The impact of comorbidities on mortality in patients with non-traumatic major lower extremity amputation.

OBJECTIVE: Major lower limb amputation is generally associated with a high risk of early and late-term mortality. In this study, 30-day, one-year and three-year mortality of non-traumatic major lower extremity amputations and comorbidities affecting the mortality rate were investigated. METHOD: Patients who underwent a major lower limb amputation secondary to diabetes or peripheral artery disease between the years 2010-2015 were retrospectively evaluated. Additional to patient demographic data and comorbidities, amputation level, survival and mortality time were extracted. Mortality rates after 30 days, one year and three years were analysed. The associations of the survival to different parameters were evaluated with Kaplan-Meier analysis and log rank test, while the impact of the risk factors on mortality was evaluated with the Cox regression test. RESULTS: A total of 193 patients were enrolled in the study. Approximately 60% of patients were aged ≥65 years, and 65.8% were male. Below-knee amputation was performed in 64.8% of patients and above-knee amputation in 35.2% of patients. The mean follow-up of patients was 29.48 months (range: 0-101 months). After non-traumatic major lower extremity amputation, 30-day, one-year and three-year mortality were 16.6%, 38.3% and 60.1%, respectively. On Cox regression analysis, age ≥65 years was the only variable that had significant impact on the 30-day mortality (hazard ratio (HR): 3.4; p=0.012), while age ≥65 years (HR: 2.5, p=0.000), diabetes (HR: 2, p=0.006) and renal failure (HR: 2, p=0.001) were found to have significant impacts on three-year mortality. CONCLUSION: The findings of this study showed that >50% of patients with non-traumatic major lower limb amputations died within three years. Advanced age, diabetes and renal failure were the risk factors that increased the mortality. The high mortality rates revealed the importance of employing all hard-to-heal wound treatment options before making an amputation decision. Further, prospective studies are needed to determine the effects of primary disease status and timing of amputation on mortality.

Evaluation of endovascular treatment of chronic limb-threatening ischemia for patients in the PLAN gray zone.

OBJECTIVE: To compare the results of endovascular therapy for chronic limb-threatening ischemia (CLTI) in patients categorized under the gray and yellow zones of the patient risk, limb severity, and anatomic pattern (PLAN) concept over a 2-year follow-up period. METHODS: Patients who underwent endovascular therapy for peripheral artery disease and presented with CLTI from February 2017 to February 2019 were retrospectively reviewed. The patients were grouped into yellow and gray zones based on the PLAN concept. Preoperative and postoperative walking distances, Rutherford classes, and postoperative target vessel patency rates were recorded and compared between the groups. Follow-up evaluations were performed at 1, 6, 12, and 24 months post-procedure. RESULTS: Of the 387 patients evaluated, the yellow and gray groups comprised 88 patients each. The overall patency rates were similar between the groups (84 (95.45%) vs. 81 (92.05%), respectively). The occlusion-/stenosis-free survival times, amputation-free survival time, and mean survival time were not significantly different. However, the gray group had a significantly higher number of atherectomy interventions (74 vs. 59) and crosser devices used (62 vs. 42). CONCLUSION: Endovascular therapy is an effective treatment option for patients in the gray zone of the PLAN color coding system.

The feasibility of falciformopexy in the repair of peptic ulcer perforation.

BACKGROUND: Modified Graham omentopexy is the most commonly used operative technique in the repair of peptic ulcer perfo-ration (PUP); however, there is little data on falciformopexy in the literature. The aim is to investigate the feasibility of falciformopexy in the repair of PUP, comparing with modified Graham omentopexy. METHODS: Data of 471 patients who were operated for PUP were retrospectively analyzed. Patients' demographics, pre-operative basic laboratory findings, American Society of Anesthesiologists (ASA) status, operative findings, and post-operative complications were recorded. The patients were classified into two groups modified Graham omentopexy and falciformopexy, and then compared with each other in terms of clinical characteristics, operative findings, and post-operative complications. RESULTS: Modified Graham omentopexy and falciformopexy were performed in 425 (90.2%) and 46 (9.8%) patients, respectively. The two groups were similar in terms of basic patient characteristics and pre-operative laboratory findings (P>0.05). ASA physical status was significantly different between the groups (P=0.001). No statistically significant difference was found between the groups in terms of complications, except for an anastomotic leak. Anastomotic leak was observed more frequently in patients who underwent falciformopexy than in patients with modified Graham omentopexy (P=0.017). CONCLUSION: Although falciformopexy technique has a higher rate of leak compared to the modified Graham omentopexy method, it should be kept in mind as an alternative method for repair of PUP, especially in cases where omentopexy cannot be applied for various reasons such as the presence of unavailable or unsuitable omentum.

Has the Covid-19 Pandemic increased the complication rate in patients with acute appendicitis?

