Does surgical experience really matter on the treatment approach to acute cholecystitis. A randomised clinical trial.

AIM: Experienced surgeons usually prefer early laparoscopic cholecystectomy (ELC) instead of delayed laparoscopic cholecystectomy (DLC) for the treatment of acute cholecystitis (AC). However, the question remains, if ELC is also safe for beginner surgeons. This study compares ELC versus DLC for the treatment of AC as a beginner surgeon approach. MATERIAL AND METHODS: In this prospective randomized clinical trial, patients suffering AC in their first 72 hours of pain were enrolled either in Group L (n:88); patients were treated surgically with ELC immediately or Group D (n:88); patients were first treated medically and than treated surgically with DLC 4-8 weeks later. All operations and medical treatments were done by the same beginner surgeon. RESULTS: In Group L operation time was 60 (50-65) minutes, total hospital stay was 1.5 (1-7) days and total cost was 337.38±78.46 (287-827) USD. In Group D operation time was 50.5 (45-60) minutes, total hospital stay was 5.5(3-15) days and total cost was 499.29±199.38 (321-1506) USD. There were no significant differences regarding to the complications (p>0.05). Hospital stay and total costs were significantly higher in Group D (p<0.001). CONCLUSIONS: This study indicates, that ELC can definitely be chosen as a treatment approach for AC even by beginner surgeons, considering that it reduces hospital stay and total cost. KEY WORDS: Acute Cholecystitis, Delayed laparoscopic cholecystectomy, Early laparoscopic cholecystectomy, Surgical work experience.

Effects of totally extraperitoneal and lichtenstein hernia repair on men's sexual function and quality of life.

BACKGROUND: In the literature, there have been scant studies that compare the effects of totally extraperitoneal (TEP) and Lichtenstein hernia (LH) repairs on men's sexual function and quality of life. Our aim in this study was to study the sexual function of men after TEP and LH repair according to SF 36 (Health Survey Scoring Demonstration) and IIEF (The International Index of Erectile Function). METHODS: A total of 176 men with unilateral inguinal hernia were randomized into two groups. Group T (n = 88) received TEP hernia repair, and Group L (n:88) received LH repair. Patients' demographics and perioperative findings were recorded. For all patients, the preoperative as well as postoperative 7th, 30th and 90th day SF 36 and IIEF were recorded. RESULTS: A total of 176 operations consisting of 88 TEP and 88 LH repairs were evaluated. There were no differences in demographics, hernia type, and complications except for body mass index (BMI). The operative time was higher in Group T (29.6 ± 5.8 vs. 43.5 ± 5.7 min; p = 0.001). The averages of the SF 36-Vitality and Social Function for Postoperative (PO) 30th day scores were higher in Group T. The averages of the SF 36-Bodily Pain, General Health, Physical Role, Emotional Role for PO 7-30th days SF36- Mental Health for PO 7th day and SF 36 Physical Function for PO 30-90th days scores were statistically higher in Group T. The averages of the IIEF- Erectile Function for PO 30th day, IIEF- Orgasmic Function, Sexual Desire, Intercourse Satisfaction, and Intercourse Satisfaction for PO 7th and 30th days scores were higher in Group T. CONCLUSIONS: TEP and LH repairs have similar results for recurrence, complications, and hospital stay; otherwise, TEP repair yields better results than the LH repair in the postoperative course at the 7th and 30th day evaluation, concerning sexual function and quality of life, but this benefit is no longer apparent at the 90th day. Although the short-term differences were statistically significant, they were moderate and might have a limited impact from the clinical point of view.

