Pay for performance system in Turkey and the world; a global overview.

Objectives: This study aimed to compare the pay for performance system applied nationally in Turkey and in other countries around the world and to reveal the effects of the system applied in our country on the general surgery. Material and Methods: Current literature and countries' programs on the implementation of the pay for performance system were recorded. The results of the Turkish Surgical Association's performance and Healthcare Implementation Communique (HIC) commission studies were evaluated in light of the literature. Results: Many countries have implemented performance systems on a limited scale to improve quality, speed up the diagnosis, treatment, and control of certain diseases, and they have generally applied it as a financial promotion by receiving the support of health insurance companies and nongovernmental organizations. It turns out that surgeons in our country feel that they are being wronged because of the injustice in the current system because the property of their works is not appreciated and they cannot get the reward for the work they do. This is also the reason for the reluctance of medical school graduates to choose general surgery. Conclusion: Authorities should pay attention to the opinions of associations and experts in the related field when creating lists of interventional procedures related to surgery. Equal pay should be given to equal work nationally, and surgeons should be encouraged by incentives to perform detailed, qualified surgeries. There is a possibility that the staff positions opened for general surgery, as well as, all surgical branches will remain empty in the near future.

Risk factors for conversion to open surgery in laparoscopic cholecystectomy: A single center experience.

OBJECTIVES: This study aimed to demonstrate the demographic characteristics for laparoscopic cholecystectomy surgeries performed in the general surgery clinics of our hospital and to identify the rate of conversion to open surgery and the main reasons for convert to open surgery. MATERIAL AND METHODS: Medical records of a total of 1.294 patients who underwent laparoscopic cholecystectomy in our hospital between October 2013 and May 2017 were retrospectively reviewed, and the rates of conversion to open surgery based on age groups were recorded. RESULTS: Of these patients, 1191 were females (92.0%) and 103 (7.9%) were males. Mean age was 48.6 ± 13.2 (range: 18 to 89) years. Indications for surgery were cholelithiasis in 1195 patients (92.4%), acute cholecystitis in 56 patients (4.4%), and gallbladder polyps in 43 patients (3.3%). The procedure was conversion to open surgery in 41 patients (3.16%), while 12 (0.9%) developed intraoperative complications. There was no mortality. Mean length of hospital stay was 1.2 (range: 1 to 6) days. The main reasons for conversation to open surgery were as follows: adhesions in the Calot's triangle (n= 3), acute cholecystitis (n= 29), choledocholithiasis (n= 2), adhesions due to previous surgery (n= 1), dissection difficulty (n= 2), organ damage (n= 2), anatomic variation (n= 1), and stone expulsion (n= 1). CONCLUSION: Acute cholecystitis appears to be the significant factor increasing the rate of conversation to open surgery during LC procedures. Male sex and older age are the other factors increasing the risk of con- vert to open surgery. However, LC should be still the first choice of intervention.

Endoscopy in surgery.

In the last 20 years, there have been important developments in endoscopy. Initially, endoscopy was developed and used as a diagnostic tool. As new technology developed, these devices also became the basis for therapeutic maneuvers. In recent years, flexible endoscopes have been used to per- form procedures replacing traditional surgical approaches. Examples of this field are transanal minimally invasive surgery, natural orifice transluminal endoscopic surgery, endoscopic metabolic surgery and third space endoscopies. Throughout history, surgeons have played a vital role in the design and development of endoscopic techniques, procedures, and equipment. Surgeons continue to lead the advancement of endoscopy, make important contributions, and serve as role models for innovation.

Predictive factors of neoplastic gallbladder polyps: Outcomes of 278 patients.

