Comparison of clinical outcomes of robotic-assisted and video-assisted esophagectomy for esophageal cancer.

INTRODUCTION: Robotic-assisted minimally invasive esophagectomy (RAMIE) is a recently developed technique for the treatment of resectable esophageal cancer. The present study compares the outcomes of RAMIE and video-assisted thoracoscopic esophagectomy (VATE). METHOD: Patients undergoing minimally invasive esophageal surgery between December 2020 and September 2022 were included in the study, while those undergoing conventional surgery were excluded. The patients were divided into two groups, as those undergoing RAMIE (Group 1) and those undergoing VATE (Group 2). The demographic and clinical characteristics, intraoperative parameters, pathological data, and postoperative parameters of the groups were compared. RESULTS: A total of 28 patients were included in the study, with 13 patients in Group 1 and 15 patients in Group 2. The gender distribution was similar (P = 0.488), and the mean age was 64.7 and 59.0 years in Groups 1 and 2, respectively (P = 0.068). The majority of the sample was in the ASA2 category (46.2% vs. 66.7%, P = 0.341); Ca19.9 levels were higher in Group 1 than in Group 2 (25.7 vs. 13.7, P = 0.027); preoperative Hb was lower in Group 1 than in Group 2 (10.9 g/dL vs. 12.2 g/dL, P = 0.043); the most commonly performed surgery was the McKeown procedure (69.2% vs. 66.7%, P = 0.492); an intraoperative feeding jejunostomy was placed only in Group 2; the operation time was similar between the groups (338.5 min vs. 340 min, P = 0.916); and the distribution of tumor localizations was similar between the groups (P = 0.407). In terms of tumor histology, squamous cell carcinoma (SCC) was the most common tumor type in the two groups (84.6% vs. 80%, P = 0.636); the tumor diameter was similar between the groups (14.9 vs. 18.1, P = 0.652); the number of removed lymph nodes was similar between the groups (24.9 vs. 22.5, P = 0.419); and the number of metastatic lymph nodes was higher in Group 2 (0.08 vs. 1.07, P = 0.27). One patient in Group 2 underwent repeat surgery due to suspected ischemic anastomosis; the distribution of postoperative complications according to the Clavien-Dindo classification system was similar in the two groups (P = 0.650); there was no early mortality within the first 30 days in either group; one patient in Group 2 was re-admitted within 90 days of discharge with decreased oral intake; the length of hospital stay was shorter in Group 1 (9 days vs. 16.5 days, P = 0.006); and the patients in Group 2 more often received neoadjuvant therapy in proportion to the disease stage (15.4% vs. 60%, P = 0.016). CONCLUSION: Robotic procedures can be safely performed in esophageal cancers with complication rates and oncological radicality similar to those of other minimally invasive techniques.

Short-term surgical outcomes of robotic gastrectomy. A single center/single surgeon experience.

AIM: Surgical resection is considered the optimum approach to the treatment of gastric cancer. The present study evaluates the efficacy of robotic surgery for the treatment of gastric cancer. METHOD: Included in the study were 30 patients who underwent robotic surgery for gastric cancer at the General Surgery Clinic between July 2021 and 2022. The demographic and clinical properties of the patients,intraoperative and postoperative results, tumor Characteristics, and early morbidity and mortality values were evaluated. RESULTS: The mean age of the 30 (F/M:8/22) patients was 63.9 (42-83) years, among which 20 (66.7%) had undergone neoadjuvant treatment. The mean surgery duration was 252.82 (110-380) minutes. A subtotal gastrectomy was performed in 10 patients (33%), while the remaining 20 patients (67%) underwent a total gastrectomy. The operation was converted to open surgery in four patients (13.2%). No intraoperative complications were seen, although one patient (3%) underwent re-anastomosis on postoperative day 3 due to an obstruction in the gastroenterostomy anastomosis. The mean largest diameter of the tumor was 4.6 (0-9) cm; the mean number of resected lymph nodes was 30.8 (11-58); and the mean duration of hospital stay was 5.9 (3-12) days. Early mortality within the first 30 days was seen in one patient with a cardiac cause. The rate of re-admission to hospital within the first 90 days was 11% (3 patients). CONCLUSION: Robotic surgery in patients with gastric cancer can be applied efficiently considering the successful clinicopathological results, short hospital stay, and low morbidity and mortality rates. KEY WORDS: Cancer, Morbidity, Mortality, Robotic Surgery, Stomach.

