Surgical reconstruction of major bile duct injuries: Long-term results and risk factors for restenosis.

BACKGROUND: A single-institution retrospective analysis was undertaken to assess long-term results of definitive surgical reconstruction for major bile duct injuries and risk factors for restenosis. METHODS: Patients treated between January 1995 and October 2020 were reviewed retrospectively. The primary outcome measure was patency. RESULTS: Of 417 patients referred to a tertiary center, 290 (69.5%) underwent surgical reconstruction; mostly in the form of a hepaticojejunostomy (n = 281, 96.8%). Major liver resection was undertaken in 18 patients (6.2%). There were 7 postoperative deaths (2.4%). Patency was achieved in 97.4% of primary repairs and 88.8% of re-repairs. Primary patency at three months (including postoperative deaths and stents removed afterwards) in primary repairs was significantly higher than secondary patency attained during the same period in re-repairs (89.3% vs 76.5%, p < 0.01). The actuarial primary patency was also significantly higher compared to the actuarial secondary patency 10 years after reconstruction (86.7% vs 70.4%, p = 0.001). Vascular disruption was the only independent predictor of loss of patency after reconstruction (OR 7.09, 95% CI 3.45-14.49, p < 0.001), showing interaction with injuries at or above the biliary bifurcation (OR 9.52, 95% CI 2.56-33.33, p < 0.001). CONCLUSIONS: Long-term outcome of surgical reconstruction for major bile duct injuries was superior in primary repairs compared to re-repairs. Concomitant vascular injury was independently associated with loss of patency requiring revision.

Choledochal cysts: Management and long-term follow-up.

BACKGROUND: Choledochal cysts are congenital anomalies that can occur at any level of the biliary tree. They carry long-term risk of biliary complications and cancer development. Complete excision of all involved bile ducts is recommended. METHODS: Patients treated between 1995 and 2019 were reviewed retrospectively. RESULTS: Sixty patients; 46 female and 14 male with a median age of 41 years (range 13-83) were included in the study. Mild abdominal pain was the most common presenting symptom (60%). Majority of the patients had Todani type I cysts (67%). Concomitant biliary malignancy was diagnosed in five patients (9%). Eight patients were followed-up conservatively (13%). Twenty-five patients were treated by excision of the extrahepatic bile ducts and Roux-en-Y hepaticojejunostomy, liver resection was added in seven, pancreatoduodenectomy was done in three and liver transplantation in one. There was no perioperative mortality. Postoperative complications developed in 17 patients (34%), two requiring surgical treatment. Four of the five patients with malignancies died at a median 42 months (range 6-95) following surgery. Median 62 months (range 8-280) follow-up was available in 45 surgically treated patients, 19 followed-up for more than 10 years. None of the patients developed malignancy during follow-up. Four patients (17%) were readmitted for anastomotic strictures requiring treatment. CONCLUSION: The majority of choledochal cysts are Todani type-I and early cyst excision is the mainstay of management, which may decrease the risk of malignant transformation.

Clinical significance of serum ADP-ribosylation and NAD glycohydrolase activity in patients with colorectal cancer.

The objective of this study was to evaluate the clinical significance of serum ADP-ribosylation and NAD glycohydrolase activity in patients with colorectal cancer (CRC). A total of 108 patients with CRC who underwent curative surgery and 20 healthy volunteers were enrolled in this study. ADP-ribosylation and NAD glycohydrolase activity levels were determined. The association of ADP-ribosylation and NAD glycohydrolase with clinical and laboratory factors and their impact on overall survival (OS) and disease free survival (DFS) were shown. The preoperative ADP-ribosylation and NAD glycohydrolase activity levels were significantly higher in patients with CRC than in the control group (p<0.001). ADP-ribosylation and NAD glycohydrolase activity levels were correlated with tumor stage (p=0.05, p=0.001), stage of disease (p<0.001, p<0.001), serum CEA level (p<0.001, p<0.001), and site of lesion (p<0.001, p<0.001), respectively. Patients with high ADP-ribosylation had significantly unfavorable OS and DFS compared with those with lower levels (p<0.001, p<0.001), respectively. Moreover, the patients with high NAD glycohydrolase activity showed significantly worse OS and DFS rates, similar to ADP-ribosylation. Serum levels of ADP-ribosylation and NAD glycohydrolase activity correlate well with tumor stage, stage of disease, serum CEA level, and site of lesion. In conclusion, elevated levels of preoperative ADP-ribosylation and NAD glycohydrolase levels in serum are associated with poor prognosis in patients with CRC.

