Routine Histopathological Examination of the Specimen After Laparoscopic Cholecystectomy: Can We Be Brave Enough to Give Up?

BACKGROUND: Selective versus routine histopathological examination after cholecystectomy is still in debate. This study aims to investigate the effect of histopathology results on treatment modality and surgery strategy. The validity of the selective histopathology approach was questioned. METHODS: The data of patients undergoing laparoscopic cholecystectomy between January 2009 and December 2019 were retrospectively analyzed. The demographics and histopathology results, whether the operation was emergent or elective, and the reasons for conversion to open surgery were recorded. Malignant and precursor histopathology diagnoses were examined, and their relationship with the surgical strategy was questioned. RESULTS: A total of 2723 patients were included in the study. Of these patients, 2600 (95.5%) were operated under elective, while 123 (4.5%) were operated under emergency conditions. While the surgery was completed laparoscopically in 2685 (98.6%) patients, it was converted to open surgery in 38 (1.4%) patients. Age, gender, the presence of primary gallbladder cancer, acute cholecystitis, and xanthogranulomatous cholecystitis in histopathological examination were found to be independent predictive factors for conversion to open surgery (P < .05). The rate of primary invasive carcinoma in the series was 0.1%. CONCLUSION: Routine histopathological examination of the gallbladder is important for demonstrating a wide spectrum of pathological changes in this organ. Invasive cancer or precursor lesions can be detected even in patients without any macroscopic abnormality. Histopathological examination also plays a role in determining follow-up, further examination, and treatment modality in addition to the diagnosis in these patients.

A new criterion to predict recurrence after laparoscopic ventral hernia repair: mesh/defect area ratio.

<b>Introduction:</b>Minimizing recurrence in hernia surgery is one of the major aims. Defining surgeon-dependent risk factors for recurrence is therefore of great importance in laparoscopic ventral hernia repair (LVHR). This study aims to analyze the predictive value of the mesh area/defect area ratio (M/D ratio) in terms of recurrence as a new criterion in LVHR.</br> </br> <b>Methods:</b> A total of 124 patients were enrolled in the study. Age, gender, hernia type, body mass index, defect size, size of the mesh, mesh overlapping, area of the defect, area of the mesh, M/D ratio, postoperative complications, follow-up time, recurrences and timing of recurrence were also recorded. The potential variables that may affect recurrence were examined by univariate and multivariate analysis.</br> </br> <b>Results:</b> There were 12 (9.7%) recurrences in our series. A statistically significant difference was found if either the mesh/defect ratio was ≤6 or >6 (p = 0.012). Multivariate analysis confirmed that M/D ratio was the only independent parameter for recurrence. </br></br><b>Conclusion:</b> Understanding M/D ratio concept and using it in surgical clinical practice may help reduce recurrence rates after LVHR.</br>.

Acute Appendicitis in Pregnancy: How to Manage?

OBJECTIVES: Acute appendicitis during pregnancy may be associated with severe maternal and fetal complications. The clinical, laboratory and radiological parameters used in diagnosis and the effects of the surgical method and timing on the results are controversial. The present study aims to reveal the relationship between clinical approach, surgical treatment methods and complications in pregnant women with suspected acute appendicitis. METHODS: Between December 2007 and August 2019, 21 pregnant women who underwent appendectomy were included in this study. Age, gestational age, complaints at admission, leukocyte count, radiological examination results, type of surgery (conventional or laparoscopic), histopathology results, time from admission to operation, maternal and fetal complications were retrospectively evaluated. RESULTS: The number of patients who developed complications was six (28.6%). Three (14.3%) of these patients had preterm birth and three (14.3%) had an abortion. There was no statistically significant relationship between trimester and complication (p=0.747). Fourteen patients (66.7%) underwent laparoscopic surgery and seven patients (33.3%) underwent conventional surgery. Although the complication rate was higher in the laparoscopic group, there was no statistically significant difference (p=0.306). The fetal loss rate in the series was 14.3% and all were in the laparoscopic group. However, there was no statistically significant difference between the groups (p=0.158). CONCLUSION: Pregnancy-related limiting factors may complicate the diagnosis of acute appendicitis. These patients definitely need a more skeptical assessment and additional diagnostic tools beyond the standard clinical approach. Although laparoscopic appendectomy appears to be a safe option in treatment, its relationship with a higher risk of fetal loss should be kept in mind.