Effect of Resection Distance from Pylorus on Weight Loss Outcomes in Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Despite the established efficacy and safety of laparoscopic sleeve gastrectomy (LSG), controversy still exists on optimal operative technique, the resection distance from pylorus (DP) being among the most controversial issues. This study aimed to examine the effect of resection distance from pylorus on % excess weight loss (EWL) during postoperative period, in patients who underwent LSG for morbid obesity. METHODS: A total of 390 patients who underwent laparoscopic sleeve gastrectomy for morbid obesity were included in this retrospective study. Patients were allocated into one of the two groups based on the distance between antrum resection margin and pylorus: group A, ≤ 3 cm and group B, > 3 cm. Follow-up data for %EWS and nausea/vomiting as well as demographical and perioperative data were retrospectively reviewed and logistic regression analysis was done. RESULTS: Follow-up data up to 12 months were available for all patients, whereas 199 patients had follow-up data at 24 months. Shorter distance from pylorus was associated with higher %EWL throughout the treatment period (p < 0.001), evident from the first postoperative month (p = 0.013 for the first month, p < 0.001 for all other time points). The benefit extended up to 24 months in ≤ 3 cm group. However, nausea/vomiting was more frequent in the ≤ 3 cm group only at 1-month visit (15% vs. 4%, p < 0.001). In multivariate evaluations, while %EWL variable was taken as a dependent variable, time variable with DP × time interaction was statistically significant in the model. CONCLUSIONS: Our findings indicate that a short distance between resection margin and pylorus is associated with better and sustained %EWL in LSG. However, these patients seem to be more prone to nausea and vomiting in the early postoperative period. Further prospective large studies would help to define an optimal resection distance.

Drain amylase monitoring for early diagnosis of anastomotic leakage in sleeve gastrectomy An animal study.

BACKGROUND: Sleeve gastrectomy(SG) is a popular bariatric surgery procedure with rare but dreaded complications. Although drain amylase levels are a reliable early predictor of anastomosis leakage in oesophagectomy and pancreaticoduodenectomy, for SG have not yet been studied. We aimed to monitor drain amylase levels to ascertain their applicability for early diagnosis of gastric leakage in SG. METHODS: Twenty-four rats were randomly divided into three groups: Group A: only laparotomy and abdominal drain; Group B: laparotomy, SG, and drain; Group C: laparotomy, SG with fistula,and drain. On postoperative days 0,1,2,3, and 4, drain lavage samples were collected to measure amylase. RESULTS: Groups were compared in pairs. Preoperative weights were not significantly different in any comparison. On postoperative days 0,1,2,3, and 4, drain amylase levels were found to be significantly lower in Group A than in Group B as well as in Group A than in Group C but were significantly higher in Group C than in Group B. For postoperative day 1, a receiver operating characteristic curve was done. Drain amylase levels over 1514 IU were statistically significant for leakage. CONCLUSIONS: Drain amylase levels were significantly high in sleeve gastrectomy with fistula. This indicates that drain amylase level monitoring might be an easy and cheap alternative for determining staple-line leakage for high risk patients with Body Mass Index(BMI)>50kg/m2 in whom we cannot use radiological imaging. KEY WORDS: Animal Experimental Study, Bariatric Surgery, Drain amylase, Sleeve gastrectomy, Staple-line leakage.

Comparative analysis of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures for the treatment of morbid obesity.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has been considered as the most efficient method in bariatric surgery. Indeed, Laparoscopic Sleeve Gastrectomy (LSG) which is easier to do, has been increasingly used in the recent years. The aim of the present study was to compare short-and mid-term outcomes of RYGB and LSG. METHODS: Medical records of 62 patients who underwent either RYGB (GroupR) or LSG (GroupL) in our General Surgery Department between 2010 and 2013 were retrospectively reviewed. Demographics, comorbidities, preoperative laboratory values, length of hospital stay and postoperative complications were recorded. During follow-up in the postoperative period, body-mass-index (BMI), excess weight loss (EWL), triglyceride levels (TG), and low-density lipoprotein (LDL) levels were recorded at the 1st, 3rd, 6th, and 12th months. RESULTS: Mean length of hospital stay was significantly higher in GroupR (p = 0.001), which was also correlated with BMI. EWL at 1st, 3rd, 6th, and 12th months was significantly higher in GroupR. Hair loss was significantly higher in GroupR (p < 0.05). The rates of diabetes mellitus and hypertension in the preoperative period and at 6th and 12th months did not significantly differ between the groups. Preoperative TG and LDL values were significantly higher in GroupR (p < 0.05). CONCLUS ONS: This study indicated, that RYGB is statistically more effective than LSG, but LSG has clinically almost the same effect as RYGB, and also hospital stay, postoperative complications as hair loss are decreased in LSG. KEY WORDS: Laparoscopic Sleeve Gastrectomy, Morbid Obesity, Roux-en-Y Gastric Bypass.

Role of Laparoscopic Appendectomy Radix Ligation Techniques on the Formation of Inner Abdomen Abscess.

