Characterization of different chitosanases of Bacillus strains and their application in chitooligosaccharides production.

Chitosanases are potential candidates for chitooligosaccharides (COS) production-based industries, therefore, the discovery of chitosanases having commercial potential will remain a priority worldwide. This study aims to characterize different chitosanases of Bacillus strains for COS production. Six different indigenous Bacillus strains (B. cereus EGE-B-6.1m, B. cereus EGE-B-2.5m, B. cereus EGE-B-5.5m, B. cereus EGE-B-10.4i, B. thuringiensis EGE-B-3.5m, and B. mojavensis EGE-B-5.2i) were used to purify and characterize chitosanases. All purified chitosanases have a similar molecular weight (37 kDa) as determined by sodium dodecyl sulfate-polyacrylamide gel electrophoresis. However, other characteristics such as optimum temperature and pH, kinetic parameters (Km and Vmax ), temperature, and pH stabilities were dissimilar among the strains of different Bacillus species and within the same species. Furthermore, chitosanases of all strains were able to successfully hydrolyze chitosan to COS and oligomers of the degree of polymerization 2-6 were detected with chitobiose and chitotriose as major hydrolysis products. The relative yields of COS were in a range of 19%-31% and chitosanase of B. thuringiensis EGE-B-3.5m turned out to be the best enzyme in terms of its characteristics and COS production potential with maximum relative yield (31%). Results revealed that Bacillus chitosanases could be used directly for efficient bioconversion of chitosan into COS and will be valuable for large-scale production of biologically active COS.

Contribution of intraoperative parathyroid hormone monitoring to the surgical success in minimal invasive parathyroidectomy.

Background: The contribution of intraoperative parathyroid hormone monitoring to minimally invasive parathyroidectomy remains controversial. We aimed to evaluate whether intraoperative parathyroid hormone monitoring monitoring could contribute to minimally invasive parathyroidectomy in these patients. Methods: The data of the patients whose preoperative ultrasonography and technetium-99 m sestamibi scintigraphy imagings were positive and concordant for one gland and who underwent minimally invasive parathyroidectomy between 2003 and 2018 in our clinic, were evaluated retrospectively. Blood samples were collected at pre-excisional period, and at post-excisional 10 and 20 min; the intaoperative parathyroid hormone was measured, and the surgery was terminated without waiting for the result. Patients were divided into 2 groups according to the postoperative results, as those with normocalcemia (Group 1) and those with persistence (Group 2). Results: There were 195 patients in Group 1 and 14 patients in Group 2. The cure rate at the first surgery was 93.3%. Cure was achieved after the second operation in all patients in Group 2. Recurrent disease developed in 1 patient in group 1 and the overall cure rate was 99.5%. If intraoperative parathyroid hormone had been evaluated, cure could have been achieved at the first surgery with additional exploration, in 10 (71.4%) of 14 patients according to the insufficient decrease in parathyroid hormone value at the 10 min in Group 2, and in 9 (64.3%) of 14 patients according to the parathyroid hormone value at 20 min. However, due to insufficient decrease (false negative) in the parathyroid hormone value at the 10 and 20 min the rate of false negatives and unnecessary exploration would be 9.5% and 2.5%, respectively. With additional exploration, the cure rate in the first surgery could be increased by 4.3%-97.6% according to the 20 min intraoperative parathyroid hormone value. Conclusion: The cure rate in minimally invasive parathyroidectomy can be increased by minimizing unnecessary conversion to bilateral neck exploration, by evaluating intraoperative parathyroid hormone at 10 min in patients with positive and concordant scans, and intraoperative parathyroid hormone at 20 min in patients with inadequate decrease at 10 min intraoperative parathyroid hormone.

The Reality of Hypoparathyroidism After Thyroidectomy: Which Risk Factors are Effective? Single-Center Study.

