How should be the Surgical Treatment Approach during the COVID-19 Pandemic in Patients with Gastrointestinal Cancer?

COVID-19 was first seen in China at the end of December 2019. COVID-19 is a novel type of coronavirus that is defined as SARS-CoV-2, which can be mild or severe in the lungs, causing acute respiratory infection. The disease was first presented in the literature as Coronavirus Disease 2019 (COVID-19) in February 2020. The disease spread rapidly and was declared as a pandemic by the World Health Organization (WHO) on March 11, 2020. There have been approximately 7734185 reported cases, and 412369 reported deaths to date (09/June/2020). As COVID-19 spread in the world and our country, hospitals struggling with this disease have also become risky areas for transmitting the disease. Health workers also have a high risk of viral contamination from direct contact of droplets and surfaces. Personal protective equipment (PPE), such as masks, coveralls, gloves, face shields and/or goggles, are mandatory. The aim is to spread the flow of cases requiring hospitalization over time, thereby preventing possible accumulation in hospitals. All non-urgent procedures, such as elective surgeries and diagnostic interventions, were significantly affected. The hospitalization procedures were mostly allocated to patients with COVID-19 infection, and surgical operations were postponed. Only urgent surgical cases and oncological surgeries that cannot be postponed were performed during this pandemic process. Patients followed by oncology are immunosuppressed both because of the disease itself and the side effects of chemotherapy and/or radiotherapy taken. This makes patients more susceptible to infections, and the prognosis of infections in these patients is worse and more destructive. Cancer patients are almost twice as likely to catch COVID-19 compared to the general population. The choice of surgical procedures and perioperative management of the patients with malignancy has become even more important in the COVID-19 pandemic. In this study, we analyzed the treatment processes of our patients with malignancy that underwent a surgical oncological procedure during this pandemic.

A comparison study of left-hand three-port videoscopy, left-hand four-port videoscopy and standard four-port videoscopy in laparoscopic cholecystectomy.

A comparison study of left-hand three-port videoscopy, left-hand four-port videoscopy and standard four-port videoscopy in laparoscopic cholecystectomy AIM: Reviewing the recent publishments on the safeness and practicality of three-port cholecystectomy we aimed to introduce the results of cholecystectomy that were performed by the primary surgeon's left hand videoscopy application through three ports. MATERIAL AND METHODS: The data of 60 total laparoscopic cholecystectomy patients were retrospectively anaylsed. 20 patients underwent three-port laparoscopic cholecystectomy with videoscopy using the primary surgeon's left hand, 20 patients underwent four-port laparoscopic cholecystectomy, again with left hand videoscopy application, and the other 20 patients underwent standard four-port laparoscopic cholecystectomy by a more experienced surgeon. Kolmogorov-Smirnov test was used to evaluate the distribution normalization of parameters. To compare the parameters of multiple groups; one-way ANOVA-Tukey HSD was used for normal distributed, the Kruskal-Wallis test was used for abnormal distributed values. Pearson's chi-squared test was used for categorical values. The results with p-values of less than 0.05 were accepted as statistically significant. RESULTS: There were no differences between the groups for preoperative (p=0.456) and perioperative clinical characteristics (p=0.918), mean operation time (p=0.855), perioperative complication (p=0.153), conversion to open surgery (p=0.362) and the need for first assistant surgeon (p=0.235). However, the need for second assistant surgeon (p=0.017), assistant nurse (p=0.014) and fourth tool usage (p=0.000) were significantly lower in the three port group. CONCLUSION: Left-hand videoscopy in three-port laparoscopic cholecystectomy is reliable and effective as the conventional techniques and cheaper than conventional techniques. It's easily applicaple and learnable for experienced surgeons. KEY WORDS: Cholecystectomy, Four ports, Laparoscopy, Left-hand videoscopy, Three ports.

Stercoral perforation of the rectosigmoid colon due to chronic constipation: A case report.

