Effects of Sarcopenia on Postoperative Outcomes in Patients Who Underwent Gastrectomy for Gastric Cancer.

BACKGROUND: The relationship between sarcopenia and postoperative outcomes in patients with gastric cancer remains controversial. This study aimed to investigate the impact of sarcopenia on short-term outcomes after surgery for gastric cancer. METHODS: Patients who underwent surgical treatment for gastric cancer were evaluated in this prospective observational study. Muscle strength, muscle mass, and physical performance were measured before surgery. Diagnosis of sarcopenia was based on the revised European Working Group on Sarcopenia criteria. Postoperative 30-day outcomes, including complications, reoperation, readmission, and operative mortality, were recorded. RESULTS: Sarcopenia was observed in 31 out of 146 patients (21.2%). The overall complication incidence was 31.5%. The postoperative complication rate was higher in the sarcopenic patients compared to the nonsarcopenic patients (54.8% versus 25.2%, P = 0.003). There was no statistically significant difference in terms of surgical complication rates (25.8% versus 14.8%, P = 0.239), although the sarcopenic group had a significantly higher systemic complication rate (38.7% versus 13%, P = 0.003). No statistically significant difference was observed in terms of major complications (3.2% versus 5.2%, P = 1.000). Muscle strength, muscle mass, and physical performance were not identified as independent factors when tested alone at adjusted multivariable analysis. Sarcopenia (Odds ratio: 2.73, 95% CI 1.02-7.52, P = 0.047) and severe sarcopenia (Odds ratio: 4.44, 95% CI 1.57-13.34, P = 0.006) were identified as independent prognostic factors for postoperative complications. CONCLUSIONS: Sarcopenia was associated with postoperative complications after gastrectomy for gastric cancer. Severe sarcopenia may serve as a more robust prognostic indicator. The variation in the complication rates between sarcopenic and nonsarcopenic patients was mainly due to difference in systemic complications rather than surgical complications.

Performance of a pilot-scale reverse osmosis process for water recovery from biologically-treated textile wastewater.

Textile industry generates a high volume of wastewater containing various type of pollutants. Although high color and chemical oxygen demand (COD) removals are achieved with the combination of biological and chemical treatment processes, reverse osmosis (RO) process is generally needed for water recovery due to high conductivity of the textile wastewater. In this study, a pilot scale RO process containing one spiral wound membrane element was operated under three different operational modes, i.e. concentrated, complete recycle and continuous, to collect more information for the prediction of a real-scale RO process performance. It was claimed that complete recycle mode of operation enabled mimicking the operational conditions exerted on the first membrane, whereas continuous mode of operation created conditions very similar to the ones exerted on the last membrane element in a real scale RO process train. In the concentrated and continuous mode of operation, water recovery and flux were around 70% and 19 L/m2/h (LMH). Permeate produced in the RO process can be safely reused in the dyeing process as the feed and permeate conductivities were around 5500 µS/cm and 150 µS/cm, respectively, at 70% water recovery. However, color concentration in the concentrate exceeded the discharge limits and would need further treatment. The RO performance was accurately predicted by ROSA simulations.

Contribution of DECT in detecting serosal invasion of gastric cancer

Background/aim: This study aimed to investigate the relationship between the iodine concentration (IC) of perigastric fat tissue as assessed by dual-energy computed tomography (DECT) and serosal invasion of gastric cancer. Materials and methods: A total of 41 patients underwent preoperative staging evaluation for gastric cancer using DECT between July 2015 and March 2018. Patients were divided into 2 groups based on pathology results: serosal invasion (stage T4a) and intact serosa (stages T1­T3). Cutoff values, the diagnostic efficacy of IC in the perigastric fat tissue, and the perigastric fat tissue/tumor (P/T) ratio were determined. Results: Among the 41 patients, 22 had stage T4a gastric cancer and 19 patients had gastric cancer with a stage lower than T4a. The mean IC of perigastric fat tissue and the P/T ratio were significantly higher in patients with serosal invasion than in those with intact serosa (P < 0.001). During the arterial phase, the area under the curve (AUC) was 0.915 and 0.854 for the IC of perigastric fat tissue and the P/T ratio, respectively. During the venous phase, the AUC was 0.890 and 0.876 for the IC of perigastric fat tissue and the P/T ratio, respectively. Conclusion: The IC in the perigastric fat tissue seems to be a reliable indicator for serosal invasion of gastric cancer.

