Can the Modified Systemic Inflammation Score Predict Complicated Appendicitis?

OBJECTIVE: To differentiate between complicated and uncomplicated acute appendicitis using the modified systemic inflammation score (mSIS) preoperatively. STUDY DESIGN: Observational study. Place and Duration of the Study: The Emergency Surgery Service of General Surgery Clinic of Ankara Bilkent City Hospital, Turkey, between 2021 and 2022. METHODOLOGY: The study included 2,584 patients older than 18 years who underwent surgery with the diagnosis of acute appendicitis. Patients with malignant diseases and those younger than 18 were excluded. The patients' demographic characteristics, laboratory data, surgical notes, and pathology results were electronically obtained and analysed. According to the surgical findings and pathology records, gangrenous, perforated, and phlegmonous cases and those with any abscess focus were included in the complicated group and the remaining cases were included in the uncomplicated group. mSIS was evaluated as 0 if albumin was ≥4.0 g/dL and LMR (the lymphocyte-to-monocyte ratio) was ≥3.4, 1 if albumin <4.0 g/dL or LMR <3.4, and 2 if albumin <4.0 g/dL and LMR <3.4. RESULTS: mSIS was 0 in 868 (33.6%) cases and 1-2 in 1,716 (66.4%) cases. When the patients with mSIS values of 0 and 1-2 were compared, there was a statistically significant difference (p=0.03). mSIS 1-2 was found to have 85% sensitivity and 42% specificity in predicting complicated appendicitis. In addition, the probability of complicated appendicitis was 1.48 times higher among the patients with an mSIS of 1-2. CONCLUSION: Complicated appendicitis cases can be predicted preoperatively by simply calculating mSIS using the routine laboratory parameters. KEY WORDS: Complicated acute appendicitis, mSIS, Appendectomy.

A new, simple marker for predicting complicated appendicitis in patients with normal white blood cell count indicator; LUC.

BACKGROUND: The aim of this study was to investigate the ability of a new marker that could be easily obtained to differentiate between complicated and uncomplicated appendicitis in a patients with a white blood cell (WBC) count within the normal range. METHODS: The patients who underwent surgery with histopathologically proven acute appendicitis (AA) between January 2021 and October 2022 were evaluated retrospectively. Patients were classified into two groups as uncomplicated and complicated appendicitis, based on the surgical and histopathological findings. Groups were compared in terms of laboratory parameters at the time of hospital admission. RESULTS: During the study period, 2589 patients underwent an appendectomy, among these 612 patients who had a WBC count within the normal range at the time of admission were analyzed. Uncomplicated appendicitis was detected in 79.6% of the patients and complicated appendicitis in 20.4%. Neutrophil%, neutrophil-to-lymphocyte ratio, C-reactive protein, and total bilirubin levels were significantly higher, whereas lymphocyte%, lymphocyte count, lymphocyte-to-monocyte ratio, sodium levels, and large unstained cells (LUC)% were significantly lower in patients with complicated appendicitis. Multiple logistic regression analysis revealed that lower LUC% (Odds Ratio [OR]: 0.45; 95% Confidence Intervals [CI]: 1.08-2.09; P=0.01) and higher total bilirubin levels (OR: 1.50; 95% CI: 1.08-2.09; P=0.01) were independent risk factors for complicated appendicitis. CONCLUSION: In patients with a diagnosis of AA with a normal WBC value, LUC% obtained from the complete blood count can be used as a new parameter predicting the diagnosis of complicated appendicitis.

Bilaterally parallel elliptic flap versus Karydakis flap in primary pilonidal sinus disease: a randomized controlled trial.

