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End-stage renal disease in the human immunodeficiency virus-positive population is increasing. Kidney transplant is the optimal therapy for this population rather than dialysis modalities if some criteria are met. These include undetectable plasma human immunodeficiency virus RNA, CD4 cell count over 200 cells/μL, and the absence of any AIDS-defining illness. Here, we describe the first living-donor kidney transplant in a human immunodeficiency virus-positive recipient in Turkey. The patient, a 52-year-old male diagnosed as human immunodeficiency virus positive, was on antiretroviral therapy, which consisted of 400 mg twice daily darunavir, 100 mg/day ritonavir, and 50 mg/day dolutegravir. He had been negative for human immunodeficiency virus RNA for the past 3 years. The patient developed renal insufficiency without any known cause and started hemodialysis. A living donor transplant from his son was performed, and the patient received ATG Fresenius-S (Neovii Biotech, Rapperswil, Switzerland) induction and a maintenance immunosuppression therapy consisting of methyl-prednisolone, mycophenolate mofetil, and tacrolimus. There were no incidences of delayed graft function or acute rejection. Because of tacrolimus and ritonavir interaction, tacrolimus trough levels were too high. With tacrolimus withdrawn, tacrolimus trough level decreased to detectable levels 2 weeks later. Antiretroviral therapy was continued on the same dosage. At month 4 posttransplant, the patient's creatinine level was 1.01 mg/dL. At present, the patient has had no complications and no episodes of rejection. Kidney transplant is the most favorable replacement therapy for HIV-positive patients who are under controlled AIDS care with highly active antiretroviral therapy. However, drug interactions should be carefully evaluated.

This study aimed to evaluate the influencing variables for outcomes in patients with septic shock having culture-proven carbapenem-resistant Gram-negative pathogens. It included 120 patients (mean age 64.29 ± 1.35 years and 58.3% female). The mean Sequential Organ Failure Assessment score during septic shock diagnosis was found to be 11.22 ± 0.43 and 9 ± 0.79 among the patients with mortality and among the survivors, respectively (P = 0.017). The logistic regression analysis showed that empirical treatment as mono Gram-negative bacteria-oriented antibiotic therapy (P = 0.016, odds ratio (OR) = 17.730, 95% confidence interval (CI): 1.728-182.691), Charlson Comorbidity Index2 (P = 0.032, OR = 7.312, 95% CI: 5.7-18.3), and systemic inflammatory response syndrome score 3 or 4 during septic shock diagnosis (P = 0.014, OR = 5.675, 95% CI: 1.424-22.619) were found as independent risk factors for day 30 mortality. Despite early diagnosis and effective management of patients with septic shock, the mortality rates are quite high in CRGNP-infected patients.

