Closing Perianal Fistulas Using a Laser: Long-Term Results in 103 Patients.

BACKGROUND: Primary closure of the fistula tract using energy emitted by a radial fiber connected to a diode laser is a novel procedure for treating perianal fistulas. OBJECTIVE: The aim of this study was to determine the long-term effectiveness of this new technique. DESIGN: The surgical objective was to seal the fistula tract using laser energy. SETTINGS: The study was conducted at a single day-case surgery center. PATIENTS: Between April 2012 and June 2016, 103 consecutive patients with primary or recurrent perianal fistula underwent a laser closure procedure using a 12-watt laser emitting at a wavelength of 1470 nm. MAIN OUTCOME MEASURES: Patients were classified according to the Park classification, and healing was evaluated based on the perianal fistula disease severity score. RESULTS: Among the 103 patients treated using the laser closure procedure, 82 (80%) were men and 21 (20%) were women. The median age of the patients was 43 years (range, 18-78 y). Fifty-three patients (52%) had previous perianal fistula repair surgery. Based on the Park classification, 56 patients (54%) had intersphincteric fistula, 29 (28%) had transsphincteric fistula, 11 (11%) had suprasphincteric or extrasphincteric fistula, and 7 (7%) had superficial perianal fistula. Based on the perianal disease severity score, 41 patients (40%) obtained overall complete healing, 38 (37%) had persistent symptomatic drainage, 20 (19%) had slight drainage with minimal symptoms, and 4 (4%) had painful symptomatic drainage. LIMITATIONS: This was a retrospective analysis of noncomparative data with a lack of formal prospective continence assessment. CONCLUSIONS: Closure of perianal fistulas using a laser should be considered as a treatment option but with modest expectations. Although our complete healing rate was not as high as in earlier studies, this technique is a reasonable option with nearly no risk of sphincter damage when treating perianal fistulas. See Video Abstract at http://links.lww.com/DCR/A545.

Manual and semi-automated computed tomography volumetry significantly overestimates the right liver lobe graft weight: a single-center study with adult living liver donors.

PURPOSE: Preoperative evaluation of donor liver volume is indispensable in living donor liver transplantation to ensure sufficient residual liver and graft-to-recipient weight ratio. This study aims to evaluate the accuracy of two computed tomography (CT) volumetry programs, an interactive manual and a semi-automated one, in the preoperative estimation of the right lobe graft weight. METHODS: One hundred and nine right liver lobe living donors between January 2008 and January 2020 were enrolled in this retrospective study. Two radiologists measured the liver graft volumes independently using manual and semi-automated CT volumetry, and the interaction time was recorded. Actual graft weight (AGW) measured intraoperatively served as the reference standard. The paired samples t-test was used to compare the estimated graft weight (EGW) and the AGW. Inter-user and inter-method agreements were assessed with Bland-Altman plots. RESULTS: Both manual and semi-automated CT volumetry significantly overestimated the graft weight (EGW manual: 893 ± 155 mL vs. AGW manual: 787 ± 128 g, P < 0.001, EGW semi-automated: 879 ± 143 mL vs. AGW semi-automated, P < 0.001). The junior radiologist measured higher volumes than the senior radiologist with either method (P < 0.001). The Bland-Altman analysis revealed mean difference and standard deviation for inter-method agreement of 7 ± 48 cc for the senior radiologist, and 34 ± 54 cc for the junior radiologist. The mean difference and standard deviation for inter-method agreement was 63 ± 59 cc in manual volumetry and 22 ± 38 cc in semi-automated volumetry. The mean interaction time was 27.3 ± 14.2 min for manual volumetry and 6.8 ± 1.4 min for semi-automated volumetry (P < 0.001). CONCLUSION: Both manual and semi-automated CT volumetry significantly overestimated the right liver graft weight, while semi-automated volumetry significantly reduced the interaction time.

lncRNA XIST Interacts with Regulatory T Cells within the Tumor Microenvironment in Chronic Hepatitis B-Associated Hepatocellular Carcinoma.

