Factors influencing cost, length of hospital stay and mortality in colorectal cancer.

PURPOSE: Colorectal cancers (CRCs) are the most common cancers in the world after lung and prostate cancer in men and breast and lung cancer in women, and usually occur in the recto-sigmoid region. There are many factors that affect their morbidity and mortality. Some markers have been evaluated to predict disease prognosis. However, a gold standard prognostic biomarker has not yet been found for CRC. In the present study, we aimed to evaluate the factors associated with the duration and cost of hospital stay and mortality. METHODS: Patients who were admitted to the emergency service and general surgery clinic with abdominal pain, rectal bleeding, weight loss, diminished stool discharge, and ileus were included in this study. Recorded were patient age, gender, comorbid factors, family history, surgical treatment procedure, elective or urgent surgical intervention, bowel cleansing before surgery, pathological stage, neutrophil/lymphocyte ratio (NLR), red cell distribution width (RDW), mean platelet volume (MPV) and CEA, CA 19.9 and hemoglobin levels. RESULTS: The mean patient age was 61.2±12.4 years. The male/female ratio was 0.596(81/136). Emergency surgery was an independent factor increasing the cost and length of hospital stay (p=0.007 and p=0.018). Additionally, patients >65 years of age had increased length of hospital stay and mortality (p=0.008 and p=0.024, respectively). Anemic patients had 50% higher mortality risk compared with patients with normal hemoglobin levels (p=0.030). CONCLUSION: Based on our results, anemic patients in the geriatric population who underwent emergency CRC surgery may have higher costs, longer hospital stay and greater mortality rates than other CRC patients.

Neutrophil-to-lymphocyte ratio as a predictor of acute appendicitis.

BACKGROUND: Accurately diagnosing appendicitis can be difficult. This retrospective study aimed to evaluate the ability of the neutrophil-to-lymphocyte ratio (NLR) to predict acute appendicitis pre-operatively and to differentiate between simple and complicated appendicitis. METHODS: A database of 1067 patients who underwent surgery was evaluated. Based on postoperative histopathological examination, the patients were divided into two groups: acute appendicitis (G1) and normal appendix (G2). Patients in the acute appendicitis group were further divided into two subgroups: simple appendicitis (G1a) and complicated (gangrenous and perforated) appendicitis (G1b). RESULTS: G1 included 897 patients and G2 included 170 patients. Among the 897 G1 patients, there were 753 G1a patients and 144 G1b patients. A NLR of 4.68 was associated with acute appendicitis (G1 vs G2, p<0.001). The sensitivity and specificity were 65.3% and 54.7%, respectively. A NLR of 5.74 was associated with complicated appendicitis (G1a vs G1b, p<0.001). The sensitivity and specificity of the two clinical features were 70.8% and 48.5%, respectively. CONCLUSION: We suggest that preoperative NLR is a useful parameter to aid in the diagnosis of acute appendicitis and differentiate between simple and complicated appendicitis, and can be used as an adjunct to the clinical examination.

A rare but distinctive cause of acute abdomen: appendiceal diverticulitis.

BACKGROUND: Diverticulosis and diverticulitis of appendix vermiformis is a rare diagnosis. Clinical and laboratory examinations do not show a difference between a progressing diverticulitis and simplex appendicitis. But this entity has a higher mortality rate than common appendicitis. OBJECTIVE: This case is presented to illustrate the point that preoperative simple diagnosis of acute appendicitis according to the clinical signs and physical examination may not only be insufficient, but could be fatal in certain circumstances, like appendiceal diverticulitis, if surgical intervention is delayed. CASE REPORT: Here we present a female patient with a history of right lower abdominal pain and fever of 3 days duration. She was diagnosed with acute appendicitis according to the preoperative physical, laboratory, and imaging examinations. The appendiceal diverticulitis accompanying acute appendicitis was an intraoperative finding, which was proven by histopathologic examination. CONCLUSION: It is not easy to document this entity preoperatively. When diagnosed either preoperatively by imaging studies or intraoperatively, the only choice is appendectomy to prevent its serious complications.

