Efficacy and perioperative safety of different future liver remnant modulation techniques: a systematic review and network meta-analysis.

BACKGROUND: In daily clinical practice, different future liver remnant (FLR) modulation techniques are increasingly used to allow a liver resection in patients with insufficient FLR volume. This systematic review and network meta-analysis aims to compare the efficacy and perioperative safety of portal vein ligation (PVL), portal vein embolization (PVE), liver venous deprivation (LVD) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). METHODS: A literature search for studies comparing liver resections following different FLR modulation techniques was performed in MEDLINE, Embase and Cochrane Central, and pairwise and network meta-analyses were conducted. RESULTS: Overall, 23 studies comprising 1557 patients were included. LVD achieved the greatest increase in FLR (17.32 %, 95% CI 2.49-32.15), while ALPPS was most effective in preventing dropout before the completion hepatectomy (OR 0.29, 95% CI 0.15-0.55). PVL tended to be associated with a longer time to completion hepatectomy (MD 5.78 days, 95% CI -0.67-12.23). Liver failure occurred less frequently after LVD, compared to PVE (OR 0.35, 95% CI 0.14-0.87) and ALPPS (OR 0.28, 95% CI 0.09-0.85). DISCUSSION: ALPPS and LVD seem superior to PVE and PVL in terms of achieved FLR increase and subsequent treatment completion. LVD was associated with lower rates of post hepatectomy liver failure, compared to both PVE and ALPPS. A summary of the protocol has been prospectively registered in the PROSPERO database (CRD42022321474).

Primary angiosarcoma of the Pancreas - A case Report and review of the literature.

BACKGROUND: Angiosarcomas are malignant neoplasms that originate from endothelial cells. The symptoms exhibit a non-specific nature, and achieving a preoperative diagnosis is frequently challenging. They are seldom encountered in the abdomen, and their occurrence in the pancreas is even rarer. METHODS: Here we document a 67-year-old man with pancreatic angiosarcoma and analyse the literature to outline the clinicopathologic characteristics of this rare phenomenon. RESULTS: This patient with family history of pancreas cancer presented with abdominal pain, and the CT-scan revealed a 4 cm mass at the neck of the pancreas but CA19-9 was normal. Radiologic findings were unusual for ordinary pancreas cancer. Fine-needle aspiration biopsy through endoscopic ultrasound revealed "undifferentiated malignant cells for which the diagnosis of "carcinoma" was favoured. Total pancreatectomy, splenectomy and portal vein reconstruction were performed and epithelioid angiosarcoma were diagnosed. Despite an uneventful postoperative period, discharge on postoperative day 8 without any complications, as well as diligent post-discharge clinical care, the patient died 65 days postoperatively, attributed to the presence of extensive metastasis. A comprehensive literature search has identified a limited number of documented cases of primary pancreatic angiosarcoma, with only ten cases reported to date. CONCLUSIONS: Pancreatic angiosarcomas are very rare and prone to misdiagnosis. The formation of a more demarcated but high-grade tumour with necrosis is a feature that distinguishes angiosarcomas from ordinary carcinomas of this organ. Pathologic diagnosis is also highly challenging closely resembling undifferentiated carcinomas. Angiosarcomas are highly aggressive when they occur in the pancreas. Prompt diagnosis at an early stage is crucial as surgery with curative intent serves as the primary treatment approach.

Surgery with curative intent is the mainstay treatment for pancreatic angiosarcoma when diagnosed at an early stage.Oncological treatment options should be taken into consideration according to the follow-up data.Why does this paper matter?This article is important in that it is the most comprehensive review of the literature on pancreatic angiosarcoma, which is a very rare pathology, from the perspective of radiology, pathology and surgery.

Feasibility of totally extraperitoneal inguinal hernia repair in patients with previous prostatectomy.