OBJECTIVE: Alterations in the expression of several long non-coding RNAs (lncRNAs) have been shown in chronic hepatitis B-associated hepatocellular carcinoma (CHB-HCC). Here, we aimed to investigate the association between the expression of inflammation-associated lncRNA X-inactive specific transcript (XIST) and the type of inflammatory cells within the tumor microenvironment. MATERIAL AND METHODS: Twenty-one consecutive cirrhotic patients with CHB-HCC were included. XIST expression levels were investigated on formalin-fixed paraffin-embedded (FFPE) tumoral and peritumoral tissue samples by real-time polymerase chain reaction (RT-PCR). Immunohistochemical staining for CD3, CD4, CD8, CD25, CD163, CTLA4, and PD-1 were performed. The findings were statistically analyzed. RESULTS: Of the 21 cases, 11 (52.4%) had tumoral and 10 (47.6%) had peritumoral XIST expression. No significant association was found between the degree of inflammation and XIST expression. The number of intratumoral CD3, CD4, CD8 and CD20 positive cells was higher in XIST-expressing tumors, albeit without statistical significance. Tumoral and peritumoral XIST expression tended to be more common in patients with tumoral and peritumoral CD4high inflammation. The number of intratumoral CD25 positive cells was significantly higher in XIST-expressing tumors (p=0.01). Tumoral XIST expression was significantly more common in intratumoral CD25high cases (p=0.04). Peritumoral XIST expression was also more common among patients with CD25high peritumoral inflammation, albeit without statistical significance (p=0.19). CONCLUSION: lncRNA XIST is expressed in CHB-HCC and its expression is significantly associated with the inflammatory tumor microenvironment, particularly with the presence and number of CD25 (+) regulatory T cells. In vitro studies are needed to explore the detailed mechanism.

Vascular Complications After Liver Transplantation.

OBJECTIVES: Vascular complications after liver transplant can be lethal. High levels of suspicion and aggressive use of diagnostic tools may help with early diagnosis and treatment. Here, we share our experiences regarding this topic. MATERIALS AND METHODS: Adult and pediatric patients who had liver transplant between February 1997 and June 2018 in our clinic were included in the study. Patients were grouped according to age (pediatric patients were those under 18 years old), male versus female, indication for transplant, type of liver transplant, type of vascular complication, treatment, and survival aftertreatment.We analyzed the statistical incidence of vascular complications according to age, male versus female, and type of liver transplant. RESULTS: Our analyses included 607 liver transplant procedures, including 7 retransplants, with 349 (57.4%) from living donors and 258 (42.6%) from deceased donors. Of total patients, 539 were adults (89.8%) and 61 were children (10.2%). Vascular complications occurred in 25 patients (4.1%), with hepatic artery complications seen in 13 patients (2.1%) (10 adults [1.8%] and 3 children [4.9%]), portal vein complications seen in 9 patients (1.5%) (6 adults [1.1%] and 3 children [4.9%]), and hepatic vein complications seen in 3 patients (0.5%) (2 adults [0.36%] and 1 child [1.6%]). Rate of vascular complications was statistically higher in pediatric patients (11.4% vs 3.3%; P = .007) and higher but not statistically in recipients of livers from living donors (5.2% vs 2.7%; P = .19). Twelve patients (48.8%) were treated with endovascular approach, and 11 (0.44%)required surgicaltreatment. Two patients underwent immediate retransplant due to hepatic artery thrombosis. CONCLUSIONS: Because vascular complications are the most severe complications afterlivertransplant,there must be close follow-up of vascular anastomoses, particularly early postoperatively, with radiologic methods. In cases of vascular complications, emergent treatment, including endovascular interventions, surgery, and retransplant, must be performed.

Evaluation of the Effects of Immunosuppressive Drugs Following Liver Transplantation on Pregnancy Outcomes: A Retrospective Study.

