Distinctive features of early onset colorectal cancer. A tertiary hospital experience.

PURPOSE: The colorectal cancer rate under the age 50 years tends to increase, and we aimed to identify the general features of early-onset colorectal cancer and the differences between cancer in younger and older patients. METHODS: The patients with colorectal cancer who underwent surgery between 2016 and 2021 were included. The subjects were divided into two groups by age under and over 50. Demographic, clinical, and pathological features of early- onset colorectal cancer were identified retrospectively. RESULTS: 226 patients were included in our study, and 36 (15.9%) of them were under 50 years old. The mean age of the patients in the early-onset colorectal cancer group was 43.1±5.9 years. Most of the young patients were male, similar to the elderly CRC group. The tumors in the EOCRC group were significantly located left site (86.1% vs. 66.8%) compared to elderly CRC. Most of the tumors were medium or poorly differentiated (80.6%). The numbers of removed lymph nodes were significantly higher in the EOCRC group compared to the elderly CRC group (p<0.05), and postoperative complications were detected lower in EOCRC. CONCLUSIONS: The incidence of EOCRC continues to increase. There is no information about the exact reason for this increase. Comprehensive studies are needed to reveal general characteristics, genetic background, and predisposing factors in cancer formation and figure out the increase in the incidence. KEY WORDS: Colorectal Cancer, Hereditary Colorectal Cancer, Early Onset, Young Adults.

Different approaches in diagnosis, follow-up and treatment of acute biliary pancreatitis: Results of attitude survey.

BACKGROUND: Acute biliary pancreatitis is one of the most frequently encountered diseases among general surgeons in emergency surgical diseases. Differences in diagnosis and treatment management of these patients, varying from physician to physician, are common in clinical practice. We aimed to present these differences and discuss the results in the light of current guidelines in the literature. METHODS: In this study, 21 questions were prepared regarding the physicians' approach in the diagnosis, follow-up and treatment of acute biliary pancreatitis (Appendix).The questionnaires were completed by face to face interviews with 94 general surgery specialists at the 20th National Surgery Congress. RESULTS: In this study, 38 (40%) of the physicians who answered the questionnaire were working in the Training and Research Hospital, 27 (29%) in the State Hospital, 19 (20%) in the University Hospital and nine in private health care was working in the establishment. 85% of the physicians were general surgery specialists with 10 years of experience. 53% (50) of the surgeons reported that they had less than five cases of acute biliary pancreatitis each month, and 35% (34) stated that they wanted amylase value daily for follow-up. Ultrasonography and computed tomography were the most commonly used imaging modalities and 15% of the respondents indicated that each patient underwent magnetic resonance cholangiopancreatography. 45% of surgeons stated that antibiotics were started at the time of diagnosis of pancreatitis. The percentage of surgeons who did not undergo cholecystectomy early in patients with mild to moderate pancreatitis was 60%. The reason for not preferring surgery in the early period was the most frequent operation difficulty with 40% and not supporting the operation in the early period. CONCLUSION: According to the attitude survey results, there are differences between general surgery specialists in the diagnosis, follow-up and treatment of acute biliary pancreatitis.

A novel simplified scoring system for predicting mortality in emergency colorectal surgery: prediction model development.

BACKGROUND: Despite advances in surgical approaches, emergency colorectal surgery has high mortality and morbidity. OBJECTIVE: We aimed to create a simple and distinctive scoring system, for predicting mortality among patients undergoing emergency colorectal surgery. DESIGN AND SETTING: Prediction model development study based on retrospective data-gathering. METHODS: Patients who underwent emergency colorectal surgery between March 2014 and December 2016 at a single tertiary-level referral center were included in our study. Patient demographics, comorbidities, type of surgery, etiology and laboratory and radiological findings were collected retrospectively and analyzed. A new clinical score (named the Numune emergency colorectal resection score) was constructed from the last logistic regression model, in which one point was assigned for the presence of each predictive factor. RESULTS: 138 patients underwent emergency colorectal surgery. These comprised 64 males (46.4%) and 74 females (53.6%), with a mean age of 64 years. Multivariate analysis revealed that blood urea nitrogen level > 65 mg/dl (odds ratio, OR: 8.03; 95% confidence interval, CI: 2.16-15.77), albumin level < 0.7 -mg/-dl (OR: 4.43; 95% CI: 1.96-14.39) and American Society of Anesthesiologists score ≥ 3 (OR: 3.47; 95% CI: 0.81-9.18) were associated with postoperative complications. The Numune score was graded from I to III. The risk of mortality was found to be 63.2% in the group with grade III, which accounted for 35.2% of the subjects. There were 37 postoperative deaths. CONCLUSIONS: Surgeons need scoring systems, especially to predict postoperative mortality. We propose the Numune emergency colorectal resection score for emergency surgical procedures as a practical, usable and effective system for predicting postoperative morbidity.

