Substernal Goiter: When is a Sternotomy Required?

The presence of substernal goiter is, per se, an indication for surgical management. Surgical approach of substernal goiter can most commonly be performed using the cervical access, but at times, a sternotomy or thoracotomy is necessary. The aim of this study was to identify the preoperative predictors of a sternotomy in the management of substernal goiter in order to provide better preoperative planning and patient consent. Between 2005 and 2012, 665 patients were referred to our clinic for thyroidectomy, 42 patients (6.3%) had substernal goiter and were included in this study. All substernal goiters were treated surgically, 38 (90.5%) by a cervical approach and 4 (9.5%) by full median sternotomy. All surgeries were successful, with no major postoperative complications. Minor postoperative complications of transient hypocalcemia and transient paralysis of the recurrent laryngeal nerve occurred in 5 (11.9%) and 2 (4.7%) cases, respectively. Indication of median sternotomy was as follows: extension of goiter below the aortic arch, large thyroid tissue extending towards tracheal bifurcation, and ectopic thyroid tissue in the mediastinum. Substernal goiter can be removed through a cervical incision, but on rare occasions, a median sternotomy may be required.Key words: Sternotomy, Substernal goiter, Surgery, TreatmentSubsternal goiter (SG) was first described by Haller in 1749 and first surgically removed by Klein in 1820.¹⁻⁴ There is no uniform definition of substernal goiter.¹⁻³ However, various different criteria have been suggested by authors. These include a thyroid gland extending 3 cm below the sternal notch or extension of the gland below the fourth thoracic vertebra.^5,6 An extension of the thyroid gland below the thoracic inlet has been defined as substernal, retrosternal, intrathoracic, or mediastinal goiter. Drawing upon the relationship of the intrathoracic extension of SG to the arcus aorta and the right atrium and findings from imaging methods, diagnostic classifications have been established that take into account the percentage of goitrous thyroid in the mediastinum.^7,8 Substernal goiters are common, with a reported incidence of 1−20% of all patients undergoing thyroidectomy.^3,5,9−14 Diagnosis of substernal goiter is most frequently made in the fifth or sixth decade of life, with a female/male rate of 4:1.^11,14,15 The vast majority of SGs (85−90%) are located in the anterior mediastinum with the remainder (10−15%) located in the posterior mediastinum.^1,10,16,17Substernal goiters show, in most cases, a slow-growing enlargement, which usually remain asymptomatic for many years; about 20−40% of substernal goiters are discovered as an incidental finding on a radiographic examination.^2,11,18 Patients with mediastinal goiter are rarely asymptomatic. The most common symptoms are related to compression of the airways and the esophagus, and represented by dyspnea, choking, inability to sleep comfortably, dysphagia, and hoarseness.^2,12,14,18 In the diagnostic management of mediastinal goiter, chest computed tomography (CT) was of the highest value. CT scanning is, at present, the most exhaustive examination for assessment of the extent of the goiter and compression effects on adjacent anatomic structures. A preoperative CT scan should be routinely performed in every suspicion of a substernal goiter.^12,19−21 Magnetic resonance imaging (MRI) adds little additional information to that obtained with CT and is not routinely used.¹¹Substernal goiter must be removed surgically due to relation to compressive symptoms, potential airway compromise, and the possibility of an association with thyroid malignancy.¹⁷ There is a general consensus that most can be successfully removed via a cervical approach and that thoracic access is rarely necessary.^9,11,12 Various factors have been reported to increase the likelihood of a median sternotomy being required. These factors include involvement of the posterior mediastinum, extension of the goiter to the aortic arch, recurrent goiter, superior vena cava obstruction, malignancy with local involvement, and emergent airway obstruction.^{6,10,12,16,17,19} In addition, inability to palpate the lowermost extent of the gland also is considered to be an indication for median sternotomy. The incidence of sternotomy in substernal goiter is variable, ranging between 0−11 %.^2,9,11,12 This wide range in incidence might be related to variation in the definition of substernal goiter.In order to improve preoperative planning and patient consent, we aimed to identify the preoperative predictors of a sternotomy in the management of substernal goiter.     

Changes in the Frequencies of Abdominal Wall Hernias and the Preferences for Their Repair: A Multicenter National Study From Turkey

Abdominal wall hernias are a common problem in the general population. A Western estimate reveals that the lifetime risk of developing a hernia is about 2%.^1–3 As a result, hernia repairs likely comprise the most frequent general surgery operations. More than 20 million hernias are estimated to be repaired every year around the world.⁴ Numerous repair techniques have been described to date however tension-free mesh repairs are widely used today because of their low hernia recurrence rates. Nevertheless, there are some ongoing debates regarding the ideal approach (open or laparoscopic),^5,6 the ideal anesthesia (general, local, or regional),^7,8 and the ideal mesh (standard polypropylene or newer meshes).^9,10Although laparoscopic procedures have gained popularity worldwide, laparoscopic repairs still constitute only a small fraction of hernia surgeries,¹¹⁻¹³ mainly due to costs and the need for expertise. Today, general anesthesia is still the most frequently-used anesthesia technique. The usage of local anesthesia has been increasing, however, although its routine use is limited to specific hernia centers.^14–16 On the other hand, standard heavyweight propylene meshes lead the market mostly because of their low cost. Newer lightweight meshes should be considered as a first alternative to heavyweight conventional polypropylene meshes, provided that adequate fixation is guaranteed.The most frequent hernia type is inguinal. According to some classical reference books, the frequency of abdominal wall hernias is as follows: inguinal (70%–75%), femoral (6%–17%), and umbilical (3%–8.5%), followed by rare forms (1%–2%).^1,2 No changes in the frequencies of different types of abdominal wall hernias have been published in 3 consecutive editions of a well-known surgical textbook between 2004 and 2012.^17–19 However, a recent UK study found that the frequencies of different types of abdominal wall hernias change with time and that the figures given in the classical books should be subject to scrutiny.³In our observations over recent years, there have been some changes not only in the frequencies but also in the repair preferences and anesthetic techniques in daily surgical practice. Therefore, we aim to carry out a multicenter study to reflect the actual frequencies of abdominal wall hernias and the technical preferences for repairing these hernias in Turkey, a country with a population of over 70 million.     