Amaç: Koronavirüs (COVID-19) pandemisi elektif ameliyat sayıları üzerinde belirgin bir değişime neden olmuştur. Bu değişimin genel cerrahi uzmanlık eğitimini etkilemesi olasıdır. Fıtık cerrahisi genel cerrahi eğitiminin temel bir öğesidir. Bu çalışmanın amacı, pandemi dönemini bir yıl önceki aynı dönemle karşılaştırmak ve fıtık ameliyatı sayısındaki değişimden yola çıkarak pandeminin genel cerrahi uzmanlık eğitimi üzerindeki etkisini ortaya koymaktır.Gereç ve Yöntem: Çalışmaya Nisan- Aralık 2019 (Kontrol grubu) ve Nisan- Aralık 2020 (Pandemi Grubu) tarihleri arasında yapılan elektif karın duvarı fıtığı ameliyatları dahil edildi. Elektronik hasta dosyaları retrospektif olarak taranarak ameliyat verileri elde edildi. İki grup toplam vaka sayısı, eğitim amacıyla uzmanlık öğrencileri tarafından yapılan ameliyat sayısı ve vaka sayılarının aylara göre dağılımı açısından karşılaştırıldı.Bulgular: Çalışmaya toplam 273 ameliyat dahil edildi. Kliniğimizde 2019 yılı döneminde 212 fıtık ameliyatı, 2020 yılı döneminde 61 fıtık ameliyatı uygulanmıştı (p:0.001). Uzmanlık öğrencileri tarafından yapılan fıtık ameliyatı sayısı 2019 yılında 88 iken 2020 yılında 18’di (p:0,009). Pandemi döneminde toplam fıtık ameliyatı sayısındaki ve uzmanlık öğrencileri tarafından yapılan ameliyat sayısındaki azalma istatiksel olarak anlamlıydı. Pandemi öncesi dönemde vakaların % 41,5’i, pandemi döneminde ise vakaların % 29,5’i uzmanlık öğrencileri tarafından uygulanmıştı. Ameliyatların asistanlar tarafından yapılma oranında gruplar arasında istatiksel olarak anlamlı fark saptanmadı (p:0,103)Sonuç: COVID-19 pandemisi döneminde elektif fıtık ameliyatı sayısı ve uzmanlık öğrencileri tarafından yapılan ameliyat sayısı azalmıştır. Cerrahi uygulamanın eğitimin önemli bir parçası olduğu göz önüne alındığında, vaka sayısındaki düşüş ve uzmanlık öğrencilerinin ameliyatlara katılımındaki azalma eğitimin kalitesini etkileyecektir. Bu sonuçlar, pandemi döneminde uzmanlık öğrencisi eğitiminin yeniden düzenlenmesi gerektiğini ortaya koymaktadır., Aim: The coronavirus disease (COVID-19) pandemic has caused a significant change in the number of elective surgeries. This change is likely to affect general surgery residency training. Hernia surgery is an essential element of general surgery training. The aim of this study is to compare the pandemic period with the same period a year ago and to reveal the effect of the pandemic on the general surgery residency training, based on the change in the number of hernia operations.Materials and Methods: Elective abdominal wall hernia surgeries performed between April-December 2019 (control group) and April-December 2020 (Pandemic Group) were included in the study. Surgical data were obtained from electronic patient files retrospectively. The two groups were compared in terms of the total number of cases, the number of surgeries performed by residents for educational purposes, and the distribution of cases by month.Results: A total of 273 surgeries were included in the study. In our clinic, 212 hernia surgeries were performed in 2019 period and 61 hernia operations in 2020 period (p: 0.001). The number of hernia surgeries performed by residents was 88 in 2019 and 18 in 2020 (p: 0.009). During the pandemic period, the decrease in the total number of hernia operations and the number of surgeries performed by residents was statistically significant. 41.5% of the cases in the pre-pandemic period and 29.5% of the cases during the pandemic period were applied by the residents. No statistically significant difference was found between the groups in the rate of operations performed by residents (p: 0.103)Conclusion: During the Covid 19 pandemic, the number of elective hernia surgeries and the number of surgeries performed by residents decreased. Considering that surgical practice is an important part of education, the decrease in the number of cases and the decrease in the participation of residents to the surgeries will affect the quality of education. These results reveal that residency student education should be reorganized during the pandemic period.

Background: Both from a medical and legal point of view, the quality of operative notes are important. in this study we hypothesized that the quality of operation notes could be improved by audit, education session and using a proforma. Methods: A total of 150 operation notes were audited for compliance with the Royal College of Surgeons guidelines. Results were announced in -clinic training session and guidelines were dis- cussed. An aide-memoire containing guideline parameters placed in the operating theaters. After eight months, operation reports were re -audited on an equal number of patients. An operative note proforma was developed and third audit was carried out. the results of each audit were compared. Results: in the first audit, it was found that fourteen parameters were written with more than 90% accuracy. the first audit revealed seven poor areas in documentation: time of operation (0%), identification of emergency/elective procedure (0%), identification of any prosthesis or devices used (65.3%), details of closure technique (36.6%), name of anesthesiologist (0%), pa- tient position (1.3%), and amount of bleeding (0%). in the second audit there was an incom- plete, but significant improvement in these seven parameters (28%, 28.6%, 82%, 75.3%, 31.3%, 32%, and 34% respectively). Following introduction of the proforma; third audit cycle demonstrated a clear improvement in operation note documentation with at least 80% compli- ance in all parameters. Conclusion: This study revealed that the accuracy of the operating room documents can be improved through audits, education of surgeon and using proformas. the use of proforma pro- vides much better results. (C) 2019 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B. V. This is an open access article under the CC BY-NC- ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Objective: Currently, sphincter-saving procedures are increasingly performed in the treatment of low rectal cancers. This study aimed to evaluate the outcomes of patients who underwent intersphincteric resection. Material and Methods: This was a single-center, retrospective, cross-sectional study. We evaluated the electronic data files of 29 patients who had intersphincteric resections at our institute between 2008 and 2018. Bowel function outcomes were assessed prospectively using Wexner incontinence score. Histopathological, surgical and functional outcomes were analyzed. Results: Mean age of nine female and 20 male patients included in the study was 55.8 ± 12.8 (30-76) years. A tumor-free surgical margin was achieved in all patients. Anastomotic leakage was detected in two patients. Mean Wexner incontinence score of 20 patients who still had functional anastomosis was 8.35, whereas 65% of the patients (n= 13) had a good continence status. There was no relationship between the continence status and sex, tumor distance from anal verge, T stage, distal surgical margin, and lymph node involvement. Twenty-one patients underwent primary coloanal anastomosis and eight patients underwent two-stage coloanal anastomosis. Conclusion: In the treatment of distal rectal cancer, adequate oncological surgery and relatively acceptable functional outcomes can be obtained with intersphincteric resection technique in suitable patients.

