The Effect of Genistein on Anastomotic Healing in Intestinal Ischemia/Reperfusion Injury.

INTRODUCTION: Genistein is a natural isoflavonoid and has several pharmacological effects, such as antioxidant, antitumor activity, and improvement of glucose metabolism. The safety of intestinal anastomosis after ischemia-reperfusion (I/R) injury is a critical issue for surgeons. This experimental study aimed to investigate the effects of genistein on anastomotic healing after intestinal I/R injury. METHODS: A total of 36 male Wistar Albino rats were divided into four groups: control, I/R, genistein, and genistein + I/R. The control group received segmental ileal resection and ileoileal anastomosis. The I/R group received resection + anastomosis after intestinal I/R. The genistein group was administered subcutaneous injection of 1 mg/kg genistein 12 h and 1 h before the procedure and received ileal resection + anastomosis. The genistein + I/R group received I/R + ileal resection + anastomosis after genistein injection. Anastomotic bursting pressure, hydroxyproline, superoxide dismutase, and glutathione peroxidase levels and histopathological wound healing scores of all rats were measured on postoperative day 5. RESULTS: The anastomotic bursting pressure was significantly higher in the genistein and genistein + I/R groups (P < 0.001). Genistein increased the hydroxyproline concentration and the superoxide dismutase and glutathione peroxidase levels in the intestinal anastomosis (P < 0.001). In histopathological assessment, the mean wound healing score was significantly higher in the genistein group than in the other groups (P < 0.001). CONCLUSIONS: Genistein, with its anti-inflammatory and antioxidant properties, shows protective effects against increased oxidative stress after intestinal I/R injury and contributes positively to intestinal anastomotic healing.

The effect of preoperative 18F-FDG PET on the surgical decision in early breast cancer: 5-Year follow-up.

OBJECTIVE: The diagnosis, treatment, and management of the breast cancer (BC) require a multidisciplinary approach. In newly diagnosed BC, fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG PET) can detect extra-axillary regional nodal and distant lesions. SUBJECTS AND METHODS: Between 2010 and 2015, this study included 101 patients with early-stage BC who were examined with 18F-FDG PET before surgery. Patients were divided into two groups: Group 1 consisted of patients with suspected 18F-FDG uptake and Group 2 with the remaining 18F-FDG-negative patients. Differences between these groups were tested using the Pearson chi-square test, Fisher's exact test, Mann Whitney-U test, independent t-test and ROC analysis. They could be followed-up after 2015 for 5 years. All patients were then rediscussed either neoadjuvant therapy or surgery in the oncology board in 2020 with changing neoadjuvant criteria and oncoplastic surgery techniques. RESULTS: Fluorine-18-FDG PET was found to have a sensitivity of 77.8% and a specificity of 90.8% in detecting axillary lymph node metastasis. During the minimum 5-year follow-up, one patient had bone metastasis, 2 patients had a local recurrence, and 3 patients had metastatic lymph nodes in the axilla. In the re-evaluation of the same patients over 5 years, the decrease in mastectomy decision was remarkable (P-value 0.01). CONCLUSION: We observed that we could not achieve a significant difference in 5-year metastasis/recurrence between the groups. Moreover, due to 18F-FDG-PET high false positivity, it significantly extended the time to surgery (P-value 0.01). In early-stage BC, 18F-FDG PET demonstrated better performance in axillary lymph nodes metastases detection in comparison with other diagnostic imaging methods, even if SLNB remains the gold standard technique.

General surgery practice under the COVID-19 pandemic: The experience of a pandemic hospital in Istanbul.

