Can neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, prognostic nutrition index, and albumin be used to predict cholecystectomy morbidity in super-elderly patients?

BACKGROUND: This study aimed to evaluate the usability of neutrophil-lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), prognostic nutritional index (PNI), and serum albumin level in predicting cholecystectomy morbidity in elderly patients (85 years and older) who underwent cholecystectomy for acute cholecystitis. METHODS: This retrospective study included super-elderly patients who underwent cholecystectomy due to acute cholecystitis at a tertiary health centre between January 2010 and January 2021. The patients were divided into two groups according to the presence of postoperative complications (morbidity). The differences between the two groups were evaluated. In addition, the role of NLR, PLR, PNI, and serum albumin level in predicting cholecystectomy morbidity for acute cholecystitis in super-elderly patients was assessed via ROC analysis. RESULTS: Of 30 patients who met the study criteria, 22 (73.3%) were female, and the mean age of all patients was 87.43±2.66 years (range 85-94 years). 7 (23.3%) patients had at least one comorbid disease during the preoperative period. The mean value of NLR, PLR, albumin, and PNI were 8.31, 153.76, 3.45, and 48.37, respectively. The morbidity rate of the study was 23.3%. The area under the curve (AUC) for NLR was 0.466 ([95% confidence interval [CI]: 0.259-0.672]; P=0.787), and the AUC for PLR was 0.429 ([95% CI: 0.201-0.656]; P=0.573). These two factors were not suitable for predicting morbidity. The AUC for PNI was 0.780 ([95% CI: 0.568-0.991]; P=0.027), and the AUC for albumin was 0.894 ([95% CI: 0.770-1.000]; P=0.002). At the cut-off value of 3.05 g/dL, the sensitivity and specificity of albumin were 91.3% and 71.4%, respectively, while the sensitivity and specificity of PNI at the 41.70 cut-off value were 82.6% and 71.4%, respectively. CONCLUSION: This study found that PNI and albumin can be used as predictive factors with high sensitivity and specificity for predicting cholecystectomy morbidity for acute cholecystitis in super-elderly patients. However, NLR and PLR had no significance in predicting cholecystectomy morbidity.

Clinicopathological Factors Affecting Mucin 1, Mucin 2, and Mucin 5AC Staining in Patients who Underwent Resection for Colorectal Cancer.

OBJECTIVE: To investigate the clinicopathological factors affecting mucins (MUC 1, MUC 2, and MUC 5AC) staining in patients who underwent resection for colorectal cancer. STUDY DESIGN: An observational study. Place and Duration of the Study: Department of General Surgery and Department of Pathology, Kafkas University Faculty of Medicine, Kars, Turkey, between January 2020 and January 2021. METHODOLOGY: Patients operated on for colorectal adenocarcinoma were included in the study. Patients who underwent colorectal surgery for benign diseases or had a pathological diagnosis other than adenocarcinoma were excluded from the study. Clinicopathological factors affecting MUC1, MUC2, and MUC5AC staining were evaluated with appropriate statistical tests, assuming a significant p-value of less than 0.05. RESULTS: Of the 30 patients who met all study criteria, 18 (60%) were males. The mean age of all patients was 62.83±16.79 (21-88). MUC1 strongly positive staining was observed in 18 (60%) cases, and high expression was detected in pT4 and pT3 cases (p=0.005). In addition, increased expression was also noted in cases with lymph node involvement (p=0.045). MUC2 expression was more than 60% (strongly positive) in 20 (66.7%). The MUC2 expression was increased in moderately differentiated cases (p=0.032). There was no staining (negativity) in 22 (73.3%) cases with MUC5AC, and more than 60% staining (strongly positive) was observed in 3 (10%) cases. In addition, strong expression was noted in rectosigmoid tumours (p=0.001), female patients (p=0.046), and patients with pT3 and pT4 tumours (p=0.05). CONCLUSION: High MUC1 and high MUC5AC staining were observed in advanced colorectal cancer, whereas high MUC2 staining was observed in patients with moderate tumour differentiation. KEY WORDS: Colorectal cancers, Gene expressions, Mucin.