PURPOSE: Pilonidal sinus disease is a disease that especially affects the young population and causes loss of workforce. Although many treatment methods have been defined, there is still no "gold standard" treatment method. Our objective was to evaluate the postoperative results of bilateral parallel elliptical flap and Karydakis flap in the surgical treatment of pilonidal sinus. METHODS: This study was conducted at the Colorectal Surgery Department of Ankara Numune Training and Research Hospital. It designed a prospective randomized controlled study. Patients that underwent surgery due to pilonidal sinus were included in the study. The patients were randomly divided into two groups. Surgery was performed with the bilateral parallel elliptical flap (BPEF) technique in one group and the Karydakis flap (KF) technique in the other group. Postoperative pain, length of hospital stay, wound complications, time taken to return to work/school, and recurrence incidence were evaluated. RESULTS: A total of 102 patients were included in the study, 49 in the BPEF group and 53 in the KF group. The length of hospital stay was similar in the BPEF and KF groups (1.41 ± 0.81 and 1.45 ± 0.84, respectively; p > 0.05). There was less postoperative pain in the BPEF group (2.47 ± 1.02 vs 3.57 ± 1.10, p < 0.05). Wound complications were observed in nine patients in the BPEF group (18.2%) and 14 patients in the KF group (26.2%). The time to return to work/school was shorter in the BPEF group (21.06 ± 6.37 vs 27.04 ± 7.45; p < 0.05). Recurrence developed in two (4%) patients in the BPEF group and three (5.6%) patients in the KF group (p > 0.05). CONCLUSIONS: The patients who underwent surgery with the bilateral parallel elliptical flap technique had less pain and a shorter time to return to work/school after the operation. The postoperative complication and recurrence rates were similar in both groups. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT05851690. (5/11/2023) (retrospectively registered).

Clinical course of percutaneous cholecystostomies: A cross-sectional study.

BACKGROUND: Although cholecystectomy is the standard treatment modality, it has been shown that perioperative mortality is approaching 19% in critical and elderly patients. Percutaneous cholecystostomy (PC) can be considered as a safer option with a significantly lower complication rate in these patients. AIM: To assess the clinical course of acute cholecystitis (AC) in patients we treated with PC. METHODS: The study included 82 patients with Grade I, II or III AC according to the Tokyo Guidelines 2018 (TG18) and treated with PC. The patients' demographic and clinical features, laboratory parameters, and radiological findings were retrospectively obtained from their medical records. RESULTS: Eighty-two patients, 45 (54.9%) were male, and the median age was 76 (35-98) years. According to TG18, 25 patients (30.5%) had Grade I, 34 (41.5%) Grade II, and 23 (28%) Grade III AC. The American Society of Anesthesiologists (ASA) physical status score was III or more in 78 patients (95.1%). The patients, who had been treated with PC, were divided into two groups: discharged patients and those who died in hospital. The groups statistically significantly differed only concerning the ASA score (P = 0.0001) and WBCC (P = 0.025). Two months after discharge, two patients (3%) were readmitted with AC, and the intervention was repeated. Nine of the discharged patients (13.6%) underwent interval open cholecystectomy or laparoscopic cholecystectomy (8/1) within six to eight weeks after PC. The median follow-up time of these patients was 128 (12-365) wk, and their median lifetime was 36 (1-332) wk. CONCLUSION: For high clinical success in AC treatment, PC is recommended for high-risk patients with moderate-severe AC according to TG18, elderly patients, and especially those with ASA scores of ≥ III. According to our results, PC, a safe, effective and minimally invasive treatment, should be preferred in cases suffering from AC with high risk of mortality associated with cholecystectomy.

The rising trend of papillary carcinoma in thyroidectomies: 14-years of experience in a referral center of Turkey.

BACKGROUND: During the past 25 years, the incidence of thyroid papillary carcinoma (TPC), especially the micropapillary subtype, has been increasing in different countries worldwide. The rise in the rate of thyroid malignancies were also determined in Turkey in the last two decades. This fact was attributed to the Chernobyl accident because Turkey is one of the affected countries by the radioactive fallout. The aim of this study was to assess the changes in the parameters of the thyroid and put forth the reasons in a 14-year period. METHODS: The patient records, demographic and malignancy characteristics, and operations of 1,585 patients who had a thyroidectomy from 1996 to 2009 were reviewed retrospectively. The study was divided in two equal time periods for comparison of data. RESULTS: A total of 216 thyroid carcinomas (13.6%) were diagnosed in the study period. There was a significant increase in the frequency of papillary (P <0.023) and micropapillary (P <0.001) carcinomas when the two different time periods were compared. The rate of follicular, medullary and other types of malignancies did not change. In the second period (2003 to 2009) of analysis, the rate of micropapillary carcinoma (P = 0.001) and within male (P = 0.031) and female (P <0.001) genders, application of total thyroidectomy (p = 0.029), and multicentric disease (P = 0.015) increased significantly. A slight decrease in the mean age of the whole number of patients and patients with papillary and micropapillary carcinomas (P >0.05) was observed. The increased number of TPC >10 mm was insignificant. Geographic region and age specific malignancy increase was not determined. CONCLUSIONS: Micropapillary carcinoma has become a dominant type of thyroid malignancy in Turkey. The main reasons of this transition were mandatory iodization and much higher application of total thyroidectomy in surgery. Improvement in healthcare and diagnostic techniques are the complementary factors. Due to its lack of molecular and genetic basis from the perspective of thyroid cancer, the Chernobyl disaster has lost its importance in Turkey.

