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Objective: To assess the risk factors for chronic pain and recurrence after laparoscopic total extraperitoneal (TEP) inguinal hernia repair. Methods: Data of the patients who underwent laparoscopic TEP repair were analyzed. Clinical and surgical characteristics, including learning curve, mesh weight, the pore size of the mesh, use of mesh fixation, and fixation methods, were assessed. Fixation by absorbable or nonabsorbable tackers was performed in all procedures except for self-fixating meshes. Mesh brands were tiered into groups regarding pore size and weight. Operative time was defined as the duration between skin incision and dressing. The minimum follow-up was 24 months. Postoperative chronic pain was defined as moderate to severe groin pain, which was accepted as a Visual Analog score ≥3 longer than three months. Pain and recurrence were evaluated at 1 and 6 weeks in clinic visits and at 3, 12, and 24 months by telephone questionnaires. The occurrence of a fascial defect in physical examination or ultrasound was defined as recurrence. Results: Three-hundred and eighty-two procedures were included. Postoperative chronic pain was seen in 31 (8.1%) patients and was higher with micropore mesh (p=0.004), mesh fixation (p=0.002), fixation with titanium tacks (p

The aim of this study was to determine the superiority between the robotic da Vinci Si (R) (Si group) and da Vinci Xi (R) (Xi group) generation in patients with mid-low rectal cancer. Between December 2011 and December 2017, 88 patients with mid-low rectal cancer were operated on using the Si robotic system, from January 2018 to May 2021, 62 more patients with mid-low rectal cancer were operated on using the Xi robotic system. Perioperative and postoperative short-term outcomes were compared between the two groups. Univariate and multivariate Cox-regression analysis were performed to determine factors affecting operating time. A cumulative sum (CUSUM) analysis was also performed to determine the learning curve of the primary surgeon. All patients underwent sphincter saving total mesorectal excision (TME). The overall operating time was significantly shorter in the Xi group (181.3 +/- 31.8 min in Si group vs 123.6 +/- 25.7 min in the Xi group, p < 0.001). There were no significant differences in terms of conversion rates, mean hospital stays, complications and histopathologic data. CUSUM analysis show completion of learning curve in 44th case of Si group. Univariate and multivariate analysis demonstrated that the learning curve of the primary surgeon (p < 0.001) and the type of robotic system (Xi) are only two factors associated with operating time (OR, 95% CI p; 3.656, 0.665-9.339, p < 0.001). Our study found that the robotic da Vinci Xi systems provide significantly shorter operating time comparing with Si systems, when performing sphincter-preserving TME in mid-low rectal cancer patients. Surgical system (da Vinci Xi) and primary surgeon learning curve are two independent risk factors which associated shortened operating time. Postoperative complication rates and histopathologic outcomes are similar in both groups.