Objectives: Laparoscopic totally extraperitoneal inguinal hernia repair (TEP) surgery technique includes three key steps: reaching the preperitoneal space, reducing hernias, and placement of mesh. However, reaching the preperitoneal space can be complicated in patients with previous lower abdominal surgeries. This study aimed to assess the feasibility of laparoscopic inguinal TEP in patients with previous prostatectomies. Material and Methods: Inguinal hernia patients who underwent laparoscopic TEP between January 2015 and February 2021 at Koç University Faculty of Medicine, Department of General Surgery, were included in this retrospective study. The operations were performed by five senior surgeons experienced in laparoscopy. Patients were divided into two study groups, as the radical prostatectomy (RP) group which included patients with previous prostatectomy non-RP which included patients without previous radical prostatectomy. Operative time (OT), length of hospital stay (LOS), and postoperative complications were compared within two groups. Results: Three hundred and forty-nine patients underwent laparoscopic TEP, and 27 had previous prostatectomies. Among them, 190 patients had unilateral inguinal hernias, and 159 had bilateral inguinal hernias. Mean age of the patients in the non-RP and RP groups was 58.1 ± 14.7 and 73.9 ± 9.6 years, respectively. Only one (3.7%) case was complicated with urinary tract infection in the RP group, and 10 (3.1%) were complicated in the non-RP group. Complications for the non-RP group include hematomas in six cases, urinary tract infection in three cases, and urinary retention in one case. No significant difference in mean operative time was seen between non-RP and RP groups (p= 0.43). There was no significant difference in the means of the length of hospital stay between the two groups (p= 0.7). Conclusion: Laparoscopic TEP in patients with a previous prostatectomy can be performed safely without prolonging the operative time and increasing the length of hospital stay.

Multimodal assessment after total neoadjuvant therapy versus standard neoadjuvant chemoradiotherapy in locally advanced rectal cancer accurately predicts complete responders.

PURPOSE: This study aimed to compare local regrowth rates after total neoadjuvant therapy (TNT) versus standard neoadjuvant chemoradiotherapy (SNCRT) in locally advanced rectal cancer (LARC) patients that were strictly selected and assessed with a multimodal approach. Secondary outcomes were 4-year disease-free (DFS) and overall survival (OS) rates. METHODS: Locally advanced rectal cancer patients without distant metastases treated at Koç Healthcare Group between January 2014 and January 2021 were included. Patients were assessed for complete response with a combination of digital rectal exam, endoscopy, and magnetic resonance imaging with a dedicated rectum protocol. The systemic evaluation was performed with an upper abdomen MRI using intravenous hepatobiliary contrast agent and a thorax CT. RESULTS: Of the 270 patients with LARC, 182 fulfilled the inclusion criteria. Ninety-seven (53.3%) underwent TNT, while 85 (46.7%) underwent SNCRT. A cumulative combination of pathological and sustained clinical complete response was significantly higher in the TNT group than in the SNCRT (45.4% vs. 20.0%, p < 0.0001). After a median follow-up of 48 months, seven patients in the W&W group had regrowth [TNT: 4 (10.8%) vs. SNCRT: 3 (23.1%), p = 0.357]. Based on pathological examination, complete/near complete mesorectum rates (p = 1.000) and circumferential resection margin positivity rates (p = 1.000) were similar between the groups. The 4-year DFS and OS rates were comparable. The patients with clinical or pathological complete response had significantly longer overall survival (p = 0.017) regardless of the type of neoadjuvant treatment. CONCLUSIONS: Multimodal assessment after TNT effectively detects complete responders, resulting in low local recurrence and increased cumulative complete response rates. However, these outcomes did not translate into a survival advantage.

A novel scoring system for the early detection of anastomotic leakage: bedside leak score-a pilot study.