Sacral Nerve Function in Child Patients After Ileal J-Pouch-Anal Anastomosis for Ulcerative Colitis

To clarify the neurological function of the puborectalis muscle (PM) in child patients with soiling after ileal J-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC), we examined the terminal motor latency in the sacral nerves that regulate the PM. Eight patients after IPAA for UC were studied (6 males and 2 females aged 11 to 13 years with a mean age of 12.8 years). All patients 6 months after IPAA showed soiling (group A) and these patients showed continence at 2 years after IPAA (group B). Group C serving as controls consisted of 16 subjects (10 males and 6 females aged 12 to 17 years with a mean age of 14.4 years). Left- and right-sided sacral nerve terminal motor latency (SNTML) tests were performed at 6 months and 2 years after IPAA in order to measure the latency of the response in the bilateral PM following magnetic stimulation of sacral nerve root segments 2 to 4 (S2–S4) of the spinal column overlying the cauda equina. The following results were obtained. (1) Right-sided SNTML: group A exhibited significant prolongation compared with groups B and C (P < 0.0001 and P < 0.0001, respectively). There was no significant difference between groups B and C (P = 0.2329). (2) Left-sided SNTML: group A exhibited significant prolongation compared with groups B and C (P = 0.0002 and P < 0.0001, respectively). There was no significant difference between groups B and C (P = 0.2315). Note that significant differences were not established between SNTML values measured on the right and left sides. Soiling in child patients 6 months after IPAA may be caused by damage to the bilateral sacral nerves during the operation. However, the damage to the sacral motor nerve improves within 2 years after IPAA.Key words: Soiling, Sacral nerve terminal motor latency, Puborectalis muscle, Ulcerative colitis, ChildThe functional results of total colectomy, mucosal proctectomy, and ileal J-pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) have been acceptable and patient satisfaction has been very high because patients are free from stoma.^1–3 In general, the functional outcomes after IPAA in children are better than those in adults.^4–12 However, some child patients experience defecation function impairments after IPAA, including minor fecal incontinence (soiling), incontinence, increased bowel movement, urgency of defecation, evacuation difficulty, irregular bowel habitus, difficulty in distinguishing gas from feces, and diarrhea.^8–10,12 The most common abnormality is soiling.^8–10 Soiling in both children and adults is usually more severe in the early postoperative period of about 3 to 6 months after operation and improves with time, but may become permanent more than 1 year after IPAA.^3–6,9 Generally, the frequency of soiling in child patients more than 1 year after IPAA is 0 to 12%,^4–6,8,9,12 and in adults 30 to 40%.^2,13,14 Over the past 20 years or so, the function of the anorectum in patients with soiling after IPAA has been studied in depth using anorectal manometry.^15–17 According to the data of anorectal manometry in child patients after IPAA, the anal sphincter complex comprising the internal anal sphincter and external anal sphincter is important to prevent soiling.¹⁷ In contrast, the puborectalis muscle (PM) was considered the most important factor preventing soiling in other studies not using anorectal manometry, which cannot detect the function of the PM, although less is known about the neurological functions in patients with soiling after IPAA in regard to the sacral nerve (SN) that regulates the PM.^18–20 To the best of our knowledge, there are no reports of electrophysiological studies of SN in child patients with soiling after IPAA for UC. We therefore studied bilateral SN function using sacral nerve terminal motor latency (SNTML) in child patients with soiling 6 months after IPAA and the same patients without soiling 2 years after IPAA for UC.     

Production of Intraperitoneal Interleukin-6 Following Open or Laparoscopic Assisted Distal Gastrectomy

The interleukin (IL)-6 concentration in plasma or serum has been considered to represent the degree of stress resulting from surgery. However, IL-6 in peritoneal fluid has rarely been considered. The aim of this study was to assess the concentration and amount of IL-6 in peritoneal fluid as indicators of surgical stress. To obtain basic data on peritoneal release of IL-6 during gastric cancer surgery, we measured IL-6 in peritoneal drainage samples, stored for up to 72 hours postoperatively, from patients who had undergone conventional open (ODG group, n = 20) and laparoscopic-assisted (LADG group, n = 19) distal gastrectomy. Within 24 hours, 61 and 77% of the IL-6 was released into the peritoneal cavity in the LADG and ODG groups, respectively. In both groups, the concentration and amount of peritoneal fluid IL-6 were significantly correlated with each other (LADG group: Spearman''s rank correlation test [rS] = 0.48, P = 0.04; ODG group: rS = 0.58, P = 0.01). The concentration and amount of IL-6 in peritoneal fluid was 2.8- and 3.6-fold higher in the ODG than in the LADG group, respectively (P < 0.01). With regard to the relationship between the serum C-reactive protein (CRP) peak and the concentration or amount of peritoneal fluid IL-6 released within 24 hours, only the concentration of peritoneal fluid IL-6 in the LADG group was significantly correlated (rS = 0.60, P = 0.01) with the serum CRP peak. Our findings suggest that the amount and concentration of IL-6 released into the peritoneal cavity for up to 24 hours after surgery can each be a reliable parameter for assessment of surgical stress.Key words: Interleukin (IL)-6, Cytokine, Peritoneal fluid, Surgical stress, Gastric cancer, Laparoscopic surgery, GastrectomyRecent advances in laparoscopy techniques have heralded a new era in the field of abdominal surgery, and laparoscopic approaches are now being employed for the treatment of malignant neoplasms of the stomach, colon and other organs.^1–5It has been reported that levels of circulating proinflammatory cytokines such as interleukin (IL)-1 beta, IL-6, IL-8, and tumor necrosis factor (TNF)-alpha are related to the extent and severity of surgical procedures.^6–8 Interleukin 6 is a sensitive and early marker of tissue damage, and in general the greater the surgical trauma, the greater the response of IL-6.⁹ Many studies have shown that the level of IL-6, as an indicator of surgical stress, is significantly lower after laparoscopic surgery than after open surgery.^9–15 Most of the studies reported so far have measured and analyzed the concentration of IL-6 in plasma or serum,^{9,10,12–16,18} and only rarely in peritoneal fluid,^{11,12,15,17,19,20} and the results have indicated significant correlations between the level of IL-6 and several clinical parameters. However, there is some concern as to whether the concentration of IL-6 in peritoneal fluid adequately reflects the degree of surgical stress. Interleukin 6 is released into the abdominal cavity in response to surgical injury.^16,20,21 Therefore, the total amount of IL-6 contained in peritoneal fluid might be regarded as a gold standard for assessing the severity of local surgical stress. However, this possibility has never been fully addressed.In the present study, we analyzed both the concentration and total amount of IL-6 in peritoneal fluid sequentially in the early postoperative period after distal gastrectomy, and compared laparoscopic and open surgical procedures in terms of intraperitoneal IL-6 production in order to observe the basic pattern of IL-6 release.     

