Evaluation of the performance of and interobserver agreement on postoperative baseline CT findings in the identification of locoregional recurrence in patients with pancreatic ductal adenocarcinoma.

PURPOSE: To evaluate interobserver agreement on the findings of baseline contrast-enhanced multidetector computed tomography (CE-MDCT) performed at the postoperative third month in patients who underwent surgery due to ductal adenocarcinoma of the pancreatic head and investigate the value of these findings in predicting locoregional recurrence. MATERIAL AND METHODS: The baseline CE-MDCT images of 198 patients who underwent the Whipple procedure due to pancreatic head tumors were evaluated independently by three radiologists at the postoperative third month. The radiologists were asked to note suspicious findings in terms of locoregional recurrence, including postoperative fat stranding, the presence of perivascular contrast-enhanced solid tissue, short diameter of solid tissue if present, the shape of solid tissue (convex/concave), presence of peritoneal implants, diameter (mm) of pancreatic duct dilatation if present, the presence of lymph nodes larger than 5 mm, portal vein stenosis (≥50 and <50%), the presence of ascites, and the presence of distant metastases, as specified by the Society of Abdominal Radiology in October 2022. The agreement between the radiologists and the value of these parameters in predicting locoregional recurrence were investigated. RESULTS: Among the CE-MDCT findings evaluated, the radiologists had a moderate-to-high level of agreement concerning the presence of perivascular contrast-enhanced solid tissue. However, there was a poor interobserver agreement on the shape of solid tissue. A very high level of agreement was found among the radiologists in the evaluation of pancreatic duct dilatation, peritoneal implants, ascites, and the presence of distant metastases. According to the univariate analysis, the rates of portal vein stenosis had a 1.419 -fold effect [odds ratio (OR)=1.419, [95% confidence interval (CI)= 0.548-3.679, p=0.041], lymph node presence had a 2.337 -fold effect [odds ratio (OR)=2.337, [95% confidence interval (CI)= 1.165-4.686, p=0.015], perivascular contrast-enhanced solid tissue had 2.241 -fold effect [odds ratio (OR)=2.241, [95% confidence interval (CI)= 1.072-4.684, p=0.005]. In the multivariate analysis, perivascular contrast-enhanced solid tissue had 2.241 -fold effect [odds ratio (OR)=2.519, [95% confidence interval (CI)= 1.132-5.605, p=0.024]. CONCLUSION: In the postoperative baseline CE-MDCT examination, the presence of solid tissue, lymph node presence, and portal vein stenosis in the surgical bed are among the findings that may indicate early locoregional recurrence in patients with pancreatic ductal adenocarcinoma.

Isolated Roux loop versus conventional pancreaticojejunostomy following pancreaticoduodenectomy.

AIM: This study aimed to examine the effects of isolated Roux loop (IP) versus conventional pancreaticojejunostomy (CP) techniques on the rate of postoperative pancreatic fistula and its severity. MATERIAL AND METHODS: This study included retrospectively collected data from 132 patients who underwent pancreaticoduodenectomy in a single institute. Collected data were compared between IP and CP groups. Postoperative pancreatic fistula and its grades were defined according to International Study Group on Pancreatic Fistula (ISGPF) definition. RESULTS: A total of 58 patients had IP and 74 patients had CP. Biochemical leak (IP 20.6% versus CP 14.9%, p=0.38) and grade B/C pancreatic fistula (IP 20.6% versus CP 32.4%, p=0.13) rates of both groups were similar. Durations of hospital stay and intensive care unit stay and 30-day mortality rates of the two groups were similar. CONCLUSION: Isolated Roux loop reconstruction following pancreaticoduodenectomy is not associated with a lower rate of pancreatic fistula but may contribute to reducing the severity of pancreatic fistula. KEY WORDS: Anastomotic leak, Pancreatic fistula, Pancreaticoduodenectomy, Roux en y anastomosis.

Natural orifice specimen extraction versus transabdominal extraction in laparoscopic right hemicolectomy.