Objective: Recent American Thyroid Association Guideline emphasizes that identifying the institutional malignancy risks for each Bethesda category is mandatory to achieve more accurate preoperative diagnosis in thyroid nodules. Aim of this study is to compare the preoperative fine needle aspiration biopsy (FNAB) and postoperative pathology results in a single institution in the era of the Bethesda System for Reporting thyroid Cytology (TBSRTC). Methods: The data of the patients who underwent FNAB and thyroidectomy between 2012 and 2018 were collected retrospectively. Patients who had available TBSRTC classification were included in the study. The malignancy risk of each TBSRTC classification was calculated. Results: One-hundred and forty-five patients were included. The mean age was 45.9±13.6. Preoperative FNAB categorization was TBSRTC I in 3 (2.1%) patients, TBSRTC II in 47 (32.4%) patients, TBSRTC III 16 (11%) patients, TBSRTC IV in 14 (9.7%) patients, TBSRTC V in 29 (20%) and VI in 36 (24.8%) patients. Postoperative pathology revealed malignancy in 66 (45.5%) of the patients. The malignancy risk was 33.3% in TBSRTC I, 4.3% in TBSRTC II, 31.3% in TBSRTC III, 42.9% in TBSRTC IV, 62.1% in TBSRTC V and 94.4% in TBSRTC VI categories. Conclusion: Our results were conformable with the malignancy risks reported by TBSRTC. Larger studies should be performed to validate and endorse nationwide standardization of the Bethesda system. Amaç: Güncel Amerikan Tiroid Derneği kılavuzu Bethesda sınıflandırmasında merkeze özel sonuçların bilinmesinin tiroid ince iğne aspirasyon biyopsisinin (İİAB) tanısal yeterliliğini artırmak için önemli olduğunu vurgulamaktadır. Bu çalışma Bethesda sınıflandırması ve postoperatif patoloji sonuçlarını kıyaslayarak her kategori için merkezimize özel kanser riskini ortaya konulmasını amaçlamaktadır. Yöntemler: Merkezimizde 2012-2018 yılları arasında tiroid nodülü nedeniyle ameliyat edilen hastaların ameliyat öncesi ve sonrası patoloji sonuçları geriye yönelik olarak incelendi. Bethesda sistemine göre sınıflandırılmış İİAB raporları olan hastalar çalışmaya dahil edildi. Ameliyat sonrası patolojiler incelenerek Bethesda sisteminin her kategorisi için ayrı ayrı kanser riskleri ortaya konuldu ve literatürle kıyaslandı. Bulgular: Çalışmaya 145 hasta dahil edildi. Ortalama yaş 45.9±13.6 idi. Bethesda sınıflandırmasına göre 3 (%2,1) hasta kategori I, 47 (%32,4) hasta kategori II, 16 (%11) hasta kategori III, 14 (%9,7) hasta kategori IV, 29 (%20) hasta kategori V ve 36 (%24,8) hasta kategori VI olarak raporlanmıştı. Ameliyat sonrası patoloji 66 (%45,5) hastada malignite ile uyumluydu. Malignite riski kategori I için %33,3, kategori II için %4,3, kategori III için %31,3, kategori IV için %42,9, kategori 5 için %62,1 ve kategori VI için %94,4 olarak hesaplandı. Sonuç: Sonuçlarımız Bethesda sistemi tarafından bildirilen malignite riskleriyle uyumluydu. Bethesda sınıflandırmasının doğrulanması ve ulusal adaptasyonun artırılması için daha geniş çalışmalara gereksinim vardır.

Aim:Peritoneal Surface Disease Severity score (PSDSS) has been used in the evaluation of patients who are scheduled for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal metastasis of colorectal origin (PMCO). The aim of this study was to evaluate the validity of PSDSS in predicting prognosis in patients who underwent CRS + HIPEC for PMCO at our center.Method:Demographic data, operation data, histopathological features, perioperative morbidity and mortality, and oncologic follow-up data were obtained retrospectively from the database and analyzed. Peritoneal carcinomatosis index (PCI) values were calculated from preoperative computed tomographies. PSDSS was calculated by evaluating clinical symptoms, PCI and histology of primary tumor. Two PSDSS groups were formed: PSDSS 1 and 2 groups as low PSDSS group, and PSDSS 3 and 4 groups as high PSDSS group.Results:Sixty-one patients, including 36 females (59%) and 25 males (41%), with PMCO who underwent CRS and HIPEC were included in the study. Forty-four patients were enrolled to the low PSDSS group and 17 patients were enrolled to the high PSDSS group. Three patients (3.2%) died during the perioperative period. Twenty-one patients (34.4%) had perioperative complications. The mean follow-up was 35.0±23.2 months. During the follow-up period, 36 patients (59%) had recurrence and 44 patients (72.1%) died. The mean survival was 46.5±5.5 months, and 1-,3- and 5-year survival rates were 85%, 47% and 21%, respectively. There was no correlation between low and high PSDSS groups in terms of morbidity and recurrence (p=0.486 and p=0.385, respectively). Mortality was more frequent in high PSDSS group (94% vs. 63%; p=0.024). The mean survival of patients in the low PSDSS group was significantly longer than in the high PSDSS group (57.2±6.7 months vs. 16.5±2.6 months; p=0.001).Conclusion:The findings of this study demonstrated the validity of PSDSS in predicting prognosis in patients with PMCO who were scheduled for CRS and HIPEC.

