Gastric cancer diagnosis and staging in coronavirus disease 2019 (Covid-19) pandemic.

AIM: The aim of the study was to analyze whether COVID-19 cause a delay in the diagnosis of gastric cancer patients particularly in the TNM staging of the tumor, or not. MATERIAL AND METHODS: This retrospective single-center study included the patients diagnosed with gastric cancer from March, 2019 to December 2020. The patients were divided into two groups: baseline and the pandemic groups. The following parameters were compared between the groups; demographic data, numbers of newly diagnosed patients, type of the surgery, location of the tumor, frequency of neoadjuvant treatment, ASA score, length of hospital stay, clinical staging and pathologic TNM staging. RESULTS: The mean monthly number of newly diagnosed gastric cancer patients showed a significant decline from 7.5 to 5.6 (p< .001). There were no statistically significant differences between the groups with regard to the demographic factors, except CA 19-9 levels. Patients in the pandemic group had higher both clinical and pathological T-stages (p < 0.05). CONCLUSIONS: Our study showed a decline in the number of the newly diagnosed patients with gastric cancer during the pandemic and also more patients presented with advanced stage during the pandemic period. This study showed that the pandemic causes a potential delay in the diagnosis of gastric cancer patients. KEY WORDS: Cancer surgery, COVID-19, Gastric cancer, Gastric surgery SARS-COV-2, Pandemic.

Invasive and Non-invasive Ductal Carcinoma within Malignant Phyllodes Tumour with Axillary Lymph Node Metastases.

Phyllodes tumours are uncommon breast neoplasms constituting 1-2% of breast malignancies. Metastasis is usually haematogenous, and axillary lymph node dissection is not routinely performed. A phyllodes tumour with concomitant invasive ductal carcinoma (IDC) is even rarer. When IDCor ductal carcinoma in-situ (DCIS) is detected, the management of the condition changes completely. We report a case of a 22-year female presenting with a mass in the right breast and palpable axillary lymph nodes. The pathological examination demonstrated a malignant phyllodes tumour with concomitant IDC and DCIS. The patient elected to have modified radical mastectomy, and the pathological examination showed metastasis in the axillary lymph nodes. The patient was administered appropriate therapy. At the last visit, she did not have the clinical signs of disease. This is the first youngest case of axillary lymph node metastases with both DCIS and IDC on pathological examination in malignant phyllodes tumour. Key Words: Malignant phyllodes, Invasive ductal carcinoma, Ductal carcinoma in-situ, Lymph node metastasis.

MRI Findings of Borderline Retroperitoneal Serous Cystadenocarcinoma.

Retroperitoneal serous cystadenocarcinoma is an extremely uncommon lesion. Here, we present MR imaging findings of a 40-year woman who was admitted to the hospital due to abdominal pain. The patient was evaluated with abdominal Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). Abdominal CT revealed a 13x18 cm large retroperitoneal and cystic mass with polypoid projections. MRI was superior than CT in showing polypoid projections. Contrast enhanced MRI detected enhancement of thin septations and cyst appearance inner the cyst. Diffusion-weighted MRI showed restricted diffusion in the polypoid component with contrast enhancement. Therefore, we thought malignant lesion. The findings of contrast-enhanced CT and MRI were helpful in the diagnosis of those lesions. In addition, diffusionweighted MRI with multiparametric modalities played unlimited role in the assesment of the differential diagnosis.

Postobstructive Cyst Formation in Pancreatic Duct affecting Surgical Approach.

How to cite this article: Ezer A, Parlakgumus A. Postobstructive Cyst Formation in Pancreatic Duct affecting Surgical Approach. Euroasian J Hepato-Gastroenterol 2018;8(1):99-100.

Solitary Cecal Diverticulitis Mimicking Cecal Carcinoma.

