Short and long term results of anatomical reconstruction of perineal body and sphincter complex in obstetric anal sphincter injuries.

Objectives: The effective way to reduce the risk of fecal incontinence (FI) in primary repaired obstetric anal sphincter injuries (OASIS) patients is to accurately detect the injury and provide complete anatomical reconstruction. The aim of the study was to evaluate the short-term and long-term results of OASIS cases that were diagnosed by an experienced surgical team and whose perineal body and anal sphincters were reconstructed separately. Material and Methods: Sixteen patients that required consultations due to anal sphincter damage during vaginal delivery and underwent anatomical reconstruction due to Grade 3c and Grade 4 sphincter damage between 2007 and 2019 were included in the study. These cases were divided into three groups [Group 1 (≤12 months), Group 2 (12-60 months), Group 3 (≥60 months)] according to the time elapsed until anal manometry, and incontinence questionnaires were conducted in the postoperative period. Recto-anal inhibitory reflex (RAIR), mean resting (IB) and squeezing (SB) pressures were measured by anal manometry. Anal incontinence (AI) and FI rates were determined by questionnaires. Anal sphincter damage repair techniques (overlapping, end-to-end) were determined. These parameters were compared between the three groups. Results: Mean age of the patients was 27.5 (16-35) years. Six (37.5%) patients had Grade 3c, while 10 (62.5%) had Grade 4 injury. The overall mean RP and SP were 35 (26-56) mmHg and 67 (31-100) mmHg, respectively. Mean RP and SP were 46/67 mmHg, 33.5/75.5 mmHg, and 37.5/70.5 mmHg in Groups 1, 2, and 3 respectively. There was no difference between the three groups in terms of mean RP and SP (p= 0.691, p= 0.673). The rate of AI and FI in all patients were 18.75% and 12.5%, respectively while the rate of severe AI incontinence was 6%. Severe AI was observed in 1 (16.7%) case in Group 1, mild AI was observed in 1 (25%) case in group 2, and in 1 (16.7%) case in Group 3. RAIR was positive in all patients. In Group 1, 5 (83.3%) patients underwent overlapping repair, and in Group 3, 6 (100%) patients underwent end-to-end repair. This difference was statistically significant (p= 0.011). Conclusion: In vaginal births, evaluation of anal sphincter damage, determination of perineal body structures and anal sphincters separately and performing anatomical reconstruction when needed significantly reduce the rate of FI in the short and long term.

Laboratory markers used in the prediction of perforation in acute appendicitis.

BACKGROUND: In this study, we aimed to evaluate the laboratory markers used in the diagnosis of acute appendicitis (AA) and present the parameters that can be used to predict acute perforated appendicitis. METHODS: The cases who underwent an appendectomy in our clinic between September 2018 and March 2020 were evaluated retrospectively. A total of 530 patients who met the study criteria were included in the study. Patients were divided into two groups according to the presence of an intraoperative perforation. Non-complicated appendicitis patients formed Group-1, and perforated appendicitis patients formed Group-2. The demographic, clinical, and laboratory characteristics of the patients were compared. RESULTS: The number of non-complicated patients in Group 1 was 443, while there were 87 (16.4%) patients in Group 2 who had perforated appendicitis. The mean age of the patients in the normal appendicitis group was 29.90±10.51 years, and the mean age of the patients in the perforated appendicitis group was 36.32±14.58 years. In the normal appendicitis group, 257 (58%) of the patients were male, 186 (42%) were female, while in the perforated appendicitis group, 38 (43.7%) were male, 49 (56.3%) were female. In the perfo-rated appendicitis group, white blood cell (WBC) value was 16.19±4.71 (p<0.001), C-reactive protein (CRP) value was 146.28±113.59 (p<0.001), total bilirubin value was 0.71±0.36 (p<0.001), and neutrophil-lymphocyte ratio (NLR) was 10.85±6.25 (p<0.001). CONCLUSION: We believe that the WBC, total bilirubin, CRP, and NLR values obtained within this study, which is tested in the rapid and easily accessible blood tests in routine examinations that can contribute to the prediction of perforation.