BACKGROUND: Although elective operations in general surgery clinics were postponed during the pandemic, non-deferrable operations such as emergency trauma, acute abdominal, and cancer surgeries continued. We aimed to present emergency and non-deferrable elective surgery cases in our hospital's general surgery clinic during the pandemic, to identify the general surgery patients that pose the greatest risk for healthcare workers who served these patients, and to share our experience in these situations. METHODS: The study was designed as a retrospective cohort study. The study included patients admitted for emergency and non-deferrable elective surgeries in Kartal Dr. Lutfi Kirdar City Hospital in Istanbul between March 10, 2020, and May 23, 2020. The patients were tested before the operation for severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) infection. They were also routinely checked for fever and coronavirus disease 2019 (COVID-19) symptoms during dressing changes and outpatient follow-up visits after discharge as well as through the national health monitoring system (e-nabiz) whether the patients were diagnosed with COVID-19 within the 15 days of discharge. Patients who tested positive in the reverse transcription-polymerase chain reaction (RT-PCR) tests in the first 15 days after discharge or had infiltration in thorax tomography were considered suspicious in terms of hospital transmission. RESULTS: During the COVID-19 pandemic period between March 10, 2020, and May 23, 2020, a total of 195 patients were operated on. Of these, 96 (49.2%) were operated due to emergencies, and 99 (50.8%) were non-deferrable elective surgeries. At the time of admission, 13 patients were diagnosed with COVID-19 through RT-PCR and thorax tomography findings. A higher proportion of the patients with COVID-19 (n=12, 92.3%) were found to be operated for emergencies. Three patients with COVID-19 died on the 1st postoperative day. Mortality was significantly higher in this group than in those who tested negative (n=3, 23.1% vs. n=8, 4.4%). During the study, none of the healthcare workers in our clinic developed COVID-19 symptoms. Three patients who had elective surgery were found to be SARS-CoV-2 (+) in the follow-up period after discharge. CONCLUSION: Maintaining functional surgery departments under challenging times, such as a pandemic, will continue to be an important aspect of health systems. We believe that the results of this study will help reduce in-hospital transmission, help prevent disease transmission to healthcare personnel, and allow the members of the surgical teams to know in which patient group they will be at higher risk of infection during the operation.

Comparison of the outcomes of overlapping and direct apposition sphincteroplasty techniques in anal sphincter repair.

Objectives: Sphincteroplasty is of great importance in the repair of anal sphincter damage. In the present study, we compared the results of overlapping sphincteroplasty and direct apposition techniques used in anal sphincter repair. Material and Methods: Between 2011 and 2021, 36 patients underwent sphincteroplasty for anal sphincter injury and were analysed retrospectively. Sex, age, etiologic factors, repair technique, degree of laceration, postoperative complications, length of hospital stay, time between injury and repair, follow-up time and postoperative Cleveland Clinic Incontinence Score (CCIS) were recorded for analysis, and the two techniques were compared statistically using SPSS statistics, Version 17.0. Results: Of the sample, 31 were females and five were males, with a mean age of 31.50 ± 6.7 years. The etiologic factors were obstetric trauma in 25 patients, perianal interventions in seven patients and other traumas in four patients. The overlapping technique was applied to 14 patients and the direct apposition technique was applied to 22 patients. Mean postoperative CCIS of all cases was 5.53 ± 2.59, and was significantly lower in those who underwent overlapping sphincteroplasty technique than those who underwent apposition repair (p= 0.006). It was observed that postoperative CCIS decreased as the time between sphincter injury and repair decreased (p <0.001; r= 0.625). Conclusion: It is vital to repair anal sphincter damage as early as possible. The overlapping sphincteroplasty and direct apposition methods can both be considered safe for anal sphincter repair although in terms of faecal incontinence, the outcomes of overlapping sphincteroplasty are better than those of the direct apposition technique.

Risk factors for mortality in Fournier's gangrene of anorectal origin.

BACKGROUND: In the present study, we aimed to determine the risk factors for mortality in Fournier's gangrene (FG), which has a high morbidity and mortality rate and requires urgent surgical intervention. METHODS: A retrospective analysis was made of 150 patients who were operated on in our clinic due to FG of anorectal origin be-tween 2010 and 2020. The cases were divided into survival and non-survival groups. Demographic, clinical, laboratory, and treatment data, FG Severity Index (FGSI), and simplified FGSI (SFGSI) scores were analyzed. RESULTS: Thirty-day mortality rate was 15.3%. In the non-survival group, rate of smoking, diabetes mellitus, malignancy and other chronic diseases, and mean age, duration of symptoms at admission, number of debridements, SFGSI, FGSI, white blood cells, and creatinine were significantly higher, while hematocrit, serum potassium, and albumin levels were significantly lower (p<0.05). Among these factors, age (OR=1.147, CI=1.019-1.291; p=0.023), smoking (OR=0.09, CI=0.023-0.418; p=0.002), malignancy (OR=0.038, CI=0.008-0.186; p=0.001), and serum potassium level (OR=0.141, CI=0.022-0.910; p=0.04) were identified as risk factors associated with mortality in FG. CONCLUSION: FG is a fatal fasciitis still associated with high mortality. Advanced age, smoking, malignancy, and hypopotassemia are independent predictive risk factors for mortality in FG.

Comparison of the effectiveness of i-scan and conventional endoscopy in the detection of the endoscopic signs of atrophic gastritis: A clinical trial.

