Surgical management of Stapfer Type 2 ERCP perforations.

BACKGROUND: While numerous studies have proposed algorithms for the management of Stapfer Type 2 ERCP perforations, there is limited research on surgical treatment options specifically for this patient group. Our aim is not to propose a new algorithm for these patients but to describe our surgical approach and contribute to the literature with our surgical procedure applied in Stapfer Type 2 ERCP perforation cases. METHODS: Between 2016 and 2023, a total of 12 patients with Stapfer Type 2 ERCP perforations underwent surgery at our hospital. Duodenal diverticulization is a commonly used method in complex duodenal perforation cases. We performed a procedure that involves the removal of the external biliary pathway, hepaticojejunostomy, and a wide Braun anastomosis in addition to the duodenal diverticulization procedure, which we have termed "modified duodenal diverticulization." RESULTS: Eleven out of the 12 patients were discharged successfully without any complications. One patient, who had a late diagnosis, underwent surgery 5 days after ERCP. This patient had ongoing sepsis before the operation, which continued postoperatively and eventually led to multiple organ failure and death. CONCLUSION: There are limited alternatives for the surgical treatment of Type 2 ERCP perforations, and the widely preferred triple ostomy method may not address the underlying pathology necessitating ERCP. The modified duodenal diverticulization method, offering a definitive treatment, can be considered a surgical option for Type 2 ERCP perforations.

The effect of well-known burn-related features on machine learning algorithms in burn patients' mortality prediction.

BACKGROUND: Burns is one of the most common traumas worldwide. Severely injured burn patients have an increased risk for mortality and morbidity. This study aimed to evaluate well-known risk factors for burn mortality and comparison of six machine learn-ing (ML) Algorithms' predictive performances. METHODS: The medical records of patients who had burn injuries treated at Izmir Bozyaka Training and Research Hospital's Burn Treatment Center were examined retrospectively. Patients' demographics such as age and gender, total burned surface area (TBSA), Inhalation injury (II), full-thickness burns (FTBSA), and burn types (BT) were recorded and used as input features in ML models. Pa-tients were analyzed under two groups: Survivors and Non-Survivors. Six ML algorithms, including k-Nearest Neighbor, Decision Tree, Random Forest, Support Vector Machine, Multi-Layer Perceptron, and AdaBoost (AB), were used for predicting mortality. Several different input feature combinations were evaluated for each algorithm. RESULTS: The number of eligible patients was 363. All six parameters (TBSA, Gender, FTBSA, II, Age, BT) that were included in ML algorithms showed a significant difference (p<0.001). The results show that AB algorithm using all input features had the best predic-tion performance with an accuracy of 90% and an area under the curve of 92%. CONCLUSION: ML algorithms showed strong predictive performance in burn mortality. The development of an ML algorithm with the right input features could be useful in the clinical practice. Further investigations are needed on this topic.

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.

Mortality prediction models for severe burn patients: Which one is the best?

BACKGROUND: For prediction of mortality and clinical course, various scoring systems had been developed. We choose four well known burn specific scoring systems and a general scoring system that using in Intensive Care Units. The primary outcome of this study was evaluate the predictive performances of this models and define the optimal one for our patient population. METHODS: Variables analyzed were age, gender, burn type, total burned surface area (TBSA), total partial thickness burn area, total full thickness burn area, inhalation injuries, mechanical ventilation supports, blood products usage, total scores of Abbreviated Burn Severity Index (ABSI), revised Baux, Belgian Outcome in Burn Injury, Fatality by Longevity, Acute Physiology and Chronic Health Eval-uation II (APACHE II) score, Measured Extent of burn and Sex (FLAMES) and APACHE II, and their relations with mortality. RESULTS: In our study, a statistically significant relationship was found with mortality between age, TBSA, full thickness burn percent-age, inhalation injury, burn type, and it was similar to literature. Female gender was found to be a significant risk factor for mortality. CONCLUSION: We compared several burn mortality scoring systems and their predictional mortality rates. ABSI scores of patients for estimated mortality rates were similar to our mortality rate. Consequently, it was thought that ABSI was included all mortality-re-lated parameters.