Primary Soft Tissue Hydatid Cysts

Objective: Hydatid cyst disease is a helminthic infection caused by Echinococcus granulous, which is encountered with cysts in many organs, especially the liver and lungs. Soft tissue and intramuscular hydatid cyst are rare even in endemic countries. It is challengig to distinguish subcutaneous and intramuscular hydatid cysts from soft tissue tumors. This study aimed to present the clinical features of primary soft tissue hydatid cyst cases without liver and lung hydatid cyst in the Southeast Anatolian region, where hydatid cyst disease is endemic. Methods: Patients admitted to the Sanliurfa Training and Research Hospital General Surgery and Orthopedics and Traumatology Outpatient Clinic between September 2018 and December 2019 with complaints of pain and/or swelling under the skin and soft tissue were evaluated. After the examinations, the records of the patients who were operated on with a pre-diagnosis of hydatid cyst and whose histopathologic evaluation was reported as a hydatid cyst were reviewed retrospectively. Results: Eight patients were included in the study. The mean age of the patients was 39.75±14.80 years. Lesions were located in neck (12.5%), left thoracic posterior area (25%), gluteus (25%), thigh (12.5%), right upper quadrant of abdominal wall (12.5%), and under the right clavicle (12.5%). When imaging methods were examined, ultrasonography was performed in 7 patients (87.5%), chest computed tomography was performed in 1 patient (12.5%), and magnetic resonance imaging was performed in 2 patients (25%). Conclusion: Diagnosis of hydatid cyst should be considered in the differential diagnosis of soft tissue tumors in countries of endemic regions for hydatid cyst disease such as Southeastern Anatolia Region, Turkey.

Genome-wide identification and characterization of high-affinity nitrate transporter 2 (NRT2) gene family in tomato (Solanum lycopersicum) and their transcriptional responses to drought and salinity stresses.

The high-affinity nitrate transporter 2 (NRT2) proteins play vital roles in both nitrate (NO3-) uptake and translocation in plants. Although the gene families coding the NRT2 proteins have been identified and functionally characterized in many plant species, the systematic identification of NRT2 gene family members has not previously been reported in tomato (Solanum lycopersicum). Moreover, little is known about their expression profiles in response to different environmental stresses. The present study sought to identify the NRT2 gene family members within the tomato genome, and then to characterize them in detail by means of bioinformatics, physiological and expression analyses. Four novel NRT2 genes were identified in the tomato genome, all of which contained the same domain belonging to the major facilitator superfamily (PF07690). The co-expression network of the SlNRT2 genes revealed that they were co-expressed with several other genes in a number of different molecular pathways, including the transport, photosynthesis, fatty acid metabolism and amino acid catabolism pathways. Several phosphorylation sites were predicted in the NRT2 proteins. The SlNRT2 genes interact with many other genes that perform various functions in many crucial pathways within the tomato genome. The sequence variations observed at the gene and protein levels indicate the dynamic regulation of the SlNRT2 gene family members in relation to cell metabolism, particularly with regard to the nitrogen assimilation pathway. The responses of the SlNRT2 genes to drought and salinity stresses are diverse, and they are neither stress- nor tissue-specific. The findings of this study should provide a useful scientific basis for future studies concerning the roles of the NRT2 gene family in plants.

Genes involved in mRNA surveillance are induced in Brachypodium distachyon under cadmium toxicity.

BACKGROUND: Cd accumulation in plant cells results in dramatic problems including oxidative stress and inhibition of vital enzymes. It also affects mineral uptakes by disrupting membrane permeability. Interaction among Cd and other plant nutrient elements changes the nutritional contents of crops and reduces their yield. METHODS AND RESULTS: In the present study, Cd stress in Brachypodium distachyon led to the upregulation of some heavy metal transport genes (influx or efflux) encoding cation-efflux proteins, heavy metal-associated proteins and NRAMP proteins. The Arabidopsis orthologs of the differentially expressed B. distachyon genes (DEGs) under Cd toxicity were identified, which exhibited Bradi4g26905 was an ortholog of AtALY1-2. Detailed co-expression network and gene ontology analyses found the potential involvement of the mRNA surveillance pathway in Cd tolerance in B. distachyon. These genes were shown to be downregulated by sulfur (S) deficiency. CONCLUSIONS: This is the first transcriptomic study investigating the effect of Cd toxicity in B. distachyon, a model plant for genomic studies in Poaceae (Gramineae) species. The results are expected to provide valuable information for more comprehensive research related to heavy metal toxicity in plants.

