Ultrasonography Guided Modified BRILMA (Blocking the Cutaneous Branches of Intercostal Nerves in the Middle Axillary Line) Block in Bariatric Surgery.

Background: Postoperative pain is one of the major problems after laparoscopic sleeve gastrectomy besides complications. Management of pain control is still unclear in the obese population. Modified BRILMA (blocking the cutaneous branches of intercostal nerves in the middle axillary line) is a new analgesia technique which is performed by ultrasonography guided through the way between eighth and ninth rib level. This study is to evaluate the efficiency of modified BRILMA in bariatric patients while comparing with trocar site infiltration. Materials and Methods: This is a prospective designed retrospective data analysis study. Patients undergoing laparoscopic sleeve gastrectomy between June 2019 and January 2020 were divided into two groups. One group underwent BRILMA block; the other group used traditional trocar site injection. Postoperative pain was followed by using visual analogue scale (VAS) (at 1, 3, 6, 12, 24, 36, 48 hours postoperatively). Results: Thirty patients were included in the study. Twenty-four (80%) of the patients were women, and 6 (20%) of the patients were men. Mean body mass index of patients were 39.83 ± 4.02 kg/m2. Mean operational time was calculated 86.16 ± 19.94 minutes. When the patients' VAS was compared, 12th hour VAS value was statistically less in the BRILMA group. There were no significant differences in other hours' VAS between two groups. When compared with the use of opioid amount, there were no statistically significant difference between the two groups (P = .66), but BRILMA group had less amount. Conclusion: Modified BRILMA is an alternative technique to the use of trocar site bupivacain injection in bariatric surgery. It is new technique that is tried in bariatric population, which is also cost-effective and has less opioid consumption.

Effect of Acellular Amniotic Membrane Matrix Patch on Healing of Cut Surface After Sleeve Gastrectomy in Rats.

Background: The aim of this study was to evaluate the effect of acellular amniotic membrane matrix patch on healing cut surface after sleeve gastrectomy in rats. Methods: Thirty male Wistar albino rats were divided into three groups: control (n = 10), Experiment-1 (n = 10), and Experiment-2 (n = 10) groups. Control group rats underwent only sleeve gastrectomy with primary gastrorrhaphy. Experiment-1 group rats underwent sleeve gastrectomy, primary gastrorrhaphy and covered with acellular amniotic membrane matrix patch. Experiment-2 group rats underwent sleeve gastrectomy, incomplete primary gastrorrhaphy and covered with acellular amniotic membrane matrix patch. All rats were sacrificed on the fifth postoperative day. Macroscopic findings and histopathologic alterations were evaluated and compared. Results: There was a statistically significant difference between levels of PMNs, granulation formation and vascularization, distributions of edema, type of mucosal epithelium, and fibroblastic proliferation according to groups (p < 0.05). The PMNs level in the Experiment-1 group was significantly lower than the control group (p < 0.05). In experiment groups, the level of granulation tissue, vascularization and fibroblastic proliferation was significantly higher than the control group (p < 0.05). The levels of edema and type of mucosal epithelium of the experiment groups were significantly lower than the control group (p < 0.05). Conclusion: Covering sleeve gastrectomy cut surface area with acellular amniotic membrane matrix results better healing. Moreover, acellular amniotic membrane matrix provides safe healing even in incomplete sutured area.

Pancreatic extragastrointestinal stromal tumor invading the duodenum.

Extragastrointestinal stromal tumors that arise in the pancreas are extremely rare and managing them can be difficult, particularly if located in the head of pancreas. This case report aims to contribute to the existing data in the literature regarding extragastrointestinal stromal tumors with rare and unusual locations. We present a 56-year-old man who presented with recurrent mild right upper quadrant abdominal pain. Abdominal computed tomography and magnetic resonance imaging revealed a mass lesion with a diameter of 10 cm localized in the head of pancreas. Pancreaticoduodenectomy with complete tumor excision was performed. He was discharged on the postoperative day 14. Only 15 extragastrointestinal stromal tumors cases have been reported. Of these 15 cases, tumors were located in the head of pancreas in six cases. Here we report the seventh case of pancreatic extragastrointestinal stromal tumor arising in the head of pancreas and also the largest of these seven tumors.