The use of Bakri balloon to reduce the anastomosis tension in hepaticojejunostomy.

One of the factors that impair anastomosis healing in patients undergoing hepaticojejunostomy is tension of the anastomosis. There may be tension, especially in cases with a short mesojejunum. In cases where the jejunum cannot be brought higher, positioning the liver a little lower may be a solution. We placed a Bakri balloon between the liver and diaphragm to position the liver to a lower level. Here we present a successful hepaticojejunostomy case in which we placed a Bakri balloon to decrease the anastomosis tension.

Is carpal tunnel release safe in electrical burn decompressive therapy: Six-years experience.

Objectives: Upper extremity electrical burn can create severe sequela and debilitation if not treated properly. Immediate decompression with fasci- otomy and carpal tunnel release seem to be the most promising choice of treatment. Neurologic functional loss can be avoided if median nerve is liberated. Material and Methods: During 6-year time interval, 50 out of 1158 burn patients underwent upper extremity decompressive fasciotomy with carpal tunnel release. Their hand motor function based on nerve innervation and daily usage questionnaire were followed in 12-month intervals. Results: Average score rose markedly after 18th month and reached nearly normal at the end of 66th month. Median, ulnar and radial nerve function tests were all positive, and no irreversible nerve function loss observed. Conclusion: All compartments of the forearm should be explored and carpal tunnel release should be added into upper extremity decompressive fasciotomy after electrical burns.

General surgery specialism in Turkey: work power currently, continuity at quality and quantity.

OBJECTIVES: As one of the oldest and main branches of medicine, process of General Surgery speciality training is long, expensive and difficult. Along with the principle of using limited sources wisely, there is a need for national forward planning in order to keep the number of General Surgery specialists in the proper level and in the proper quality. This study is made for the assurement of training quality specialists and for the sustainability in the best conditions after determining of the number of general surgeons, work force, and working conditions. MATERIAL AND METHODS: The number of General Surgery specialists (professors, associate professors, specialists or General Surgery subspecialists) and assistants who actively work in our country from the end of 2017 in the public sector, private sector, and university hospitals, is examined. These numbers were subjected to cross evaluation according to the provinces, academic titles and number of assistants. The estimated ratio of the existing number of General Surgery specialists to upcoming five and ten years were calculated according to the data of Turkish Statistical Institute. RESULTS: From the end of 2017, 3957 General Surgery specialists are actively working in 1031 of 1499 health facilities. Four hundred and forty of them are titled as professors, 324 of them are titled as associate professors. For every 25 thousand people, there exist 1.22 surgeons. Ten years ago, this ratio was calculated as 1.27. The number of assistans, which was 1005 ten years ago, is decreased to 768 today, but the increase of the number of specialists is 409. CONCLUSION: The number of General Surgeons in our country is above the ideal ratio, which is one for 25 thousand people. In case rate of increase of the number of General Surgeons for the last 10 years continues, when the decrease of population growth rate is considered, there will be an uncontrolled increase in the number of surgeon per 25 thousand people. Just as the distribution of General Surgery specialists -whether or not having an academic title- is not balanced, the number of instructor per assistant is also excessive.

Anti-inflammatory and Anti-apoptotic Effect of Valproic Acid and Doxycycline Independent from MMP Inhibition in Early Radiation Damage.