Effectiveness of new parameters in the evaluation of pneumoperitoneum-related acute kidney injury in rats

Background/aim: Pneumoperitoneum with high pressure results in decreased glomerular filtration rates (GFRs). Cystatin-C (Cys-C), neutrophil gelatinase-associated lipocalin (NGAL), and interleukin 18 (IL-18) are new parameters in the evaluation of GFR instead of creatinine. The aim of this study is to show the effects of pneumoperitoneum on renal function with the help of these new acute kidney injury markers. Materials and methods: Sixty rats were divided into 10 groups according to the length of time and degree of pneumoperitoneum pressure achieved during CO2 insufflation: 0 mmHg (control) for 1 h; 4 mmHg for 1, 2, and 4 h; 8 mmHg for 1, 2, and 4 h; and 12 mmHg for 1, 2, and 4 h. Serum samples were obtained to measure the serum creatinine, blood urea nitrogen (BUN), Cys-C, NGAL, and IL-18. Results: There were no differences between the serum creatinine levels of the groups. Serum levels of BUN, Cys-C, NGAL, and IL-18 were significantly increased in the 2nd hour of the experiment. This increase was more prominent at high pressures. Conclusion: Although serum creatinine is a practical way of estimating GFR, it has been shown that Cys-C, NGAL, and IL-18 are superior in the estimation of decreased GFR in pneumoperitoneum.

Intra-Operative Frozen Section Histology of the Pancreatic Resection Margins and Clinical Outcome of Patients with Adenocarcinoma of the Head of the Pancreas Undergoing Pancreaticoduodenectomy.

BACKGROUND The aim of this study was to compare the clinical outcome in patients with pancreatic ductal adenocarcinoma who underwent frozen section and paraffin section histology of the surgical resection margins during pancreaticoduodenectomy. MATERIAL AND METHODS Frozen section and routine paraffin section histopathology were performed using the following categories: R0 (no tumor cells at the surgical resection margin), R1 (tumor cells at, or within 1 mm, of the surgical resection margin), and R2 (tumor seen macroscopically at the surgical resection margin). R1 and R2 patients underwent additional resection to achieve R0. RESULTS Of 346 patients who underwent pancreaticoduodenectomy, frozen section histology showed positive resection margins in 22 patients (9.2%) and paraffin section histology was positive in 20 patients (8.4%). The OS was nine months in frozen section-positive patients and 20 months in frozen section-negative patients (p=0.001). The OS rates were significantly different between the paraffin section-positive and paraffin section-negative patients (11 months vs. 21 months) (p=0.001). Univariate and multivariate analysis showed that increased tumor size, high tumor grade, lymph node metastases, a positive superior mesenteric artery and retroperitoneal margin, and a positive resection margin on frozen section were significantly correlated with reduced OS (p<0.05). Twenty-two patients with positive resection margins on frozen section histology underwent further resection; R0 was achieved in 14 patients, with no significant difference in OS. CONCLUSIONS For patients who underwent pancreaticoduodenectomy for pancreatic carcinoma with positive resection margins on frozen section, further surgical resection to achieve R0 had no significant positive impact on OS.

Prevention and acute management of biliary injuries during laparoscopic cholecystectomy: Expert consensus statement.

Gallstone disease is very common and laparoscopic cholecystectomy is one of the most common surgical procedures all over the world. Parallel to the increase in the number of laparoscopic cholecystectomies, bile duct injuries also increased. The reported incidence of bile duct injuries ranges from 0.3% to 1.4%. Many of the bile duct injuries during laparoscopic cholecystectomy are not due to inexperience, but are the result of basic technical failures and misinterpretations. A working group of expert hepatopancreatobiliary surgeons, an endoscopist, and a specialist of forensic medicine study searched and analyzed the publications on safe cholecystectomy and biliary injuries complicating laparoscopic cholecystectomy under the organization of Turkish Hepatopancreatobiliary Surgery Association. After a series of e-mail communications and two conferences, the expert panel developed consensus statements for safe cholecystectomy, management of biliary injuries and medicolegal issues. The panel concluded that iatrogenic biliary injury is an overwhelming complication of laparoscopic cholecystectomy and an important issue in malpractice claims. Misidentification of the biliary system is the major cause of biliary injuries. To avoid this, the "critical view of safety" technique should be employed in all the cases. If biliary injury is identified intraoperatively, reconstruction should only be performed by experienced hepatobiliary surgeons. In the postoperative period, any deviation from the expected clinical course of recovery should alert the surgeon about the possibility of biliary injury.