INTRODUCCIÓN: La extracción de muestras de orificio natural (NOSE) para resecciones colorrectales, que mejoran aún más las ventajas de la cirugía mínimamente invasiva, se utilizan cada vez con mayor frecuencia. En este estudio, nuestro objetivo fue comparar los métodos de extracción de muestras de nariz y transabdominales en casos de resecciones de colon derecho totalmente laparoscópicas. MÉTODOS: Se incluyeron datos de 52 pacientes que se sometieron a cirugía laparoscópica de colon derecho entre 2013 y 2019. La extracción de muestras transabdominales se realizó en 35 pacientes, mientras que 17 pacientes fueron sometidos a NOSE. Se compararon datos demográficos, hallazgos operativos, resultados patológicos y datos de seguimiento. RESULTADOS: Las mujeres (94% frente a 28%, p = 0,0001), comórbidas (76% frente a 40%, p = 0,01) y antecedentes de cirugía abdominal previa (75% frente a 23%, p = 0,001) fueron más altas en el grupo NOSE . Todas las otras características preoperatorias de los grupos fueron comparables. La pérdida de sangre intraoperatoria, el tiempo de operación y las tasas de complicaciones fueron similares en ambos grupos. La escala VAS postoperatoria (2.8 ± 1.2 vs. 4.5 ± 2.4, p = 0.001) y los puntajes cosméticos fueron mejores en el grupo NOSE (10 vs. 7, p = 0.0001). Los resultados oncológicos fueron similares después de un seguimiento medio de 27.4 ± 20.5 (1-77) meses. CONCLUSIÓN: El método NOSE después de la resección laparoscópica del colon derecho fue un método más ventajoso en términos de cosméticos y dolor postoperatorio que la extracción de muestras transabdominales. INTRODUCTION: Natural orifice specimen extraction (NOSE) for colorectal resections, which further enhance the advantages of minimally invasive surgery, are being used increasingly more often. In this study, we aimed to compare NOSE and transabdominal specimen extraction methods in cases of totally laparoscopic right colon resections. METHODS: Data of 52 patients who underwent laparoscopic right colon surgery between 2013 and 2019 were included in the study. Transabdominal specimen removal was done in 35 patients, while 17 patients underwent NOSE. Demographic data, operative findings, pathological results, and follow-up data were compared. RESULTS: Female (94% vs. 28%, p = 0.0001), co-morbid (76% vs. 40%, p = 0.01), and previous abdominal surgery history (75% vs. 23%, p = 0.001) were higher in the NOSE group. All the other pre-operative features of the groups were comparable. Intraoperative blood loss, operation time, and complication rates were similar in both groups. Post-operative visual analog scale (2.8 ± 1.2 vs. 4.5 ± 2.4, p = 0.001) and cosmetic scores were better in the NOSE group (10 vs. 7, p = 0.0001). Oncologic results were similar after a mean follow-up of 27.4 ± 20.5 (1-77) months. CONCLUSION: The NOSE method following laparoscopic right colon resection was a more advantageous method in terms of cosmetics and post-operative pain than transabdominal specimen extraction.

Acute Liver Failure following Sleeve Gastrectomy with Jejuno-Ileal Bypass.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric surgery in recent years, and some modifications have emerged to improve its efficacy. Melissas has described SG plus jejuno-ileal bypass (JIB), which has reported good results in a few studies. We performed this procedure in 21 cases and in one case, we observed acute liver failure (ALF) that has not been reported before. CASE PRESENTATION: A 38-year-old female (BMI: 56.1 kg/m2) underwent laparoscopic SG plus JIB. There was no sign of diarrhea, malnutrition or liver failure for eight months and her BMI was 43.0 kg/m2. At the 9th month, she was hospitalized for abdominal pain, jaundice and ALF. The patient was treated by plasmapheresis and molecular absorptive recirculation system. She was planned to undergo liver transplantation but died of multiorgan failure on the 40th day of hospitalization. CONCLUSION: ALF can be observed following SG plus JIB. JIB reversal before compromising liver functions should be taken into consideration.

Totally minimally invasive radical gastrectomy with the da Vinci Xi® robotic system versus straight laparoscopy for gastric adenocarcinoma.

BACKGROUND: Data regarding the outcomes of pure minimally invasive techniques of radical gastrectomy are scarce. We aimed to compare short-term post-operative outcomes in patients undergoing totally minimally invasive radical gastrectomy with the da Vinci Xi® robotic system versus straight laparoscopy for gastric adenocarcinoma. METHODS: Between December 2013 and March 2018, robotic and laparoscopic radical gastrectomy performed in two centres were included. Both groups were compared with respect to perioperative short-term outcomes. RESULTS: Ninety-four patients were included in the study. Anticoagulant and neoadjuvant chemotherapy use were higher in the robotic group (p = 0.02, p = 0.02). There were conversions in the laparoscopy group whereas no conversions occurred in the robotic group (p = 0.052). Operating time in the robotic group was longer (p = 0.001). The number of harvested lymph nodes in the laparoscopic group was higher (p = 0.047). CONCLUSION: Totally robotic technique with the da Vinci Xi® robotic system provides similar short-term results compared to laparoscopic surgery in radical gastrectomy.

