Optimal use of oral nutritional supplements (ONS) in medical nutrition therapy: ONS consensus report from KEPAN.

Medical nutrition therapy is one of the core components of the patient management, although its implication is still limited in daily practice globally. Clinicians are in need of guidance that will ease the application of medical nutrition therapy. The first treatment choice in medical nutrition therapy is the use of oral nutritional supplements (ONS) after or concomitant with dietary interventions. The pre and post-graduate curriculum for medical nutrition therapy is limited in most regions, worldwide. A report that is short, clear, and having clear-cut recommendations that will guide the primary healthcare professionals in indications, choice, practical application, follow-up, and stopping ONS would facilitate the application and success of medical nutrition therapy. KEPAN is the Clinical Enteral and Parenteral Nutrition Society of Turkey and is an active member of the European Society for Clinical Nutrition and Metabolism (ESPEN). In this study, we present the KEPAN ONS consensus report on optimal ONS use in medical nutrition therapy as outlined by works of academicians experienced in clinical application of ONS (eight working group academicians and 19 expert group academicians). This report provides 22 clear-cut recommendations in a question-answer format. We believe that this report could have a significant impact in the ideal use of ONS in the context of medical nutrition therapy when clinicians manage everyday patients.

Single-Center Results of Choledochal Cysts in Turkish Population.

BACKGROUND: Choledochal cysts are seen commonly in Asian populations, but rarely in Western populations. The pathogenesis of these premalignant lesions is not fully understood yet and the risk of malignant transformation increases with age. The overall malignancy risk is 10%-15% in East Asian countries. In this study, we aimed to present our surgical experience as a hepatobiliary center to the literature. METHODS: We retrospectively analyzed the data from the medical records of 70 patients operated for choledochal cyst between 2008-2019. RESULTS: Sixty-two of the 70 (89%) patients were female and 8 (11%) were male, the mean age was 45.89 ± 15.32 years. Overall, 44 (63%) patients had type I (a+b+c), 20 (28%) type V (Caroli), 2 (3%) type II, 2 (3%) type III and 2 (3%) type IVb cysts. The most common operation was cyst excision combined with hepaticojejunostomy (n: 26, 37%). The median diameter of the resected cysts was 3 cm (min- max: 1-11 cm). Malignancy was observed only in three (4%) patients with type III, type Ib, and type V cyts, who were 19, 38, and 72 years old, respectively. Mortality was not observed, morbidity was determined totally in 30 (43%) cases during early and late postoperative periods. CONCLUSION: Type of surgery in choledochal cysts differs according to the type of the cyst. Malignancy was observed at a rate of 4% in all age groups. Although the frequency of malignancy varies, the main treatment of choice should be surgery because malignancy can be seen at a young age.

Management of Laparoscopic Cholecystectomy-Related Bile Duct Injuries: A Tertiary Center Experience.

BACKGROUND: Laparoscopic cholecystectomy (LC)-related bile duct injuries remains a challenging issue with major implications for patient's outcome. METHODS: Between January 2008 and December 2012, we retrospectively analyzed the management and treatment outcomes of 90 patients with bile duct injury following LC. RESULTS: Forty-seven patients (52.2%) were treated surgically while the remaining 43 patients (47.8%) underwent non-surgical intervention. Injuries of Strasberg Type A and C were significantly more frequent in the non-surgical intervention group (P = 0.016, P = 0.044) whereas Type E2 was more frequent in the definitive surgery group (P < 0.001). The success rate of non-surgical intervention decreased as the waiting time increased whereas the success of definitive surgery was not time-dependent (P = 0.048). Initial jaundice (direct biluribin >1.3 gr/dL) significantly reduced the success rate of non-surgical interventions (P = 0.017). Presence of intraabdominal abscess significantly increased the complication rate after both definitive surgery and non-surgical interventions (P = 0.04, P = 0.023). Treatment success rates were similar in both surgery and non-surgical intervention groups according to the distribution of Strasberg injury types. CONCLUSION: A multimodality approach is recommended in planning for patient-based treatment. Delayed referral reduces the success of nonsurgical interventions while it does not seem to significantly affect the success of surgical interventions when intraabdominal sepsis is under control.

Changing Trends in Gastric Cancer Surgery.

