal laparoscopic operations. KEY WORDS: Hepatic hydatid cysts, Laparoscopic surgery.

Outcomes of silver nitrate use in perianal fistula: are perianal fistulas still a nightmare for surgeons?

INTRODUCTION: In this study, we aimed to evaluate outcomes of % 20 silver nitrate (SNS) application in perianal fistula patients. MATERIAL AND METHOD: All patients who received 20 % SNS treatment for intersphincteric and transsphincteric fistulas between January 2017 and December 2017 were included in our study. Patients were invited for control examinations after one week. Patients with continued discharges after single dose of SNS kept receiving solution six more times with one month intervals. Stopping of discharges were considered as finalization of the study. Cases with discharges after 6 episodes of SNS were described as insufficient healing. The patients were grouped according to healing status (healing patients in Group 1, non-healing patients in Group 2) .Gender, age, follow-up times, date of the complaint start, number of SNS application, type of fistula and frequency of fistula discharge were recorded. RESULTS: A total of 49 patients were included in this study. Forty-four (% 89.8) of them were male. The mean age was 44.9. Twenty-eight patients (57.1%) had intersphincteric fistulas, while twenty-two patients (42.9%) had intersfinteric fistulas. Mean number of SNS application was 4.1 (1-6). Patients in Group 1 had mean number of SNS therapy as 3.42 (1-6), whereas cases in Group 2 this number was 5.5 (3-6). Patients were observed approximately for 8.84 months (6-12). We were able to reach sufficient healing in 13 (%26) cases via 2 times and 20 (%40) cases via 3-6 times application of SNS. CONCLUSION: We were able to reach complete healing rates as % 67 with SNS application in perianal fistula. This is a non-invasive procedure and could be applied in out patient clinics, with low costs. Less complication rates enhances attraction. Patients will not loose chance of surgical treatment. Therefore, we believe SNS may be used as first line treatment in perianal fistulas. KEY WORDS: Follow-up, Perianal fistula, Silver nitrate.

Anal canal squamous cell cancer: surgical therapy, when?

Aim To describe a therapeutic approach, indications for abdominoperineal resection (APR), survival and oncological results for patients who received treatment in our surgical clinic for anal canal squamous cell cancer (SCC). Methods Patients were randomized into two groups according to the treatment method: Group 1- Chemoradiotherapy (CRT) without surgery, Group 2- CRT + APR. Results Eighteen patients with anal canal SCC were included in the study; 11 (61.1%) patients were in Group 1 and 7 (38.8%) in Group 2. Reasons for APR was as follows: three patients had insufficient CRT, two had recurrence after CRT, one had complete faecal incontinence and one patient had rectovaginal fistula. Overall five year survival (OS) and disease free survival (DFS) was 77.7% and 72.7%, respectively. Comparing two groups five year OS was 90.9% and 57.1%, whereas DFS was 81.8%, 57.1%, respectively (p=0.389 and 0.324, respectively). Conclusion Gold standard therapy for anal canal SCC is CRT. However, APR should be applied as an escape treatment for patients suffering from tumour progression, insufficient CRT and recurrence (30%).

Are the single-step resection and primary anastomosis suitable for obstructive colorectal patients in older cases?

Aim To investigate the efficacy and safety of the single-step surgery in elderly patients with obstructive colorectal cancer. Methods All patients who underwent single-step surgery and primary anastomosis for obstructive colorectal cancer in the period between January 2021 December 2017 were evaluated in this study. The patients were divided into two groups: younger than 65 (Group Young) and older than 65 (Group Old). Demographic data, American Society of Anesthesiologists scores (ASA) scores, comorbidities, preoperative albumin levels, type of surgery, postoperative morbidity and mortality, pathological stages, and overall survival rates were investigated. Results A total of 89 patients were included: 49 (54%) were older than 65 (Group Old). In Group Old, the mean age was 75 (65-97), of which 28 (58.3%) were males. There were 41 patients younger than 65 (Group Young) with the mean age of 52.6 (41-64 years of age), of which 21 (51.2%) were males. There was no difference between groups according to albumin level. There was no statistical difference between two groups according to tumour localization, pathological stage and type of surgery, as well as according to surgical complications. The median overall survival rate was 11 months in both groups (0-66) (p=0.320). Conclusion Meticulous preparation of older patients (correction of anaemia, electrolyte levels and pH ) paves the road for successful surgeries, including single-step resection and primary anastomosis.