The Current Status of International Partnerships for Child Surgery in Sub-Saharan Africa

Disparity still exists in the surgical care between sub-Saharan Africa and developed countries. Several international initiatives have been undertaken in the past decades to address the disparity. This study looks at the impact of these programs in child surgery in Sub-Saharan Africa. Review of electronic databases Medline and African Index Medicus on international partnerships for child surgery in Sub-Saharan Africa was undertaken. Four types of international initiatives were identified and consist of periodic medical missions; partnerships between foreign medical institutions or charities and local institutions; international health electives by surgical residents; and training of individual surgeons from developing countries in foreign institutions. The results of these efforts were variable, but sustainability and self-reliance of host nations were limited. Sociocultural factors, dearth of facilities, and lack of local governments'' commitment were main impediments to effective local development or transfer of modern protocols of surgical management and improvement of pediatric surgical care at the host community level. Current initiatives may need improvements with better understanding of the sociocultural dynamics and local politics of the host nation, and improved host nation involvement and commitment. This may engender development of locally controlled viable services and sustainable high level of care.Key words: Partnership, Medical mission, Child surgery, Africa, Developing countryDuring the last three decades of the 20th century, significant efforts were undertaken to reduce child morbidity and mortality globally and more especially in developing countries.¹ In Sub-Saharan Africa, the traditional focus of global health in this regard was control of infectious diseases, nutritional support, malaria controls, and lately, HIV/AIDS control.¹ Recently, however, the surgical needs of the pediatric population in developing countries have received attention.² Emerging evidence demonstrates that childhood surgical conditions are a significant public health care problem in Sub-Saharan Africa, and hence the need to consider them as an essential component of child health programs.^3,4 Despite this recognition and increasing globalization, child surgery in Sub-Saharan Africa is still challenged by ignorance, delayed diagnosis, limited diagnostic and support facilities, critical shortage of surgeons and trained personnel, poor access to surgical care, and inadequate governmental support.^1,3,5 As a result of these disadvantages, substantial disparity exists in the surgical care and outcome in this setting and the developed countries.^1,4,6 To address this discrepancy and elevate the level of child surgery standards in some of these countries, strong efforts have been expended over the past decades through a variety of international partnership programs.^6–11 Some of these programs have been published in medical literature, but a review of the programs is rarely reported.This review evaluates the programs in Sub-Saharan Africa that have been published in Medline, African Index Medicus, and the African Journals Online. The focus is on the types, outcome, challenges, and recommendations to improve the impact in the host communities.     

The Effects of Dexketoprofen on Endogenous Leptin and Lipid Peroxidation During Liver Ischemia Reperfusion Injury

Hepatic ischemia reperfusion (IR) injury has complex mechanisms. We investigated the effect of dexketoprofen on endogenous leptin and malondialdehyde (MDA) levels. Wistar albino rats were divided into 4 equal groups and were subjected to 1-hour ischemia and different subsequent reperfusion intervals. Dexketoprofen was administered in a dose of 25 mg/kg 15 minutes before ischemia induction and 1-hour reperfusion to the Dexketoprofen one-hour reperfusion group, n = 6 (DIR1) group and 6-hour reperfusion to the Dexketoprofen six-hour reperfusion group, n = 6 (DIR6) group. In the control groups, 0.9% physiologic serum (SF) was administered 15 minutes before ischemia induction and 1-hour reperfusion to the one-hour reperfusion group, n = 6 (IR1) group and 6-hour reperfusion to the six-hour reperfusion group, n = 6 (IR6) group. Although serum leptin (P = 0.044) and hepatic tissue MDA levels (P = 0.004) were significantly higher in the IR6 group than in the IR1 group, there were no significant differences in dexketoprofen pretreatment between the DIR1 and DIR6 groups. There were no differences in serum MDA levels among the 4 groups, and serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) activities were significantly higher in the IR1 (P = 0.026 and P = 0.018, respectively) and IR6 (P = 0.000 and P = 0.002, respectively) groups than in the DIR1 and DIR6 groups. Dexketoprofen pretreatment can protect the liver from IR injury by decreasing inflammation and lipid peroxidation. Our study shows that dexketoprofen has no effects on endogenous leptin during IR injury.Key words: Ischemia-reperfusion injury, Liver, Ketoprofen, Malondialdehyde, LeptinHepatic ischemia reperfusion (IR) injury is a complication of several surgical conditions, such as liver resection and transplantation, and prolonged states of shock that lead to local injury or remote dysfunction of multiple organs.^1,2 Incipient tissue hypoxia; production of reactive oxygen species (ROS); activation of the inflammatory cascade, resulting in inflammatory responses^3,4 and microcirculatory problems⁵ further aggravate injury. Although ischemic stress eventually causes cell death, cell injury often does not manifest itself until after the ischemic liver is reperfused.⁶ ROS are highly reactive ions that include hydrogen peroxide (H₂O₂), lipid peroxides, hypochlorous acid (HOCl), and free oxygen radicals.⁷ Malondialdehyde (MDA) is the end product of lipid peroxidation; increased MDA levels reflect excessive production of free oxygen radicals and indicate organ damage.^8,9The role of polymorphonuclear leukocytes (neutrophils) in the acute inflammatory response during IR injury has been investigated in several studies.^10,11 Vane and Botting described inflammatory response and the role of chemical mediators, such as prostaglandins, platelet-activating factor, interleukin-1, histamine, and bradykinin.¹² That study was followed by studies showing the ROS scavenging effects of nonsteroidal anti-inflammatory drugs (NSAIDs).¹³ Dexketoprofen trometamol, the active enantiomer of racemic ketoprofen, possesses cyclooxygenase inhibitory effects, as do other members of the NSAID family. Properties of this formulation are more rapidly absorbed and have a faster onset of action than does ketoprofen.¹⁴Leptin, an adipose tissue–derived hormone, decreases body weight by both suppressing appetite and promoting energy expenditure.¹⁵ It also regulates inflammatory response, primarily by exerting pro-inflammatory actions.¹⁶ The structure of leptin and its receptor suggest that leptin should be classified as a cytokine. The helical structure of leptin is similar to the structures of the long-chain helical cytokine family, which includes interleukin (IL)-6, IL-11, IL-12, leukemia inhibitory factor (LIF), and granulocyte colony-stimulating factor (G-CSF). Cytokines play an important role in the host response to infectious and inflammatory stimuli. Previous studies have shown the importance of leptin in the activation of the immune system and as a mediator of inflammation.^17–19 Faggioni and colleagues (1998) demonstrated that leptin production does not increase during inflammation in IL-1b-deficient mice.²⁰ Thus, the increase in leptin during infection and inflammation indicates that leptin is part of the immune response and host defense mechanism.²¹ Leptin-deficient (ob/ob) and leptin-receptor–deficient (db/db) mice are not only obese but they also show immune/endocrine abnormalities.²² While dexketoprofen inhibits inflammation, its effects on the level of leptin, which plays an important role in immune response, are unknown.The aim of this study was to evaluate the role of dexketoprofen on endogenous leptin levels and lipid peroxidation at different reperfusion intervals during IR injury.     