Synchronous and metachronous neoplasms of different histogenesis with gastrointestinal stromal tumor (GIST): 10 years experience of a single institution.

AIM: Gastrointestinal stromal tumors (GISTs) are the most common primary mesenchymal neoplasms of the gastrointestinal tract. Significant advances have been made in its pathogenesis, diagnosis, and treatment over the past few decades. However, little is known about the occurrence of synchronous or methacronous tumors with other histogenesis in addition to GISTs. The aim of this study was to present a series of 15 patients diagnosed with a second primary neoplasm in addition to GIST. MATERIAL AND METHODS: Patients who were diagnosed with both GIST and other primary neoplasm between January 2010 and December 2019 were included in the study. Demographic, clinicopathologic and immunohistochemical parameters of the patients were analyzed along with the follow-up results RESULTS: This study included 12 men and 3 women with a median age of 68 years (range: 57-83 years). Of the GISTs, 93.3% were localized in the stomach and 73.3% were at very low / low risk category. Of the second primary tumors, 66.6% were in the gastrointestinal tract. Detection of the GIST was synchronous in 9 cases, metachronous in 2 cases and preceded the GIST diagnosis in 4 cases. GIST was incidentally found intra-operatively in 3 of the cases. The mean size of the synchronous GISTs was 20 mm while the most common GIST-associated malignancy was gastric adenocarcinoma. The median follow-up times was 62 months (range: 13-129 months). CONCLUSIONS: The prevalence of secondary malignancies in GIST patients is significantly higher than the healthy population. The high occurrence rate of additional primary tumors in GIST patients has focused the attention of surgeons on this problem. While it is not yet clear if there is a causal association or a common genetic mechanism for the concomitant occurrence of GIST with other malignancies, a closer surveillance of GIST patients is needed due to their proved increased prevalence of a second primary tumor especially during the first year after diagnosis. KEY WORDS: Gastrointestinal stromal tumor, Coexistence, Synchronous malignancy, Second neoplasm, Gastric adenocarcinoma.

An early experience with the Da Vinci Xi surgical system in colorectal surgery. A single-center study.

AIM: Surgery is the optimum treatment approach in cases of colorectal cancer, with open or minimally invasive surgery options applied to patients in general surgery clinics. We present here an assessment of our use of robotic colorectal surgery for the treatment of colorectal cancer. METHOD: The outcomes of robotic colorectal surgeries performed in the General Surgery Clinic of Basaksehir Cam and Sakura City Hospital were evaluated. The demographic data, indications, type of surgery, complications, duration of postoperative stay and pathology results of the patients were recorded, and the surgical results were evaluated retrospectively. RESULTS: Of the 50 patients who underwent robotic colorectal surgery selected for the study, 19 were female and 31 were male, with a mean age of 60.9 years. Among the patients, 48% received neoadjuvant treatment and the most common tumor localization was the rectosigmoid region (40%), the most frequently performed operation was low anterior resection (44%). An ostomy was created in 50% of the patients, and two patients were converted. The mean duration of surgery was 191 minutes, the mean tumor diameter was 36 mm, the mean total number of lymph nodes dissected was 22.2 and the rate of complications of Clavien Dindo grade 3 or higher was 10%, namely anastomotic leak, anastomotic bleeding and chylous fistula. The mean length of hospital stay was 5 days, and one patient was reoperated due to the development of stomal necrosis. The rate of 90-day unplanned readmission was 10% and the most frequent cause was sub-ileus. One patient died in the postoperative period. CONCLUSION: Robotic surgery is a minimally invasive surgical approach that can be successfully applied in centers where perioperative and postoperative complications can be managed. KEY WORDS: Colorectal Cancer, Minimally Invasive Surgery, Robotic Surgery.

Diagnostic Value of Preoperative Haemoglobin, Albumin, Lymphocyte and Platelet (HALP) Score in Predicting Tumour Budding in Colorectal Cancer.