BACKGROUND: Matrix metalloproteinase (MMP) inhibitors decrease inflammation in normal tissues and suppress cancer progress in normal tissues. Valproic acid (VA) and doxycycline (DX) are MMP inhibitors that have radio-protective effects. Their ability to inhibit MMPs in irradiated tissue is unknown and the role of MMPs in radio-protective effects has not been tested to date. AIMS: The purpose of this study was to examine whether administration of VA and DX to rats before irradiation affects tissue inflammation and apoptosis in the early phase of radiation, and whether the effect of these drugs is mediated by MMP inhibition. STUDY DESIGN: Animal experimentation. METHODS: Twenty-six Wistar rats were randomized into four groups: control (CTRL), radiation (RT), VA plus radiation (VA+RT), and DX plus radiation (DX+RT). Three study groups were exposed to a single dose of abdominal 10 Gy gamma radiation; the CTRL group received no radiation. Single doses of VA 300 mg/kg and DX 100 mg/kg were administered to each rat before radiation and all rats were sacrificed 8 hours after irradiation, at which point small intestine tissue samples were taken for analyses. Levels of inflammatory cytokines (TNF-α, IL-1ß, and IL-6) and matrix metal-loproteinases (MMP-2 and MMP 9) were measured by ELISA, MMP activities were measured by gelatin and casein zymography and apoptosis was assessed by terminal deoxynucleotidyl transferase dUTP nick end labeling assay. RESULTS: VA decreased the levels of TNF-α and IL-1ß proteins insignificantly and decreased apoptosis significantly in the irradiated tissue, but did not inhibit MMPs. In contrast, VA protected the basal MMP activities, which decreased in response to irradiation. No effect of DX was observed on the levels of inflammatory cytokines or activities of MMPs in the early phases of radiation apoptosis. CONCLUSION: Our findings indicated that VA protects against inflammation and apoptosis, and DX exhibits anti-apoptotic effects in early radiation and these effects are independent from MMP inhibition.

Recurrent pilonidal disease surgery: Is it second primary or reoperative surgery?

OBJECTIVE: Pilonidal sinus disease (PSD) effects mainly young men's social and work life with frequent recurrence rate. Reoperation for unimproved or recurrent disease is somehow troublesome. Surgeons may think that changing treatment strategy after recurrence may prevent further relapses of PSD. We analyzed patients with recurrent pilonidal sinus to determine their predisposing features for recurrence and the outcomes of the preferred surgical methods. MATERIAL AND METHODS: From 2007 to 2012, out of 95 recurrent pilonidal sinus disease (rPSD) patients, 62 operated cases were included and examined retrospectively. Their retrospective data were examined for demographics, 1(st) and 2(nd) operation types, patient satisfaction and pain scores. For cases with insufficient preoperative or postoperative data, phone call and interviews were done to obtain data. Some were kindly invited to the outpatient examination. Student's t test, Mann-Whitney U test, and Kaplan Meier test for disease free survival time were used where appropriate. P values less than 0.05 were accepted to be statistically significant. RESULTS: Total of 62 rPSD patients were examined. Male:female ratio was 2.9:1. The mean age after 1(st) and 2(nd) operations were 24.7 and 28.1 years, respectively. One and five-year recurrence rates were 33.9% and 66.1%, respectively. The mean interval between the 1(st) and 2(nd) operations was 45.6 months. Excision and midline closure was the most frequent type of operation followed by flap reconstructions and excision-lay open procedures. The 1(st) operation types of rPSD cases were different from that of 2(nd) operations. Pain perception and satisfaction scores were better in flap reconstruction groups. CONCLUSION: Reoperative surgery of rPSD is satisfactory with certain precautions. Relapses after flap reconstruction procedures with a well-being period should be referred as second primary disease. Changing surgical strategy is not always indicated as some patients with recurrence have relapsing or second primary disease that have distinct clinical course. Re-flap surgery after any kind of relapse is well appreciated.

Negative-pressure Wound Therapy in Chronic Inflammatory Breast Diseases.

Mastitis is inflammation of breast tissue that may or may not originate from an infection. Two different forms of mastitis have been described, lactational and non-lactational. Lactational mastitis is the most common type and generally conservative therapy that includes milk removal and physical therapy provides symptomatic relief, but antibiotic therapy is also needed. Common types of non-lactational mastitis are periductal mastitis and idiopathic granulomatous mastitis. Treatment includes antibiotics, drainage, and surgery, but usually this is a chronic process and a therapeutic management algorithm for chronic breast inflammation is unclear and has no consensus. Negative-pressure wound therapy is commonly used for various types of wounds but is limited for breast wounds. In this report, we present and discuss two patients with chronic breast inflammation who underwent surgery and were successfully treated using negative-pressure wound therapy to minimize wide tissue defects and cosmetic problems after surgery. Use of negative-pressure wound therapy for breast wounds might be benefical as it is with other wounds but there is scarce information in the literature.