Safe Transanal Tumor Resection Using a Harmonic Scalpel

We performed a safe and simple transanal tumor resection involving total layer resection using a harmonic scalpel as a resecting device. Here we report the results of our experience with this technique between 2005 and 2011. This study involved 32 patients who underwent transanal tumor resection using a harmonic scalpel. The subjects comprised 18 men and 14 women ranging in age from 34 to 87 years (mean: 64.5 years). The tumors measured 8 to 70 mm (mean: 31 mm) in diameter. The operation took 7 to 86 minutes (mean: 29 minutes), and the amount of bleeding was 0 to 165 mL (mean: 16.2 mL). There was no intraoperative blood loss that necessitated hemostatic procedures. Histopathologically, the lesions included hyperplastic polyp in 1 case, adenoma in 9, carcinoma in situ in 7, submucosal invasive cancer in 6, muscularis propria cancer in 4, carcinoid in 1, malignant lymphoma in 1, gastrointestinal stromal tumor in 1, mucosal prolapsed syndrome in 1, and mucosa-associated lymphoid tissue lymphoma in 1. With our technique, en bloc resection was achieved in all patients, and the use of a harmonic scalpel enabled us to complete the operation within 30 minutes, on average, without intraoperative bleeding.Key words: Rectal tumor, Transanal tumor resection, Harmonic scalpelWith technical developments and advances in colonoscopic diagnosis, such as magnifying endoscopy^1–3 and the narrow band imaging system,^4,5 and ablative surgery, such as endoscopic mucosal resection (EMR)^1,6 and endoscopic submucosal dissection (ESD),⁷ cures have become achievable with endoscopic resection (ER) alone in many cases of early colorectal carcinoma. ER is the treatment of choice for early colorectal carcinoma. However, with large lesions, conventional EMR cannot be performed as an en bloc resection; and even with lesions smaller than 20 mm in diameter, incomplete resection or piecemeal resection often occurs. After endoscopic piecemeal mucosal resection, histopathological assessment of complete resection is difficult and the risk of local recurrence is high.⁸ ESD has also been used to treat large colorectal adenomas, with recurrence rates of 0 to 9% and complication rates of only 0 to 9%.^9–11 However, compared with conventional EMR, the ESD technique is technically challenging and time consuming and requires a steep learning curve.^9,12 In addition, there are some issues involved in ER of lower rectal neoplastic lesions. Specifically, ER of these lesions is associated with higher risk of postoperative bleeding than that of lesions at other sites, because the rectum has abundant blood flow, and resection of some lower rectal lesions causes pain because of the sensory nerve distribution in this area.On the other hand, spread of laparoscopic surgery for colorectal cancer has led to a marked improvement of the quality of life (QOL) of these patients after resection,^13,14 and the incidence of lymph node metastasis in cases of submucosal invasive (SM) cancer is as low as about 10%.^15–18 Taking these into account, radical surgical resection, including abdominoperitoneal resection that requires a permanent stoma, seems to be excessively invasive in cases of early colorectal cancer. Recent years have seen great benefits of surgical treatment for lower rectal cancer, because intersphincteric resection (ISR)¹⁹ has become more common, allowing sphincter-preserving surgery even in patients in whom creation of a permanent stoma would have otherwise been required. The feasibility of ISR under laparoscopy has also improved the postoperative QOL.²⁰ However, even at present, the QOL is not necessarily satisfactory in terms of bowel function. In this regard, transanal tumor resection is a useful procedure for tumor removal in some cases, yielding a postoperative QOL comparable with that after EMR.We perform safe transanal tumor resection involving total layer resection using a harmonic scalpel as a resecting device. Here we report the results of our experience with this technique.     