Aim: To assess the effect of duration of the symptoms on outcome after botulinum toxin injection in anal fissure treatment. Method: Data of the patients who underwent botulinum toxin injection for chronic anal fissur were reviewed. Patients with a minimum follow-up of 18 months were included. One-hundred IU botulinum toxine was injected in the internal anal sphincter through 4 quadrants. Follow-up was carried out by clinic visits on post-procedure days 7, 15 and 30 and by telephone survey in 3, 6, 12 and 18th months. Refractory symptoms or recurrence were recorded as failure. The relationship between duration of the symptoms and failure was investigated and a cut-off value was determined. Patients were divided into two groups according to duration of the symtoms and outcome was compared with the patients who underwent lateral internal sphincterotomy within the same period. Results: There were 56 patients fulfilling inclusion criteria. Mean age was 33.1±9.4 and 39 (69.6%) patients were female. Presence of the symptoms longer than 8.5 months was predicting treatment failure (Area under curve: 0.721, confidence interval: 0.500-0.942, p=0.037). There were 38 patients in shorter symptoms group, 18 patients in longer sypmtoms group and 32 patients in lateral internal sphincterotomy group. The compelte healing rates after 21 (18-28) months of median survival were 61.1% in longer symptom botulinum toxin group, 94.7% in shorter symptom botulinum toxin group and 96.2% in lateral internal sphincterotomy group (p=0.003). One patient in botulinum toxin groups had local hematoma and one (3.1%) had minor incontinence in lateral internal sphincterotomy group. Conclusion: Botulinum toxin has similar outcome with lateral internal sphincterotomy in patients with shorter suration of sypmtoms. Proper patient selection may contribute to the success of the treatment in chronic anal fissur. Amaç: Anal fissürde semptom süresinin botulinum toksini uygulaması sonrası tedaviye yanıtsızlık ve nüks üzerindeki etkisini araştırmaktır. Yöntem: Mart 2016’dan itibaren anal fissür nedeniyle botulinum toksini uygulanan hastaların verileri incelendi. Takip süresi en az 18 ay olan hastalar çalışmaya dahil edildi. Hastalara internal sfinktere 4 kadrandan 100 IU botulinum toksin-A uygulandı. İşlem sonrası 7, 15, 30. günlerde poliklinik kontrolü ile; 3, 6, 12 ve 18. aylarda telefonla aranarak değerlendirme yapıldı. Botulinum toksini uygulamasına yanıtsızlık ya da nüks başarısızlık olarak kaydedildi. Semptom süresi ve başarısızlık arasındaki ilişki alıcı işletim karakteristiği analizi ile araştırıldı ve bulunan kesme değerine göre iki gruba ayrılan botulinum toksini uygulanan hastalar aynı dönemde lateral internal sfinkterotomi ile tedavi edilmiş hastalarla karşılaştırıldı. Bulgular: Botulinum toksini uygulanan 56 hastada ortalama yaş 33,1±9,4 idi. Hastaların 39’u (%69,6) kadındı. Ortalama semptom süresi 8,5±7,4 aydı. Ortanca 21 (18-28) aylık izlem süresinde 47 (%83,9) hastada iyileşme oldu. Semptom süresinin 8,5 aydan uzun olması tedavi başarısızlığını öngörmekteydi (Eğri altındaki alan: 0,721, güven aralığı: 0,500-0,942, p=0,037). Hastalar semptom süresine göre 2 gruba ayrılarak aynı dönemde lateral internal sfinkterotomi yapılan 32 hasta ile sonuçları karşılaştırıldı. İyileşme oranları semptom süresi uzun olan botulinum toksini grubunda %61,1, semptom süresi kısa olan botulinum toksini grubunda %94,7 ve lateral internal sfinkterotomi grubunda %96,2 idi (p=0,003). Botulinum toksini uygulaması sonrası 1 hastada lokal hematom, lateral internal sfinkterotomi uygulaması sonrası 1 (%3,1) hastada minör inkontinens görüldü. Sonuç: Anal fissür tedavisinde botulinum toksini uygulaması semptom süresi kısa olan hastalarda lateral internal sfinkterotomi ile benzer etkinliktedir. Botulinum toksini uygulamasında hasta seçimi tedavi başarısını etkileyebilir.

