Venous reconstruction thrombosis after pancreaticoduodenectomy with superior mesenteric/portal vein resection due to pancreatic cancer: an 8 years single institution experience.

BACKGROUND: Superior mesenteric/portal vein reconstruction (SMPVR) thrombosis remains a challenging complication following pancreaticoduodenectomy concomitant with venous resection. In this context, we aimed to present our SMPVR experiences and identify potential clinicopathological factors that increased SMPVR thrombosis. METHODS: A total of 33 patients who underwent SMPVR during pancreaticoduodenectomy were analyzed. Of these, 26 patients who experienced pancreatic head ductal adenocarcinoma met our inclusion criteria. Patients' data were compared as classified by SMPVR type and the development of SMPVR thrombosis. All interposition grafts were Dacron in this cohort. RESULTS: Types of SMPVR included: tangential resection with primary repair (n = 12); segmental resection with splenic vein preservation and either primary anastomosis (n = 8) or 14 mm tubular Dacron grafting (n = 1); segmental resection with splenic vein division either 14 mm tubular Dacron grafting (n = 2) or 14/7 mm 'Y'-shaped Dacron grafting (n = 3). A total of four patients having 14/7 mm 'Y'-shaped (n = 3) and 14 mm tubular Dacron (n = 1) developed SMPVR thrombosis (p = .001). Dacron grafting (p = .001) and splenic vein division (p = .010) were associated with SMPVR thrombosis. The median time to detection of SMPVR thrombosis was 4.3 months (2.5-21.0 months). The median follow-up time was 12.2 months (3.0-45 months). CONCLUSIONS: During pancreaticoduodenectomy for pancreatic head ductal carcinoma, extended venous resection requiring SMPVR with 'Y'-shaped and use of Dacron interposition grafts appeared to be associated with the development of SMPVR thrombosis. This result warrants further investigations.

Serum amylase on postoperative day one is a strong predictor of pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort.

Background/aim: Early identification of patients at risk for developing postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) may facilitate drain management. In this context, it was aimed to examine the efficiency of the serum amylase (SA) value on postoperative day (PoD) 1 in predicting the occurrence of POPF. Materials and methods: A total of 132 patients who underwent PD were studied. Occurrences of POPF were classified according to the International Study Group on Pancreatic Fistula classification as a biochemical leak (BL) or clinically relevant grade b/c POPF (CR-POPF). Receiver operating characteristic analysis identified a threshold value of SA on PoD 1 associated with POPF formation. Results: Overall, 66 (50%) patients had POPF, including 51 (38.7%) with BL and 15 with CR-POPF (11.3%). The threshold value of SA associated with the development of POPF was 120 IU/L (odds ratio [OR]: 3.20; p = 0.002). In the multivariate analysis, independent POPF risk factors were SA ≥120 IU/L, soft pancreatic texture, and high-risk pathology (i.e., duodenal, biliary, ampullary, islet cell, and benign tumors); SA ≥120 IU/L outperformed soft pancreatic texture and high-risk pathology in predicting POPF, respectively (OR: 2.22; p = 0.004 vs. OR: 1.37; p = 0.012 vs. OR: 1.35; p = 0.018). In a subset analysis according to gland texture (soft vs. hard), patients with soft pancreatic texture exhibited a significantly higher incidence of POPF (63.4% vs. 34.4%) and SA ≥120 IU/L (52.1% vs. 27.9%); SA <120 IU/L had a negative predictive value of 82.5% for developing POPF in patients with hard pancreatic texture (OR: 4.28, p = 0.028). Conclusion: A SA value ≥120 IU/L on the day after PD, which is the strongest predictor for POPF, can be used as a biomarker of the occurrence of POPF. The advantage of SA measurement is that it can contribute to identifying suitable patients for early drain removal.

Early extubation after liver transplantation: Is dexmedetomidine a good option?: A retrospective cohort study.