The Role of 3-D Endorectal Ultrasound in Rectal Cancer: Our Experience

In the last 20 years, endorectal ultrasound (ERUS) has been one of the main diagnostic methods for locoregional staging of rectal cancer. ERUS is accurate modality for evaluating local invasion of rectal carcinoma into the rectal wall layers (T category). Adding the three-dimensional modality (3-D) increases the capabilities of this diagnostic tool in rectal cancer patients. We review the literature and report our experience in preoperative 3-D ERUS in rectal cancer staging. In the group of 71 patients, the staging of preoperative 3-D endorectal ultrasonography was compared with the postoperative morphologic examination. Three-dimensional ERUS preoperative staging was confirmed with morphologic evaluation in 66 out of 71 cases (92.9%). The detection sensitivities of rectal cancer with 3-D ERUS were as follows: T1, 92.8%; T2, 93.1%; T3, 91.6%; and T4, 100.0%; with specificity values of T1, 98.2%; T2, 95.4%; T3, 97.8%; and T4, 98.5%. Three-dimensional ERUS correctly categorized patients with T1, 97.1%; T2, 94.3%; T3, 95.7%; and T4, 98.5%. The percentage of total overstaged cases was 2.75% and that of understaged cases was 6.87%. The metastatic status of the lymph nodes was determined with a sensitivity of 79.1% (19 of 24), specificity of 91.4% (43 of 47), and diagnostic accuracy of 87.3% (62 of 71). In our experience, 3-D ERUS has the potential to become the diagnostic modality of choice for the preoperative staging of rectal cancer.Key words: Three-dimensional endorectal ultrasound, Rectal cancerEndorectal ultrasound (ERUS) has been used as a diagnostic tool for evaluation and staging of rectal cancer since the 1980s.¹ According to the literature, in studies with more than 50 patients included, an overall accuracy of approximately 81.8% was reported.² Most of the studies present data between 85% and 95%, but in the studies with more than 200 patients, the accuracy rates are relatively lower—63.3% and 69%, respectively.^3,4 A common disadvantage of ERUS and magnetic resonance imaging (MRI) is the overstaging of T2 tumors owing to an irregular outer rectal wall resulting from transmural tumor extension or inflammation around the tumor. Another challenge for the ERUS, and especially the rigid probes, are the locally advanced, stenotic tumors, where the probe may not be able to pass above the lesion.⁵ The nodal staging accuracy of ERUS ranges from 70% to 75%.^1,5,6 The metastatic lymph nodes are distinguished by hypoechoic appearance, round shape, peritumoral location, and size >5 mm.^7,8 Lymph nodes >5 mm have a 50% to 70% chance of being malignant, while those <4 mm have only a 20% chance.^9,10 A new modality of endorectal ultrasound represents a three-dimensional (3-D) ERUS that provides better visual images of the tumor volume and spatial relations to the adjacent organs and structures, even better than those of MRI, which leads to better diagnostic accuracy than MRI and standard ERUS.^11–15 The unique 3-D–ERUS longitudinal scan can precisely assess the tumor size and location.¹⁶ The most important feature of this upgraded modality is the ability to reduce interpreter errors and offer potential predictive value. Three-dimensional ERUS provides the possibility to distinguish blood vessels from lymph nodes and allow precise fine needle aspiration (FNA) biopsies.^13,17 The infiltration of circumferential margin has been proven to correlate with T category, lymph node metastasis histologic tumor differentiation, and lymphovascular invasion.^13,17 Three-dimensional ERUS gives the possibility of multiplane evaluation of the tumor, allowing visualization of more subtle changes in the tumor characteristics and therefore better T and N categorizing.¹⁸ A review of 86 patients who underwent standard 3-D ERUS, ERUS and 4-channel detector computed tomography (CT) demonstrated T-category accuracy of 78%, 69%, and 57%, respectively.¹⁹ After analysis of the examiner''s error, the accuracy of 3-D ERUS for T category has reached 91% for 3-D ERUS and 88% for standard ERUS, and the N category accuracy improved to 90% and 76%, respectively. Also, ERUS can be used for diagnosis of premalignant lesions such as adenomas and polyps.²⁰ The main goal is to properly identify any chance of tumor invasion in the primary lesion and involvement of the surrounding lymph nodes in case the absence of those alarming characteristics allows for endoscopic resection of the lesion. Using higher-resolution probes, ERUS can distinguish T0 from T1 lesions. According to a meta-analysis of 258 biopsy-negative tumors, ERUS identified tumor mass in 81% of the 24 lesions, which were found to be invasive tumors on morphologic examination.²⁰ Another series of 60 patients with pT0/pT1 lesions demonstrated sensitivity and specificity of ERUS 89% and 88%, respectively.²¹ As with MRI, 3-D ERUS could provide an evaluation of the mesorectal fascia.^14,22The reported data lead to the position that 3-D ERUS combines the high-resolution images of the rectal wall and cost-effectiveness of standard ERUS with the multiplanar and stereoscopic imaging capabilities of MRI. Three-dimensional ERUS may be the future premier imaging modality used in rectal cancer management.     

A New Anterolateral Approach for Type C Fractures of the Distal Femur

To provide an anatomic basis for treating type C distal femoral fractures by a new anterolateral approach. Twenty surgical procedures were performed in 10 adult cadaveric specimens using a new anterolateral approach followed by dissection of all lower limbs. The main anterolateral muscles and ligaments were observed. Vessels and nerves related to the new anterolateral approach were also evaluated. Full exposure of the distal femur was achieved. The iliotibial band was protected, and damage to the quadriceps femoris was reduced. The distance between the common peroneal nerve and the new incision line at the level of the lateral epicondyle of the femur was ($\bar{\chi }$ ± s) 8.19 ± 0.79 cm (range, 7.48–9.57 cm). This new anterolateral approach to the distal femur is safe. Although it induces slight soft tissue damage, its exposure is excellent. Knee rehabilitation can be performed in the early postoperative period.Key words: Distal femur fracture, New anterolateral approach, AnatomyThe number of high-energy traumas causing distal femoral fractures is increasing.^1,2 The estimated frequency is 3% of femoral fractures.³ Müller⁴ classified these fractures according to their location and pattern. Their classification broadly divides distal femoral fractures into type A (extra-articular), type B (condylar or partial articular), and type C (bicondylar or complete articular). Types A and B permit less-invasive repair procedures, such as less-invasive stabilization systems and intramedullary nailing,⁵ but type C refers to comminuted fractures of both the lateral and medial femoral condyles in association with severe soft tissue injuries. This type of fracture requires anatomic reduction of the articular surface, internal fixation, and early functional rehabilitation to improve outcomes and reduce the incidence of posttraumatic complications.^6–8Although indirect reduction maneuvers are available for type C fractures of the distal femur, direct exposure with visualization of the articular surface and fracture fragments is recommended to ensure anatomic reduction.^8,9 Adequate exposure can reduce the operation time and address fractures anatomically, reducing the rates of malunion, nonunion, and infection.^9,10 Many approaches to the distal femur have been described. Lateral and anterolateral approaches are commonly used, but full exposure is difficult, and soft tissue injury may occur, potentially leading to malunion, nonunion, knee dysfunction, and other problems.¹¹ To minimize soft tissue injury, widely expose the joint, operate easily, and implement early postoperative functional exercise, we designed a new anterolateral approach termed the “S-shaped approach.” We performed a cadaveric anatomic study to confirm the technical feasibility of this approach.     

