Role of contrast-enhanced serial/spot abdominal X-rays in perioperative follow-up of patients undergoing abdominal surgery: An observational clinical study.

BACKGROUND: Many imaging methods such as ultrasonography, computed tomography (CT), magnetic resonance imaging, and endoscopy are used to identify the problems or complications that occur in the perioperative period and to determine the appropriate therapeutic approach. Specialists at surgical clinics and intensive care units sometimes need diagnostic procedures that can give quick results or reveal unexpected results. In particular, rapid on-site evaluation of patients followed under intensive care conditions has several advantages. AIM: To determine the problems developing in patients in the perioperative period by contrast-enhanced abdominal X-ray (CE-AXR), revealing their current status or defining the effectiveness of CE-AXR. METHODS: The files of the patients who underwent hepatopancreatobiliary or upper gastrointestinal surgery, whose CE-AXR film was taken, were reviewed retrospectively. Abdominal X-ray radiographs taken after ingestion of a water-soluble contrast agent (iohexol, 300 mg, 50 cc vial) and its application in a drain, nasogastric tube, or stent were evaluated. The contribution of the data obtained in patients who underwent CE-AXR to the diagnosis, follow-up, and treatment processes and the effectiveness of the application were investigated. RESULTS: CE-AXR was applied to 131 patients in our clinic, most of whom underwent hepatopancreatobiliary or upper gastrointestinal surgery. It was determined that the data obtained from CE-AXR films taken in 98 (74.8%) of the patients contributed to the diagnosis, treatment, and follow-up expectations and positively affected the clinical processes. CONCLUSION: CE-AXR is a simple procedure that can be applied anywhere, especially in intensive care patients and at bedside, with a portable X-ray device. The simplicity of the procedure, less radiation exposure for the patients, less time wastage, reduction in the CT and endoscopy procedure burden and costs, quick results, rapid assessment of the situation, and enabling the monitoring of processes with repetitive procedures are important advantages. X-rays taken will be useful in terms of being a reference value during the follow-up period of the patient and determining the situation in medicolegal processes.

Management of hepatic artery trauma during hepato-pancreato-biliary procedures: Evolving approaches, clinical outcomes, and literature review.

BACKGROUND: One of the most feared complications of surgeons dealing with hepato-pancreato-biliary (HPB) surgery is hepatic artery (HA) injury. Here, we aimed to evaluate our clinical experience (laceration, transection, ligation, and resection) related to HA traumas, which have serious morbidity and mortality risks, in the light of literature data and the rapidly evolving management methods in recent years. METHODS: The files of 615 patients who were operated on for HPB pathologies in the last decade, in our hospital, were retrospectively reviewed. Clinical, laboratory, and imaging data obtained from patients' files were evaluated. RESULTS: A total of 13 HA traumas were detected, eight of them had HA injury and five had planned HA resection. During the post-operative follow-up period, liver abscess, anastomotic leakage, and late biliary stricture were detected. CONCLUSION: Complications and deaths due to HA injury or ligation are less common today. The risk of complications increases in patients with hemodynamically unstable, jaundice, cholangitis, and sepsis. Revealing the variations in the pre-operative radiological evaluation and determining the appropriate approach plan will reduce the risks. In cases where HA injury is detected, arterial flow continuity should be tried to be maintained with primary anastomosis, arterial transpositions, or grafts.

The impact of splenectomy on human lipid metabolism.

Background: Splenectomy impacts hematological, immunological, and metabolic functions of the patient. Since our understanding of its metabolic effects, in particular effects on lipid metabolism, is limited, this study aims to investigate the effects of splenectomy on lipid metabolism. Methods: The data from 316 patients undergoing splenectomy between 2009 and 2019 were retrospectively analyzed. Thirty-eight patients whose serum lipid values were measured both preoperatively and 1 year after surgery were included in this study. Results: Significantly higher levels of total cholesterol, low-density lipoprotein (LDL), and non-high-density lipoprotein (HDL) lipid profile were found in the postsplenectomy measurements. However, no significant differences were recorded in levels of triglyceride, HDL, or very-LDL. Conclusion: We determined that splenectomy does impact lipid metabolism, and that the metabolic effects of splenectomy should further be investigated.

Isolated Roux loop versus conventional pancreaticojejunostomy following pancreaticoduodenectomy.

