Oversewing the Staple Line: Does It Safe to Prevent Leakage?

Introduction: The staple line (SL) leak remains one of the most serious complications after laparoscopic sleeve gastrectomy (LSG). The present study aims to determine whether reinforcing the SL with sutures is effective in maintaining tissue integrity. Materials and Methods: LSG Specimens of 60 patients were ex vivo studied. The specimens were divided into three groups: In group 1, the entire SL was reinforced, while the upper half part of the SL was reinforced from fundus to antrum in group 2. The SL was not reinforced in group 3. Then, the pressure inside the sample was increased, and the bursting pressure location and pressure value during the bursting were recorded. Results: The bursting pressure was significantly higher in entire and half oversewed SL groups than the none reinforced group (group 1: 115 mmHg [95-170]; group 2: 95 mmHg [80-120]; group 3: 40 mmHg [22-60], respectively, [P < .001]). The most common site of bursting was in the middle ⅓ of SL (35, 53.8%), followed by the proximal ⅓ part of SL (18, 27.7%), and the distal ⅓ part of SL (12, 18.5%), respectively. The bursting site was significantly more frequent in the corpus than the other parts of the SL (P = .013). Conclusion: Reinforcing the SL with sutures preserves tissue integrity. Although bursting was most frequently observed in the corpus region ex vivo, the fact that almost all real-life leaks develop in the area close to the Angle of His. This situation suggests that strengthening the suture line with reinforcement alone will not be protective enough against leaks in the fundus line, and factors such as tissue ischemia may be considered.

Peripheral Expression of ADORA2A Is Increased and Is Correlated with Autism Spectrum Disorder Severity in a Sample of Turkish Children.

Background: The aim of this study was to evaluate the peripheral expression of ADORA2A (Adenosine A2A receptor gene) in young subjects with autism spectrum disorder compared with healthy controls and its relationship with clinical characteristics. Method: This study included 93 children and adolescents with a diagnosis of autism spectrum disorder as the study group and 105 healthy age- and gender-matched controls. Blood samples were obtained from all participants, and a real-time quantitative polymerase chain reaction was performed. Parent- and clinician-rated assessment instruments were used to assess and rate the severity of autism spectrum disorder and other emotional/behavioral problems. Results: The mean age of the study group was 9.06 ± 3.57 and 86% were male (n = 83), whereas the mean age of the control group was 9.22 ± 3.86 and 86.7% were male (n = 91). We have found a higher level of peripheral expression of ADORA2A in children and adolescents with autism spectrum disorder compared with healthy controls (fold change = 1.33, P = .001). We also found a weak negative correlation with autism spectrum disorder severity (r = -0.216; P = .038) and stereotyped behaviors (r = -0.207, P = .046). Conclusion: ADORA2A genes may have a role in the pathophysiology of autism spectrum disorder. Further studies are needed to evaluate whether peripheral expression of ADORA2A genes may be among the biomarkers for diagnosing or measuring the severity of autism spectrum disorder.

Comparison of scoring systems regarding the gender as a parameter with the traditional scoring systems for predicting appendicitis.

Although acute appendicitis remains the most common cause of acute abdomen in General Surgery practice, negative appendectomy rates are still high in particularly female patients. Appendicitis scoring systems considering gender can help the clinician to reduce negative appendectomy rates in females. This present study aims to compare the Lintula, Ripasa, Fenyo-Lindberg scoring systems, which use gender as a variable, with the Alvarado, Karaman, scoring systems to evaluate which CSS is more successful in the differential diagnosis of appendicitis in females. We analyzed the records of the patients operated on with a prediagnosis of acute appendicitis in our clinic between 2020 and 2021, retrospectively. Alvarado, adult appendicitis score (AAS), appendicitis inflammatory response score (AIRS), Ripasa, Karaman, Lintula, and Fenyo Lindberg scores were calculated for each patient. The patients were divided into two groups as male and female, according to gender. Receiver operator characteristic (ROC) curve analysis was used to identify the best cut-off value and assess the performance of the test score for appendicitis. Three hundred and sixty-three patients were included in the study. One hundred seventy-two (47.4%) of the patients were male, and 191 (52.6%) were female. Alvarado and AAS were the most valuable score in female (AUC: 0.805, sensitivity: 0.63, specificity: 0.83; and area under curve (AUC): 0.794, Sensitivity 0.71, Specificity: 0.76, respectively), male group (AUC: 0.828, Sensitivity: 0.71, Specificity: 0.83; and AUC: 0.834, Sensitivity 0.74, Specificity: 0.77, respectively), and when patients were not categorized by gender (AUC: 0.818, Sensitivity: 0.67 Specificity: 0.83; and AUC: 0.794, Sensitivity 0.71, Specificity: 0.76, respectively). Although the Alvarado scoring system is the first defined appendicitis scoring system, it seems as superior to the many scoring systems defined after it in predicting appendicitis, even in female patients.