Early Versus Delayed Laparoscopic Cholecystectomy for Acute Cholecystitis: A Prospective,Randomized Study

We aimed to compare the clinical outcome and cost of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Sixty patients with acute cholecystitis were randomized into early (within 24 hours of admission) or delayed (after 6–8 weeks of conservative treatment) laparoscopic cholecystectomy groups. There was no significant difference between study groups in terms of operation time and rates for conversion to open cholecystectomy. On the other hand, total hospital stay was longer (5.2 ± 1.40 versus 7.8 ± 1.65 days; P = 0.04) and total costs were higher (2500.97 ± 755.265 versus 3713.47 ± 517.331 Turkish Lira; P = 0.03) in the delayed laparoscopic cholecystectomy group. Intraoperative and postoperative complications were recorded in 8 patients in the early laparoscopic cholecystectomy group, whereas no complications occurred in the delayed laparoscopic cholecystectomy group (P = 0.002). Despite intraoperative and postoperative complications being associated more with early laparoscopic cholecystectomy compared with delayed intervention, early laparoscopic cholecystectomy should be preferred for treatment of acute cholecystitis because of its advantages of shorter hospital stay and lower cost.Key words: Acute cholecystitis, Laparoscopic cholecystectomy, Outcome assessment, Cost and cost analysisElective laparoscopic cholecystectomy has become the gold standard for treatment of symptomatic gallstones.¹ However, in the early days, acute cholecystitis was a contraindication of laparoscopic cholecystectomy, and patients with acute cholecystitis were managed conservatively and discharged for re-admission in order to have elective surgery performed for the definitive treatment.^2,3 Then, randomized controlled trials and meta-analyses had shown the benefits of early surgery (within the acute admission period, which is 24 to 72 hours) compared with delayed cholecystectomy with respect to hospital stay and costs, with no significant difference in morbidity and mortality.^2,4,5 Thus, in the late 1980s early surgery for acute cholecystitis had gained popularity. The updated Tokyo Guidelines announced in 2013 by the Japanese Society of Hepato-Biliary-Pancreatic Surgery suggested that early laparoscopic cholecystectomy is the first-line treatment in patients with mild acute cholecystitis, whereas in patients with moderate acute cholecystitis, delayed/elective laparoscopic cholecystectomy after initial medical treatment with antimicrobial agent is the first-line treatment.⁶With the increased experience in laparoscopy, surgeons started to attempt early laparoscopic cholecystectomy for acute cholecystitis.² However, early laparoscopic cholecystectomy is still performed by only a minority of surgeons.^7–9 Furthermore, the exact timing, potential benefits, and cost-effectiveness of laparoscopic cholecystectomy in the treatment of acutely inflamed gallbladder have not been clearly established and continue to be controversial.^1,10The aim of this study was to compare the intra-operative and postoperative outcomes, and cost of early versus delayed laparoscopic cholecystectomy for acute cholecystitis.     

The Comparison of the Effects of Ellagic Acid and Diclofenac Sodium on Intra-Abdominal Adhesion: An In Vivo Study in the Rat Model

Peritoneal adhesions are seen frequently after abdominal surgery and can cause serious complications. We aimed to evaluate the effects of the oral use of diclofenac sodium and ellagic acid on formation of postoperative adhesions in rats Studies have shown that agents with anti-inflammatory properties and antioxidant substances can prevent adhesion by decreasing oxidative stress. We compared and evaluated the effects of ellagic acid that has strong antioxidant and anti-inflammatory properties and the nonsteroidal anti-inflammatory diclofenac sodium on peritoneal adhesion development in our experimental study. Laparotomy was performed with a midline incision under general anesthesia and an adhesion model was created on the antimesenteric side of the cecum in Groups I, II, and III. Group I received 85 mg/kg ellagic acid and Group II, 50 mg/kg diclofenac sodium through the nasogastric catheter while Group III received no medication. Only laparotomy was performed in Group IV. The rats were sacrificed at the end of the 14th day. Following macroscopic scoring, tissue samples were removed and subjected to biochemical and histopathologic evaluation. The degree of adhesion and the malondialdehyde level were decreased (P < 0.05), and glutathione level increased (P < 0.05) in Group I compared to Group II and Group III. The effects of ellagic acid on the prevention of peritoneal adhesion were found to be stronger than diclofenac sodium. This can be explained by the fact that ellagic acid is a strong antioxidant and decreases oxidative stress with anti-inflammatory and anti-angiogenic effects.Key words: Ellagic acid, Diclofenac sodium, Intraabdominal adhesion, RatPeritoneal adhesions are fibrotic adhesions that are formed intra-abdominally on the visceral or peritoneal surface during the healing of peritoneal injury.^1,2 Adhesions often occur after laparotomy and are also a significant cause of postoperative morbidity.^3,4 Adhesions can be asymptomatic but can also lead to serious complications such as intestinal obstruction, perforation and fistula.^3–6Adhesion formation begins with mesothelial cell injury on the peritoneal membrane surface. An inflammatory process consisting of cellular elements of small venules and fibrin exudation, edema, and hyperemia begins in this region and a serous exudates develops.^5,7–9 Fibrous bands develop between fibrinous exudate and serosal surfaces, leading to formation of fibrinous bridges. Mesothelial cells produce plasminogen activator that dissolves fibrin clots, and the fibrinolytic system is engaged causing the fibrinous exudates to be rapidly resorbed. Adhesions are formed otherwise.^10–12DS (diclofenac sodium) is a nonsteroidal anti-inflammatory agent often used in clinical practice for postoperative analgesia and is known to have a fibrinolytic effect.^13,14 EA (ellagic acid) is a natural antioxidant reported to be present in walnuts, carrots, tomatoes, pomegranate, grape juice, grape wine, blueberries, blackberries, and strawberries in significant quantities.^15–18 EA is a phenolic acid derivative that inhibits lipid peroxidation in addition to its anti-inflammatory, antiproliferative, anti-angiogenic and anticarcinogenic effects.^16,17We aimed to evaluate the effects of the oral use of DS that has an anti-inflammatory effect and EA that has an antioxidant effect in addition to its anti-inflammatory effect on intra-abdominal adhesion development in comparison in the present study.     

