Kolorektal kanserlerin karaciğer metastazlarında hepatik rezeksiyon uygulanan hastalarda sağkalımı etkileyen faktörlerin incelenmesi

Kolorektal kanser en sık görülen malignitelerden biridir ve hastalığın seyri sırasında bu hastaların %50’sinde karaciğer metastazı gelişir. Kolorektal kanserlerin karaciğer metastazlarında hepatik rezeksiyon en etkili tedavi yöntemidir. Bu çalışmanın amacı kolorektal kanserlerin karaciğer metastazında hepatik rezeksiyon uygulanan hastalarda sağkalımı etkileyen faktörlerin ortaya konmasıdır. 2003-2009 yılları arasında Ege Üniversitesi Tıp Fakültesi Genel Cerrahi Anabilim Dalı’nda kolorektal kanserin karaciğer metastazı nedeniyle hepatik rezeksiyon uygulanmış olan 62 hastanın verileri retrospektif olarak incelendi. İstatistiksel yöntem olarak Kaplan-Meier sağkalım analizi ve Cox-Mantel Logrank Testi kullanıldı. Sağkalıma etkisini araştırdığımız değişkenler yaş, cinsiyet, primer tümörün yerleşimi, primer tümörün invazyon derinliği (T-skoru), lenf nodu durumu, kolorektal ve hepatik cerrahiler arası süre, operasyon öncesi CEA,Ca19-9, serum albumin düzeyi ve lenfosit sayısı, operasyonu yapan cerrahın deneyimi, metastazın çapı, metastaz sayısı, metastazın yerleşimi (Unilober/bilober), cerrahi rezeksiyonun genişliği ve cerrahi sınır idi. Hastanın yaşı, lenf nodu tutulumu, bilober karaciğer metastazı varlığı ve cerrahi sınırda tümör varlığı sağkalıma etkili faktörler olarak belirlendi. Sonuçlarımız literatürdeki verileri destekler nitelikteydi. Özellikle cerrahi sınırda tümör olmayan hastalarda cerrahi sınır uzaklığının 1 cm’nin üstünde ya da altında olmasının sağkalıma etkisinin olmadığı görüldü

COVID-19 pandemisinin genel cerrahi uzmanlık eğitimine etkisi

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

Rektal Tümörlerde Transanal Endoskopik Cerrahi: Tek Merkez Deneyimi

Amaç: Bu çalışmada, transanal endoskopik operasyon platformunun uygunluğunu, güvenliğini, onkolojik sonuçlarını araştırmayı ve klinik deneyimimizi paylaşmayı amaçladık. Yöntem: Çalışmaya Ege Üniversitesi Tıp Fakültesi Hastanesi’nde 2014–2020 yılları arasında transanal endoskopik cerrahi ile opere edilen hastalar dahil edildi. Hastalara ait veriler retrospektif olarak elde edildi. Ameliyatlar transanal endoskopik operasyon platformu (TEO®; Karl Storz, Tuttlingen, Almanya) kullanılarak gerçekleştirildi. Bulgular: Çalışmaya 39 hasta dahil edildi. Hastaların 12’si (%31) kadındı. Ortanca yaş 63 yıl (yaş aralığı 17-88 yıl) idi. Tümörün anal girimden ortanca uzaklığı 8 cm (4–15 cm) idi. Ortanca tümör çapı 39 mm (4-90 mm) idi. Histopatolojik inceleme sonucunda 23 (%59) hastada malignite saptandı (pTis: 14 [%36], pT1: 9 [%23]). Bir (%3) hastada komplikasyon görüldü. Ortanca takip süresi 38 ay (10-88 ay) idi. İki (%5) hastada nüks görüldü. Sonuç: Transanal endoskopik cerrahi, düşük bir morbidite oranı ile geleneksel bir yaklaşımla eksize edilemeyen rektal lezyonların eksize edilebilmesini sağlar. Ayrıca patolojisi tam ortaya konulamamış lezyonların kesin histopatolojik tanısı için de kullanılabilir. Erken evre malign rektum tümörlerinin uygun cerrahi sınır ile çıkarılması için güvenle kullanılabilir