BACKGROUND AND STUDY AIMS: This study aimed to determine whether the use of i-scan endoscopy provides additional benefits to conventional endoscopy in the diagnosis of gastric precancerous lesions. PATIENTS AND METHODS: A total of 120 patients with histologically-verified intestinal metaplasia (IM) or atrophic gastritis (AG) were prospectively evaluated by esophagogastroduodenoscopy. Endoscopic examinations were performed using i-scan and high-definition white-light endoscopy (HD-WLE). The diagnostic yields of both techniques and the number of targeted biopsies per patient were compared. RESULTS: A total of 318 suspicious lesions were detected in 108 patients with i-scan (n = 186) and 81 patients with HD-WLE (n = 132). The diagnostic yields of i-scan and HD-WLE were 81.6% (98/120) versus 77.5% (93/120), respectively (p > 0.05). When only targeted biopsies were taken into account, the diagnostic yields of i-scan and HD-WLE were 89.8% versus 65.4%, respectively (p < 0.05). The mean number of biopsies per patient for i-scan and HD-WLE were 3.27 (393/120) and 7.3 (882/120), respectively (p < 0.05). The mean endoscopic procedure times were 16 and 17 min for i-scan and HD-WLE, respectively (p > 0.05). CONCLUSIONS: Although targeted biopsies with i-scan were not found to be significantly superior to either targeted or random biopsies with HD-WLE, the number of biopsies required to confirm these lesions was much lower.

An investigation into the predictive role of serum inflammatory parameters in the diagnosis of complicated acute cholecystitis.

BACKGROUND: Gallbladder gangrene and perforation are an important complication of acute calculous cholecystitis and are dif-ficult to detect preoperatively. Therefore, in this study, we aimed to evaluate whether serum inflammatory parameters are predictive factors for complicated cholecystitis (CC). METHODS: In the present study, histopathological findings of 250 patients who were operated on with the diagnosis of acute chole-cystitis (AC) in the emergency department between 2014 and 2019 were evaluated and the cases were divided into two groups as AC and CC. Parameters, including age, gender, body mass index, white blood cell (WBC) count, C-reactive protein (CRP), neutrophil-to-lym-phocyte ratio (NLR), mean platelet volume (MPV), and platelet distribution width (PDW), were examined for their ability to predict CC. RESULTS: The findings obtained in this study showed that WBC, CRP, and NLR were significantly higher in the CC group (p<0.05). WBC >9.000 cells/ml, CRP >29.0, and NLR >4.3 were the factors that could predict CC. There was no significant difference between the two groups concerning MPV and PDW (p>0.05). CC was observed more frequently in patients over 65 years of age, but there was not a statistically significant difference (p=0468). CONCLUSION: WBC, CRP, and NLR are valuable biochemical markers in predicting complicated AC. Advanced age may be a help-ful predictive factor for CC. These factors may be helpful in making an early cholecystectomy decision.

Primary extra gastrointestinal stromal tumors of the abdomen.

OBJECTIVE: In the present study, we aimed to evaluate the clinicopathological features and prognostic factors in extra-gastrointestinal stromal tumor (EGIST) cases, which are observed very rare, by examining the data the cases obtained in a single center. METHODS: Data of 14 EGIST cases who were operated by a general surgeon between January 2007 and May 2020 were obtained and analyzed. RESULTS: The median age was 47.5 (range: 34-87) years. A total of 135 patients were operated for GIST, and 14 (10.4%) of these patients were EGIST. The mean tumor diameter was 16.8±10.5 (range: 2.8-40) cm. The mitotic index was 5/50 high power field and below in seven (50%) cases. Twelve (85.7%) of the patients were in the high-risk group. The overall survival (OS) rate was 80%, and the 5-year survival rate was 88.9%. Mean OS was 78.5±50.7 months, 5-year OS and disease-free survival (DFS) were both 53.3±20.0 months, and overall DFS was 58.0±59.8 months. The mean OS and DFS durations were found to be significantly lower in women than men (p=0.006 for both comparisons). The mean OS was found to be significantly lower in patients over 60 years of age compared to those aged 60 and under (p=0.013). CONCLUSION: In the present study, it has been determined that the rare EGISTs are large in size and that the mitotic index is often low. In addition, it has been observed that the prognosis may be similar to other GISTs, however, may be worse in elderly patients and in women.

Gastrointestinal Stromal Tumours of the Small Intestine.