Tryptophan degradation and serum neopterin concentrations in intensive care unit patients.

Alterations in neopterin concentrations and tryptophan degradation accompany the activation of cellular immune systems. Accordingly, in a variety of diseases, mainly in infections, elevated neopterin levels and tryptophan degradation have been observed. This study aimed to assess serum neopterin levels and tryptophan degradation in intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS, n = 9), sepsis (n = 8), septic shock (n = 10), and multiple organ dysfunction syndrome (MODS, n = 7) at the first day of ICU hospitalization. The kynurenine-to-tryptophan (kyn/trp) ratio was used in order to evaluate the degree of tryptophan degradation. The results of each patient group were compared with the control group (n = 30). The differences among the ICU groups and the correlations between APACHE II scores and neopterin concentrations or tryptophan degradation were investigated. All patient groups presented statistically higher kyn/trp and neopterin levels than the controls. The sepsis, septic shock, and MODS group had markedly higher neopterin levels than the SIRS group (all P < 0.05). Additionally, it was found that the survivor group had significantly lower neopterin levels compared with non-survivors (P < 0.05) and lower kyn/trp, but the latter difference was not significant. Neopterin levels and kyn/trp were both correlated with APACHE II score (both P < 0.05). The results indicate that serum neopterin levels and tryptophan degradation correlate well with the severity of the disease in ICU patients, and this was true even at the first day of hospitalization in the unit.

The protective role of anandamide in mesenteric ischemia reperfusion injury in guinea pig.

BACKGROUND: Acute mesenteric ischemia is an entity characterized by rapid developing of circulatory failure. Reperfusion following ischemia causes further mucosal injury. METHODS: In our study, an experimental model of 15 minutes of reperfusion following 45 minutes of superior mesenteric artery occlusion was established. The segments which underwent I/R injury were histopathologically examined, and blood samples obtained from the heart were analyzed for alkaline phosphatase and creatine kinase levels. RESULTS: The results of the study demonstrated that mucosal injury in anandamide injected group was less expressed than in other groups suggesting that anandamide might have a protective effect on the mucosa. After L-NAME and indomethacin injection, the protective effect of anandamide seems to disappear due to inhibition of NO and prostaglandins. The results of histopathological examination of specimens from CB1 receptor and anandamide injected group indicate that I/R injury has regressed. CONCLUSION: The protective effect of endogenous anandamide on I/R injury may take place through CB2 receptors in the small intestine; NO and prostaglandin, which are activated through the stimulation of CB2 receptors may be responsible for this protective effect (Fig. 8, Ref. 29). Full Text (Free, PDF) www.bmj.sk.

The timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreaticography in cholelithiasis coexisting with choledocholithiasis.

BACKGROUND: An accepted treatment strategy for cholelithiasis with secondary choledocholithiasis is the laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreaticography (ERCP). Although early cholecystectomy is advised, there is no consensus about the time interval between LC and ERCP. The aim of this study is to evaluate the effects of the time interval between ERCP and ERCP on operation outcomes. METHODS: Patients with cholelithiasis and a risk of choledocholithiasis underwent ERCP. Patients were grouped as those operated on between 24 and 72 h after ERCP (group 1) and those operated on more than 72 h after ERCP (group 2). Patients' age, gender, body mass index, American Society of Anesthesiologists Physical Status, abdominal ultrasonography findings, white blood cell count, total serum bilirubin, ALP, amylase, ALT, AST, GGT levels, ERCP findings, time interval between ERCP and LC, conversion rate, median postoperative hospital stay, median operation time, intraoperative complication and postoperative complication rates were collected. RESULTS: There was no significant difference between the demographics of the patients in both groups. The median operation time, median postoperative hospital stay and conversion rate in group 2 were significantly higher than those of group 1. More postoperative complications were seen in group 2. CONCLUSION: Early cholecystectomy after ERCP, within 72 h, has better outcomes, probably due to the inflammatory processes.