The effects of rectal cancer surgery on the anatomical localisation of ureters - a prospective observational study.

INTRODUCTION: Anatomical changes after surgery and fibrotic adhesions increase the organ laceration risk, including that of the ureter, in recurrent cases and secondary operations. The aim of this study was to investigate the changes in the anatomical localisations of the ureters via computed tomography urography in patients undergoing rectal cancer surgery. MATERIAL AND METHODS: The study involved prospectively collected data on the changes of ureteral location preoperatively and postoperatively in patients with operated rectal cancer. Distances (mm) of ureters determined midline in the computed tomography urogram phase. RESULTS: A total of 18 patients were included. The mean distances between the right (R1 ) and left (L1 ) ureters and the mid-vertebral line before the surgery were 30.9 ±5.4 mm and 34.5 ±9.9 mm, respectively. The postoperative distances between them (R2 and L2 ) were 26.4 ±9.1 mm and 29.5 ±9.9 mm, respectively. The R2 measurement showed that 83.3% (15/18) of the right ureters had deviated medially, whereas 16.7% (3/18) of them had deviated laterally. The L2 measurements showed that 88.8% (16/18) of the left ureters had deviated medially, whereas 11.2% (2/18) of them had deviated laterally. The differences between the preoperative and postoperative measurements of the right and left ureter positions were 4.5 ±9.2 mm and 4.9 ±4.6 mm, respectively, with the displacement in the left ureter being statistically significant (p ≤ 0.001). CONCLUSIONS: Rectal cancer surgery causes medially deviated changes in the positions of the ureters.

Spontaneous splenic rupture related to anticoagulant and antiaggregant treatment.

INTRODUCTION: Trauma is the most frequent cause of splenic rupture. In contrast to traumatic rupture of the spleen, spontaneous splenic rupture (SSR) is a rare and life-threatening condition. AIM: To present the cases of patients with SSR, who had no history of trauma, and who had been receiving anticoagulant and/or antiaggregant treatment while hospitalised for cardiac reasons. MATERIAL AND METHODS: The cases of 6 patients with SSR at Gastroenterological Surgery Department, Kartal Kosuyolu High Speciality and Training Hospital were retrospectively evaluated. The clinicodemographic factors and the diagnostic and therapeutic methods utilised for these patients with SSR while hospitalised were investigated as well. RESULTS: Five (83.3%) of the patients were male and 1 (16.6%) was female. The median age of the patients was 71 (61-73) years. Three of the patients had only been receiving antiaggregant treatment, while 2 had only been receiving anticoagulant treatment; only 1 patient had been receiving both anticoagulant and antiaggregant treatments. The decrease in haematocrit (HCT) levels ascertained on the day of SSR diagnosis and the HCT levels ascertained on the day of hospitalisation were statistically significant. All the patients received a blood transfusion. While 5 (83.33%) of the 6 patients had splenectomy, 1 (16.66%) patient received conservative treatment. Mortality was seen in 4 (66.6%) patients. CONCLUSIONS: Spontaneous splenic rupture is a condition that should be taken into consideration in the differential diagnosis of patients hospitalised for cardiac reasons, who are receiving anticoagulant and/or antiaggregant treatment in cases of newly developed abdominal pain and low HCT levels.

A Rare Case; Hydatid Cyst of the Breast

Hydatid cyst is a helminthic infection caused by Echinococcus granulosus that we encounter in various organs, especially in the liver and the lungs. Hydatid cyst of the breast is seen very rarely even in regions where the disease is endemic. In this article, we aimed to present a female patient who presented with complaints of a mass in her right breast, was diagnosed as having hydatid cyst as a result of physical examination and radiological imaging methods, and was treated.

Risk factors and laboratory markers used to predict leakage in esophagojejunal anastomotic leakage after total gastrectomy.