AIM: The aim of this study is to compare the numbers of patients, clinical outcomes, and complication rates of acute appendicitis before and after COVID-19 pandemic in our clinic. MATERIAL AND METHOD: This is a retrospective clinical study. Patients of 19 to 88 years of age that underwent emergency surgery with the diagnosis of acute appendicitis at Ankara City Hospital Department of General Surgery between 11 December 2019 and 11 June 2020 were included. The first case of COVID-19 in Turkey was announced on 11 March 2020. We studied the demographics, surgical procedures, and complication rates in 3 months periods before and after the first case was announced. RESULTS: A total number of 462 patients were analyzed between the ages of 19-88, 184 of which (39.8%) were females and 278 were males (60.2%). 253 of these patients were diagnosed with AA and underwent surgery before March 11 whereas 209 patients were diagnosed and treated after March 11. DISCUSSION: There was no statistical difference between the two groups in terms of complication rates before and after the pandemic. Although the rate of open appendectomy was increased after the pandemic, no statistical difference has been found. CONCLUSION: No change was observed in terms of hospital admissions, methods of treatment, complication rates, length of stay before and after the COVID-19 pandemic. KEY WORDS: Acute Appendicitis, Appendectomy, COVID-19.

Does COVID-19 increase the incidence of spontaneous rectus sheath hematoma?

BACKGROUND: The COVID-19 pandemic started to affect Turkey in March 2020. In this study, we retrospectively investigated spontaneous rectus sheath hematoma (S-RSH) in patients with COVID-19 presenting with acute abdominal pain during the ongoing pandemic. METHODS: The demographic characteristics, laboratory findings, length of hospital stay, and treatment processes of COVID-19 cases with S-RSH detected between March and December 2020 were recorded. The rectus sheath hematoma diagnosis of the patients was made using abdominal computed tomography, and the patients were followed up. Low-molecular-weight heparin treatment, which was initiated upon admission, was continued during the follow-up. RESULTS: S-RSH was detected in 13 out of 220 patients with COVID-19 who were referred to general surgery for consultation due to acute abdominal pain. The mean age of these patients was 78±13 years, and the female-to-male ratio was 1.6. Mechanical ven-tilation support was applied to three patients, all of whom were followed up in the intensive care unit. Two patients died for reasons independent of rectus sheath hematoma during their treatment. Among the laboratory findings, the activated partial thromboplastin time (aPTT) values did not deviate from the normal range. While there was no correlation between the international normalized ratio (INR) and aPTT (p>0.01), a significant correlation was found between INR and interleukin-6 (IL-6) (p<0.002). None of the patients required surgical or endovascular interventional radiology procedures. CONCLUSION: In the literature, the incidence of S-RSH in patients presenting with acute abdominal pain is 1.8%. However, in our series, this rate was approximately 3 times higher. Our patients' normal INR and aPTT values suggest that coagulopathy was mostly secondary to endothelial damage. In addition, the significantly higher IL-6 values (p<0.002) indicate the development of vasculitis along with the acute inflammatory process. S-RSH can be more commonly explained the high severity of vasculitis and endothelial damage due to viral infection.

The Predictive Value of the Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratio in Patients with Recurrent Idiopathic Granulomatous Mastitis.

OBJECTIVE: The aim of this study was to investigate the relationship between the inflammatory parameters including neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) and the prognosis of idiopathic granulomatous mastitis (IGM). MATERIALS AND METHODS: In this retrospective study, a total of 41 patients with IGM who had no malignant disease or inflammatory pathologies were included between January 2010 and December 2017. The patients were divided into two groups according to presence or absence of recurrence. Subsequently, the relationship between patient characteristics, pre- and postoperative NLR and PLR levels and disease recurrence were evaluated. RESULTS: With a mean follow-up period of 28.4 months, 19.5% of patients were found to have recurrent IGM. Age, body mass index, patient characteristics such as oral contraceptive use, smoking status, and family history, surgical treatment and postoperative NLR, preoperative PLR, and postoperative PLR were not statistically significant between groups. However, only preoperative NLR was significantly associated with a recurrent IGM (p=0.024). Preoperative NLR predicted recurrence with a sensitivity of 62.5% and specificity of 84.8%. CONCLUSION: These results demonstrated that a high level of NLR was predictive of poor outcome in patients with IGM.

The outcomes of intestinal resection during debulking surgery for ovarian cancer.

OBJECTIVE: To evaluate the clinical and surgical outcomes of intestinal resection during primary debulking surgery for ovarian cancer. MATERIAL AND METHODS: This retrospective study was conducted at Zekai Tahir Burak Women's Health Training and Research Hospital between 2009 and 2013. The patients who underwent intestinal resection during debulking surgery for stage 3 ovarian cancer were included in the analysis. Data regarding patient age, body mass index, tumor histology, disease stage, the site of intestinal resection, all postoperative complications, duration of intensive care unit admission and hospital stay were collected and analyzed. RESULTS: A total of 22 patients with a mean age of 53.4 years were included in the study. Optimal cytoreduction was achieved in 14 (63%) patients. Transverse colectomy was the most common type of intestinal resection (63%). The most common postoperative complication was transfusion of blood products (63%). No postoperative mortality was observed. CONCLUSION: Intestinal resection is a crucial part of debulking surgery for advanced ovarian cancer, with acceptable complication rates. Despite the limited number of patients, the results obtained from the present study are comparable with previous reports.