Liver schwannoma incidentally discovered in a patient with breast cancer.

BACKGROUND: Benign schwannomas, also referred to as neurilemomas, neurinomas, and perineural fibroblastomas, are encapsulated nerve sheath tumors. Primary schwannomas of the liver are extremely rare. We present a case of liver schwannoma, incidentally found in a patient with breast cancer. CASE: A 66-year-old female consulted her physician for a mass she palpated on her left breast. The abdominal ultrasonography (USG) revealed a 44 x 28 mm mass in the medial segment of the left lobe of her liver suspicious of a metastasis. An USG-guided biopsy was performed and the histo-pathological examination revealed a "peripheral nerve sheath tumor". Positron emission tomography (PET-CT) revealed a pathologic FDG uptake in the lesion that was previously defined in the liver. The tumor resected from the liver was 5 x 4 x 3 cm, yellowish, soft, and capsulated tumor. Microscopic examination revealed that the mass consisted of bundles of spindle cells with hypercellular and hypocellular areas. In immunohistochemistry, there was a strong positive staining for S-100. The tumor was diagnosed as benign liver schwannoma. CONCLUSION: Schwannomas are benign, encapsulated neoplasms. Symptoms and signs vary depending on the anatomical site and the size of the neoplasm; however, most schwannomas present as an asymptomatic or painless mass. Recurrence is unusual, despite of an incomplete removal, and malignant transformation is exceedingly rare (Fig. 4, Ref. 8). Full Text (Free, PDF) www.bmj.sk.

Neopterin as a prognostic biomarker in intensive care unit patients.

PURPOSE: The present study was undertaken to evaluate urinary neopterin in intensive care unit patients. MATERIALS AND METHODS: Urinary neopterin levels were determined in systemic inflammatory response syndrome (n = 10), sepsis (n = 18), septic shock (n = 9), and multiple organ dysfunction syndrome (n = 5). It was tested whether neopterin is a differential parameter among the patient groups. Furthermore, the results were also evaluated by comparing with a healthy control group (n = 30), and the relationship between neopterin and mortality or Acute Physiology and Chronic Health Evaluation II scores were investigated. RESULTS: Neopterin levels of the control group and patients were detected as 111 +/- 11 and 3850 +/- 1081 mumol/mol creatinine, respectively (P < .05). It was significantly increased in the sepsis and septic shock groups compared to the systemic inflammatory response syndrome group (P < .05). Neopterin levels were significantly higher in the patients with mortality and lower Acute Physiology and Chronic Health Evaluation II scores. CONCLUSION: This study showed that monitoring of urinary neopterin profile can be used in intensive care units to show the degree and prognosis of the disease.

Intermittent pneumatic sequential compression of the lower extremities restores the cerebral oxygen saturation during laparoscopic cholecystectomy.

BACKGROUND: Pneumoperitoneum causes intracranial pressure elevation and blood stasis at lower extremities. This study investigates cerebral oxygen saturation changes during laparoscopy and the effects of intermittent sequential compression (ISC) of the lower extremities in patients during elective laparoscopic cholecystectomy. PATIENTS AND METHOD: Sixty patients were randomly divided into two groups according to the application of ISC to the lower extremities. Group I served as control group whereas ISC was applied to group II. Cerebral oxygen saturation, peripheral blood oxygen saturation, heart rate, mean blood pressure, and associated changes have been recorded during the operation. RESULTS: Peripheral blood oxygen saturation and mean blood pressure values did not change significantly after pneumoperitoneum. Cerebral oxygen saturation levels of the group II patients were higher in than the group I patients and the difference between the groups was statistically significant (p = 0.0001). The difference became more prominent following the 35(th) minute of the operation. Mean heart rate of the patients in group II was lower than the patients in group I and the difference was also statistically significant (p = 0.0001). CONCLUSION: In this study, it was found that the decrease in cerebral oxygen saturation was recovered with ISC application. This simple and reliable technique helps to restore cerebral oxygen saturation levels while increasing blood return from the lower extremities.

[Hepatic portal venous gas: a case report]. / Hepatik portal vende gaz: olgu sunumu.