Gastric cancer is one of the most common causes of cancer-related death. It requires multimodal treatment and surgery is the most effective treatment modality. Radical surgery includes total or subtotal gastrectomy with lymph node dissection. The extent of lymphadenectomy still remains controversial. Eastern surgeons have performed D2 or more extended lymphadenectomy while their Western colleagues have performed more limited lymph node dissection. However, the trend has been changing in favour of D2 lymph node dissection in both hemispheres. Currently, D2 is the recommended type of lymphadenectomy in experienced centres in the west. In Japan, D2 lymph node dissection is the standard surgical approach. More extensive lymphadenectomy than D2 has not been found to be associated with improved survival and generally is not performed. Bursectomy and splenectomy are additional controversial issues in surgical performance, and trends regarding them will be discussed. The performance of bursectomy is controversial and there is no clear evidence of its clinical benefit. However, a trend toward better survival in patients with serosal invasion has been reported. Routine splenectomy as a part of lymph node dissection has largely been abandoned, although splenectomy is recommended in selected cases. Minimally invasive surgery has gained wide popularity and indications for minimally invasive procedures have been expanding due to increasing experience and improving technology. Neoadjuvant therapy has been shown to have beneficial effects and seems necessary to provide a survival benefit. Diagnostic laparoscopy should be kept in mind prior to treatment.

Surgical Outcomes of Solid Pseudopapillary Neoplasm of the Pancreas: A Single Institution's Experience of 16 Cases.

INTRODUCTION: Solid-pseudopapillary tumor (SPT) of the pancreas is a rare tumor, generally characterized by a well-encapsulated mass. The aim of the current study was to analyse the clinicopathological characteristics and treatment outcomes of patients with SPT. In this study, we report our clinical experience with 16 cases of SPTs. METHODS: Sixteen patients who underwent surgery for pathologically confirmed SPT were included. Data of the patients were reviewed from the prospectively recorded database. Patients' demographics, laboratory values, clinical presentation, radiological imaging findings, surgical treatment, perioperative complications, pathological features, post-operative course, and long-term survival were collected and analyzed. Statistical analyses were performed using the computer program Statistical Package for Social Sciences (SPSS) 16.0 for Windows. RESULTS: The tumors ranged from 2 to 11 cm in diameter and were located in the head in ten patients (62.5%), the neck in two patients (12.5%), and the body or tail in four patients (25%). All patients were women whose ages ranged from 21 to 79 years (mean age was 41.62 ± 15.08). Patients had resection margins free of tumor resections and there were no preoperative or postoperative mortalities. There was no recurrence or metastasis after the surgical resection. All patients were alive at a mean follow-up of 49.06 ± 29.53 months (range 6 to 99). CONCLUSION: SPT is a rare pancreatic neoplasm with a low malignant potential, and is common in young women. If SPT is diagnosed before surgery, complete surgical resection, generally enucleation is the most effective therapy for SPT.

The rationality of resectional surgery and palliative interventions in the management of patients with gallbladder cancer.

The aim of the present study was to evaluate in a retrospective manner, the survival period and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions. Between 2003 and 2012, 67 patients diagnosed with gallbladder carcinoma were retrospectively analyzed. Patient demographics, the survival period, and survival rate according to stages and groups after R0, R1, R2 resections and palliative interventions were retrospectively analyzed. Sixty-seven patients were diagnosed with gallbladder carcinoma. Thirty-eight patients (56.7%) were female and 29 patients (43.3%) were male. The median survival period was significantly longer in stage II and III diseases than in stage IV disease (P < 0.001). The R0, R1, and R2 resection rates in patients who underwent surgery with curative intent were 67.7, 19.4, and 12.9 per cent, respectively. The R0 resection rate according to the tumor stages was 100 per cent for stage I, 87.5 per cent for stage II, 66.7 per cent for stage III, and 42.8 per cent for stage IV disease. The median follow-up period was six months (eight days to 36 months). During this follow-up period, 53 patients (79.1%) died. In conclusion, R0 resection rate decreases when tumor stage increases. The highest survival rates after R0 resection are achieved in patients with stage I, II, and III diseases. Radical surgery has no benefit over palliative surgery for stage IV disease in terms of survival.

Giant hemangiomas: effects of size and type of surgical procedure on postoperative outcome.