Objectives: One of the most common complications of thyroidectomy is hypoparathyroidism and that complication has a multifactorial etiology. The etiology of post-operative hypoparathyroidism is multifactorial, some factors affecting hypoparathyroidism have been revealed in the literature, and there are some conflicting results about this complication. In the present study, we aimed to evaluate pre-operative and intraoperative factors affecting development of hypoparathyroidism. Methods: Data of 542 patients underwent thyroidectomy±central dissection (±lateral dissection) and whose post-operative parathormone values could be obtained, between 2012 and 2020 were collected prospectively and evaluated retrospectively. A parathyroid hormone (PTH) value of <15 pg/mL at the post-operative 4th h was defined as hypoparathyroidism, and a calcium (Ca) value of <8 mg/dl on the 1st post-operative day was defined as biochemical hypocalcemia. Patients were divided into two groups as post-operative hypoparathyroidism (Group 1) and non-hypoparathyroidism (Group 2). In addition, PTH value below the reference value at the post-operative 6th month and/or still needing calcium treatment was defined as permanent hypoparathyroidism. Demographic data of the patients, pre-operative biochemical values, surgical indications, intraoperative findings, post-operative 4th h PTH values, post-operative 1st day calcium values, and pathological examination of the specimen whether there was an unintenionally resected parathyroid gland or not were evaluated as risk factors for hypoparathyroidism. A logistic regression model was used to determine independent risk factors for the development of hypoparathyroidism. Results: Hypoparathyroidism was determined in 124 (22.9%) and hypocalcemia was determined in 120 (22.1%) patients. According to 6-month follow-up period; 110 (20.3%) patients were transient, 7 (1.3%) patients were permanent, and 7 (1.3%) patients data could not be obtained. The hypocalcemia rate was higher in Group 1 (39.3% vs. 14.3%, p<0.0001), also the post-operative 1st day calcium values were lower (8.2+0.7 mg/dl vs. 8.5+0.6 mg/dl; p=0.000). The rate of parathyroid autotransplantation, the rate of parathyroid gland in pathological specimen, and the rate of central dissection were significantly higher in Group 1 compared to group 2 (15.8% vs. 8%; p=0.006; 20% vs. 10.6%; p=0.003; 16.4% vs. 5.3%, p<0.0001, respectively). The difference between the two groups was significant in terms of the number of remaining parathyroids, and the rate of the number of patients with four remaining parathyroids in place was higher in Group 2 than in Group 1 (84.1% vs. 67.9; p=0.000). In the logistic regression analysis, only central dissection is an independent risk factor affecting the development of hypoparathyroidism, and central dissection increases the risk of hypoparathyroidism approximately 2.3 times (p=0.014; OR: 2.336). The other factors were not determined as independent risk factor. Conclusion: Performing central neck dissection with total thyroidectomy may increase the risk of hypoparathyroidism development. The risk of hypoparathyroidism should be considered when evaluating the indications and dissection extent in the central dissection. Maximum effort should be made to preserve the parathyroid glands and their vascularization during central dissection, and if there is a removed parathyroid gland, it should be autotransplanted.

Relationship Between Thyroid-Stimulating Hormone Level and Aggressive Pathological Features of Papillary Thyroid Cancer.

Objectives: Thyroid-stimulating hormones (TSHs) are associated with the risk of differentiated thyroid cancer. The relationship between pre-operative TSH levels and aggressive features is unclear. We aimed to evaluate the relationship between pathological features of papillary thyroid carcinoma (PTC) and high TSH levels. Methods: Patients who were operated between 2012 and 2017 and who were found to have PTC in their pathology were included in the study. The relationship between TSH and the features of tumor aggressiveness was evaluated in the patients. Results: Of the 132 patients, TSH level was significantly higher in those with lymphovascular invasion than those without (p=0.048), in those with central metastases than in those without (p=0.014), and in those with extrathyroidal spread than in those without (p=0.003). When patients were categorized into four 25% quartiles according to TSH (mUI/mL) level; the rate of extrathyroidal invasion increased as the TSH level increased, and the level was significantly higher in quartile 1 than the others, with significant difference (p=0.030). Conclusion: Pre-operative increase in TSH level is associated with an increased risk of extrathyroidal spread and central lymph node metastasis. TSH level may be a pre-operative valuable predictive factor for patients' risk of central metastasis.