BACKGROUND: Liver transplantations can be safely performed in women of reproductive age. Women with chronic liver disease may have infertility for various reasons, although fertility returns after recovering >90% of sexual disorders following liver transplantation. The present study examined the effects of immunosuppressive drugs used by women of reproductive age undergoing liver transplantation in our clinic on pregnancy and pregnancy outcomes and evaluated mortality and morbidity in this patient population. METHODS: Among the patients undergoing liver transplantation in our clinic between 1997 and 2020, those conceiving after liver transplantation were evaluated in the present study. Demographic data on maternal and newborn health, as well as mortality and morbidity, were recorded. Maternal transplant indications, graft type, the interval between transplantation and pregnancy, maternal age at pregnancy and the number of pregnancies, the number of living children, complications, delivery mode, immunosuppressive drugs, and blood levels were investigated. RESULTS: A total of 615 liver transplantations (353 from a living donor, 262 from a cadaveric donor) were performed in our clinic. Furthermore, 33 pregnancies occurred in 22 women following transplantation (17 living donor liver transplantations, 5 deceased donor liver transplantations), and the data of these patients were recorded. Tacrolimus and mycophenolate mofetil were used as immunosuppressive therapy. CONCLUSIONS: Liver transplantations can be safely performed in women of reproductive age if indicated, and these patients can be safely followed up throughout the pregnancy and during labor by a multidisciplinary team.

Complications and Long-Term Outcomes in Adult Patients Undergoing Living Donor Liver Transplantation Because of Fulminant Hepatitis.

BACKGROUND: The present study investigates the complications that may occur during long-term follow-up in patients aged 18 years and older undergoing living donor liver transplantation (LDLT) in our clinic because of fulminant hepatitis. METHODS: The study included patients aged 18 years and older with a minimum survival of 6 months who underwent an LDLT between June 2000 and June 2017. The demographic data of the patients were evaluated in terms of late-term complications. RESULTS: Of the 240 patients who met the study criteria, 8 (3.3%) underwent LDLT for fulminant hepatitis. The indication for transplantation in patients with fulminant hepatitis was cryptogenic liver hepatitis in 4 patients, acute hepatitis B infection in 2 patients, hemochromatosis in 1 patient, and toxic hepatitis in 1 patient. Of the 240 patients, 65 (27%) undergoing LDLT underwent a liver biopsy for suspected rejection because of an elevation in liver function test results during follow-up. Histopathologic scoring was carried out according to the Banff scoring system. A diagnosis of late acute rejection was made in only 1 of the 8 patients (12.5%) who underwent LDLT for fulminant hepatitis. CONCLUSION: Patients with fulminant hepatitis must be prepared for an LDLT, if available, while waiting for a cadaveric donor. The results of the present study suggest that LDLTs in patients with fulminant hepatitis are safe, and the outcomes are acceptable in terms of survival and complications.

COVID-19 in Liver Transplant Patients: A University Hospital Experience.

BACKGROUND: We aimed to examine the comorbidity, disease progress, and vaccination status of liver transplant patients followed up in our hospital who had COVID-19. METHODS: Liver transplant patients with COVID-19 were included between 11 March 2020 and 15 September 2022. Demographic data, disease progress, and COVID-19 vaccines were recorded. The SPSS 24.0 (IBM SPSS, Inc, Armonk, NY, United States) program was used for analysis. The data were analyzed using the χ2 test. P values < .05 were considered clinically significant. RESULTS: Sixteen SARS-CoV-2 polymerase chain reaction (+) patients were detected. Twelve (75.0%) patients were male; the mean age was 49.56 ± 14.0 years (24-76 years). The mean transplant time was 156.69 ± 54.05 months. Four (25.0%) of the 5 (31.3%) patients with comorbidities had hypertension, and 1 (6.3%) had diabetes. None of the patients had an underlying lung disease. All the patients received immunosuppressive therapy, and the most common combination was antimetabolite and calcineurin inhibitor (9 patients [69.2%]). Nine patients (56.3%) had a fever, whereas 6 (37.5%) had respiratory symptoms. Two (33.3%) had pneumonia. Five (31.4%) patients were hospitalized, and 1 (20%) was admitted to the intensive care unit due to non-invasive mechanical ventilation needs. No patient died due to COVID-19. A statistically significant correlation was found between the presence of fever, respiratory symptoms, and hospitalization (P < .05). Of those vaccinated, 10 (66.7%) were infected before the COVID-19 vaccination. CONCLUSIONS: The course of COVID-19 in liver recipients without any underlying disease other than transplantation is not different from that in the healthy population. Immunosuppressive therapy was continued in patients with the disease, and two-thirds did not require hospitalization.