Gallbladder perforation during elective laparoscopic cholecystectomy: Incidence, risk factors, and outcomes.

OBJECTIVE: This study aimed to reveal the risk factors and outcomes of gallbladder perforation (GP) during laparoscopic cholecystectomy. METHODS: Videotapes of all patients who underwent an elective cholecystectomy at our department were retrospectively analyzed, and the patients were divided into two groups based on the presence of GP. The possible risk factors and early outcomes were analyzed. RESULTS: In total, 664 patients [524 (78.9%) females, 49.7±13.4 years of age] were observed, and GP occurred in 240 (36.1%) patients, mostly while dissecting the gallbladder from its bed (n=197, 82.1%). GP was not recorded in the operation notes in 177 (73.8%) cases. Among the studied parameters, there was no significant risk factor for GP, except preoperatively elevated alanine transaminase level (p=0.005), but the sensitivity and specificity of this measure in predicting GP were 14.2% and 7.4%, respectively. The two groups had similar outcomes, but the operation time (35.4±17.5 vs 41.4±18.7 min, p=0.000) and incidence of drain use (25% vs 45.8%, p=0.000) increased in the GP group. CONCLUSION: The present study reveals that GP occurs in 36.1% of patients who undergo laparoscopic elective cholecystectomy, but it may not be recorded in most cases. We did not find any reliable risk factor that increases the possibility of GP. GP causes an increase in the operation time and incidence of drain use; however, the other outcomes were found to be similar in patients with GP and those without.

J-pouch vs. side-to-end anastomosis after hand-assisted laparoscopic low anterior resection for rectal cancer: A prospective randomized trial on short and long term outcomes including life quality and functional results.

PURPOSE: To analyze the outcomes of j-pouch and side-to-end anastomosis in rectal cancer patients treated with laparoscopic hand-assisted low anterior resection. METHODS: Prospective trial on cases randomized to have a colonic j-pouch or a side-to-end anastomosis after low anterior resection. Demographics, characteristics of disease and treatment, perioperative results, and functional outcomes and life quality were compared between the groups. RESULTS: Seventy four patients were randomized. Reservoir creation was withdrawn in 17 (23%) patients, mostly related to reach problem (n = 11, 64.7%). Anastomotic leakage rate was significantly higher in j-pouch group (8 [27.6%] vs. 0, p = 0.004). Stoma closure could not be achieved in 16 (28.1%) patients. Life quality and functional outcomes, measured 4, 8 and 12 months after the stoma reversal, were similar. CONCLUSIONS: Colonic j-pouch and side-to-end anastomosis are similar regarding perioperative measures including operation time, rates of postoperative complications, reoperation and 30-day mortality, and hospitalization period except anastomotic leak rate, which is higher in j-pouch group. Postoperative aspects are not different in patients receiving either technique including functional outcomes and life quality for the first year after stoma closure. In our opinion, both techniques may be preferred during the daily practice while performing laparoscopic surgery; but surgeons may be aware of a possibly higher anastomotic leak rate in case of a j-pouch.

Unusually located primary hydatid cysts.

The hydatid disease caused by Echinococcus granulosus is an endemic parasitic disease affecting several Mediterranean countries. Echinococcal cysts are mostly located in the liver and the lung, but the disease can be detected anywhere in the body. In this study, we present uncommon extrahepatic localizations of primary hydatid disease. Patients who were operated on for hydatid disease or cystic lesions, which were later diagnosed as hydatid disease, between 2004 and 2010 were retrieved retrospectively. Patients with lesions localized outside the liver and the lung were enrolled in the study. Eight patients with extrahepatic primary hydatid disease were treated surgically at our clinic. The cysts were located in the scapular region, spleen, pancreas, lumbosacral region and gluteal muscle. Surgical techniques were partial or total cystectomy with or without tube drainage. Splenectomy was performed for splenic hydatid disease and partial pericystectomy, Roux-en-Y cystojejunostomy, cholecystectomy and T-tube drainage for pancreatic hydatid disease. There were no complications or mortality in the postoperative period. Hydatid cyst should be considered in the differential diagnosis of cystic lesions, especially in endemic areas. Surgical technique should be planned according to the location of the cyst.