Parathyroidectomy Results in Primary Hyperparathyroidism: Analysis of the Results From a Single Center.

OBJECTIVES: The curative treatment of primary hyperparathyroidism (PHPT) is surgery. Persistent and recurrent disease may develop after surgical treatment. In this study, we aimed to evaluate the surgical cure rate in patients who underwent surgery for PHPT in our clinic. METHODS: The data of patients who underwent parathyroidectomy for PHPT by two experienced surgeons between 2000 and 2015 in our clinic were retrospectively evaluated. Patients who were followed for at least 6 months after their first parathyroidectomy were included in the study. Surgical cure and persistent and recurrent disease rates were evaluated in patients. RESULTS: During this period, 368 interventions were performed in 357 patients (293 F and 64 M) who were operated for PHPT in our clinic, with a mean age of 54.9±13.1 years. In the first surgery, 116 patients (32.5%) had bilateral neck exploration, 251 patients (67.5%) had unilateral neck exploration (UNE) or focused parathyroid surgery (FPS). In the first operation, 343 patients (96.1%) had cure, 14 patients (13 F and 1 M) remained persistent. Secondary surgical intervention was performed in 11 patients. UNE or FPS was performed to 10 patients (90.9%); partial sternotomy was performed to one patient. Ten of the patients had cure. Three of these patients had a solitary parathyroid adenoma that was not removed in the first surgery, and seven patients had a second adenoma. Four patients remained persistent (1.1%). Recurrent disease developed in four patients during follow-up (1.1%). Total cure rate was 97.8%. CONCLUSION: The only definitive treatment for PHPT is surgery. High surgical cure can be achieved by pre-operative evaluation and appropriate surgical planning. However, persistent PHPT may develop, especially due to double adenoma or ectopic location. Patients with persistent PHPT can be evaluated with repeat imaging methods and with appropriate surgical planning, a high cure rate can be obtained in secondary surgery, which can increase the total surgical cure rate. Recurrence rate is rare.

The Relationship of Magnesium Level with the Recovery of Parathyroid Function in Post-thyroidectomy Hypoparathyroidism.

OBJECTIVES: Hypocalcemia is the most common complication and acute parathyroid gland insufficiency is the main cause of it after thyroidectomy. In this study, we aimed to evaluate the relationship between the recovery time of parathyroid gland function and patient characteristics, preoperative and postoperative electrolyte changes, and intraoperative parathyroid findings in patients with postoperative hypoparathyroidism. METHODS: Patients who underwent total thyroidectomy (TT) with or without central neck dissection ± lateral neck dissection with a parathyroid hormone (PTH) value of <15 pg/mL within the postoperative 4th hour were included in this study. Postoperative calcium level of <8mg/dL was defined as biochemical hypocalcemia and a PTH value of <15 pg/mL was defined as hypoparathyroidism. The patients were divided into three groups according to the time of PTH recovery (>15 pg/mL); within the first 24 hours, between one day and 30 days, after 30 days, respectively. RESULTS: One hundred eleven patients (mean age, 49.3±14.4 years) consisted of Groups 1, 2 and 3, including 19 (16F, 3M), 67 (54F, 13M) and 25 (19F, 6M), respectively. Vitamin D deficiency rates for Groups 1, 2, 3 were 41.7%, 53.1% and 88.2%, respectively (p=0.018). Postoperative day 0 PTH values were 11.69±2.79pg/mL, 6.92±3.45 pg/mL, 4.99±2.36 pg/mL, (p<0.001). Biochemical hypocalcemia rates of Groups 1, 2, 3 on postoperative day 1 were 15.8%, 53.7%, 64%, (p=004) respectively, and calcium values were 8.68±0.67 mg/dL, 8.15±0.66 mg/dL, 7.75±1 mg/dL, (p=0.014), respectively. Magnesium values on postoperative day 1 and 7 for Groups 1, 2, 3 were 1.85±0.1 mg/dL, 1.77±0.17 mg/dL, 1.64±0.17 mg/dL, (p=0.005), and 1.86±0.16mg/dL, 1.82±0.21mg/dL, 1.59±0.15mg/dL (p=0.001), respectively. PTH values on postoperative day 1 and 7 in Groups 1, 2, 3 were 20.5±6.4 pg/mL, 7.06±4.35 pg/mL, 4.66±3.26 pg/mL (p<0.001), and 31.04±10.54pg/mL, 18.72±13.84pg/mL, 4.55±4.9pg/mL (p<0.0001), respectively. Parathyroid function improved in 106 patients, and permanent hypoparathyroidism developed in five patients (4.5%). CONCLUSION: Hypoparathyroidism can recover rapidly in the first 24 hours in patients with a PTH value of around 10 pg/mL at postoperative 4th hour. As the number of preserved parathyroids increased, recovery time decreased. In patients with postoperative hypoparathyroidism, postoperative low magnesium levels may be associated with delayed recovery of parathyroid function.