Tumoral and Parenchymal Morphological Assessment in Liver Metastases of Colorectal Carcinoma: Micrometastasis, Peritumoral Lymphocytes, Tumor Budding and Differentiation are Potential Prognostic Factors.

Introduction: Various potential prognostic histopathologic factors for colorectal carcinoma liver metastasis have been proposed. However, there is still no consensus on pathological reporting of colorectal carcinoma liver metastasis resection materials. The aim of this study was to investigate the relation between selected tumoral and parenchymal histopathologic features and prognostic factors for better characterization and prognostic prediction of the patients with colorectal carcinoma liver metastasis. Methods: Hematoxylin-eosin stained slides from 100 patients who underwent hepatic resection were evaluated. Pathologic characteristics; including number of tumor nodules, largest tumor size, status of surgical margin, tumor distance to closest margin, tumor necrosis, the presence of tumor capsule, tumor differentiation, perineural and lymphovascular invasion, micrometastasis, tumor budding, peritumoral lymphocytic infiltrate and parenchymal features including steatosis, steatohepatitis, lobular inflammation, confluent necrosis, hepatocyte ballooning, portal inflammation were assessed. For 49 patients who were treated with preoperative chemotherapy, tumor regression grade and chemotherapy-related parenchymal changes such as sinusoidal damage, venous obstruction, nodular regenerative hyperplasia, steatosis and steatohepatitis were also evaluated. Results: The presence of lymphovascular invasion (p < 0.001), micrometastasis (p=0.004), absent or mild peritumoral lymphocytic infiltration (p =0.013), high tumor budding score (p=0.033) and moderate/poor differentiation (p=0.022) were significantly associated with shorter overall survival. Lymphovascular invasion (p < 0.001) was an independent predictor of mortality in multivariate analysis. Conclusions: We conclude that tumor differentiation, lymphovascular invasion, micrometastasis, peritumoral lymphocytic reaction and tumor budding score are potential prognostic histopathological features and candidates for inclusion in pathology reports of colorectal carcinoma liver metastasis resections.

The Site of Lymph Node Metastasis: A Significant Prognostic Factor in Pancreatic Ductal Adenocarcinoma.

OBJECTIVE: While the presence and number of metastatic lymph nodes (LNs) are important prognostic factors for pancreatic ductal adenocarcinoma (PDAC), there is no recommendation to specify metastatic regional LN localization in the current staging system. The aim of this study was to evaluate the prognostic effect of regional metastatic LN localizations in PDAC. MATERIAL AND METHOD: Metastatic sites of 101 consecutive PDAC patients who underwent pancreaticoduodenectomy were classified as peripancreatic, perigastric, hepatica communis, hepatoduodenal, and superior mesenteric artery. The frequency of metastasis in each region and the association between the presence of metastasis in each site and overall and disease-free survival were statistically analyzed. RESULTS: Eighty cases (79.2%) had peripancreatic, 7 (6.9%) had perigastric, 6 (5.9%) had hepatica communis, 7 (6.9%) had hepatoduodenal, and 4 (4%) had superior mesenteric artery LN metastasis. The overall and disease-free survival values were significantly shorter in patients with hepatoduodenal LN metastasis (log rank; p= 0.001, p=0.017, respectively). The presence of metastatic superior mesenteric artery LN was significantly associated with shorter disease-free survival in univariate analysis (p=0.017). Hepatoduodenal LN metastasis was an independent predictor of mortality (p=0.005) in multivariate analysis. CONCLUSION: The presence of hepatoduodenal LN metastasis is an independent poor prognostic factor for mortality. The presence of metastatic LN in the superior mesenteric artery region was significantly associated with shorter disease-free survival time, although not an independent predictor. We conclude that the metastatic regional LN sites, especially the hepatoduodenal region, have an impact on the prognosis, and should be included in synoptic pathology reports.

Peritumoral histopathologic findings in patients with chronic viral hepatitis-associated hepatocellular carcinoma.