The role of general surgery consultations in patient management.

OBJECTIVE: Consultation results of patients who were thought to require a surgical intervention and were evaluated in the General Surgery Department for diagnostic support and treatment, upon detection of pathology in clinical and/or laboratory tests. MATERIAL AND METHODS: In a six-months period, 221 patients were retrospectively analyzed. There were 121 male (54.75%) and 100 female (45.25%) patients and the mean age was 46 years (15-102). The departments which requested consultation, the reason for consultation, test and physical examination findings before consultation, required additional tests after consultation and results of consultations were recorded as well as performed interventions. RESULTS: The majority of consultations were from the emergency department (91.9%) and the most frequent reason was abdominal pain (29.9%). No tests were performed before consultation in 21% of cases. Physical examination was completely fulfilled in 100% of judicial cases, but this ratio was 35% in perianal diseases and 30% in patients with bowel obstruction. Additional tests were required in 54.3% of the patients after consults. Out of the whole group with surgical consultation, 21% were operated under general anesthesia, 9% under local anesthesia, while an elective operation was suggested in 3%. CONCLUSION: Currently, it is mandatory that patient management is carried out with a multidisciplinary approach; however, we believe that consultations should be asked in a more selective manner.

Does topical rifampicin reduce the risk of surgical field infection in hernia repair?

OBJECTIVE: Inguinal hernia operations are common procedures in general surgery. There have been many approaches in the historical development of hernia repair; tension free repair with mesh being the most commonly used technique today. Although it is a clean wound, antibiotic use is still controversial due to concerns about infection related to synthetic mesh. We aimed to determine the probable role of topical rifampicin in patients with tension-free hernia repair and mesh support. MATERIAL AND METHODS: The charts of patients who underwent tension-free inguinal hernia repair were retrospectively analyzed. Information and operative notes on patients, in whom synthetic materials were used, were identified. The patients were divided into two groups, placebo group (G1) and patients with application of topical rifampicin on the mesh (G2). Infection rates between the groups in the early postoperative period were compared. RESULTS: The mean age of the 278 patients who were included in the study was 49.6±15.39 and the female/male ratio was 10/268. There were recurrent hernias in four patients and superficial wound infections in 22 patients in the early period. One patient had testicle torsion and underwent an orchiectomy. There were no significant differences between the groups in terms of age and gender. The types of hernia and body mass index were homogenous between the two groups. In the early postoperative period the infection rates were 16/144 (11.1%) and 6/134 (4.48%) in the groups, respectively, with the difference being statistically significant (p=0.041). CONCLUSION: We suggest that applying rifampicin locally can decrease surgical site infection in hernia operations where meshes are used.

Methemoglobinemia incidence after the application of lidocaine for small surgical procedures.

OBJECTIVES: Methemoglobinemia (MetHb) is a rare condition that may have mortal consequences. Literature shows cases of methemoglobinemia due to the use of lidocaine and other local anesthetics. This is a cross-sectional study to determine the incidence of methemoglobinemia after the application of lidocaine. METHODS: In this study, 88 patients admitted to the emergency department of a university hospital between May 2014 and May 2015 and needed lidocaine application for small surgical procedures were included. When compared before and after the administration of lidocaine <2 mg/kg and >2 mg/kg, there was not a significant difference in the level of methemoglobin, hemoglobin, or in the hematocrit (p=0.604, p=0.502, and p=0.367, respectively). RESULTS: Mean age of the patients was 33.85 (±17.58) years, and 83% of the patients were male. Methemoglobin levels were not significantly different before and after the procedures (p>0.05). CONCLUSION: The results of our study were consistent with the literature; lidocaine associated methemoglobinemia is a rare complication.

Comparison of open appendectomy and laparoscopic appendectomy with laparoscopic intracorporeal knotting and glove endobag techniques: A prospective observational study.

