Mean arterial pressure versus cardiac index for haemodynamic management and myocardial injury after hepatopancreatic surgery: A randomised controlled trial.

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) frequently complicates the peri-operative period and is associated with increased mortality. OBJECTIVES: We hypothesised that cardiac index (CI) based haemodynamic management reduces peri-operative high-sensitive troponin-T (hsTnT) elevation and MINS incidence in patients undergoing hepatic/pancreatic surgery compared to mean arterial pressure. DESIGN: A randomised controlled study. SETTING: A single-centre study conducted in a university-affiliated tertiary hospital between June 2022 and March 2023. PATIENTS: Ninety-one patients, who were ≥ 65 years old or ≥ 45 years old with a history of at least one cardiac risk factor were randomised to either mean arterial pressure (MAP) based (n = 45) or CI-based (n = 46) management groups, and completed the study. INTERVENTIONS: In group-MAP, patients received fluid boluses and/or a noradrenaline infusion to maintain MAP above the predefined threshold. In group-CI, patients received fluid boluses and/or dobutamine infusion to keep CI above the predefined threshold. When a low MAP was observed despite a normal CI, a noradrenaline infusion was started. MAIN OUTCOME MEASURES: The primary outcome was peri-operative hsTnT elevation. The secondary outcomes were MINS incidence and 90-day mortality. RESULTS: The median absolute troponin elevation was 4.3 ng l-1 (95% CI 3.4 to 6) for the CI-based group, and 9.4 ng l-1 (95% CI 7.7 to 12.7) for the MAP-based group (median difference: 5.1 ng l-1, 95% CI 3 to 7; P < 0.001). MINS occurred in 8 (17.4%) patients in the CI-based group and 17 (37.8%) patients in the MAP-based group (relative risk: 0.46, 95% CI: 0.22 to 0.96; P = 0.029). Two patients in group-MAP died from cardiovascular-related causes. One patient in group-CI and two in group-MAP died from sepsis-related complications (for all-cause mortality: χ2 = 1.98, P = 0.16). MAP-AUC and CI-AUC values of the CI- and MAP-based groups were 147 vs. 179 min × mmHg (P = 0.85) and 8.4 vs. 43.2 l m-2 min-1 × min (P < 0.001), respectively. CONCLUSIONS: CI-based haemodynamic management assures sufficient flow and consequently is associated with peri-operative hsTnT elevation and the incidence of MINS compared to MAP. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT05391087.

Is the increased incidence of pathologically proven acute appendicitis more likely seen in elderly patients? A retrospective cohort study.

AIM: Although appendicitis is a disease of the young, it has been speculated that its incidence has increased among the elderly people. In this study, it was aimed to evaluate annual changes of appendicitis seen in older patients (≥60 years) throughout a 10-year period. METHODS: All adult patients who were surgically treated for acute appendicitis were retrospectively analyzed with respect to pathological analysis, gender, age and proportion of the patients aged 60 or over in an annual base. Variability in the mean age and proportion of the older patients aged 60 or over throughout the study years were regarded as the main outcomes. RESULTS: There were 3296 patients with a mean age of 30.42 ± 12 years. Distribution of gender was similar (p = 0.636). There was a significant positive correlation in the mean age of the patients throughout the study years (p = 0.043). Stratification by the age of 60 yielded a significant increase in percent of the older patients, from 0.93% at 2007 to 4.28% at 2016 (p = 0.019). CONCLUSIONS: The mean age of the patients with acute appendicitis is going to increase. Therefore, it is expected that all surgeons are more likely to be confronted with elderly patients with appendicitis in the near-future.

Protective effects of resveratrol on hepatic ischemia reperfusion injury in streptozotocin-induced diabetic rats.