Is there any role of thrombin activatable fibrinolysis inhibitor in the development of a hypercoagulable state in gastric cancer.

BACKGROUND: The purpose of this study was to investigate plasma levels of thrombin activatable fibrinolysis inhibitor (TAFI) and TAFI's relationship with coagulation markers (prothrombin fragment 1 + 2) in gastric cancer patients. METHODS: Thirty-three patients with gastric adenocarcinoma and 29 healthy control subjects were prospectively enrolled in the study. Patients who had a history of secondary malignancy, thrombosis related disease, oral contraceptive use, diabetes mellitus, chronic renal failure or similar chronic metabolic disease were excluded from the study. A fasting blood sample was drawn from patients to determine the plasma levels of TAFI and Prothrombin Fragment 1 + 2 (F 1 + 2). In addition, data on patient age, sex, body mass index (BMI) and stage of disease were recorded. The same parameters, except stage of disease, were also recorded for the control group. Subsequently, we assessed the difference in the levels of TAFI and F 1 + 2 between the patient and control groups. Moreover, we investigated the relation of TAFI and F 1 + 2 levels with age, sex, BMI and stage of disease in the gastric cancer group. RESULTS: There were no statistical differences in any demographic variables (age, gender and BMI) between the groups (Table 1). The mean plasma TAFI levels of the gastric cancer group (69.4 ± 33.1) and control group (73.3 ± 27.5) were statistically similar (P = 0.62). The mean plasma F 1 + 2 level in the gastric cancer group was significantly higher than for those in the control group (549.7 ± 325.3 vs 151.9 ± 67.1, respectively; P < 0.001). In the gastric cancer group, none of the demographic variables (age, gender and BMI) were correlated with either TAFI or F 1 + 2 levels. Also, no significant associations were found between the stage of the cancer and either TAFI or F 1 + 2 levels. CONCLUSION: In our study, TAFI levels of gastric cancer patients were similar to healthy subjects. The results of our study suggest that TAFI does not play a role in pathogenesis of the hypercoagulable state in gastric cancer patients.

The effectiveness of hyaluronan-carboxymethylcellulose membrane in different severity of adhesions observed at the time of relaparotomies: an experimental study on mice.

PURPOSE: This study was designed to evaluate the effect of Seprafilm use in the presence of different severity of adhesions encountered in relaparotomies. METHODS: A total of 110 male Balb/c mice were randomized into two experiment groups: Sepra and Control. All animals underwent cecal and small-bowel abrasions during the first operation. The severity of adhesions were evaluated as "slight" or"dense" at the time of relaparotomy performed 14days after the initial operation, and Seprafilm was applied to the animals in Group Sepra. Accordingly, the groups were documented as Sepra-slight, Sepra-dense, Control-slight, and Control-dense. All subjects were killed 14days later, the adhesion severity was evaluated with a scale scoring 0 to 5, and the results were compared between the groups. RESULTS: The death of 21 animals (19.1 percent) before (n = 10) and after (n = 11) the second operation left 22, 24, 26, and 17 animals in groups Sepra-slight, Sepra-dense, Control-slight, and Control-dense, respectively. Seprafilm significantly reduced the adhesion severity score (1.1 +/- 1.1 vs. 2.1 +/- 1.5 in Groups Sepra and Control, respectively; P < 0.05). Seprafilm did not significantly decrease the severity of adhesions in the presence of slight adhesions at the time of relaparotomy (P > 0.05). However, the analysis of groups revealed that Seprafilm was more effective when used during the observation of severe adhesions at the time of relaparotomy (1.7 +/- 1.4 vs. 2.7 +/- 1.5 in Groups Sepra-dense vs. Control-dense, respectively; P < 0.05). CONCLUSIONS: Seprafilm is effective in preventing adhesions even if it is used at the time of relaparotomy, but the antiadhesive effect of product peaks when it is used during the observation of dense adhesions at the time of relaparotomy.