Optimizing the Personalized Care for the Management of Rectal Cancer: A Consensus Statement.

Colorectal cancer is the third most common cancer in Turkey. The current guidelines do not provide sufficient information to cover all aspects of the management of rectal cancer. Although treatment has been standardized in terms of the basic principles of neoadjuvant, surgical, and adjuvant therapy, uncertainties in the management of rectal cancer may lead to significant differences in clinical practice. In order to clarify these uncertainties, a consensus program was constructed with the participation of the physicians from the Acibadem Mehmet Ali Aydinlar and Koç Universities. This program included the physicians from the departments of general surgery, gastroenterology, pathology, radiology, nuclear medicine, medical oncology, radiation oncology, and medical genetics. The gray zones in the management of rectal cancer were determined by reviewing the evidence-based data and current guidelines before the meeting. Topics to be discussed consisted of diagnosis, staging, surgical treatment for the primary disease, use of neoadjuvant and adjuvant treatment, management of recurrent disease, screening, follow-up, and genetic counseling. All those topics were discussed under supervision of a presenter and a chair with active participation of related physicians. The consensus text was structured by centralizing the decisions based on the existing data.

Comparative study between ghost ileostomy and defunctioning ileostomy in terms of morbidity and cost-effectiveness in low anterior resection for rectal cancer.

PURPOSE: The aim of this study was to compare ghost ileostomy (GI) and defunctioning ileostomy (DI) in patients who underwent low anterior resection (LAR) for rectal cancer in terms of postoperative morbidity, rehospitalization rates, and total costs. METHODS: Patients with an anastomosis level between 5 and 10 cm from the anal verge after LAR were analyzed retrospectively. Clinical characteristics, operative outcomes, postoperative morbidity, rehospitalization rates, and total costs were compared. RESULTS: A total of 123 patients were enrolled as follows: 42 patients in the GI group and 81 patients in the DI group. Anastomotic leakage (AL) was identified in three patients who underwent GI, and in all of them, GI was easily converted to DI. There were 96.3% of the patients with DI rehospitalized at least one time because of surgery-related and/or stoma-related complications or stoma closure. When we did not take into account the patients who were rehospitalized for stoma closure, the rates of rehospitalization were 4.7% and 22.2% in the GI and DI groups, respectively (P= 0.01). The mean total costs calculated by removing additional surgical procedures and adding all of the rehospitalization costs were 25,767 USD and 41,875 USD in the GI and DI groups, respectively (P= 0.0001). CONCLUSION: GI may be a safe and cost-effective method in patients who underwent LAR with low or medium risk factors for AL. It is possible to avoid unnecessary ileostomy and reduce unwanted outcomes due to it, such as postoperative complications, rehospitalizations, and increased total costs by performing GI.

A new technique of doppler dearterialization for hemorrhoidal disease: arterial detection ligation (ADL).

PURPOSE: We describe the arterial detection ligation (ADL) technique, designed to find arteries at time-appropriate depth for ligating, and report our preliminary results of using this technique to treat patients with the hemorrhoidal disease (HD). METHODS: The subjects of this retrospective analysis were patients with symptomatic grades 2 or 3 HD. We analyzed the clinical characteristics, postoperative complications, recurrence, and patient satisfaction of the patients treated with ADL. RESULTS: A total of 75 patients were included in the study (male/female ratio 1.88; mean age 48 ± 19 years; mean BMI 24 ± 3 kg/m2). Thirty-nine patients (52%) did not require hospitalization and were discharged from the day clinic approximately 4 h postoperatively. Four patients (5.3%) suffered tenesmus for about 1 week postoperatively and two (2.7%) suffered temporary rectal bleeding. The mean VAS scores 1 day postoperatively, then at 1 week, 1 month and 1 year were 2.9, 1.5, 0.4, and 0, respectively. At the 1-month follow-up, there was no sign of recurrence and the satisfaction rate was 78.6% (n = 59). At the 1-year follow-up, three patients (4%) had a recurrence and the satisfaction rate was 86.7% (n = 65). CONCLUSION: Based on our preliminary findings, ADL is an effective technique for treating HD, generally as an outpatient procedure, without serious morbidity. We anticipate that the incidence of tenesmus, which is encountered frequently after other dearterialization methods, will be lower after the ADL technique, which avoids both mass ligation of hemorrhoidal arteries deeper than 12 mm and running a long mucopexy suture line.

Hyperthermic intraperitonal chemotherapy is an independent risk factor for development of acute kidney injury.

PURPOSE: Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) or hyperthermic intrapleural chemotherapy (HIC) has been established as the new treatment modality for selected patients with peritoneal and pleural malignancies. The purpose of the study was to compare the development of acute kidney injury (AKI) in patients who received intravenous cisplatin alone, HIPEC and underwent surgery. METHODS: This retrospective study included 104 patients who underwent different therapeutic procedures including systemic cisplatin, surgery and HIPEC or HIC using cisplatin for the treatment of peritoneal carcinomatosis from a variety of primary tumors at Koc University Hospital and American Hospital between January 2015 to December 2017. RESULTS: AKI developed in 18 (17.3%) patients. Baseline creatinine was significantly increased in 3 groups after therapies. The development of AKI was highest in patients treated with HIPEC compared to patients treated with intravenous cisplatin and patients who underwent surgery. AKI developed 31.2% in the HIPEC group (10 of 32 patients), 11.7% in the surgery group (4 of 34 patients) and 10.5% in intravenous cisplatin group (4 of 38 patients), respectively (p 0.04). CONCLUSION: HIPEC may not be so safe with regard to kidney function. Every attempt should be taken to decrease kidney damage during this procedure.