Data on peritumoral histopathologic findings in patients with hepatocellular carcinoma (HCC) is limited. In this retrospective study, we evaluated the peritumoral histopathologic changes in patients with chronic viral hepatitis (CVH)-associated HCC (CVH-HCC) and their prognostic value. 61 consecutive cirrhotic patients who underwent liver transplantation due to CVH-HCC were included. Histopathologic features within 1 cm distance of the tumor, and their association with clinicopathological characteristics and prognosis were evaluated. A random representative slide of cirrhotic parenchyma unrelated to invasive and/or dysplastic foci was also evaluated for the same histopathologic criteria. The majority (85%, n = 52) were male with a median age of 55 ± 6.38 (range, 39-67). The etiologic agent was only HBV in 90% (n = 55). The most common peritumoral findings were portal inflammation (100%; n = 61), ductular reaction (100%; n = 61) and sinusoidal dilatation (95%; n = 58). Macrovascular invasion was observed only in four cases (7%) with mild peritumoral portal inflammation. Neutrophilic infiltration of the peritumoral portal tracts (n = 18; 30%) was significantly associated with pT4 tumor stage, tumor grade, macrovascular invasion, and pretransplant therapy. Patients with moderate or severe peritumoral sinusoidal dilatation tended to have worse prognosis, albeit not significantly. Peritumoral ballooning degeneration was associated with multifocality, recurrence and recurrence-free survival in both uni- and multivariate analysis. Peritumoral histopathologic changes in CVH-HCC can be classified as: changes related to pathogenesis, changes indirectly affecting prognosis, and changes directly affecting prognosis. Peritumoral prominent ballooning degeneration may be a predictor of recurrence while portal neutrophilic infiltration and sinusoidal dilatation seem to indicate poor prognosis.

Reconsideration of Clinicopathologic Prognostic Factors in Pancreatic Neuroendocrine Tumors for Better Determination of Adverse Prognosis.

The question of how successful we are in predicting pancreatic neuroendocrine tumors (panNET) with poor prognosis has not been fully answered yet. The aim of this study was to investigate the effects of clinicopathological features on prognosis and to determine their validity in prediction of prognosis and whether a better prognostic classification can be made. Fifty-six patients who underwent pancreatic resection for pancreatic neuroendocrine tumor were included. The associations between clinicopathological parameters and prognosis were evaluated statistically. Efficiencies of different thresholds for tumor size, mitotic count, and Ki67 proliferation index for prognosis prediction were compared. Vascular invasion was statistically associated with high tumor grade, advanced pT stage, and mortality rate. The presence of non-functional tumor, lymphatic invasion, and > 10 cm tumor size were significantly related to shorter overall survival. Advanced pT stage (pT3-4), > 5 cm tumor size, and high tumor grade (grades 2-3) were significantly associated with shorter disease-free survival. The mortality rate showed the strongest statistical significance with mitotic count when grouped as 1: < 2, 2: 2-10, and 3: > 10 mitosis/ 2 mm2. The 10% threshold value for Ki67 index was more successful in predicting adverse prognosis. Among the morphologic variants, the ductulo-insular variant was the most promising to have positive prognostic value in our series, although no statistical significance was detected. In conclusion, threshold values of 5 cm and 10 cm for tumor size, 10% for Ki67 proliferation index, and 10/2 mm2 for mitotic count and vascular and lymphatic invasion assessed separately are potential prognostic candidates for better stratification of panNETs.

Analysis of Causes and Risk Factors for Late Mortality After Liver Transplant: How Can We Obtain Better Long-Term Survival?