Cecal diverticulum is a rare clinical condition which may present as acute abdomen through diverticulitis and perforation of diverticulitis. Surgical treatment of cecal diverticulitis has been controversial, with studies recommending options ranging from conservative management with antibiotics alone to aggressive resection. Two cases, one of which was pre- diagnosed with cecal tumor perforation and the other with cecal tumor leading to intestinal obstruction, were urgently operated. To both patients, right hemicolectomy was applied. Pathologic evaluation revealed cecal diverticulitis in both patients. Right hemicolectomy is principally reserved for patients experiencing perforation of the diverticulum and extensive inflammatory reaction.

Utility of Diffusion Weighted Magnetic Resonance Imaging with Multiple B Values in Evaluation of Pancreatic Malignant and Benign Lesions and Pancreatitis.

OBJECTIVE: To determine the feasibility of diffusion-weighted imaging in evaluation of pancreatic lesions and in differentiation of benign from malignant lesions. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Baskent University Adana Teaching and Research Center, Adana, Turkey, between September 2013 and May 2015. METHODOLOGY: Forty-three lesions [pancreas adenocarcinoma (n=25)], pancreatitis (n=10), benign lesion (n=8)] were utilized with diffusion-weighted magnetic resonance imaging with multiple b-values. Different ADC maps of diffusion weighted images by using b-values were acquired. RESULTS: The median ADC at all b values for malignant lesions was significantly different from that for benign lesions (p<0.001). When ADCs at all b values were compared between benign lesions/normal parenchyma and malignant lesions/normal parenchyma, there was a significant statistical difference in all b values between benign and malignant lesions except at b 50 and b 200 (p<0.05). The lesion/normal parenchyma ADC ratio for b 600 value (AUC=0.804) was more effective than the lesion ADC for b 600 value (AUC=0.766) in differentiation of benign and malignant lesions. The specificity and sensitivity of the lesion/normal parenchyma ADC ratio were higher than those of ADC values of lesions. When the ADC was compared between benign lesions and pancreatitis, a significant difference was found at all b values (p<0.001). There was not a statistically significant difference between the ADC for pancreatitis and that for malignant lesions at any b value combinations (p>0.05). CONCLUSION: Diffusion-weighted magnetic resonance images can be helpful in differentiation of pancreatic carcinoma and benign lesions. Lesion ADC / normal parenchyma ADC ratios are more important than lesion ADC values in assessment of pancreatic lesions.

Abdominal CT Findings in Patients with Primary Lymphoma Causing Small Bowel Obstruction.

The purpose of this study was to investigate retrospectively CTfindings in patients with primary lymphoma causing small bowel obstruction. CTscans of 11 patients with small bowel lymphoma were separately analysed in terms of affected section of the small bowel, focality, wall thickness, pattern and degree of contrast enhancement, lymphadenopathy, organ involvement, perforation, and the presence of intraabdominal fluid. Eight patients had diffuse large B-cell lymphoma, and one patient each had marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT), T-cell lymphoma, and anaplastic T-cell lymphoma. Affected sections of the bowels involved were jejunum (n=5, 45.4%), ileum (n=2, 18.1%), and one case (9%) each of distal ileum, distal jejunum, distal jejunum and ileum, and distal jejunum and colon. Primary gastrointestinal (GI) lymphoma is an uncommon disease, that may lead to small bowel obstruction sometimes.

Polymeric Clips for Stump Closure in Laparoscopic Appendectomy.

Many different techniques are used to perform laparoscopic appendectomy in terms of locations of trocars and closure of the appendiceal stump. They include mechanical endostaplers, endoligature, metal clips, bipolar endocoagulation, polymeric clips and intracorporeal sutures. The method of choice for appendiceal stump closure should be inexpensive and easy to perform. Non-absorbable polymer clips is an acceptable option for this purpose. Polymeric clips provide considerable cost savings as compared with endoscopic staplers, and are easy to apply in comparison to suture ligature techniques. In this study, we aimed to investigate outcomes of appendectomy carried out by using polymeric clips in 123 patients without any intraabdominal collection of pus or abscess. As such, the authors found polymeric clips to be safe, cheap and effective for stump closure in laparoscopic appendectomy.