Effects of melatonin on colonic anastomosis healing following chemotherapy in rats.

INTRODUCTION: This study aimed to investigate the effects of melatonin on the healing of colon anastomosis following chemotherapy. METHODS: 32 rats were randomised into four groups: (a) control group, which underwent sigmoid colon transection and primary anastomosis; (b) melatonin group, which received melatonin daily following anastomosis; (c) 5-fluorouracil (5-FU) group, which received 5-FU for five days prior to anastomosis; and (d) 5-FU+melatonin group, which received 5-FU for five days prior to anastomosis and melatonin daily following anastomosis. The rats were sacrificed on Postoperative Day 7 and anastomotic bursting pressures were measured. The anastomotic segment was extracted for hydroxyproline, luminol and lucigenin measurement and histopathological examination. Blood samples were obtained from the vena cava for measurement of tumour necrosis factor-alpha (TNF-α) and interleukin-1 beta (IL-1ß) plasma levels. RESULTS: Compared to the 5-FU group, bursting pressures of anastomosis and hydroxyproline levels were significantly higher, while luminol and lucigenin levels were significantly lower, in the control and 5-FU+melatonin groups. In addition, TNF-α and IL-1ß plasma levels were significantly lower in the control and 5-FU+melatonin groups than in the 5-FU group. Histopathological examination showed a significant decrease in inflammation and necrosis formation in the melatonin group when compared to the control group. The positive effect of melatonin was also seen in the rats that received 5-FU. CONCLUSION: Our study results showed that the adverse effects of chemotherapy on the mechanical, biochemical and histopathological parameters of anastomosis healing were attenuated through melatonin treatment.

Preoperative immunonutrition regulates tumor infiltrative lymphocytes and increases tumor angiogenesis in gastric cancer patients.

INTRODUCTION: An increased number of tumor infiltrative lymphocytes (TILs) is considered a favorable prognostic factor in various cancers because it is a marker of antitumoral activity of the immune system. In this prospective, non-randomized clinical trial, we evaluated the impact of preoperative immunonutrition on tumor infiltrative lymphocytes and neoangiogenesis in cancerous tissue in patients with locoregional and resectable gastric adenocarcinoma. MATERIAL AND METHODS: Patients with locoregional and resectable gastric adenocarcinoma were divided non-randomly into two study groups. The first (control) group included patients who had standard nutrition, and the second group included those who had immunonutrition for 7 days before surgery. The biopsy samples taken endoscopically in the preoperative period, as well as the gastrectomy samples, were subjected to immunohistochemical staining for quantitative analysis of CD4, CD8, CD16, CD56, CD31 and CD105 antibodies. Main outcome measures were CD4-to-CD8 ratio and CD105 levels. RESULTS: Fifty patients were included in the study between January 2013 and December 2014. Twenty-five patients were assigned to each of the first and second group. The CD4-to-CD8 ratio and CD105 levels determined in endoscopic biopsy samples were similar in both groups. The CD4-to-CD8 ratio in gastrectomy samples was significantly higher in the first group (p = 0.0001). The CD105 levels in gastrectomy samples were significantly lower in the first group (p = 0.01). CONCLUSIONS: Seven-day preoperative immunonutrition use regulates TILs in gastric cancer patients, but prolonged use increases tumor angiogenesis.

In vitro effects of rabeprazole on human pylorus tone.

BACKGROUND/AIMS: It has been reported that proton pump inhibitors induce relaxation in different types of smooth muscles. The aim of this study is to investigate in vitro effects of proton pump inhibitors on human pylorus muscle. METHODS: Pyloric sphincters were studied in 10 patients who were operated for stomach cancer. In isolated organ bath, control and re-sponse to rabeprazole were recorded following contraction with carbachol. During the treatment experiment, while distilled wa-ter was applied during the control experiment in every 5 minutes, rabeprazole was administered in every 5 minutes at doses of 10(-6), 10(-5), 10(-4), and 10(-3) M respectively. Contraction frequencies, maximum contraction values and muscle tones were measured. RESULTS: The contraction frequencies in the control group were greater than the rabeprazole group in the second, third and fourth in-tervals while the maximum contraction values in the rabeprazole group were lower in the fourth interval. Even though muscles tones were not different in both groups during all intervals, it was remarkable that the muscle tone was significantly decreased in the rabeprazole group during the fourth interval compared to the first and second intervals. CONCLUSIONS: In the present study, high doses of rabeprazole reduced contraction frequencies, maximum contraction values, and muscle tone of human pylorus.