AIM: This study aimed to examine the effects of isolated Roux loop (IP) versus conventional pancreaticojejunostomy (CP) techniques on the rate of postoperative pancreatic fistula and its severity. MATERIAL AND METHODS: This study included retrospectively collected data from 132 patients who underwent pancreaticoduodenectomy in a single institute. Collected data were compared between IP and CP groups. Postoperative pancreatic fistula and its grades were defined according to International Study Group on Pancreatic Fistula (ISGPF) definition. RESULTS: A total of 58 patients had IP and 74 patients had CP. Biochemical leak (IP 20.6% versus CP 14.9%, p=0.38) and grade B/C pancreatic fistula (IP 20.6% versus CP 32.4%, p=0.13) rates of both groups were similar. Durations of hospital stay and intensive care unit stay and 30-day mortality rates of the two groups were similar. CONCLUSION: Isolated Roux loop reconstruction following pancreaticoduodenectomy is not associated with a lower rate of pancreatic fistula but may contribute to reducing the severity of pancreatic fistula. KEY WORDS: Anastomotic leak, Pancreatic fistula, Pancreaticoduodenectomy, Roux en y anastomosis.

Laparoscopic Splenopexy Due to Wandering Spleen: Feasible Technique.

Wandering spleen (WS) is a rare disease caused by the looseness of the splenic ligaments. A 29-year-old female patient presented to the emergency department with complaints of abdominal pain and a palpable mass in the abdomen. A diagnosis of WS was made as a result of preoperative imaging. We performed urgent laparoscopic splenopexy with non-absorbable mesh in a patient with torsioned WS. WS is a disease that must be operated on urgently because it causes ischemia and necrosis in cases where it causes torsion in the splenic pedicle. Many researchers also recommend surgery in asymptomatic patients. While splenectomy was previously recommended for WS, current recommendations advocate for splenopexy. As a result, the only and definite treatment option in the case of WS is surgery. Splenopexy with minimally invasive techniques should be the first choice if possible. Splenopexy with non-absorbable mesh is an inexpensive and feasible method to prevent re-torsion. The use of non-absorbable mesh in laparoscopic splenopexy has not been shared before in the literature.

Splenic surgery: a ten years experience of a tertiary center in Turkey.

AIM: Splenectomy has been performed for various indications. In this study, we aimed to present the experience of a tertiary center on splenic surgery and analyze what has changed in the last 10 years. MATERIAL AND METHODS: Three hundred and sixteen patients who underwent splenic surgery were enrolled in the study. Demographic data, comorbidities, American Society of Anesthesiologists score, indications, operation type, postoperative complications, and mortality were analyzed retrospectively. RESULTS: The most common indication was traumatic splenic injury. Immune thrombocytopenic purpura (ITP) and gastric cancer were the second and third. Splenectomy was performed on 300 (94.9%) patients. Splenorrhaphy, partial splenectomy, and splenopexy were the other procedures performed. Postoperative complications occurred in almost onethird of the patients (n=118, 37.3%). Most of them were grade 5 according to the Clavien-Dindo classification. CONCLUSIONS: Splenectomy has become a less preferred treatment option with the development of non-operative management in splenic trauma, medical treatments for hematological diseases, and a better understanding of the immune, hematological and metabolic functions of the spleen. In the future, minimally invasive and spleen-sparing surgeries will be performed more frequently for patients who need splenectomy even for those with trauma. KEY WORDS: Cyst, Hematology, Laparoscopy, Sepsis, Splenectomy, Trauma.

Percutaneous Drainage of a Splenic Abscess via Laparoscopic Trocar in a Kidney Transplant Patient.

Spleen abscess is a life-threatening disease. Treatment can be done by medical, radiological, or surgical methods. Here, we offer an innovative method of laparoscopic trocar-assisted percutaneous abscess drainage in the treatment of splenic abscess. Our patient, a 48-year-old male who had a kidney transplant 3 years previously, was admitted due to abdominal pain and fever. A-25-cm splenic abscess was detected, and ultrasonography-guided percu-taneous catheter 10F drainage was attempted. However, this attempt was not successful due to the high viscosity of the abscess content. Under general anesthesia, we then attempted abscess drainage percutaneously via a 12-mm laparoscopic trocar, and a large-bore drain of 28F was inserted into the abscess cavity. The drainage was successful (5300 mL high viscosity content) without any complications. The patient was discharged on day 8 and remained well at 9-month follow-up. Percutaneous drainage instead of splenectomy is preferred in the treatment of spleen abscess by preserving the immunologic functions of the spleen, particularly in immunocompromised patients. When percutaneous catheter drainage therapy fails, percutaneous treatment with a laparoscopic trocar is an innovative and reliable alternative.