Background: Acute mesenteric ischemia (AMI) is a catastrophic abdominal emergency characterized by sudden critical interruption to the intestinal blood flow which commonly leads to bowel infarction and death. AMI still has a poor prognosis with an in-hospital mortality rate of 50-69%. This high mortality rate is related to the delay in diagnosis which is often difficult and overlooked. Early intervention is crucial and gives a chance for intestinal viability. Methods: The charts of 140 patients who were hospitalized with AMI between May 1997 and August 2013 in Ege University Faculty of Medicine, Department of General Surgery were retrospectively reviewed. Demographical and clinical features of patients constituting the best predictors of morbidity and mortality were evaluated with Multiple Logistic Regression analysis by Enter method after adjustment for all possible confounding factors. Results: Out of 140 patients, 77 were men (55%) and 63 were women (45%). The mean age was 66.6 +/- 14.5 (16-94) years. Demographical findings, comorbidities, ASA scores, drugs used for mesenteric ischemia and diagnostic imaging materials were summarized. The most common comorbidities were cardiac problems (42.9%). Twenty-seven (19.3%) patients had diabetes mellitus. The median ASA score was 3. Abdominal computed tomography (CT) was the most commonly used imaging modality and it was performed in 119 (85%) patients. Twenty-five (17.9%) patients were in shock and 48 (34.3%) had acidosis. The time of delay between the onset of acute abdominal pain to surgery was 24 hours in 80 patients (57.1%). The most common etiology in AMI was thrombus, in 69 patients (49.3%). The most affected or involved organ was both small and large bowel - in 80 patients (57.1%) in total. The most commonly performed surgery was small bowel resection - in 42 patients (30%).As many as 127 (90.7%) of all patients underwent surgery and 18 (12.9%) patients underwent a second-look laparotomy. Small bowel length of less than 100 cm was recorded in 46 patients (32.9%). The length of hospital stay was 7 days (1-90 days). Morbidities were found in 51 patients (36.4%) and death in 74 patients (52.9%). Conclusion: The purpose of this study was to evaluate the prognostic factors of AMI to better understand it and optimize both medical and surgical management with improvement of treatment results. We suggested that the diagnosis of AMI should be based on suspicion of a clinician only and that laparotomy should be performed as soon as possible, before the onset of the clinical signs of peritonitis. Age and time of delay between the onset of acute abdominal pain and surgery longer than 24 hours are the most important prognostic factors for mortality in patients presenting with shock and acidosis.

BackgroundThe optimal timing of surgery following preoperative chemoradiotherapy (CRT) is controversial. This trial aimed to compare pathological complete response (pCR) rates obtained after an interval of 8 weeks or less versus more than 8 weeks.MethodsPatients with locally advanced rectal adenocarcinoma situated within 12 cm of the anal verge (T3–4 or N+ disease) were randomized to undergo total mesorectal excision (TME) within 8 weeks (classical interval, CI group) or after 8 weeks (long interval, LI group) following CRT.ResultsAmong the 327 included patients (CI 160, LI 167), the pCR rate was significantly higher in the LI group than in the CI group (10·0 versus 18·6 per cent; P = 0·027). The highest pCR rate (29 per cent) was observed between 10 and 11 weeks. There was statistically significant disease regression in the LI group, with better stage (P = 0·004) and T category (P = 0·001) than in the CI group. There was no significant difference in surgical quality (rates of tumour-positive margins, TME quality, anastomotic leakage and intraoperative perforation) between the groups. The overall morbidity rate was 22·5 per cent in the CI group and 19·8 per cent in the LI group (P = 0·307). Regression analysis including sex, age, clinical stage, tumour location, tumour differentiation, TME quality, concomitant chemotherapy and interval to surgery revealed no statistically significant predictors of pCR.ConclusionDisease regression and pCR rate are increased with an interval between CRT and surgery exceeding 8 weeks. Registration number: NCT03287843 (http://www.clinicaltrials.gov).