Is Endoscopic Sphincterotomy Sufficient in the Treatment of Sump Syndrome? A 25-Year Experience.

Background: Sump syndrome is one of the rare long-term complications of side-to-side choledochoduodenostomy (CD) leading to attacks of cholangitis due to accumulation of food and debris in the common bile duct distal to the anastomosis is one of the rare long-term complications after CD. Methods: Fifteen patients treated with the Sump syndrome in our institution between 1996 and 2023 were retrospectively evaluated for long-term outcome. Results: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and bile duct clearance was done in 11 patients, while four were subjected to revisional surgery in the form of a Roux-en-Y hepaticojejunostomy. No complications were recorded. There were 5 (38%) recurrences in a median follow-up period of 8 years (10 months-23 years). Of those, 3 patients were treated surgically and two with repeat ERCP. None of the patients developed any cholangiocarcinoma during follow-up. Conclusion: We conclude that although a high recurrence rate was observed, endoscopic treatment may be a valid approach in the treatment of Sump syndrome, with revisional surgery in the form of a Roux-en-Y hepaticojejunostomy as salvage therapy in recurrences.

Effects of intraperitoneal bevacizumab administration on colonic anastomosis and early postoperative adhesion formation.

AIM: The purpose of this study is to investigate the effect of intraperitoneal (IP) bevacizumab on colonic anastomosis and evaluate the effects on early postoperative adhesion formation. MATERIALS AND METHODS: A total of 24 mature female Sprague-Dawley rats were used for this study. Rats were randomly assigned to a control group that received saline (n = 8) or to experimental groups (n = 8 each) that received bevacizumab at a dose of 2.5 mg/kg (group 1) or 5 mg/kg (group 2). Animals were killed humanely on the seventh day after operation, and measurements of anastomotic strength and biochemical variables were performed. RESULTS: The mean adhesion grade was 2.63 ± 0.92, and 1 ± 0.93 and 0.75 ± 0.71 for the control and test groups, respectively. Bevacizumab significantly reduced adhesion formation in both low-dose and high-dose IP applications (P < .05). When all groups were compared, it was found that VEGF levels decreased significantly only in the tissue (P = .001), whereas there was no significant difference in the blood and the IP fluid (P = .73 and .08, respectively). We evaluated hydroxyproline levels, anastomosis bursting pressure, and histopathological healing scores. When each of these parameters were examined, there was statistical difference between groups (P = .01, .004, and .01, respectively). It was found that these parameters significantly decreased depending on increasing drug dose. CONCLUSION: IP administration of bevacizumab effectively reduced the formation of adhesions and caused significant impairment of anastomotic wound healing when standard doses were administered (5 mg/kg), but the 2.5-mg/kg dosage did not affect the anastomotic wound healing and also effectively reduced the formation of adhesions.

An atypically localized gastrointestinal stromal tumor: a case report of pancreas gastrointestinal stromal tumor.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. They can arise from any part of the tract as well as the omentum, mesentery or retroperitoneum. In this study, we present a case of a GIST originating from an extraordinary site, the pancreas. Evaluation of 30-year-old man with complaints of abdominal distension revealed a cystic, distal pancreatic lesion 13 cm in diameter. There were no intra-abdominal or distant organ metastases. The patient was operated with a diagnosis of cystic pancreas tumor, distal pancreatectomy and splenectomy was performed. The lesion was diagnosed as gastrointestinal stromal tumor upon histopathological examination. He was discharged on the sixth postoperative day without any complications and is being followed up for 21 months without systemic or local recurrence. Extragastrointestinal GISTs are reported rarely. To our knowledge, only one pancreatic GIST has been reported previously in the English literature.