Parameters for Predicting Surgical Outcomes for Gastric Cancer Patients: Simple Is Better Than Complex.

BACKGROUND: Various parameters are used to predict perioperative surgical outcomes. However, no comprehensive studies in gastrectomy have been conducted. This study aimed to compare the performance of each parameter in patients with gastric cancer. METHODS: The medical records of 1032 gastric cancer patients who underwent curative gastrectomy between 2009 and 2015 were reviewed. Laboratory values and associated parameters (neutrophil count, lymphocyte count, platelet count, albumin level, Prognostic Nutritional Index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and Systemic Immune-Inflammation Index) as well as body weight-related data and associated parameters [body mass index (BMI), percentage of weight loss, Nutritional Risk Screening 2002 assessment, the Malnutrition Universal Screening Tool, and the Nutritional Risk Index] were measured and calculated. The study end points were major complications, operative mortality, prolonged hospital stay, overall survival (OS), and recurrence-free survival (RFS). RESULTS: Multivariable logistic regression analysis showed that male gender, total gastrectomy, advanced-stage gastric cancer, and low albumin level were risk factors for major complications. Old age, total gastrectomy, advanced-stage cancer, and high BMI were risk factors for operative mortality. Old age, open approach, and total gastrectomy were risk factors for prolonged hospital stay. Multivariable Cox proportional hazards models showed that old age, total gastrectomy, advanced-stage cancer, and high neutrophil count were unfavorable risk factors for OS. Old age, advanced-stage cancer, high neutrophil count, and high BMI were unfavorable risk factors for RFS. CONCLUSIONS: Albumin level, BMI, and neutrophil count are the most useful parameters for predicting short- and long-term surgical outcomes. Compared with complex parameters, simple-to-measure parameters are better for predicting surgical outcomes for gastric cancer patients.

Skip lymph node metastasis in gastric cancer: is it skipping or skipped?

BACKGROUND: Skip metastasis is the presence of a metastatic lymph node (LN) in an extraperigastric (EP) area without perigastric (PG) involvement. The mechanism and prognosis of skip metastasis are still unknown. The purpose of this study was to scrutinize the clinical significance of skip metastasis in gastric cancer. METHODS: Data were reviewed from 6,025 patients who had undergone gastrectomy for primary gastric cancer. Patients were categorized as a PG-only group when the metastatic LNs were limited to only the PG area, as a PG + EP group if metastatic LNs extended to both the PG area and the EP area, and as a skip group if metastatic LNs were in the EP area but there were no metastatic LNs in the PG area. RESULTS: After we had performed matching, the prognosis of the skip group was worse than that of the PG-only group (adjusted hazard ratio 1.69, 95% confidence interval 1.13-2.54) and was similar to that of the PG + EP group (adjusted hazard ratio: 1.54, 95% confidence interval 0.92-2.59). The number of retrieved LNs was less in the skip group than in the other groups, especially from the PG area (p < 0.001). CONCLUSIONS: The prognosis of the skip group was worse than that of the PG-only group and was similar to that of the PG + EP group when the tumor stage was considered. It is difficult to conclude whether skip metastasis is real skipping of cancer cells or a result of inadequate LN sampling. Further evaluation of LNs in the PG area of the skip group could provide more clues for the mechanism of skip metastasis.

Liver-directed treatments for liver metastasis from gastric adenocarcinoma: comparison between liver resection and radiofrequency ablation.