Surgical site infection and risk factors following right lobe living donor liver transplantation in adults: A single-center prospective cohort study.

INTRODUCTION: Surgical site infection (SSI) is an important cause of decreased graft survival, prolonged hospital stay, and higher costs following living donor liver transplantation. There are several risk factors for SSI. In this cohort study, we aimed to investigate the incidence of SSI at our center and the associated risk factors. MATERIALS AND METHODS: Adult right lobe living donor liver transplantations were included in this prospective cohort. Patients who died postoperatively within 3 days; patients with infected ascites or open abdomen, cadaveric, or pediatric transplants; and patients with biologic or cryopreserved vascular grafts were excluded. Patients' demographic characteristics and perioperative surgical findings were recorded. SSI follow-up was continued for 90 days. CDC-2017 criteria were used to diagnose SSI. In the presence of superficial, deep, and organ/space SSI, only the organ in the poorest condition was included in SSI evaluation. The patients were administered similar to antibiotic prophylaxes and immunosuppressive protocols. RESULTS: A total of 101 patients were enrolled in this study, of which 30 (29.7%) were diagnosed with SSI. Organ/space, only deep, and only superficial SSI were noted in 90% (27/30), 6.7% (2/30), and 3.3% (1/30) of the patients, respectively. Twenty-five of 30 patients with SSI had a remote site infection. One or more bacteria observed in cultures were obtained from 28 patients. A donor-recipient age difference of >10 years, cold ischemia lasting for ≥150 minutes, surgical duration of ≥600 minutes, intraoperative hemorrhage of ≥1000 mL, intraoperative blood transfusion, biliary leak or stricture, prolonged mechanical ventilation, prolonged intensive care unit and hospital stay, remote site infection, and the need for reoperation were associated with increased SSI incidence. Preoperative and intraoperative levels of blood glucose, albumin, and hemoglobin were not associated with SSI. A donor-recipient age difference of >10 years, remote site infection, and biliary leak were found to be independent risk factors for SSI. Hospital mortality with and without SSIs was 6.7% vs 4.4%, P = .61. DISCUSSION: Organ/space SSIs were the essential part of SSIs following right lobe living donor liver transplantations. Donor-recipient age gap, prolonged cold ischemia time, complicated surgery, and postoperative biliary complications were the main causes of SSIs. Although they did not increase the perioperative mortality, they promote increased rate of reoperations, remote infections, prolonged intensive care unit, and hospital stays.

Transverse colon stenosis following laparoscopic total gastrectomy for gastric remnant carcinoma.

Laparoscopic surgery for remnant gastric cancer has been reported in a limited number of cases, and data on post-operative complications are lacking. A 58-year-old male was admitted with remnant gastric cancer. He had undergone open subtotal gastrectomy 9 years ago for gastric cancer. Laparoscopic total gastrectomy was performed, and he was discharged on the 10th day uneventfully. The patient had complained of nausea and vomiting in the 2nd post-operative month. He clinically and radiologically diagnosed as ileus and required open emergency surgery. There was a transverse colon stenosis near the splenic flexure. Hartmann's procedure was done, and he was discharged on day 17. We have limited knowledge about colonic complications after laparoscopic gastric surgery. The development of stenosis in the transverse colon is one of these complications that should be kept in mind. As far as we know, such a complication has never been reported before.

Laparoscopic resection of choledochal cysts in adults: a series from Turkey.

OBJECTIVES: Choledochal cyst is a congenital disease in which surgical treatment is preliminary because of the potential for malignancy. In recent years, increase in technological developments and laparoscopic experience have popularised the use of laparoscopy in adult choledochal cyst surgery. This study aimed to present the results of eight adult patients undergoing laparoscopic choledochal excision surgery. MATERIAL AND METHODS: Patients who underwent laparoscopic choledochal cyst excision and hepatico-jejunostomy anastomoses between the years 2013 and 2018 were evaluated retrospectively. Demographic characteristics, preoperative and postoperative findings, pathological results and final condition of the patients were examined. RESULTS: Of the eight patients, three were males and five were females. Median age was 41.5 years (22-49). One of the patients had Type IVa and the rest had Type I choledochal cysts. Laparoscopic choledochal cyst excision, cholecystectomy, and hepatico-jejunostomy anastomoses were performed on all of the patients. One patient was converted to open surgery. Three patients had postoperative biliary leakage. Duration of the operations was determined as median 330 (240-480) minutes and blood loss was 50 (10-100) mL. Hospitalization of the patients was median 6 (4-23) days and follow-up time was median 20 (2-65) months. In the late period, cholangitis occured in a patient who was treated with medical therapy and there was no mortality in the follow-up period. CONCLUSION: We suggest that laparoscopic choledochal cyst excision in adults may be an alternative to open surgery due to the satisfactory results in the late period in spite of early problems like self-limiting bile leakage.