OBJECTIVE: To investigate the value of preoperative haemoglobin, albumin, lymphocyte, and platelet (HALP) score in predicting tumour budding in colorectal carcinoma. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: University of Health Sciences, Basaksehir Çam and Sakura City Hospital Istanbul/Turkey, between May 2020 and May 2021. METHODOLOGY: The colorectal cancer patients who underwent surgery were divided into two groups according to the presence or absence of tumour budding. A total of 110 patients were included in the study, and there were 31 patients in group 1 and 79 patients in group 2. The predictive value of the HALP score in predicting tumour budding at the determined cut-off point was evaluated. RESULTS: The mean HALP score was similar in both groups (p=0.459). The rate of lymphovascular invasion was higher in group 2 (p=0.002), and T3 and T4 tumours were more common in group 2 (p<0.001). The number of metastatic lymph nodes was higher in group 2 (p=0.049). When the patients in group 2 were divided into subgroups according to the degree of tumour budding, the HALP score differed between intermediate and high budding groups (p=0.032). A HALP value of >31.6 predicted the presence of tumour budding with a sensitivity of 70.89% and a specificity of 48.39%. CONCLUSION: The presence of tumour budding is associated with aggressive phenotypic features in colorectal carcinoma. The preoperative prediction of tumour budding can serve as a guide in the development of individualised therapy plans. The HALP score was associated with the presence of intermediate or high degree of tumour budding. KEY WORDS: Colorectal cancer, Tumor, Pathology, Hemoglobin, Albumin.

Complete mesocolic malposition of the gallbladder: An unusual case report with literature's review.

Anatomic variations and congenital anomalies involving the gallbladder position, shape, and number are frequently encountered on routine abdominal imagings and at surgery. However, most have no clinical significance, but their recognition is important because they may predispose to gallbladder diseases, serve as a potential source of confusion and diagnostic pitfalls for radiologists and surgeons, and increase the risk of inadvertent injury during biliary tract surgery or intervention. We observed an intra-mesocolic gallbladder found unexpectedly during the cholecystectomy in a 65-year-old male patient who was being operated on for acute calculous cholecystitis. An abdominal ultrasonography and computed tomography scan reported no anomalous or malpositioned gallbladder pre-operatively. As the location of this organ could not be definitely clarified in his previous operation elsewhere, we performed an explorative lapa-rotomy. There was no gallbladder at the normal position. The organ was found embedded deeply within the proximal portion of the transverse mesocolon, and then it was successfully excised. We established the diagnosis of an ectopic gallbladder in mesocolic position.

Clinicopathologic characteristics and surgical management of schwannomas of the upper digestive tract.

AIM: Schwannoma is a peripheral nervous system tumor arising from Schwann cells of the neural sheath, and they are very rarely seen in the upper digestive tract. In this study, we aimed to present the clinicopathologic characteristics and surgical management of patients who underwent surgical treatment for esophageal or gastric schwannoma. MATERIAL AND METHODS: Patients who were diagnosed with esophageal or gastric schwannoma between January 2013 and January 2020 were included in the study. Demographic, clinicopathological and immunohistochemical parameters of the patients were analyzed along with the follow-up results. RESULTS: There were 13 patients in our study. Nine patients had gastric schwannoma and 4 patients had esophageal schwannoma. Female gender was dominant (61.5%). The mean age was 56 years. Esophageal tumors were all enucleated. Minimal invasive approach was preferred in 3 patients. Gastric tumors were most commonly localized in the lesser curvature. Three patients underwent laparoscopic wedge resection, 3 patients open wedge resection, 2 patients subtotal gastrectomy, and one patient proximal gastrectomy. Intraoperative or postoperative complications did not develop in any patient. No patient required reoperation, and there were no deaths within 90 days postoperatively. In the postoperative 90-day period, there was no unplanned re-admission to the hospital. The mean follow-up period was 53.4 months (range: 23-93 months). No recurrence was detected in any patients. CONCLUSIONS: Definitive diagnosis of schwannomas is made only by histopathologic examination postoperatively. S-100 expression has diagnostic significance. The preferred treatment is complete surgical excision with negative margins, and the long-term outcome is excellent as these lesions are mostly benign. KEY WORDS: Esophagus, Enucleation, Schwannoma, Stomach, Wedge resection.

Laparoscopic revisional surgery for failed anti-reflux procedures.

