Incidence and Risk Factors of Acute Kidney Injury in Pediatric Liver Transplant Patients: A Retrospective Study.

Background: Acute kidney injury (AKI) significantly contributes to the mortality and morbidity rates among pediatric liver transplant (LT) recipients. Objective: Our study aimed to assess the potential factors contributing to AKI in pediatric LT patients and to analyze the impact of AKI on postoperative mortality and hospitalization duration. Materials and methods: About 235 pediatric LT patients under the age of 18 between the years 2015 and 2021 were evaluated retrospectively. The relationship between preoperative and intraoperative variables of the patients and AKI developed when the early postoperative period was assessed. Results: A correlation was found between the patients' preoperative age, albumin levels, and AKI. AKI was found to be associated with the duration of surgery and intraoperative blood transfusion. Conclusion: Our findings revealed that the severity of AKI in pediatric LT patients is linked to extended surgical durations and increased blood transfusions resulting from hemodynamically compromised blood loss. Furthermore, independent risk factors for AKI were identified as prolonged warm ischemia and the overall duration of the operation. How to cite this article: Demiroz D, Colak YZ, Ozdes OO, Ucar M, Ali Erdogan M, Toprak HI, et al. Incidence and Risk Factors of Acute Kidney Injury in Pediatric Liver Transplant Patients: A Retrospective Study. Indian J Crit Care Med 2024;28(1):75-79.

Critical overview of resection for Bismuth-Corlette type IV perihilar cholangiocarcinoma.

BACKGROUND: Current standard treatment for perihilar cholangiocarcinoma (pCCA) is surgical resection. Bismuth-Corlette (BC) type IV pCCA is accepted as an unresectable disease. In the present study, the results of non-transplant surgical approaches in patients with BC type IV pCCA were examined. METHODS: Medical records of consecutive patients with BC type IV pCCA between 2010 and 2021 were retrospectively reviewed. Patients were subdivided according to operation type. Postoperative survival rates were compared. RESULTS: Hemihepatectomy with caudate lobe and extrahepatic bile duct (EHBD) resection was performed in 15 patients and only EHBD resection was performed in 10 patients. Ten of the cases were found to be unresectable at the stage of laparotomy. Median follow-up was 41.3 (24.8-57.9) months. Overall survival rate for all 35 patients was 56.4% at 1 year, 32.2% at 2 years, and 16.1% at 3 years. When survivals were compared according to operation type, 1, 2, and 3-year survivals were 80%, 57.1% and 42.9% for the hepatectomy group; 55.6%, 44.4% and 11.1% for the EHBD resection group; 75%, 0% and 0% in laparotomy-only group, respectively (p = 0.13). The best survival rates were obtained in patients with pCCA who underwent hepatectomy and were lymph node negative, 100% for 1 year, 66.7 for 2 years and 50% for 3 years. CONCLUSION: It is difficult to achieve high survival rates in BC type IV pCCA. However, these patients mostly benefit from resective treatments. Acceptable survival rates can be achieved, especially in the R0N0 patient group.

Portal vein reconstruction with cryopreserved vascular grafts: A two-edged sword.

BACKGROUND: Portal vein anastomotic complications related to size discrepancy are important causes of morbidity and mortality in pediatric liver transplantation. Interposed vascular grafts in portal vein anastomosis can solve this problem. The aim of this study is to evaluate the results of pediatric liver transplantations performed using cryopreserved interposed vascular grafts between graft portal vein and superior mesenteric vein (SMV)-splenic vein (SpV) confluence. METHODS: Twenty-nine pediatric patients received liver transplantation using cryopreserved venous grafts in our Liver Transplant Institute between 2013 and 2020 were included in this study. Demographic, clinical, and operative characteristics and postoperative follow-up were analyzed. RESULTS: Sixteen patients (55.2%) had portal hypoplasia and five patients (17.2%) had portal vein thrombosis. In total, six patients (20.6%) suffered portal vein thrombosis in the early postoperative period. Three patients (10.3%) experienced portal vein thrombosis in the late postoperative period. Late portal vein thrombosis rate was significantly higher in patients with early portal vein thrombosis (3/6 patients [50%] versus 0/23 patients [0%]; p = .034). Lack of portal flow was significantly higher in patients with both early (50% versus 0%; p = .002) and late portal vein thrombosis (66.7% versus 6.7%; p = .03). CONCLUSION: Preoperative portal vein thrombosis and insufficient flow are important factors affecting success of liver transplant in children. The use of interposed vein grafts in problematic portal anastomoses can overcome portal flow problems.