Laparoscopic gastrectomy in remnant gastric cancer.

OBJECTIVES: Remnant Gastric Cancer (RGC) describes cancers occurring in the remaining stomach and/or anastomosis in the follow-up after gastric cancer or benign gastric surgery. RGC is diagnosed in esophago-gastroscopy follow-ups of patients who underwent this surgery in the past. Again, the increase in the success of gastric cancer surgery and following medical treatments has increased the incidence of RGC in long-term follow-up after gastric cancer surgery. Laparoscopic surgery has been also reported in few cases. In the present study, the purpose was to present the results of the first five patients that underwent laparoscopic total gastrectomy due to RGC in our clinic. MATERIAL AND METHODS: The patients who underwent laparoscopic gastric cancer surgery between November 2014 and December 2018 were evaluated retrospectively. RESULTS: Mean age of the patients was 62.4 years (ranging between 49 and 74 years). Two of these patients had a surgical history due to gastric cancer and 3 due to peptic ulcer. Surgery was completed laparoscopically in all patients. In the early period, one patient had to undergo re-surgery due to stenosis in Jejuno-Jejunostomy, and the patient died. One patient underwent laparotomy due to colonic stenosis in the second month after the surgery. Recurrence was detected on the 140th and 180th days of follow-up in the other two patients. CONCLUSION: Laparoscopic surgery is a technically applicable method in RGC; however, it is also a risk factor for past surgical postoperative complications. Early recurrence in this group of patients requires a comparison of open and laparoscopic surgery.

Natural orifice specimen extraction versus transabdominal extraction in laparoscopic right hemicolectomy.

INTRODUCCIÓN: La extracción de muestras de orificio natural (NOSE) para resecciones colorrectales, que mejoran aún más las ventajas de la cirugía mínimamente invasiva, se utilizan cada vez con mayor frecuencia. En este estudio, nuestro objetivo fue comparar los métodos de extracción de muestras de nariz y transabdominales en casos de resecciones de colon derecho totalmente laparoscópicas. MÉTODOS: Se incluyeron datos de 52 pacientes que se sometieron a cirugía laparoscópica de colon derecho entre 2013 y 2019. La extracción de muestras transabdominales se realizó en 35 pacientes, mientras que 17 pacientes fueron sometidos a NOSE. Se compararon datos demográficos, hallazgos operativos, resultados patológicos y datos de seguimiento. RESULTADOS: Las mujeres (94% frente a 28%, p = 0,0001), comórbidas (76% frente a 40%, p = 0,01) y antecedentes de cirugía abdominal previa (75% frente a 23%, p = 0,001) fueron más altas en el grupo NOSE . Todas las otras características preoperatorias de los grupos fueron comparables. La pérdida de sangre intraoperatoria, el tiempo de operación y las tasas de complicaciones fueron similares en ambos grupos. La escala VAS postoperatoria (2.8 ± 1.2 vs. 4.5 ± 2.4, p = 0.001) y los puntajes cosméticos fueron mejores en el grupo NOSE (10 vs. 7, p = 0.0001). Los resultados oncológicos fueron similares después de un seguimiento medio de 27.4 ± 20.5 (1-77) meses. CONCLUSIÓN: El método NOSE después de la resección laparoscópica del colon derecho fue un método más ventajoso en términos de cosméticos y dolor postoperatorio que la extracción de muestras transabdominales. INTRODUCTION: Natural orifice specimen extraction (NOSE) for colorectal resections, which further enhance the advantages of minimally invasive surgery, are being used increasingly more often. In this study, we aimed to compare NOSE and transabdominal specimen extraction methods in cases of totally laparoscopic right colon resections. METHODS: Data of 52 patients who underwent laparoscopic right colon surgery between 2013 and 2019 were included in the study. Transabdominal specimen removal was done in 35 patients, while 17 patients underwent NOSE. Demographic data, operative findings, pathological results, and follow-up data were compared. RESULTS: Female (94% vs. 28%, p = 0.0001), co-morbid (76% vs. 40%, p = 0.01), and previous abdominal surgery history (75% vs. 23%, p = 0.001) were higher in the NOSE group. All the other pre-operative features of the groups were comparable. Intraoperative blood loss, operation time, and complication rates were similar in both groups. Post-operative visual analog scale (2.8 ± 1.2 vs. 4.5 ± 2.4, p = 0.001) and cosmetic scores were better in the NOSE group (10 vs. 7, p = 0.0001). Oncologic results were similar after a mean follow-up of 27.4 ± 20.5 (1-77) months. CONCLUSION: The NOSE method following laparoscopic right colon resection was a more advantageous method in terms of cosmetics and post-operative pain than transabdominal specimen extraction.