Delayed Reconstruction of a Traumatic Cloaca Following Obstetric Anal Sphincter Rupture.

Permanent communication between the rectum and the vagina along with full thickness of anal sphincter faults can be a result of an unsuccessful primary repair of fourth degree obstetric trauma. This results into complete fecal incontinence and impaired quality of life. Anterior overlapping sphincteroplasty can be chosen as a method of treatment for fecal incontinence due to obstetric injuries. However, large perineal body reconstructions are generally pretty challenging tasks for surgeons. What we will describe here for the repair of a traumatic cloaca, occurred 23 years ago during vaginal delivery, is the use of a transpositional flap following overlapping sphincteroplasty. Anatomic recovery and fecal continence restoration have been accomplished completely by a follow-up of 24 months.

A Novel Technique for Detection and Suturing of Biliary Fistula in a Giant Hydatid Cyst: Video-assisted Biliary Fistula Suturing in Hydatid Cyst.

Hydatid disease remains an important health problem in endemic areas; and by the way of travel and immigration, it can also be encountered in non-endemic areas. The most common cases with complications following hydatid liver surgeries are biliary fistulas with a frequency of 14.6 - 27.5%. Postoperative biliary leakage is generally due to unnoticed biliary tract communications. It is technically difficult to determine and suture the biliary fistulas, particulary for deep located ones with giant cavities for patients with high body mass index. We report a novel technique viavideo-assisted suturing of potentially unnoticeable biliocystic fistula in open surgery for patients with hydatid disease.

Diagnosis and management of retained foreign objects.

Retained surgical foreign objects (RFO) include surgical sponges, instruments, tools or devices that are left behind following a surgical procedure unintentionally. It can cause serious morbidity as well as even mortality. It is frequently misdiagnosed. It should be considered in the differential diagnosis of any postoperative case with unresolved or unusual problems. Risk factors for RFOs include emergency procedures, unplanned change in operation, and body mass index and are clarified as being more frequent approximately 1 in 700 emergent cases. Although human errors cannot be completely prevented, medical training and consistency to rules seem to reduce the incidence to a minimum. It is a legal issue and potentially dangerous medical error. The definition, types, incidence, risk factors, complications and prevention strategies from RFOs are reviewed, from the comprehensive series until the year 2014.

Results of surgery in general surgical patients receiving warfarin: retrospective analysis of 61 patients.

The aim of this study is to investigate postoperative complications, mortality rates, and to determine the factors affecting mortality on the patients receiving warfarin therapy preoperatively, as well as comparing the results obtained from emergency and elective surgeries. Surgical outcomes of 61 patients on long-term oral anticoagulation with warfarin who underwent surgery in our center were retrospectively reviewed over an 8-year period. Thirty-three (54.1%) patients were female, with a mean age of 53 years. Mitral valve replacement (62.3%) was the most frequent indication for chronic anticoagulation therapy. Twelve out of 61 (19.2%) patients underwent emergency surgery; 59 (96.7%) operations were classified as major surgery. We did not observe any thromboembolic events on patients receiving our bridging therapy protocol. Cardiopulmonary dysfunction (CPD; 19.7%) and hemorrhage (16.4%) were the most encountered postoperative complications. Presence of CPD, bleeding, endocarditis, and mortality were statistically significant for emergency surgeries when compared with the results obtained from elective surgeries. There were 5 (8.2%) deaths observed during follow-up. It was found that advanced age, prolonged duration of operations, and presence of CPD had a statistically significant effect on mortality (P < 0.05). The patients receiving oral anticoagulant had high postoperative complication and mortality rates. This case was more evident in emergency surgeries. It is recommendable that as mortality is more apparent in the patients who undergo emergency surgeries-being older, having long duration of operations as well as CPD. Therefore during the postoperative follow-up process, the patients should be closely monitored.

GNRH agonists and antagonists in rescue for cyclophosphamide-induced ovarian damage: friend or foe?