Comparison of open and laparoscopic gastrectomy for gastric cancer: a low volume center experience.

OBJECTIVES: In gastric cancer, laparoscopic gastrectomy is commonly performed in Asian countries. In other regions where tumor incidence is relatively low and patient characteristics are different, developments in this issue have been limited. In this study, we aimed to compare the early results for patients who underwent open or laparoscopic gastrectomy for gastric cancer in a low volume center. MATERIAL AND METHODS: We retrospectively analyzed the data of patients who underwent curative gastric resection (open gastrectomy n: 30; laparoscopic gastrectomy n: 30) by the same surgical team between 2014 and 2019. RESULTS: The tumor was localized in 60% (36/60) of the patients in the proximal and middle 1/3 stomach. In laparoscopic gastrectomy group, the operation time was significantly longer (median, 297.5 vs 180 minutes; p <0.05). In open gastrectomy group, intraoperative blood loss (median 50 vs 150 ml; p <0.05) was significantly higher. Tumor negative surgical margin was achieved in all cases. Although the mean number of lymph nodes harvested in laparoscopic gastrectomy group was higher than the open surgery group, the difference was not statistically significant (28.2 ± 11.48 vs 25.8 ± 9.78, respectively; p= 0.394). The rate of major complications (Clavien-Dindo ≥ grade 3) was less common in the laparoscopic group (6.7% vs 16.7%; p= 0.642). Mortality was observed in four patients (2 patients open, 2 patients laparoscopic). CONCLUSION: In low-volume centers with advanced laparoscopic surgery experience, laparoscopic gastrectomy for gastric cancer can be performed with the risk of morbidity-mortality similar to open gastrectomy.

Laparoscopic Surgery for Adult Intussusception: Case Series.

BACKGROUND/AIMS: Intussusception is a rare condition in adults which accounts for 1% of all intestinal obstructions. It usually requires surgical treatment and the classic approach is laparotomy. This article presented six adult patients who underwent laparoscopic surgery for intestinal obstruction due to intussusception. MATERIALS AND METHODS: Between January 2017 and July 2019, six adult patients underwent laparoscopic surgery for intestinal obstruction due to intussusception. The patients were evaluated in terms of presenting symptoms, diagnosis, treatment modality, morbidity, mortality and histopathological results. RESULTS: All patients presented with acute (50%) or subacute (50%) symptoms. All patients had intestinal obstruction (partial, complete) findings. Intussusception was diagnosed by abdominal computed tomography (CT). The patients with ileocolic and colo-colonic intussusception underwent colonoscopy. In the preoperative period, the etiology of intussusception (neoplasm, idiopathic, etc.) was diagnosed only in one patient (16.6%). Two patients underwent laparoscopic segmental small bowel resection, two patients underwent laparoscopic right hemicolectomy, one patient underwent laparoscopic left hemicolectomy, and one patient underwent laparoscopic anterior resection. None of the patients developed intraoperative or postoperative complication. The histopathological examination revealed malignancy in two patients (33.3%). CONCLUSION: CT is helpful in diagnosing of adult intussusception. However, it is usually difficult to define the underlying pathology with CT. Laparoscopic approach seems to be safe and effective as open surgery, both in diagnosis and treatment of intussusception.

Gynecomastia: A Rare Adverse Effect of Methylphenidate in an Adolescent Boy.

Gynecomastia is a benign condition developing in association with localized fat deposition and glandular tissue proliferation in the breast in males, and characterized by breast growth. Drug is one of the most important factors in the etiology of gynecomastia. Methylphenidate is a commonly preferred and well-tolerated drug in the treatment of attention deficit hyperactivity disorder in children and adolescents. Gynecomastia is an uncommon side-effect of methylphenidate use. We report a case of bilateral gynecomastia developing in a dose-dependent manner during methylphenidate monotherapy and resolving with discontinuation of medication in a 15-year-old patient with a history of a similar side-effect during previous use of the drug. To the best of our knowledge this is one of the few case reports of gynecomastia developing in association with methylphenidate.

The effect of immunonutrition on bacterial translocation after Pringle maneuverer in rats.