Diaphragmatic hernias after pediatric liver transplantation: Experience of a high-volume transplant center.

Diaphragmatic hernias (DHs) are rare complications after pediatric liver transplantation (PLT). It is now widely accepted that DHs after liver transplantation (LT) is a pediatric related condition. PLTs (under of age 18) performed between January 2013 and June 2019 at Malatya Inonu University Institute of Liver Transplantation were retrospectively scanned. Study group consisting DHs and a control group were compared. Among 280 PLTs, 8 of them were complicated with DHs (%2.9). Median age of the patients with DH was 3.0 (0.8-9.5) years. Median graft recipient weight ratio was 2.5 (0.9-4.4). Five patients were below 5th percentiles in terms of pediatric weight growth chart at the time of LT. Also, 6 patients were below 5th percentiles in terms of pediatric height growth chart. There was no statistical difference between study and control groups. There are many risk factors mentioned in literature that may be primarily responsible for DHs after PLT. These factors are left lobe and large-for-size grafts, malnutrition, trauma or diathermy of diaphragmatic nerve and vessels and immunosuppressants. In our study, we could not specify any reason that differs in DHs. In our aspect, narrow diaphragma and thorax are exposed to high intra-abdominal pressure from abdomen. Large-for-size grafts, which are specific to children, also may contribute to this affect. Excessive diathermy and trauma to diaphragmatic collaterals may aggravate the risk of DH. More patients are needed to make an exact conclusion, in order to evaluate with comparable study on this aspect.

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.

Determination of risk factors affecting mortality in patients with gastrointestinal perforation after pediatric liver transplantation.

Gastrointestinal perforation (GIP) is one of the most serious complications occurring after liver transplantation (LT), especially in pediatric patients. This study aimed to determine the risk factors affecting mortality in pediatric patients with GIP after LT. GIP developed in 37 (10%) of 370 pediatric patients who underwent LT at our institute. Patients were divided into two groups: alive (n = 22) or dead (n = 15), and both groups were compared in terms of demographic and clinical parameters using univariate analysis. There was no statistically significant difference between groups in either demographic or clinical parameters, except for perforation site (P = 0.001) and median follow-up (P = 0.001). Stomas arose in 17 (45.9%) patients: 76% of patients with stomas and 45% of those without survived (P = 0.052). Kaplan-Meier analysis indicated that patients with stomas had a significantly higher overall survival (P = 0.029) and that patients with duodenal and colonic perforation had a significantly lower overall survival. Multivariate analysis showed that re-perforation was an independent risk factor for mortality (P = 0.035; OR: 17.674; 95% CI for OR: 1.233-253.32). Although there are many options for management of GIP, including primary repair, resection plus anastomosis, and resection plus end or loop ostomy, gastrointestinal diversion is still the best option.

Reconstruction of Anomalous Portal Venous Branching in Right Lobe Living Donor Liver Transplantation: Malatya Approach.