AIM: Failure ratio of an anti-reflux surgery is 2-17% in adults. After unsuccessful fundoplications, if necessary, revisional surgeries can be performed. Revisional surgeries are technically difficult to perform and require professionally advanced experience. On the other hand, it is still controversial which technique should be used in revisional surgery. The aim of this study is to present our experience with revisional surgical procedures for complications or recurrences after anti-reflux surgeries. MATERIAL AND METODS: A total of 18 patients, 16 of whom were referred to our clinic from other centers, and who underwent revisional surgery for failed fundoplication between 2014 and 2019 were retrospectively analyzed RESULTS: Five patients were male and 13 were female. The mean age was 40.3±11.7 years. The most common symptom was the persistence of reflux symptoms (61.2%). Indications for revisional surgery were recurrent hiatal hernia in 10 patients, thightness in 4 patients, mesh migration in 2 patients, mesh migration with recurrent hiatal hernia in 1 patient, and mesh migration with thightness in 1 patient. The mean operative time was 107.2+29.2 minutes. The median hospital stay was 2.9 days (range: 1-6 days). The most common surgical procedure performed was the repair of hiatal crura with mesh, and reconstruction of fundoplication and fixation of neo-fundoplication to the right crus (44.4%). In addition, other surgical procedures performed were takedown of the previous fundoplication (16.6%), takedown of the previous fundoplication and reconstruction of fundoplication (11.1%), cruroplasty and fundoplication with gastric wedge resection (11.1%), removal of the mesh and takedown of the previous fundoplication (5.6%), removal of sutures from the hiatal crura (5.6%), and gastric wedge resection (5.6%). Four patients (27.8%) developed morbidity due to gastric perforation and pleural opening during these procedures. The median follow-up period was 29 months (range: 6-69 months). Two cases (11.1%) who underwent revisional surgery failed, and re-revisional surgery was performed. CONCLUSIONS: Revisionary surgical procedures performed for failed anti-reflux surgery are not limited to re-fundoplication. Different procedures such as takedown of the previous fundoplication, reconstruction of fundoplication, removal of the mesh, removal of the sutures or wedge resection may be necessary. These procedures can successfully be performed laparoscopically by experienced surgeons in well-equipped centers. KEY WORDS: Fundoplication, Gastroesophageal reflux, Laparoscopy, Revisional Surgery, Antireflux surgery.

Laparoscopic versus open complete meso-colic excision for right-sided colon cancer. Analysis of short-term outcomes.

SCOPO DELLO STUDIO: L'emicolectomia destra per escissione mesocolica completa (EMC) laparoscopica mostrerebbe benefici comparabili a breve termine, nonché esiti patologici e oncologici per la chirurgia a cielo aperto. Lo scopo di questo studio era di confrontare la tecnica laparoscopica e la EMC aperta per i tumori del colon sul lato destro in termini di campioni patologici e risultati a breve termine. MATERIALE E METODI: I dati dei pazienti sottoposti a EMC laparoscopica (n=31) e EMC aperto (n=35) per adenocarcinoma del colon destro tra gennaio 2016 e giugno 2019 sono stati analizzati retrospettivamente. Sono stati confrontati dati demografici, parametri preoperatori, peroperatori e postoperatori e campioni di patologia dei due gruppi. RISULTATI: Non ci sono state differenze statistiche tra il gruppo laparoscopico di EMC e il gruppo aperto di EMC in termini di età, sesso, indice di massa corporea, posizione del tumore, punteggio dell'American Society of Anesthesiologists (ASA), presenza di comorbidità, storia di altre neoplasie e precedente chirurgia addominale (p>0,05). I pazienti nel gruppo EMC laparoscopico presentavano lunghezze d'incisione più brevi, tempi operativi più lunghi, minore perdita di sangue operativa, tempi di mobilizzazione più brevi, recupero precoce del movimento intestinale, tempo più breve per dieta leggera, durata ridotta della degenza e dimensioni del tumore più piccole (p<0,05). Il numero medio di linfonodi raccolti in gruppi laparoscopici e di EMC aperti non era statisticamente significativo (29,83+8,90 e 31,34+13,10, rispettivamente). Non ci sono state differenze statistiche in termini di lunghezza del campione tra i gruppi laparoscopici e aperti di EMC (35,19+9,8 cm e 32,71+11,12 cm, rispettivamente). Il tasso di complicanze postoperatorie di 30 giorni era più elevato nel gruppo EMC aperto (35,5% contro 42,9%, rispettivamente), ma non statisticamente significativo (p>0,05). CONCLUSIONI: Patologici (lunghezze dei campioni, lunghezze dei margini di resezione, numero di linfonodi e resezione R0) e risultati a breve termine del gruppo laparoscopico di EMC erano comparabili. Inoltre, la EMC laparoscopica ha conferito benefici a breve termine in termini di lunghezze di incisione più brevi, minore perdita di sangue operativa, riduzione dei tempi di mobilizzazione, recupero precoce dei movimenti intestinali, minor tempo di dieta leggera e riduzione della durata della degenza ospedaliera. Sulla base di questi risultati, la EMC laparoscopica può essere considerata come un approccio elettivo di routine per il carcinoma del colon destro.