BACKGROUND: Although various liver-directed treatment modalities, such as liver resection and radiofrequency ablation (RFA), have been applied to treat liver metastases from gastric cancer, optimal management of them remains controversial. In patients with liver metastasis from gastric cancer, we investigated the short- and long-term outcomes of liver resection and RFA and analyzed factors influencing survival. METHODS: A total of 98 gastric cancer patients with liver metastasis and no extrahepatic disease were treated by liver resection (n = 68) or RFA (n = 30). Short- and long-term outcomes were evaluated retrospectively for each of the liver-directed treatments. RESULTS: Severe complication rates did not differ between liver resection (18 %) and RFA (10 %) (p = 0.333). Only one treatment-related mortality occurred in the liver resection group. No statistically significant difference in survival was noted between the treatment groups. Median overall survival after liver resection was 24 months, with 3-year overall and progression-free survival rates of 40.6 % and 30.4 %, respectively. Median overall survival after RFA was 23 months, with 3-year overall and progression-free survival rates of 43.0 % and 37.4 %, respectively. Only the size of the metastases was shown to be an independent prognostic factor for gastric cancer patients with liver metastasis. CONCLUSIONS: In select patients with liver metastasis from gastric cancer, liver resection and RFA showed satisfactory and comparable short- and long-term results. Thus, systemic chemotherapy may not be the only therapeutic option for patients with liver metastasis, and possible liver-directed treatment options for such patients should be considered on an individual basis.

A proposed staging system for chronic symptomatic pilonidal sinus disease and results in patients treated with stage-based approach.

BACKGROUND: Although there are many therapeutic options to manage patients with sacrococcygeal pilonidal sinus disease, there remains controversy over a gold standard method for treating such patients. Most studies regarding sacrococcygeal pilonidal sinus, collected patients in a single pool, and single modality was performed to all patients so far. Staging according to the progressive nature of disease and comparisons of stage-based treatment approaches are yet to be conducted. This study aimed to define a staging system and to evaluate outcomes with the use of stage-based treatment approach. METHODS: The collected data of patients who underwent surgery for the treatment of pilonidal sinus disease prior to June 2011 were analyzed. Following this analysis, a staging system was defined based on morphological extent of disease (stage I to stage IV for primary disease, and stage R for recurrent disease). Specific surgical technique was used for each stage. Between June 2011 and December 2014, 367 patients were operated based on proposed staging system and treatment algorithm. Demographics, perioperative data, short-term and long-term outcomes were evaluated according to the disease stage. RESULTS: For all patients, the median length of hospital stay was 1 (range, 0-4) day. Primary healing without any wound complications was achieved in 320 (87.2%) patients. The median time to functional recovery was 10 (range, 2-35) days and for wound healing was 12 (range, 10-55) days. Disease recurrence was identified in six (1.6%) patients within the median follow-up period of 29 (range, 5-47) months. The outcomes of each stage were evaluated separately. CONCLUSIONS: We believe that the proposed staging system and stage-based treatment approach, which need further validation, will have an efficacy in the treatment of chronic pilonidal sinus disease and will contribute to the development of more appropriate individualized management approaches. Moreover, the use of this staging system will likely facilitate sharing and comparing more specific clinical data from future studies. TRIAL REGISTRATION: NCT02712970 (ClinicalTrials.gov/09.03.2016).

Minimally invasive surgery as a treatment option for gastric cancer in the elderly: comparison with open surgery for patients 80 years and older.

BACKGROUND: As life expectancy is increasing, the use of minimally invasive surgery (MIS) in the elderly is gaining interest. The aim of this study was to identify the impact of minimally invasive gastrectomy by comparing the procedure to open surgery in octogenarians. In addition, we also evaluated the role of gastrectomy in elderly gastric cancer patients by assessing long-term outcomes. METHODS: We retrospectively analyzed data from 99 gastric cancer patients aged 80 years or older, who underwent gastrectomy by either MIS or open surgery from 2005 to 2010. Patient characteristics, operative outcomes, pathologic results, morbidity, mortality, and follow-up data (including survival) were compared. RESULTS: Thirty patients underwent gastrectomy with MIS (19 laparoscopic and 11 robotic) and 69 patients underwent open gastrectomy. MIS demonstrated significantly less blood loss, lower analgesic consumption, faster time to first flatus and soft diet, and a shorter post-operative hospital stay. Multivariate analysis revealed that the type of operation had no effect on the occurrence of complications. There were two postoperative mortalities, both in the open group. Excluding these patients, the overall and disease-specific 5-year survival rates were 57.4 and 70.0 %, respectively. The overall (MIS 70.0 %; open 52.0 %) and disease-specific (MIS 81.8 %; open 65.1 %) 5-year survival rates were similar for the two groups. When we analyzed the 85 patients underwent curative resection only, the overall (MIS 71.4 %; open 58.4 %) and disease-specific (MIS 84.1 %; open 73.6 %) 5-year survival rates were similar for the two groups. CONCLUSIONS: MIS for gastric cancer may be performed safely and maintains the advantages of minimal invasiveness, even in extremely old patients. Furthermore, gastrectomy by either by MIS or open surgery can reduce gastric cancer-related deaths, even in patients 80 years or older.