Randomized controlled trial of monopolar cautery versus clips for staple line bleeding control in Roux-en-Y gastric bypass.

BACKGROUND: Bleeding from the staple line is a rare but serious problem following bariatric surgery. Staple line bleeding control (SLBC) can be achieved in different ways such as the application of sutures, clips, glue or buttressing materials over the staple line. Cauterization alone is generally not preferred due to concerns about debilitating the staple line. OBJECTIVES: The aim of this study was to compare the clip and monopolar cauterization methods for SLBC in laparoscopic Roux-en-Y gastric bypass. SETTING: University hospital. METHODS: A total of 70 morbidly obese patients were randomized into two groups. Patients with previous upper gastrointestinal surgery, re-do procedures and open surgeries were excluded. Their demographic characteristics, intraoperative and postoperative outcomes were examined. RESULTS: A total of 489 SLBC interventions (274 clips and 215 cauterizations) were performed after 280 stapling applications. SLBC intervention number and location, additional trocar requirement, blood loss and operation time were not different between the groups. In the clip group, two patients required monopolar cauterization when clipping failed. No intraabdominal bleeding or gastrointestinal leakage was seen in any group. Postoperative gastrointestinal hemorrhage was seen in three patients, two in the clip group and one in the cautery group. There was no difference between the groups in terms of postoperative pain score, abdominal drainage amount, hemoglobin level alteration, morbidity or length of stay. CONCLUSIONS: In laparoscopic Roux-en-Y gastric bypass, monopolar cauterization for SLBC can be used instead of clipping. It appears that monopolar cautery is a safe and effective approach for SLBC in laparoscopic Roux-en-Y gastric bypass.

Influence of Drain Placement on Postoperative Pain Following Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity: Randomized Controlled Trial.

BACKGROUND: There is currently no evidence to support the routine use of an abdominal drain following laparoscopic Roux-en-Y gastric bypass (RYGB). Our aim was to investigate drain use in laparoscopic RYGB and its effects on postoperative pain. METHODS: Sixty-six patients were randomly divided into two groups as no-drain (n = 36) and with-drain (n = 30). Intraoperative (time, blood loss, complications) and postoperative outcomes (morbidities, pain scores, hospital stay) were compared. RESULTS: Demographics of both groups were comparable. Three patients in the no-drain group required a drain (8.3%). Median visual analog scale scores for days 1-3 for with-drain and no-drain groups were 4.5 (2-9) vs. 3 (0-8) (p = 0.02), 3 (0-7) vs. 2 (0-7) (p = 0.10), and 2 (0-7) vs. 0 (0-4) (p = 0.0004), respectively. There was no difference between the groups in terms of complications and length of hospital stay. CONCLUSION: Drain use increased the postoperative pain following laparoscopic RYGB. Drain placement following laparoscopic RYGB should be selective instead of a routine application.

The predictive value of red cell distribution width levels on mortality in intensive care patients with community-acquired intra-abdominal sepsis.

BACKGROUND: Red cell distribution width (RDW) is a part of the complete blood count (CBC) panel reflecting quantitative measure of variability in the size of circulating red blood cells. It has been known that higher RDW is associated with increased mortality in several diseases. The aim of this study was to investigate the association between RDW and hospital mortality in intensive care unit (ICU) patients with community-acquired intra-abdominal sepsis (C-IAS). METHODS: A retrospective analysis of the patients with C-IAS was performed between January 1, 2010 and March 31, 2013. Patients' demographics, co-morbidities, laboratory measures including RDW on admission to the ICU, and Acute Physiologic and Chronic Health Evaluation II (APACHE II) score were analyzed. RESULTS: A total of one hundred and three patients with C-IAS were included into the study with a mean age of 64±14 years. Overall mortality was 50.5%. RDW day 1 (RDW1) values and APACHE II scores were significantly higher in non-survivors than in survivors. In multivariate analysis, only RDW1 and APACHE II predicted mortality. The area under the receiver operating curves (AUC) of RDW1 and APACHE II were 0.867 (95% CI, 0.791-0.942) and 0.943 (95% CI, 0.902-0.984), respectively. CONCLUSION: This study suggests that increased RDW is associated with mortality in ICU patients with C-IAS.

Performance of venous port catheter insertion by a general surgeon: a prospective study.