Pathologic and Clinical Characteristics of Elderly Patients With Breast Cancer: A Retrospective Analysis of a Multicenter Study (Anatolian Society of Medical Oncology)

There is very little information about breast cancer characteristics, treatment choices, and survival among elderly patients. The purpose of this multicenter retrospective study was to examine the clinical, pathologic, and biologic characteristics of 620 breast cancer patients age 70 years or older. Between June 1991 and May 2012, 620 patients with breast cancer, recruited from 16 institutions, were enrolled in the retrospective study. Patients had smaller tumors at diagnosis; only 15% of patients had tumors larger than 5 cm. The number of patients who had no axillary lymph node involvement was 203 (32.7%). Ninety-three patients (15.0%) had metastatic disease at diagnosis. Patients were characterized by a higher fraction of pure lobular carcinomas (75.3%). The tumors of the elderly patients were also more frequently estrogen receptor (ER) positive (75.2%) and progesterone receptor (PR) positive (67.3%). The local and systemic therapies for breast cancer differed according to age. An association between age and overall survival has not been demonstrated in elderly patients with breast cancer. In conclusion, the biologic behavior of older patients with breast cancer differs from younger patients, and older patients receive different treatments.Key Words: Breast cancer, Elderly patients, Clinical characteristics, Pathologic characteristicsBreast cancer is a major health problem worldwide, and its incidence is increasing.¹ Age is one of the major risk factors for breast cancer: more than 30% of all new breast cancers occur in women aged 70 years or more. Furthermore, breast cancer–related mortality increases with age.^2,3 Despite the high incidence, there is very little information about breast cancer characteristics, treatment choices, and survival among elderly patients. Elderly patients over 70 years of age have generally been excluded from randomized clinical trials of breast cancer treatments.⁴Several studies of breast cancer biology show that older patients are estrogen receptor–positive (ER+) and/or progesterone receptor–positive (PR+), which are predictive factors of response to hormonal therapies; the treatment of these patients with endocrine therapies is the gold standard with which other systemic adjuvant treatments are compared.^5–7 Although little is known about the pathology and biology of breast cancer in older patients, many clinical trials have shown that women who develop breast cancer at an elderly age have less aggressive disease and decreased risk of recurrence.^8–11 In contrast, a few studies have demonstrated that in postmenopausal patients with hormone receptor–positive breast cancer, increasing age is associated with higher disease-specific mortality.^2,3The purpose of this multicenter retrospective study was to examine the clinical, pathologic, and biologic characteristics of 620 breast cancer patients age 70 years or older.     

Improved Health-Related Quality of Life After Surgical Management of Severe Refractory Constipation-Dominant Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is the most common of the functional gastrointestinal disorders (FGIDs). Despite its prevalence and health-care costs, there are few effective therapies for patients with severe symptoms. Our objective was to determine whether surgical management would improve health-related quality of life (HRQOL) in severe refractory constipation-dominant FGIDs. From 2003 to 2005, 6 patients underwent total colectomy with end ileostomy or primary anastomosis. They completed Short Form 36 (SF-36) and IBS-36 questionnaires preoperatively and postoperatively. HRQOL was compared with age- and sex-matched Canadian norms using Welch''s unpaired t test. Preoperative SF-36 physical and mental health summary scores were significantly lower than Canadian norms (P < 0.0001), while postoperative scores were not significantly different than Canadian norms (P = 0.50 and P = 0.57, respectively). After surgical management, HRQOL in patients with severe constipation-dominant IBS improved from drastically below that of Canadian norms to a comparable level. This finding questions the convention of avoiding operations in IBS patients and demonstrates that surgical management may be suitable for the appropriately screened patient.Key words: Health-related quality of life, Surgery, Irritable bowel syndromeIrritable bowel syndrome (IBS) is one of 20 functional gastrointestinal disorders (FGIDs). These are a heterogeneous group of chronic disorders in which the presenting gastrointestinal (GI) symptoms cannot be explained by structural or biochemical abnormalities.^1,2 IBS is characterized by abdominal pain associated with defecation, change in bowel habit, bloating, and distension.^3,4 The ROME III committee developed a set of diagnostic criteria for each FGID separately.^3,4 However, it has become increasingly accepted that the FGIDs overlap considerably and therefore, IBS should not be considered as a single entity but rather on a spectrum of related disorders.^1,5IBS is the most common of the FGIDs with a prevalence rate in the United States anywhere from 3% to 20%, with most studies quoting around 10%.^1,2 Although up to 70% of IBS sufferers in the United States do not seek medical attention, the total health-care costs and burden to the health-care system is substantial.^5,6 In fact, in the United States, among GI illnesses, IBS was second only to gastroesophageal reflux disease in prevalence in a comprehensive assessment of burden of illness.⁵ In addition, the estimated direct and indirect annual health-care costs of IBS in the United States are $1.6 billion and $19.2 billion, respectively.^1,5 Despite the high expenditure for this illness, there are very limited effective treatment options, and patients continue to demonstrate poor health-related quality of life (HRQOL), which is comparable to that seen in patients with organic disease.^1,7–12Treatment options have largely been directed at symptom relief and vary depending on symptom severity. They include any and all of the following: education and reassurance, diet and lifestyle modification, pharmacotherapy directed at relief of bowel-specific symptoms with medications (such as anticholinergics, antispasmodics, antidiarrheals, and laxatives), as well as antidepressants and narcotics, along with referrals to mental health and pain services.^2,5,13 A combination of the above therapies has been somewhat effective in patients with mild to moderate symptoms; however, in moderate to severe cases, patients often have symptoms that are refractory and persistent despite exhaustive use of the above modalities.Patients who suffer from severe symptoms of IBS commonly present with a picture of acute severe abdominal and/or pelvic pain and frequently undergo unnecessary emergent abdominopelvic surgeries.^14–17 As the literature would suggest, these surgeries are often nontherapeutic, and thus it is a general convention to avoid operating on patients with IBS and other FGIDs for the purpose of symptom control.^14–17 Nevertheless, there are some motility-disordered patients who have such intractable symptoms as to severely diminish their quality of life. These patients have received operative management aimed at ameliorating their symptoms and thus improving their lives. At our tertiary care center, we have identified a group of such motility-disordered patients. Patient accounts of their disease experience relate severe pain and constipation leading to debilitating loss of daily functioning, emotional distress, disability, and impaired quality of life. The objective of this study was to determine whether surgical management of severe refractory constipation-dominant motility disorders in adult patients would result in improved HRQOL.     