Reconstruction of anomalous portal vein branching (APVB) during right lobe living donor liver transplantation (LDLT) can be challenging. The goal of this article is to describe our surgical technique, named the Malatya Approach, in case of APVB during right lobe LDLT. The technique unifies the APVB and obtains a funnel-shaped common extension with a circumferential fence by a saphenous vein conduit. In total, 126 (10.6%) of 1192 right lobe grafts had APVB that were divided into 2 groups according to the adopted surgical techniques: the Malatya Approach group (n = 91) and the previously defined other techniques group (n = 35). Both groups were compared regarding portal vein thrombosis (PVT), postoperative 90-day mortality and survival. PVT developed in 3 patients (3.3%) in the Malatya Approach group and developed in 10 (28.6%) patients for the other group (P < 0.001). There were 8 (8.8%) 90-day mortalities in the Malatya Approach group (1 PVT related) and 15 patients (9 PVT related) died in the other techniques group (P < 0.001). Mean follow-up time for both groups was similar (999.1 days for the Malatya Approach group versus 1024.7 days for the other group; P = 0.47), but longterm survival in the Malatya Approach group was better than in the other group (84.6% versus 40%; P < 0.001). Multivariate analysis revealed that the Malatya Approach group showed less PVT development and longer survival (P < 0.001). This technique is promising to avoid PVT and mortalities in cases of APVB during right lobe LDLT. Liver Transplantation 23 751-761 2017 AASLD.

New Markers in Atherosclerosis: Thrombospondin-2 (THBS-2) and Leukocyte Cell-Derived Chemotaxin-2 (LECT-2); An Immunohistochemical Study.

BACKGROUND Current research investigating the role of THBS2 and LECT-2 in atherogenesis is very limited. Therefore, we designed this study to demonstrate the role of THBS-2 and LECT-2 in atherosclerosis at the tissue level in fresh specimens. MATERIAL AND METHODS A total of 32 patients who underwent coronary bypass surgery were enrolled. Aortic wall punch biopsies were obtained at the site of proximal aortosaphenous bypass graft anastomosis. A specimen of left internal mammarian artery (LiMA) was taken from the segment just proximal to its anastomosis. The aortic tissue is representive of the atherosclerotic tisue, and LiMA tissue is representative of the non-atherosclerotic area. The specimens were painted with CD68 for macrophage, and THBS-2 and LECT-2 antibodies for immunohistochemical staining. RESULTS Aortic THBS-2 levels were significantly lower, whereas aortic LECT-2 levels were significantly higher when compare to LiMA (14.4±9.9 (5-30) and 36.9±13.0 (5-60) p: 0.0001 and 20.3±15.0 (5-60) and 20.8±13,8 (10-30) p: 0.0001, respectively). CD68+ and monocyte level correlated significantly with AHA atherosclerosis grade (p=0.01, r=0.45 and p=0.001, r=0.56, Spearman's test). CD68+ level correlated significantly with LECT-2 levels in atherosclerotic aortic tissue (p=0.026, r=0.392, Spearman's test), whereas aortic TSBN-2 levels were not. CONCLUSIONS The present study has taken the first steps to highlight new markers in atherosclerosis by using immunohistochemical method. The study results suggest that the tissue levels of THBS2 and LECT-2 may correlate with the stage of atherosclerosis.

Laparoscopic choledochal cyst excision and Roux-en-Y hepaticojejunostomy.

Congenital choledochal cysts are rare in adults. Due to the risk of developing cholangiocarcinoma, the current standard of care is complete excision of the cyst and reconstruction with hepaticojejunostomy. So far, more than 200 laparoscopic resections have been reported in adults, the majority being from Far Eastern countries over the last five years. Herein, the technique of laparoscopic type I choledochal cyst excision and hepaticojejunostomy is presented in a 37-year-old male with an accompanying video. The advantages of laparoscopic surgery are applicable for choledochal cyst excision as well. We believe that teamwork, expertise on intracorporeal suturing and hepatobiliary surgery are central issues for this operation.

Controlling massive hemorrhage from the retropancreatic portal vein as a complication of thromboendovenectomy during liver transplantation with balloon catheter tamponade: how to do it.