OBJECTIVE: Despite the recent increase in the use of laparoscopic appendectomy procedures to treat acute appendicitis, laparoscopic appendectomy is not necessarily the best treatment modality. The aim of this study is to examine the value of laparoscopic intracorporeal knotting and glove endobag in terms of various parameters and in terms of reducing the costs related to laparoscopic appendectomy procedures. MATERIAL AND METHODS: Seventy-two acute appendicitis patients who underwent laparoscopic appendectomy and open appendectomy surgery were enrolled in the study and were evaluated prospectively. The patients were divided into two groups: group 1 was treated with laparoscopic appendectomy using laparoscopic intracorpreal knotting and glove endobag (n=36) and group 2 was treated with open appendectomy (n=36). The two groups were statistically compared in terms of preoperative symptoms and signs, laboratory and imaging findings, operation time and technique, pain score, gas and stool outputs, duration of hospital stay, return to normal activity, and complications. RESULTS: No statistically significant differences were found between the groups in relation to gender, age, body mass index, or pre-operation findings, which included loss of appetite, vomiting, time when pain started, displacement of pain, defense, rebound, imaging methods, and laboratory and pathology examinations (p>0.05). Moreover, there were no differences between the groups with respect to drain usage, hospital stay time, or complications (p>0.05). In contrast, a statistically significant difference was found between the groups in terms of operation time, pain scores, gas-stool outputs, and return to normal activity in the laparoscopic appendectomy group (p=0.001). CONCLUSION: Laparoscopic appendectomy can be performed in a facile, safe, and cost-effective manner with laparoscopic intracorporeal knotting and glove endobag. By using these techniques, the use of expensive instruments can be avoided when performing laparoscopic appendectomy.

Mastalgia-Cancer Relationship: A Prospective Study.

OBJECTIVE: Mastalgia is an important symptom affecting approximately 70% of women and it disrupts the quality of life especially due to the worry of having cancer. In our study, the type and severity of mastalgia symptom of patients who presented to the outpatient clinic with mastalgia complaint were assessed along with their physical examination findings and radiology results. The purpose of the study is to demonstrate the relationship between mastalgia and malignity when assessed in combination with the risk factors of patients. MATERIALS AND METHODS: The age, family history, menopausal status, age at the first childbirth, menarche, presence/absence of hormone replacement therapy, type of mastalgia, comorbidities and examination findings of 104 patients, who presented to the General Surgery outpatient clinic with mastalgia symptom, were recorded and assessed in the light of radiological study results. RESULTS: With respect to the mastalgia types of the patients, 38.5% had cyclic pain, 57.7% non-cyclic pain and 3.8% other types of pain. Mild mastalgia was present in 46.2% of the patients, moderate mastalgia in 24% and severe mastalgia in 29.8% of them. According to the BIRADS category, 48.1% of the patients were identified to have BIRADS 1 mass lesions, 39.4% BIRADS 2, 9.6% BIRADS 3 and 2.9% BIRADS 5 mass lesions. The patients who were identified to have BIRADS 5 mass lesions described non-cyclic and severe pain in the post-menopausal period. They had palpable masses along with the pain symptom. CONCLUSION: Our study suggests that mastalgia symptom does not per se result in suspicion of malignancy, but physical examination and radiological imaging should also be used as needed for confirmation. Studies with a larger patient population are needed to shed light on the mastalgia epidemiology and its relationship with cancer.

Are fibrinogen and complete blood count parameters predictive in incarcerated abdominal hernia repair?

Therapeutic delays in cases of external incarcerated hernias typically result in increasing morbidity, mortality, and health expenditures. We investigated the diagnostic role of blood fibrinogen level, white blood count (WBC), mean platelet volume (MPV), and platelet distribution width (PDW) in patients with incarcerated hernia. Two groups, each containing 100 patients, were studied. Group A underwent elective, and group B underwent incarcerated and urgent external hernia repair. We observed high fibrinogen and WBC levels but low MPV and PDW values for patients in group B. Contrary to our expectations, we found lower MPV and PDW values in the complicated group than in the elective group. The morbidity rate and cost burden were higher in group B, and the results were statistically significant. Early operation should be recommended for patients with incarcerated external hernias if their fibrinogen and WBC levels are high.