Xanthogranulomatous cholecystitis: a rare gallbladder pathology from a single-center perspective.

PURPOSE: The aim of this study was to review patients with xanthogranulomatous cholecystitis (XGC). METHODS: A total of 79 patients diagnosed with XGC were included in the study. The criteria for XGC in the pathology specimens were the presence of histiocytes, cholesterol deposits, lipids, and focal or widespread wall enlargement. RESULTS: Patients were diagnosed with XGC, of which 52 (65.8%) were male and 27 (34.2%) were female, creating a male-to-female ratio of 2:1. The mean age was 65.8 ± 14.3 years (range, 36-97 years). The most common presenting symptom was abdominal pain (63.3%), and the least common presenting symptom was jaundice (8.9%). Of the total, 25 patients were found to have pathological conditions with the potential to obstruct the bile duct or to slow bile flow. A frozen section examination was performed on 20 patients due to suspicion of a tumor by intraoperative macroscopic examination. However, no malignancy was detected in the cases who underwent a frozen section examination. An increase in wall thickness of the gallbladder was observed in 81.6% (n = 31) of the patients on computed tomography scans and in 81.8% (n = 18) of the patients on magnetic resonance imaging scans in which possible tumor lesions were reported, but no tumor was detected. CONCLUSION: It is difficult to diagnose XGC either preoperatively or intraoperatively, and further imaging methods are needed in the preoperative period other than ultrasonography. However, a definitive diagnosis depends exclusively on pathologic examination.

Free perforation of primary small bowel lymphoma in a patient with celiac sprue and dermatitis herpetiformis.

Small bowel lymphomas are rare and constitute approximately 1% of the malignant gastrointestinal tumors. However, the risk of malignant disease in adult celiac disease is about 8-10%, and non-Hodgkin lymphoma is the most common. In the literature, cases with celiac disease and small bowel lymphoma have been reported, but the emphasis on emergency surgery is extremely rare. We herein present a case of primary small intestinal lymphoma diagnosed after surgery in a 55-year-old male patient who presented to our emergency department with findings of gastrointestinal perforation and had a history of celiac disease and dermatitis herpetiformis. The purpose of this report is to review this situation briefly and discuss it in the light of literature.

Giant pedunculated colonic lipoma causing colo-colic intussusception in a patient with mechanical ileus.

A giant colonic lipoma causing colo-colonic intussusception is extremely rare in adults. A 35-year-old woman visited our emergency room with abdominal pain, abdominal distension, nausea and vomiting. Physical examination showed a painful distended abdomen. Abdominal computed tomography revealed that there was a soft-tissue mass with a fat density of approximately 6 cm in diameter in the distal part of the transverse colon. Since the clinical presentation was that of a mechanical ileus, a laparotomy was performed. An intussusception was detected in the transvers colon. A soft and mobile mass was palpated in the transverse colon. Therefore, an extended right hemicolectomy with ileo-transversostomy was performed. Pathological examination revealed a giant pedunculated lipoma of 7 cm in diameter with no evidence of malignancy. Colonic lipomas are the third most common benign pathology seen in the colon. They are more common in women with a peak incidence between 50 and 60 years of age. The most common site of lipomas in the large bowel is the right hemicolon. Colonic lipomas are usually asymptomatic but may cause bleeding, obstruction, intussusception, or abdominal pain. Colonic lipoma causing colo-colic intussusception is extremely rare in the current literature. Surgical approach remains the treatment of choice for giant colonic lipomas. A colonic lipoma causing colo-colic intussusception should be considered in the differential diagnosis of mechanical bowel obstruction. The most important factor for establishing the diagnosis of intussusception caused by a colonic lipoma is awareness of the possibility, especially in adult patients with abdominal symptoms and episodes of intestinal obstruction. KEY WORDS: Colon, Lipoma, Colonic lipoma, Intussusception, Intestinal obstruction, Ileus.

Bilateral breast lesions mimicking metastases of hepatocellular carcinoma in a male patient.