We herein describe two cases of liver transplantation with portal vein thrombosis. In both cases, a tear advancing to the retropancreatic area occurred during portal vein thrombectomy. Hemorrhage from the limited visibility retropancreatic area made it impossible to stop the bleeding by clamping or direct suturing, and the clamping and suturing efforts actually increased the hemorrhage, possibly due to the damaged and thin portal vein wall. First, finger compression over the retropancreatic area was employed to stop the bleeding, then a Foley urinary catheter was introduced into the portal vein under the finger. The balloon of the catheter was inflated with 8 cc of normal saline, and the finger was released. The bleeding was stopped temporarily, and two different venous conduits were sutured to the trimmed portal vein stump in a bloodless surgical area. The venous conduits were easily controlled with vascular clamps after deflating the balloon catheters, and implantation of the liver was then done in a standard manner. Balloon tamponade can be a lifesaving technique that can temporarily stop a hemorrhage to allow for definitive repair in cases of retropancreatic portal vein hemorrhage.

Thyroid pathologies accompanying primary hyperparathyroidism: a high rate of papillary thyroid microcarcinoma.

OBJECTIVE: Thyroid pathologies and non-medullary thyroid cancer often accompany primary hyperparathyroidism (PHPT). The purpose of this study was to examine the association between thyroid diseases, especially micropapillary thyroid cancer, with PHPT. MATERIAL AND METHODS: Data regarding 46 patients who were operated on with a diagnosis of PHPT at Inonu University Faculty of Medicine, General Surgery Clinic between June 2009 and March 2013 were retrospectively analyzed. Age, gender, levels of preoperative calcium, parathyroid hormone and phosphorus, and the histopathological results of the removed parathyroid and thyroid tissues were evaluated. All of the patients had a preoperative diagnosis of PHPT and there was no history of radiation to the head and neck region in any of the patients. RESULTS: Out of the 46 patients who were operated on for PHPT, 39 were female and 7 were male. The mean age was 52.8 years (25-76). Simultaneous thyroidectomy was performed in 35 patients (76.1%) due to an accompanying thyroid disorder. Papillary microcarcinoma was detected in 5 of these 35 (10.9%) patients who underwent thyroidectomy, two of which (40%) were multifocal tumors. The benign thyroid pathologies detected in the remaining 30 (65.2%) cases included lymphocytic thyroiditis in 3, Hashimoto thyroiditis in 1, follicular adenoma in 3 (two of which was Hurtle cell), and nodular colloidal goiter in 23 patients. The preoperative serum phosphate level was significantly higher in the group with papillary thyroid microcarcinoma (p=0.013). CONCLUSION: In regions where goiter is endemic, thyroid diseases and thyroid papillary microcarcinoma occur in association with PHPT at a higher rate compared to the normal population. Therefore, we believe that patients who are planned for surgery due to PHPT should be thoroughly investigated for the presence of any concomitant malignant thyroid pathologies in the preoperative period. It should also be kept in mind that patients with high blood serum phosphate values may have an increased risk of papillary thyroid microcarcinoma.

The effects of levosimendan exposure on oxidant/antioxidant status and trace element levels in the pulmonary artery of rats.

We investigated both the effect of levosimendan and the role of oxidant/antioxidant status and trace element levels in the pulmonary artery of rats. Fourteen male Wistar albino rats were randomly divided into two groups of seven animals each. Group 1 was not exposed to levosimendan and served as a control. Levosimendan (12 µg/kg) diluted in 10 ml 0.9 % NaCl was administered intraperitoneally to group 2. Animals of both groups were killed after 3 days, and their pulmonary arteries were harvested to determine changes in tissue oxidant/antioxidant status and trace element levels. The animals in both groups were killed 72 h after the levosimendan exposure treatment, and pulmonary arteries were harvested to determine levels of the lipid peroxidation product MDA and the antioxidant GSH as well as the decreased activity of antioxidant enzymes such as SOD, GSH-Px and CAT. It was found that MDA levels increased in pulmonary artery tissues of rats after levosimendan administration. The GSH level decreased in the pulmonary artery of rats after levosimendan treatment. Co, Mn, Fe, Cd and Pb levels were significantly higher (P < 0.001) and Mg, Zn and Cu levels significantly lower (P < 0.001) in the levosimendan group compared to the control group. These results suggest that levosimendan treatment caused an increase in free radical production and a decrease in antioxidant enzyme activity in the pulmonary artery of levosimendan-treated rats. It also caused a decrease or increase in the levels of many minerals in the pulmonary artery, which is an undesirable condition for normal pharmacological function.