Resveratrol (RSV) is a natural polyphenolic compound having antioxidant effects. This study was designed to investigate the protective effects of resveratrol against oxidative stress in hepatic ischemia-reperfusion (I/R) injury in streptozotocin (STZ)-induced diabetic rats. STZ was injected intraperitonally (i.p.) to 18 Sprague-Dawley albino rats, which were divided into three groups, each having six rats. First group was non-treated diabetic group (D), second diabetic group was subjected to 30 min of hepatic ischemia followed by a 45-min reperfusion period (D + I/R), and third diabetic group was subjected to 30 min of hepatic ischemia followed by a 45-min reperfusion period and treated with 20 mg/kg/day oral RSV before 30 min I/R injury (D + I/R + RSV). At the end of the experimental period, animals were decapitated, and blood samples were collected to determine tissue tumor necrosis factor-α (TNF-α) levels. Liver and lung tissue samples were obtained for the evaluation of biochemical parameters including malondialdehyde (MDA) and glutathione (GSH) levels and histopathological examinations. Compared to control, I/R injury resulted in decreases in GSH levels and increases in MDA levels. Tissue TNF-α levels were also increased in the D + I/R group compared to D group. Treatment with RSV prevented the alterations on biochemical parameters and histopathological changes induced by I/R. We demonstrate that in diabetic rats, hepatic I/R injury is associated with an augmented inflammatory response and oxidative stress, while RSV pre-treatment significantly decreased these responses. Larger clinical studies are desirable to determine the exact role(s) of RSV on hepatic I/R injury among diabetic subjects.

Evaluating factors affecting survival in colon and rectum cancer: A prospective cohort study with 161 patients.

CONTEXT: Colorectal cancers are frequent among cancers of gastrointestinal system. Whether there are any differences between survival in rectum and colon cancer patients is controversial. AIMS: In this study, we aimed to compare survival in surgically treated rectum and colon cancers and determine the factors affecting survival. SUBJECTS AND METHODS: The patients with colon and rectum cancer operated between 2009 and 2013 were examined retrospectively using prospective database. Patients were categorized as colon and rectum according to the tumor's location. Survival was identified as the primary outcome. Kaplan-Meier survival analysis and log-rank tests in survival assessment were used. RESULTS: One hundred and sixty-one patients with a mean age of 62.8 ± 12.7 years were included in the study. Male/female ratio was 1.6. Colon and rectum patients were counted as 92 (%57.1) and 69 (%42.9), respectively. Both groups were similar in demographic data (P > 0.05). It was observed that in 46 months (mean) of follow-up, 39.7% (n: 64) died, and 60.3% (n: 97) survived. Median survival time was 79 months, and 5-year cumulative survival rate was 60.8%. Five-year cumulative survival rates in stages for 1, 2, 3 and 4 were 88.2%, 64.7%, 48.5%, and 37.0%, respectively. It was noted that median survival time for colon cancer was 78 months and for rectum cancer was 79 months. Five-year cumulative survival rates for colon and rectum cancers were calculated as 56.7% and 63.4%, respectively. There were no significant differences in colon and rectum cancers in the means of survival rate (P: 0.459). CONCLUSIONS: While location of colorectal cancers shows no significant effect on survival, treatment in the early stages increases survival rate.

Ischemic colitis of the colon in streptozotocin-induced diabetic rats.

This study focuses on two inflammatory diseases, viz., "diabetes mellitus (DM)" that causes serious complications such as retinopathy, nephropathy, and neuropathy, and "ischemic colitis" which is evoked by DM. Ischemic colitis originates from the reduction in mesenteric blood flow to the colon with existence of the occlusive or non-occlusive reasons. Our study objective was to provide early diagnostic approach for ischemic colitis in streptozotocin (STZ)-induced diabetic rats. Sprague-Dawley rats were divided into four groups: (i) control use of 0.1 M citrate buffer, the solvent of streptozotocin (C), (ii). induced ischemia (I), (iii) rats subjected to 60 mg/kg STZ intraperitoneally to induce type 1 diabetes (D) (48 h after STZ injection, blood glucose levels >200 mg/dl were considered as diabetic), and (iv) diabetic rats subjected to intestinal ischemia (D+I). The third diabetic group (D) was not operated. At the end of the experimental period, rats were sacrificed, C-reactive protein (CRP) and calprotectin levels were measured in the serum and colon tissue specimens. Tissue specimens were also analyzed histologically. We found that serum and colon calprotectin levels were elevated in the D+I group compared to the D and/or I group alone, but relatively calprotectin levels increased in I as compared to C group in colon tissues. CRP levels were significantly increased with ischemic colitis in diabetes, while colon CRP levels were decreased. These results provide evidence for the existence of inflammation in the STZ-induced diabetic rats with ischemic colitis. In conclusion, our measurements of serum calprotectin levels of STZ-induced diabetic rats with ischemic colitis provide a practical approach for an early diagnosis of ischemic colitis. Furthermore, these biochemical analyses correlate well with the histopathologic findings of STZ-induced diabetic rats with ischemic colitis. Future studies would be desirable to further strengthen the role of calprotectin in the early diagnosis of ischemic colitis in diabetics clinical settings.