BACKGROUND/AIMS: Controversies still exist regarding the management of giant hemangiomas. The purpose of this study was to evaluate in a retrospective manner the effects of size and type of surgical procedures on early postoperative results. METHODOLOGY: Between January 2000 and January 2011, a total of 82 patients underwent surgery. Patients were divided into 2 groups; according to size (Group 1 >10cm and Group 2 ≤10cm) and the selected operative procedure. RESULTS: When the patients were compared according to size of the lesions, the operation time was significantly longer (p=0.01) and the amount of blood loss was significantly higher (p=0.04) in hemangiomas >10cm. If the patients were compared according to type of the surgical procedure, hepatic resection was more frequently preferred in bilobar and left lobe localized lesions, whereas enucleation was significantly more chosen in lesions localized to the right lobe (p=0.01). CONCLUSIONS: Size of the hemangioma did not alter selection of the surgical procedure in this series. Larger hemangiomas are associated with longer operation time and more blood loss. Surgical results after enucleation and resection are similar. Although enucleation seems preferable, it is not an easy procedure, and may result in severe bleeding.

Multidetector computed tomography diagnosis of adenomyomatosis of the gallbladder.

The differentiation of gallbladder adenomyomatosis from gallbladder carcinoma is important as both conditions may present with thickening of the gallbladder wall or as a focal mass. Identification of Rokitansky-Aschoff sinuses is the key feature in making an accurate diagnosis of gallbladder adenomyomatosis on imaging studies. The diagnosis of gallbladder adenomyomatosis can be made with accurately by multidetector computed tomography when the presence of Rokitansky-Aschoff sinuses (small cystic spaces within the thickened gallbladder wall) are noted. Herein we present multidetector computed tomography findings of a 27-year-old patient with gallbladder adenomyomatosis.

A prospective observational study of 468 patients undergoing D2 or D3 lymphadenectomy for gastric cancer.

BACKGROUND/AIMS: A single-center, prospective observational study was performed to evaluate outcomes in patients undergoing D2 or D3 lymphadenectomy for gastric cancer. METHODOLOGY: Lymphadenectomies were performed according to the classification published by the Japanese Gastric Cancer Association. RESULTS: Of 468 consecutive patients, 370 underwent D2 and 98 underwent D3 lymphadenectomy. Postoperative complications were significantly less common in the D2 group than in the D3 group (19.2% vs. 35.7%, p=0.001). Postoperative mortality in the two groups was similar, being 3.8% in the D2 group and 5.1% in the D3 group (p>0.05). Median postoperative survival times were also similar, in the D2 group being 37.8 months (95% CI: 23-52.5), and in the D3 group 30.2 months (95% CI: 13-47.3, p>0.05). CONCLUSIONS: In patients who underwent gastrectomy with curative intent, lymphadenectomy that was more extensive than D2 did not provide a survival benefit compared to D2 dissection.

Multiple synchronous anorectal malignant melanoma coexisting with adenocarcinoma of the sigmoid colon.

Primary anorectal malignant melanoma is an exceptionally rare neoplasm associated with poor prognosis. Anorectal malignant melanoma has been very rarely described with coexisting primary tumors of the colorectum. A 56-year-old female patient was admitted with a history of rectal bleeding. She had experienced increasing constipation and a sense of obstruction in the rectum for 6 months. Flexible rectosigmoidoscopy showed a large, pedinculated polypoid lesion extending from the anal canal to the rectum. She underwent a transanal local excision and was diagnosed with a melanoma of the anorectum with positive margins. Therefore, a formal abdominoperineal resection was performed. In addition to multiple synchronous anorectal malignant melanoma, we incidentally found another primary tumor in the proximal surgical margin of the resected specimen. Histopathologically, the lesion was an intramucosal adenocarcinoma of the sigmoid colon. Postoperatively, the patient received adjuvant chemotherapy of six cycles duration. At present, the patient has completed 18 months of follow-up.

Self-expanding covered metallic stent treatment of esophagojejunostomy fistulas.