PURPOSE: To find out if GnRH agonist (GnRHa) and GnRH antagonist (GnRHant) offer ovarian protection from cyclophosphamide (Cyc) and if AMH expression is affected. METHODS: This experimental study was conducted in Baskent University Animal research laboratory and 66 virgin Wistar albino rats were assigned to six groups. The control group received intraperitoneal saline injection. The GnRHa group had a single dose of leuprolide acetate (1 mg/kg) 28 days prior to saline injection. The GnRHant group had a single dose of cetrorelix acetate (0.1 mg/kg) 1 h prior to saline injection. The Cyc group had a single intraperitoneal dose of Cyc (75 mg/kg). The GnRHa+Cyc group had a single dose of leuprolide acetate (1 mg/kg) 28 days prior to Cyc (75 mg/kg). The GnRHant+Cyc group had single dose of cetrorelix acetate (0.1 mg/kg) 1 h prior to Cyc (75 mg/kg). At day 35, the animals were euthanized, and their ovaries were removed. Primordial follicles were counted and AMH expression was determined. The Kruskal-Wallis, χ(2), or Fisher's exact test was used where appropriate. p < 0.05 was considered statistically significant. RESULTS: PMF count was reduced in GnRHant (p < 0.01) and Cyc (p < 0.01) groups. Cyc, GnRHa+Cyc and GnRHant+Cyc groups had similar numbers of PMF. AMH expression was reduced in Cyc, GnRHa+Cyc and GnRHant+Cyc groups (p < 0.01). CONCLUSION: Neither GnRHa nor GnRHant can offer protection against Cyc-induced damage. GnRHant itself reduces the number of primordial follicles.

Surgical interventions for late complications of arteriovenous fistulas.

Our aim was to determine the most effective surgical treatment for arteriovenous fistula (AVF) complications after all other methods of salvage have failed. We evaluated 110 patients for 139 complications that occurred after the initial AVF placement and for whom surgical intervention was the last hope for retaining fistula access. Vascular steal syndrome and venous hypertension were the most common complications seen in our patients. The anastomoses of 17 of the vascular steal syndrome cases were narrowed either by stitches or by a polytetrafluoroethylene graft. The second most performed revision surgery was excision of the aneurysm and repair with primary suturing, followed by excision of the aneurysm and interposition grafting. Successful surgical outcomes were achieved in 111 of 139 procedures after revision surgery without constructing a new AVF. AVF salvage surgery is of paramount importance in order to increase the patency rate, which prolongs survival and increases the patient's quality of life.

Atorvastatin for ovarian torsion: effects on follicle counts, AMH, and VEGF expression.

OBJECTIVE(S): To determine if atorvastatin protects ovarian follicles against ischemia reperfusion (I/R) injury and to determine how anti-Müllerian hormone (AMH) and vascular endothelial growth factor-A (VEGF-A) expression is altered. STUDY DESIGN: This experimental study was conducted at the Baskent University Animal Research Laboratory. Forty-four rats were arbitrarily assigned into four groups of 11 rats each. The control group underwent a laparotomy. The atorvastatin group received atorvastatin (10mg/kg/day), by oral gavage 7 days before and 7 days after the sham operation. The torsion group had bilateral torsion and detorsion of the ovaries. The atorvastatin+torsion group received atorvastatin (10mg/kg/day) 7 days before and 7 days after the torsion/detorsion operation. At day 7, the animals were euthanized and their ovaries were removed. Ovarian follicles were counted, and AMH and VEGF-A expression was determined. The Kruskal-Wallis, χ(2), or Fisher's exact test were used when appropriate. RESULTS: Primordial follicles (p=0.001), VEGF-A expression (p=0.018) and vascularization (p=0.02) were significantly higher in the atorvastatin group compared to controls. Primordial (p=0.002), primary (p=0.001), and secondary follicles (p=0.001), AMH expression (p=0.001), and vascularization (p=0.001) were lower in the torsion group compared with the control group. Primordial follicles (p=0.001), AMH (p=0.001) and VEGFA expression (p=0.001), and vascularization (p=0.001) were significantly higher in the atorvastatin+torsion group compared to the torsion group. CONCLUSION(S): Atorvastatin increased the primordial follicle pool and vascularization and protected primordial follicles and vascular structures against I/R injury.