Surgical Site Infections after Laparoscopic Bariatric Surgery: Is Routine Antibiotic Prophylaxis Required?

Background: It is a challenging question, especially in bariatric surgery (BS), whether antibiotic prophylaxis is necessary in all cases; considering the serious consequences of surgical site infection (SSI) on the one hand and irrational use of antibiotics on the other. The aim of this study was to determine the need/rationale for antibiotic prophylaxis in patients undergoing laparoscopic bariatric surgery, especially low-risk patients. Methods: This retrospective analysis involved 313 morbidly obese patients (body Mass Index [BMI] ≥40) who underwent laparoscopic BS at three medical centers between September 2018 and June 2019. During the trial, no inducement was given to use antibiotics, and the centers had chosen whether to use prophylaxis. The U.S. Centers for Disease Control and Prevention (CDC)-2016 criteria were used for the diagnosis of SSI. Results: Antibiotic prophylaxis was given to 181 patients, and the SSI rate in the entire series was 4.5% (14/313). There was no significant difference in SSI between the group who received antibiotics and that who did not (2.8% versus 6.8%, respectively; p = 0.09). Post-operative intra-abdominal complications were the main independent determinant for SSIs (p < 0.001). Antibiotic prophylaxis did not have any significant effect on the rate of SSI caused by these complications (2.2% versus 3.8%, respectively; p = 0.50). The second independent factor was the rate of SSI in patients with super-obesity (BMI ≥60), particularly incisional SSIs (p < 0.001). Antibiotic prophylaxis did not produce any significant decrease in the rate of SSI in patients with a BMI < 60 (2.8% versus 5.5%, respectively; p = 0.24). When these two independent factors were excluded, there were no patients with SSI in the no-antibiotics group, and only one in the antibiotic prophylaxis group (0.5%) (p = 1.00). Conclusions: Routine antibiotic prophylaxis should be questioned in laparoscopic BS. Prophylaxis may reduce incisional SSI in patients with a BMI of ≥60. In other cases, antibiotic prophylaxis does not provide a decrease in SSI.

Hirschsprung's Disease Complicated by Sigmoid Volvulus: A Systematic Review.

BACKGROUND: Hirschsprung's disease and sigmoid volvulus can sometimes be seen in the same patient. AIMS: To investigate the presence of Hirschsprung's disease in patients with sigmoid volvulus and to discuss the diagnosis and treatment methods. STUDY DESIGN: Systematic review. METHODS: This systematic review has been reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the methodological quality of systematic reviews guidelines. The PubMed and Scopus databases were scanned using the keywords "Hirschsprung* volvulus*" and "congenital aganglionic megacolon volvulus*". The reference list of the selected studies was reviewed for cross-checking. Two reviewers independently screened the available literature. Only the Hirschsprung's disease cases involving sigmoid volvulus were included, and cases of patients with volvulus in other sites was excluded. There was no restriction with respect to the publication language and type of writing. The primary outcome was morbidity and mortality. RESULTS: A total of 31 cases were analyzed in 22 articles; 97% of the patients were under the age of 40, 90% were male. There was a statistically significant difference in the necessity for relaparotomy between patients who were scheduled for sigmoid volvulus therapy with the suspicion of Hirschsprung's disease and patients who were treated without suspicion of Hirschsprung's disease (0% vs 37.5%, p=0.02). While there was no postoperative death in cases with suspected Hirschsprung disease, this mortality rate was 25% in cases without suspicion (p = 0.08). CONCLUSION: Hirschsprung's disease should be excluded with rectal biopsy if a patient with sigmoid volvulus is under 40 years of age and has complaints of constipation from childhood.

Totally minimally invasive radical gastrectomy with the da Vinci Xi® robotic system versus straight laparoscopy for gastric adenocarcinoma.

BACKGROUND: Data regarding the outcomes of pure minimally invasive techniques of radical gastrectomy are scarce. We aimed to compare short-term post-operative outcomes in patients undergoing totally minimally invasive radical gastrectomy with the da Vinci Xi® robotic system versus straight laparoscopy for gastric adenocarcinoma. METHODS: Between December 2013 and March 2018, robotic and laparoscopic radical gastrectomy performed in two centres were included. Both groups were compared with respect to perioperative short-term outcomes. RESULTS: Ninety-four patients were included in the study. Anticoagulant and neoadjuvant chemotherapy use were higher in the robotic group (p = 0.02, p = 0.02). There were conversions in the laparoscopy group whereas no conversions occurred in the robotic group (p = 0.052). Operating time in the robotic group was longer (p = 0.001). The number of harvested lymph nodes in the laparoscopic group was higher (p = 0.047). CONCLUSION: Totally robotic technique with the da Vinci Xi® robotic system provides similar short-term results compared to laparoscopic surgery in radical gastrectomy.