A Comparative Study on Removal of Appendectomy Specimen during Laparoscopy.

This study included 151 patients and compared four techniques for appendectomy specimen removal during laparoscopy in a tertiary health centre. An endo bag was the most common removal technique which is preferred in the elderly, whereas, direct removal is preferred in younger patients (p=0.045). A lower median CRP level was observed in the powdered glove group (p=0.025), and median values of hospital stay were longer in powder-free and powdered glove groups (p<0.001). In comparing the powder-free glove group and powdered glove group, there was only a difference in median hospital stays, and the median level was higher in the powdered glove group. The present study's results show direct removal is the best method because of the reduced need for catheters during surgery and the short hospital stay. However, powdered gloves technique is preferred method in cases with less inflammation, though, it prolongs the need for drainage catheter use and length of hospital stay. Therefore, we emphasise that removal via powdered gloves is the worst technique among the four techniques. Key Words: Appendectomy, Appendicitis, Laparoscopy, Morbidity, Readmission.

How has the COVID-19 pandemic changed the diagnosis of rectus sheath hematoma and its follow-up?

BACKGROUND: There has been an increased incidence of rectus sheath hematoma (RSH) due to chronic cough attacks and anti-coagulant therapy due to the COVID-19 pandemic. The present study aims to determine, in which parameters differ before and during the diagnosis of RSH in COVID-19 patients and what may be expected during diagnosis and follow-up. METHODS: Thirty-five patients diagnosed with RSH were evaluated retrospectively between March 2016 and March 2021. The COVID-19 group comprised 11 patients. Various information including patient history and time of discharge/death were retrieved and compared between the experimental groups. RESULTS: The rates of hypotension on admission (p=0.011) and the rates of defense and rebound (p=0.030) were higher in the patients with COVID-19 than in those without. Although there was no difference in terms of bleeding width, there was a greater decrease in the hemoglobin levels (p=0.009) in the COVID-19 patients and the need for erythrocyte suspension (p=0.040) increased significantly in that group. CONCLUSION: The present study constitutes the first evaluation of RSH in COVID-19 patients. The clinical situation is serious due to high rates of hypotension, defense or rebound, and decreases in hemoglobin levels in COVID-19 patients. This makes the clinical management of RSH more difficult, resulting in longer hospitalization. Despite these difficulties, COVID-19 infection does not increase morbidity or mortality.

Splenectomy during Gastric Cancer Surgery versus Splenectomy during Extra-gastric Abdominal Cancer Surgery.

OBJECTIVE: To evaluate the clinicopathological differences between splenectomy during gastric cancer surgery and splenectomy during extra-gastric abdominal cancer surgery. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Erzurum Regional Education and Research Hospital, Erzurum, Turkey between January 2015 and January 2020. METHODOLOGY: Patients who were operated due to intra-abdominal malignancies were searched retrospectively. Among those patients, concomitant splenectomy cases were filtered for the study. The patients' general clinicopathological characteristics were retrieved from their medical records. Patients were divided into two groups, according to the objectives. The clinicopathological differences between the groups were evaluated with appropriate statistical tests, assuming significant p value of less than 0.05. RESULTS: The study included 45 patients. The mean age of the patients was 62.84 ± 12.59 (30-86 years), and male to female ratio was 19:26. Splenectomy was performed during gastric cancer surgery in 30 patients (66.7%) and 43 patients (95.6%) were operated in elective conditions. There was a need for more erythrocyte suspension in patients, who underwent splenectomy during gastric cancer surgery (p=0.040). However, length of hospital stay and overall morbidity were higher at splenectomy with extra-gastric cancer group, (p = 0.036 and p = 0.011, respectively). CONCLUSION: Splenectomy during gastric cancer surgery is more demanding; and requires more erythrocyte suspension. However, these patients had less morbidity tendencies. Length of stay was longer with splenectomy during extra-gastric abdominal cancer group. KEY WORDS: Splenectomy, Gastric cancer, Length of stay, Morbidity.