OBJECTIVES: We investigated late mortality causes and risk factors in patients who were undergoing deceased-donor liver transplant. MATERIALS AND METHODS: Patients who had deceased-donor liver transplant from February 1997 to June 2014 in the hepatopancreaticobiliary surgery and liver transplant unit at Dokuz Eylul University Hospital were analyzed. Inclusion criteria were patients over 18 years of age and who survived more than 1 year after liver transplant. Causes of mortality and related risk factors after the first year were analyzed. RESULTS: Of the 157 included patients, 102 patients (72%) received transplant procedures for hepatitis B and C secondary to chronic liver disease. Mean follow-up was 89.85 months (range, 14.4-240 months). Of 157 patients, 20 patients (12.7%) died: 12 patients (60%) died during posttransplant years 2-5 and 8 patients (40%) died after 5 years. Causes of death included malignancy in 8 patients (40%), recurrent hepatitis C infection in 3 patients (15%), infection in 3 patients (15%), coronary artery disease in 2 patients (10%), graft rejection in 2 patients (10%), and biliary complications in 2 patients (10%). Univariate analyses showed that long-term survival was significantly lower in patients older than 50 years (P = .001), when there was presence of hepatocellular carcinoma (P = .011), and when donor age was higher than 38 years (P = .045). Multivariate analyses identified recipient age (P = .007) and presence of hepatocellular carcinoma (P = 0.033) as factors that reduced long-term survival. CONCLUSIONS: The main causes of late mortality in liver transplant are malignancy, recurrence of hepatitis C, infection, coronary artery disease, graft rejection, and biliary complications. Advanced age and hepatocellular carcinoma are independent risk factors that increase late mortality.

The Role of Log Odds of Positive Lymph Nodes in Predicting the Survival after Resection for Ampullary Adenocarcinoma.

Lymph node metastasis is a important factor on survival in ampullary adenocarcinoma. Log odds of positive lymph nodes (LODDS) is a novel prognostic indicator on lymph node status. We aimed to evaluate the prognostic impact of LODDS for the patients with ampullary adenocarcinoma who underwent R0 pancreaticoduodenectomy. The study includes 42 patients.. LODDS was calculated as "log (number of metastatic lymph nodes+0.5)/(number of total harvested nodes - metastatic lymph nodes+0.5)". LODDS subgroups were created based on their LODDS value: LODDS1(LODDS≤ - 1.5), LODDS2(-1.5 < LODDS≤ - 1.0), LODDS3(-1.0 < LODDS≤ - 0.5), LODDS4(LODDS> - 0.5). The mean survival time was 72.7 ± 7.82 months. Survival rates for 1, 3 and 5 years were 93%, 65% and 45%, respectively. The mean LODDS value was -1.0466 ± 0.51. LODDS subgroups show strong correlation with Overall Survival(OS). The mean survival were 114.8, 81.8, 56.6 and 25.6 months in LODDS subgroups 1, 2, 3 and 4, respectively (Log-rank; p = 0.002), in addition LOODS values shows correlation with perineural invasion and micro vascular invasion (p = 0.015 and p = 0.001 respectively). Findings in our patient group support the hypothesis that LODDS subgroups correlate with OS, and that value of LODDS has considerable role in prediction of OS as well.

Comparison of Resection and Liver Transplant in Treatment of Hepatocellular Carcinoma.

OBJECTIVES: Hepatic resection and liver transplant are regarded as 2 potentially curative treatments for hepatocellular carcinoma. Here, we compared both options in patients with hepatocellular carcinoma secondary to cirrhosis seen at a single center over 12 years. MATERIALS AND METHODS: We evaluated early complications and survival of patients with hepatocellular carcinoma treated with liver transplant (57 patients) or hepatic resection (36 patients) at our center between 1998 and 2010. RESULTS: The 34-month mean follow-up period was similar for both treatment groups. The liver transplant group had a longer hospital stay than the hepatic resection group (P ⟨ .001). Patients with Child-Turcotte-Pugh A stage were treated by hepatic resection more than by liver transplant (P ⟨ .001),with Child-Turcotte-Pugh B stage patients treated by liver transplant more than by hepatic resection (P = .03). All patients with Child-Turcotte-Pugh C stage had liver transplant. Both treatment groups had similar postoperative complications and early postoperative mortality rates, but liver transplant resulted in longer overall (P = .001) and higher event-free (P = .001) survival than hepatic resection. Among the liver transplant group, 57.8% of patients met the Milan criteria. Patients who met Milan criteria were treated by liver transplant statistically more than hepatic resection, and these patients had longer overall survival (P = .01) and higher event-free survival (P ⟨ .001) than patients who had hepatic resection. Hepatocellular carcinoma recurrence rates were higher after hepatic resection (P = .232). CONCLUSIONS: In patients with hepatocellular carcinoma, hospital stay was longer after liver transplant, but morbidity and mortality rates for liver transplant versus hepatic resection were similar. However, overall and event-free survival rates were better after liver transplant than after hepatic resection. These results suggest that liver transplant should be considered as the primary treatment option for patients with hepatocellular carcinoma secondary to cirrhosis.