Effects of Standard Ostomy Self-care Program on Peristomal Skin Complications and Quality of Life of Patients with Colorectal Cancer: A Single-Blind Study

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Czynniki prognostyczne w ostrym niedokrwieniu krezki i ocena ich wpływu na wskaźniki chorobowości i śmiertelności metodą regresji logistycznej

Wprowadzenie: Ostre niedokrwienie krezki (ang. acute mesenteric ischaemia; AMI) jest katastrofalnym w skutkach i wymagającym natychmiastowej pomocy stanem jamy brzusznej, będącym następstwem nagłego, krytycznego przerwania dopływu krwi do jelit i często prowadzącym do zawału jelita i zgonu. AMI wciąż charakteryzuje się niekorzystnym rokowaniem, ze wskaźnikiem śmiertelności wynoszącym 50–69% wśród pacjentów hospitalizowanych. Ten wysoki wskaźnik śmiertelności jest związany z opóźnieniem w rozpoznaniu, które często nastręcza trudności i może zostać niewłaściwie postawione. Wczesna interwencja ma kluczowe znaczenie dla zachowania żywotności jelit. Metody: Dokonano retrospektywnej oceny dokumentacji klinicznej 140 pacjentów z AMI leczonych od maja 1997 r. do sierpnia 2013 w Klinice Chirurgii Ogólnej Wydziału Medycznego Uniwersytetu Ege. Parametry demograficzne i kliniczne, decydujące o najlepszych rokowaniach w zakresie chorobowości i śmiertelności, określono w analizie regresji logistycznej metodą wprowadzania (Enter) po uwzględnieniu poprawek na wpływ wszystkich możliwych czynników zakłócających. Wyniki: W grupie 140 pacjentów 77 osób stanowili mężczyźni (55%), zaś 63 kobiety (45%). Średnia wieku wyniosła 66,6 ± 14,5 (16–94) lat. Podsumowano: dane demograficzne, dane o chorobach współistniejących, wyniki w skali ASA, dane nt. stosowania leków związanych z niedokrwieniem krezki oraz materiały z badań diagnostyki obrazowej. Najczęstszymi chorobami współistniejącymi były problemy kardiologiczne (42,9%). U 27 (19,3%) pacjentów stwierdzono cukrzycę. Średni wynik w skali ASA wynosił 3. Najczęściej stosowaną metodą obrazowania była tomografia komputerowa (TK) jamy brzusznej, którą wykonano u 119 (85%) pacjentów. U 25 (17,9%) chorych stwierdzono wstrząs, zaś u 48 (34,3%) – kwasicę. Zwłoka między wystąpieniem ostrego bólu brzucha a zabiegiem wyniosła 24 godziny u 80 pacjentów (57,1%). Najczęstszą etiologią AMI był zakrzep (69 pacjentów, 49,3%). Najbardziej dotkniętymi bądź zajętymi narządami były jednocześnie jelito cienkie i grube (80 pacjentów, 57,1%). Najczęściej wykonywaną operacją była resekcja jelita cienkiego (42 pacjentów, 30%). Operacji chirurgicznej poddano 127 (90,7%) pacjentów, zaś 18 (12,9%) poddano laparotomii sprawdzającej. W przypadku 46 chorych (32,9%) stwierdzono jelito cienkie o długości poniżej 100 cm. Średni czas hospitalizacji wynosił 7 dni (1–90 dni). Wystąpienie chorób odnotowano u 51 pacjentów (36,4%), zaś wystąpienie zgonu u 74 pacjentów (52,9%). Wniosek: Celem niniejszego badania była ocena czynników prognostycznych AMI, mająca prowadzić do lepszego zrozumienia AMI, optymalizacji metod leczenia zarówno niechirurgicznego, jak i chirurgicznego, oraz poprawy wyników leczenia. Sugerujemy, że diagnostykę AMI należy wykonywać w oparciu o samo podejrzenie, oraz że w przypadkach takich konieczne jest niezwłoczne wykonanie laparotomii, w miarę możliwości przed wystąpieniem klinicznych objawów zapalenia otrzewnej. Wśród pacjentów z obrazem klinicznym obejmującym wstrząs i kwasicę najważniejszymi parametrami prognostycznymi śmiertelności są wiek i zwłoka między wystąpieniem ostrego bólu brzucha a zabiegiem wynosząca więcej niż 24 godziny