Background: Anastomotic leakage is a major complication in colorectal surgery, resulting in significant morbidity and mortality rates. Despite substantial progress in surgical technique, anastomotic leakage rates remain stable. An early diagnosis of anastomotic leaks was proven to reduce adverse outcomes and improve survival. Objective: This study aims to find a novel scoring system for detecting anastomotic leaks using inflammatory and nutritional indicators after colorectal surgery. Our purpose was to analyze the diagnostic accuracy of leak scores ((CRPPOD3)(CRPPOD1)∗preoperativealbuminlevel) in predicting postoperative complications. Design: The study included colorectal cancer patients who underwent curative surgery at Koc University Hospital between 2014 and 2018. Patients were categorized into two groups depending on the presence of anastomotic leaks and compared in terms of preoperative albumin levels, CRP levels in postoperative days 1 and 3, anastomotic leakage rates, length of hospital stay, and CRP quotient, which was calculated by dividing POD 3 CRP level to POD 1 CRP level. The bedside leak score is calculated by dividing the CRP quotient by the preoperative albumin level. The predictive value of bedside leak score, CRP quotient, and preoperative albumin levels in estimating anastomotic leakage was analyzed, and a cutoff value for the leak score was calculated. Results: A total of 184 patients were included in the study. The leak score, CRP POD 3-1 ratio, and preoperative albumin levels were found to successfully detect anastomotic leakage. The area under the curve for the leak score was calculated as 0.78. The optimal cutoff value was found to be 50.3 for the bedside leak score, which shows 90.9% sensitivity and 59.3% specificity. Conclusion: The leak score may represent a valuable diagnostic tool for detecting patients at risk for anastomotic leakage after colorectal surgery and planning a better strategy to reduce morbidity and mortality rates and associated costs. However, further multicenter studies with large cohorts are necessary to confirm these results.

Pancreatic surgery in elderly patients: results of 329 consecutive patients during 10 years.

Introduction: There is a progressive shift from a younger population to an older population throughout the world. With the population age shift, surgeons will be more encountered with older patient profiles. We aim to determine age-related risk factors of pancreatic cancer surgery and the effect of patient age on outcomes after pancreatic surgery. Materials and methods: A retrospective review was conducted with data obtained from consecutive 329 patients whose pancreatic surgery was performed by a single senior surgeon between January 2011 and December 2020. Patients were divided into three groups based on age: patients younger than 65 years old, between 65 and 74 years old, and older than 74 years old. Demographics and postoperative outcomes of the patients were evaluated and compared between these age groups. Results: The distribution of a total of 329 patients into the groups was 168 patients (51.06%) in Group 1 (age <65 years old), 93 patients (28.26%) in Group 2 (age ≥65 and <75 years old), and 68 patients (20.66%) in Group 3 (age ≥75 years old). The overall postoperative complications were statistically significantly higher in Group 3 than in Group 1 and Group 2 (p = 0.013). The comprehensive complication index of the patients in each group was 23.1 ± 6.8, 20.4 ± 8.1, and 20.5 + 6.9, respectively (p = 0.33). Fisher's exact test indicated a significant difference in morbidity in patients with ASA 3-4 (p = 0.023). In-hospital or 90-day mortality was observed in two patients (0.62%), one from Group 2 and one from Group 3. The 3-year survival rates for each group were 65.4%, 58.8%, and 56.8%, respectively (p = 0.038). Conclusion: Our data demonstrate that comorbidity, ASA score, and the possibility of achieving a curative resection do have significantly more impact than age alone.

Safety and Feasibility of Laparoscopic Right or Extended Right Hemi Hepatectomy Following Modulation of the Future Liver Remnant in Patients with Colorectal Liver Metastases: A Systematic Review.