Adult morgagni hernia: a single center experience of 5 cases and review of literature.

Morgagni hernia is a rare congenital anomaly arising through the fusion defect between the septum transversum and sternum. Diagnosis is usually confusing as the presentation may be asymptomatic as well as with respiratory symptoms, abdominal and/or retrosternal pain, abdominal fullness or gastrointestinal obstruction. In this paper, we discussed the clinical presentation and management of this rare situation with five consecutive cases. Between 2009 and 2015, five cases underwent surgery for Morgagni hernia (3 laparoscopic and 2 open repair); one patient had recurrent hernia after 7 months from laparoscopic surgery. This case is the first recurrence in the literature after laparoscopic repair in an adult group. In Morgagni hernias, the only treatment is surgery, which can be performed by transthoracic, transabdominal, laparoscopic or thoracoscopic approaches. The issues of using mesh and reducing the hernia sac are still controversial.

Do the stump knotting technique and specimen retrieval method effect morbidity in laparoscopic appendectomy?

BACKGROUND: Stump closure is the most important part of a laparoscopic appendectomy (LA). Closing the appendix base with knot tying is the most cost-effective method. The defined risk factor for surgical site infection (SSI) after LA is the contamination of trocar entry area by inflamed appendicitis. This study aims to compare the single and double knot technique for stump control and specimen removal methods in LA. METHODS: The data of patients who underwent LA between January 2015 and January 2017 were obtained from prospectively collected database. Single and double knot technique, specimen removal method, operation duration, hospital stay, and perioperative-postoperative complications were compared. RESULTS: Extracorporeal double knot was used in 134 patients (63%), and single knot was used in 79 patients (37%). There was no difference between operation duration in the two groups (p=0.97). No stump leakage was observed in any patient. Intraabdominal abscess developed in three patients (1.4%). Appendix was removed from the abdomen directly in 101 patients (47%) and using specimen retrieval bag in 112 (53%). SSI developed in five patients (2.3%), and appendices of all of these five patients were removed from abdomen without using specimen retrieval bag. No SSI was detected in the group that used the specimen retrieval bag (p=0.02). CONCLUSION: Single or double knot(s) tying can be defined as safe and cost-effective stump closure method. The risk of developing SSI can be reduced using specimen retrieval bag.

De Novo Malignancies After Liver Transplantation: A Single Institution Experience.

OBJECTIVES: Our objective was to analyze characteristics, risk factors, and incidence of de novo malignancies after liver transplant. MATERIALS AND METHODS: The hospital records of 557 patients who underwent liver transplant were analyzed from the point of de novo malignancy development. We evaluated the demographic features and survival of these patients retrospectively. RESULTS: The research covered 429 patients, 9 (2%) of whom developed de novo malignancy. All of these patients were male (100%), and their mean (SD) age was 51.33 (4.69) years (range, 45-65 y). Indications for transplant included alcohol related in 4 cases, chronic hepatitis B in 2 cases, chronic hepatitis B and C in 1 case, chronic hepatitis B and D in 1 case, and chronic hepatitis C and alcohol-related cirrhosis in 1 case. The mean (SD) time from transplant to cancer diagnosis was 63.41 (37.10) months (range, 17-122 mo). The types of tumors were lung cancer, lymphoma, neuroendocrine tumor of lung, nasopharyngeal cancer, and squamous cell carcinoma of the skin. Seven cases received chemotherapy with or without radiotherapy. Two cases received surgery and radiotherapy. One patient underwent surgical treatment. One patient died before treatment was started. CONCLUSIONS: In recent years, improvements in surgical techniques and immunosuppressive therapies have helped prolong survival of patients who undergo liver transplant. However, this also has led to a rise in the incidence of long-term complications such as de novo malignancy. These patients are more likely to develop de novo malignancy than the general population, for which chronic immunosuppression is identified as a major risk factor. Early diagnosis and treatment of de novo malignancies can help obtain better prognosis and higher survival rates in these patients.