Background: The aim of this study was to determine whether incision irrigation with chlorhexidine gluconate (CHG) reduces surgical site infections (SSIs) in pilonidal disease surgery. Methods: Between 2013 and 2018, patients who underwent wide excision with primary closure for pilonidal disease were enrolled in this prospective observational multi-institutional cohort. The incision was irrigated with either saline or 0.05% CHG before skin closure. The infection risk of each patient was determined by the National Nosocomial Infection Surveillance System. Post-operative site care and follow-up were carried out according to the U.S. Centers for Disease Control and Prevention guideline by two surgeons blinded to the irrigation solution used. Surgical site infection rates in the saline and 0.05% CHG groups were compared. The secondary outcomes were seroma formation, incision dehiscence, and time to healing. Results: There were 129 patients in the control group and 138 patients in the CHG group. The mean age was 25.1 +/- 5.4, and 225 patients (84.3%) were male. Surgical site infection was seen in 35 patients (13.1%): 26 (20.2%) in the control group and 9 (6.5%) in the CHG group (p = 0.001). There were no differences in seroma formation (n = 12; 9.3% in the control vs n = 12; 8.7% in the CHG group; p = 0.515) or incision dehiscence (n = 9; 7% in the control vs n = 9; 6.5% in the CHG group; p = 0.537). The primary healing rate was higher in the CHG group (n = 130; 94.2%) than in the control group (n = 104; 80.6%). Time to healing was 20.5 +/- 7.8 days in the control group and 16 +/- 4.3 days in the CHG group (p < 0.001). Conclusion: Intra-operative incision irrigation with CHG decreased the SSI rate and time to healing in pilonidal disease surgery. Further randomized trials should focus on specific irrigation methods and procedures to build a consensus on the effect of incision irrigation on SSIs.

Background The management of thyroid nodules with intermediate category of the Bethesda System for Reporting Thyroid Cancer (TBSRTC) is still debatable. Aim of this study is to investigate the diagnostic accuracy of neutrophil-to-lymphocyte ratio (NLR) in detecting cancer in intermediate TBSRTC categories.Methods Data of the patients who underwent thyroidectomy between 2012 and 2018 were analyzed retrospectively. Demographic characteristics, complete blood count, TSH value, TBSRTC categories and postoperative pathology of the patients were collected. The association with preoperative NLR and postoperative pathology was assessed.Results Of 146 patients included in the study, 57 (39%) were in TBSRTC III, IV and V category. The mean NLR in this subgroup was 2.1±0.8 and similar between TBSRTC III, IV and IV groups (p=0.737). Thyroid cancer was detected in 38 (66.7%) patients. The mean NLR was 2.4±0.8 in thyroid cancers and significantly higher when compared with patients with benign postoperative pathology (1.6±0.4, p=0.014). There was a significant difference between papillary and follicular cancer; the mean NLR was 2.3±0.8 in papillary cancer and 2.6±0.7 in follicular cancer patients (p=0.005). The cut-off value of NLR for predicting cancer at 89% sensitivity and 53% specificity was 1.6 (Area under curve: 0.769, 95% confidence interval: 0.643-0.895, p=0.001).Conclusions Preoperative NLR is elevated in patients with thyroid cancer in intermediate TBSRTC categories. Despite low diagnostic accuracy, considering its availability and low costs, NLR has merit for further studies.

Aim The aim was to compare the pathological complete response (pCR) rate at 8 compared to 12 weeks' interval between completion of neoadjuvant chemoradiotherapy (CRT) and surgery in patients with locally advanced rectal cancer. Method This was a randomized trial which included a total of 330 patients from two institutions. Patients with locally advanced (T3-4N0M0, TxN+M0) rectal cancer were randomized into 8- and 12-week interval groups. All the patients received long-course CRT (45 Gy in 1.8 Gy fractions and concomitant oral capecitabine or 5-fluorouracil infusion). Surgery was performed at either 8 or 12 weeks after CRT. The primary end-point was pCR. Secondary end-points were sphincter preservation, postoperative morbidity and mortality. Results Two-hundred and fifty-two patients (n = 125 in the 8-week group, n = 127 in the 12-week group) were included. Demographic and clinical characteristics were similar between groups. The overall pCR rate was 17.9% (n = 45): 12% (n = 15) in the 8-week group and 23.6% (n = 30) in the 12-week group (P = 0.021). Sphincter-preserving surgery was performed in 107 (85.6%) patients which was significantly higher than the 94 (74%) patients in the 12-week group (P = 0.016). Postoperative mortality was seen in three (1.2%) patients overall and was not different between groups (1.6% in 8 weeks vs 0.8% in 12 weeks, P = 0.494). Groups were similar in anastomotic leak (10.8% in 8 weeks vs 4.5% in 12 weeks, P = 0.088) and morbidity (30.4% in 8 weeks and 20.1% in 12 weeks, P = 0.083). Conclusion Extending the interval between CRT and surgery from 8 to 12 weeks resulted in a 2-fold increase in pCR rate without any difference in mortality and morbidity.