Factors Affecting Morbidity, Mortality, and Recurrence in Incarcerated Femoral Hernia.

OBJECTIVE: To ascertain the factors that govern morbidity, mortality, and recurrence in incarcerated femoral hernia. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of General Surgery, Faculty of Medicine, Van Yuzuncu Yil University, Van, Turkey, between January 2010 and January 2020. METHODOLOGY: This observational study included patients operated on due to incarcerated femoral hernias under emergency conditions. The preoperative, intraoperative, and postoperative parameters of the patients were gathered. The study excluded pregnant patients and patients in the pediatric age group (0‒18 years). Mann-Whitney U-test was used to compare quantitative variables. In addition, a Chi-square test and Likelihood-ratio test were used to compare the qualitative variables. A p-value <0.05 was deemed statistically significant. RESULTS: The mean age of the 50 patients was 54.56 ± 19.34 (19‒91) years and the female/male ratio was 33:17. The morbidity, mortality, and recurrence rates of the study were 14%, 4%, and 6% respectively. Higher morbidity was observed in patients who had preoperative nausea (p = 0.003), vomiting (p <0.001), tachycardia (p <0.001), recurrent hernia (p <0.001), surgery under general anesthesia (p <0.001) or who underwent both laparotomy (p = 0.007) and visceral resection during surgery (p <0.001). Higher rates of mortality were observed in patients who had preoperative tachycardia (p = 0.054) or visceral resection during surgery (p = 0.029). However, the study identified no factors affecting recurrence. CONCLUSION: In cases of incarcerated femoral hernia, symptoms of intestinal obstruction or signs of strangulation are more important in the development of postoperative morbidity. In addition, the probability of mortality is higher in patients who had preoperative tachycardia and in patients who underwent visceral resection. To the extent possible, regional anesthesia should be preferred in suitable cases. Key Words: Femoral hernia, Laparotomy, Morbidity, Mortality, Recurrence.

Traumatic diaphragmatic ruptures: A multidisciplinary study in a tertiary health center.

Background: In this study, we present diagnostic and therapeutic approaches in diaphragmatic rupture cases secondary to trauma and treated using surgical intervention. Methods: Between March 2010 and December 2020, a total of 24 patients (23 males, 1 female; mean age: 35.0±13.7 years; range, 18 to 61 years) who were operated for traumatic diaphragm rupture were retrospectively reviewed. Preoperative, intraoperative, and postoperative data of the patients were evaluated. Differences between the groups with and without morbidity were analyzed. Results: The mean total length of stay in the hospital was 16.2±10.9 (range, 6 to 56) days. The morbidity rate was 50% (n=12), and the mortality rate was 4.2% (n=1). In the comparison of groups with and without morbidity, three factors were found to be statistically significant: instability at the time of admission (p=0.009), gastrointestinal system perforation regardless of its location (p=0.014), and rib fracture (p=0.027). There was a significant difference in the total length of hospital stay (p=0.045). Conclusion: Patients whose condition is unstable at the time of admission to the emergency room and who have gastrointestinal system perforations and rib fractures are more prone to developing morbidity, which prolongs the duration of hospital stay.

Rectus Sheath Hematoma Due to Low Molecular Weight Heparin in a COVID-19 Patient in Turkey.

This case report presents a large left rectus sheath hematoma (RSH) case developed in a COVID-19 patient who had received no anticoagulant therapy before hospital admission. It discusses the patient's diagnosis and treatment process. A 78-year-old woman was admitted to the ED with acute cough and shortness of breath. On CT scan, the pulmonary findings were consistent with COVID-19 pneumonia. Subcutaneous enoxaparin sodium was started to the patient, in accordance with the COVID-19 treatment guidelines applied in Turkey. On the ninth day after admission, her hemoglobin level decreased to 7.3 g/dL. At that point, her blood pressure was 84/52 mmHg, and her heart rate was 120 beats/min. There was a mass in the left lower quadrant on the physical exam. CT examination of the abdomen and pelvis showed a left inferior RSH approximately 9 cm wide. Enoxaparin sodium was stopped. Vital signs monitoring and fluid replacement were begun. One week after the diagnosis of RSH, a CT of the abdomen and pelvis was performed. The scan showed no significant increase in the size of the hematoma. On the 18th day after admission, the patient was discharged because her hemoglobin value, which was 10.2 g/dL at that point, had not decreased, her vital signs were stable, and her treatment for COVID-19 was completed. From the moment of diagnosis to discharge, the patient required no interventional or surgical procedures.