BACKGROUND: Dexmedetomidine is a potent and highly selective alpha-2 adrenoceptor agonist with sympatholytic, sedative, anxiolytic and analgesic properties. The aim of this study is to determine the effect of a dexmedetomidine infusion in liver transplant recipients in the early postoperative period on early and smooth extubation. METHODS: We performed a retrospective chart review of 21 patients undergoing liver transplantation between December 1, 2018 and February 31, 2020. Patients were divided into the dexmedetomidine and midazolam groups. The primary outcome was the extubation time. Secondary outcomes were mean arterial pressure and heart rate before and after extubation. The collected data included the patients' age, gender, surgery time, Model for End-stage Liver Disease score, cold ischemia time, blood transfusion amount and extubation visual analogue scale (VAS) scores. RESULTS: Extubation time was significantly shorter in the dexmedetomidine group than in the midazolam group (median [minimum-maximum], 4 [0-6], 8 [4-13] hours, respectively, P = .000). Extubation VAS scores were statistically significantly lower in dexmedetomidine group (P = .000). Mean arterial pressure values before and after extubation were significantly higher in patients' midazolam group than the dexmedetomidine group (P = .003, P = .005, respectively). CONCLUSIONS: Dexmedetomidine infusions provided early and smooth extubation with stable haemodynamics in our patients.

Portomesenteric venous gas does not always mean intestinal necrosis: report of a case.

Portomesenteric venous gas is a rare condition most commonly caused by mesenteric ischaemia. Mesenteric ischemia, can be life-threatining and requires immediate surgical intervention with a poor prognosis. During the laparotomy, intestinal necrosis and perforation are most common findings although some patients reveal no surgical pathology. In this report we present a case of portomesenteric venous gas which is secondary to acute intramural intestinal haematoma.

First-line therapy in Helicobacter pylori eradication therapy: experience of a surgical clinic.

OBJECTIVE: Helicobacter pylori (HP) is the world's most common infectious agent. Despite conventional therapy consisting of proton pump inhibitor (PPI), amoxicillin (AMO) and clarithromycin (CLA), approximately half of the patients remain infected. We compared the PPI-based triple therapy with quadruple treatment (BPMT) including bismuth citrate (BS), PPI, metronidazole (MET) and tetracycline (TET). MATERIAL AND METHODS: Forty-three patients who used triple therapy (LAC) consisting of lansoprazole (L), AMO and CLA and 42 patients who used quadruple therapy (BPMT) for 14 days between May 2008 and November 2013 were included in the study. The LAC group included patients who received 30 mg L 2×1, 1000 mg AMO 2×1, and 500 mg CLA 2×1 for 14 days, whereas the BPMT group was designed from patients who received 600 mg BS 2×1, 40 mg omeprazole (O) 2×1 or 30 mg L 2×1, 500 mg MET 3×1 and 500 mg TET 4×1. RESULTS: Demographic characteristics and endoscopic findings were similar in both groups. The eradication rate was 53.4% in the LAC group and 78.5% in the BPMT group (p<0.05). Compliance problems and side effects were significantly higher in the BPMT group as compared to the LAC group (p<0.05). CONCLUSION: Due to high antibiotic resistance in Turkey, the efficacy of LAC treatment has reduced. The BPMT protocol should be kept in mind in the first line of treatment, since it provides a higher eradication rate.

Laparoscopic resection of retroperitoneal bronchogenic cyst clinically presenting like adrenal cyst.

Bronchogenic cyst that is localized to retroperitoneum is a rare clinical entity. It is a congenital malformation generally occuring in the posterior mediastinum due to abnormal development of the foregut. We report the case of a retroperitoneal cyst presented like left adrenal cyst. A 38 years old female was presented with left upper abdominal pain. Endocrinologic evaluation was done and no adrenal hormonal secretion was detected. The cyst was removed laparoscopically. It was confirmed in pathologic examination as a bronchogenic cyst. Bronchogenic cysts should be considered in the differential diagnosis of retroperitonal cysts. Laparoscopic resection of retroperitoneal cysts results in better outcome.

An intraoperative serum parathormone level study in patients with chronic renal failure that underwent subtotal parathyroidectomy What extent of decrease is sufficient at which moment?