OBJECTIVES: Esophagojejunal anastomotic leakages, which occur in the reconstruction procedures performed after total or proximal gastrectomy, still account for one of the most significant causes of morbidity and mortality in spite of the developments seen in perioperative management and surgical techniques in gastric cancer surgery. The aim of the present study was to ascertain the risk factors for Esophagojejunal anastomotic leakages. MATERIAL AND METHODS: A total of 80 patients with gastric cancer, who had total gastrectomy +D2 lymph node dissection and Esophagojejunal anastomotic between January 2013 and December 2016, were retrospectively evaluated. Patients who did not have anastomotic leakages during their clinical follow-ups were allocated to Group 1, whereas those who had anastomotic leakages were allocated to Group 2. RESULTS: A total of 58 (72.5%) out of 80 patients were males, whereas 22 (27.5%) were females. Mean age of the patients was 61.2 ± 11.2 years. There were no demographic differences between the groups. Postoperative recurrent fever (p= 0.001), C-reactive protein values on postoperative days 3 and 5 (p= 0.01), and neutrophil-to-lymphocyte ratio on postoperative day 5 (p= 0.022) were found to be statistically significant with regard to Esophagojejunal anastomotic leakages and other postoperative complications. The duration of operation (p= 0.032) and combined organ resection (p= 0.008) were ascertained as risk factors for Esophagojejunal anastomotic leakages. CONCLUSION: Surgeons should be careful about Esophagojejunal anastomotic leakages which are significant postoperative complications seen especially in cases where the duration of operation is prolonged, and additional organ resections are performed. Recurrent fever, high C-reactive protein levels, and neutrophil-to-lymphocyte ratio may serve as warnings for complications in postoperative follow-ups.

Endoscopic and histopathological features of the upper gastrointestinal system polyps: evaluation of 12.563 procedures.

OBJECTIVES: With the widespread use of esophagogastroduodenoscopy (EGD) in recent years, upper gastrointestinal system polyps have started to be encountered more often. Although most patients with gastric polyps are asymptomatic, these are important due to their malign potential, and gastric cancer may develop if left untreated. MATERIAL AND METHODS: Records of 12.563 patients who underwent EGD at Kartal Kosuyolu High Specialization Health Application and Research Center for any reason between January 2013 and June 2016 were reviewed retrospectively. Patients with at least 1 histopathologically proven polyp were included in this study. RESULTS: A total of 12.563 endoscopic procedures of the upper gastrointestinal system were investigated and 353 (2.8%) polypoid lesions were detected. Mean age of these patients was 56.3 years and 241 (68.3%) of the patients were female. Gastric polyps were found most commonly in the antrum (50.1%) and of all gastric polyps, 245 (69.5%) were less than 1 cm. Histopathological evaluation showed that hyperplastic polyp (HP) (n= 151, 42.8%) was the most common polyp type, followed by fundic gastric polyp (FGP) (n= 51, 14.4%). Non-polyp gastric mucosa evaluation of 298 patients revealed that 34.9% of the cases were Helicobacter pylori positive, 19.4% had intestinal metaplasia, and 11.4% had atrophic gastritis. CONCLUSION: Polyps of the upper gastrointestinal system are generally detected coincidentally as they have no specific symptoms. Polypectomy is required for gastric polyps because of their potential for malign transformation according to medical evidence.

Risk factors and laboratory markers used to predict leakage in esophagojejunal anastomotic leakage after total gastrectomy.

OBJECTIVE: Esophagojejunal anastomotic leakages, which occur in the reconstruction procedures performed after total or proximal gastrectomy, still account for one of the most significant causes of morbidity and mortality in spite of the developments seen in the perioperative management and surgical techniques in gastric cancer surgery. The aim of the presentstudy was to ascertain the risk factors for Esophagojejunal anastomotic leakages. MATERIALAND METHODS: A total of 80 patients with gastric cancer, who had total gastrectomy + D2 lymph node dissection and Esophagojejunal anastomotic between January 2013 and December 2016, were retrospectively evaluated. Patients who did not have anastomotic leakages during their clinical follow-ups were allocated to Group 1, whereasthose who had anastomotic leakages were allocated to Group 2. RESULTS: A total of 58 (72.5%) out of 80 patients were males, whereas 22 (27.5%) were females.The mean age of the patients was 61.2±11.2 years. There were no demographic differences between the groups. Postoperative recurrent fever (p=0.001), C-reactive protein values on postoperative days 3 and 5 (p=0.01), and neutrophil-to-lymphocyte ratio on postoperative day 5 (p=0.022) were found to be statistically significant with regardto Esophagojejunal anastomotic leakages and other postoperative complications. The duration of operation (p=0.032) and combined organ resection (p=0.008) were ascertained as risk factors for Esophagojejunal anastomotic leakages. CONCLUSION: Surgeons should be careful about Esophagojejunal anastomotic leakages thatare significant postoperative complications seen especially in cases where the duration of operation is prolonged, and additional organ resections are performed. Recurrent fever, high C-reactive protein levels, and neutrophil-to-lymphocyte ratio may serve as warnings for complications in postoperative follow-ups.