Gas in hepatic portal vein is a rare entity. This may be apparent after mesenteric ischemia, blunt abdominal trauma, intestinal obstruction, and intra-abdominal infection. Intrahepatic gas was detected by direct abdominal graphy in a 58 year-old man who was admitted to our emergency service with acute abdomen. On computed tomography; portal vein gas, pneumatosis intestinalis, and occlusion of superior mesenteric vein and artery were detected. The patient who had had significant concomittant operative risks, died prior to surgery. Gas in portal vein is a good predictive factor for diagnosis, management, and prognosis. This sign may avoid unnecessary surgery and also it may help to make an early decision for surgery.

Adult ileal intussusception: an unusual emergency condition.

Adult intussusception occurs infrequently and differs from the childhood condition in its presentation, cause, and treatment. Nonspecific symptoms can delay diagnosis; most cases are diagnosed at emergency laparotomy. Increased use of computed tomographic scanning to evaluate patients with abdominal pain can enhance reliable preoperative diagnosis. Treatment entails simple bowel resection in most cases. Reduction is controversial, especially in cases of colonic intussusception. This report describes the diagnosis and management of a case of adult ileal intussusception caused by an inflammatory fibroid polyp-a rare lesion of the gastrointestinal tract.

The effects of carbon dioxide pneumoperitoneum on tyrosine hydroxylase activity.

PURPOSE: The aim of this study is to investigate the effects of carbon dioxide (CO2) pneumoperitoneum on tyrosine hydroxylase (TH) activity and total protein (TP) levels. METHODS: Forty male Sprague-Dawley rats were randomized into 10 groups, each consisting of 10 rats. Groups 1 and 2 consisted of anesthesia and sham-operated control rats, respectively. In the study groups, 10 mm Hg (group 3) and 15 mm Hg (group 4) pneumoperitoneum with CO2 were accomplished. At the end of the procedures, the brains and adrenals were removed quickly, and the hypothalamus and adrenal medulla separated, weighed, and homogenized. TH activity and TP levels were determined. RESULTS: The adrenal medulla TP and TH activity levels were decreased consistently and this decrease was significant in the sham and pneumoperitoneum groups compared with the control group (P<0.05). The adrenal medulla TP and TH activity levels were reduced significantly in group 4, as compared with the other groups (P<0.05). Elevation of hypothalamic TH activity in group 4 was significantly higher than in the other groups (P<0.05). CONCLUSIONS: These results indicate that CO2 pneumoperitoneum applied with 10 and 15 mm Hg pressure gradually decreases the adrenal medulla TH activity; TH is an indispensable enzyme for the biosynthesis of catecholamines. CO2 pneumoperitoneum with 15 mm Hg pressure significantly elevated hypothalamus TH activity.

Laparoscopic cholecystectomy in patients with previous abdominal surgery.

BACKGROUND: Laparoscopic cholecystctomy has become the treatment of choice for symptomatic gallstones. The potential risks have dissuaded some surgeons from using the laparoscopic procedure in patients with previous abdominal surgery. Therefore, we aimed to investigate the effect of previous abdominal surgery on the feasibility and safety of laparoscopic cholecystectomy. METHODS: This study included 600 well-documented patients with gallstones who underwent laparoscopic cholecystctomy at our surgical department between May 2000 and January 2004. The patients were classified into 3 groups: group 1, patients without a history of previous abdominal surgery (n = 408); group 2, patients with a history of upper abdominal surgery (n = 92); group 3, patients with a history of lower abdominal surgery (n = 100). The data were collected and analyzed for open conversion rates, operative times, perioperative and postoperative complications, and hospital stay. RESULTS: Of the 600 study patients, 192 had undergone previous abdominal surgery (92 upper, 100 lower). Conversion rate, hospital stay, and complication rates were similar in each group. Mean operating time was the longest (57 +/- 9.8 min) in patients with previous upper abdominal surgery (P < 0.05). On the other hand, the operative time was similar in groups 1 and 3 (P > 0.05). CONCLUSION: Previous abdominal surgery is not a contraindication to safe laparoscopic cholecystectomy. However, previous upper abdominal surgery is associated with a prolonged operation time.

Ultrasonography in the diagnosis of true gallbladder polyps: the contradiction in the literature.