AIM: The aim of this study is to determine when to perform intraoperative parathormone (ioPTH) measurement and what extent of decrease in intraoperative serum PTH concentrations indicate success in the operations performed on patients with SHPT associated with chronic renal failure. MATERIAL AND METHODS: 50 consecutive patients who underwent subtotal parathyroidectomy between January 2012 and January 2019 were retrospectively included in this study. Patients were grouped according to persistent hyper parathyroidism (Group1, n:6) and curative surgery (Group 2, n:44). Preoperative serum PTH, calcium, phosphorus and ALP concentrations, intraoperative serum PTH concentrations; and serum PTH, calcium, phosphorus and ALP concentrations of 24th hour after surgery were included to the study. Intraoperatively, 20 minutes after parathyroid gland removal, blood was drawn for PTH assay. The changes in PTH levels between preoperative and intraoperative serum samples were calculated in percentage (ioPTH%) and postoperative 6th month serum PTH and ALP concentrations were included in the study. RESULTS: No significant differences were found by gender, BMI, elapsed period of dialysis treatment and preoperative laboratory values between Group 1 and Group 2. The meanage of Group 1 was 35 years which is lower than Group 2. With the second group, the mean decrease in PTH levels between intraoperative and preoperative serum samples (ioPTH%) was about 90%, which was higher than Group 1. CONCLUSIONS: In conclusion, we believe that, to encounter fewer persistent SHPT cases, it is essential that surgeons monitor ioPTH concentration 20 minutes after gland removal and confirm a decrease of 90% or more in ioPTH concentration. And we should not forget that young patients may tend to develop persistent SHPT. KEY WORDS: Chronic renal failure, Intraoperative parathormone, Secondary hyperparathyroidism, Parathyroidectomy, Subtotal patathyroidectomy.

Laparoscopic resection of retroperitoneal bronchogenic cyst clinically presenting as adrenal cyst.

Bronchogenic cyst localized in the retroperitoneum is a rare clinical entity. It is a congenital malformation generally occurring in the posterior mediastinum due to the abnormal development of the foregut. We report the case of a retroperitoneal cyst presenting as left adrenal cyst. A 38-year-old female presented with left upper abdominal pain. Endocrinological evaluation was done, and no adrenal hormonal secretion was detected. The cyst was removed laparoscopically. Pathologic examination confirmed it as a bronchogenic cyst. Therefore, bronchogenic cysts should be considered in the differential diagnosis of retroperitoneal cysts. Laparoscopic resection of retroperitoneal cysts results in favorable outcome.

The effects of silymarin plus glutathione on the prevention of liver ischemia-reperfusion injury

Abstract Liver ischemia-reperfusion (IR) injury is a major clinical trouble encountered in clinical practice. This study aimed to examine the therapeutic effects of silymarin (SM) plus glutathione (GSH) on hepatic IR injury using a rat model of liver IR. Fifty male rats were randomly divided into five groups, each consisting of 10 rats as follows: Sham, IR, SM-IR, GSH-IR and SM plus GSH-IR. All groups except sham were subjected to 30-min ischemia and 24-h reperfusion. The treated groups received 100 mg/kg of SM, GSH and a mixture of SM plus GSH, 60 min prior to the IR. After a period of 24 h, blood and liver samples were collected for biochemical and histopathological evaluations. Pretreatment with SM, GSH and SM plus GSH before hepatic IR significantly decreased IR-induced elevations of aminotransferases, and significantly reduced the histopathological damage scores of the liver in the late phase of IR injury. Moreover, SM plus GSH treatment prior to liver IR significantly suppressed inflammatory process and oxidative stress as demonstrated by attenuations in tumor necrosis factor-α, myeloperoxidase and the thiobarbituric acid-reactive substances. These findings suggest that administration of SM plus GSH prior to liver IR may protect the liver parenchyma from the effects of an IR injury

Single-Port Laparoscopic Liver Resection: Largest Turkish Experience.