Is Vitamin D Deficiency Associated with Chronic Lymphocytic Thyroiditis?

Objectives: Vitamin D deficiency is a very common global health problem. Evidence from recent studies focuses on the extraskeletal effects of vitamin D (Vit D) deficiency. Chronic lymphocytic thyroiditis (or Hashimoto's thyroiditis) is an autoimmune disease of the thyroid. Although there are many studies reporting that autoimmune thyroid diseases may be associated with Vitamin D deficiency, this is still a controversial issue that has not yet been proven. In this study, we aimed to appraise whether there is a relationship between lymphocytic thyroiditis diagnosed by histopathological evaluation and Vitamin D deficiency. Methods: Data of 256 patients whom were operated by a single surgeon in a single center between 2012 and 2017 and whose preoperative vitamin D tests and thyroid pathologies have been collected, were retrospectively evaluated. Due to the pathological examination, two groups were formed considering the presence of lymphocytic thyroiditis (Group 1), and the absence of lymphocytic thyroiditis (Group 2). Vitamin D deficiency was defined as the level <20 ng/mL (50 nmol/L) and Vitamin D insufficiency was defined as the level 21-29 ng/mL (525-725 nmol/L). Results: There were 108 (92F/16M) patients in Group 1, and 148 (116F/32M) patients in Group 2, and the mean age was lower in Group 1 (p=0.053). The mean vitamin D levels (16.6±15.2 vs. 14±10, p=0.409) and vitamin D deficiency rates (67.6% vs. 72.3%, p=0.416) were found similar between the Groups 1 and 2. No positive significant correlation was found between lymphocytic thyroiditis and vitamin D level or vitamin D deficiency rates. There was a positive correlation between lymphocytic thyroiditis and age, preoperative thyroid-stimulating hormone level, preoperative anti-thyroglobulin ,and anti-thyroid peroxidase levels, but no significant relationship was found with Vitamin D level. Conclusion: According to our results, lymphocytic thyroiditis was not associated with either Vitamin D deficiency or Vitamin D level.

Factors Influencing the Relationship of the External Branch of the Superior Laryngeal Nerve with the Superior Pole Vessels of the Thyroid Gland.

OBJECTIVES: In a thyroidectomy, the external branch of the superior laryngeal nerve (EBSLN) is a potential risk during the superior pole dissection due to its close anatomical relationship with the superior thyroid artery and its highly variable anatomy. In this study, we aimed to evaluate the relationship of EBSLN with the superior pole considering Cernea classification and the factors affecting this relationship. METHODS: The data of thyroidectomized 126 patients (95 female, 31 male) with 200 neck sides (mean age of 45.6±12.1 years) using intraoperative neuromonitoring (IONM) for the EBSLN exploration were evaluated retrospectively. During the superior pole dissection, the EBSLN course was classified according to Cernea classification after being confirmed with IONM. It was defined as a large goiter in the case of the thyroid lobe volume being >50 cc. The factors influencing the presence of type 2b, which has the highest risk of injury, were evaluated using logistic regression analysis. RESULTS: Of the 200 EBSLNs evaluated, 52 (26%) were type 1, 134 (68%) were type 2a, and 14 (7%) were type 2b. The mean volumes of the resected thyroid lobes were 22±25 cc (min-max: 2-136), 23±20 cc (3-163), and 39±24 cc (3-65) in type 1, 2a and 2b, respectively, which was significantly higher in type 2b (p=0.035). Presence of large goiter rates were 5.8% (n=3), 8.2% (n=11), 64.3% (n=9) in type 1, 2a, and 2b, respectively, and was significantly higher in type 2b (p=0.0001). There was no significant difference between EBSLN Cernea types concerning age, sex, nerve side, presence of cancer and hyperthyroidism. In logistic regression analysis, large goiter was the only independent factor associated with Cernea type 2b. In case of a lobe volume greater than 50 cc, the probability of type 2b presence was approximately 25 times higher (p<0.001, odds ratio: 25.262). CONCLUSION: Type 2b course of EBSLN is more common in large goiters, and it is 25 times more likely to be seen in the presence of a lobe volume over 50 cc. Thus, it should be considered that the probability of this high-risk course is significantly higher in large goiters.