Background: Major hepatectomies after future liver remnant (FLR) modulation are technically demanding procedures, especially when performed as minimally invasive surgery. The aim of this systematic review is to assess current evidence regarding the safety and feasibility of laparoscopic right or extended right hemihepatectomies after FLR modulation. Materials and Methods: The Medline, PubMed, Cochrane Library, and Embase databases were searched for studies involving laparoscopic right or extended right hemihepatectomies after FLR modulation, from their inception to December 2021. Two reviewers independently selected eligible articles and assessed their quality using the Newcastle-Ottawa Quality Assessment Scale (NOS). Baseline characteristics and outcomes were extracted from the included studies and summarized. Results: Six studies were included. In these studies, the median length of stay after the second stage ranged from 4.5 to 15.5 days and postoperative complication rates between 4.5% and 42.8%. Overall, 7.4% of patients developed liver failure, and 90-day mortality occurred in 3.2% of patients. The R0 resection rate was 93.5%. Only one study reported long-term outcomes, describing comparable 3-year overall survival rates following laparoscopic and open surgery (80% versus 54%, P = .154). Conclusions: The current evidence is scarce, but it suggests that in experienced centers, laparoscopic right or extended right hemihepatectomy, following FLR modulation, is a safe and feasible procedure.

What Is the Current Role and What Are the Prospects of the Robotic Approach in Liver Surgery?

In parallel with the historical development of minimally invasive surgery, the laparoscopic and robotic approaches are now frequently utilized to perform major abdominal surgical procedures. Nevertheless, the role of the robotic approach in liver surgery is still controversial, and a standardized, safe technique has not been defined yet. This review aims to summarize the currently available evidence and prospects of robotic liver surgery. Minimally invasive liver surgery has been extensively associated with benefits, in terms of less blood loss, and lower complication rates, including liver-specific complications such as clinically relevant bile leakage and post hepatectomy liver failure, when compared to open liver surgery. Furthermore, comparable R0 resection rates to open liver surgery have been reported, thus, demonstrating the safety and oncological efficiency of the minimally invasive approach. However, whether robotic liver surgery has merits over laparoscopic liver surgery is still a matter of debate. In the current literature, robotic liver surgery has mainly been associated with non-inferior outcomes compared to laparoscopy, although it is suggested that the robotic approach has a shorter learning curve, lower conversion rates, and less intraoperative blood loss. Robotic surgical systems offer a more realistic image with integrated 3D systems. In addition, the improved dexterity offered by robotic surgical systems can lead to improved intra and postoperative outcomes. In the future, integrated and improved haptic feedback mechanisms, artificial intelligence, and the introduction of more liver-specific dissectors will likely be implemented, further enhancing the robots' abilities.

The first case: acute abdomen due to gastric gastrointestinal stromal tumor perforation with synchronous renal cell carcinoma.

AIM: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract and they may coexist with renal cell cancers (RCC). The main treatment method of GIST and RCC is curative elective surgery. Surgery followed by oncological treatment with sunitinib is the main treatment option when these tumors coexist. CASE REPORT: A 32-year-old male, after a traffic accident applied to the emergency department. A thoraco-abdominopelvic computed tomography was performed, which demonstrated the presence of diffuse hemorrhagic fluid in the abdomen with 11x10 cm exophytic gastric mass and 2 x 2 cm right renal mass. After emergent laparotomy with gastric wedge resection and partial nephrectomy, patient was discharged uneventfully. CONCLUSIONS: If the patient's clinical condition is suitable for surgery, both tumors can be removed simultaneously, even in emergency situations. Thus, difficulties and complications that may occur during follow-up and the second operation can be avoided. KEY WORDS: Acute Abdomen, Gastrointestinal Stromal Tumor, Renal Cell Carcinoma.

A rare tumor of the male breast "angiolipoma" Case report and review of literature.

AIM: Angiolipoma is uncommon lesion in the breast and has clinical importance due to the potential of confusion with malignant breast lesions. To date, there is no defined diagnosis and treatment algorithm for breast angiolipomas. We aim to contribute to the literature for the diagnosis and treatment of angiolipomas with this case report and literature review. CASE REPORT: A 29-year-old male patient presented with a newly emerged palpable mass in the right breast. Physical examination revealed a palpable mass in the lower inner quadrant of the right breast without any presence of skin changes, nipple discharge or palpable axillary lymph nodes. The lesion was found to be 3 cm in diameter and showed minimal vascularization on Doppler Ultrasound examination. Surgical excision of the lesion was performed and the lesion was diagnosed as angiolipoma. CONCLUSION: Angiolipomas of the breast in male are rare pathological entities and must always be considered during differential diagnosis, as it can be confused clinically, radiologically and pathologically with other lesions, especially with malignant lesions KEY WORDS: Angiolipoma, Breast, Male breast lesions.