Red cell distribution width predicts new-onset atrial fibrillation after coronary artery bypass grafting.

INTRODUCTION: Red cell distribution width (RDW) has been associated with poor outcomes in patients with cardiovascular diseases. However, little is known about the role of RDW in prediction of new-onset atrial fibrillation (AF) after coronary artery bypass grafting (CABG). We aimed to investigate the relation between the RDW and postoperative AF in patients undergoing CABG. METHODS: A total of 132 patients undergoing nonemergency CABG were included in the study. Patients with previous atrial arrhythmia or requiring concomitant valve surgery were excluded. We retrospectively analyzed 132 consecutive patients (mean age, 60.55 ± 9.5 years; 99 male and 33 female). The RDW level was determined preoperatively and on postoperative Day 1. RESULTS: Preoperative RDW levels were significantly higher in patients who developed AF than in those who did not (13.9 ± 1.4 vs. 13.3 ± 1.2, p = 0.03). There was not any correlation between postoperative RDW levels and AF. Using a cutpoint of 13.45, the preoperative level correlated with the incidence of AF with a sensitivity of 61% and specificity of 60%. CONCLUSION: Preoperative RDW level predicts new-onset AF after CABG in patients without histories of AF.

ABO-incompatible liver transplantation in acute and acute-on-chronic liver failure.

BACKGROUND/AIMS: ABO-incompatible (ABO-I) liver transplantation (LTx) may be mandatory in urgent conditions such as acute liver failure (ALF) or acute-on-chronic liver failure (ACLF) when deceased donor (DD) is unavailable or living donor (LD) selection is limited. This study specifically addresses the problem of urgent ABO-I LTx in critically ill adult patients having ALF or severely decompensated end-stage liver disease. METHODOLOGY: This series included 16 patients, 10 underwent ABO-I LD LTx and 6 underwent 7 ABO-I DD LTx. Multiple sessions of plasmapheresis reduced isoaglutinin titres to 1/16 or below, before and after LTx. RESULTS: Mean follow-up period was 10.37 months (1 to 38). Median for MELD scores was 22.5 (17 to 30). Median survival was 9 months and mean survival was 19.5 months. Hospital mortality was 3 (18.7%). Two patients died due to small for size graft syndrome and cerebrovascular bleeding respectively. Hepatic artery thrombosis developed in 3 patients. Two of them died at postoperative 4th and 9th months. Third patient is still alive with hepatic necrosis problem. CONCLUSIONS: ABO-I LTx remains an important and unavoidable therapeutic option in adult patients with ALF or ACLF and urgent need for an allograft without the possibility to allocate a blood group compatible liver graft.

Single-center analysis of the first 304 living-donor liver transplantations in 3 years.

BACKGROUND/AIMS: Living donor liver transplantations (LDLT) is a definitive treatment for patients with end-stage liver disease (ESLD), especially in the countries with donation problem. Between April 2007 and April 2010, we performed LDLT in 289 patients. Fifteen of the cases required re-transplantations. This study evaluates these 304 consecutive LDLTs donor and recipient outcomes. METHODOLOGY: Complication rates and survival data of the recipients and donors of 304 LDLT cases were analyzed. RESULTS: All donors are alive and well. Overall complication rate was 27%. Early postoperative recipient complication rate was 51%. Most frequent complication was infection. In the long-term there were 57 biliary stricture and 5 chronic bile fistula cases. Chronic and acute rejection attacks developed in 7 and 103 patients, respectively. Hepatic artery thrombosis rate was 8%. One, two and three year survival rates were 82%, 79% and 75%, respectively. Recipient mortality was 25%, mostly due to vascular complications, septic complications, liver dysfunction and chronic rejection. CONCLUSIONS: More than 150 liver tranplantations per year in a single center is a challenge in Turkey, where there is a shortage of deceased donor grafts. LDLT is a safe procedure for donors and effective for ESLD. Improvement in surgical technique would provide better outcomes.

The effect of iloprost on renal function in patients with critical limb ischemia.

