Gastric pouch cancer after mini gastric bypass surgery: The first case report.

Development of gastric cancer following bariatric surgery is very rare. Nearly all patients with cancer after mini gastric bypass/one anastomosis gastric bypass have carcinoma in their remnant stomach. This is the first case with the development of gastric cancer in the gastric pouch following mini gastric bypass surgery. Our case was a 32-year-old woman who was admitted to our department with oral intolerance 5 years after mini gastric bypass. In her endoscopic examination, an ulcerovegetan mass in the gastric pouch (Siewert type III) was detected. The pathological examination of the biopsies was reported as low differentiated adenocarcinoma. Clinical staging was performed using Positron emission tomographycomputed tomography (PET-CT) and endoscopic ultrasonography (T3N1M0). Following four cycles of neoadjuvant chemotherapy, en-bloc total gastrectomy, D2 lymph node dissection, and partial small intestine resection were performed. In pathological evaluation, no tumors were detected in the specimen and a total of 38 lymph nodes were dissected. This finding was accepted as a pathologic complete response. Signs and symptoms such as anemia, oral intolerance, and vomiting that develop after bariatric surgery can often be attributed to the surgical procedure performed, but it should be kept in mind that similar symptoms may also be associated with malignancy. In case of clinical suspicion, endoscopic examination and cross-sectional imaging should be performed.

Is extereme cytoreductive surgery beneficial to survival in malignant peritoneal mesothelioma?

INTRODUCTION: Malign peritoneal mesothelioma (MPM) is an uncommon disease that is difficult to treat. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) are the gold standards for treating MPM. Sometimes extreme cytoreductive surgery (eCRS) is required to achieve complete cytoreduction, which is one of the most important prognostic factors. There is limited information in the literature about the contribution of eCRS in patients with MPM. In this study, we aimed to investigate the impact of eCRS on survival and perioperative outcomes. METHODS: The Department of Surgical Oncology at Cumhuriyet University database was retrospectively reviewed for MPM patients who underwent CRS-HIPEC between January 2004 and December 2018. Patients who underwent CRS-HIPEC were divided into eCRS and less extensive CRS (leCRS) groups. A resection of ≥5 organs or ≥3 small bowel anastomoses were defined as eCRS. Both groups were compared regarding survival, demographic information, and perioperative outcomes. RESULTS: A total of 31 patients were included. eCRS-HIPEC was used in 15 patients. Complete cytoreduction (CC score 0/1) was achieved in all 31 patients. Compared to leCRS, the eCRS group had a longer median length of stay, longer intensive care unit stay, a higher median peritoneal cancer index (PCI), higher intraoperative blood loss, more frequent occurrence of any complication, and a longer operative time (all p values < 0.001). Clavien Dindo 3-4 complications, ASA, and gender were similar in both groups of patients (p > 0.05). It was found that there was no significant difference between the OS of the eCRS and leCRS groups (37.5 vs. 42.8 months, p = 0.895). CONCLUSIONS: Rates of serious complications and morbidity are similar in patients undergoing eCRS compared to leCRS. In patients with high PCI and multiorgan involvement, complete cytoreduction can be achieved by performing eCRS, and survival results equivalent to those with low PCI can be achieved.

The Role of Axillary SUVmax in 18F-FDG PET/CT in Predicting the Number of Axillary Metastases of Breast Cancer.