A novel simplified scoring system for predicting mortality in emergency colorectal surgery: prediction model development

ABSTRACT BACKGROUND: Despite advances in surgical approaches, emergency colorectal surgery has high mortality and morbidity. OBJECTIVE: We aimed to create a simple and distinctive scoring system, for predicting mortality among patients undergoing emergency colorectal surgery. DESIGN AND SETTING: Prediction model development study based on retrospective data-gathering. METHODS: Patients who underwent emergency colorectal surgery between March 2014 and December 2016 at a single tertiary-level referral center were included in our study. Patient demographics, comorbidities, type of surgery, etiology and laboratory and radiological findings were collected retrospectively and analyzed. A new clinical score (named the Numune emergency colorectal resection score) was constructed from the last logistic regression model, in which one point was assigned for the presence of each predictive factor. RESULTS: 138 patients underwent emergency colorectal surgery. These comprised 64 males (46.4%) and 74 females (53.6%), with a mean age of 64 years. Multivariate analysis revealed that blood urea nitrogen level > 65 mg/dl (odds ratio, OR: 8.03; 95% confidence interval, CI: 2.16-15.77), albumin level < 0.7 ­mg/­dl (OR: 4.43; 95% CI: 1.96-14.39) and American Society of Anesthesiologists score ≥ 3 (OR: 3.47; 95% CI: 0.81-9.18) were associated with postoperative complications. The Numune score was graded from I to III. The risk of mortality was found to be 63.2% in the group with grade III, which accounted for 35.2% of the subjects. There were 37 postoperative deaths. CONCLUSIONS: Surgeons need scoring systems, especially to predict postoperative mortality. We propose the Numune emergency colorectal resection score for emergency surgical procedures as a practical, usable and effective system for predicting postoperative morbidity.

Role of computed tomography tractography in evaluation of back/flank stab wounds.

BACKGROUND: The clinical approach to back/flank wounds has evolved over the years. The aim of this study was to discuss the potential of computed tomography tractography in patients with a stab wound to the back or flank. METHODS: A total of 25 stable patients with stab wounds confined to the back/flank region were enrolled in this retrospective study. After initial resuscitation and physical examination, tractography was performed at the site of the stab wound. The patients subsequently underwent computed tomography with intravenous contrast. RESULTS: Computed tomography tractography helped avoid a laparotomy in 15 (60%) patients and accurately revealed a peritoneal breach in 10 (40%) patients. No missed injuries were reported in the conservatively followed patients. CONCLUSION: The addition of tractography to computed tomography is a safe, fast, and cost- and time-effective technique to evaluate back/flank stab wounds.

Venous stent placement ameliorates cutaneous microvascular function in iliocaval venous obstruction.

BACKGROUND: The role of cutaneous microvascular dysfunction is well known in the development of chronic venous disease. However, the effects of venous obstruction on microcirculation have not been well investigated. The aim of this study was to assess cutaneous microvascular function in patients with iliocaval venous obstruction (ICVO) before and after venous stent placement. METHODS: Endothelium-dependent and endothelium-independent vasodilator responses to iontophoretic administration of incremental doses of acetylcholine (ACh) and sodium nitroprusside (SNP) were evaluated using a laser Doppler scanner in the perimalleolar region in the supine and sitting positions in patients with ICVO (n = 11) and in healthy control subjects (n = 15). Cutaneous microvascular function, the Venous Clinical Severity Score (VCSS), and the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class were re-evaluated 3 months after stent placement in patients with ICVO. RESULTS: The vasodilatory responses to ACh and SNP in the cutaneous microcirculation were lower in patients with ICVO than in healthy subjects in the sitting position (P < .05). Recanalization and stent placement were successful in all patients in the evaluation of VCSS and clinical class, and a significant decrease was determined in the signs and symptoms of the venous disease (P < .01). Stent placement resulted in a significant increase in vasodilation response to both ACh and SNP in the supine position and no improvement in the sitting position in patients with ICVO. CONCLUSIONS: ICVO impairs endothelium-dependent and endothelium-independent vasodilation in the perimalleolar region. Iliocaval venous stent placement may recover microvascular dysfunction at different levels.