BACKGROUND: Iloprost, which has efficacy in the microvascular space, is shown to have beneficial effects on the kidney, which has an extensive microvascular network. OBJECTIVE: We aimed to evaluate the effect of iloprost treatment on kidney functions in patients with critical limb ischemia. METHODS: Forty-eight patients with critical limb ischemia who were not suitable for revascularization and who were treated with iloprost were evaluated prospectively in our clinic between September 2010 and December 2012. The patients were divided into 2 groups as patients with chronic renal dysfunction (Group I) and patients with normal renal function (Group II). Urine albumin:creatinine ratio and glomerular filtration rate (GFR) calculated using serum creatinine and serum cystatin C (GFRcyc) were used to establish the presence of renal dysfunction. The decrease analgesic requirement, walking distance, reduction in ulcer diameter, the increase in ankle-brachial index, and changes in The Society of Vascular Surgery/International Society of Cardiovascular Surgery criteria were used in the evaluation of treatment response. RESULTS: Opioid analgesic requirement and decubitus pain disappeared after treatment in 58.3% (n = 28) of subjects. Walking distance increased in 66.6% (n = 32). Iloprost treatment significantly increased ankle-brachial index (P < 0.01). In Group I the levels of serum urea, creatinine, and cystatin C significantly decreased (P < 0.05), whereas GFRcyc and GFR calculated using the equation of the Chronic Kidney Disease Epidemiology Collaboration (ie, GFR expressed for specified race, sex, and serum creatinine in milligrams per deciliter) was increased significantly compared with pretreatment levels (P < 0.05). No significant change was observed in urine albumin:creatinine ratio (P > 0.05). CONCLUSIONS: The use of iloprost in critical limb ischemia can slow down the progress of early stage renal damage. GFRcyc and cystatin C, which are indicators of early stage chronic renal dysfunction, can be used for the evaluation of treatment response.

Ischaemic mitral regurgitation: The effects of ring annuloplasty and suture annuloplasty repair techniques on left ventricular re-remodeling.

OBJECTIVE: To examine the mid-term results of patients on whom a coronary revascularization as well as a mitral ring and suture annuloplasty have been performed due to coronary artery disease (CAD) and ischaemic mitral regurgitation (IMR). METHODOLOGY: Totally 73 patients on whom a revascularization and a mitral valve repair due to CAD and IMR had been performed in our clinic between 2000-2008 were included in the study. Patients were divided into two groups one of which included 38 patients (52.05%) on whom a coronary artery bypass graft (CABG) and a ring annuloplasty on the mitral valve had been performed (Group 1) and the other one 35 patients (47.95%) on whom only suture annuloplasty as well as a CABG had been performed (Group 2). The study was planned retrospectively and study data have been obtained by screening the hospital registries retrospectively. In the mid-term, patients were invited for a check and their intragroup and intergroup echocardiographic parameters and functional capacities were assessed statistically. RESULTS: In pre-operational and post-operational intragroup assessment in terms of echocardiographic findings; although LVEDD, LVESD, EDV, PAP and the degree of recurrent MR have been decreased in both groups, the decrease in LVESD and PAP and the low degree of recurrent MR were statistically significant in Group 1 patients (p=0.047, p=0.023, p=0.01, respectively). When the mid-term intergroup echocardiograpic findings were assessed; PAP and recurrent MR have been determined statistically lower in Group 1 patients (p=0.005, p=0.08, respectively). The length of intensive care unit stay, length of hospitalization and length of detachment from respiratory support were statistically significantly longer in ring annuloplasty performed group (p=0.012, p=0.033, p=0.029, respectively). CONCLUSIONS: In moderate to severe IMR patients, a positive contribution can be provided to ventricular remodeling by a ring annuloplasty through a significant decrease in left ventricular diameter and a low recurrent MR and PAP.

Predictive Factors of Postoperative Pancreatic Fistula in Geriatric Patients Undergoing Pancreatoduodenectomy for Periampullary Malignancy.