Gastric cancer with situs inversus totalis: does it really create difficulties for surgeons?

INTRODUCTION: Situs inversus totalis (SIT) is a very rare condition that is seen at a rate of one in about 6000-8000 births. AIM: To offer a general view on the coexistence of SIT and gastric cancer, accompanied by a literature review. MATERIAL AND METHODS: Within the scope of this study, the case of a patient with gastric adenocarcinoma and SIT has been presented. Previous research on gastric cancer cases with SIT was reviewed through a comprehensive search of the PubMed, Medline, and Google Scholar databases. The keywords used to conduct this research were "situs inversus totalis and gastric cancer," "situs inversus totalis and gastric malignant," and "situs inversus totalis and gastric resection." The database search covered English studies published between 2000 and 2016. RESULTS: The results of our literature review revealed 20 studies of patients with gastric cancer and SIT, and 21 related cases. Overall, 12 of the patients were male, 9 were female, and their mean age was 61.8 ±10.97 years. The vascular assessment data showed that three out of the 13 mentioned cases had vascular anomalies. Eleven of the patients had laparoscopic resections, and one of the patients that had a surgical procedure exhibiting a postoperative mechanical obstruction. CONCLUSIONS: The coexistence of SIT and gastric cancer is a very rare condition, and a careful preoperative radiological assessment should be conducted because there can be accompanying vascular anomalies. Laparoscopies and robotic surgeries can be performed for suitable patients at experienced centres, consistent with oncological principles.

Ischemic colitis following infrarenal abdominal aortic aneurysm treatment: Results from a tertiary medical center.

OBJECTIVE: The aim of this study was to investigate the effects of ruptured aneurysm on morbidity and mortality in patients with ischemic colitis (IC) and resection following infrarenal abdominal aortic aneurysms (AAA) surgery. METHODS: Between January 2012 and December 2016, patients who underwent resection for ischemic colitis in our clinic were retrospectively reviewed. Data on the ruptured condition of the aneurysm, the emergency or elective form of aneurysm surgery, treatment method for the aneurysm (EVAR-open) were obtained. The patients were compared and divided into two groups as those with ruptured aneurysm and those without. RESULTS: A total of 275 infrarenal AAA cases were treated by the cardiovascular surgery clinic between January 2012 and December 2016. Fourteen patients (5%) developed ischemic colitis requiring resection. Four (1.8%) patients with EVAR and 10 (17.5%) patients with open surgery were operated because of IC. No statistically significant difference was observed between the two groups in terms of demographic data and surgical procedures. The intergroup comparison did not reveal any statistically significant difference among gastrointestinal (GIS) symptoms, the time period until surgery, the involved colon segment, and the surgical procedures performed. The mortality rate in ruptured AAA group was 83.3%, while it was 62.5% in the non-ruptured AAA group. In spite of the fact that the mortality rate was high in the ruptured group, it was not statistically significant (p=0.393). CONCLUSION: IC is a complication of AAA surgery with a high mortality rate. Rupture in abdominal aortic aneurysm increasing mortality in IC patients. This complication with a high mortality rate following open AAA surgery should be noted by surgeons and we believe that the liberal utilization of laparotomy and early intervention in suspected cases will decrease mortality rates.

Emergency cases following elective colonoscopy: Iatrogenic colonic perforation.