OBJECTIVE Fine needle aspiration biopsy provides one of the most important data that determines the treatment algorithm of thyroid nodules. Nevertheless, the reliability of fine needle aspiration biopsy is controversial in large nodules. The aim of this study was to evaluate the adequacy of fine needle aspiration biopsy in thyroid nodules that are four cm or greater. MATERIAL AND METHODS We retrospectively examined 219 patients files who underwent thyroidectomy for thyroid nodules that were greater than four centimeter between May 2007 and December 2012. Seventy-four patients with hyperthyroidism, and 18 patients without preoperative fine needle aspiration cytology were excluded from the study. Histopathologic results after thyroidectomy were compared with preoperative cytology results, and sensitivity and specificity rates were calculated. RESULTS False-negativity, sensitivity and specificity rates of fine needle aspiration biopsy of thyroid nodules were found to be 9.7%, 55.5%, and 85%, respectively. Within any nodule of the 127 patients, 28 (22.0%) had thyroid cancer. However, when only nodules of at least 4 cm were evaluated, thyroid cancer was detected in 22 (17.3%) patients. CONCLUSION In this study, fine needle aspiration biopsy of large thyroid nodules was found to have a high false-negativity rate. The limitations of fine-needle aspiration biopsy should be taken into consideration in treatment planning of thyroid nodules larger than four centimeters.

BACKGROUND AND AIMS Minimally invasive surgery of the adrenal gland is widespread. Although reports demonstrate the safety and feasibility of robot-assisted adrenalectomy, the objective benefits are still unclear, compared to those of conventional laparoscopy. Recently, robot-assisted approach has also become possible for pheochromocytoma resection. Since cardiopulmonary changes during robot-assisted dissection of the pheochromocytoma patient has not been studied in detail, we aimed to assess these concerns, compared to the routine laparoscopic technique. METHODS In this case-control study, 19 consecutive robot-assisted adrenal resections were compared with a control group consisting of 14 conventional laparoscopic adrenalectomy. Patient characteristics and intraoperative hemodynamic and respiratory parameters were assessed. Groups were compared using the χ2 test for categorical variables and Student's t-test for continuous variables. Significance was considered p < 0.05. RESULTS The robot-assisted procedure was performed successfully in all patients, except one. The duration of the robot-assisted procedure, compared to the conventional laparoscopy group, was significantly longer (p < 0.05). Intraoperative blood loss was significantly less in the robot-assisted group (p < 0.05). Dissection of pheochromocytoma showed a significant difference between the groups, according to the incidence of intraoperative blood pressure fluctuations (p < 0.05). The robot-assisted approach resulted in less incidents. Other hemodynamic and respiratory parameters did not differ between groups significantly. There were no perioperative deaths. Complication rates and postoperative hospital stays were not significantly different. CONCLUSION Robot-assisted adrenalectomy is a safe and technically feasible procedure for a pheochromocytoma patient. Robot-assisted resection of pheochromocytoma minimized the occurrence of intraoperative blood pressure fluctuations and blood loss.

INTRODUCTION Metastatic tumors of the pancreas are uncommon and rarely detectable clinically. Metastases to the pancreas are rare. We present a patient with pancreatic metastases from a leiomyosarcoma of the uterus and review the literature about the clinical features of pancreatic metastasis and its surgical management. PRESENTATION OF CASE A 40-year-old woman, who underwent hysterectomy, left oophorectomy, omentectomy and lymp node dissection for leiomyosarcoma of the uterus. At the follow up, the patient complained of non-specific abdominal discomfort. Preoperative diagnosis were pancreatic pseudocyst, cystadenoma or cystadenocarcinoma. At laparotomy, a cystic mass was found in the tail of the pancreas which was invased to the transverse colon mesenterium and the spleen. Distal pancreatectomy with splenectomy and transverse colon resection was performed. Histologically, the tumor was evaluated as poorly differentiated leiomyosarcoma. DISCUSSION Metastatic lesions of the pancreas are uncommon and less than 2% of all pancreatic malignancies. However a few cases of leiomyosarcoma with metastases to the pancreas have been reported in the literature. Before deciding that the lesion in the pancreas was metastasis, primary leiomyosarcoma of the pancreas had to be ruled out. Histologically, leiomyosarcoma of the pancreas contains interlacing spindle cells with varying degrees of atypia and pleomorphism. The surgical approach to the pancreatic metastases must be aimed complete excision of the tumor with a wide negative margin of clear tissue and maximum preservation of pancreatic remnant if possible. CONCLUSION In the absence of widespread metastatic disease, aggressive surgical approach with negative margins must be aimed.