Single-port laparoscopic surgery has the advantage of a hidden scar and reduced abdominal wall trauma. Although single-port laparoscopic surgery is widely performed for other organs, its application is very limited for liver resection. Here, we report our experience with nine patients who underwent single-port laparoscopic liver resection. Nine patients underwent single-port laparoscopic liver resection for the indications of hydatid cyst, hepatocellular carcinoma, and colorectal cancer liver metastasis. Nine patients were successfully treated with single-port laparoscopic surgery. The operative time was between 60 and 240 min. The only operative complication was bleeding up to 650 mL in a patient with cirrhosis. No postoperative complications occurred. All patients were discharged earlier than usual. Single-port laparoscopic liver surgery is a challenging surgery. Surgeon with the experience of laparoscopic liver surgery should perform the single-port laparoscopic liver surgery. It is technically feasible with a good outcome in well-selected patients. Initial cases must be benign lesions to avoid jeopardizing oncological safety.

The Whitehead operation procedure: Is it a useful technique?

OBJECTIVE: Hemorrhoidal disease is a very common entity in the general population; however, the therapeutic approaches to hemorrhoids remain controversial. The choice of treatment method depends on the grade of the hemorrhoid as well as the experience of the surgeon. The Whitehead hemorrhoidectomy procedure is often applied for grade IV hemorrhoids. MATERIAL AND METHODS: We studied 49 patients who underwent surgery between December 1982 and January 2013. The indications for the Whitehead procedure in all patients were grade IV hemorrhoidal disease. The data on these patients were evaluated retrospectively with respect to age, gender, preoperative diagnosis, and postoperative complications. RESULTS: Of the patients included in this study, 34 were male and 15 were female. The mean age of the patients was 41.93±12.42, and the age range was 24-70 years. Complications of the Whitehead procedure included bleeding (6.12%, three cases), stricture (2.04%, one case), urinary retention (16.33%, eight cases), and temporary anal incontinence (2.04%, one case). No patients developed Whitehead deformities, entropion, or infectious complications. All patients were discharged from hospital between the fifth and eighth days post-surgery (6.45±1.00 days). The follow-up period was 1-234 months (70.02±54.89). CONCLUSION: The Whitehead procedure is successful in patients with prevalent peripheral prolapse and/or thrombosed hemorrhoids. With the right indications, and if the surgeon has adequate experience, the morbidity rate of the Whitehead procedure is similar to that of other treatment methods.

A First Report of Synchronous Intracapsular and Extracapsular Hepatic Adenoma.

Although the gallbladder is the most common site of ectopic liver, it has been reported in many other organs, such as kidney, adrenal glands, pancreas, omentum, stomach, esophagus, mediastinum, lungs, and heart. Hepatocytes in an ectopic liver behave like normal hepatocytes; furthermore, they can be associated with the same pathological findings as those in the main liver. Ectopic liver in the gallbladder can undergo fatty change, hemosiderosis, cholestasis, cirrhosis, hemangioma, focal nodular hyperplasia, adenoma, and even carcinogenesis. The incidence of extracapsular hepatic adenoma is not known, but only two cases have been reported. Here, we provide the first case report of synchronous multiple intracapsular and extracapsular hepatic adenomas. A 60-year-old woman with multiple hepatic adenomas and one 7 × 5 × 5 cm ectopic hepatic adenoma attached to the gallbladder fundus complicated with abdominal pain is presented.

Factors affecting the conversion to open surgery during laparoscopic cholecystectomy in patients with cholelithiasis undergoing ERCP due to choledocholithiasis.