The purpose of this study was to assess the feasibility and safety of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in elderly patients with peritoneal carcinomatosis of colorectal cancer.Patients who underwent curative complete CRS and HIPEC for peritoneal carcinomatosis of colorectal cancer with minimum follow-up of 24 months were included in the analysis. Charlson comorbidity index and ECOG performance status were used to evaluate preoperative condition. Patients were tiered into two groups according to age (65 and ≥65 years). Postoperative morbidity, mortality, recurrence, and overall survival were compared between groups.One-hundred patients were meeting the inclusion criteria. Median age was 56 years (ranging, 20-86). The origin of peritoneal carcinomatosis (PC) was colon in 77 and rectum in 23 patients. There were 31 patients in the elderly group. Mean hospital stay was 1711.8 and 16.814.3 days in young and elderly groups (p=0.937). In young patients, postoperative morbidity was seen in 26 (37.6%) patients versus 9 (29%) patients in elderly group (p=0.272). Mortality was higher in elderly group (n=4, 12.9%) than in the younger group (n=5, 7.2%), but the difference was not statistically significant (p=0.287). Median follow-up was 25 months (ranging, 2-112). Local and/or distant recurrence occurred in 30 (43.4%) patients in the young group and 9 (29%) patients in elderly group (p=0.169). Two-years disease-free survival was similar: 67.1% in the young and 74% in the elderly groups (p=0.713).CRS and HIPEC offer comparable oncologic outcome in meticulously selected medically-fit elderly patients without increased postoperative morbidity and mortality.

WOS: 000443033500013 PubMed ID: 30040537 Background: The aim of this study was to investigate the effect of irrigating the surgical site with 0.05% chlorhexidine gluconate (CHG) on surgical site infection (SSI) in temporary loop ileostomy closure. Methods: In this observational cohort, patients who underwent diverting loop ileostomy and elective ileostomy closure for any reason between September 2014 and July 2016 were enrolled. Irrigation of the surgical site with 0.05% CHG or saline were compared regarding post-operative incision complications. Infection risk was estimated by the National Nosocomial Infection Surveillance System (NNIS) and Study of the Effect of Nosocomial Infection Control (SENIC) scores. Post-operative follow-up was performed by a surgeon blinded to the treatment. Diagnosis of SSI was recorded according to the Guidelines for Prevention of Surgical Site Infection. Wound healing was evaluated by the Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of the deep tissues, Isolation of bacteria, and the duration of inpatient Stay (ASEPSIS) score. Results: There were 122 patients meeting the inclusion criteria: 60 in the saline (control) and 62 in the CHG (study) group. The mean age was 56.5 +/- 13.5 (standard deviation [SD]); 74 patients were male. The groups were similar regarding age, sex, indication for ileostomy, neoadjuvant therapies, and SENIC and ASEPSIS scores. The overall SSI rate was 18%: 19 patients (31.6%) in the control group and 3 (4.8%) patients in the study group (p < 0.001). The mean ASEPSIS score was higher in the control group (12.8 +/- 17.7) than in the study group (3.7 +/- 7.8) (p < 0.001). Patients in the control group had significantly higher rates of seroma (13.3% vs 1.6%; p = 0.014) and incision dehiscence (31.6% and 4.8%; p = 0.001). Time to healing was 9.9 +/- 5.1 days in the control group and 7.3 +/- 5.3 days in the study group (p = 0.007). Conclusions: Irrigation of the incision with 0.05% CHG reduces the SSI rate compared with saline irrigation. There is a need for randomized and wider trials to clarify the effect and standards of incision irrigation.

Advances in preoperative localization studies and demands for scarless surgery have promoted the investigation for remote techniques in parathyroid surgery. Transoral vestibular approach seems to provide the most comfortable and safest access to the neck. In this paper, we report our initial experience with robotic transoral vestibular parathyroidectomy (RTVP) in four patients with primary hyperparathyroidism. The surgery was performed with the Da Vinci system through three trocars introduced from the lower lip vestibule. The procedure was converted to open in two patients due to inappropriate preoperative localization. The mean operative time was 169 min. No postoperative complications were seen. Patients were discharged on postoperative day 1. RTVP is a feasible and safe technique, which allows better surgical exposure and manipulation of the instruments. The advantages of transoral vestibular approach can be enhanced by robotics. Further studies are needed to analyze complications and costs. © The Author(s) 2018.