The impact of PET/CT on the management of hepatic and extra hepatic metastases from gastrointestinal cancers.

PURPOSE: To investigate the efficacy of positron emission tomography/computed tomography (PET/CT) in detection and management of hepatic and extrahepatic metastases from gastrointestinal cancers. MATERIALS AND METHODS: Between February 2008 and July 2010, patients histopathologically diagnosed with gastrointestinal cancer and showing suspected metastasis on CT screening were subsequently evaluated with PET/CT. All patients were subgrouped according to histopathological origin and localization of the primary tumor. Localization of gastrointestinal cancers was further specified as lower gastrointestinal system (GIS), upper GIS, or hepato-pancreato-biliary (HPB). Both accuracy and impact of CT and PET/CT on patient management were retrospectively evaluated. RESULTS: One hundred and thirteen patients diagnosed histopathologically with gastrointestinal cancers were retrospectively evaluated. Seventy-nine patients had adenocarcinoma and 34 patients other gastrointestinal tumors. Forty-one patients were in the upper GIS group, 30 patients in the HPB group, and 42 patients in the lower GIS group. Evaluation the diagnostic performance of PET/CT for suspected metastasis according to histopathological origin of the tumor, revealed that the sensitivity of PET/CT - although statistically not different - was higher in adenocarcinomas than in non-adenocarcinomas (90% (95% CI, 0.78-0.96) vs. 71.4% (95% CI, 0.45-0.88), P=0.86). The specificity was not significantly different (85.7% (95% CI, 0.70-0.93) vs. 85% (95% CI, 0.63-0.94), P=1.00). In the overall patient group; CT was significantly more sensitive than PET/CT for detection of hepatic metastases (94.7% vs. 78.9%, P=0.042), whereas PET/CT was significantly more specific than CT (48% vs. 98.7%, P<0.001). In subgroup analysis, sensitivity was not significantly different (P>0.05) but specificity was significantly higher in PET/CT than CT (P<0.05). The specificity of PET/CT was highest in upper GIS (100%) and HPB (100%) subgroups. In the overall patient group; for detection of extrahepatic metastasis, the sensitivity of CT (75%) and PET/CT (87.5%) showed no significant difference (P=0.437). However, PET/CT was significantly more specific than CT (88.7% vs. 70.4%, P=0.007). In subgroup analysis, no significant difference was found between CT and PET/CT either in sensitivity or in specificity (P>0.05). The specificity of PET/CT was highest in the lower GIS subgroup (93%). The management of 45 patients (39.8%) was revised after PET/CT evaluation. CONCLUSIONS: PET/CT has a higher specificity than CT in detecting suspected hepatic and extrahepatic metastases of gastrointestinal cancers, and has an impact of nearly 40% on changing patient management strategies.

Preoperative serum tumor marker levels in gastric cancer.

OBJECTIVE: Tumor markers have shown little benefit as a method for screening. However, they can be used clinically for the monitoring of tumor recurrence and used as prognostic factors because higher levels have been observed in advanced disease. This study aimed to investigate the relationship between the preoperative tumor marker levels and different clinical aspects of gastric cancer. METHODS: One hundred and six consecutive patients with confirmed diagnosis of gastric cancer and 106 subjects (age and sex matched) with no malignancy as control group were included prospectively in this study in 3 years. The relationships between tumor markers CEA, CA 19-9 and stage of disease, tumor differentiation, presence of ringlet cell type, presence of peritoneal carcinomatozis were investigated. RESULTS: The serum CEA and CA 125 levels were found to be significantly elevated in gastric cancer patients than in controls. The serum level of CEA had showed a significant elevation with the presence of distant metastasis. The CA 19-9 and CA 125 levels had showed significant elevations with the presence of peritoneal carcinomatozis. Conclusions : This study showed that there is a limited clinical benefit of preoperative tumor marker measurements in gastric cancer such as estimation of peritoneal dissemination.