Colostomy reversal after a Hartmann's procedure Effects of experience on mortality and morbidity.

AIM: Hartmann's procedure (HP) is mostly lifesaving procedure especially for obstructive colorectal carcinomas, but remains bothersome requiring staged operation and subsequent reversal colostomy. We aimed to investigate risk factors for unfavorable surgical outcome after Hartmann's reversal. MATERIALS AND METHODS: Between September 2003 and September 2014, all patients who underwent colostomy reversal surgery after HP were enrolled into the study. Retrospective data collection included demographics (age, gender, body mass index (BMI), ASA scores) primary pathologies, interval period, surgeon who performed procedure [general surgeon (GS)/colorectal specialty (CRS)], postoperative complications and hospital stay. RESULTS: There were 72 patients (49M/23F) with a median age of 64 (range: 29-83) years. The median BMI was 24 (21-44). Most of the patients (82%) had ASA score 3-4. Colorectal cancer was the primary diagnosis in 79% while others included diverticular perforation, volvulus, trauma and Crohn disease. Hartmann's procedure was performed as an emergency in three-fifths of patients. Median interval period between index surgery and reversal colostomy was 7 (1-24) months. The morbidity and mortality rates for colostomy reversal surgery were 34% and 8.3%, respectively. The most common postoperative complication was surgical site infection (22%) followed by anastomotic leak 5%. Mortality and morbidity rates were significantly higher in patients with higher BMI (p=0.031), higher ASA scores (p=0.028) and patients who underwent procedure not by a CRS. CONCLUSION: Reversal colostomy procedure resulted in significant morbidity and mortality, particularly in those with high BMI and ASA scores. Efforts to improve risk management and specialization in colorectal surgery may help to improve the outcome in reversal colostomy after Hartmann's procedure. KEY WORDS: Colorectal surgery, Experience, Hartmann's procedure, Reversal colostomy, Morbidity.

Thyroid hemiagenesis: a case report.

Thyroid hemiagenesis is a rare entity in the literature. Developmental hemi-thyroid anomalies can result from either an abnormal descent or an agenesis of one lobe of the thyroid gland. This study aimed at presenting a thyroid hemiagenesis case incidentally diagnosed by neck ultrasonography (USG), who had complaints of pain and swelling in the neck. USG examination revealed lack of left thyroid lobe and multiple nodules in the right lobe. Fine Needle Aspiration Biopsy (FNAB) showed follicular neoplasia, and right subtotal thyroidectomy was performed. We report the rarity of the condition and emphasize the role of imaging techniques in preoperative diagnosis and subsequent management.

Emergency computed tomography for the diagnosis of acute appendicitis: How effectively we use it?