Management of Gastric Tumor Perforation with Conservative Treatment during Neoadjuvant Chemotherapy.

Perioperative chemotherapy provides advantage for gastric cancer patients in terms of survival. A 56-year male with a diagnosis of locally advanced gastric carcinoma presented with complaints of acute abdominal pain; and was diagnosed as gastric tumor perforation during neoadjuvant therapy. Gastric perforation may occur during neoadjuvant chemotherapy for gastric cancer. While the treatment of choice for these perforations was surgery in the past, it is now shifting towards a minimally invasive or non-invasive approach. We used the minimally invasive treatment approach with nasogastric drainage, intravenous antibiotics and proton pump inhibitors, which was effective in the treatment of perforation. Althrough, conservative treatment approach may be an effective management option in selected patients with gastric cancer perforation. Key Words: Gastric cancer, Neoadjuvant chemotherapy, Perforation.

Effects of the Largest Metastatic Lymph Node Size on the Outcomes of Patients who Underwent Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma.

Objectives: Prognostic importance of metastatic lymph nodes in pancreatic cancer is always garnered attention due to dismal prognosis, with some quantitative factors drawing attention for significantly predicting outcomes. Size is one of the easy approach morphological characteristics of the lymph node, and data for effect of largest metastatic lymph node (LMLN) size on survival outcomes are lacking in pancreatic cancer. We aim to evaluate the effect of LMLN size on the prognosis of patients with pancreatic ductal adenocarcinoma (PDAC). Methods: This retrospective study evaluates the effect of LMLN size on survival outcomes by grouping the patients who were surgically treated for PDAC, according to their lymph node stage and calculated cutoff value for LMLN size, between February 2015 and May 2020. Results: In the study cohort of 131 patients, the mean age was 63.9±10.8 years and 77 patients were female. Ninety-nine of the patients had pN1, 32 had pN2 stage disease. The optimal cutoff point of LMLN size for predicting the prognosis was calculated as 7.5 mm (sensitivity = 81% and specificity = 81%). 34 (34.3%) of pN1 and 7 (21.9%) of pN2-staged patients had lymph node smaller than 7.5 mm. Three-year survival was significantly longer for patients whose LMLN size was <7.5 mm (56.2-18.2%, p<0.001). Whereas, the patients with LMLN size <7.5 mm had statistically significant longer median survival rate in the subgroup of patients with pN1 lymph node stage, no significant difference in median survival rates was observed between subgroups of pN2 patients (p=0.237). Conclusion: The present study demonstrated that the LMLN size was one of the potential predictors of survival in patients with PDAC.

Invasive lobular carcinoma of the breast: clinicopathological features and patient outcomes.