Surgical site infection and risk factors following right lobe living donor liver transplantation in adults: A single-center prospective cohort study.

INTRODUCTION: Surgical site infection (SSI) is an important cause of decreased graft survival, prolonged hospital stay, and higher costs following living donor liver transplantation. There are several risk factors for SSI. In this cohort study, we aimed to investigate the incidence of SSI at our center and the associated risk factors. MATERIALS AND METHODS: Adult right lobe living donor liver transplantations were included in this prospective cohort. Patients who died postoperatively within 3 days; patients with infected ascites or open abdomen, cadaveric, or pediatric transplants; and patients with biologic or cryopreserved vascular grafts were excluded. Patients' demographic characteristics and perioperative surgical findings were recorded. SSI follow-up was continued for 90 days. CDC-2017 criteria were used to diagnose SSI. In the presence of superficial, deep, and organ/space SSI, only the organ in the poorest condition was included in SSI evaluation. The patients were administered similar to antibiotic prophylaxes and immunosuppressive protocols. RESULTS: A total of 101 patients were enrolled in this study, of which 30 (29.7%) were diagnosed with SSI. Organ/space, only deep, and only superficial SSI were noted in 90% (27/30), 6.7% (2/30), and 3.3% (1/30) of the patients, respectively. Twenty-five of 30 patients with SSI had a remote site infection. One or more bacteria observed in cultures were obtained from 28 patients. A donor-recipient age difference of >10 years, cold ischemia lasting for ≥150 minutes, surgical duration of ≥600 minutes, intraoperative hemorrhage of ≥1000 mL, intraoperative blood transfusion, biliary leak or stricture, prolonged mechanical ventilation, prolonged intensive care unit and hospital stay, remote site infection, and the need for reoperation were associated with increased SSI incidence. Preoperative and intraoperative levels of blood glucose, albumin, and hemoglobin were not associated with SSI. A donor-recipient age difference of >10 years, remote site infection, and biliary leak were found to be independent risk factors for SSI. Hospital mortality with and without SSIs was 6.7% vs 4.4%, P = .61. DISCUSSION: Organ/space SSIs were the essential part of SSIs following right lobe living donor liver transplantations. Donor-recipient age gap, prolonged cold ischemia time, complicated surgery, and postoperative biliary complications were the main causes of SSIs. Although they did not increase the perioperative mortality, they promote increased rate of reoperations, remote infections, prolonged intensive care unit, and hospital stays.

A Comparison of Natural Orifice Versus Transabdominal Specimen Extraction Following Laparoscopic Total Colectomy.

INTRODUCTION: Natural orifice surgery has been increasingly used in colon surgery since the early 2000s. However, it is rarely used for total colectomy. In this study, we aimed to retrospectively compare natural orifice specimen extraction (NOSE) with transabdominal specimen extraction in patients undergoing laparoscopic total colectomy. MATERIALS AND METHODS: Twenty-six patients who underwent laparoscopic total colectomy between 2013 and 2017 were enrolled and the patients were divided into two groups: NOSE (n = 13) and transabdominal group (n = 13). The patients' demographic characteristics, perioperative and postoperative outcomes, pathology results, visual analog scale scores, and cosmetic scores were compared. RESULTS: There was no significant difference between the two groups in terms of demographic characteristics as well as perioperative and postoperative outcomes, including complications. Benign pathologies were more common in the NOSE group (85% versus 15%, P = .001). The pain scores of the postoperative first, second, and third days were significantly lower in the NOSE group 4.1 ± 2.1 versus 7.1 ± 1.3 (P = .005), 3.7 ± 2.2 versus 6.0 ± 1.5 (P = .003), and 2.2 ± 2.0 versus 4.1 ± 0.9 (P = .03), respectively. As expected, the mean cosmetic score was significantly better in the NOSE group (8.3 ± 1.5 versus 6.7 ± 1.8, P = .02). CONCLUSION: NOSE combined with laparoscopic total colectomy provided better patient comfort in benign diseases and small-sized malignant diseases.