Comparison of propofol-based sedation regimens administered during colonoscopy.

BACKGROUND: The ideal sedative agent for endoscopic procedures should allow a rapid modification of the sedation level and should not have any adverse effects. AIM: To evaluate and compare the efficacy, safety, cost and patient satisfaction of some propofol-based sedation regimens administered during colonoscopy. MATERIAL AND METHODS: One hundred twenty one patients scheduled for elective outpatient colonoscopy with conscious sedation were randomized to four groups to evaluate the administration of dexmedetomidine, sufentanil, meperidine and midazolam in combination with propofol to maintain sedation during the procedure. Evaluated outcomes were efficacy, safety, cost and patient satisfaction of sedation procedures. RESULTS: Patients receiving dexmedetomidine achieved a higher degree of sedation when compared with the other groups (p < 0.05). The lapse to recover protective reflexes and motor function, was significantly shorter in groups receiving dexmedetomidine or sufentanil than in groups receiving meperidine or midazolam (p < 0.05). There were no differences between groups in pre-sedation and post-sedation neurophysiologic performance, measured by the Trail Making A and B tests. CONCLUSIONS: Sedation for endoscopy can be safely and effectively accomplished with low doses of propofol combined with dexmedetomidine, intranasal sufentanil, IV meperidine and IV meperidine with midazolam.

Comparison of propofol-based sedation regimens administered during colonoscopy / Comparación de protocolos de sedación basados en propofol para obtener sedación durante endoscopias

Background: The ideal sedative agent for endoscopic procedures should allow a rapid modification ofthe sedation level and should not have any adverse effects. Aim: To evaluate and compare the efficacy, safety, cost and patient satisfaction of some propofol-based sedation regimens administered during colonoscopy. Material and Methods: One hundred twenty one patients scheduled for elective outpatient colonoscopy with conscious sedation were randomized to four groups to evaluate the administration of dexmedetomidine, sufentanil, meperidine and midazolam in combination with propofol to maintain sedation during the procedure. Evaluated outcomes were efficacy, safety, cost and patient satisfaction of sedation procedures. Results: Patients receiving dexmedetomidine achieved a higher degree of sedation when compared with the other groups (p < 0.05). The lapse to recoverprotective reflexes and motor function, was significantly shorter in groups receiving dexmedetomidine or sufentanil than in groups receiving meperidine or midazolam (p < 0.05). Therewere no differences between groups in pre-sedation and post-sedation neurophysiologic performance, measured by the Trail MakingA and B tests. Conclusions: Sedation for endoscopy can be safely and effectively accomplished with low doses of propofol combined with dexmedetomidine, intranasal sufentanil, IV meperidine and IV meperidine with midazolam.

Antecedentes: El protocolo de sedación ideal para procedimientos endoscópi-cos es aquel que permita efectuar modificaciones rápidas del nivel de sedación y no tenga efectos secundarios. Objetivo: Comparar la eficacia, seguridad, costos y satisfacción del paciente con protocolos de sedación basados en propofol, durante colonoscopias. Material y Métodos: Ciento veinte pacientes programados para una colonoscopia fueron aleatorizados en cuatro grupos en que se evaluó la administración de dexmedetomidina, sufentanil, meperidina y midazolam en combinación con propofol, para mantener la sedación durante el procedimiento. Se evaluó la eficacia, seguridad, costo y satisfacción del paciente con los diferentes protocolos de sedación. Resultados: Los pacientes que recibieron dexmedetomidina, alcanzaron un mayor nivel de sedación que el resto de los grupos. El lapso necesario para recuperar reflejos y funciones motoras protectoras, fue significativamente menor en los grupos que recibieron dexmedetomidina o sufentanil comparado con los grupos que recibieron meperidina o midazolam (p < 0,05). No hubo diferencias entre los grupos en la capacidad neuro-cognitiva, medida con los Tests de Reitan A y B, antes o después de la sedación. Conclusiones: Se puede obtener una buena sedación para endoscopia combinando dosis bajas de propofol con dexmedetomidina, sufentanil intranasal, meperidina endovenosa con o sin midazolam.