Splenic hamartoma is a rare cause of abdominal pain: Case report and literature review.

Hamartoma is a rare benign tumor of the spleen. It is often asymptomatic and diagnosed incidentally. In this study, we report the case of a 51-year-old female patient who was admitted to our department for intermittent epigastric pain since the last 6 months and left upper quadrant fullness. She was diagnosed with splenic hamartoma histopathologically after splenectomy. Although splenic hamartoma is very rare, it must be included in the differential diagnosis of splenic mass-forming lesions.

Laparoscopic surgery for complex and recurrent Crohn's disease.

Crohn's disease (CD) is a chronic inflammatory disease of digestive tract. Approximately 70% of patients with CD require surgical intervention within 10 years of their initial diagnosis, despite advanced medical treatment alternatives including biologics, immune suppressive drugs and steroids. Refractory to medical treatment in CD patients is the common indication for surgery. Unfortunately, surgery cannot cure the disease. Minimally invasive treatment modalities can be suitable for CD patients due to the benign nature of the disease especially at the time of index surgery. However, laparoscopic management in fistulizing or recurrent disease is controversial. Intractable fibrotic strictures with obstruction, fistulas with abscess formation and hemorrhage are the surgical indications of recurrent CD, which are also complicating laparoscopic treatments. Nevertheless, laparoscopy can be performed in selected CD patients with safety, and may provide better outcomes compared to open surgery. The common complication after laparoscopic intervention is postoperative ileus seems and this may strongly relate excessive manipulation of the bowel during dissection. But additionally, unsuccessful laparoscopic attempts requiring conversion to open surgery have been a major concern due to presumed risk of worse outcomes. However, recent data show that conversions do not to worsen the outcomes of colorectal surgery in experienced hands. In conclusion, laparoscopic treatment modalities in recurrent CD patients have promising outcomes when it is used selectively.

Endoscopic Management of Colonic Perforation due to Ingestion of a Wooden Toothpick.

BACKGROUND Toothpick ingestion is implicated in bowel injuries that may cause violent complications, mimicking diseases causing acute abdomen. CASE REPORT A 18-year-old man was admitted with a 3-day history of a swallowed wooden toothpick. The patient had tenderness in the left flank area. Computed tomography indicated toothpick impaction at the splenic flexura of the colon. It was successfully removed with colonoscopy. After the procedure, abdominal radiography showed free air as a sign of perforation. Along with conservative management, the patient was discharged without surgery. CONCLUSIONS There is need for greater awareness of the hazardous of an ingested toothpick. Endoscopic approach should be considered in the first-line management of toothpick perforations.

Minimally invasive management of anastomotic leaks in colorectal surgery.

Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient's quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.

The role of fine needle aspiration cytology and core biopsy in the diagnosis of palpable breast masses.

BACKGROUND: The modern approach to palpable breast masses is to get cytopathologic diagnosis before definitive surgery. We aimed to compare fine needle aspiration cytology (FNAC) with core biopsy in histopathologic diagnosis of palpable breast masses. MATERIALS AND METHODS: Data were collected on 123 women who have suspicious palpable breast masses from 2007 to 2010. RESULTS: Of the 123 patients, core biopsies were performed on 64 patients (Group 1) and FNAC on 59 patients (Group 2). Malignancy was confirmed in 25 out of 32 clinically suspicious patients in Group 1 (78.1%), and 20 out of 21 participants in Group 2 (95.2%). Among the clinically suspicious patients, 81.8% of 33 patients in Group 1, and 90.3% of 31 patients in Group 2 were identified malignancy. Sensitivity was 100% for core biopsy and 95% for FNAC. Specificity was 100% in both procedures. False negativity rate in FNAC were 5%. CONCLUSION: Sensitivity and specificity showed that in the case of true histopathologic classification, core biopsy is superior to FNAC. Nevertheless, FNAC's role as a fast, simple and cheap diagnosis cannot be ignored. It is an effective diagnostic tool in most patients, in comparison to the correct and specific typing of core biopsies in benign lesions which protect patients from the open biopsy.

Renal Angiomyolipoma With Caval Extension and Pulmonary Fat Embolism: A Case Report.