INTRODUCTION: Chronic constipation is very common in elderly patients. As a result of this situation fecaloma is also frequently seen at these ages. However, the stercoral perforation caused by fecaloma is a rare situation to occur. The rectosigmoid colon is the most affected colonic segment. It is seen in older patients with concomitant diseases and a low quality of life. PRESENTATION OF CASE: Here in this case, we have to report an 83 - year-old male patient who came to the emergency room with complaints of abdominal pain and constipation for two days. He had Type II Diabetes Mellitus, had a cardiac stent and also Alzheimer's disease. We diagnosed a rectosigmoid perforation due to a large fecaloma. This case presentation was prepared in accordance with the scare checklist guidelines (Agha et al., 2016 [1]). DISCUSSION: Constipation and faecal impaction are common entities, particularly in elderly and bedridden patients. Fecalomas are collections of dehydrated, hardened stool. They rarely can cause colonic ischemia and/or stercoral perforation. Stercoral perforation is the perforation or rupture of the intestine walls by a stercoraceous mass. Stercoral perforation is a very dangerous, life-threatening situation, as well as a surgical emergency, because the spillage of contaminated intestinal contents into the abdominal cavity leads to peritonitis, a rapid bacteremia with many complications. CONCLUSION: Fecalomas can cause stercoral perforations. This situation can be confused with other causes of acuteabdomen in these patients. Early surgery can be life saving.

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.

Sedation-analgesia in elective colonoscopy: propofol-fentanyl versus propofol-alfentanil.

BACKGROUND AND OBJECTIVES: Sedation-analgesia is recommended for comfortable colonoscopy procedures, which are invasive and can be painful. This study aimed to compare the combinations of propofol-alfentanil and propofol-fentanyl for sedation-analgesia in elective colonoscopy patients. METHODS: This prospective and randomized study was planned in ASA I-II groups and included 80 patients between the ages of 18 and 65 years. Sedation-analgesia induction was performed as 1 µg.kg-1 fentanyl, 1 mg.kg-1 propofol in the propofol-fentanyl group (Group PF) and 10 µg.kg-1 alfentanil, 1 mg.kg-1 propofol in the propofol-alfentanil group (Group PA). Patients' scores were limited to 3-4 values on the Ramsey Sedation Scale (RSS) by 0.5 mg.kg-1 bolus additional doses of propofol in sedation-analgesia maintenance. We recorded demographical data, heart rate, mean arterial pressure (MAP), oxygen saturation of hemoglobin (SpO2), RSS value, colonoscopy time, total dose of propofol, complications, recovery time, and discharge time, as well as colonoscopist and patient satisfaction scores. RESULTS: MAP at the 15th minute in Group PA was signifi cantly higher than in Group PF (p = 0.037). Group PA's beginning mean heart rate was higher than the mean heart rate at subsequent readings (p = 0.012, p = 0.002). The mean total propofol dose of Group PA was signifi cantly higher than the total dose of Group PF (p = 0.028). The mean recovery time of Group PA was signifi cantly longer than that of Group PF (p = 0.032). CONCLUSION: Fentanyl provides better operative conditions and reduces the need for additional propofol doses. These advantages cause a shorter recovery time. Therefore, propofol-fentanyl is superior to the propofol-alfentanil for sedation-analgesia in colonoscopy.