OBJECTIVES: Our aim was to study whether laparoscopic appendectomy radix ligation techniques were eutrophic in the development of intra-abdominal abscess. METHODS: Between September 2009 and April 2017, all emergency cases admitted to our surgery polyclinic were reviewed, and the results of the patients who underwent laparoscopic appendectomy were collected. Appendectomy radix ligation techniques were reviewed from surgical notes on discharge reports. Postoperative controls were also reviewed, and any cases with abscess formation were reported. RESULTS: A total of 350 patients were included in the study. Of these cases, 207 were males, and 143 were females. The mean age of the patients was 26.89±4.9 years. One hundred eighty-nine cases were found to have two endoloops placed on top of each other, whereas 161 cases had a 2 mm distance left in between the two endoloops and tied. None of the 189 cases who had endoloops placed on top of each other developed abscess formation. However, of the 161 cases who had endoloops with a 2 mm distance in between, 8 reported with abscess formation in the inner abdomen. Of these eight cases, seven had percutaneous abscess drainage by an interventional radiologist, whereas one was treated with relaparoscopy. CONCLUSION: In the present study, patients who had endoloops placed on top of each other developed no abscess formation, whereas in the literature's gold standard procedure, those with a 2 mm distance left between two endoloops developed an inner abdominal abscess formation in 8 (4.9%) of the patients. We believe that this 2 mm dead space distance left between the two endoloops contributes to the formation of the abscess.

Drain amylase monitoring for early diagnosis of anastomotic leakage in sleeve gastrectomy An animal study.

BACKGROUND: Sleeve gastrectomy(SG) is a popular bariatric surgery procedure with rare but dreaded complications. Although drain amylase levels are a reliable early predictor of anastomosis leakage in oesophagectomy and pancreaticoduodenectomy, for SG have not yet been studied. We aimed to monitor drain amylase levels to ascertain their applicability for early diagnosis of gastric leakage in SG. METHODS: Twenty-four rats were randomly divided into three groups: Group A: only laparotomy and abdominal drain; Group B: laparotomy, SG, and drain; Group C: laparotomy, SG with fistula,and drain. On postoperative days 0,1,2,3, and 4, drain lavage samples were collected to measure amylase. RESULTS: Groups were compared in pairs. Preoperative weights were not significantly different in any comparison. On postoperative days 0,1,2,3, and 4, drain amylase levels were found to be significantly lower in Group A than in Group B as well as in Group A than in Group C but were significantly higher in Group C than in Group B. For postoperative day 1, a receiver operating characteristic curve was done. Drain amylase levels over 1514 IU were statistically significant for leakage. CONCLUSIONS: Drain amylase levels were significantly high in sleeve gastrectomy with fistula. This indicates that drain amylase level monitoring might be an easy and cheap alternative for determining staple-line leakage for high risk patients with Body Mass Index(BMI)>50kg/m2 in whom we cannot use radiological imaging. KEY WORDS: Animal Experimental Study, Bariatric Surgery, Drain amylase, Sleeve gastrectomy, Staple-line leakage.

Effects of Laparoscopic Sleeve Gastrectomy on Parathyroid Hormone, Vitamin D, Calcium, Phosphorus, and Albumin Levels.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) reduces obesity-related co-morbidities, such as diabetes, hypertension, and hyperlipidemia. Endocrinological abnormalities may occur as undesired side effects. Most centers routinely prescribe folic acid, cyanocobalamin (vitB12), and protein replacement in the postoperative period, but 25-OH-vitamin-D3 (vitD) and intact parathyroid hormone (iPTH) levels are not routinely followed up. The aim of this study was to identify the effects of LSG on iPTH, vitD, calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), and albumin levels. METHODS: Data of morbidly obese patients who underwent LSG between January and December 2014 were studied in this prospectively designed study. Serum levels of iPTH, vitD, Ca, P, folic acid, vitB12, ALP, and albumin were measured preoperatively and postoperatively at the 3rd, 6th, and 12th months. RESULTS: In total, 119 patients were analyzed. All patients had normal iPTH, vitD, Ca, P, folic acid, vitB12, ALP, and albumin values preoperatively, and 31.6% had received vitD supplementation during their nutritionist observation time before surgery. At the 3rd, 6th, and 12th postoperative months, 21 (17.6%), 17 (17.3%), and 1 (0.8%) patients, respectively, had increased iPTH and ALP and decreased vitD levels. A total of 39 (32.7%) patients needed high-dose vitD treatment during a 1 year follow-up. Approximately 37.5% of the patients who received vitD supplementation preoperatively needed vitD supplementation postoperatively. Hospital records of 101 of 119 patients who underwent LSG could be screened to determine their vitD supplementation requirements previously ordered by their nutritionist for a 1-year period before LSG. Thirty-two (31.6%) of the 101 patients had received vitD supplementation during the 1-year period preoperatively. CONCLUSIONS: Although serum levels of iPTH, vitD, Ca, P, vitB12, ALP, and albumin may be normal preoperatively, severe vitD insufficiency requiring high-dose vitD replacement may develop in morbidly obese patients postoperatively. Instead of iPTH and vitD, which are expensive to measure, ALP serum level, which is correlated with iPTH levels, can be a good indicator to monitor calcium metabolism.