As part of the vascular access procedures, venous ports, commonly referred to as catheters, are placed under the skin to enable safe and easy vascular access for administration of repeated drug treatments. 122 patients who had received a venous port catheter insertion procedure in the general surgery department between January 1012 and January 2014 were involved in this study. Patients were divided into two groups: those who had undergone a fluoroscopy (group 1) and those who had not undergone a fluoroscopy (group 2). Complications that emerged during and after the port catheter insertion procedure and successful insertion rates were recorded in the database. Data of these patients were presented in a prospective manner. There were 92 to 30 patients in groups 1 and 2, respectively. In group 1, the mean age was approximately 56.8, total catheter stay time was 20,631 days, and mean time of port use was 224.2 days. In group 2, the mean age was approximately 61.2, total catheter stay time was 13,575 days, and mean time of port use was 452.5 days. Successful insertion rate was 100% and 90% in groups 1 and 2, respectively (P < 0.05). The proper insertion of the port catheter accompanied by monitoring methods can decrease procedure-related complications. Statistical comparisons between the two groups in terms of malposition and successful insertion rates also support this view (P < 0.05). The findings support the view that in cancer patients, a venous port catheter insertion accompanied by a fluoroscopy can be safely performed by general surgeons.

Evaluation of mean platelet volume as a diagnostic biomarker in acute appendicitis.

BACKGROUND: Diagnosis of acute appendicitis remains to be challenging with up to 30% negative exploration rates. In addition to careful clinical history and physical examination, we still need easily applicable, cheap and effective biomarker. PATIENTS AND METHODS: A retrospective case-controlled study was designed in two groups, both containing 100 patients, acute appendicitis and control. Leukocyte count, neutrophil percentage, platelet count and meal platelet volume (MPV) were compared. RESULTS: MPV values for acute appendicitis and control groups were 7.4 ± 0.9 fL (5.6-10.6) and 9.1 ± 1.6 fL (5.1-13.1). For the diagnosis of acute appendicitis, ROC analysis revealed 74% sensitivity and 75% specificity for a cut-off value of 7.95 fL of MPV, however, the diagnostic value of leukocyte count and/or neutrophil ratio was superior. CONCLUSION: Our results suggest that, MPV value is an important parameter in the diagnosis of acute appendicitis, but in terms of sensitivity and specificity, leukocyte count and/or neutrophil percentage is superior.

Rhomboid Flap Technique in Breast-conserving Surgery: An Alternative Method for the Reconstruction of Lumpectomy Defects.

OBJECTIVE: We aimed to present our experience with rhomboid flap reconstruction, which is a simple technique, in breast cancer patients who underwent breast-conserving surgery. METHODS: We reviewed the medical records of 13 patients with breast cancer who underwent rhomboid flap reconstruction. The patients were evaluated for tumor size, safe surgical margin, and other clinical and pathological features. RESULTS: The mean age of the patients was 43.1 years (range: 28-69 years). The mean tumor diameter was 30.8 mm (range: 15-60 mm). The mean of the safe margin of resection was evaluated to be 17.8 mm (range: 5-30 mm). Re-excision was required for one patient in the same session. CONCLUSION: Rhomboid flap reconstruction can facilitate the applicability of breast-conserving surgery in early breast cancer patients with large tumor-to-breast-size ratio or tumors close to the skin.

The management of penetrating abdominal trauma by diagnostic laparoscopy: a prospective non-randomized study.

BACKGROUND: Penetrating abdominal trauma (PAT) has been traditionally treated by exploratory laparotomy (EL). The aim of our study was to examine the use of diagnostic laparoscopy (DL) in the management of hemodynamically stable patients with PAT. METHODS: A prospective study was performed to compare the outcomes of hemodynamically stable patients with suspected intra-abdominal injuries due to abdominal stab wounds who underwent either EL or DL. Data extracted for analysis included demographic information, operative findings, rates of non-therapeutic laparotomy, operation time, length of hospital stay, mortality, and postoperative complications. RESULTS: Fifty-two hemodynamically stable patients were admitted to the trauma service. There were 45 male (86.5%) and 7 female (13.5%) patients. The average age was 34.5 years-old (18-60). 26 (50%) patients underwent EL, and 26 (50%) patients underwent DL. Re-exploration by laparotomy was required in 9 of the 26 cases (34.6%). Patients who underwent DL had significantly shorter hospital stays (1.82±0.63 days vs. 5.4±2.1 days, p<0.05) and shorter operation time (17.9±6.38 vs. 68.4±33.2 min, p<0.05) than patients who underwent EL. CONCLUSION: Selective use of DL in the hemodinamically stable penetrating trauma patients effectively decreased the rate of negative laparotomies, minimized morbidity, and decreased hospital stay.