Renal angiomyolipoma (AML) is a rare benign tumor of the kidney. Occasionally, it may extend into the renal vein or the inferior vena cava (IVC), but so far of pulmonary embolism in patients with renal AML was rarely reported. Here, a case of symptomatic pulmonary embolism secondary to AML that was placed IVC filter before the operation and then treated with radical nephrectomy is reported.This case highlights the rare possibility of renal vein and IVC involvement with symptomatic pulmonary fat embolism in renal AML, which may potentially result in fatal complications if not appropriately and cautiously managed with surgical intervention.

The effects of ventilation with high density oxygen on the strength of gastrointestinal anastomosis.

PURPOSE: The aim of our study is to evaluate the effects of administration of perioperative supplemental oxygen on anastomoses. METHODS: Forty male Wistar albino rats were used in the study and randomized into 4 groups. Ischemia-reperfusion models were built in groups 3 and 4. Jejunojejunostomy was performed in all rats and assigned to an oxygen/nitrous oxide mixture with a fraction of inspired oxygen of 30% in groups 1 and 3 and 80% in groups 2 and 4. The measurements of perianastomotic tissue oxygen pressure, bursting pressure, level of hydroxyproline were evaluated and compared in all groups. RESULTS: The perianastomotic tissue oxygen pressures, bursting pressures and levels of hydroxyproline were identified as significantly high in groups 2 and 4, administered a fraction of inspired oxygen of 80%, compared to groups 1 and 3, administered a fraction of inspired oxygen of 30%. CONCLUSION: Perioperative supplemental oxygen contributes positively to the anastomotic healing.

Benefits of CT tractography in evaluation of anterior abdominal stab wounds.

INTRODUCTION: The study aimed to identify the presence of peritoneal penetration in management of anterior abdominal stab wound by using computed tomography (CT) tractography. MATERIAL AND METHODS: Hemodynamically stabile, CT tractography-performed patients who were admitted to our emergency clinic with anterior abdominal stab wounds between the years 2012 and 2014 were included in this study, and all images were evaluated in terms of peritoneal penetration and possible intra-abdominal injury. RESULTS: In the study CT tractography identified necessity of laparotomy accurately in 90% of the patients, and none of the patients without peritoneal penetration needed surgical treatment in their follow-up. CONCLUSION: The procedure may be used for some selected cases of hemodynamically stable patient with anterior abdominal stab wounds to abstain from local wound exploration.

Is local resection sufficient for parathyroid carcinoma?

OBJECTIVES: Parathyroid carcinoma is a rare malignant disease of the parathyroid glands that appears in less than 1% of patients with primary hyperparathyroidism. In the literature, the generally recommended treatment is en bloc tumor excision with ipsilateral thyroid lobectomy. Based on our 12 years of experience, we discuss the necessity of performing thyroid lobectomy on parathyroid carcinoma patients. RESULTS: Eleven parathyroid carcinoma cases were included in the study. All operations were performed at the Department of Endocrine Surgery at Ankara University Medical School. Seven of the patients were male (63.6%), and the mean patient age was 48.9 ± 14.0 years. Hyperparathyroidism was the most common indication for surgery (n ϝ 10, 90.9%). Local disease was detected in 5 patients (45.5%), invasive disease was detected in 5 patients (45.5%) and metastatic disease was detected in 1 patient (9.1%). The mean follow-up period was 99.6 ± 42.1 months, and the patients' average disease-free survival was 96.0 ± 49.0 months. During the follow-up period, only 1 patient died of metastatic parathyroid carcinoma. CONCLUSION: Parathyroid carcinoma has a slow-growing natural progression, and regional lymph node metastases are uncommon. Although our study comprised few patients, it nevertheless showed that in selected cases, parathyroid carcinoma could be solely treated with parathyroidectomy.

The use of porcine acellular dermal matrix for management of gastrocutaneous fistula after laparoscopic sleeve gastrectomy.

Sleeve gastrectomy is an effective and single stand-alone surgical procedure for the treatment of morbid obesity. One of the most frequent and serious complications of this procedure is staple-line leak. It can usually be treated with self-expandable stents. If this process results in failure and gastrocutaneous fistula occurs, a challenging period starts for the patient and the surgeon. We describe a new, relatively simple and quick endoscopic technique for closing a chronic gastrocutaneous fistula. A plug prepared with porcine acellular dermal matrix was used for this purpose. Gastrocutaneous fistula following an obesity surgery can be successfully treated endoscopically with this technique. This method can prevent the need for aggressive reconstructive surgery following a gastrocutaneous fistula and can prompt rapid improvement while decreasing the average hospital stay for this condition.

Is local resection sufficient for parathyroid carcinoma?