Differential of cholangiocarcinoma disease using Raman spectroscopy combined with multivariate analysis.

Cholangiocarcinoma (CCA) is a type of cancer, which 5-year survival is lower than 20 %, and which is detected mostly in advanced stage of the disease. Unfortunately, there are no diagnostic tools, which could show changes in the body indicating the development of the disease. Therefore, in this study, we investigate Raman spectroscopy as a promising analytical tool in medical diagnostics and as a method, which would allow to distinguish between healthy patients and patients suffering from cholangiocarcinoma. The obtained Raman spectra showed, that lower intensities of peaks corresponding to amino acids and proteins, as well as higher intensities of peaks originating from lipids vibrations were observed in healthy individuals in comparison with cancer patients. Moreover, Partial Last Square (PLS), Principal Component Analysis (PCA) and Hierarchical Component Analysis (HCA) of Raman spectra indicate that the ranges between 800 cm-1 and 1800 cm-1, 3477 cm-1 -3322 cm-1 and 1394 cm-1 -1297 cm-1 allow to distinguish cancer patients from healthy ones. The obtained results showed, that Raman spectroscopy is a good candidate, to become in future one of the diagnostic tools of Cholangiocarcinoma.

Acinar Cystic Transformation of the Pancreas: Report of Three Cases.

Acinar cystic transformation (ACT) of the pancreas is a rare non-neoplastic cystic lesion. It is most frequently observed in the head of the pancreas. Despite advances in radiologic imaging methods, preoperative diagnosis of acinar cystic transformation is difficult, it is often confused with other cystic lesions. Here, we report three cases of acinar cystic transformation, one of which showed diffuse involvement of the pancreas, and the remaining two were multilocular localized cystic lesions. We analyzed their histomorphologic and immunohistochemical features. The patients' ages ranged between 15 and 43 years and the ratio of females to males was 2:1. On microscopic examination, the cysts were lined by a single layer of flattened-cuboidal or columnar epithelial cells. The epithelial cells were diffusely positive with trypsin and keratin 7, but patchy with keratin 19. Due to its rarity and lack of radiologic and clinical awareness compared with other pancreatic cystic lesions, preoperative diagnosis of acinar cystic transformation is difficult and not definitive. All cases reported to date have been clinically benign and there is no evidence of recurrence or malignant transformation. The optimal treatment and whether to perform surgery remain controversial.

A New Era in Minimally Invasive Liver Resection (MILR) Single-Incision Laparoscopic Liver Resection (SIL-LR): The First Two Cases.

Laparoscopy has gained a place in everyday surgical routine as an alternative surgical approach that decreases morbidity and postoperative hospitalization. Single port laparoscopic surgery has been introduced as a further development of laparoscopy. The feasibility and safety of single port laparoscopy is under extensive evaluation in specialized laparoscopic centers. Nevertheless, wide acceptance of the technique requires adequate documentation of the advantages of the approach over conventional laparoscopy and further refinement of surgical instrumentation to overcome intraoperative ergonomic problems.

Spontaneous regression of liver hemangiomas: a single-institution analysis of 46 patients.

OBJECTIVE: The aim of this study was to determine the nature of spontaneous regression of liver hemangiomas. PATIENTS AND METHODS: The records of the liver hemangioma patients who attended the out-patient clinic between 1988 and 2018 were evaluated. The data of the 716 adult patients who were followed for at least 3 years with cross-sectional imaging were analyzed. RESULTS: Spontaneous regression was documented in 46 patients (6.4%). Twenty-eight patients had a single hemangioma (61%), eight (17%) had two hemangiomas; the other 10 patients had 3-6 hemangiomas. Of the 87 lesions in 46 patients, 69 actually regressed during the study. Twelve patients with more than one lesion exhibited discordant courses - one of the hemangiomas of a patient with multiple lesions regressed, whereas the other enlarged or remained stable. Eleven of the regressed hemangiomas exhibited enlargement first, followed by spontaneous regression. Fourteen (20%) of the regressed hemangiomas acquired atypical characteristics that would have suggested a malignancy had the original films been unavailable. CONCLUSION: Spontaneous regression of liver hemangiomas is an underrecognized phenomenon. Enlargement should not be a straightforward indication for intervention because it may be followed by regression. A regressed hemangioma should be considered in the differential diagnosis of liver lesions suspicious for malignancy.