Prognostic factors in acute mesenteric ischemia and evaluation with multiple logistic regression analysis effecting morbidity and mortality

Background: Acute mesenteric ischaemia (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 diffucult and overlooked. Early intervention is crucial and the potential for intestinal viability. Methods: The charts of 140 patients who were hospitalazed 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 determining the best predictors which effect on morbidity and mortality were evaluated by Multiple Logistic Regression analysis by Enter method after adjustment for all possible confounding factors. Results: After Multiple LR analysis by Enter method after adjustment for all possible confounding factors affecting morbidity; shock, exploration and stay in hospital were statistically significant. Age, cardiac comorbidities, ASA scores, the time delay between onset of acute abdominal pain to surgery, the presence of acidosis and shock, the involved organs (small bowel and both), type of surgery and medical treatment and small bowel length under 100 cm were statistically significant on mortality. Conclusion: Risk factors related to mortality and morbidity have been poorly analyzed due to lack of prospective studies and smaller number of patients. Early diagnosis generally depends on clinical awareness and suspicion. Age and time of delay between onset of acute abdominal pain to surgery longer than 24 hours are the most important parameters that predict the mortality for patients presenting with shock and acidosis

Acute appendicitis during coronavirus disease 2019 in Turkiye: Changes in clinical approach, treatment, and diagnosis modalities: A retrospective and cohort study

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) has resulted in major changes in health-care systems and emergency surgical interventions. Here, we examined patients with acute appendicitis who presented to emergency departments and compared diagnosis, treatment, and post-treatment processes before and during the pandemic period and investigated how the pandemic affected management of acute appendicitis. METHODS: A national, multicenter, and cohort study model was designed that included patients older than 18 years of age diagnosed with acute appendicitis clinically and/or radiologically, with patients compared before (pre-pandemic period: January 1-April 30, 2019) and after (pandemic period: January 1-April 30, 2020) the pandemic. Our investigation included comparisons of pre-operative imaging methods, presence of plastron appendicitis/abscess, conservative/surgical approach, type of anesthesia given, laparoscopic/ open surgical approach, bowel resection rates, drain insertion rates, and presence of post-operative complications RESULTS: For the two study groups, 8972 patients from 69 centers were examined, with 4582 patients operated in the pre-pandemic period and 4234 patients operated in the pandemic period. During the pandemic period, 63.6% of patients underwent open surgery, whereas 34.4% had laparoscopic surgery. Although 60 patients (1.3%) requested non-operative follow-up in the pre-pandemic period, 94 patients (2.2%) requested this in the pandemic period. When conditions of patients were evaluated regardless of their own wishes, 114 patients (2.4%) before and 163 patients (3.8%) during the pandemic received non-operative follow-up. CONCLUSION: Our study did not show the direct correlation between the application of COVID-19-related restrictions and the severity of acute appendicitis. Although non-operative management rates have been increased during the COVID-19 period, the incidences of both complicated and the uncomplicated appendicitis were similar during the COVID-19 crisis period. Given this information non-operative management can be employed for patients diagnosed with appendicitis

Isolated metastasis of uterine leiomyosarcoma to the pancreas: Report of a case and review of the literature

AbstractINTRODUCTIONMetastatic 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 CASEA 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.DISCUSSIONMetastatic 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.CONCLUSIONIn the absence of widespread metastatic disease, aggressive surgical approach with negative margins must be aimed

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background: Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods: The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results: A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion: Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).ESCP; NIHR Global Health Research Unit on Global Surgery [NIHR133364]The EAGLE study was funded by the ESCP. Ethicon provided an unrestricted educational grant to the ESCP which was used in supporting the development of the online education materials. The NIHR Global Health Research Unit on Global Surgery (NIHR133364) provided support, notably in accessing and supporting collaborating teams in low-and middle-income countries. The funders had no role in the design, set-up, running or analysis of this study, or writing of this report. The views expressed are those of the authors and not necessarily those of the ESCP, Ethicon, or NIHR