Comparison of perioperative surgical outcomes between a bipolar device and an ultrasonic device during laparoscopic gastrectomy for gastric cancer.

BACKGROUND: The use of energy devices during laparoscopic gastrectomy for gastric cancer has increased as the frequency of laparoscopic surgery has increased. Our aim was to compare the perioperative surgical outcomes between using a bipolar device and an ultrasonic device during laparoscopic gastrectomy. METHODS: Retrospective review of a prospectively maintained database identified 186 patients who underwent laparoscopic gastrectomy performed by a single surgeon between November 2010 and August 2013. A bipolar device was used for 116 patients, and an ultrasonic device was used for 70 patients. Patient characteristics and perioperative surgical outcomes were compared between groups. RESULTS: Clinicopathologic characteristics were similar for both groups. The bipolar group had a significantly shorter operation time (154.9 vs. 167.8 min, p = 0.028) and higher rate of D2 lymph node dissection (29.3 vs. 15.7 %, p = 0.012). The bipolar device group experienced significantly less pain at 12 h [visual analog scale (VAS) pain score: 3.9 vs. 4.7, p = 0.027) and 18 h (VAS pain score: 3.5 vs. 4.1, p = 0.036) postoperatively. The bipolar group had earlier abdominal drain removal (p = 0.001) and a shorter hospital stay (p = 0.024). No significant differences in laboratory value changes, morbidity, or mortality were observed between the groups. CONCLUSION: Compared with the ultrasonic device, the bipolar device provided advantages in operation time, degree of postoperative pain, time of drain removal, and length of hospital stay. The bipolar device may be a useful and efficient energy device for laparoscopic gastrectomy. However, larger studies to confirm the safety of bipolar device during laparoscopic gastrectomy are warranted.

Minimally invasive surgery for remnant gastric cancer: a comparison with open surgery.

BACKGROUND: Completion total gastrectomy for remnant gastric cancer (RGC) is technically challenging, especially using the minimally invasive approach. Only a few small case series have reported the technical feasibility of completion total gastrectomy by minimally invasive surgery (MIS). The aim of this study was to compare the efficacy and safety of MIS and open surgery for RGC. METHODS: We retrospectively analyzed 76 completion total gastrectomies for RGC between 2005 and 2012. Indications for MIS were limited to no evidence of serosa invasion or lymph node metastasis to extraperigastric areas on preoperative evaluation. We compared patient characteristics, intraoperative factors, post-operative outcomes, and survival for the MIS and open surgery groups. RESULTS: Eighteen patients underwent completion total gastrectomy with MIS (10 laparoscopic, 8 robotic) and 58 patients underwent open surgery. Operation time was longer in the MIS than the open group (266 vs. 203 min, P = 0.004), but the groups had similar estimated blood loss, frequency of unplanned other organ resection, and number of retrieved lymph nodes. The MIS group had a significantly earlier initiation of soft diet, shorter hospital stay, and fewer pain medication injections. Complication rates, recurrence, and overall 5-year survival were similar for the two groups. When we compared laparoscopy with robotic, similar result was shown in all parameters except operation time. CONCLUSIONS: Compared to open surgery, MIS for RGC demonstrated better short-term outcome and comparable oncologic results. MIS for RGC is feasible and safe and maintains advantages of minimal invasiveness. Both laparoscopic and robotic approaches are reasonable to the management of RGC.