Polypoid lesions of the gallbladder (PLGs) are often incidentally identified during ultrasonographic examination of abdominal pain. The present study was designed to determine the reliability of ultrasonography (US) in the diagnosis of PLGs. The records of 853 patients who underwent laparoscopic cholecystectomy (LC) for PLGs in Gazi Medical School from January 2000 to January 2004 were reviewed. Data were collected regarding the patients' gender, age, symptoms, serum lipid levels, the size and the number of polyps on US, surgical indications for PLGs and histopathological diagnosis. In all, 56 of 853 patients had PLGs and underwent LC. Right upper quadrant pain (59%) was the most common presenting symptom that led to gallbladder US. Nearly 75% of the lesions were smaller than 10 mm. At histopathologic examination cholesterolosis was found in 17 of 56 (30%) patients, and 12 of 56 (21%) demonstrated only cholelithiasis; 17 (30%) patients had both cholesterolosis and stones. Only 10 (18%) patients had adenomatous polyp and 8 of these polyps were larger than 1 cm. Overall US-based diagnosis of gallbladder polyp was inaccurate in 82%. The sensitivity and specificity of US for polyps <1 cm was 20% and 95.1%, respectively, whereas the sensitivity and specificity of US for polyps >1 cm was 80% and 99.3%, respectively. The accuracy of US in diagnosing PLGs was poor, especially in polyps <1 cm.

Unexpected gallbladder cancer during laparoscopic cholecystectomy.

BACKGROUND/PURPOSE: In the present study, we investigated the effectiveness of surgeons in determining incidental gallbladder pathologies at laparoscopic cholecystectomy (LC). METHODS: This study included 548 patients with gallstones who underwent LC between May 1, 2001 and October 15, 2003. The surgeon made an incision on the gallbladder wall for inspection, and palpated the mucosa after removing the gallbladder from the abdominal cavity to look for unsuspected pathologies. If an abnormal mucosa was observed or palpated, it was marked with a silk suture and then histopathologic examination was performed. RESULTS: Fifty of 548 LC specimens were found to be suspi-cious by the surgeon. Histopathological examination of frozen sections revealed incidental pathologies in 15 of these specimens. Strikingly, 5 of these specimens were considered to have gallbladder cancer (GBC). The other incidental pathologies were consistent with adenomyomatosis, xanthogranulomatous cholecystitis, and fibroepithelial and hyperplastic polyps. Four of the other 498 specimens revealed incidental pathologies at definitive histopathological examination, and all of them were consistent with gastric metaplasia. The sensitivity and specificity of the procedure was 78.9% and 93%, respectively. CONCLUSIONS: A simple prosedure; that is, incision and inspection, and palpation of the gallbladder, seems to be useful for the diagnosis of incidental gallbladder pathologies.

Prognostic value of serum IL-18 and nitric oxide activity in breast cancer patients at operable stage.

Interleukin-18 (IL-18) is a multifunctional cytokine that was previously termed interferon-gamma-inducing factor. It has been suggested that serum IL-18 level may be used as a prognostic factor in some cancer types. Nitric oxide is a potent biologic molecule involved in the pathogenesis of cancer. In this study, we measured serum IL-18 and nitrate + nitrite levels in 56 patients with nonmetastatic breast cancer and 14 control subjects. Serum IL-18* and nitrate + nitrite** levels were significantly higher in patients with breast cancer when compared to the control subjects (*p < 0.05, **p < 0.001). Serum IL-18 levels were significantly higher in patients whose tumor size was greater than or equal to 5 cm when compared to patients whose tumor size was less than or equal to 2 cm (p < 0.05). Patients who were axillary lymph node negative (ALN) had lower serum IL-18 levels when compared to patients with positive ALN (p < 0.001). Serum IL-18 levels were significantly higher in patients with stage IIB or IIIA when compared to patients with stage I or IIA (p < 0.05). There was no significant difference in serum nitrate + nitrite levels in terms of age, tumor stage, estrogen receptor, and menopausal and ALN status (p > 0.05). In conclusion, serum IL-18 level may be a useful marker to predict prognosis of patients with breast cancer in complete remission after surgery. Long-term follow-up is required to clarify this hypothesis.