The effect of rabeprazole on LES tone in experimental rat model.

INTRODUCTION: Despite adequate treatment with proton pump inhibitors (PPIs), symptoms of gastroesophageal reflux disease (GERD) may remain persistent as well as Barrett's esophagus may emerge. It may be proposed that the relaxant effect of PPIs on the smooth muscles may lead to resistance of symptoms. The aim of this study is to investigate effects of rabeprazole on the lower esophageal sphincter (LES) pressure with a rat model. MATERIALS AND METHODS: Sixteen rats were grouped as control and treatment groups. After obtaining LES tissues followed by a 60 min equilibration period for stabilization, contractile response to carbachol was obtained by application of single dose of carbachol to have a final concentration of 10(-6) M in the organ bath. After the contractions reached a plateau, concentration-response relationships for rabeprazole were obtained in a cumulative manner in the treatment group. RESULTS: In the carbachol contracted LES preparations; 1.5 × 10(-6) and 1.5×10(-5) M of rabeprazole caused 6.08% and 11.34% relaxations respectively which were not statistically significant. However, mean integral relaxation value for 4.5 × 10(-5) M of rabeprazole was 17.34% and this relaxation was significant compared with controls. CONCLUSIONS: In the present study, rabeprazole caused no direct significant change in LES tone in the therapeutic dose range applied to the organ bath. However, rabeprazole at the high dose caused a significant decrease in the LES tone.

Effects of carbon dioxide pneumoperitoneum on hepatic function in obstructive jaundice: an experimental study in a rat model.

BACKGROUND AND AIMS: The physiology of the patient during laparoscopy differs from that of open surgery. Both pneumoperitoneum and obstructive jaundice impair the hepatic function, but the combined insult has not been previously examined. In this study, we aimed to investigate the effects of carbon dioxide (CO(2)) pneumoperitoneum on hepatic function in a rat model of obstructive jaundice. METHODS: Forty-four male Sprague-Dawley rats were divided into four groups: group 1 (n = 10), sham-operated group; group 2 (n = 12), obstructive jaundice group; group 3 (n = 10), CO(2) pneumoperitoneum group; and group 4 (n = 12), obstructive jaundice and CO(2) pneumoperitoneum group. Common bile duct was ligated and divided in the obstructive jaundice groups. After 6 days, a 12-mmHg pneumoperitoneum was induced, maintained for 60 min, and released for 120 min. Blood samples were drawn for the measurement of white blood cell and platelet counts, serum liver enzymes (aspartate aminotransferase [AST], alanine aminotransferase [ALT], total bilirubin). Tissue samples were obtained for analyses of malondialdehyde (MDA), glutathione (GSH), and superoxide dismutase (SOD) levels. We evaluated the degree of liver injury on a grading scale from 0 to 4, histopathologically. RESULTS: Pneumoperitoneum after biliary obstruction resulted in an increase in AST and ALT levels and a decrease in white blood cell and platelet counts. However, changes in liver tissue MDA, GSH, and SOD levels did not correlate with the changes in AST and ALT levels and white blood cell and platelet counts. After sham operation with pneumoperitoneum, the GSH levels in liver homogenate were significantly decreased in the group 3 when compared to the group 2. On the other hand, obstructive jaundice itself caused significant reduction in the SOD activity of liver homogenate in comparison to the group 3. Histopathologically, sinusoidal congestion and vacuolization were more severe in the group 3. CONCLUSIONS: Alterations in hepatic function occur in pneumoperitoneum applied jaundiced subjects. However, there were no statistically significant differences between the groups 2 and 4 with regard to white blood cell and platelet counts, serum liver enzymes including AST, ALT, and total bilirubin values, MDA and GSH levels and SOD activity of liver homogenate, and histologic damage. These results indicate that there is no additional risk on liver function associated with pneumoperitoneum performed in obstructive jaundice.

A rare complication of D3 dissection for gastric carcinoma: chyloperitoneum.