WOS: 000447980700002 PubMed ID: 29961173 PurposeTo investigate the impact of the pelvic dimensions and tumor volume on surgery in locally advanced rectal cancer.MethodsPatients who underwent open surgery after neoadjuvant long-course chemoradiation for primary rectal cancer were included. The predictive value of magnetic resonance-based pelvic measurements and tumor volume on the surgical difficulty and oncologic outcome were analyzed.Results125 patients were included. The independent risk factors related to the circumferential resection margin status were the pT stage [odds ratio (OR) 3.64, confidence interval (CI) 1.409-7.327] and tumor volume after neoadjuvant chemoradiotherapy (OR 1.59, CI 1.018-2.767). The operative time (p=0.014, OR 1.453) and pelvic depth (p=0.023, OR 1.116) were independent predictive factors for anastomotic leak. The median follow-up was 72 (2-113) months. Local recurrence was seen in 17 (14.1%) patients. Anastomotic leak (OR 1.799, CI 0.978-3.277), the circumferential resection margin status (OR 3.217, CI 1.262-7.870) and the relative tumor volume rate (OR 1.260, CI 1.004-1.912) were independent prognosticators of local recurrence. The 5-year overall survival was 66.7%. The circumferential resection margin status (hazard ratio: 4.739, CI 2.276-9.317), pN stage (OR 3.267, CI 1.195-8.930) and relative tumor volume rate (OR 2.628, CI 1.042-6.631) were independent prognostic factors for the overall survival.ConclusionsRelative dimensions of the tumor in the pelvis influence the local recurrence and overall survival rates. Magnetic resonance-based measurements can predict the difficulty of surgery and allow surgeons to consider the appropriate surgical approach.

Morgagni hernia is a rare congenital anomaly arising from the fusion defect between the septum transversum and sternum. The diagnosis is usually difficult since the presentation may be asymptomatic or with respiratory symptoms, abdominal and/or retrosternal pain, abdominal fullness, or gastrointestinal obstruction. In this report, we discuss the clinical presentation and management of this rare condition in five consecutive cases. Between 2009 and 2015, five cases underwent surgery for Morgagni hernia (three laparoscopic and two open repair surgeries); one patient developed recurrent hernia 7 months after the laparoscopic surgery. This case is the first reported recurrence in literature following laparoscopic repair in adults. Surgery is the only treatment option for Morgagni hernias, which can be performed through transthoracic, transabdominal, laparoscopic, or thoracoscopic approach. The issues of using mesh and reducing the hernial sac remain controversial.

Introduction Because of the shortage of organs available for transplantation, living related sequential transplantation with the use of liver and a kidney from the same donor has emerged as a reasonable therapeutic alternative. However, there is insufficient literature about the complications that living donors experience after simultaneous kidney and liver transplantations. Methods From December 2001 to October 2009, 5 living donors provided simultaneous donation of livers and kidneys and 1 living donor donated first her kidney and then her liver. Demographic data of the donors and information concerning the surgery and postoperative observation were collected prospectively. Results All of the donors were female. The median age was 27.5 (range, 19–36) years. Indications requiring the simultaneous transplantation of livers and kidneys were primary hyperoxaluria type 1 (PH1) in 5 potential recipients and cirrhosis due to chronic hepatitis B infection and idiopathic chronic renal insufficiency in 1 potential recipient. Four recipients underwent right hepatectomy (segments 5–8) and right nephrectomy; 1 recipient underwent left hepatectomy (segments 2–4) and right nephrectomy; and 1 recipient underwent left lobectomy (segments 2–3) and right nephrectomy. There were no complications except in 1 donor (postoperative ileus). No donor developed hypertension or microalbuminuria. Conclusions With the right indications, appropriate preoperative evaluation, meticulous surgical technique, proper postoperative care, and long-term close monitoring to minimize morbidity and mortality risks, liver and kidney donation from the same donor can be considered for simultaneous kidney and liver transplantation.