Hepatocellular carcinoma metastases to the breast have been reported only rarely. A 63-year-old male patient with metastatic hepatocellular carcinoma presented with a lump in his left breast. On physical examination, there was a hard, well-circumscribed, and partially mobile mass of 2 cm in diameter in the lower middle quadrant of the left breast. Breast ultrasound revealed a hypoechoic solid lesion of 1.8 cm × 1.9 cm in diameter in the lower middle quadrant of the left breast. F-18 FDG PET/CT imaging revealed bilateral subcutaneous nodular lesions of anterior chest wall that were adjacent but not invasive to the glandular tissues of the breasts, with high SUVmax values. Tru-cut biopsy result of the mass in the left breast region was reported as hepatocellular carcinoma metastasis. Positive immunohistochemical staining for Hep Par 1 and glypican-3 were detected. While the patient was on sorafenib therapy, he died 6 months later. Hepatocellular carcinoma is a common malignancy for which chronic hepatitis B infection has been defined as the most common etiologic factor. The most frequent metastatic sites are the lung, bone, lymphatics, and brain, respectively, and metastases to the breast have been reported extremely rarely. Breast metastasis from non-mammary malignant neoplasm is rare, accounting for approximately 2% of breast tumors. Metastasis to the breast from an extramam mary neoplasm usually indicates disseminated metastatic disease and a poor prognosis. It should be borne in mind that a mass lesion detected in the breast region by physical examination and imaging methods may be a hepatocellular carcinoma metastasis in male or female patients with hepatocellular carcinoma. KEY WORDS: Breast, Hepatocellular carcinoma, Metastasis.

Prolapsed giant rectal gastrointestinal stromal tumor presented with incarceration A rare case of emergency rectal lesion.

Prolapse of the tumor is an extremely rare clinical presentation in patients with rectal gastrointestinal stromal tumor (GIST). A 79-year-old male patient was consulted in the in-patient ward of internal medicine clinic of our hospital due to his incarcerated hemorrhagic mass protruding from the anal canal. Anal inspection revealed an incarcerated prolapsed hemorrhagic mass larger than 10 cm in diameter that looked like a cauliflower. The incarcerated rectal GIST protruding from the anal canal was removed by transanal excision under the emergency conditions. Clean surgical margins were obtained. No postoperative complications occurred. The histological diagnosis of high-risk GIST was made. Imatinib mesylate treatment was started postoperatively. The colorectum are the less common primary sites in adult GISTs (5%). Giant GISTs of the anorectum represent a real potential for anorectal emergency. They may be involved in rectal bleeding, obstruction, prolapse or incarceration. Prolapse of the tumor is an extremely rare clinical presentation in cases of rectal GISTs, and only a few cases have been reported in the medical literature so far. Complete surgical resection with en bloc excision of the tumor is the treatment of choice. Lower rectal GISTs are a rare entity that requires multidisciplinary management and long-term surveillance. We recommend, in case of lower rectal GIST, to perform an initial transanal local excision that achieves the essential R0 resection and define the risk of aggressive behavior and the involvement of the resection margins. Patients' close follow-up is mandatory to disclose as soon as possible local recurrences or metastases. Preoperative imatinib mesylate therapy and downstaging of the tumor may play an important role. KEY WORDS: Gastrointestinal stromal tumor, Incarceration, GIST, Prolapse, Transanal excision.

The efficacy of 18F-FDG PET/CT in the preoperative evaluation of pancreatic lesions.

PURPOSE: Since the treatment strategy for benign and malignant pancreatic lesions differ, we aimed to evaluate the clinical value of PET/CT in the diagnosis and management of pancreatic lesions. METHODS: Ninety patients who had a histologically confirmed pancreatic lesion were studied. Receiver operating characteristic (ROC) curve analysis was used to investigate the ability of PET/CT to differentiate malignant lesions from benign tumors. RESULTS: The malignant and benign groups comprised 64 and 26 patients, respectively. Despite the similarity in the size of primary tumors (P = 0.588), the mean maximum standardized uptake values (SUVmax) obtained from PET/CT imaging were significantly higher in malignant lesions (9.36 ± 5.9) than those of benign tumors (1.04 ± 2.6, P < 0.001). ROC analysis showed that the optimal SUVmax cutoff value for differentiating malignant lesions (to an accuracy of 91%; 95% confidence interval, 83%-98%) from benign tumors was 3.9 (sensitivity, 92.2%; specificity, 84.6%). CONCLUSION: PET/CT evaluation of pancreatic lesions confers advantages including fine assessment of malignant potential with high sensitivity and accuracy using a threshold SUVmax value of 3.9.