INTRODUCTION: Temporary clamping of the hepatoduodenal ligament (the Pringle manoeuvre) is the most commonly used method to prevent intraoperative blood loss in liver surgery. Some side effects of the Pringle manoeuvre (PM) can occur. AIM: To investigate the effectiveness of preoperative immunonutritional support to prevent bacterial translocation (BT) in rats due to PM. MATERIAL AND METHODS: Forty Wistar albino rats were randomly divided into four groups. Groups 1 and 2 were fed with normal rat diet and water, and groups 3 and 4 were fed with enteral immunonutrition (Impact Glutamine) containing 1 g/kg/day amino acid in the preoperative period. Group 1 (n = 10) and 4 (n = 10) rats were treated only with laparotomy; group 2 (n = 10) and 3 (n = 10) rats were treated with PM for 30 min with laparotomy. After 30 min, relaparotomy was applied to all groups and portal blood, mesentery, spleen samples were taken for culture purposes. RESULTS: Proliferation in portal blood cultures was significantly higher in the samples from the normally fed group (group 2) in whom PM was applied, compared to the other groups (p < 0.001). No proliferation was observed in the PM-treated group (group 3), who also received preoperative immunonutritional support. CONCLUSIONS: Preoperative immunonutritional support is effective in the prevention of BT due to PM in rats.

High Rates of Psychiatric Disorders and Below Normal Mental Capacity Associated With Spastic Peroneal Flatfoot: A New Relationship.

Spastic peroneal flatfoot (SPFF) is a rare hindfoot pathology usually seen in the adolescent age group that is characterized by painful spasms in the peroneal muscles. We have clinically observed that patients with SPFF also have some behavioral and emotional difficulties and problems in their academic achievements. Because of these observations, we investigated the prevalence and patterns of psychiatric disorders and intellectual disability among young subjects with SPFF. Our cohort consisted of 16 patients with SPFF. Their mean age at presentation was 21 (range 13 to 31) years. Only 6 patients had a tarsal coalition as an underlying condition. The psychometric evaluation was conducted using validated instruments (Wechsler Intelligence Scale for Children-revised form, Stanford Binet intelligence quotient [IQ] test, and Cattell IQ test). Psychiatric disorders were assessed using a semistructured diagnostic instrument (Schedule for Affective Disorders and Schizophrenia for School Age Children Present and Lifetime Version). The testers and psychiatrists were unaware of the orthopedic condition and the preliminary psychiatric diagnoses. The ethical committee approved the study protocol. The mean follow-up period was 41 (range 12 to 97) months. The mean IQ score of the patients was 75.1 ± 17.9 (range 52 to 107). Compared with the general population, the rate of intellectual disability was significantly greater (p = .0001) and the rate of normal intelligence significantly lower (p = .0015) in our patient group. Furthermore, according to the community schooling ratio, our cohort also had lower junior high and secondary education rates compared with the general population. The rate of most psychiatric disorders diagnosed in the SPFF patients was greater than that in the normal population. The most commonly identified psychiatric disorders were social phobia and attention deficit and hyperactivity disorder (75%). Timely interventions of the psychosocial and academic problems of patients with SPFF might increase their compliance with orthopedic treatment and help with their psychological well-being and academic achievement. In addition, this relationship might be a clue for uncovering the etiology of this disease, which has not yet been clarified.

Delayed presentation of a sigmoid colon injury following blunt abdominal trauma: a case report.

INTRODUCTION: The low incidence of colon injury due to blunt abdominal trauma and the lack of a definitive diagnostic method for the same can lead to delays in diagnosis and treatment, subsequently resulting in high morbidity and mortality. CASE PRESENTATION: A 66-year-old woman with sigmoid colon injury was admitted to our emergency department after sustaining blunt abdominal trauma. Her physical examination findings and laboratory results led to a decision to perform a laparotomy; exploration revealed a sigmoid colon injury that was treated by sigmoid loop colostomy. CONCLUSIONS: Surgical abdominal exploration revealed gross fecal contamination and a perforation site. Intra-abdominal irrigation and a sigmoid loop colostomy were performed. Our patient was discharged on post-operative day six without any problems. Closure of the sigmoid loop colostomy was performed three months after the initial surgery.

A rare cause of gastrointestinal phytobezoars: diospyros lotus.