Adult morgagni hernia: A single-center experience of five cases and a review of literature.

Morgagni hernia is a rare congenital anomaly arising from the fusion defect between the septum transversum and sternum. The diagnosis is usually difficult since the presentation may be asymptomatic or with respiratory symptoms, abdominal and/or retrosternal pain, abdominal fullness, or gastrointestinal obstruction. In this report, we discuss the clinical presentation and management of this rare condition in five consecutive cases. Between 2009 and 2015, five cases underwent surgery for Morgagni hernia (three laparoscopic and two open repair surgeries); one patient developed recurrent hernia 7 months after the laparoscopic surgery. This case is the first reported recurrence in literature following laparoscopic repair in adults. Surgery is the only treatment option for Morgagni hernias, which can be performed through transthoracic, transabdominal, laparoscopic, or thoracoscopic approach. The issues of using mesh and reducing the hernial sac remain controversial.

Liver Transplant in Patients with Primary Sclerosing Cholangitis: Long-Term Experience of a Single Center.

OBJECTIVES: Primary sclerosing cholangitis is a chronic inflammatory disease of the intrahepatic and extrahepatic bile ducts. More than half of the patients will face end-stage liver disease and require liver transplant. Here, we describe the long-term outcomes of liver transplant in patients with primary sclerosing cholangitis at our center. MATERIALS AND METHODS: For this retrospective, observational study, we investigated all patients who underwent liver transplant for primary sclerosing cholangitis between January 2005 and June 2013 at the Dokuz Eylul University Hospital. Patient data were obtained from hospital records. Our inclusion criteria were patients over 18 years old and diagnosed with primary sclerosing cholangitis. RESULTS: Of 11 patients included the study, 6 (54.5%) were male and 5 (45.5%) were female. Mean age was 40.6 ± 11.0 years (range, 23-60 y). All patients had cirrhosis due to primary sclerosing cholangitis. With regard to Child-Turcot-Pugh classification, 2 patients (18.2%) were classified as having Child-Turcot-Pugh A cirrhosis, 7 patients (63.6%) were classified as having B cirrhosis, and 2 patients (18.2%) were classified as having C cirrhosis. Mean Modified End-Stage Liver Disease score was 17.5 ± 6.1 (range, 7-25). Cholangiocarcinoma was not detected in explant pathologic examinations. Primary sclerosing cholangitis recurrence developed in 2 patients (18.1%). Three patients (27.2%) died during the follow-up period. CONCLUSIONS: Liver transplant is a good therapeutic option for primary sclerosing cholangitis with satisfactory long-term outcomes. Liver transplant should be reserved for patients with end-stage liver disease and other conditions that significantly impair quality of life.

En Bloc Pancreaticoduodenectomy for Locally Advanced Right Colon Cancers.

Locally advanced right colon cancer may invade adjacent tissue and organs. Direct invasion of the duodenum and pancreas necessitates an en bloc resection. Previously, this challenging procedure was associated with high morbidity and mortality; however, today, this procedure can be done more safely in experienced centers. The aim of this study is to report our experience on en bloc right colectomy with pancreaticoduodenectomy for locally advanced right colon cancers. Between 2000 and 2012, 5 patients underwent en bloc multivisceral resection. No major morbidities or perioperative mortalities were observed. Median disease-free survival time was 24.5 months and median overall survival time was 42.1 (range: 4.5-70.4) months in our series. One patient lived 70 months after multivisceral resection and underwent cytoreductive surgery and total pelvic exenteration during the follow-up period. In locally advanced right colon tumors, all adhesions should be considered as malign invasion and separation should not be done. The reasonable option for this patient is to perform en bloc pancreaticoduodenectomy and right colectomy. This procedure may result in long-term survival with acceptable morbidity and mortality rates. Multidisciplinary teamwork and multimodality treatment alternatives may improve the results.