Approach to inguinal hernia in high-risk geriatric patients: Should it be elective or emergent?

BACKGROUND: Elderly patients are more prone to have inguinal hernia due to weakened abdominal musculature. However, surgical repair of inguinal hernia (SRIH) may not be performed or may be delayed due to greater risk in presence of comorbidities. Present study is investigation of outcome of elective and emergency SRIH in geriatric patients. METHODS: Records of total of 384 high-risk (American Society of Anesthesiology classification III-IV) patients aged >65 years who underwent SRIH between January 2010 and December 2014 were reviewed. Patients were divided into 2 groups according to procedure type: elective (Group EL) or emergency (Group EM). Demographic features and surgical and postoperative period data of 2 groups were recorded and compared. RESULTS: Demographic data were similar, but number of ASA IV patients was greater in Group EM. Frequency of intestinal resection was significantly greater in emergency surgery group (1% vs 21%; p<0.01). Length of hospital stay (1.3 days vs 7.9 days; p<0.01) and intensive care unit stay (0.17 days vs 4.04 days; p<0.01) were also greater in Group EM. Morbidity (1% vs 24%; p<0.01) and mortality (0.3% vs 11%; p<0.01) were also significantly higher in Group EM compared to elective SRIH group. CONCLUSION: Emergency inguinal hernia surgery is associated with significantly higher morbidity and mortality compared with elective SRIH in high-risk geriatric patients. Elective hernia repair in these patients should be considered to reduce risk of need for intestinal resection as well as length of hospital stay.

Postoperative effects of laparoscopic sleeve gastrectomy in morbid obese patients with type 2 diabetes.

BACKGROUND: Laparoscopic Sleeve Gastrectomy has become one of the most popular bariatric surgery types and helps treating not only obesity but also endocrinological diseases related to obesity. Therefore we aimed to evaluate the effects of laparoscopic sleeve gastrectomy on the treatment of type 2 diabetes. METHODS: All patients, who underwent morbid obesity surgery during 2013-2014 and had a HbA1c >6 % were included in this prospective study. Demographical data, usage of oral antidiabetic drugs or insulin were recorded, and laboratory findings as HbA1c and fasting plasma glucose were evaluated preoperatively and postoperatively at the 6th and 12th months. Diabetes remission criteria were used to assess success of the surgical treatment. RESULTS: Totally 88 patients were included in this study. 55 patients were using oral antidiabetic drugs and 33 patients were using insulin. At the 6th month complete remission was observed in 80 (90.9 %), partial remission in 3 (3.4 %) and persistent diabetes in 5 (5.6 %) patients. At the 12th month complete remission was observed in 84 (95.4 %), partial remission in 1 (1.1 %) and persistent diabetes in 3 (3.4 %) patients. CONCLUSIONS: This study indicated that laparoscopic sleeve gastrectomy surgery achieved a complete remission of diabetes in 95.4 % patients having type 2 diabetes during a 1 year fallow up period. However, complete remission of type 2 diabetes has been reported as 80 % during long term fallow up in the literature. In our opinion this rate may change with longer follow up periods and studies involving more patients suffering type 2 diabetes.

Benefits of xiphoidectomy in total gastrectomy: Technical note.