Totally Curative Surgical Resection of Retrorectal Tumors.

BACKGROUND/AIMS: Retrorectal (also known as presacral) tumor (RT) is a rare disease of retrorectal space. There is no large numbered case series in the literature. Well documented small numbered case series will help to establish meta-analysis and surgical decision making. METHODOLOGY: Between 2000 and 2014 medical records of patients with diagnosis of RT at two institutions were reviewed. Clinical features, diagnostic studies, type of surgery, surgical findings, surgical technique, and histopathology of the tumor, morbidity and survival are examined based on data registry. RESULTS: During 14 years period of time, total of 12 patients operated with diagnosis of RT were retrieved to this study. There were five men and seven women. The median age at the time of diagnosis was 43 (27-56) years. The most frequent findings were pain and palpable mass. There were five anterior, four posterior and three anteroposterior approaches for surgery. There is no recurrence or disease related mortality observed after median of 7 years (1-14). CONCLUSION: The primary and only satisfactory treatment is surgery for RTs. Prognosis is directly related primary local control with complete excision, which is often difficult to achieve for malignant lesions.

Characteristics of Emergency Gastrointestinal Stromal Tumor (GIST).

BACKGROUND/AIMS: Gastrointestinal Stromal Tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract (GIT). Importance of GISTs is increasing while surgeons are facing with more frequent either in emergency setting of elective cases. Delineating the presentation and management of emergency GIST is important. METHODOLOGY: From 2005 to 2014, emergency cases with final diagnosis of GIST were examined retrospectively. Total of 13 operated cases were evaluated by patients characteristics, clinical presentation, operational findings and postoperative prognosis. RESULTS: There were 9 male and 4 female with the mean age of 48.15 years. The most frequent presentations are ileus and GIT hemorrhage both covering the 84% of patients. Small bowel was the dominating site with ileus. Stomach was the second frequent site of the disease with the finding of hemorrhage. CONCLUSION: Emergency patients are more likely to come with small bowel GIST and obstruction symptoms. Hemorrhage is the most frequent symptom for emergency GIST of stomach and duodenum.

Gastric Remnant Cancer: Continuing Serious and Insidious Problem for Surgeons.

BACKGROUND/AIMS: Gastric remnant cancers (GRC) are usually detected at a later stage resulting in low rates of curative resection and a consequently poor prognosis. The incidence and etiology of GRC have been changing recently because of early detection and improved outcomes in patients with gastric cancers. This study was performed to evaluate the clinicopathological characteristics and prognosis of patients with GRC. METHODOLOGY: From January 2004 and July 2014, 27 patients with GRC who underwent surgery were analyzed retrospectively. The clinicopathological and follow-up data of 27 patients were evaluated including age, gende types of reconstruction, tumor location, histological types, TNM stages, surgical treatment and prognosis. RESULTS: Total 221 patients underwent gastrectomy for gastric cancer and ulcer disease and 27 (12.7%) consecutive GRC patients were included in this study. The median survival for all 27 patients was 20.0 ± 2.4 months. Previous malign disease, advanced TNM stage and non-curative resection were the negative prognostic factors for survival in patients with remnant stomach cancer (p < 0.05). CONCLUSIONS: Regular follow-up is one of the important factors affecting the early diagnosis and median survive time of patients with GRC. Curative resection is recommended operative treatment procedure to improve the survival when GRC patient diagnosed.

Heterotopic gastric mucosa of upper oesophagus: evaluation of 12 cases during gastroscopic examination.