OBJECTIVES: Parathyroid carcinoma is a rare malignant disease of the parathyroid glands that appears in less than 1% of patients with primary hyperparathyroidism. In the literature, the generally recommended treatment is en bloc tumor excision with ipsilateral thyroid lobectomy. Based on our 12 years of experience, we discuss the necessity of performing thyroid lobectomy on parathyroid carcinoma patients. RESULTS: Eleven parathyroid carcinoma cases were included in the study. All operations were performed at the Department of Endocrine Surgery at Ankara University Medical School. Seven of the patients were male (63.6%), and the mean patient age was 48.9 ± 14.0 years. Hyperparathyroidism was the most common indication for surgery (n ϝ 10, 90.9%). Local disease was detected in 5 patients (45.5%), invasive disease was detected in 5 patients (45.5%) and metastatic disease was detected in 1 patient (9.1%). The mean follow-up period was 99.6 ± 42.1 months, and the patients' average disease-free survival was 96.0 ± 49.0 months. During the follow-up period, only 1 patient died of metastatic parathyroid carcinoma. CONCLUSION: Parathyroid carcinoma has a slow-growing natural progression, and regional lymph node metastases are uncommon. Although our study comprised few patients, it nevertheless showed that in selected cases, parathyroid carcinoma could be solely treated with parathyroidectomy. .

Intact parathormone measurement 1 hour after total thyroidectomy as a predictor of symptomatic hypocalcemia.

OBJECTIVE: Postoperative iPTH assay may predict significant hypocalcemia after thyroid surgery. The present study aimed to evaluate the ability of iPTH assay to monitor parathyroid function and to identify the risk of postoperative hypocalcemia in patients underwent thyroid surgery. MATERIALS AND METHODS: One hundred patients participated in the study (7 male and 93 female). Hypocalcemia was defined as a serum calcium concentration less than 8.0 mg/dL and symptoms of hypocalcemia. Concomitant serum calcium and iPTH levels were measured before operation and at 1(st) h for iPTH, 24(th) h for calcium after thyroidectomy. RESULTS: Postoperative hypocalcemia was observed in 31 patients. The mean postoperative serum calcium concentration in normocalcemic patients was 8.8 ± 0.5 mg/dL, whereas it was 7.6 ± 0.3 mg/dL in hypocalcemic patients. The mean postoperative 1(st) hour iPTH of patients in the hypocalcemia group was 9.1 ± 4.9 pg/mL, whereas patients of the normocalcemia group had a mean postoperative iPTH of 35.8 ± 20.2 pg/mL. CONCLUSION: Postoperative 1(st) hour iPTH < 8 pg/mL with drop in iPTH level ≥ 81.5% together showed the highest diagnostic accuracy in predicting postoperative hypocalcemia.

Effects of surgery on microvascular function in venous insufficiency.

BACKGROUND: The aim of our study was to assess the effects of venous stripping on microvascular functions in isolated great saphenous vein insufficiency. METHODS: Two groups of participants were prospectively evaluated. The first group included 15 healthy participants without any evidence of venous insufficiency. The second group included 20 patients with varicose veins because of great saphenous vein insufficiency. The demographics, venous clinical severity scores, and CEAP classifications of the patients were recorded. Next, all individuals underwent evaluations for microvascular vasoreactivity using an iontophoretic laser Doppler imager, and the outcomes were recorded. Patients with varicose veins underwent stripping surgeries, and microvascular vasoreactivity evaluations were repeated 6 weeks postoperatively. RESULTS: There was a statistically significant decrease in the patients with varicose veins compared with the control group in response to nitroprusside (SNP) applied at 4 mC in the supine position. Furthermore, there was also a significant difference in the response to acetylcholine (ACh) in patient group in the sitting position (P < 0.05). We also observed a statistically significant decrease in the responses to SNP applied for 1, 2, and 4 mC (P < 0.05) in the patients in the sitting position. The relief of pain and edema after surgery was found to be significant (P < 0,001). In the subgroup in which ACh was applied for 1 and 4 mC in the supine position, postoperative microvascular flow was significantly increased (P < 0.005). Moreover, based on the measurements taken in the supine position, the patients in the subgroup in which SNP was applied for 1, 2, or 4 mC exhibited significantly increased postoperative microvascular dilatation (P < 0.005). CONCLUSIONS: Saphenous vein insufficiency impairs the endothelium-dependent vasodilatation response in the perimalleolar region, and partial recoveries in microvascular function were observed after surgical treatment.