AIM: The incidence of invasive lobular carcinoma (ILC), a breast cancer type comprising several variants with distinct morphological and molecular features and clinical behaviors, has been increasing in recent years. Unlike the well-defined classical lobular carcinoma, the most common ILC variant, some uncertainties remain regarding the features of other ILC variants. Therefore, we investigated the clinicopathological features and survival outcomes of specific ILC variants. MATERIAL AND METHODS: This retrospective study compared the tumor and patient characteristics and outcomes according to specific ILC variants in 77 patients who underwent surgery for ILC between January 2010 and December 2016 at a single center in Turkey. RESULTS: The mean patient age was 54.58 ± 11.7 years. The ILC variants were classical, pleomorphic, tubulolobular, solid, and signet ring cell in 49(63.6%), 14(18.2%), 10(12.8%), 2(2.7%), and 2(2.7%) patients, respectively. The mean tumor diameter, histological grade, Ki-67 proliferation index, nodal metastasis, E-cadherin expression, lymphovascular invasion, and type of surgery were significantly different among the variants. However, there were no significant differences in the rates of local recurrence, distant metastasis, and overall survival among the variants. CONCLUSIONS: Despite the good prognostic characteristics and good response to treatment, several studies have reported that ILC is associated with poor long-term outcomes. Therefore, significant challenges remain in the management of ILC. Although it is believed to be a specific histological type, ILC is clinically and pathologically heterogenous. Therefore, the identification of patients with poor prognostic variants should aid in the implementation of efficient and personalized treatment options. KEY WORDS: Breast cancer, Invasive cancer, Invasive lobuler carcinoma, Prognosis, Variants of lobuler carcinoma.

The rapid effects of sleeve gastrectomy on glucose homeostasis and resolution of diabetes mellitus.

Aims: Type 2 diabetes caused by obesity is increasing globally. Bariatric surgical procedures are known to have positive effects on glucose homeostasis through neurohormonal action mechanisms. In the present study, we aimed to investigate the factors influencing glucose homeostasis independent of weight loss after the laparoscopic sleeve gastrectomy (LSG). Methods: Patients who underwent LSG for morbid obesity in a 3-year period were evaluated. Data on demographics, clinical characteristics (duration of diabetes, resected gastric volume, antral resection margin) and laboratory parameters (preoperative and postoperative blood glucose on fasting, preoperative HbA1c levels and first-year HbA1c levels) were retrospectively reviewed. Effect of patients' body mass index (<50 kg/m2, ≥50 kg/m2), first-year excess weight loss (EWL%) rates, age (≥50 years, <50 years), duration of diabetes (≥5 years, <5 years) and antral resection margin (≥3 cm, <3 cm) on postoperative blood glucose profile and diabetic resolution status were investigated. Results: Total of 61 patients constituted the study group. There were 40 female and 21 male patients with an average age of 43.8 ± 10.5 years (19-67 years). Preoperatively, mean BMI, blood glucose levels and HbA1c were 48.8 ± 8.5 kg/m2, 133.6 ± 47.4 mg/dL and 7.4 ± 1.1, respectively. The mean blood glucose level at the postoperatively 5th day was 88.0 ± 16.3 mg/dL (median: 84 mg/dL) (P < .001). Fifty-nine out of 61 patients improved their glycaemic control. Conclusions: It is noteworthy that LSG can control blood glucose levels in short term after surgery regardless of weight loss. Therefore, LSG should be preferred at earlier stages in the treatment of obesity-related T2DM in order to prevent T2DM-related complications.

Relationships between androgen receptor expression and clinicopathological parameters in male breast cancer.

INTRODUCTION: Most patients with male breast cancer (MBC) express the androgen receptor (AR). AR expression in these tumors may have both prognostic and predictive values because its presence indicates the potential benefits of an anti-androgen therapeutic approach. The present study aimed to investigate the relationship between AR expression and clinicopathological parameters in MBC. MATERIAL AND METHODS: The data of 35 patients who received a histological diagnosis of MBC at the pathology department of our hospital between January 2007 and December 2017 were retrospectively reviewed. The patients' demographic data, follow-up records and pathology reports were recorded. AR expression status and its relationship with clinicopathological parameters were evaluated. The chi-square test was used to compare independent groups. Univariate survival analyses were performed using the Kaplan-Meier survival procedure. A p value of ≤0.05 was considered statistically significant. RESULTS: There was no significant relationship between AR expression and AJCC stage (p=0.585), pathologic stage (p=0.696), histologic grade (p=0.685), lymph-node status (p=0.685), survival rate (p=1.000), age(p=1.000), lymphovascular invasion (p=0.700), perineural invasion(p=1.000), skin invasion (p=1.000), nipple involvement(p=1.000), DCIS presence(p=1.000), ER positivity(p=1.000), PR positivity (p=0.218), Her2 expression (p=0.523), Ki67 index (p=0.685), Luminal A group (p=0.700), Luminal B group (p=0.691), triple negative group (p=1.000). CONCLUSION: Further investigation of the relation between AR expression and clinicopathological parameters of patients with MBC might yield important information and lead to the development of additional treatment options. KEY WORDS: Androgen receptor, AR expression, breast cancer, Male Breast cancer, Prognosis, Receptor status.