BACKGROUND: Chyloperitoneum is the accumulation of lymphatic fluid in the peritoneal cavity. Although uncommon, it has been reported after retroperitoneal lymph node dissection. But the incidence of this complication after radical gastrectomy is unknown. In the present study, we analyzed our patients who underwent D3 dissection for gastric carcinoma and developed chyloperitoneum. METHODS: Between June 1999 and June 2002, a total of 134 patients with gastric cancer underwent radical lymph node dissection, performed according to the Japanese Research Society for Gastric Cancer guidelines, as the standard procedure for gastric cancer treatment. Of these patients, 34 underwent D3 lymphadenectomy, and chyloperitoneum was detected in 4 of them. RESULTS: There were three male patients and one female patient. All patients were in stage III according to the International Union Against Cancer (UICC)-TNM classification. In three patient, chyle leakage was noticed during the surgery, and surgical ligation of the duct was performed. Abdominal distension developed in one patient 7 days after the surgery, and chylous ascites was diagnosed. This patient was success-fully treated with fasting and total parenteral nutrition, within 2 weeks. CONCLUSION: The incidence of chyloperitoneum is not low, and may increase with more aggressive surgery. Surgeons should be aware of this complication after retroperitoneal lymph node dissection, and injured lymphatics must be controlled and ligated intraoperatively.

Extensive adult colo-colonic intussusception from ascending colon to sigmoid colon: report of a case.

Intussusception in adults is relatively rare. Here we report a 52-year-old man with an extensive colo-colonic intussusception caused by a polypoid mass in the ascending colon. The mass, which was 10 x 8 x 5 cm in size, had been palpated preoperatively and was suspected to be a sigmoid tumor. The patient was treated successfully by reduction of the invagination and subsequent right hemicolectomy.

Epiphrenic diverticulum with abnormal manometry: a case report.

A 50-year-old man was admitted to our hospital with the chief complaints of vomiting and nocturnal cough for one year. His complaints were progressive and had worsened within the last two months. Chest X-ray revealed a right-sided paracardiac opacity. Computed tomography of the thorax showed a supradiaphragmatic mass lesion containing air and solid components. Barium esophagogram revealed a giant distal esophageal diverticulum and hiatal hernia. Stationary manometric examination of the esophagus showed non-specific esophageal motility disorder. The patient underwent a successful abdominal approach diverticulectomy operation and the postoperative course was uncomplicated. There is a high prevalence of esophageal motility abnormalities in patients with epiphrenic diverticula, though they are very rare, and, as in this case, may be difficult to classify.

Laparoscopic treatment of small bowel phytobezoar obstruction.

An intestinal bezoar causing obstruction is usually treated by an open approach, either with manual mechanical fragmentation or with enterotomy and removal of the bezoar. In this article, we report the minimally invasive surgical management of a 59-year-old man in whom a bezoar obstructing the small intestine developed at the site of an adhesion from a previous gastric surgery. The bezoar was laparoscopically broken down and milked through the ileocecal valve. In the future, the laparoscopic approach may be the treatment of choice for patients with a bezoar when surgery is indicated.

Drainage of liver abscess via laparoscopic trocar with local anesthesia.

There are several methods for treatment of liver abscess. These include drainage by open surgery, laparoscopic surgery, or percutaneous catheterization. In this report a new therapeutic approach is presented. A 47-year-old man admitted to the hospital had an abscess 12 cm in diameter, originating from the left liver lobe. After the patient's permission was obtained, a laparoscopic trocar was inserted into the abscess with the patient under local anesthesia in the operating room. A 28-French chest tube catheter was introduced through the trocar cannula, and approximately 1,000 mL of pus was drained. There were no complications, and the patient was discharged on the same day. After computed tomography showed an obliterated abscess cavity, the drain was removed on postoperative day 7. The pus culture, performed on the day of surgery, was found to be positive for Escherichia coli, which was responsive to cefaclor. Oral antibiotic therapy was given for 1 month. At follow-up 2 months after surgery, the patient was asymptomatic. This report describes the first case of a liver abscess drained by a laparoscopic trocar with local anesthesia. This method can be the treatment of choice for some easily accessible liver abscesses.