Minimally invasive surgery for gastric cancer.

The interest in minimally invasive surgery (MIS) has rapidly increased in recent decades and surgeons have adopted minimally invasive techniques due to its reduced invasiveness and numerous advantages for patients. With increased surgical experience and newly developed surgical instruments, MIS has become the preferred approach not only for benign disease but also for oncologic surgery. Recently, robotic systems have been developed to overcome difficulties of standard laparoscopic instruments during complex procedures. Its advantages including three-dimensional images, tremor filtering, motion scaling, articulated instruments, and stable retraction have created the opportunity to use robotic technology in many procedures including cancer surgery. Gastric cancer is one of the most common causes of cancer-related deaths worldwide. While its overall incidence has decreased worldwide, the proportion of early gastric cancer has increased mainly in eastern countries following mass screening programs. The shift in the paradigm of gastric cancer treatment is toward less invasive approaches in order to improve the patient's quality of life while adhering to oncological principles. In this review, we aimed to summarize the operative strategy and current literature in laparoscopic and robotic surgery for gastric cancer.

Diagnostic models for predicting malignancy in thyroid nodules classified as Bethesda Category III in an endemic region.

BACKGROUND: This study aims to develop a diagnostic model to help physicians determine whether thyroid nodules categorized as atypia of undetermined significance (AUS) in category III of the Bethesda system are benign or malignant preoperatively. To create a diagnostic model for predicting thyroid nodules' benign or malignant with AUS cytology based on clinical, ultrasonographic, and cytopathological findings. METHODS: This is a retrospective cohort study involving patients (>19) at risk of thyroid cancer who had thyroidectomy after an AUS cytology. The dataset consists of 53 variables 204 nodules from 183 patients. Binary logistic regression and factor analysis methods were used to identify risk factors for malignancy. Finally, four prediction models were developed using different approaches, based on clinical, pathological clinical + pathological, and the factors. RESULTS: A total of 88 (48.1%) of 183 patients diagnosed with AUS were benign and 95 (51.9%) the malignant. After determining risk factors, four prediction models were developed based on different approaches to assist physicians in deciding to detect AUS nodules early. It was seen that bilaterality was found to be a risk factor for malignancy in the clinical model (pbilaterality = .03) and it was also seen that the pathological variables pale chromatin and irregular contours in the oncocyte variables were risk factors for malignancy (ppalechromatin = .02, pirregularcontoursintheoncocyte = .04). The best model obtained sensitivity and specificity values are 73% and 87% based on clinical and pathological variables. CONCLUSION: This comprehensive study may provide a more in-depth understanding of AUS and make a notable contribution to healthcare professionals before surgery.

The protective effects of glutamine on radiation-induced diarrhea.

INTRODUCTION: Glutamine is a neutral amino acid that is used by rapidly dividing cells such as erythrocytes, lymphocytes, and fibroblasts. It is also the substrate of glutathione synthesis. In normal metabolic rates, glutamine is an amino acid synthesized endogenously, but in high metabolic conditions such as cancer, it must be taken exogenously. Animal studies strongly demonstrate that glutamine protects both the upper and lower gastrointestinal tract mucosa from the effects of chemotherapy, radiotherapy, or other causes of injury. In this study, we investigated the protective effect of glutamine on radiation-induced diarrhea. PATIENTS AND METHOD: The patients were divided into glutamine-treated and placebo groups. In the glutamine-treated group, 15 g of oral glutamine was administered three times daily. The patients were evaluated for diarrhea grade according to the National Cancer Institute Common Toxicity Criteria version 3.0, (Table 1), need for loperamide use, need for supportive parenteral therapy, and treatment breaks due to diarrhea. RESULTS: There was no difference in overall diarrhea incidence when the two groups were compared. When diarrhea grade was evaluated, none of the patients in the glutamine-treated group had grade 3-4 diarrhea, but in the placebo group, grade 3-4 diarrhea was seen in 69 % of the patients. In the placebo-treated group, patients requiring loperamide and parenteral supportive therapy were 39 and 92 %, respectively. There was no treatment break in glutamine-treated patients. CONCLUSION: Glutamine may have protective effect on radiation-induced severe diarrhea.