OBJECTIVE: To investigate the role of positron emission tomography/computed tomography (PET-CT) in determining the maximum number of axillary lymph node metastasis (ALNM) detectable in sentinel lymph node biopsy (SLNB). STUDY DESIGN: Observational study. Place and Duration of the Study: Sivas Cumhuriyet University Faculty of Medicine, Turkiye, from January 2015 to August 2021. METHODOLOGY: A total of 104 breast cancer patients who underwent surgery after a PET-CT scan were examined. A receiver operating characteristic (ROC) analysis was utilised to determine optimal cut-off values for the standardised uptake values of the primary tumour (pSUVmax) and axillary lymph nodes (nSUVmax) in the presence of ALNM and the presence of more than two ALNMs. RESULTS: The presence of more than two ALNMs was associated with pSUVmax, nSUVmax, LVI, and the number of LNs detected on PET-CT. In the ROC analysis, for the ability to predict more than two ALNMs in SLNB/axillary lymph node dissection (ALND), cut-offvalues were calculated as 4.65 for pSUVmax (AUC=0.669, sensitivity=66.7%, specificity=62%, PPV=0.482, NPV=0.800, p=0.006) and 1.75 for nSUVmax (AUC=0.838, sensitivity=81.8%, specificity=88.7%, PPV= 0.676, NPV=0.913, p<0.001). CONCLUSION: Low sensitivity, NPV, and accuracy values that limit the use of PET-CT in preoperative axillary evaluation can be increased by targeting the criterion of more than two ALNMs. Thus, PET-CT can be used more effectively in axilla management. KEY WORDS: Breast cancer, Positron emission tomography, SUVmax values, Axillary lymph node, ACOSOG Z0011.

Is complete mesocolic excision or total mesorectal excision necessary during cytoreductive surgery in ovarian peritoneal carcinomatosis with colonic involvement?

INTRODUCTION: Cytoreductive surgery (CRS) and intraperitoneal chemotherapy are effective in the treatment of ovarian peritoneal carcinomatosis (OPC). Colon resection is often required to achieve maximal cytoreduction during CRS. The success of complete mesocolic excision (CME) and total mesorectal excision (TME) in the surgical treatment of primary colorectal tumors is well-known. Our study aimed to investigate the factors affecting mesocolic lymph node metastasis (MLNM) and the contribution of CME/TME techniques to maximal cytoreduction in patients diagnosed with ovarian peritoneal carcinomatosis (OPC) with colon metastasis. PATIENTS AND METHODS: Between 2004-2020, 30 patients who underwent colorectal resection with CME/TME techniques due to OPC-related colon metastasis were retrospectively analyzed. RESULTS: The median age of patients was 61 (33-86). Six (20%) patients underwent total colectomy, 7 (23%) subtotal colectomy, 6 (20%) right hemicolectomy, 4 (13%) left hemicolectomy, and 7 (23%) rectosigmoid resection. Histopathological diagnosis was high-grade serous carcinoma in 29 (97%) patients, and malignant mixed Mullerian tumor in 1 (3%) patient. MLNM was detected in 17 (56%) of 30 patients. There was a significant relationship between MLNM and pelvic and para-aortic lymph node metastasis (PALNM) (p = 0.009) and lymphovascular invasion in primary ovarian tumors (p = 0.017). There was no significant relationship between MLNM and depth of colonic invasion (p = 0.463), histological grade (p = 0.711), and primary/secondary surgery (p = 0.638). MLNM was seen in 8 (47%) of 17 patients with only serosal invasion. CONCLUSION: A high rate of MLNM can be seen in OPC-induced colon metastasis regardless of the degree of colon wall invasion. In patients with PALNM, the frequency of MLNM increases. We believe that if colon resection is to be performed in OPC, a colectomy should be performed by CME/TME principles to achieve maximal cytoreduction.

Is diabetes onset at advanced age a sign of pancreatic cancer?

AIM: Pancreatic cancer is the 11th most common cancer in the world. The importance of early diagnosis and treatment for curative treatment is very high. Many studies have shown a relationship between diabetes mellitus (DM), smoking, genetic factors, obesity, nutritional habits and sedentary life and pancreatic ductal adenocarcinoma (PDAC). In this study, we aimed to investigate the relationship between DM onset age and PDAC. MATERIALS AND METHODS: 158 patients with PDAC and DM were compared with 244 patients with DM in the control group. We retrospectively analyzed PDAC risk factors with a focus on DM onset age. RESULTS: It was calculated that the risk of PDAC increased 8.5 times in patients diagnosed with DM after 60 years of age compared to those diagnosed with DM before 60 years of age (HR = 8.54, 95% CI 5.66-12.90, p<0.0001). The interval between the diagnosis of DM and the diagnosis of PDAC peaked at 32 months (95% CI 27.90-35.56). When the age of DM onset was evaluated, it was observed that peaks were around 50 years in the group without PDAC and 60 years in the group with PDAC. CONCLUSION: In patients with DM onset after the age of 60, we recommend keeping in mind the increased risk of PDAC and evaluating these patients for PDAC, even if they are asymptomatic. KEY WORDS: Diabetes, Early detection of cancer, New onset diabetes, Pancreatic cancer, Relative risk, Screening.

Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy Experience in Peritoneal Carcinomatosis: Single-Center Analysis of 180 Cases.

BACKGROUND: In peritoneal carcinomatosis (PC), increased life span and disease-free survival times are shown in patients with hyperthermic intraperitoneal chemotherapy (HIPEC) and early postoperative intraperitoneal chemotherapy (EPIC) following cytoreductive surgery (SRC). In this study, our main objective was to present our experience of performing SRC and perioperative intraperitoneal chemotherapy (HIPEC and EPIC) on patients with PC, in light of the literature. METHODS: Demographic data, follow-up results, peritoneal carcinomatosis index (PCI), completeness of cytoreduction (CCR) score, and morbidity and mortality rates of 180 patients treated with SRC + HIPEC + EPIC for PC at the Department of Surgical Oncology at Sivas Cumhuriyet University between January 2008 and July 2020 were analyzed retrospectively. RESULTS: Distribution of 180 PC cases according to primary organs included 53 ovarian, 39 colorectal, 33 stomach, 25 primary peritoneum, 10 uterus, 10 tuba, five soft tissue, and five appendix originated carcinoma. The average PCI of the cases detected preoperatively was 21 (5-30). Completeness of cytoreduction scores of CCR-0 in 102 cases, CCR-1 in 67 cases, CCR-2 in eight cases, and CCR-3 in three cases was obtained. Median operation time was 300 (200-540) minutes. Perioperative morbidity rate was 47.0%, and perioperative mortality rate was 13.5%. CONCLUSION: The peritonectomy procedure is a difficult, long-lasting, troublesome intervention, but it is the most important treatment option with acceptable morbidity and mortality rates in patients selected for PC treatment in experienced centers.

Comparision of Hem-o-lok polymeric clip and tri-staple in laparoscopic splenectomy.

AIM: This study aimed to compare the hem-o-lok polymeric clip (HC) and tri-staple (TS) methods used in dividing the splenic hilum in terms of results, and to reveal their superiority to each other. MATERIAL AND METHODS: Medical records of patients undergoing elective laparoscopic splenectomy at the Ondokuz Mayis University Faculty of Medicine General Surgery Clinic between March 2011 and March 2020 were retrospectively analyzed. Forty-two laparoscopic splenectomy cases performed using hem-o-lok polymeric clip (HC) or tri-staple (TS) were included in this study. Demographic features, primary diagnoses, splenic size, intraoperative data and postoperative complications, as well as the clip and stapler prices used in the surgery were analyzed. RESULTS: The mean operative time was significantly longer for HC group than TS group (116.7 min vs. 87.6 min, p<0.05). The mean cost of surgical instruments used to divide the splenic hilum was significantly lower for HC group than TS group (34.1 usd vs. 165.4 usd, p<0.05). There was no postoperative mortality, with a morbidity rate 6 (26.1%) for TS group and 4 (21.1%) for HC group (p>0.05). No significant difference existed in the complication rates. CONCLUSIONS: In the HC group, the operation time was longer, but the surgical cost was significantly lower. There was no significant difference when comparing other perioperative results. Although both techniques can be applied safely, we would like to emphasize that hemostasis is the most important factor for good results. KEY WORDS: Hem-o-lok polymeric clip, Laparoscopic splenectomy, Tri-staple.

Novel RET Proto-oncogene variants identified in Turkish patients with thyroid carcinoma.