A prospective comparative study of ultrasonography, contrast-enhanced MRI and 18F-FDG PET/CT for preoperative detection of axillary lymph node metastasis in breast cancer patients.

AIM: We aimed to evaluate; (i) the accuracy of ultrasonography (US), contrast-enhanced magnetic resonance imaging (cMRI) and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) for detection of axillary lymph node metastases (ALNMs), (ii) the role of late prone imaging, and (iii) the effect of PET/CT on preoperative staging of breast cancer. MATERIAL AND METHODS: From June 2015 to January 2019, 236 breast cancer patients were preoperatively exam ined using US, cMRI, and PET/CT and whom underwent pathological evaluations of axillary lymph nodes were analyzed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy (ACC) of US, cMRI, and PET/CT for ALNMs were determined. RESULTS: There were 235 female and one male in our study. The mean age was 55,6±11,3 years. Of 158 patients who were histopathologically evaluated, 85 patients (36%) were negative and 73 patients (30.9%) were positive for ALNMs. The remaining 78 patients who were only radiologically evaluated with US and/or cMRI, 24 patients (10.2%) were negative and 54 patients (22.9%) were positive for ALNMs. The sensitivity, specificity, PPV, NPV, and ACC of PET/CT were 80.0%, 92.2%, 92.0%, 80.3%, and 85.7%, re spectively. The axillary lymph node, which was suspicious in supine imaging, remained in the suspicious group again in prone imaging in PET/CT. CONCLUSIONS: There is no single absolute modality for de tecting ALNMs in breast cancers to replace sentinel lymph node biopsy or axillary lymph node dissection. If ALNM is suspected based on PET/CT, axillary lymph node dissection without sentinel lymph node biopsy might be a better option because it is related to high possibilities of ALNM. KEY WORDS: Axillary lymph node metastasis, Magnetic resonance imaging, Ultrasonography, 18F-FDG PET/CT.

A prospective comparative study of contrast-enhanced CT, contrast-enhanced MRI and 18F-FDG PET/CT in the preoperative staging of colorectal cancer patients.

AIM: In patients with colorectal cancer an accurate diagnostic work-up is mandatory in order to perform the most specific treatment. In this study, we aimed to evaluate the accuracy of computed tomography (CT), magnetic resonance imaging (MRI) and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) for detection of regional lymph node metastases (RLNMs) and the additional value of PET/CT in the preoperative staging of colorectal cancer. MATERIAL AND METHODS: From June 2015 to May 2018, 72 colorectal cancer patients were preoperatively examined using CT, MRI, and PET/CT. Histopathological examination of regional lymph nodes were performed in 53 patients who underwent colorectal surgery. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy (ACC) of CT, MRI, and PET/CT for RLNMs, and the additional value of PET/CT in distant metastases were determined. RESULTS: There were 44 male and 28 female in our study. The mean age was 61±11 years. Histopathologically, 27 patients (51%) were negative and 26 patients (49%) were positive for RLNMs. The sensitivity, specificity, PPV, NPV, and ACC of PET/CT were 88.5%, 59.3%, 67.6%, 84.2%, and 73.6%, respectively. PET/CT changed the patient management with diagnostic contribution to the suspicious lesions identified by radiological imaging modalities. CONCLUSION: PET/CT is a useful tool in the evaluation of colorectal cancer, and it allows to metabolically characterize undetermined lesions suspected for recurrence of disease, to perform a complete pre-surgical staging and to identify occult metastatic disease. PET/CT should be considered an essential diagnostic tool in the management of patients with colorectal cancer, especially in the preoperative staging. KEY WORDS: Colorectal Cancer, Computed tomography, Magnetic resonance imaging, Positron emission tomography.

Primary mesenteric fibromatosis: A single Center experience.