Over the last decade, developments in technology have led a rapid progress in robotic endocrine surgery applications. Robotics is attractive to the surgeon because of the three-dimensional image quality, articulating instruments, and stable surgical platform. Safety and effectiveness of robotic adrenalectomy and thyroidectomy have been shown in many studies. While these robotic procedures offer better ergonomics for the surgeon, they provide similar outcomes compared to the laparoscopic approach for adrenalectomy and better cosmetic results versus the conventional option for thyroidectomy. Recently, while the robotic approach for adrenalectomy has been popularized, enthusiasm for robotic thyroidectomy has decreased. In the present review we aim to describe emerging robotic procedures and review the literature regarding outcomes.

The association between systemic inflammatory response and tumor biology has been well documented over the last decade. The aim of this study is to investigate the prognostic role of neutrophilto- lymphocyte ratio (NLR) in gastrointestinal stromal tumors (GISTs).A prospectively recorded database of 67 patients who underwent surgical resection for GIST was reviewed. High and low NLR were defined with respect to the sample median, which was 1.92. Demographical, clinicopathological, and surgical characteristics were analyzed as well as disease free survival (DFS) rates according to NLR classification.We observed better disease free survival rates in patients with low NLR compared to patients with high NLR (85.7% and 69%, respectively; p=0.037). Estimated five-year overall and disease free survival rates were 95.1% and 78.7%, respectively. In univariate analysis synchronous sarcomatosis, tumor size, mitotic rate, presence of necrosis, lymph node metastasis, surgical margin status, risk category and NLR were associated with DFS. On multivariate analysis sarcomatosis (HR: 30.455), surgical margin status (HR: 4.228) and necrosis (HR: 4.415) were found as independent prognostic factors for DFS.NLR can give information about inflammatory status, tumor aggressivity and prognosis in GIST patients. It could be a new prognostic factor for GIST patients.

A small‐bowel enteroatmospheric fistula (EAF) is an especially challenging complication for patients with open abdomens (OAs) and their surgeons. Manipulation of the bowel during treatment (e.g. dressing changes) is one of the risk factors for developing these openings between the atmosphere and the gastrointestinal tract. Unlike enterocutaneous fistulae, EAFs have neither overlying soft tissue nor a real fistula tract, which reduces the likelihood of their spontaneous closure. Surgical closure is necessary but not always easy to do in the OA environment. Negative pressure wound therapy (NPWT) has been used successfully as an adjunct therapy to heal the wound around EAFs. This review discusses many aspects of managing EAFs in patients with OAs, and presents techniques that have been developed to isolate the fistula and divert effluent while applying NPWT to the surrounding wound bed.

Development of pancreatic fistula after distal pancreatectomy is still a major problem. Various methods have been defined to prevent the development of the fistula. In this study, the results of suture closure of pancreatic duct and closure of pancreatic stump with “U” sutures passing through each other and the risk factors affecting the development of fistula are studied.Fifty-one patients with prospectively collected data were included in the study. In all patients, pancreatic stump was closed with the same surgical technique. Risk factors that may affect fistula formation were studied between groups with and without fistula. Pancreatic fistula definition was made according to the International Study Group on Pancreatic Fistulas classification.Eight (15.7%) of the 51 patients had fistula. Clinically significant fistula ratio was 9.8% (according to ISGPF B and C). Additional organ resections were performed in 18 patients (35.3%). In multivariate analysis, the soft texture of pancreatic parenchyma (OR: 12.420, p = 0.048) and over 150 mL of blood loss (OR: 1.003, p = 0.043) were found as risk factors for the development of fistula.Closure of pancreatic stump after distal pancreatectomy with “U” shaped sutures passing through each other is a method that can be performed safely.

Aim This study aimed to investigate the prognostic impact of the log odds of positive lymph nodes (LODDS) in colon cancer. Method Four hundred and forty patients with colon cancer were divided into three each groups according to their lymph node ratio (LNR) and LODDS. Survival analysis was performed. Results The 5-year overall survival (OS) rate was 70.2%. In univariate analysis age, pT and pN stage, tumour grade, lymphatic, venous and perineural invasion, surgical margin clearance, LNR and LODDS were significantly associated with OS. In multivariate analysis age, surgical margins, perineural invasion and LODDS were found to be independent prognostic factors. In subgroup analysis of patients with an inadequate number of examined lymph nodes (NELN) (n = 76) and node-negative patients (n = 210), LODDS retained its prognostic value, whereas the impact of LNR was not statistically significant (P = 0.063). The overall survival rates of node-negative patients in the LODDS groups 0, 1 and 2 were 81%, 74.2% and 50%, respectively (P = 0.020). LNR and LODDS classifications were both significantly associated with survival in Stage III colon cancer, but only LODDS was an independent prognostic factor. Conclusion Conventional TNM staging for nodes (pN) and LNR status cannot reliably classify node-negative patients into homogeneous groups. LODDS provides more valuable information than LNR independently of the NELN.