Peptic ulcer complications requiring surgery: what has changed in the last 50 years in Turkey.

BACKGROUND/AIMS: The incidence and prevalence of peptic ulcer disease has decreased in recent years, but it is not so easy to make the same conclusion when complications of peptic ulcer are taken into consideration. The aim of this study is to determine the time trends in complicated peptic ulcer disease and to state the effects of H2 receptor blockers, proton pump inhibitors (PPI), and H. pylori eradication therapies on these complications. MATERIALS AND METHODS: This study retrospectively evaluated the patients who were operated on for complications (perforation, bleeding, and obstruction) of peptic ulcer for the last 50 years. Patients were grouped into four groups (G1-G4) according to the dates in which H2 receptor blockers, PPIs, and eradication regimens for H. pylori were introduced The time periods that were studied were: (G1) 1962-1980, (G2) 1981-1990, (G3) 1991-1997, and (G4) 1998-2012. RESULTS: In total, 2953 patients were operated on for complications of peptic ulcer disease, of which 86% of the patients were male. In G1, perforation and obstruction were significantly the most frequent complications (p<0.001), followed by bleeding. In groups G2 and G3, obstruction was still the most frequent complication requiring surgery (p<0.001). In G2 and G3, obstruction was followed by perforation and bleeding, respectively. In G4, perforation was significantly the most frequent complication (p<0.001). CONCLUSION: From 1962 to 1990 obstruction was the most common complication requiring surgery. In the last decade, perforation became the most common complication. In contrast to reports in the literature, bleeding was the least common complication requiring surgery in Turkey.

The appearance of free-air in the abdomen with related pneumatosis cystoides intestinalis: Three case reports and review of the literature.

INTRODUCTION: Pneumatosis sistoides intestinalis (PSI) is a rare condition with unknown origin, defined as the appearance of gas-filled cysts in the intestinal wall. It usually occurs due to respiratory infections, tumor or collagen disease, traumas, immunosuppression. PRESENTATION OF CASE: Three patients with PSI were examined that followed up and treated in our clinic. The first patient was hospitalized for emergency treatment of previously diagnosed free-air under the diaphragm. He had a defense on physical examination and free-air was detected in X-ray and abdomen CT. We decided to laparatomy and peroperatively, stenotic pylorus with an abnormally increased stomach and gas-filled cysts were seen in the terminal ileum. Antrectomy and gastrojejunostomy with partial ileum and cecum resection and end ileostomy were performed. The second patient underwent laparatomy because of intraperitoneal free-air and acute abdomen. Partial ileum and cecum resection and ileotransversostomy were performed. The third patient with intraperitoneal free-air was treated with antibiotics, oxygen treatment and bowel rest. DISCUSSION: PSI is usually asymptomatic. Plain radiographs, USG, CT, upper gastrointestinal endoscopy, colonoscopy can use for diagnosis. Treatment of PSI depends on the underlying cause; include elemental diet, antibiotics, steroids, hyperbaric oxygen therapy and surgery. CONCLUSION: In patients with asymptomatic and symptomatic PSI are different treat. Symptomatic PSI can be safely treated antrectomy and gastrojejunostomy with partial ileum and cecum resection.

Are neutrophil-lymphocyte ratio and platelet-lymphocyte ratio as effective as Fournier's gangrene severity index for predicting the number of debridements in Fourner's gangrene?