INTRODUCTION: Oesophageal heterotopic gastric mucosa mostly presents in the upper part of the oesophagus. It is commonly under-diagnosed because of its localisation. AIM: To expose the association between heterotopic gastric mucosa and endoscopic features of the upper gastrointestinal tract. MATERIAL AND METHODS: A total of 1860 upper endoscopic examinations performed between January 2012 and July 2013 were analysed retrospectively. Endoscopic features and histological examinations of 12 heterotopic gastric mucosa (HGM) of the upper oesophagus were documented and evaluated retrospectively. RESULTS: There were 7 (58%) male and 5 (42%) female patients aged between 22 and 80 years with a mean age of 43.2 years. Heterotopic gastric mucosa was present in 12 (0.6%) of all patients. We were able to perform biopsy for histopathological observation on 8 (66%) of the 12 patients in which HGM was seen during endoscopy. Five (42%) patients with heterotopic gastric mucosa had oesophagitis. Los Angeles Grade A oesophagitis was found in all patients, and histologically proven Barrett's oesophagus was detected in only one patient. CONCLUSIONS: When a patient has ongoing dyspeptic complaints and reflux symptoms despite the treatment, one should be careful about possible HGM during upper gastrointestinal endoscopy. The point to be taken into consideration for patients who have metaplasia or dysplasia within HGM may need to be considered for surveillance.

Determination of optimal operation time for the management of acute cholecystitis: a clinical trial.

INTRODUCTION: Although all studies have reported that laparoscopic cholecystectomy (LC) is a safe and effective treatment for acute cholecystitis, the optimal timing for the procedure is still the subject of some debate. AIM: This retrospective analysis of a prospective database was aimed at comparing early with delayed LC for acute cholecystitis. MATERIAL AND METHODS: The LC was performed in 165 patients, of whom 83 were operated within 72 h of admission (group 1) and 82 patients after 72 h (group 2) with acute cholecystitis between January 2012 and August 2013. All data were collected prospectively and both groups compared in terms of age, sex, fever, white blood count count, ultrasound findings, operation time, conversion to open surgery, complications and mean hospital stay. RESULTS: The study included 165 patients, 53 men and 112 women, who had median age 54 (20-85) years. The overall conversion rate was 27.9%. There was no significant difference in conversion rates (21% vs. 34%) between groups (p = 0.08). The operation time (116 min vs. 102 min, p = 0.02) was significantly increased in group 1. The complication rates (9% vs. 18%, p = 0.03) and total hospital stay (3.8 days vs. 7.9 days, p = 0.001) were significantly reduced in group 1. CONCLUSIONS: Early LC within 72 h of admission reduces complications and hospital stay and is the preferred approach for acute cholecystitis.

Evaluation of affecting factors for conversion to open cholecystectomy in acute cholecystitis.

INTRODUCTION: Laparoscopic cholecystectomy has become the gold standard for the surgical treatment of gallbladder disease. Severe inflammation makes laparoscopic dissection technically more demanding in acute cholecystitis. Conversion to open cholecystectomy due to adverse conditions is still required in some patients. AIM: To evaluate predictive risk factors associated with conversion to open cholecystectomy in acute cholecystitis. MATERIAL AND METHODS: A retrospective analysis was performed on 165 patients who underwent a laparoscopic cholecystectomy for acute cholecystitis in our clinic. Patients who completed laparoscopic cholecystectomy and required conversion to open cholecystectomy were compared in terms of age, sex, fever, laboratory and USG findings, operation timing, complications, and duration of hospital stay. RESULTS: There were 53 (32%) male and 112 (68%) female patients; the mean age was 52.4 ±12.5 years. Forty-six (27.9%) of the 165 patients were converted to open cholecystectomy. Male sex of the patients who underwent conversion (47.1%) was found to be statistically significant (p < 0.001). Preoperative white blood count, blood glucose and amylase values, morbidity rate, and hospital stay were raised in patients who underwent conversion, and all were found to be statistically significant (p < 0.05). CONCLUSIONS: Male sex, blood leucocyte, glucose, and raised amylase emerged as the effective factors for conversion cholecystectomy in our study. These factors should help the clinical decision-making process when planning laparoscopic cholecystectomy in acute cholecystitis. By predicting these risk factors for conversion, preoperative patient counselling can be improved.