AIM: To assess the validity of the Milan and University of California San Francisco (UCSF) criteria and examine the long-term outcome of orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC) in a single-center study. METHODS: This study is a retrospective review of prospectively collected data. Between 1998 and 2009, 56 of 356 OLTs were performed in patients with HCC. Based on pathological examination of liver explants, patients were retrospectively categorized into 3 grou-ps: Milan + (n = 34), Milan -/UCSF + (n = 7) and UCSF - (n = 14). RESULTS: Median follow-up period was 39.5 (1-124) mo. The 5-year overall survival rates in the Milan +, Milan -/UCSF + and UCSF-groups were 87.7%, 53.6% and 33.3%, respectively (P < 0.000). Within these groups, tumor recurrence was determined in 5.8%, 14.3% and 40% of patients, respectively (P < 0.011). Additionally, the presence of microvascular invasion within the explanted liver had a negative effect on the 5-year disease free survival (74.7% vs 46.7%, P < 0.044). CONCLUSION: The Milan criteria are reliable in the selection of suitable candidates for OLT for the treatment of HCC. For cases of OLT involving living donors, the UCSF criteria may be applied.

The peritoneal stromal tissue which provides a rich source of growth factors and chemokines is a favorable environment for tumor proliferation. The pathophysiological mechanism of peritoneal carcinomatosis is an individual sequence consisting of genetic and environmental factors and remains controversial. The natural history of the disease reveals a poor median prognosis of approximately 6 mo; however aggressive surgery and multimodal treatment options can improve oncologic outcomes. Considering peritoneal carcinomatosis as though it is a locoregional disease but not a metastatic process, cytoreductive surgery and and intraperitoneal chemotherapy has been a curative option during recent years. Cytoreductive surgery implies a series of visceral resections and peritonectomy procedures. Although the aim of cytoreductive surgery is to eliminate all macroscopic disease, viable tumor cells may remain in the peritoneal cavity. At that point, intraperitoneal chemotherapy can extend the macroscopic disease elimination to microscopic disease elimination. The successful treatment of peritoneal carcinomatosis requires a comprehensive management plan including proper patient selection, complete resection of all visible disease, perioperative intraperitoneal chemotherapy and postoperative systemic chemotherapy. Surgical and oncologic outcomes are strictly associated with extent of the tumor, completeness of cytoreduction and patient-related factors as well as multidisciplinary management and experience of the surgical team. In this review, pathophysiology and current management of peritoneal carcinomatosis originating from gastrointestinal tumors are discussed according to the latest literature. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

Background/Aims: The association between systemic inflammatory response and tumor biology has been well documented over the last decade. The aim of this study is to investigate the prognostic role of neutrophil-to-lymphocyte ratio (NLR) in gastrointestinal stromal tumors (GISTs). Methodology: A prospectively recorded database of 67 patients who underwent surgical resection for GIST was reviewed. High and low NLR were defined with respect to the sample median, which was 1.92. Demographical, clinicopathological, and surgical characteristics were analyzed as well as disease free survival (DFS) rates according to NLR classification. Results: We observed better disease free survival rates in patients with low NLR compared to patients with high NLR (85.7% and 69%, respectively; p=0.037). Estimated five-year overall and disease free survival rates were, 95.1% and 78.7%, respectively In univariate analysis synchronous sarcomatosis, tumor size, mitotic rate, presence of necrosis, lymph node metastasis, surgical margin status, risk category and NLR were associated with DFS. On multivariate analysis sarcomatosis (HR: 30.455), surgical margin status (HR: 4.228) and necrosis (HR: 4.415) were found as independent prognostic factors for DFS. Conclusion: NLR can give information, about inflammatory status, tumor aggressivity and prognosis in GIST patients. It could be a new prognostic factor for GIST patients.