A rare complication of intraabdominal hydatid disease: gastric fistula and recurrent gastric bleeding.

Intra-abdominal hydatid disease is a type of echinococcosis. This silent disease becomes symptomatic with serious complications. A 50-year-old woman presented with abdominal pain and recurrent hematemesis. A computed tomographic scan demonstrated a large retrogastric hydatid cyst and suggested gastric fistula. An emergent laparotomy was performed, and gastric fistula of the intraperitoneal hydatid cyst and arterial bleeding around the fistula were demonstrated intraoperatively. Clinical course, complications, and management of intra-abdominal hydatid disease are discussed.

Isolated intrathoracic hiatal herniation of the twisted sigmoid colon: report of a case.

The hiatus hernia and sigmoid volvulus are usually found in older patients. The delay of the treatment of both of these illnesses may result in increased morbidity and mortality. We report a case of an isolated intrathoracic hiatal herniation of the twisted sigmoid colon. The patient complained about cramping abdominal pain, vomiting, and dyspnea. Chest X-ray and CT scan of the thorax showed a distended colonic segment in the posterior mediastinum. The patient underwent cruroplasty, Nissen fundoplication, and sigmoid colon resection. This is the first report of such a rare case.

Conservative management of hemorrhoids: a comparison of venotonic flavonoid micronized purified flavonoid fraction (MPFF) and sclerotherapy.

PURPOSE: To compare the results of the conservative management of hemorrhoids between venotonic flavonoid micronized purified flavonoid fraction (MPFF) and sclerotherapy, in terms of the subjective and objective outcome of patients after a follow-up period of 2 years. METHODS: One hundred and twenty-six patients who suffered from 1st-and 2nd-degree hemorrhoids were divided into 2 groups. The first (n = 64) and second (n = 62) groups underwent venotonic flavonoid MPFF (VF) and sclerotherapy (SCL). The Average Symptoms Score (ASS), Average Anascopy Score (AAS) and the subjective scale were used to assess the success of the treatments. RESULTS: A total of 113 patients agreed to participate in the follow-up study. ASS and AAS decreased in both of the groups in the first three visits (P < 0.05). At the end of the second visit, ASS and AAS significantly declined in the VF group. In addition, ASS and AAS decreased to the nadir level in the groups at the end of the 26th week. During the remaining time of the follow-up period, ASS showed a significant rise pattern in the VF group in comparison to the SCL group. The resolved and improved rate was significantly higher in the SCL group at the end of the study (P < 0.05). CONCLUSIONS: Sclerotherapy was a more efficient treatment modality than VF in the long-term follow-up. SCL also had an acceptable success rate in the short-term follow-up.

Serum tumor marker CA19-9 in the follow-up of patients with cystic echinococcosis.

BACKGROUND: The aim of this study was to compare results of the determination of carcinoembryonic antigen, carbohydrate antigens, alpha-fetoprotein, and human chorionic gonadotropin before and after surgical and pharmacologic treatment in patients with cystic echinococcosis (CE). METHODS: Serum samples were obtained from 40 CE patients (all with cysts in the liver) and from 10 sex- and age-matched healthy donors (control group). Serum samples were drawn (1) before (presurgical group) and after (postsurgical group, including a 3-month cycle of albendazole) surgical and pharmacologic treatment. Serum tumor markers were measured, and indirect hemagglutination assay was performed. RESULTS: In 90% of confirmed cases of CE, indirect hemagglutination assay was positive. Mean (SD) serum CA19-9 concentrations for all patients in the presurgical and postsurgical groups were 45.1 +/- 30 kU/L and 17.02 +/- 11 kU/L, respectively. CA19-9 concentrations were significantly greater in CE patients in the presurgical compared with the control group. Also, increased CA19-9 concentrations decreased significantly in the postsurgical compared with the presurgical group. CONCLUSIONS: A significant decrease in serum CA19-9 concentrations after surgical and pharmacologic therapy was demonstrated in the clinical follow-up of patients with CE (patients were tested 3 months after surgery). If our findings are confirmed and more-sensitive methods are developed for measuring serum CA19-9 concentrations, new and interesting perspectives will be gained for the monitoring and treatment of patients with CE.