Complementary Roles of Cadaveric and Living Donor Liver Transplantation in Acute Liver Failure.

BACKGROUND: Living donor liver transplantation may complement cadaveric transplantation in acute liver failure (ALF) patients. METHODS: Between 2008 and 2017, 89 patients were treated for ALF; 15 patients (17%) recovered with intensive care treatment; 31 (35%) died without transplant. The records of the remaining 43 patients (median (range) age: 14 (1-62)) who underwent transplantation were evaluated. RESULTS: The etiologic factors were toxic agents (10; mushrooms: 8; herbs: 2), hepatitis viruses (7; A: 1; B: 6), Wilson's disease (7), autoimmune hepatitis (4), and Budd-Chiari syndrome (2); 13 cases were idiopathic. Cadaveric organs (whole, split, reduced) were transplanted to 32 patients; 11 patients underwent living donor transplantation. One patient (2%) died of septic shock on the second postoperative day. Bacterial infection was the most common early (< 3 months) complication in the remaining patients (31/42; 74%), followed by delirium (5/42; 12%) and acute rejection requiring steroid pulse (5/42; 12%). Seven other patients died during median (range) follow-up of 94 (14-142) months: various infections (5), leukemia (1), and acute myocardial infarction (1). The 1-, 5-, and 10-year survival rates were 100%, 96%, and 92% in children and 94%, 82%, and 65% in adults respectively. CONCLUSIONS: Cadaveric organ sharing and transplantation from living donors when appropriate yield a high survival rate, despite high early morbidity, in ALF patients whose conditions deteriorate despite intensive care treatment. Efforts to eliminate preventable causes of acute liver failure will lead to more efficient use of health care resources.

[Venous thromboembolism prophylaxis methods in trauma and emergency surgery intensive care unit patients: low molecular weight heparin versus elastic stockings + intermittent pneumatic compression]. / Travma ve acil cerrahi yogun bakim hastalarinda venöz tromboemboli profilaksisi: Düsük molekül agirlikli heparin ile elastik çorap + aralikli pnömotik kompresyonun karsilastirilmasi.

BACKGROUND: We aimed to evaluate the efficacy and safety of low molecular weight heparin (LMWH) compared to elastic stockings in combination with intermittent pneumatic compression (ES+IPC) in venous thromboembolism (VTE) prophylaxis in the intensive care unit (ICU) of trauma and emergency surgery. METHODS: From June 2005 to June 2007, 259 patients who were on mechanic ventilation in the ICU were assigned to two groups as either LMWH (152 patients) or ES+IPC (94 patients). Color flow Doppler sonography was performed on the 3rd and 7th days. RESULTS: Deep venous thrombosis was determined in 3 (2%) of the LMWH group and in 1 (1%) in the ES+IPC group. Minor bleeding was seen in 15 patients. The frequency of VTE was 1.5%. Two patients suffered from fatal pulmonary embolism (PE) among a total of 4 patients with PE. CONCLUSION: We believe that the protocol applied for VTE prophylaxis in the Emergency Surgery Department of Istanbul Medical Faculty is effective and safe in this group with such high mortality and morbidity.

Is There Still a Role for Surgical Shunts in the Treatment of Budd-Chiari Syndrome? A 25-Year Experience.