BACKGROUND: The rate of conversion to open surgery is high in laparoscopic cholecystectomy (LC) after Endoscopic Retrograde Cholangiopancreotocography (ERCP). The present study aimed to evaluate the risk factors associated with the conversion to open cholecystectomy and minimize the rate of conversion to open surgery. METHODS: A total of 157 patients admitted to the Ondokuz Mayis University Medical Faculty Hospital due to cholelithiasis and choledocholithiasis between January 2002 and December 2012, and they receiving laparoscopic cholecystectomy were included in the study. The patients were analyzed retrospectively. The predictive factors for conversion to open cholecystectomy were evaluated. Patients were compared to each other in terms of time passing from ERCP to operation, number of ERCPs, stent usage, stone extraction and complications that occurred while waiting for the operation. Patients were separated into three groups according to the time passing from ERCP to laparoscopic cholecystectomy, as follows; group I (short time intervals: 7 days or less): 53 patients, group II (intermediate time intervals: 8-42 days): 70 patients and group III (long time intervals: 43 days and more): 34 patients. RESULTS: Of the 157 patients, 57 were male and 100 were female. The mean age was 54.5 (range: 19-87) years. Of these 157 patients who received laparoscopic cholecystectomy following ERCP, 22 (14%) underwent open surgery. The conversion to open cholecystectomy was distributed in groups, as follows: seven (13.2%) patients in group I, eight (11.4%) patients in group II and seven (20.6%) patients in group III. When the rate of conversion to open surgery was compared between groups, there was no statistically significant difference (p=0.406). The laparoscopic operations were converted to open surgery in 15 (11.3%) of the 133 patients who underwent single ERCP, and in seven (29.2%) of the 24 patients who underwent two or more ERCPs before surgery (p=0.048). The number of ERCPs was determined to be the most important factor that affects the conversion to open surgery in laparoscopic cholecystectomies following ERCP. The removal of stones from the common bile duct, stent placement in the common bile duct, and existence of biliary complications during waiting time from ERCP to LC had no effect on the conversion to open surgery (p=0.454, p=0.058, and p=0.465, respectively). CONCLUSIONS: The results of this study reveal that the timing of LC following ERCP, removal of stones from the common bile duct, stent placement in the common bile duct and the existence of biliary complications during the waiting period have no effect on the rate of conversion to open surgery. The number of ERCPs is the only factor that affects the conversion to open surgery in LC following ERCP. KEY WORDS: Choledocholitiasis, Conversion, Endoscopic retrograde cholangiopancreatography, Laparoscopic cholecystectomy.

Single port laparoscopic liver surgery: A minireview.

Nowadays, the trend is to perform surgeries with "scarless" incisions. In light of this, the single-port laparoscopic surgery (SPLS) technique is rapidly becoming widespread due to its lack of invasiveness and its cosmetic advantages, as the only entry point is usually hidden in the umbilicus. The interest in "scarless" liver resections did not grow as rapidly as the interest in other scarless surgeries. Hepatopancreatobiliary surgeons are reluctant to operate a malignant lesion through a narrow incision with limited exposure. There are concerns over adverse oncological outcomes for single-port laparoscopic liver resections (SPL-LR) for hepatocellular carcinoma or metastatic colorectal cancer. In addition, getting familiar with using the operating instruments through a narrow incision with limited exposure is very challenging. In this article, we reviewed the published literature to describe history, indications, contraindications, ideal patients for new beginners, technical difficulty, advantages, disadvantages, oncological concern and the future of SPL-LR.

Cholangiocarcinoma Arising from a Type VI Biliary Cyst: A Case Report and Review of the Literature.

Cystic dilatations of the cystic duct which are suggested as type VI biliary cysts are very rare and many of them go unrecognized or are confused with other cysts until the operation although they are obvious on imaging studies. They can present with fusiform or saccular dilatations and can be accompanied by common bile duct dilatations. It is important to identify these cysts as they share the same characteristics as the other biliary cyst types and can be complicated with malignancy. We herein present a very unusual case of a cholangiocarcinoma arising from a type VI biliary cyst in a 58-year-old female patient and review the literature. The patient presented with jaundice, weight loss, and abdominal pain. On imaging, the cystic duct and common bile duct were fusiformly dilated and had a wide communication. There was a mass filling the distal parts of both ducts. The patient was urgently operated on after perforation following ERCP. Histopathology was compatible with a type VI biliary cyst and an associated cholangiocarcinoma.

Intraoperative nerve monitoring in thyroid surgery.