Limberg flap versus Bascom cleft lift techniques for sacrococcygeal pilonidal sinus: prospective, randomized trial.

BACKGROUND: Although various methods have been described for surgical treatment of pilonidal sinus disease, which is best is under debate. Tension-free techniques seem to be most ideal. We aimed to evaluate the effects of two tension-free methods in terms of patient satisfaction, postoperative complications, and early recurrence. METHODS: A group of 122 patients were prospectively included in the study. Patients were divided into two groups based on the operative method used: Limberg flap or Bascom cleft lift. Quality of life scores, pain scores, length of time for healing, hospital stay, surgical area-related complications, excised tissue weight, and early recurrence information were evaluated. RESULTS: Follow-up of patients in each group was completed. Patients in the Bascom cleft lift group had shorter operation duration, less excised tissue weight, better bodily pain score, and less role limitation due to physical problems score on postoperative day 10. There was no statistically significant difference between groups for the other criteria. CONCLUSIONS: Although both techniques provided good results during the early period, the Bascom cleft lift procedure is a reliable technique that provides shorter operation duration and better quality of life during the early postoperative period.

A novel computer based risk prediction model for vocal cord palsy before thyroidectomy.

BACKGROUND: Thyroidectomy may be performed for clinical indications that include malignancy, benign nodules or cysts suspicious findings on fine needle aspiration (FNA) biopsy, dyspnea from airway compression or dysphagia from cervical esophageal compression, etc. The incidences of vocal cord palsy (VCP) caused by thyroid surgery were reported to range from 3.4% to 7.2% and 0.2% to 0.9% for temporary and permanent vocal fold palsy respectively which is a serious complication of thyroidectomy that is worrisome for patients. OBJECTIVE: Therefore, it is aimed to determine the patients who have the risk of developing vocal cord palsy before thyroidectomy by using machine learning methods in the study. In this way, the possibility of developing palsy can be reduced by applying appropriate surgical techniques to individuals in the high-risk group. METHOD: For this aim, 1039 patients with thyroidectomy, between the years 2015 and 2018, have been used from Karadeniz Technical University Medical Faculty Farabi Hospital at the department of general surgery. The clinical risk prediction model was developed using the proposed sampling and random forest classification method on the dataset. CONCLUSION: As a result, a novel quite a satisfactory prediction model with 100% accuracy was developed for VCP before thyroidectomy. Using this clinical risk prediction model, physicians can be helped to identify patients at high risk of developing post-operative palsy before the operation.

Outcomes of the Use of Hyaluronic Acid-Based Wound Dressings for the Treatment of Partial-Thickness Facial Burns.

The purpose of this study was to assess clinical, functional and cosmetic outcomes of the use of hyaluronic acid-based wound dressings for partial-thickness facial burns. Patients with partial-thickness facial burns hospitalized at the Burn Center between April 2014 and April 2017 were evaluated. Data pertaining to demographic characteristics, etiology, and degree of burn and percentage of burn to TBSA were collected. Pain, infection rates, reapplication rates, length of hospital stay, duration of healing, and presence of scar formation were analyzed. Median percentage of burn to TBSA was 15% (interquartile range [IQR]: 9-20). Fifteen patients had only facial burns, while 39 patients had burns on other parts of the body in addition to the face. Nine patients had deep partial-thickness burns, while 45 had superficial partial-thickness burns. Median length of hospital stay was 7 days (IQR: 3-15) for the entire study population and 4 days (IQR: 2-7.5) for patients who had only facial burns. Median healing time was 9 days (IQR: 7-12). Fifty-one (94%) patients had a Vancouver Scar Scale score of zero at 6 months. Use of hyaluronic acid-based wound dressings for facial burns is an effective and safe option.

Does surgeon specialization add value to surgeon volume in gastric cancer surgery?