Comparison of bariatric and non-bariatric elective operations in morbidly obese patients on the basis of wound infection.

BACKGROUND: Wound infection rates after various types of bariatric operations have been well described. The question of whether bariatric surgery increases wound infection rate compared with similar elective surgical procedures in obese patients has not been clearly answered. The purpose of this study was to investigate wound status of morbidly obese patients after elective general surgery. METHODS: A prospective evaluation was conducted of 141 morbidly obese patients undergoing bariatric (n=60) and non-bariatric elective general surgery operation of similar invasiveness (n=81) with the ASEPSIS wound surveillance method. RESULTS: Median age of patients undergoing non-bariatric elective surgery (51, 32-68) was significantly higher than patients exposed to bariatric surgery (39, 24-57). Patients undergoing bariatric surgery had higher BMIs (44.0, 35-52.5) compared to the others (38.4, 35-43). All patients enrolled in the study were followed for a 21-day period. At the 7th postoperative day, 9 patients in the bariatric surgery group developed infection (15%), whereas 13 patients (16%) in the non-bariatric surgery group suffered wound infection. Wound infection was still present in 2 patients (3.4%) in the bariatric surgery group and 3 patients (3.7%) in the non-bariatric surgery group at the 21st day. Risk factors for wound infection included history of coronary artery diseases, diabetes, chronic respiratory illness and malignant disease. CONCLUSION: Bariatric surgery does not cause an additional risk of postoperative wound infection in morbidly obese patients, compared to elective general surgical operations of the same invasiveness.

V-Y advancement flap closures for complicated pilonidal sinus disease.

BACKGROUND AND AIMS: Hair entry into the midline is the generally accepted theory in pilonidal sinus formation. This theory is also involved in the pathogenesis of the recurrence after different types of operations for pilonidal sinus disease. The relationship of the suture lines and the midline was evaluated in this study. PATIENT AND METHODS: Thirty-four patients with stage 4 or recurrent pilonidal sinus disease who underwent V--Y advancement flap closure were randomized into two groups: vertical suture line unrelated to midline (VLUM, n=18) and vertical suture line related to midline (VLRM, n=16). RESULTS: None of the patients with or without a suction drain developed flap necrosis, local haematomas or seromas. The median length of the postoperative hospital stay was 3 days for theVLRM group and the VLUM group (p>0.05). The median follow-up period was 32 months. During the follow-up period, two recurrences were determined 22 and 15 months after operation in the VLRM group. Recurrences were situated in the scar tissue over the midline. INTERPRETATION AND CONCLUSION: Routine application of suction drains is not recommended after V--Y advancement flap closure. Avoidance of the relationship of the postoperative suture line and the midline, if possible, offers a safe method of definitive reconstruction.

Improvement of vertical banded gastroplasty by strict dietary management.

BACKGROUND: Vertical banded gastroplasty (VBG) has been found to reduce BMI significantly during the first postoperative year. However, the same trend in weight loss has not been established thereafter. The purpose of this study was to evaluate the effects of our dietary program on morbidly obese patients treated with VBG. METHODS: A prospective evaluation of 40 obese patients (25 female, 15 male) undergoing VBG over a 3-year period was undertaken. RESULTS: The age range was 24-57 (median 38) years, mean weight 133+/-2 SD kg, and mean BMI 45+/-6.4 SD kg/m2. After VBG, a special follow-up program was applied to patients. All patients (100%) were available for follow-up. Operative mortality was zero. 4 patients developed an early postoperative complication, and 1 patient was re-operated because of staple-line disruption 8 months after VBG. BMI decreased to 34+/-3.2 after 12 months, 27+/-1.3 after 24 months, and 28+/-1.4 after 36 months. All patients showed weight loss after VBG, and the weight loss continued with the strict follow-up program during a 3-year period, except in 1 patient who regained the weight lost despite an intact staple-line and stoma. CONCLUSION: Our policy for patients after VBG appears to be effective.