Intraoperative diagnosis of cecal diverticulitis during surgery for acute appendicitis: Case series.

OBJECTIVE: Cecal diverticulum is a rare entity, and can cause acute abdomen by the way of diverticulitis and perforation of diverticulitis. In this study, we aimed to perform an analysis of patients that have cecal diverticulitis, and presented with acute abdomen. MATERIAL AND METHODS: Patients who were admitted to emergency clinic between 2009-2012 and had acute abdomen due to cecal diverticulitis were included into study retrospectively. RESULTS: Six patients were included in the study with a mean age of 34 years (range 24-43). Four patients were male and two were female (male/female: 2). All six patients presented with abdominal pain, additional symptoms were nausea in five patients, and vomiting in one patient. The mean white blood cell count was 11.900/mm(3) (5850-17.400/mm(3)), while the remaining laboratory results were normal. There were no specific findings on abdominal X-ray or ultrasonography. The surgical exploration revealed an inflamed cecal diverticulitis and normal appendix in all patients. Five patients underwent appendectomy and diverticulectomy. Right hemicolectomy was performed in one patient due to suspicion of malignancy. The early postoperative period was uneventful in all patients. The mean length of hospital stay was 4.5 days with a range of 2-6 days. Histopathological examination showed acute perforated diverticulitis with underlying true diverticulum in three patients, and true diverticulum with acute diverticulitis in the remaining three patients. CONCLUSION: Pre-operative diagnosis of cecal diverticulitis is challenging due to symptoms and signs that resemble acute appendicitis. Diverticulectomy and incidental appendectomy is the treatment of choice in uncomplicated cases.

Management of strangulated abdominal wall hernias with mesh; early results.

OBJECTIVE: Surgery for abdominal wall hernias is a common procedure in general surgery practice. The main causes of delay for the operation are comorbid problems and patient unwillingness, which eventually, means that some patients are admitted to emergency clinics with strangulated hernias. In this report, patients who admitted to the emergency department with strangulated adominal wall hernias are presented together with their clinical management. METHODS: Patients who admitted to our clinic between January 2009 and November 2011 and underwent emergency operation were included in the study retrospectively. Demographic characteristics, hernia type, length of hospital stay, surgical treatment and complications were assessed. RESULTS: A total 81 patients (37 female, 44 male) with a mean age of 52.1±17.64 years were included in the study. Inguinal, femoral, umbilical and incisional hernias were detected in 40, 26, 9 and 6 patients respectively. Polypropylene mesh was used in 75 patients for repair. Primary repair without mesh was used in six patients. Small bowel (n=10; 12.34%), omentum (n=19; 23.45%), appendix (n=1; 1.2%) and Meckel's diverticulum (n=1; 1.2%) were resected. Median length of hospital stay was 2 (1-7) days. Surgical site infection was detected in five (6.2%) patients. No significant difference was detected for length of hospital stay and surgical site infection in patients who had mesh repair (p=0.232 and 0.326 respectively). CONCLUSION: The need for bowel resection is common in strangulated abdominal wall hernias which undergo emergency operation. In the present study, an increase of morbidity was seen in patients who underwent bowel resection. No morbidity was detected related to the usage of prosthetic materials in repair of hernias. Hence, we believe that prosthetic materials can be used safely in emergency cases.