BACKGROUND: Technological developments support using ultrasonography (US) in all patients, if available, and advanced diagnostic methods such as abdominal computed tomography (CT) in case of clinical suspicion during diagnostic process of acute appendicitis. We aimed to investigate whether CT was appropriately and efficiently used in the diagnosis of acute appendicitis. METHODS: Between May 2013 and February 2016, 811 patients who underwent appendectomy were retrospectively reviewed from an IRB-approved database, and those who underwent a preoperative CT were enrolled into the study. Results of Alvarado scores and US were recorded in addition to which clinic requested the CT (general surgery or emergency department). RESULTS: The frequency of CT use in the diagnostic process was 25% (n=208/811). Ultrasound was negative for appendicitis in 53% of these patients. The mean Alvarado score was 5±1.5 (range: 3-8). General surgeons requested 57% of CTs. Alvarado scores were significantly higher in patients whose CT was requested by general surgery than in those whose CT was requested by the emergency clinic (5.6 vs. 4.7, p=0.013). Regarding histopathological results, age and Alvarado scores were significantly lower (p=0.015 and 0.037, respectively), whereas the frequency of negative CT was significantly higher (p=0.042) in those with negative appendectomy (n=29, 14%). CONCLUSION: Most patients who underwent CT in the diagnostic process had an Alvarado score between 5 and 8 and negative ultrasound for appendicitis preoperatively. These findings may provide efficient use of CT in the diagnosis of appendicitis with an acceptable rate of 25% compared with the findings in current literature. However, further research is needed to ensure more efficient use of CT because negative appendectomy has been a concern in our series despite promising results of this study.

Cycloartane-type sapogenol derivatives inhibit NFκB activation as chemopreventive strategy for inflammation-induced prostate carcinogenesis.

Chronic inflammation is associated to 25% of cancer cases according to epidemiological data. Therefore, inhibition of inflammation-induced carcinogenesis can be an efficient therapeutic approach for cancer chemoprevention in drug development studies. It is also determined that anti-inflammatory drugs reduce cancer incidence. Cell culture-based in vitro screening methods are used as a fast and efficient method to investigate the biological activities of the biomolecules. In addition, saponins are molecules that are isolated from natural sources and are known to have potential for tumor inhibition. Studies on the preparation of analogues of cycloartane-type sapogenols (9,19-cyclolanostanes) have so far been limited. Therefore we have decided to direct our efforts toward the exploration of new anti-tumor agents prepared from cycloastragenol and its production artifact astragenol. The semi-synthetic derivatives were prepared mainly by oxidation, condensation, alkylation, acylation, and elimination reactions. After preliminary studies, five sapogenol analogues, two of which were new compounds (2 and 3), were selected and screened for their inhibitory activity on cell viability and NFκB signaling pathway activity in LNCaP prostate cancer cells. We found that the astragenol derivatives 1 and 2 as well as cycloastragenol derivatives 3, 4, and 5 exhibited strong inhibitory activity on NFκB signaling leading the repression of NFκB transcriptional activation and suppressed cell proliferation. The results suggested that these molecules might have significant potential for chemoprevention of prostate carcinogenesis induced by inflammatory NFκB signaling pathway.

Synchronous Occurrence of Primary Breast Carcinoma and Primary Colon Adenocarcinoma.

A 65-year-old female patient presented to the emergency clinic with abdominal pain, meteorism, and intermittent rectal bleeding. Colonoscopy was performed, and a hepatic flexure tumor was detected. Histopathological examination of biopsy revealed adenocarcinoma. Thoracoabdominal CT was performed for staging, and a spiculated contour mass was found incidentally on the left breast. Mammography and ultrasonography were performed for the cause of these findings, and suspicious lesions of malignancy were seen in the left breast. Invasive ductal carcinoma was detected in core needle biopsy samples from lesions. In the multidisciplinary council consisting of oncologist, pathologist, radiologist, and general surgery specialist, it was decided to perform breast operation first and then colon operation, followed by adjuvant chemotherapy. In the first operation, left total mastectomy and sentinel lymph node biopsy were performed. One week after her initial operation, the patient underwent right hemicolectomy. After operations, the patient did not develop postoperative complications and was sent to medical oncology department for adjuvant chemotherapy.

Delaying surgery after neoadjuvant chemoradiotherapy improves prognosis of rectal cancer.