BACKGROUND: This study aimed to assess the combined impact of surgeon specialization and surgeon volume on both short- and long-term outcomes in patients underwent curative gastrectomy for gastric cancer. METHODS: Patients with cStage1-3 gastric adenocarcinoma who underwent curative-intent surgery between January 2010 and December 2020 were evaluated. The impact of surgeon specialization and surgeon volume on clinical outcomes was scrutinized, both individually and in combination. For the purpose of assessing the combined effect, surgeons were classified into three groups: Non-specialized low-volume (NS-low), non-specialized high-volume (NS-high), and specialized high-volume (S-high). Postoperative outcomes and survival were evaluated. The adjusted effect sizes were expressed as odds ratio (OR) or hazard ratio (HR) with the corresponding 95% confidence interval. RESULTS: Total of 537 patients operated by twelve surgeons were included in the analysis. For all cohort, the 30d-, in-hospital and 90d-mortality were 3.5%, 3%, and 6.3%, respectively. High surgeon volume alone had a significant impact (OR: 0.31 [0.10-0.82, p = 0.023]) on 30-day mortality. However, upon evaluating the combined effects of the parameters, while the most favorable 30-day mortality rate was observed in the S-high group, neither the NS-low group (OR: 3.82 [1.10-18.17, p = 0.054]) nor the NS-high group (OR: 1.37 [0.23-8.37, p = 0.724]) demonstrated a statistically significant difference when compared to the S-high group. The NS-low group showed poor results for several types of postoperative outcomes. In terms of overall survival, the S-high group outperformed, while the NS-low and NS-high groups presented with notably worse outcomes (HRs: 2.04 [1.51-2.75, p < 0.001], and 1.75 [1.25-2.44, p = 0.001], respectively). CONCLUSION: The primary factor influencing short-term outcomes for patients who underwent gastric cancer surgery was found to be surgeon volume, while specialization provided a limited additional value. However, specialization emerges as an independent factor with a greater contribution to long-term survival than the impact attributed to high-volume.

Management of delayed presentation of a right-side traumatic diaphragmatic rupture.

BACKGROUND: Right-side diaphragmatic rupture is an unusual condition after blunt trauma. The diagnosis may be missed during the early period of trauma and may lead to progressive herniation of intraabdominal contents into the thorax. In this study, we aimed to evaluate the diagnosis and treatment options for the late diagnosis of cases of right-side traumatic diaphragmatic rupture. METHODS: We evaluated the patients with diaphragmatic hernia who were admitted to the hospital during an 8-year period. Only patients with a right-side diaphragmatic hernia and a history of high-energy trauma were included in the study. Patients with left-side diaphragmatic hernia or those who were subjected to emergency operation due to diaphragmatic rupture were excluded from the study. Patient characteristics, clinical presentations, diagnostic tools, and treatment options were evaluated. RESULTS: Eight patients (five men, three women) were enrolled in the study. The most common trauma type was a traffic accident, and the average interval between the trauma and diagnosis was 10 years. Thoracoabdominal computed tomography had high sensitivity and specificity for visualizing the diaphragmatic hernia. No predisposing factor was found to add laparotomy to thoracotomy. There was no postoperative mortality, and no late complications were observed at the assessments during the 45-month follow-up. CONCLUSIONS: Clinical presentation of late diagnosed diaphragmatic hernia, which is encountered only rarely on the right side, requires diagnostic and therapeutic approaches different from those associated with acute diaphragmatic rupture. It should not be forgotten during the differential diagnosis in patients with a history of trauma.

Delayed enterothorax and hepatothorax due to missed right-sided traumatic diaphragmatic rupture.

Traumatic diaphragma ruptures (DRs) are an unusual condition after blunt thoracoabdominal trauma, and there are some difficulties in the diagnosis, in the absence of the additional life-threatening injuries. Right-sided injuries are less frequent than left-sided injuries and may be missed easily. Intrathoracic herniation of abdominal organs is an uncommon condition for right-sided DR. Particularly, to our knowledge, progressive hepatothorax and enterothorax that develop over years are a very rare presentation of DR. Herein, we present a case of progressive thoracic herniation of the abdominal organs, diagnosed 22 years after the initial trauma.