OBJECTIVE: To identify predictive factors associated with the occurrence of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) in an increasingly geriatric population. STUDY DESIGN: Observational study. Place and Duration of the Study: Department of General Surgery, Inonu University, Malatya, Turkey, from January 2010 to April 2022. METHODOLOGY: Demographic and clinicopathological data of 74 geriatric patients who underwent PD for periampullary tumours in the clinic at Inonu University were retrieved from the patient database. POPF was defined and categorised based on the guidelines established by the International Study Group for Pancreatic Surgery (ISGPS). The patients were stratified into two cohorts of POPF and no POPF. Univariate and multivariate analyses were conducted to compare variables between the two groups. RESULTS: The median age of the patient population was 72 (65-92) years, and 51 (68.9%) individuals were male. Among the 74 patients, 35 (47.3%) experienced POPF. In the multivariate analysis, hypertension (HT, p=0.012), Wirsung diameter <3.5 mm (p<0.01), and pancreaticojejunostomy (PJ, p=0.022) emerged as independent risk factors for POPF. CONCLUSION: In the context of geriatric patients undergoing PD, HT, intraoperative wirsung diameter <3.5 mm, and PJ were identified as independent risk factors for POPF. These findings can guide the adoption of safer techniques in preoperative and intraoperative evaluations, as well as in postoperative follow-ups of patients presenting with these risk factors. KEY WORDS: Elderly, Whipple procedure, Anastomotic leakage, Predictive factor, Postoperative pancreatic fistula, Pancreatoduodenectomy.

A new model for prediction of bowel gangrene in sigmoid volvulus.

BACKGROUND: Sigmoid volvulus is a pathology that can be mortal because it is frequently encountered in elderly patients. In case of bowel gangrene, mortality and morbidity increase further. We planned a retrospective study, in which the effectiveness of the model was evaluated by creating a model that aims to predict whether intestinal gangrene is present in patients with sigmoid volvulus only by blood tests and thus to quickly guide treatment methods. METHODS: In addition to demographic data such as age and gender, laboratory values such as white blood cell, C-reactive protein (CRP), lactate dehydrogenase (LDH), potassium, and colonoscopic findings and whether there was gangrene in the colon during the operation were evaluated retrospectively. In the analysis of the data, independent risk factors were determined by univariate and multivariate logistic regression analyzes as well as Mann-Whitney U and Chi-square tests. Receiver operating characteristic (ROC) analysis was performed for statistically significant continuous numerical data, and cutoff values were determined and Malatya Volvulus Gangrene Model (MVGM) was created. The effectiveness of the created model was again evaluated by ROC analysis. RESULTS: Of the 74 patients included in the study, 59 (79.7%) were male. The median age of the population was 74 (19-88), and gangrene was detected in 21 (28.37%) patients at surgery. In univariate analyzes, leukocytes <4000/mm3 and >12000/mm3 (OR: 10.737; CI 95%: 2.797-41.211, p=0.001), CRP ≥0.71 mg/dl (OR: 8.107 CI 95%: 2.520-26.082, p<0.0001), potassium ≥3.85 mmoL/L (OR: 3.889; 95% CI): 1.333-11.345, p=0.013), and LDH ≥288 U/L (OR: 3.889; CI 95%: 1.333-11.345, p=0.013), whereas, in multivariate analyzes, only CRP ≥0.71 mg/dL (OR: 3.965; CI 95%: 1.071-15.462, p=0.047) was found to be an independent risk factor for bowel gangrene. The strength of MVGM was AUC 0.836 (0.737-0.936). In addition, it was observed that the probability of bowel gangrene increased approximately 10 times if MVGM was ≥7 (OR: 9.846; 95% CI: 3.016-32.145, p<0.0001). CONCLUSION: Besides being non-invasive compared to the colonoscopic procedure, MVGM is a useful method for detecting bowel gangrene. In addition, it will guide the clinician in taking the patients with intestinal loop gangrene to emergency surgery without wasting time in the treatment steps, as well as avoiding complications that may occur during colonoscopy. In this way, we think that morbidity and mortality rates can be reduced.