PURPOSE: The purpose of this study is to analyze the outcomes of the self-expanding covered metallic stent (SECMS) therapy in the management of the postoperative anastomotic leaks that seen after total gastrectomy-esophagojejunostomy (EJ) operations. MATERIALS AND METHODS: Contrast radiography and endoscopy revealed EJ fistulas in 14 patients. SECMSs were implanted both fluoroscopically and endoscopically to seal fistulas. Postoperative fistula diagnosis times, postoperative covered stent implantation times, primary success rates, clinical success rates, postinterventional oral feeding beginning times, reduction of the drainage from the surgical drains, procedure-related mortality-morbidity, and mortality related with factors other than the procedure were noted. RESULTS: Technical success rate was 100 %. Clinical success rate was 79 %. Reduction of the fluid from surgical drains was observed in all patients. There were no procedure-related mortality. Recurrent fistula was observed in two patients (14 %) at the third and fifth day after the intervention. In one patient (7 %), stent dislocation was observed at the 10th day after the intervention. Non procedure-related mortality was 21 %. No anastomotic stricture, no in-stent stenosis was observed during the follow up period(11.09 ± 3.21 months). CONCLUSION: From the above results we concluded that SECMS treatment for EJ fistulas is a safe, effective and technically easy procedure.

Surgical outcome of patients with perforation after endoscopic retrograde cholangiopancreatography.

BACKGROUND: The most important criterion in the management of endoscopic retrograde cholangiopancreatography (ERCP)-related perforations is the delineation of the injury pattern. The aim of the present study was to evaluate in a retrospective manner the patients who undergo surgery due to ERCP-related perforations. PATIENTS AND METHODS: Between January 2006 and December 2010, a total of 9209 ERCPs were performed at Turkiye Yuksek Ihtisas Teaching and Research Hospital, Ankara, Turkey. From these, perforation was diagnosed in 52 patients (0.56%). Twenty-four patients (46.2%) underwent surgery. Patients were evaluated according to age, gender, ERCP indication, comorbid disease, the time between diagnosis and perforation, the time between ERCP and surgical intervention, radiological and clinical signs, localization of the perforation, surgical procedure, hospitalization period, and postoperative outcome. RESULTS: Twenty-four patients underwent surgery. Thirteen patients (54.1%) had lateral duodenal wall perforation, 4 patients (16.7%) had perforation in the afferent loop (these patients had Billroth-II gastroenterostomy at ERCP admission), 2 patients (8.3%) had bile duct perforation, and 1 patient (4.1%) had esophageal perforation. In 4 patients (16.7%), the localization of the perforation could not be found. Nine patients (37.5%) died in the postoperative period. Six patients had lateral duodenal wall perforation, 2 patients had afferent loop perforation, and one patient had esophagus perforation. Three patients died of nonsurgical reasons (myocardial infarction, serebrovascular occlusion, and cardiac dysrhythmia). CONCLUSIONS: Duodenal wall perforations have a serious fatal outcome even if early surgical intervention is performed. In contrast to duodenal wall injuries, perivaterian and choledochal injuries have a better outcome.

Presence of free cancer cells in the peritoneal cavity of patients who underwent curative gastrectomy with lymph node dissection.

BACKGROUND/AIMS: The aim of this study was to determine the ratio of patients with positive peritoneal cytology who underwent radical gastrectomy for gastric cancer, to evaluate the factors effecting risk of positive cytology and to analyze the effects cytology findings on survival. METHODOLOGY: Peritoneal lavage samples were obtained from 255 patients who underwent radical gastrectomy with D2 (184 patients) or D3 (71 patients) lymph node dissection between January 2000 and December 2007. RESULTS: Thirty-six (14.1%) of 255 patients had free cancer cells in the wash cytology samples. T stage (T4) and differentiation were found to be independent risk factors for positive peritoneal cytology in multivariate analysis. Survival rate of cytology negative patients was significantly higher, however cytology findings were not found to be an independent prognostic factor for survival. T stage, lymph node metastasis and Borrmann classification (Borrmann type 4) appeared to be independent prognostic factors for survival in multivariate analyses. CONCLUSIONS: Peritoneal cytology does not provide additional information according to the TNM (1997) staging system. However, it should be employed intraoperatively before potentially curable serosa involved gastric carcinomas, especially for T4 tumors. Surgery alone will not be enough for patients with positive cytology and further therapies should be employed.

Management of choledochal cysts in adults: a retrospective analysis of 23 patients.