PURPOSE: To investigate the long-term results of shunt surgery in the treatment of Budd-Chiari Syndrome. METHODS: Medical records of patients treated with Budd-Chiari Syndrome between 1993 and 2006 were reviewed. RESULTS: Thirty-seven patients (26 female, 11 male) were identified, with a median age of 30 years (range 14-51). Median duration of symptoms was 3 months (range 1 month to 10 years). Twenty-five patients, all in acute or subacute stages of disease, were treated surgically. Constructed shunts were mesoatrial in 17, portocaval in five (one was converted from a failed portorenal shunt) and mesocaval in three. Median portal pressure decreased from 44 cm H2O (range 31-55) to 20 cm H2O (range 5-27). Seven patients (28%) died in the perioperative period. Eighteen patients (72%) were followed up for a median of 186 months (24-241 months). Seven patients died during follow-up, five due to reasons related to the underlying cause and treatment. Remaining 11 patients (61%) were alive at a median of 18 years (13-25 years) with patent shunts. One-, 5-, and 10-year survival rates in patients undergoing shunt surgery were 78%, 72%, and 66%, respectively. CONCLUSION: Portosystemic shunts may still be considered when expertise for transjugular intrahepatic portosystemic shunt or liver transplantation is not available.

Challenges in Retrorectal Cysts: Is Preoperative Diagnosis Essential?

Developmental cysts are a subgroup of perirectal cysts seen extremely rarely. They have no symptoms in 50% of cases, and mostly occur among middle-aged women. The ratio of male to female is approximately 1/3. In the differential diagnosis, malignancies and pilonidal cysts are common. Although they usually occur as benign lesions, 30% of cases are reported as malignant in literature. Preoperative diagnosis is quite challenging, but may be essential for appropriate treatment. The main treatment is surgical removal of the entire cyst for the prevention of complications and the potential for malignancy. In addition to the trans-sacral or perineal approach, anterior laparoscopy can be performed as an optional surgical technique. Herein, we report two consecutive patients with two different developmental cyst pathologies. A 17-year girl, who had no specific symptoms for a retrorectal giant cyst, was admitted to this clinic because of pilonidal cyst disease. A giant retrorectal cyst was diagnosed through pelvic MRI,which was performed upon her reporting a mild fullness feeling. The other cyst was diagnosed in a 30-year woman who had mild gastrointestinal symptoms that could not be related to the cyst. Both underwent surgery via the trans-sacral approach. The cysts were completely removed without abdominal intervention. Key Words: Epidermoi cyst, Pilonidal cyst, Tail-gut cyst, Retrorectal Space.

Retrospective Analysis of Primary Suturing of the Internal Orifice of Perianal Fistula During FiLaC Procedure.

PURPOSE: We aimed to evaluate the results of the fistula-tract laser closure associated with primary closure of internal orifice. MATERIALS AND METHODS: The surgical objective was to seal the fistula tract using laser energy and closing internal orifice with purse-string suture. Between January 2017 and December 2018, 35 consecutive patients who underwent the laser closure plus internal orifice suturing included. In all 35 patients, the laser procedure was applied then internal orifice was primarily closed with 2-0 polyglactin suture after the debridement of necrotic tissue. RESULTS: Among 35 patients (11 female, 24 male), mean age was 43.9±12.9 years. Median follow-up was 11 months (6.0 to 17.6 mo). According to the Park classification; 21 patients (60%) had intersphincteric fistula, 12 (34%) had transsphincteric fistula, 2 (6%) had suprasphincteric or extrasphincteric fistula. There were low/simple and high/complex fistula in 21 (60%) and 14 patients (40%), respectively. Overall, 15/35 (42.9%) patients showed complete healing, 12/35 (34%) had slight drainage with minimal symptoms, 8/35 (22%) patients had persistent symptomatic drainage, and there was no patient with painful symptomatic drainage. On the basis of the Jorge-Wexner continence score, there was no significant difference in patients before and after the procedure. The perfect continence rate was achieved in 32 patients (91%). CONCLUSION: Although the absence of major and minor complications after Fistula Laser Closure (FiLaC) procedure seemed to be a major advantage, we thought that closure of the internal opening by primary suturing has no positive effect on the healing of the perianal fistula.