OBJECTIVES: To describe the spectrum of small intestine gastrointestinal stromal tumour (GIST) cases; and to analyse prognostic factors. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Kartal Dr. Lütfi Kirdar City Hospital, Istanbul, Turkey, from 2010 to 2020. METHODOLOGY: Forty patients with small intestine GIST followed up between 2010-2020 were included in this study. The demographic information and clinical laboratory, histopathology, and radiology findings of all patients were analysed and compared. Five-year overall survival (OS) rate and five-year disease-free survival (DFS)were calculated. RESULTS: The mean patient age at diagnosis was 58.9 ± 12.6 years (34-79 years). Thirty-seven (92.5%) tumours were in the jejunum and ileum, and three (7.5%) were in the duodenum. The most common symptoms were bleeding (50%) and pain (37.5%). A total of 5% of the patients were asymptomatic, and 67.5% were in the high-risk group. Two patients (5%) died within a 30-day postoperative period, and 13 (32.5%) died during the follow-up period. The five-year overall survival (OS) rate was 54.2%. The mean five-year OS and five-year disease-free survival (DFS) were 47.5 ± 16.8 months and 40.9 ± 25.0 months, respectively. The mortality risk was calculated as 4.5-fold increased in the patients aged over 60 years and as 3.556-fold increased in those with recurrence/metastasis detected in their follow-ups. CONCLUSION: The OS ratio and OS duration were not as high as expected for small intestine GIST cases. Tumour diameter, mitotic index, and risk classification may not provide sufficient information for prognosis prediction in some cases. The frequency of recurrence and/or metastasis was higher than expected - although complete resection was achieved. Key Words: Gastrointestinal stromal tumours, Small intestine, Tumour diameter, Mitotic index.

Effects of hypertonic saline replacement on colonic anastomosis in experimental hemorrhagic shock model in rats.

BACKGROUND: Inadequate intestinal perfusion resulting from hemorrhagic shock negatively affects wound healing. In this experimental study, we aimed to evaluate the effects of resuscitation with hypertonic saline on colonic anastomosis in rats with controlled hemorrhagic shock. METHODS: A total of 24 male Wistar albino rats weighing between 200 and 250 g were used in this study. The rats were divided into four groups as: Control, hypotonic, isotonic, and hypertonic. Median laparotomy, colon resection, and colocolonic anastomosis were performed to the rats in the control group. After creating controlled hemorrhagic shock to rats in other three groups, resuscitation was achieved with hypotonic, isotonic, and hypertonic saline. After resuscitation, median laparotomy, colon resection, and colocolonic anastomosis were performed on rats in these three groups. On the 5th post-operative day, a median laparotomy was applied to the rats in all groups and anastomosis lines were evaluated. Anastomotic bursting pressure, tissue hydroxyproline level, and tissue fibrosis degree were compared between the groups. RESULTS: There was no statistically significant difference between the groups in terms of anastomotic bursting pressure, tissue hydroxyproline level, and tissue fibrosis degree (respectively; p=0.320, p=0.537, p>0.05). CONCLUSION: In rats with controlled hemorrhagic shock, resuscitation with hypertonic saline does not differ significantly from isotonic or hypotonic saline in terms of healing of colonic anastomosis.

Impact of the COVID-19 pandemic on operations in general surgery clinics in Turkey.

INTRODUCTION: The Covid-19 pandemic spread rapidly throughout Turkey from March 2020 onward, and despite modified working conditions in the surgical clinics of our hospitals, some surgical patients became infected with the coronavirus during their perioperative period. AIM: The present study investigates the impact of the novel coronavirus on patients undergoing general surgical operations in our clinics during the Covid-19 pandemic. METHODS: A retrospective analysis was conducted of all surgeries performed in the general surgery clinics of two 'pandemic hospitals' between March 19 and April 30, 2020 - a period when all elective surgeries were suspended in hospitals within Turkey. Demographic data, comorbidities, choice of anesthesia method, blood parameters, duration of stay in hospital and the intensive care unit and mortality rates were compared statistically with the frequency of postoperative Covid-19 positivity in these patients. RESULTS: A total of 275 surgical operations were performed during this period. Covid-19 was identified in seven patients during the postoperative period, and was more commonly diagnosed in those who were elderly and those with comorbidities. (p=0.02, p=0.02). Statistically significant correlations were found between a Covid-19 diagnosis and admission to the intensive care unit, the length of hospital stay and the length of stay in intensive care (p<0.001, p<0.001, p=0.01). Mortality was observed in two patients who developed Covid-19 postoperatively (p= 0.03). CONCLUSIONS: The Covid-19 pandemic has had a significant impact on patients undergoing operations in our general surgery clinics. Precautionary measures taken during postoperative care should be maximized for high-risk patients. KEY WORDS: Covid-19 pandemic, General surgery clinics, Novel coronavirus, Gastrointestinal system surgery.