Crohn’s disease (CD) is an inflammatory bowel disease with the characteristics of idiopathic, granulomatous inflammation which affects any area along the gastrointestinal system from the anus to the oral cavity. We present here an unusual case of a 25-year-old male patient, who consulted us because of abdominal pain for 2 days. The computer tomography showed free fluid at the pelvis, acute appendicitis findings and mural thickening of the terminal ileum, secondary to the appendicitis, were reported, and during the examination together with the acute abdomen findings it was decided to perform surgery on the patient. During surgery free fluid extensive inside the abdomen, at the terminal ileum indigenous for the inflammatory appearance of CD and a perforation of approximately 0.5 cm at the front face of the gastric pylorus, were seen. After the perforation at the stomach was primarily sutured and the inner abdomen was irrigated with physiological saline solution, so the surgery was brought to an end. After postsurgical antibiotherapy and hydration support, the patient was discharged and improved on the seventh day after surgery. Although CD is a chronic inflammatory disease of the gastrointestinal system, it is able to imitate the inner abdominal pathologies during an acute attack (acute appendicitis, hollow organ perforation, etc.). On patients with acute abdomen findings, where the CD diagnosis is not known, a laparotomy must be performed when a differential diagnosis of the inner abdominal pathologies cannot be made radiologically. As it is in this case, even if ileitis due to CD is determined during laparatomy, all inner abdominal organs must be explored carefully, and it should be kept in mind that the other organ pathologies can occur together. In this case the aim was to analyze the association of gastric perforation and acute CD at the terminal ileum of a patient with acute abdomen, where the diagnosis of CD is not known. J Curr Surg. 2014;4(4):124-126 doi: http://dx.doi.org/10.14740/jcs239w

Highlights • Retroperitoneal paragangliomas are mostly benign with good prognosis. • Complete surgical excision is the treatment of choice for extra-adrenal paragangliomas. • Reactive thrombocytosis is a common cause of thrombocytosis after splenectomy., Introduction Paragangliomas are tumors that arise from extraadrenal chromaffin cells and most of them are asymptomatic presenting with painless mass. Retroperitoneal paragangliomas are mostly benign with good prognosis; however, they can present with abdominal pain, palpable mass, or hypertensive episodes. Surgical resection is still the main treatment and necessary for histological assessment. Case report A 41 year old female patient presented with 6 months of loss of appetite, weight loss, weakness and breathlessness on exertion.. The patient’s initial blood examination showed marked anemia, reduced leukocyte count with neutropenia and lymphopenia and a marked reduction in the platelet count. The patient was admitted for evaluation of her pancytopenia. Magnetic resonance imaging revealed a 8 × 7 × 8 cm sized mass closed to the pancreatic tail invading splenic hilum. A large mass was identified retroperitoneally, closed to the tail of pancreas with a splenic hilum invasion. Total mass resection and splenectomy was performed. Discussion Complete surgical excision is the treatment of choice for extra-adrenal paragangliomas as well as for recurrent or metastatic neoplasms. Reactive thrombocytosis is a common cause of thrombocytosis. Splenectomy was found to be one of the main causes of extreme reactive thrombocytosis. Reactive thrombocytosis is a predictable finding after splenectomy and management of the thrombocytosis and prevention of complications should be initiated.

Introduction. Hydatid disease (HD) is an infestation that is caused by the larval stage ofEchinococcus granulosus. The liver is affected in approximately two-thirds of patients, the lungs in 25%, and other organs in a small proportion. Primary retroperitoneal hydatid cyst is extremely rare. The most common complaint is abdominal pain; however, the clinical features of HD may be generally dependent on the location of the cyst.Case Presentation. A 43-year-old female was admitted with the complaint of abdominal pain. Her physical examination was normal. Computed tomography (CT) revealed a17×11 cm cystic lesion, with a thick and smooth wall that is located among the left liver lobe, diaphragm, spleen, tail of the pancreas, and transverse colon and invading the splenic hilum. Total cystectomy and splenectomy were performed. Pathological examination was reported as cyst hydatid.Discussion. Cysts in the peritoneal cavity are mainly the result of the spontaneous or traumatic rupture of concomitant hepatic cysts or surgical inoculation of a hepatic cyst. Serological tests contribute to diagnosis. In symptomatic and large hydatid peritoneal cysts, surgical resection is the only curative treatment. Total cystectomy is the gold standard. Albendazole or praziquantel is indicated for inoperable and disseminated cases. Percutaneous aspiration, injection, and reaspiration (PAIR) technique is another nonsurgical option.