BACKGROUND/AIMS: Distinguishing between neoplastic and nonneoplastic gallbladder polyps (GBPs) in the preoperative workup is of great importance for appropriate treatment. The present study aimed to investigate the characteristics of GBPs and to determine potential predictive factors of neoplastic polyps. MATERIALS AND METHODS: The data of 278 patients who were confirmed to have GBPs through laparoscopic cholecystectomy were retrospectively analyzed. Polyps were classified as nonneoplastic and neoplastic GBPs, according to histopathological diagnoses. All clinicopathological characteristics were compared between these two groups. RESULTS: There were 264 (95%) nonneoplastic GBPs and 14 (5%) neoplastic GBPs. In univariate analysis, there were significant differences in age with a cutoff value of 60 years (p=0.002), polyp size (p<0.001), number of polyps (p=0.014), and polyp morphology (p<0.001) between the groups. Multivariate analysis showed that solitary polyp (p<0.001) and sessile morphology (p<0.001) were the independent predictors of neoplastic GBPs. Receiver-operating characteristic curve analysis of three cut-off values of polyp sizes (6, 10, and 15 mm) indicated that a polyp size of 10 mm had the highest area under curve (0.942). CONCLUSION: Age above 60 years, solitary polyps larger than 1 cm, and sessile morphology are associated with an increased risk of neoplasia in GBP. Therefore, these characteristics should be considered in the management of GBPs to reduce the incidence of unnecessary surgeries and to prevent delays in the treatment of a possible cancer.

Effects of postoperative parenteral nutrition with different lipid emulsions in patients undergoing major abdominal surgery.

PURPOSE: This study was designed to investigate the effects of total parenteral nutrition (PN) using different lipid emulsions in patients undergoing major abdominal surgery. METHODS: Fifty-two patients were randomized to receive soybean oil + medium chain triglycerides (MCT) (group I), soybean oil + olive oil (group II), soybean oil + olive oil + fish oil (group III) as a lipid source. PN was started on postoperative day 1 and patients were maintained on PN for a minimum period of 4 days. Laboratory variables (CRP, prealbumin, transferrin) were measured before surgery and on postoperative days. RESULTS: Three treatment groups were included in the study. Patients in group I received long chain triglycerides (LCT) + LCT/MCT emulsion (%75 LCT + %25 LCT/MCT); Patients in group II received olive oil based emulsion (80% olive oil + 20% soybean oil, ClinOleic); Patients in group III received fish oil in addition to olive oil based emulsion (%85 ClinOleic + %15 Omegaven; Fresenius Kabi). The following 14 parameters were assessed: body weight, CRP, prealbumin, transferrin, tumor necrosis factor-α, interleukin-6, total antioxidant status, thiobarbituric acid reactive substances, oxidized low density lipoprotein-2, complete blood cell, international normalized ratio, D-dimer, activated partially thromboplastin time, prothrombin time. All other parameters showed no differences among the groups. CONCLUSION: The results of our trial demonstrate a potential beneficial effect of soybean oil/olive oil based lipid emulsions for use in PN regarding inflammatory response and oxidant capacity in the treatment of patients.

Comparison of Limberg flap and excision and primary closure of pilonidal sinus disease, in terms of quality of life and complications.

PURPOSE: The aim of this study was to compare two different treatment methods for pilonidal sinus with respect to complications, recurrence, and patient quality of life. METHODS: Five hundred forty-nine patients who underwent surgery for pilonidal sinus between January 2007 and August 2012 were included in this study. The patients were classified into group I (excision and primary closure) and group II (Limberg flap). RESULTS: There was no significant difference in the mean age and gender of the patients between groups I and II (P = 0.512 and P = 0.472). The duration of surgical operation was lower in group I (P < 0.001). There was no significant difference in hospitalization time after surgery, minor complications, and recurrence between the groups (P = 0.674, P = 1.000, and P = 1.000, respectively). The time required for pain-free walking, urinating, and returning to work was significantly lower in group II (P < 0.001, P < 0.001, and P < 0.001, respectively). The patients in group I stated that they were more satisfied in terms of aesthetics (P < 0.001). CONCLUSION: According to the results of this study, Limberg flap method has better outcomes compared with excision and primary closure. Therefore, we recommend Limberg flap for treatment of pilonidal sinus disease.

Splenic infarction as a complication of celiac artery thromboembolism: an unusual cause of abdominal pain.