Complex Anal Fistula: Long-Term Results of Modified Ligation of Intersphincteric Fistula Tract=LIFT.

OBJECTIVES: The anal fistula is a permanent infectious tunnel formed between the anal canal and skin in the perianal region. Fistulas are treated by surgery at any stage. Many surgical methods have been reported to treat anal fistula. One of the promising surgical methods with a high success rate is ligation of the intersphincteric fistula tract, which is performed in anatomical spaces without damage to the internal and external sphincters. We evaluated the success rate of a modified ligation of the intersphincteric fistula tract procedure for complex anal fistulas in which the technical differences were minimized by the surgery being performed by the same surgical team. METHODS: In this study, Data of the 56 patients were retrospectively collected. Data regarding patient history, visual and digital anal examination, Cleveland Clinic Florida Fecal Incontinence (CCF-FI) score, anal-phase pelvic magnetic resonance imaging (MRI), rectosigmoidoscopy or colonoscopy and anal manometry were recorded. The changes in data recorded during the preoperative and postoperative periods were compared in each other. RESULTS: The mean age of the patients was 41±15.5 years. The number of patients for each fistula type compromised in this study was as follows in accordance with frequency: high transsphincteric fistula, high intersphincteric fistula, and horseshoe abscess. The fistula recurred in seven patients during postoperative follow-up and the success rate of modified LIFT was calculated as 87.5%. The change in the mean±SD preoperative and postoperative CCF-FI scores and anal pressure was not statistically significant. CONCLUSION: One promising advantage of the ligation of the intersphincteric fistula tract procedure is that it turns a complex fistula into a simple fistula that can be treated with minimal risk of sphincter damage.

Treatment of acute appendicitis: Urgent surgery or emergent surgery?

BACKGROUND: The standard treatment of acute appendicitis, which is a rapidly progressive inflammatory disease, remains surgery. However, several studies have suggested antibiotics treatment for acute appendicitis, especially in centers where surgery at all hours is not possible. Therefore, in this study, we investigated the relationship between the preoperative waiting period and postoperative complications in patients who underwent interval surgery following conservative management during the same admission. METHODS: All patients who were diagnosed with uncomplicated acute appendicitis between October 2014 and February 2015 and underwent surgery at a single center were included in this retrospective study. Patients were divided into two groups based on the waiting period between the diagnosis and the time of surgery: group A (emergency, waiting period <10 h) and group B (urgency, waiting period ≥10 h). The demographic features, preoperative waiting period, antibiotics use, pathological diagnosis, postoperative complications, length of hospital stay, and readmission were compared between the two groups. RESULTS: This study comprised 160 patients, including 79 and 81 patients in groups A and B, respectively. The demographic features, comorbidities, and pathological diagnosis were comparable between the two groups. The average preoperative waiting period was significantly longer in group B than in group A. However, the mean length of hospital stay and the rate of postoperative complications, including infections at the surgical sites and intra-abdominal abscesses, were similar between the two groups. CONCLUSION: Our analyses revealed that there were no disadvantages associated with a longer preoperative waiting period in patients diagnosed with uncomplicated appendicitis.

The Impact of Micropapillary Component Ratio on the Prognosis of Patients With Invasive Micropapillary Breast Carcinoma.