AIM: To investigate the prognostic effect of a delayed interval between neoadjuvant chemoradiotherapy (CRT) and surgery in locally advanced rectal cancer. METHODS: We evaluated 87 patients with locally advanced mid- or distal rectal cancer undergoing total mesorectal excision following an interval period after neoadjuvant CRT at Sisli Hamidiye Etfal Training and Research Hospital, Istanbul between January 2009 and January 2014. Patients were divided into two groups according to the interval before surgery: < 8 wk (group I) and ≥ 8 wk (group II). Data related to patients, cancer characteristics and pathological examination were collected and analyzed. RESULTS: When the distribution of timing between group I (n = 45) and group II (n = 42) was viewed, comparison of interval periods (median ± SD) of groups showed a significant difference of as 5 ± 1.28 wk in group I and 10.1 ± 2.2 wk in group II (P < 0.001). The median follow-up period for all patients was 34.5 (9.9-81) mo. group II had significantly higher rates of pathological complete response (pCR) than group I had (19% vs 8.9%, P = 0.002). Rate of tumor regression grade (TRG) poor response was 44.4% in group I and 9.5% in group II (P < 0.002). A poor pathological response was associated with worse disease-free survival (P = 0.009). The interval time did not show any association with local recurrence (P = 0.79). CONCLUSION: Delaying the neoadjuvant CRT-surgery interval may provide nodal down-staging, improve pCR rate, and decrease the rate of TRG poor response.

Endoscopic stent placement in the management of malignant colonic obstruction: Experiences from two centers.

OBJECTIVE: Intestinal obstruction due to colorectal tumors requires immediate surgical decompression. Endoscopic stent placement for acute malignant colonic obstruction is gaining widespread acceptance as an alternative to emergency surgery. Our aim in this study was to evaluate the success and complication rates of endoscopic stenting for malignant colonic obstruction. MATERIAL AND METHODS: Patients with acute malignant colonic obstruction who underwent endoscopic stenting between 2011-2014 were retrospectively reviewed. Data included demographic features, localization of obstruction, endoscopic stenting indications, rate of technical and clinical success, complications, morbidity and mortality. RESULTS: Endoscopic stent was successfully placed in 77 out of 82 procedures (93.9%). A colostomy was placed in five cases in which endoscopic stent could not be inserted. There were complications in seven patients with technically successful stents (9.0%). These included three stent migrations, one perforation, and rectal hemorrhage in three patients. There were no stent-related deaths. CONCLUSION: The mortality rate of emergency surgery for malignant bowel obstruction is relatively high. The use of colonic stents can avoid surgery in patients who are not suitable for emergency surgery and may allow adequate time for preoperative preparation, counseling and staging for those who are suitable for further intervention. We believe that self-expandable metallic stent placement is a safe, effective, and minimal invasive alternative treatment method for malignant colonic obstruction.

Giant perianal condyloma acuminatum: Reconstruction with bilateral gluteal fasciocutaneous V-Y advancement flap.

Condyloma acuminatum caused by human papilloma virus is the most common sexually transmitted infection in the anogenital region. On the other hand, giant condyloma acuminatum that is also known as Buschke-Lowenstein tumor is a rare disease. Its primary treatment is surgical excision. The purpose of this report is to present a case that reached immense dimensions in the perianal region, and to emphasize the importance of wide surgical excision. A 17-year-old woman presented with a giant mass in the perianal region for 2 years, which progressively increased in size. Local examination revealed a large vegetative lesion in the perianal area. Wide surgical excision of the involved skin and lesion was undertaken. The wound was reconstructed by bilateral gluteal fasciocutaneous V-Y advancement flap. Response to various treatments is often poor, with a high recurrence rate. In conclusion, surgical treatment with wide excision and plastic reconstruction is an effective therapy for giant anal condylomas.

Single Incision Laparoscopic Cholecystectomy for Gallbladder Duplication.

Duplication of the gallbladder is a rare congenital anomaly of the gallbladder, with an estimated prevalence of 1-3 per 3800 individuals. Unless properly diagnosed preoperatively, it can lead to biliary tract injuries and postoperative complications which may require reoperative surgeries. While previously reported cases have been treated with conventional laparoscopic cholecystectomy (LC), treatment with single incision laparoscopic surgery (SILS) has not been reported yet. We herein present the case of a 58-year-old female with gallbladder duplication who was successfully treated with SILS cholecystectomy.