BACKGROUND: Fournier's gangrene (FG) is a rapidly progressive and necrotizing infection of the subcutaneous and fascial tissues with a high mortality rate. In the present study, we aimed to investigate prognostic factors and analyze the outcomes of 68 patients in a tertiary reference hospital. METHODS: Patients admitted to the emergency department were investigated retrospectively between January 2006 and January 2013 and divided into two groups. The patients in Group I (G1) required one debridement, and Group II (G2) patients required more than one. Patient demographic and clinical characteristics were encoded. Fournier's Gangrene Severity Index (FGSI) scores, neutrophil-lymphocyte ratios (NLR), and platelet-lymphocyte ratios (PLR) were calculated. Prognostic factors were compared between the groups. RESULTS: There were no statistically significant differences between the groups in terms of mean age, female-male ratio, or duration of symptoms on admission; however, there were more infection sources, predisposal factors, and positive culture results in G2. Additionally, hospital stay, total cost, and mortality rate values were high in G2. We found statistically higher NLR and PLR ratios in G2, but there was no significant difference in FGSI scores between the groups. CONCLUSION: The FGSI scoring system was not found to be valuable in determining prognosis. However, NLR and PLR were valuable, and previous use of NLR and PLR for determining Fournier's gangrene prognosis could not be found in the English literature.

Effects of intraabdominal pressure on mean platelet volume during laparoscopic cholecystectomy.

BACKGROUND/AIM: Intraabdominal hypertension is a common occurrence, especially in intensive care unit patients, and it has high mortality and morbidity rates. The onset is commonly insidious and the poor prognosis is attributed to the long delay in diagnosis. Unfortunately, diagnosis is often delayed until loss of function in the affected tissues has already occurred. The aim of this study was to determine the predictive value of mean platelet volume (MPV) in assessing the risk of intraabdominal hypertension. MATERIALS AND METHODS: Pneumoperitoneum during elective laparoscopic cholecystectomy was used as a model for intraabdominal hypertension. The study included 103 patients who met the inclusion criteria. MPV evaluations were made at 3 distinct times during laparoscopic cholecystectomy based on the actual intraabdominal pressure. RESULTS: MPV values during preinsufflation, insufflation, and desufflation were 8.483 fL (range: 6.7 to 11.1), 8.901 fL (range: 6.8 to 11.9), and 8.538 fl (range: 5.8 to 10.9), respectively. A statistically significant increase in MPV values was found during high intraabdominal pressures (P < 0.001). A significant decrease in MPV values was also detected with desufflation (P < 0.001). CONCLUSION: Increasing MPV values may reflect increased intraabdominal pressures, which may have a clinical implementation in intraabdominal hypertension.

Neutrophil-lymphocyte ratio as a predictive factor for tumor staging in colorectal cancer.

BACKGROUND/AIM: In the preoperative period, simple methods to identify the tumor stage of colorectal cancer patients are needed. In recent years, the neutrophil-lymphocyte ratio (NLR) has been used as a predictive parameter for systemic inflammatory response in many different clinical entities. This study aims to determine if the NLR predicts the tumor stage in colorectal cancer patients in the preoperative period. MATERIALS AND METHODS: A total of 206 patients diagnosed with colorectal cancer and admitted for surgical treatment over a 6-year period were identified from a retrospectively maintained database. NLR was calculated from preoperative full blood counts. NLRs were compared with the tumor stages as determined in histopathological reports and scanning tests to determine the extent of metastasis. RESULTS: We found NLRs to be statistically higher in patients with T3 and T4 tumors than in patients with T1 and T2 tumors (mean: 5.261 vs. 4.499, respectively, P = 0.010). Similarly, we found statistically higher NLR values in the N1 and N2 groups than in the NO group (mean: 6.597 vs. 4.501, respectively, P < 0.001). Additionally, NLRs were statistically higher in M1 patients than in MO patients (mean: 8.261 vs. 5.158, respectively, P = 0.004). CONCLUSION: In the preoperative period, NLR was found to be a valuable predictive parameter for tumor staging in patients with colorectal cancer, thus informing us as to the kind of tumor we will meet when we open the abdomen.