Surgical management of endoscopic retrograde cholangiopancreatography related injuries.

BACKGROUND/AIMS: The aim of this study was to determine timing and outcomes of surgical treatment options of endoscopic retrograde cholangiopancreatography (ERCP) related injuries. METHODOLOGY: Nine patients with ERCP related injury were underwent surgical treatment at our institution. Data about these patients and outcomes of the treatment options used were retrospectively analyzed. RESULTS: Out of 9 patients, 5 were female and mean age of 68.2 years (36-92 years). Out of 5 patients with duodenal injury (55.6%), 4 patients were treated with simple repair and 1 patient was treated with duodenostomy. Six patients were treated with pyloric closure and gastrojejunostomy. A T tube was placed in 5 patients with choledochal calculus and 1 patient with biliary fistula. One patient with a tumor in the periampullary region underwent pancreaticoduodenectomy. A total of 4 patients died (44.4%). Out of 5 patients followed, 5 (60%) had postoperative problems such as sepsis, wound infection and abdominal abscess. The mean hospital stay was 22.6±7.9 days. CONCLUSION: Duodenal injuries should be treated with surgery immediately. Findings from physical examination and computed tomography should guide in making decisions about surgery. ERCP indications, type of injuries and abdominal inflammation should be kept in mind in decisions for the type of surgical treatment.

Two drugs with paradoxical effects on liver regeneration through antiangiogenesis and antifibrosis: Losartan and Spironolactone: a pharmacologic dilemma on hepatocyte proliferation.

BACKGROUND: There is a strong relationship between liver regeneration and angiogenesis and fibrosis. It is known that Spironolactone, an aldosterone antagonist, acting on rennin-aldosterone axis, and Losartan, an angiotensin II type I antagonist, have both antifibrotic and antiangiogenic effects. Theoretically, the end result of these mechanisms with contradictory influences on liver regeneration is not known well. In this study, we aimed to reveal the effects on liver regeneration of administration of Spironolactone and Losartan, having contradicting effects on regeneration through antiangiogenesis and antifibrosis. MATERIALS AND METHODS: A total of 72 Wistar albino rats were divided into control, Spironolactone, and Losartan groups and subdivided to conduct examinations on days 1, 3, 5, and 7. The specimens were treated with proliferating cell nuclear antigen to evaluate the characteristics of liver regeneration; with phosphorylated Smad2 (phospho-Smad2), serum transforming growth factor beta (TGF-B) 1, and tissue TGF-B1 to evaluate the termination of regeneration and with vascular endothelial growth factor receptor 2, Flk-1/KDR, to evaluate angiogenesis. RESULTS: The proliferating cell nuclear antigen-labeling index was found to be significantly higher in Spironolactone and Losartan groups than in the control group on days 1, 3, and 5 (P = 0.031, 0.0023, and 0.032, respectively). Vascular endothelial growth factor receptor 2, Flk-1/KDR, expression was significantly lower in Spironolactone and Losartan groups than in the control group on days 3, 5, and 7 (P = 0.032, 0.0024, and 0.007, respectively). Phospho-Smad2 was significantly lower on days 1, 3, and 5 in Spironolactone and Losartan groups than in the control group (P = 0.011, 0.0020, and 0.05, respectively). Tissue TGF-B1 levels were significantly lower in Spironolactone and Losartan groups than in the control group only on day 3 (P = 0039). Serum TGF-B1 levels in Losartan groups were significantly different from those of control and Spironolactone groups only on day 1 (P < 0.05). CONCLUSIONS: Liver regeneration, expected to decrease on day 3, was prolonged and increased even on day 5 despite antiangiogenic effects of Losartan and Spironolactone, which in fact inhibit fibrosis through phospho-Smad2 and increase regeneration. In addition, serum and tissue TGF-B1 levels are not sensitive enough to show active TGF-B1 for the evaluation of regeneration.