Splenic infarction is a relatively uncommon diagnosis and this clinical presentation can mimic other causes of acute abdominal pain. Cardiologic and hematologic disorders are common reasons for this entity. There have been a few series and single case reports of splenic infarction published in peer-reviewed medical journals. We report a 53-year-old patient who had splenic infarction caused by celiac artery thromboembolism. The importance of this case, without any etiological predisposing factors, is that this kind of clinical situation should be considered in the differential diagnosis of abdominal pain.

Multiple renal arteries challenge in laparoscopic donor nephrectomy: how far can we go?

PURPOSE: Living donor kidneys with multiple arteries are routinely procured laparoscopically. We aim to present our experience with laparoscopic donor nephrectomy (LDN) and to compare the graft function and outcome between cases with single versus multiple arteries. METHODS: We compared the demographic data, operation time, warm ischemia time, rejection rate, and graft function between LDN kidneys with single artery and those with multiple arteries. RESULTS: Seventy-three cases with 1 renal artery (group LDN-1), 8 cases with 2 renal arteries (group LDN-2) and 5 cases with 3 or more renal arteries (group LDN-3) were included in the study. The mean operative time was significantly higher in groups LDN-2 (100.3 ± 9.5 minutes) and LDN-3 (120.6 ± 10.3 minutes) compared to group LDN-1 (75.7 ± 10 minutes, P < 0.001). Similar results were detected with respect to the warm ischemia time. There were no statistically significant differences related to graft function and outcome among these groups. CONCLUSION: Multiple renal arteries present a special challenge in both donor nephrectomy and renal transplantation. However, laparoscopic procurement of a kidney with multiple renal arteries, regardless of the number, is reliable and has no significant impact on the graft outcome.

Prevalence of cholelithiasis in a Turkish population sample of postmenopausal women.

BACKGROUND/AIMS: Gallstone disease is a global health problem worldwide. Potential risk factors for gallstone disease have not been well established except for age and gender. We aimed to investigate the prevalence and potential risk factors for gallstone disease in a population of postmenopausal women. METHODS: A detailed Turkish questionnaire was prepared, and 474 of 502 postmenopausal women seen at the menopause clinic of Dr. Zekai Tahir Burak Hospital were included in the study. Sociodemographic, medical and reproductive characteristics were analyzed. Subjects were divided into two groups. The gallstone disease group (Group 1, n=73) was defined by both prior histories of gallstones diagnosis or cholecystectomy in the postmenopausal period and the presence of current sonographically diagnosed gallstones; Group 2 (n=401) included women with no gallstone disease. RESULTS: The present study found a 15.4% prevalence rate of cholelithiasis in a Turkish population sample of postmenopausal women. The demographic characteristics were similar between the two groups. The mean gravidity was 5.25 in Group 1 and 4.9 in Group 2. The number of subjects with past oral contraceptive use was 17 (23.3%) in Group 1 and 56 (13.9%) in Group 2. The number of women who took hormone replacement therapy was 40 (54.8%) in Group 1 and 222 (55.3%) in Group 2. There was no significant difference related to mean total cholesterol levels (216.5±44.9 mg/dl versus 215.9±44.3 mg/dl; p=0.915) and mean triglycerides (134.5±54.8 mg/dl versus 143.2±77 mg/dl; p=0.202) between the two groups. CONCLUSIONS: No risk factors for developing gallstones were determined among the evaluated parameters in postmenopausal women.

Why is isolated spleen metastasis a rare entity?

Primary and metastatic tumors of the spleen are uncommon, excluding involvement by lymphoma. Isolated spleen metastasis from other organs is a rare incident. Herein, we report the case of a 59-year-old man who developed isolated splenic metastasis from ascending colon cancer. The patient underwent right hemicolectomy for T3N1M0 tumor of the ascending colon. During the postoperative follow-up, increasing serum level of carcinoembryonic antigen was observed. Furthermore, abdominal computed tomography scan showed a splenic tumor measuring 4 cm. Curative splenectomy was performed. Pathologic investigation confirmed the adenocarcinoma metastasis. The interesting point of our report is that the spleen metastasis arose from the ascending colon. This report is the third described case in the literature of isolated spleen metastasis from a right colon carcinoma.