Sedação e analgesia em colonoscopia eletiva: propofol-fentanil versus propofol-alfentanil / Sedation-analgesia in elective colonoscopy: propofol-fentanyl versus propofol-alfentanil / Sedación y analgesia en colonoscopia electiva: propofol-fentanilo versus propofol-alfentanilo

JUSTIFICATIVA E OBJETIVO: Sedação e analgesia são recomendadas em colonoscopia para propiciar conforto, pois são procedimentos invasivos e podem ser dolorosos. Este estudo teve como objetivo comparar as combinações de propofol-alfentanil e propofol-fentanil para sedação e analgesia em pacientes submetidos à colonoscopia eletiva. MÉTODOS: Estudo prospectivo e randomizado. Participaram do estudo 80 pacientes, ASA I-II, entre 18 e 65 anos. A indução de sedação e a analgesia foram feitas com propofol (1 mg.kg-1) e fentanil (1 µg.kg-1) no grupo propofol-fentanil (PF) e com propofol (1 mg.kg-1) e alfentanil (10 µg.kg-1) no grupo propofol-alfentanil (PA). Para manutenção, doses adicionais de propofol foram administradas em bolus de 0,5 mg.kg-1 para obter escores de 3-4 na Escala de Sedação de Ramsey (ESR). Registrados os dados demográficos, a frequência cardíaca, a pressão arterial média (PAM), a saturação de oxigênio da hemoglobina (SpO2), os valores da ESR, o tempo de colonoscopia, a dose total de propofol, as complicações, o tempo de recuperação e o tempo para alta, bem como os escores de satisfação do colonoscopista e do paciente. RESULTADOS: A PAM aos 15 minutos no Grupo PA foi significativamente maior do que no Grupo PF (p = 0,037). A frequência cardíaca média do grupo PA foi maior no início do que nas mensurações subsequentes (p = 0,012, p = 0,002). A média da dose total de propofol do Grupo PA foi significativamente maior do que a do Grupo PF (p = 0,028). O tempo médio de recuperação do grupo PA foi significativamente maior do que o do grupo PF (p = 0,032). CONCLUSÃO: Fentanil proporciona melhores condições de operação e reduz a necessidade de doses adicionais de propofol. Essas vantagens diminuem o tempo de recuperação. Portanto, propofol-fentanil é superior ao propofol-alfentanil para sedação e analgesia em colonoscopia.

BACKGROUND AND OBJECTIVES: Sedation-analgesia is recommended for comfortable colonoscopy procedures, which are invasive and can be painful. This study aimed to compare the combinations of propofol-alfentanil and propofol-fentanyl for sedation-analgesia in elective colonoscopy patients. METHODS: This prospective and randomized study was planned in ASA I-II groups and included 80 patients between the ages of 18 and 65 years. Sedation-analgesia induction was performed as 1 µg.kg-1 fentanyl, 1 mg.kg-1 propofol in the propofol-fentanyl group (Group PF) and 10 µg.kg-1 alfentanil, 1 mg.kg-1 propofol in the propofol-alfentanil group (Group PA). Patients' scores were limited to 3-4 values on the Ramsey Sedation Scale (RSS) by 0.5 mg.kg-1 bolus additional doses of propofol in sedation-analgesia maintenance. We recorded demographical data, heart rate, mean arterial pressure (MAP), oxygen saturation of hemoglobin (SpO2), RSS value, colonoscopy time, total dose of propofol, complications, recovery time, and discharge time, as well as colonoscopist and patient satisfaction scores. RESULTS: MAP at the 15th minute in Group PA was significantly higher than in Group PF (p = 0.037). Group PA's beginning mean heart rate was higher than the mean heart rate at subsequent readings (p = 0.012, p = 0.002). The mean total propofol dose of Group PA was significantly higher than the total dose of Group PF (p = 0.028). The mean recovery time of Group PA was significantly longer than that of Group PF (p = 0.032). CONCLUSION: Fentanyl provides better operative conditions and reduces the need for additional propofol doses. These advantages cause a shorter recovery time. Therefore, propofol-fentanyl is superior to the propofol-alfentanil for sedation-analgesia in colonoscopy.