Background and Objectives: Invasive micropapillary carcinoma (IMPC) of the breast is a rare and aggressive variant of invasive ductal carcinoma characterized by high-grade lymphovascular invasion and high rates of nodal metastasis. The prognostic significance of the micropapillary component (MC) ratio that constitutes this aggressive variation is controversial. In this study, we aimed to investigate the effect of the MC ratio on the prognosis of these patients. Methods: The data of 47 patients with IMPC were retrospectively reviewed. Patients were divided into two groups: MC ratio of 10-75% (Group 1) and greater than 75% (Group 2). The demographic characteristics of the patients, histopathologic features of the tumors, and survival rates were compared. Results: We detected no significant difference in demographic characteristics between groups 1 and 2 (p = 0.21). No significant difference was detected in terms of tumor diameter, lymph node metastasis, lymphovascular invasion, histologic grade, multicentricity, local recurrence, distant metastasis, and overall survival. Conclusion: In the micropapillary subgroup of invasive ductal carcinoma, although positive receptor characteristics are directly proportional to the increase in MC ratio, recurrence and survival rates are not affected by micropapillary component level.

Prospective multi-center study of surgeon's assessment of the gallbladder compared to histopathological examination to detect incidental malignancy.

PURPOSE: Routine histopathological examination after cholecystectomy for gallstones is performed despite the low rates of incidental findings of malignancy. The aim of this study was to assess predictive values of macroscopic examination of cholecystectomy specimens by surgeons in gallstone disease. METHODS: A prospective multi-center diagnostic study was carried out between December 2015 and March 2017 at four different centers. All patients undergoing cholecystectomy for gallstone disease were consecutively screened for eligibility. Patients whose ages are 18 to 80 years, and preoperative imaging findings without any pathology except cholelithiasis were included. The gallbladder was first evaluated macroscopically ex situ by two operating surgeons and rated as macroscopically benign (group S1), suspicious for a benign diagnosis (group S2), and suspicious for malignancy (group S3). Thereafter, a pathologist made a final histopathological examination whose results are grouped as chronic cholecystitis (group P1), benign or precancerous lesions in which only cholecystectomy is the adequate treatment modality (group P2), and carcinoma (group P3). Diagnostic accuracy of the surgeon's assessment to the histopathological examination was evaluated using sensitivity, specificity, positive and negative predictive values, and accuracy, and correlated by a kappa agreement coefficient. RESULTS: A total of 1112 patients were included in this trial. The specificity rates were 96.5%, 100%, and 98.7% for group S1-group S2, group S1-group S3, and group S2-group S3, respectively. Accuracy rates to detect malignancy were 100% and 95. 2% for group S1 and group S2, respectively. Kappa coefficient values were 1.0 and 0.64 for group S1-group S3 and group S2-group S3, respectively (p < 0.001 for both). CONCLUSION: Assessment of the gallbladder specimen and selective histopathological examination may be adequate after cholecystectomy for gallstone diseases. Such a procedure would have the potential to reduce costs and prevent unnecessary loss of labor productivity without affecting patients' safety. However, higher number of patients in more centers is needed to confirm this hypothesis.

How does the extent of antral resection affect the residual gastric volume and excessive weight loss?

AIM: To identify the effect of the extent of antral resection on the residual gastric volume (RdGV) and excess weight loss (EWL) among patients who underwent laparoscopic sleeve gastrectomy(LSG) due to the obesity. MATERIAL AND METHODS: The demographical data, operative details, postoperative morbidity, mortality and the percentages of EWL in the postoperative 3, 6 and 12 months of the patients who underwent LSG between January 2014 and August 2015 were analyzed. These patients were divided into three groups regarding the antral resection margin (ARM): Group 1(n=80): ARM≤3cm; Group2 (n=35): 3 6cm from pylorus) resulted in reduced operating cost and decelerated reach to optimal EWL% with similar postoperative outcomes. KEY WORDS: Antral resection margin, Excess weight loss, Laparoscopic sleeve gastrectomy, Residual gastric volume, Surgical technique.