BACKGROUND/AIMS: Choledochal cysts are rare congenital anomalies of the pancreaticobiliary system, whose etiology remains unknown. We aimed to review patients with choledochal cysts and to compare our results with current literature. METHODOLOGY: Twenty-three patients diagnosed as having choledochal cysts between January 2004 and July 2010 were evaluated retrospectively. RESULTS: Thirteen patients had type I (56.5%), 3 patients type II (13%), 3 patients type III (13%), 1 patient type IV-A (8.3%) and the remaining 3 patients had type V (13%) choledochal cysts. All patients with type I cysts underwent cyst excision with Roux-en-Y hepaticojejunostomy. Two patients with type II cysts underwent cyst excision with choledochoduodenostomy, whereas cyst excision with T-tube drainage was applied to the other. Endoscopic unroofing was performed type III cysts. The patient with type IV-A cyst was not eligible for surgery due to low cardiopulmonary performance status but ERCP was applied successfully more than 3 times for the extraction of the stones which fell from the intrahepatic ducts into the common bile duct. Patients with Type V cysts underwent left hepatectomy, choledocoduodenostomy and cadaveric liver transplantation, respectively. Wound infection developed in 5 patients and anastomotic leakage occurred in 3; one died from sepsis. CONCLUSIONS: Choledochal cysts are rare congenital malformations. Although treatment varies depending on the type of the cysts, complete excision of the cysts should be performed if possible.

Basic hemostatic parameters in patients with long-term oral anticoagulation undergoing cholecystectomy.

BACKGROUND: The current hemostatic data in relation to laparoscopic cholecystectomy (LC) is limited particularly for patients receiving chronic oral anticoagulant treatment. The aim of this study is to assess hemostatic alterations before, during and after LC for the patients placed on long-term oral anticoagulant treatment. PATIENTS AND METHODS: A prospective, nonrandomized, controlled study was designed to compare the characteristics, hemostatic system, and postoperative complications of patients maintained on long-term anticoagulation with those who did not receive such therapy. In the period from January 2009 to December 2009, a total of 31 patients who underwent elective LC for symptomatic cholelithiasis were enrolled in the study. Sixteen of these patients were on long-term anticoagulation therapy with warfarin (OAC group). The other 15 patients did not receive anticoagulant or antiaggregant drugs and served as the control group. RESULTS: Five patients (31.5%) of the OAC group had postoperative bleeding, whereas no bleeding occurred in the control group. Significant reductions in postoperative hemoglobin levels were observed in the OAC group when compared with the control group (P<.05). Although within normal ranges, international normalized ratio values and the tissue plasminogen activator activity were significantly higher, whereas factor II, VII, IX, and X levels were significantly lower in the OAC group when compared with the control group (P<.05). CONCLUSION: Patients receiving oral anticoagulant treatment are at risk of postoperative bleeding and the basic parameters of coagulation appear unable to predict which patients undergoing anticoagulant therapy are candidates for bleeding after surgery. More sensitive methods should be developed to measure the degree of hemorrhagic risk.

Short-term outcomes after surgery for colorectal cancer in Turkish patients aged 70 and above.

BACKGROUND/AIMS: We aimed to evaluate the impact of age on short-term surgical outcomes and to investigate the risk factors for postoperative mortality in 660 Turkish colorectal cancer patients. METHODS: Between January 2002 and January 2007, 660 consecutive patients who were operated for colorectal cancer at our institution were enrolled in this study. The patients were divided into two groups as: a younger group (<70 years) and an older group (≥70 years). Patient data were recorded prospectively with the use of specially designed forms. Variables and short-term patient results were compared. RESULTS: American Society of Anesthesiologists (ASA) scores were significantly higher and albumin levels were lower in the older group compared with the younger group (p<0.05). Morbidity and mortality rates were 16.8% (83/494) and 2.6% (13/494) in the younger group and 22.9% (38/166) and 3.0% (5/166) in the older group, respectively. These differences in rates were not statistically significant. ASA score (ASA 4) and non-resective procedures were found to be independent risk factors for mortality. CONCLUSIONS: Age should not be regarded as a reason for limited surgery. Elderly patients should undergo the same standard surgical approach as younger patients. The patient's general state of health is more effective on postoperative mortality.