BACKGROUND: Nerve injury is one of the specific complications of thyroid surgery despite many advances in surgical technique. The recurrent laryngeal nerve (RLN) and the external branch of superior laryngeal nerve are the nerves at risk during thyroid surgery (1). Morbidity related to recurrent laryngeal nerve injury varies from changes in voice quality to severe dyspnea requiring tracheal intubation or tracheostomy. To minimize the risk of nerve injury, intraoperative nerve monitoring (IONM) being suggested as a tool for helping visual control for RLN has gained significant interest in recent years (1,2). We aimed to determine the effectiveness of nerve monitoring during thyroid surgery and to provide a clinical experience. MATERIALS AND METHODS: This study was performed from June 2010 to June 2012. We prospectively evaluated 94 patients who had thyroid surgery with or without nerve monitoring. Of those patients 48 were in monitored group (M) and 46 were in unmonitored group (UM). RESULTS: The mean age was 48 (27-76) in M group and 52 (73-17) in UM. There was only one patient had transient hoarseness in M group and also one patient had transient hoarseness in UM group. One each in both groups had persistent hoarseness. No patients experienced airway problem. Operation time was significantly shorter in M group (p<0.001). CONCLUSIONS: Use of a nerve monitoring system does not substitute for careful dissection and visual identification of nerves, but monitoring can assist the surgeon in identifying the RLN anatomic variability and may decrease the operation time during thyroid surgery.

Is it possible to use transaminases for deciding on surgical or non-operative treatment for blunt liver trauma?

BACKGROUND: We aimed to research the relation of transaminase levels in blunt liver trauma (BLT) with the intensity of the trauma and the use of transaminase levels for deciding on surgical or non-operative treatment. METHODS: In all, 44 patients with BLT diagnosed by computerized tomography (CT) were involved in this retrospective study. By testing the correlation of the transaminase levels and the grade of liver injury with receiver operator characteristics (ROC), area under the curve (AUC) was calculated; besides, the sensitivity, specificity, and cut-off values of transaminases were calculated separately for the grades. Moreover, same method was repeated for the surgically and non-operatively treated patients. Cut-off value was assessed for surgical and non-operative treatments. The efficiency of transaminases in deciding non-operative treatment was compared with that of other methods using ROC test applied on focused abdominal sonography in trauma (FAST), hemodynamic instability, blood replacement rate, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). RESULTS: It was observed that the AUC, sensitivity, and specificity increased correspondingly with the grade rise of transaminase levels in BLT. In the selection of non-operative treatment/surgery, following values have been confirmed: AUC for AST: 0.851 (sensitivity: 86%, specificity: 73%, cut-off value: 498 U/L), AUC for ALT: 0.880 (sensitivity: 86%, specificity: 81%, cut-off value: 498 U/L), AUC for replacement: 0.948 (sensitivity: 86%, specificity: 94%), AUC for hemodynamic instability: 0.902 (sensitivity: 86%, specificity: 94%), and AUC for FAST: 0.642 (sensitivity: 57%, specificity: 75%). CONCLUSIONS: It was found that in BLT, transaminases can predict the injury rating with higher accuracy as the grade rises, and they outrival FAST in terms of determining the need for laparotomy.

Long-term outcomes of intraoperative and perioperative albendazole treatment in hepatic hydatidosis: single center experience.

PURPOSE: The aim of this study was to evaluate long-term outcome of the intraoperative and perioperative albendazole (ALB) treatment on the recurrence and/or secondary hydatidosis. METHODS: One hundred and one patients with hepatic hydatidosis were treated intraoperatively and perioperatively with ALB, in addition to surgery. Perioperative ALB treatment was given in a dose of 12-15 mg/kg/day. The ALB treatment was started 13.27 ± 14.34 days before the surgery, and it was continued for 4.39 ± 3.11 months postoperatively. A total of 1.7 µg/mL of ALB solution was used as a protoscolidal agent. The follow-up period was 134.55 ± 51.56 months. RESULTS: Four patients died, with only one death was secondary to hydatid disease (cerebral eccinococcus). There was only one recurrence (1%) of hepatic hydatidosis. Early and late morbidity rates were 8.91% and 7.92%, respectively. CONCLUSION: Our results suggest that intraoperative and perioperative ALB is effective for the prevention of hepatic hydatidosis recurrence and/or secondary hydatidosis.

Recurrent bilateral breast abscesses after sternotomy.

Median sternotomy is the most commonly used incision in cardiothoracic procedures. Development of breast abscess after sternotomy is a very rare situation. We present a case of sternal wound infection with recurrent bilateral breast abscess after sternotomy. Our case is the first and only case in the literature due to the presence of sternal wound infection with recurrent bilateral breast abscess after sternotomy.