AIM: Diospyros Lotus ("Wild Date Palm of Trabzon or Persimmon"), which has been proven to cause phytobezoars, is a widely consumed fruit in the Black Sea and Northeast Anatolia regions of Turkey. The aim of the present study was to investigate the effects of Diospyros Lotus together with other predisposing factors, on the development of gastrointestinal phytobezoars and to discuss the treatment results in comparison to the literature. MATERIAL AND METHOD: The records of 13 patients, who had been admitted to the General Surgery Clinic of Düzce Atatürk State Hospital between August 2008 and August 2011, were retrospectively reviewed. Demographic characteristics, predisposing factors, clinical and radiological findings, diagnostic and therapeutic methods, and the outcomes of the patients were recorded from the patient files. Written informed consent was obtained from each patient for publication of this research article and accompanying images. RESULTS: All the patients had a history of consuming Diospyros Lotus. Of the patients, 30,7% had a history of previous gastric surgery, 30,7% had diabetes mellitus and 23% had dental implants. None of the patients had hypothyroidism, which is another predisposing factor for phytobezoars.The phytobezoars were located in the stomach alone in 23% of the patients, whereas 15,3% was detected in the jejunum and stomach, 15,3% was detected in the jejunum alone, and 46,1% was detected in the ileum alone. All patients were treated with surgery, and there were no deaths. CONCLUSION: Gastric phytobezoars are rare. Preventive measures have particular importance in the management of this condition, which is difficult to treat. For this purpose, excessive consumption of herbal nutrients containing a high amount of indigestible fibers such as Diospyros Lotus should be avoided in patients with a history of gastrointestinal surgery or poor oral and dental health.

Treatment of gastric phytobezoars with Coca-Cola given via oral route: a case report.

BACKGROUND: A 43-year-old female patient presented with a chief complaint of upper abdominal pain. As her complaints had lasted for 1 month, an upper gastrointestinal system endoscopy was performed and discovered a bezoar in the stomach. CASE PRESENTATION: The bezoar was quite hard and light green-yellow in color. Pathological examination revealed phytobezoar. The patient was hospitalized and given oral Coca-Cola(®) Zero for seven days at a dose of 500 mL three times daily. CONCLUSION: The upper gastrointestinal system endoscopy performed at the end of 7 days showed that the phytobezoar had softened and become smaller. The phytobezoar was broken into pieces with biopsy forceps and washing was applied, so the phytobezoar pieces could pass through the pylorus. The patient was discharged after the procedure without problem.

Psychiatric Co-morbidity and Efficacy of Mirtazapine Treatment in Young Subjects With Chronic or Cyclic Vomiting Syndromes: A Case Series.

The aim of this case report was to evaluate the psychiatric co-morbidity and efficacy of mirtazapine treatment in young subjects with chronic or cyclic vomiting syndromes. This is a case series of 8 young subjects (age range of 6-16 years, 11.12 ± 3.52 years) who were referred or consulted to child psychiatry department. They were referred or consulted by pediatric gastroenterology or surgery departments for the presence of non-remitting and medically unexplained vomiting. They were investigated for co-morbid psychiatric disorders using a structured psychiatric interview. An open trial of mirtazapine was conducted for the treatment and/or prevention of vomiting. Primary outcome measure was Clinical Global Impression-Improvement scale. Subjects were diagnosed with chronic (n = 5) or cyclic (n = 3) vomiting syndromes. Duration of vomiting ranged from 6 months to 10 years (3.5 ± 3.2 years). All subjects received multiple psychiatric diagnoses with anxiety disorders being the most frequent. Maximum mirtazapine dosage was 7.5-30 mg/day (16.00 ± 6.16 mg/day). Three subjects showed complete remission and 5 subjects showed much to very much improvement in vomiting. Most frequent side effects were increased appetite, weight gain and sedation. Young subjects with chronic or cyclic vomiting may frequently suffer anxiety and/or depressive symptoms or disorders. Mirtazapine could be an effective treatment option for the treatment of vomiting and co-morbid anxiety or depressive disorders in these subjects. More systematic research are needed on this topic.

Prosthetic repair of incarcerated inguinal hernias: is it a reliable method?

BACKGROUND AND AIM: It is generally accepted that most inguinal hernias should be operated on electively using synthetic grafts. However, limited information is available on the usage of these materials in patient with incarcerated and strangulated hernias. The objective of this study is to compare the outcomes of incarcerated inguinal hernia repair with or without graft. MATERIALS AND METHODS: One hundred-thirteen patients with incarcerated inguinal hernia that underwent surgery were included in this study. Patients who underwent Lichtenstein repair were assigned to group I; those who underwent primary repair were assigned to group II. Demographics and characteristics of patients in each group were compared. Chi-square and Student's t-tests were used. RESULTS: No statistical difference was found between patients who did and did not receive anastomosis in both groups in terms of surgery duration, length of hospital stay, postoperative morbidity, and mortality. Recurrence was found in 4.0% and 20.8% patients in group I and group II, respectively (P = 0.036). CONCLUSIONS: Mesh repair can be preferred in incarcerated inguinal hernia patients because recurrence rate was significantly lower in patients who underwent Lichtenstein repair in this study.