Predictive factors of neoplastic gallbladder polyps: Outcomes of 278 patients.

BACKGROUND/AIMS: Distinguishing between neoplastic and nonneoplastic gallbladder polyps (GBPs) in the preoperative workup is of great importance for appropriate treatment. The present study aimed to investigate the characteristics of GBPs and to determine potential predictive factors of neoplastic polyps. MATERIALS AND METHODS: The data of 278 patients who were confirmed to have GBPs through laparoscopic cholecystectomy were retrospectively analyzed. Polyps were classified as nonneoplastic and neoplastic GBPs, according to histopathological diagnoses. All clinicopathological characteristics were compared between these two groups. RESULTS: There were 264 (95%) nonneoplastic GBPs and 14 (5%) neoplastic GBPs. In univariate analysis, there were significant differences in age with a cutoff value of 60 years (p=0.002), polyp size (p<0.001), number of polyps (p=0.014), and polyp morphology (p<0.001) between the groups. Multivariate analysis showed that solitary polyp (p<0.001) and sessile morphology (p<0.001) were the independent predictors of neoplastic GBPs. Receiver-operating characteristic curve analysis of three cut-off values of polyp sizes (6, 10, and 15 mm) indicated that a polyp size of 10 mm had the highest area under curve (0.942). CONCLUSION: Age above 60 years, solitary polyps larger than 1 cm, and sessile morphology are associated with an increased risk of neoplasia in GBP. Therefore, these characteristics should be considered in the management of GBPs to reduce the incidence of unnecessary surgeries and to prevent delays in the treatment of a possible cancer.

Phyllodes Tumor of the Breast: Analysis of 48 Patients.

OBJECTIVE: Phyllodes tumor (PT) is a rare biphasic breast neoplasm that accounts for less than 1% of all breast tumors. The aim of this study was to evaluate the clinicopathologic features, diagnostic difficulties, and therapeutic outcomes of patients with PT. MATERIALS AND METHODS: A total of 48 female patients who underwent surgery for PT were included in the study. Patient characteristics, clinicopathologic features of tumors, diagnostic findings, surgical outcomes, adjuvant therapies, and follow-up findings were retrospectively evaluated. RESULTS: The mean age of patients was 35 years. Painless breast mass was the most common (85.4%) presenting symptom. Total excision with at least 1 cm macroscopic clear margins was the most frequently performed (87.5%) surgery. Most patients (n=34, 70.8%) had benign PT; however, borderline and malignant tumors were found in 9 (18.8%) and 5 (10.4%) patients, respectively. During the mean follow-up period of approximately 30 months, local and distant recurrence was detected in three (6.3%) patients and one (2.1%) patient, respectively. Patients with malignant PT had larger tumors than those with benign and borderline PTs (p=0.010). No significant difference in other clinical, diagnostic, and pathologic characteristics was found between the groups. CONCLUSION: PT can be easily confused with other breast masses such as fibroadenoma due to the non-specific clinical and radiologic findings. Surgical excision with at least 1 cm clear margins is of great importance to reduce the risk of local recurrence. However, recurrence can develop even after appropriate surgery, thus patients should be closely followed up after surgery.

Parameters for predicting granulosa cell tumor of the ovary: a single center retrospective comparative study.

BACKGROUND: To evaluate factors for predicting the granulosa cell tumor of the ovary (GCTO) pre-operatively. MATERIALS AND METHODS: This retrospective designed study was conducted on 34 women with GCTO as the study group and 76 women with benign ovarian cysts as the control group. Data were recorded from the hospital database and included age, body mass index (BMI), parity, serum estradiol (E2) levels, diameter of the mass, ultrasonographic features, serum CA125 level, risk of malignancy index (RMI), duration of menopause, postoperative histopathology result, and the neutrophil/lymphocyte ratio (NLR). RESULTS: The demographic parameters showed no statistically significant difference between the groups. Preoperative diameter of the mass, CA125, duration of menopause, and neutrophil/lymphocyte ratio were significantly different between the groups. ROC curve analysis demonstrated that diameter of the mass, serum estradiol and Ca125 levels, RMI and NLR may be discriminative factors in predicting GCTO preoperatively. CONCLUSIONS: In conclusion, we think that a careful preoperative workshop including diameter of the mass, serum estradiol (E2) and Ca125 levels, RMI and NLR may predict GCTO and may prevent incomplete approaches.