Treatment of rectus sheath hematomas: Eight years of single-center experience with a review of literature.

BACKGROUND: Rectus sheath hematoma is a rare and frequently misdiagnosed cause of acute abdominal pain. In the management of the patients with rectus sheath hematoma, which are mostly with advanced age and comorbid diseases, positive results can be obtained by avoiding unnecessary surgical procedures with correct diagnosis and treatment approaches. The presented study aims to contribute to the lack of algorithms and optimal treatment strategies in the management of rectus sheath hematoma patients with the description of our experience in their management. METHODS: Patients who underwent treatment with the diagnosis of rectus sheath hematoma between May 2010 and July 2018 were retrospectively analyzed. Demographic characteristics, medical histories, physical and laboratory findings and imaging methods, treatment processes, complications, morbidity, mortality, length of hospitalization and long-term follow-up results were searched. Data were analyzed from patient files, hospital computer registry system and radiology archives. Data analysis was performed using Microsoft Excel and IBM-SPSS-Statistics-24. RESULTS: The mean age of the 31 patients was 63.03 years (24-85 years). The female/male ratio (21/10) was 2.1. The most common presenting sign or symptom was abdominal pain (100%), followed by abdominal wall mass in 25 patients (80.6%). Twenty-five patients (80.6%) were receiving some form of anticoagulation and antiplatelet therapy. Diagnosis was confirmed by Computed Tomography in 11 (45.4%), Ultrasonography in five (16.1%) and Computed Tomography with Ultrasonography in 15 (33.3%). Eight patients (25.8%) were evaluated as Type-1, 10 (32.2%) as Type-2 and 13 (41.9%) as Type-3. Mean International Normalized Ratio (INR) value of patients was 2.59. Bleeding was controlled by surgery in three cases (9.6%). The conservative approach was preferred in 28 cases (90.3%). 29 (93.5%) patients were discharged after an average hospital stay of 7.48 days (4-21). One patient died on the postoperative 5th day and other on the 14th day of conservative treatment (6.45% mortality). The mortality rate of conservatively and surgically treated patients was 3.5% and 33.3%, respectively. CONCLUSION: Rectus sheath hematoma should be suspected in elderly patients using anticoagulants with acute abdominal pain, severe cough attacks and an umbilical palpable or radiologically supported mass. Computed Tomography and Ultrasonography should be performed in case of clinical suspicion. Early and correct diagnosis ensures successful conservative treatment and prevents unneces-sary surgical procedures. In the management of cases where clinician experience is at the forefront, we are hopeful that a new effective algorithm system and guidelines for the diagnosis will be identified after increasing the presentations of case series and experiences.

Evaluation of preoperative and postoperative total serum sialic acid levels in patients with colon cancer.

AIM: The aim of this study was to compare the preoperative and postoperative (48th hour) total serum sialic acid levels of the patients with colon cancer and to investigate if the total serum sialic acid levels can be used as a tumor marker in colon cancer. METHODS: Preoperative and postoperative (48th hour) total serum sialic acid levels of 100 patients that were diagnosed with colon cancer and 70 healthy individuals were examined. All total serum sialic acid levels were determined by the methods of Warren. RESULTS: Total sialic acid levels of both patient groups were significantly higher when compared to the control group (p<0.0001). Also, highly significant difference was found between preoperative and postoperative total serum sialic acid levels (p<0.001). CONCLUSION: Evaluation of total serum sialic acid levels may play a critical role in colon cancers. Total serum sialic acid levels may serve as a non-invasive tool for early diagnosis of colon cancer. KEY WORDS: Colon cancer, Preoperative, Postoperative, Total sialic acid.