OBJECTIVE: Our aim in this study was to present the cases of our patients who contracted colonic perforation during elective colonoscopy and became emergency cases; we also discuss treatment modalities along with literature reports on the subject. MATERIAL AND METHODS: Cases of patients who contracted iatrogenic colonic perforation following endoscopy of the colorectal system between January 2009 and December 2015 at Kartal Kosuyolu Yüksek Ihtisas Training and Research Hospital's Endoscopy Unit were reviewed retrospectively. RESULTS: Within the duration of the study, 5.586 patients underwent colonoscopies at our hospital; 7 (0.12%) of these patients contracted iatrogenic colonic perforation. Three (42.8%) of these patients were male, four (57.2%) were female, and their mean age was 69 years (46 to 84). Six (85.7%) patients were diagnosed intraoperationally, while one (14.3%) patient was diagnosed 12 hours after the procedure. The perforation area was the sigmoid colon in six patients and the ascending colon in one patient; all patients underwent surgery. Four patients were discharged with no complications. One of the remaining three patients had enterocutaneous fistula, one had acute renal failure, and one died of sepsis. CONCLUSION: The progress of perforation due to colonoscopy varies according to the underlying diseases, the mechanism of perforation formation, the treatment modality used, and the experience of the physicians treating the patient. Special attention should be paid to senior and comorbid patients receiving therapeutic procedures during colonoscopy.

Examination of anastomotic leak with aqueous contrast swallow after total gastrectomy: Should it be carried out routinely?

AIM OF THE STUDY: Examination of esophagojejunal (EJ) anastomosis with aqueous contrast swallow after total gastrectomy is still routinely conducted by many centres. The present study aimed to answer the question: Is it necessary to evaluate EJ anastomosis in terms of leakage by having every patient drink oral contrast agent before initiation of oral food intake after total gastrectomy (TG) performed due to gastric cancer? MATERIAL AND METHODS: Clinical and radiological results of patients on whom total gastrectomy was performed due to gastric cancer between January 2013 and December 2016 were retrospectively reviewed. Diagnostic method used for patients in whom leak developed and therapeutic interventions were assessed. Evaluation results from aqueous contrast agent and clinical, laboratory, and tomographic findings were studied. RESULTS: Sixty of the 69 patients who underwent total gastrectomy with a diagnosis of gastric adenocarcinoma swallowed aqueous contrast agent on postoperative day 7 ±2 days and were evaluated in terms of anastomotic leak. Leak developed in 14 patients (20.2 %), 10 of whom ingested contrast agent. Leak was identified in 6 of those patients; however, diagnosis was made with multislice computed tomography (CT) in four patients (40%). The sensitivity of the examination with aqueous contrast agent was 60%. CONCLUSIONS: Evaluating anastomotic leak with aqueous contrast agent after TG has low sensitivity, and it would be wise to resort to this procedure in cases with clinical suspicion, rather than routinely performing it in every patient.

Spontaneous rectus sheath hematoma in cardiac in patients: a single-center experience.

BACKGROUND: This study presents the relationship between mortality and spontaneous rectus sheath hematoma (RSH) in inpatients receiving anticoagulant and antiaggregant treatment for cardiac pathology at cardiology and cardiovascular surgery clinics. METHODS: Within the scope of our study, the cases of 27 patients who were diagnosed with spontaneous RSH between January 2010 and December 2015 at Kartal Kosuyolu High Speciality Training and Research Hospital were retrospectively evaluated. RESULTS: Of the 27 patients, 19 (70.4%) were female and 8 (29.6%) were male. The mean age was 63±12 (32-84) years. All the patients had at least one comorbidity that necessitated follow-up. Fourteen patients received only anticoagulant treatment, 8 received only antiaggregant treatment, and the remaining 5 received both types of treatment. Physical examination of all patients revealed painful palpable masses in the lower quadrants of the abdomen. According to the results of computed tomography (CT) scans, which showed the size and localization of the masses, 7 of the cases were classified as Type I, 6 as Type II, and 14 as Type III. Although 23 of the cases received medical treatment, the remaining 4 patients received surgical treatment. Eight (29.6%) patients suffered mortality. CONCLUSION: RSH is rare, but its prevalence is increased among patients receiving anticoagulant and antiaggregant treatment for cardiac reasons. The mortality rate markedly increased among patients who contracted RSH during hospitalization for cardiac reasons, had comorbidities, and experienced additional complications due to extended hospitalization.