Laparoscopic Total Extraperitoneal (TEP) Inguinal Hernia Repair Using 3-dimensional Mesh Without Mesh Fixation.

BACKGROUND: Approximately one fifth of patients suffer from inguinal pain after laparoscopic total extraperitoneal (TEP) inguinal hernia repair. There is existing literature suggesting that the staples used to fix the mesh can cause postoperative inguinal pain. In this study, we describe our experience with laparoscopic TEP inguinal hernia surgery using 3-dimensional mesh without mesh fixation, in our institution. MATERIALS AND METHODS: A total of 300 patients who had undergone laparoscopic TEP inguinal hernia repair with 3-dimensional mesh in VKV American Hospital, Istanbul from November 2006 to November 2015 were studied retrospectively. Using the hospital's electronic archive, we studied patients' selected parameters, which are demographic features (age, sex), body mass index, hernia locations and types, duration of operations, preoperative and postoperative complications, duration of hospital stays, cost of surgery, need for analgesics, time elapsed until returning to daily activities and work. RESULTS: A total of 300 patients underwent laparoscopic TEP hernia repair of 437 inguinal hernias from November 2006 to November 2015. Of the 185 patients, 140 were symptomatic. Mean duration of follow-up was 48 months (range, 6 to 104 mo). The mean duration of surgery was 55 minutes for bilateral hernia repair, and 38 minutes for unilateral hernia repair. The mean duration of hospital stay was 0.9 day. There was no conversion to open surgery. In none of the cases the mesh was fixated with either staples or fibrin glue. Six patients (2%) developed seroma that were treated conservatively. One patient had inguinal hernia recurrence. One patient had preperitoneal hematoma. One patient operated due to indirect right-sided hernia developed right-sided hydrocele. One patient had wound dehiscence at the umbilical port entry site. Chronic pain developed postoperatively in 1 patient. Ileus developed in 1 patient. CONCLUSIONS: Laparoscopic TEP inguinal repair with 3-dimensional mesh without mesh fixation can be performed as safe as repair with tack fixation.

Use of smooth muscle plasty after intersphincteric rectal resection to replace a partially resected internal anal sphincter: long-term follow-up.

PURPOSE: Patients with very low rectal cancer were treated by intersphincteric rectal resection employing partial internal anal sphincter resection. They then underwent smooth muscle plasty to restore internal anal sphincter function. We assessed the functional and oncological outcomes. PATIENTS AND METHODS: Patients were selected if their biopsies revealed well-differentiated or moderately well-differentiated very low rectal tumors with distal tumor margins that permitted preservation of part of the internal anal sphincter. Functional results after closing the loop ileostomy were assessed by use of a standardized questionnaire. Continence was evaluated by use of the Kirwan score. RESULTS: Forty-seven patients with T2 to T3 very low rectal carcinomas underwent intersphincteric rectal resection and smooth muscle plasty that extended into the anal canal. All received neoadjuvant treatment. Postoperative morbidity was 38.3%. There were 46 R0 resections based on frozen section analysis; one patient achieved an R0 resection after reexcision of a positive distal margin on the frozen section. The median follow-up period was 67.2 months. One patient had local recurrence. The five-year overall and disease-free survival rates were 85% and 82%, respectively. Six months, one year, and two years after intersphincteric rectal resection, 80%, 87%, and 89%, respectively, had good continence (Kirwan I and II). Evacuation difficulty was detected in two patients with colonic S-pouches. CONCLUSION: Providing neodjuvant treatment and preserving at least half of the functional internal anal sphincter mass produces acceptable oncological and functional outcomes in patients undergoing intersphincteric rectal resection for very low rectal cancer. However, whether smooth muscle plasty further improves postoperative continence should be tested by further studies.

Early vs. delayed closure of temporary covering ileostomy: a prospective study.

BACKGROUND/AIMS: Temporary loop ileostomies constructed to protect distal anastomoses are generally closed at 8 to 12 weeks, a period long enough to encounter stoma-related complications, which reduces the quality of life. Early closure may be considered to overcome these adverse effects. This prospective study was designed to investigate the reliability of early closure of loop ileostomies. METHODOLOGY: Fifty consecutive patients were sequentially distributed either to group A (delayed closure) or group B (early closure). Anastomotic integrity was examined before closure in all patients. RESULTS: There were 25 patients in each group who were comparable in terms of age, sex, comorbid conditions, primary pathology, and tumor stage. Early closure was achieved in 88% (n=22) of the patients in group B. Stoma-related complications were significantly greater in group A patients (44% vs. 16%) (p<0.05) while the complications following closure were similar in both groups (16% vs. 8%) (p>0.05). CONCLUSIONS: Early closure during the same hospital admission produces less stoma-related complications with similar accomplishment as the late closure. Early closure of temporary ileostomy is recommended in suitable patients without anastomotic complications.

A rare case of splenic infarct presenting with acute abdominal pain due to polyarteritis nodosa: case report and review of the literature.

A 44 year-old man presented to the Emergency Department of American Hospital with severe pain persisting in the left upper quadrant for several hours. A computed tomographic scanning (CT scan) and celiac digital substraction angiography (DSA) of the abdomen demonstrated a splenic infarct. Histopathological examinations showed diffuse acute vasculitis, thrombosis, panvasculitis which led us to diagnose the case as "polyarteritis nodosa". The diagnosis is usually difficult to establish and it is usually delayed due to variable clinical manifestations dependent on the site and the extent of arterial involvement.