AIM: Primary mesenteric fibromatosis is a rare, locally invasive, non-metastasizing type of intra-abdominal fibromatoses with a very high rate of recurrence. In this study, we aimed to present our surgical approach, tumor characteristics, clinical presentation and long-term follow-up results in cases of primary mesenteric fibromatosis. MATERIAL AND METODS: The data collected from 11 patients who underwent surgery due to primary mesenteric fibromatosis in our clinic between 2010 and 2019 were analyzed retrospectively. RESULTS: Abdominal ipain, abdominal distention, and two patients (18.2%) were operated on with a diagnosis of acute abdomen in the emergency setting due to mechanical bowel obstruction in one patient There were 11 patients in our study. Six patients were female and 5 were male. The mean age was 44.2±15.8 years. Abdominal mass was detected in 5 patients (45.5%) who had complaints of mechanical bowel obstruction such as nausea and vomitingand gastrointestinal perforation in other patient. Mesenteric mass was detected in 3 patients (27.3%) with vague abdominal pain. One patient (9.1%) presented with abdominal pain and swelling of the right leg. After a mean follow-up period of 43.4±28.4 months, only 1 patient (9.1%) had recurrence and required reoperation approximately 80 months after the first operation. One patient (9.1%) died of anastomotic leakage and sepsis in the first 30 days postoperatively, and other patient (9.1%) idied of other reasons 1 year later postoperatively. CONCLUSIONS: Although mesenteric fibromatosis is a benign tumor pathologically, the main principle in the treatment of this tumor which is clinically aggressive and has high recurrence rate is wide surgical resection. Mesenteric fibromatoses have a varied clinical presentation. Radiological imaging methods helps diagnosis and planning the surgical treatment. Immunohistochemical characteristics confirms the diagnosis and differentiates from other similar tumors. KEY WORDS: Desmoid tumor, Fibromatosis, Mesentery, Mesenteric tumor,Mesenteric fibromatosis.

Intractable external pancreatic fistula post-necrosectomy treated successfully with a fistulojejunostomy.

Pancreatic fistula formation is a known complication of pancreatic surgery, pancreatitis, and pancreatic injury. We here report a case of a 65-year-old man who was diagnosed with gallstone-induced acute pancreatitis with walledoff pancreatic necrosis. The patient initially underwent medical treatment and percutaneous drainage at 4 weeks. After a four-week period, a formal laparotomy with necrosectomy, and the catheter drainage of the cavity were performed. Having postoperatively developed a pancreatic fistula, the patient was managed conservatively. After 6 weeks of medical treatment, patient underwent an endoscopic retrograde pancreatography and was diagnosed with disconnected duct syndrome. The conservative management was continued for 3 more months. Pancreatic duct stenting was attempted but was not successful in cannulating the disconnected duct, and he was finally planned for a Roux-en-Y fistulojejnuostomy. The fistulojejunostomy was performed on an average of 6 months after placement of peri-pancreatic drain. The patient recovered uneventfully and is doing well at a 12-month follow-up. Refractory external pancreatic fistula is defined as an external pancreatic fistula not resolving with these measures for longer than 6 weeks. Most fistulas developing after acute pancreatitis are related directly to the need for necrosectomy to treat infected necrosis. Patients are initially approached conservatively. When patients fail to respond to either percutaneous drainage, endoscopic interventions, or novel techniques, operative intervention is the most viable approach to treat the fistula. Fistulojejunostomy is a safe and effective treatment for intractable pancreatic fistula having the benefit of avoiding a difficult major pancreatic resectional surgery, along with low postoperative morbidity and mortality. KEY WORDS: Acute pancreatitis, Pancreatic necrosis, Pancreatic fistula, Fistulojejunostomy.

Spilled gallstones found incidentally in a direct inguinal hernia sac: Report of a case.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is the preferred surgical treatment for symptomatic gallstones. Iatrogenic gallbladder perforation and spillage of gallstones during LC is a frequent occurrence. There are many different clinical presentations of complications resulting from dropped gallstones. We herein present a case of scattered gallstones after LC encountered incidentally during a direct inguinal hernia repair. PRESENTATION OF CASE: A 62-year-old male presented with a 4-year history of swelling of both right and left groins. He had undergone LC for acute calculous cholecystitis at another hospital 5 months earlier. Physical examination revealed reducible both right and left direct inguinal hernias. Surgical exploration of the right side revealed foreign bodies at the fundus of the sac attached to the inner wall, with a fibrotic reaction around it. On closer inspection these foreign bodies were macroscopically consistent with gallstones. The gallstones were removed, and bilateral herniotomies and Lichtenstein's prolene mesh repair were performed. Pathologic evaluation confirmed 10 foreign bodies of 5-mm in size to be cholesterol gallstones. DISCUSSION: Gallstones have been very rarely reported previously within a hernia sac after LC. Most of the spilled gallstones are clinically silent and rarely become symptomatic. Complications may occur from the immediately postoperative period to a long time interval of 20 years. Treatment of complications is based on its type and location. CONCLUSION: This case presents a very rare entity resulting from leaving spilled gallstones behind. We recommend that every effort should be made to retrieve any scattered stones during LC in order to avoid complications.