Does Helicobacter pylori infection influence the major postoperative complication rate after sleeve gastrectomy? A retrospective cohort study in an endemic region.

BACKGROUND/AIMS: Helicobacter pylori infection is very common in Eastern countries. Little is known about the impact this infection has on bariatric surgery outcomes. This retrospective cohort study conducted on obese Turkish adults who underwent sleeve gastrectomy at a single center aimed to determine the prevalence of H. pylori infection and the effect of this infection on the rate of early major postoperative complications. MATERIALS AND METHODS: All consecutive patients who underwent sleeve gastrectomy for obesity between 2014 and 2015 and who had complete data were enrolled. A single surgeon performed all procedures. All resected specimens were sent to pathology for analysis. RESULTS: Of the 460 patients who met the eligibility criteria, 326 (71%) were female. The average (±standard deviation) age and body mass index were 37.5±10.0 years and 42.7±7.7 kg/m2, respectively. Histology revealed that 150 (33%) patients had H. pylori infection. The H. pylori-infected group developed two complications (leakage and intra-abdominal collection). The uninfected group developed three complications (all bleeding related). The two groups did not differ significantly regarding postoperative complication rates (1.3% vs. 1.0%; p=0.717). CONCLUSION: H. pylori infection did not affect the rate of early complications after sleeve gastrectomy. This suggests that H. pylori screening or eradication policy is not essential for asymptomatic candidates who have undergone sleeve gastrectomy.

Pituitary Adenoma and Hyperprolactinemia Accompanied by Idiopathic Granulomatous Mastitis.

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory disease of the breast, and its etiology remains not fully elucidated. IGM is observed more often in patients with autoimmune disease. Hyperprolactinemia is observed during pregnancy, lactation, and a history of oral contraceptive use. A 39-year-old patient with no history of oral contraceptive use presented with complaints such as redness, pain, and swelling in her left breast. Ultrasound and magnetic resonance imaging (MRI) revealed a suspicious inflamed mass lesion. Core biopsy was performed to exclude breast cancer and to further diagnose. The breast abscess was drained and steroids were given for treatment. In order to monitor any progression during the three months of treatment, hormone levels were routinely examined. Prolactin level was above the reference range, and pituitary MRI revealed a pituitary prolactinoma. After treatment with prolactin inhibitors, IGM also improved with hyperprolactinemia. This report emphasizes attention to hyperprolactinemia in cases of IGM diagnosis and treatment.

Laparoscopic Sleeve Gastrectomy Improves Olfaction Sensitivity in Morbidly Obese Patients.

BACKGROUND: Olfactory abilities of the patients are known to be altered by eating and metabolic disorders, including obesity. There are only a number of studies investigating the effect of obesity on olfaction, and there is limited data on the changes in olfactory abilities of morbidly obese patients after surgical treatment. Here we investigated the changes in olfactory abilities of 54 morbidly obese patients (M/F, 22/32; age range 19-57 years; body mass index (BMI) range 30.5-63.0 kg/m(2)) after laparoscopic sleeve gastrectomy. METHOD: A laparoscopic sleeve gastrectomy was performed by the same surgeon using five-port technique. Olfactory abilities were tested preoperatively and 1, 3, and 6 months after the surgery using a standardized Sniffin' Sticks Extended Test kit. RESULTS: Analyses of variance indicated statistically significant improvement in T, D, and I scores of morbidly obese patients within time factors (preoperative vs. 1, 3, and 6 months; 1 vs. 3 and 6 months; and 3 vs. 6 months; p < 0.001 for all). There was a statistically significant improvement in overall TDI scores with an increase from 25 to 41 during the 6 months follow-up period (p < 0.001 for all). CONCLUSIONS: Here, for the first time in literature, we were able to show the significant improvement in olfactory abilities of morbidly obese patients after laparoscopic sleeve gastrectomy.