OBJECTIVE: The esophago-gastric junction may be challenging during total gastrectomy due to gastric cancer. This situation may compromise the security of both the dissection and anastomosis. The purpose of this study was to investigate the usefulness of xiphoidectomy to overcome this issue. MATERIAL AND METHODS: The files of patients who underwent total gastrectomy + D2 lymph node dissection due to proximal gastric cancer or cardia cancer between April 2002-December 2013 were retrospectively evaluated. We assessed the outcome in patients with xiphoidectomy in addition to the midline incision in terms of xiphoidectomy technique, xiphoidectomy time, and operative and postoperative complications. RESULTS: Thirty cases were identified to undergo xiphoidectomy. Nineteen patients were male and 11 were female, with a mean age of 51 (21-80) years. The time required for xiphoidectomy was 7-15 minutes (mean 8.7 minutes). The mean additional time required for the closure of the incision in cases with xiphoidectomy was 2 minutes. There was minimal arterial bleeding from the diaphragmatic surface in one patient, which was controlled by electrocautery. Only two patients developed wound infection. CONCLUSION: Performing xiphoidectomy is quite easy, after a certain learning phase. The operative time was 7-15 minutes longer due to excision of xiphoid and closure of the related defect. Minor hemorrhage was a problem during surgery. There were no early or late post-operative complications. We suggest that the procedure is beneficial in selected cases with requirement of a wider operative field or better exposure of the esophago-gastric junction during total gastrectomy for gastric cancer, and recommend removal of the xiphoid bone.

Less is more: "incision and curettage" as an optimal procedure for recurrent pilonidal disease.

AIM: Although pilonidal disease has been a well-known entity for more than a century, recurrence of pilonidal disease is still not rare. The optimal surgical approach to recurrent disease is under debate. In this study, we aimed to investigate the efficacy of "incision and curettage" procedure for recurrent pilonidal disease. MATERIAL AND METHODS: From May 2009 to May 2013, 42 patients (37 male/5 female) underwent surgical treatment for recurrent pilonidal disease. Incision and curettage of granulation tissue, hair and debris in the cavity were performed in all cases. Data collection included demographics, visual analogue scale (VAS) score, hospital stay, return to daily activities (lying, sitting down in comfort) and work, and complete wound healing time. RESULTS: Mean operating time was 16.6±4.7 (10-24) minutes. Mean pain score was 1.4±1.1 (0-5) with VAS. The mean duration of returning to daily activities such as comfortable lying down, sitting and returning to work were 1.6±0.8 (1-4) days, and 3.3±2.3 (1-15) days, and 10.2±5.4 (5-33) days, respectively. The mean wound healing time was 19.9±7.8 (7-52) days. During the three-year follow-up period, no recurrence was observed. DISCUSSION: "Incision and curettage" may be performed as first-line treatment for recurrent cases. It does not require surgical skill and can be easily applied in a short time. CONCLUSION: This simple surgical option, incision curettage provides short hospital stay and quick return to daily activities, in addition to patient comfort and satisfaction. KEY WORDS: Pilonidal sinus, Recurrence, Sacrococcygeal.

Comparison of Spinal Anaesthesia and Paravertebral Block in Unilateral Inguinal Hernia Repair.

OBJECTIVE: We aimed to compare the efficacy of spinal anaesthesia (SA) and paravertebral block (PVB) in unilateral inguinal hernia repair. METHODS: Sixty American Society of Anesthesia physical status (ASA) I-III patients aged between 18-64 years with unilateral inguinal hernia were enrolled in this study. Two patients in Group SA and 4 patients in Group PVB were excluded, and statistical analyses were done on 54 patients. In regard to anaesthetic choice, patients were divided into two groups, with 30 patients in each: Group SA, spinal anaesthesia and Group PVB, paravertebral block. Standard monitoring was done, and mean arterial pressure (MAP) and heart rate (HR) were recorded during the surgical procedure. Demographic variables, surgical data, patient satisfaction, the onset times to reach T10 dermatome and to reach peak sensory level, and onset time to reach modified Bromage 3 motor block were recorded. Postoperative nausea and vomiting and pain at postoperative hours 0-24 with the visual analog scale (VAS) were also measured. RESULTS: Compared to pre-anaesthesia measurements, the decrease in HR and MAP during the 10(th)-90(th) minute period was significant in Group SA (p<0.01). In Group PVB, sensory block duration time was higher, whereas paralysis rate was higher in Group SA (p<0.01). Bromage scores were significantly different between the groups (p<0.01). In Group SA, VAS score at the 24(th) postoperative hour, nausea, and vomiting were significantly higher compared to Group PVB (p<0.01). CONCLUSION: In conclusion, paravertebral block provides acceptable surgical anaesthesia, maintaining good quality and long duration on postoperative analgesia in unilateral hernia repair.