Prediction of the grade of acute cholecystitis by plasma level of C-reactive protein.

BACKGROUND: Acute cholecystitis is the most common complication of gallbladder stones. Today, Tokyo guidelines criteria are recommended for diagnosis, grading, and management of acute cholecystitis. OBJECTIVES: We aimed to evaluate the levels of C-reactive protein (CRP) at different cut-off values to predict the severity of the disease and its possible role in grading the disease with regard to the guideline. PATIENTS AND METHODS: This is a retrospective study, analyzing 682 cases out of consecutive 892 patients with acute cholecystitis admitted to two different general surgery clinics in Istanbul, Turkey. Records of patients diagnosed with acute cholecystitis were screened retrospectively from the hospital computer database between January 2011 and July 2014. A total of 210 patients with concomitant diseases causing high CRP levels were excluded from the study. The criteria of Tokyo guidelines were used in grading the severity of acute cholecystitis, and patients were divided into 3 groups. CRP values at the time of admission were analyzed and compared among the groups. RESULTS: Mean CRP levels of groups were found to be significantly different, 18.96 mg/L in Group I, 133.51 mg/L in Group II, and 237.23 mg/L in Group III (P < 0.001). Having examined CRP values among the groups, they were found to be highly and significantly correlated with the disease grade (P < 0.0001). After evaluating CRP levels according to the grade of the disease, group 2 was distinguished from group 1 with a cut-off CRP level of 70.65 mg/L, and from group 3 with a value of 198.95 mg/L. Those results were found to be statistically significant (P < 0.001). CONCLUSIONS: CRP, a well-known acute phase reactant that increases rapidly in various inflammatory processes, can be accepted as a strong predictor in classifying different grades of the disease, and treatment can be reliably planned according to this classification.

Effects of totally extraperitoneal (TEP) and Lichtenstein hernia repair on testicular blood flow and volume.

BACKGROUND: Laparoscopic totally extraperitoneal hernia repair (TEP) has been compared with the open technique in several studies in terms of technical properties and perioperative outcomes. There are few studies that compare the long-term effects of each technique on testicular structure and function on the side of the hernia repair. The objective of this study is to investigate the effects at 6 months of the TEP and the Lichtenstein technique on testicular volume and arterial flow by the use of Doppler ultrasonography. METHODS: A total of 148 men with a unilateral hernia were randomized prospectively to undergo TEP or Lichtenstein repair. In both groups, unilateral resistive indices, pulsatile indices of capsular and intratesticular artery flow, and testicular volume (in milliliters) were measured preoperatively and 6 months postoperatively by the use of grayscale and color Doppler ultrasonography (CDUS). The primary outcomes of the study were postoperative findings from history, physical examination, and CDUS measurements at 6 months postoperatively. Demographics, clinical and operative data, CDUS measurements, and recurrence patterns were analyzed. RESULTS: Of 148 procedures, 134 cases consisting of 64 TEP and 70 Lichtenstein repairs were evaluated. Pre- and postoperative CDUS findings, rates of complications, and recurrence in both groups did not show any difference. Operative time was greater with a Lichtenstein repair (36 vs 30 minutes; P = .01). CONCLUSION: Complications and recurrence rates and effects on testicular perfusion and testicular volume in both laparoscopic and open techniques are similar, whereas the laparoscopic approach has shorter operative time than open hernia repair.

Minimal invasive management of anastomosis leakage after colon resection.

The gold standard of surgical treatment of colorectal anastomotic leak is abdominal drainage of collected fluid and stoma formation. Conventional laparotomy has been the preferred approach for treatment. However, both laparoscopic surgical techniquesand endoscopic stenting have gained popularity over the past years as minimal invasive approaches, especially in the management and treatment of perforations of the gastrointestinal system. We present here a successful treatment with a minimal invasive management of anastomosis leak in the early postoperative period after colon resection in a 62-year-old female patient who had undergone urgent laparoscopic intra-abdominal lavage and drainage followed by endoscopic stenting.