JUSTIFICATIVA Y OBJETIVO: La sedación y la analgesia están recomendadas en la colonoscopia para propiciar la comodidad, porque son procedimientos invasivos y pueden ser dolorosos. Este estudio tuvo el objetivo de comparar las combinaciones de propofol-alfentanilo y propofol-fentanilo para la sedación y la analgesia en pacientes sometidos a la colonoscopia electiva. MÉTODOS: Estudio prospectivo y aleatorio. Participaron en el estudio 80 pacientes, ASA I-II, entre 18 y 65 años. La inducción de sedación y la analgesia fue hecha con propofol (1 mg.kg-1) y fentanilo (1 µg.kg-1) en el grupo propofol-fentanilo (PF) y con propofol (1 mg.kg-1) y alfentanilo (10 µg.kg-1) en el grupo propofol-alfentanilo (PA). Para el mantenimiento, dosis adicionales de propofol se administraron en bolos de 0,5 mg.kg-1 para obtener las puntuaciones de 3-4 en la Escala de Sedación de Ramsey (ESR). Se registraron los datos demográficos, la frecuencia cardíaca, la presión arterial promedio (PAP), la saturación de oxígeno de la hemoglobina (SpO2), los valores de la ESR, el tiempo de colonoscopia, la dosis total de propofol, las complicaciones, el tiempo de recuperación y el tiempo para el alta, como también las puntuaciones de satisfacción del colonoscopista y del paciente. RESULTADOS: La PAP a los 15 minutos en el Grupo PA fue significativamente mayor que en el Grupo PF (p = 0,037). La frecuencia cardíaca promedio del grupo PA fue mayor al inicio que en las mensuraciones posteriores (p = 0,012, p = 0,002). El promedio de la dosis total de propofol del Grupo PA fue significativamente mayor que la del Grupo PF (p = 0,028). El tiempo promedio de recuperación del grupo PA fue significativamente mayor que el del grupo PF (p = 0,032). CONCLUSIONES: El Fentanilo proporciona mejores condiciones de operación y reduce la necesidad de dosis adicionales de propofol. Esas ventajas reducen el tiempo de recuperación. Por tanto, el propofol-fentanilo es superior al propofol-alfentanilo para la sedación y la analgesia en la colonoscopia.

Sedation-analgesia in elective colonoscopy: propofol-fentanyl versus propofol-alfentanil.

BACKGROUND AND OBJECTIVES: Sedation-analgesia is recommended for comfortable colonoscopy procedures, which are invasive and can be painful. This study aimed to compare the combinations of propofol-alfentanil and propofol-fentanyl for sedation-analgesia in elective colonoscopy patients. METHODS: This prospective and randomized study was planned in ASA I-II groups and included 80 patients between the ages of 18 and 65 years. Sedation-analgesia induction was performed as 1 µg.kg(-1) fentanyl, 1mg.kg(-1) propofol in the propofol-fentanyl group (Group PF) and 10 µg.kg(-1) alfentanil, 1mg.kg(-1) propofol in the propofol-alfentanil group (Group PA). Patients' scores were limited to 3-4 values on the Ramsey Sedation Scale (RSS) by 0.5mg.kg(-1) bolus additional doses of propofol in sedation-analgesia maintenance. We recorded demographical data, heart rate, mean arterial pressure (MAP), oxygen saturation of hemoglobin (SpO2), RSS value, colonoscopy time, total dose of propofol, complications, recovery time, and discharge time, as well as colonoscopist and patient satisfaction scores. RESULTS: MAP at the 15(th) minute in Group PA was significantly higher than in Group PF (p = 0.037). Group PA's beginning mean heart rate was higher than the mean heart rate at subsequent readings (p = 0.012, p = 0.002). The mean total propofol dose of Group PA was significantly higher than the total dose of Group PF (p = 0.028). The mean recovery time of Group PA was significantly longer than that of Group PF (p = 0.032). CONCLUSION: Fentanyl provides better operative conditions and reduces the need for additional propofol doses. These advantages cause a shorter recovery time. Therefore, propofol-fentanyl is superior to the propofol-alfentanil for sedation-analgesia in colonoscopy.