Thyroid cancer is one of the few malignancies whose incidence is increasing in the last decades. Advances in understanding the molecular mechanisms lead to provide opportunity for prevention, effective early identification and targeted therapies for management. A total of 63 patients with participated in this study Genomic DNA samples were obtained from the samples formalin- embedded tissue and peripheral blood. Following polymerase chain reaction amplification of the 6 RET key exons (10, 11, 13, 14, 15, and 16) were applied and PCR products were subjected to next generation DNA sequencing (ABI 3730). Results revealed that; genotype frequencies were for rs1800961 (G > T) , GG 6 (%9.5), GT 17 (%27) TT40 (%63.5) for rs2472732 (G > A), GG31 (%49.2) GA29 (%46) AA3 (%4.8,) for rs1799939, (G > A) GG42 (%66.7) GA19 (%30.2) AA2 (%3.2), for rs1800962, (C > T) CC54 (%85.7) CT9 (%14.3), for rs1800863 (C > G), CC39 (%61.9) CG22 (%34.9) GG2 (%3.2), for rs3026272 (C > G) CC 13 (%20.6) CG 50 (%79.4). Additionally 15 potential novel genetic variants were identified in these key exons. Detailed information was given both known and new detected variants in supplementary table. Genetic variants distribution frequencies and new variants represented in Turkish thyroid cancer patients for RET proto-oncogene and that results would provide contribution to the literature.

Efficacy of Ultrasound and Shear Wave Elastography for the Diagnosis of Breast Cancer-Related Lymphedema.

OBJECTIVES: To assess the feasibility of ultrasound and shear wave elastography (SWE) in the diagnosis of breast cancer-related lymphedema. METHODS: Forty-one patients with a history of unilateral breast surgery and axillary dissection or sentinel lymph node excision were included in this prospective study. The patients were classified as having normal findings, latent lymphedema, and clinical lymphedema on the basis of a physical examination, lymphedema index scores, and limb circumference measurements. The thickness and stiffness of the cutaneous and subcutaneous tissue of the forearm and arm were measured by ultrasound and SWE. The thickness and stiffness of the cutaneous and subcutaneous tissue of the affected limb and contralateral limbs of the normal, latent lymphedema, and clinical lymphedema groups were compared. RESULTS: The mean age ± SD of the 41 patients was 55.42 ± 10.12 years. There were 15 patients with normal findings, 10 with latent lymphedema, and 16 with clinical lymphedema. In the latent lymphedema group, the thickness measurements of the cutaneous tissue of the affected forearm and the cutaneous and subcutaneous tissue of the affected arm were significantly greater than those of the contralateral forearm and arm (P = .034; P = .022; and P = .002, respectively), and the stiffness measurements of the cutaneous and subcutaneous tissue of the affected forearm were significantly greater than those of the contralateral forearm (P = .011; and P = .002). In the clinical lymphedema group, the thickness and stiffness measurements of the cutaneous and subcutaneous tissue of the affected forearm and arm were significantly greater than those of the contralateral limb (P < .001-P = .032). CONCLUSIONS: Ultrasound and SWE are effective for diagnosing breast cancer-related lymphedema even at a latent stage.

Early Diagnosis of Lymphedema after Breast Cancer Treatment: Bio-Impedance Spectroscopy.

OBJECTIVE: Breast cancer-related lymphedema is an important health problem. The aim of this study is to ensure early diagnosis of patients at risk of developing lymphedema and revealing the predisposing factors. MATERIALS AND METHODS: Measurements in the pre-operative period and in postoperative months 3, 6, 9 and 12 and years 2 and 3 were performed prospectively with bio-impedance spectroscopy for patients treated for breast cancer between November, 2013 and November, 2016. Demographic and clinical-pathological data of the patients were investigated to assess the factors that affect the development of lymphedema. RESULTS: 245 measurements were obtained from the 67 patients who participated in the study. 18 (26.8%) patients were diagnosed with lymphedema and 16 (89%) of these patients were clinically diagnosed with stage 0 and 2 (1%) patients with stage 1 lymphedema. The median age was 50.7 (32-77) years. Performing axillary dissection and positivity in more than 3 nodes were found to be statistically significant with a percentage of 63.3% (n=15) and 64.7% (n=11) p=0.049 and p<0.001, respectively. CONCLUSION: Periodic measurements with bio impedance spectroscopy can be an effective method to diagnose early stage lymphedema after breast cancer, and enable selecting the group of patients who would benefit from early treatment.

A Pancreatic Fistula after the Laparoscopic Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is a popular surgical weight-loss procedure in the treatment of morbid obesity. There are some complications regarding this procedure in the literature. This report presents a pancreatic fistula (PF) case, which has not been previously seen.