Significance of the Lower Esophageal Sphincter Preservation in Preventing Alkaline Reflux Esophagitis in Patients After Total Gastrectomy Reconstructed by Roux-en-Y for Gastric Cancer

To clarify the significance of the lower esophageal sphincter (LES) for prevention of alkaline reflux esophagitis (ARE) after total gastrectomy reconstructed by Roux-en-Y (TGRY) for gastric cancer, we investigated LES function and lower esophageal pH in TGRY patients with or without LES preservation. A total of 51 patients 5 years after TGRY were divided into groups A (26 patients without preserved LES) and B (25 patients with preserved LES) and compared with 22 control participants (group C). Manometric study and ambulatory 24-hour esophageal pH monitoring were performed on all patients. Symptomatic and endoscopic AREs in group A were significantly higher than those in group B (P < 0.05). The length of LES and maximum LES pressure in group A were significantly shorter and lower, respectively, than in groups B and C (P < 0.01). The length of LES and maximum LES pressure in patients with symptomatic ARE were significantly shorter and lower, respectively, than in patients without symptomatic ARE (P < 0.01). Percentages of time with pH >7 and pH >8 within 24 hours in group A were significantly higher than those in groups B and C (P < 0.01). Preservation of the LES may be necessary to prevent ARE after TGRY.Key words: Alkaline reflux esophagitis, Total gastrectomy reconstructed by Roux-en-Y, Lower esophageal sphincter, Manometric study, Ambulatory 24-hour esophageal pH monitoringTotal gastrectomy reconstructed by Roux-en-Y (TGRY) is the global “gold standard” treatment for gastric cancer because it offers a simple procedure and better quality of life.^1,2 The abdominal esophagus, including the lower esophageal sphincter (LES), is excised by the TGRY procedure. Generally, some patients after TGRY experience postgastrectomy syndromes, including alkaline reflux esophagitis (ARE), dumping syndrome, microgastria, and so on.^3–6 After TGRY, patients particularly experience such symptoms of ARE as regurgitation, dysphagia, heartburn, and chest pain.^2,7 Symptoms of ARE are usually more severe in the early postoperative period and improve with time, but they may become permanent about 1 to 2 years after TGRY.^8,9The frequency of ARE after TGRY in Japan is approximately 20% to 30% and reduces the patient''s quality of life.^6,10,11 ARE after total gastrectomy has been considered to reflect impaired function of the LES.^12–14 In LES preservation, it is functionally important to leave 3 cm or more of the abdominal esophagus from the esophagogastric mucosal junction (EGJ), based on manometric studies.^12,15 However, no convincing evidence has yet been reported regarding the function of LES in patients with symptomatic and/or endoscopic ARE after TGRY for gastric cancer. Ambulatory 24-hour esophageal pH monitoring (A24EPM) is the most reliable method for demonstrating reflux esophagitis.^16–18 To the best of our knowledge, there are no physiologic studies of ARE in patients 5 years after TGRY using both manometric study and A24EPM. We thus studied the LES function using esophageal manometry and the lower esophageal pH using A24EPM in patients with or without preserved LES 5 years after TGRY for gastric cancer.     

Clinical Impact of Intraoperative Navigation Using a Doppler Ultrasonographic Guided Vessel Tracking Technique for Pancreaticoduodenectomy

During pancreaticoduodenectomy (PD), early ligation of critical vessels such as the inferior pancreaticoduodenal artery (IPDA) has been reported to reduce blood loss. Color Doppler flow imaging has become the useful diagnostic methods for the delineation of the anatomy. In this study, we assessed the utility of the intraoperative Doppler ultrasonography (Dop-US) guided vessel detection and tracking technique (Dop-Navi) for identifying critical arteries in order to reduce operative bleeding. Ninety patients who received PD for periampullary or pancreatic disease were enrolled. After 14 patients were excluded because of combined resection of portal vein or other organs, the remaining were assigned to 1 of 2 groups: patients for whom Dop-Navi was used (n = 37) and those for whom Dop-Navi was not used (n = 39; controls). We compared the ability of Dop-Navi to identify critical vessels to that of preoperative multi-detector computed tomography (MD-CT), using MD-CT data, as well as compared the perioperative status and postoperative outcome between the 2 patient groups. Intraoperative Dop-US was significantly superior to MD-CT in terms of identifying number of vessels and the ability to discriminate the IPDA from the superior mesenteric artery (SMA) based on blood flow velocity. The Dop-Navi patients had shorter operation times (531 min versus 577 min; no significance) and smaller bleeding volumes (1120 mL versus 1590 mL; P < 0.01) than the control patients without increasing postoperative complications. Intraoperative Dop-Navi method allows surgeons to clearly identify the IPDA during PD and to avoid injuries to major arteries.Key words: Pancreaticoduodenectomy, Doppler ultrasonography, Blood flowmeterPancreaticoduodenectomy (PD) is a standard treatment for malignant tumor of periampullary and pancreas head. As lymphatics (lymph node and lymph vessels) accompany the arteries and are distributed in the surrounding neural plexuses, complete clearance of peripancreatic tissue, including lymphatics and nerve plexus, is necessary for curative resection of the tumor.^1–4 As this operation is considered a complex procedure, a surgeon is required to be well trained in this specific surgical technique and to possess sufficient anatomic knowledge.Despite a low mortality rate and improvements in perioperative care and operative management, there is still a relatively high complication rate following PD.^5,6 Several studies showed that intraoperative bleeding and red blood cell (RBC) transfusion are serious risk factors of postoperative complications in PD.^6,7 Recently, several procedures for artery-first approaches such as posterior, uncinated, and mesenteric approach have been introduced for improving perioperative outcomes such as curability and decreasing blood loss and morbidity.^8–11 Incidentally, it has been well known that early ligation of the inferior pancreaticoduodenal artery (IPDA)—one of the efferent arteries of the pancreas head—considerably reduces intraoperative bleeding and postoperative complications.^12–14 Owing to the various anatomic origins of IPDA, identification is difficult in some patients. Therefore, some groups have attempted to locate the origin of IPDA by preoperative enhanced multi-detector computed tomography (MD-CT) and 3-dimensional angiogram using MDCT data (3D-CT angiography).^12,13 In addition, an augmented reality technique using MD-CT data is being considered an innovative navigation system for PD.¹⁵ However, no simple intraoperative guidance system, which would greatly facilitate the complex procedure of vessel ligation and reduce intraoperative bleeding, has been tested for ligation of the IPDA during PD.Intraoperative ultrasonography provides useful information for diagnosis and for guidance during the hepatobiliary-pancreatic surgery.^16,17 Color Doppler flow imaging facilitates to delineate the anatomy and to identify the vascular structures invading malignant tumors.^18–22 Recently, advanced navigation techniques have been introduced, such as 3D-CT angiography and intraoperative ultrasonography.^21–24 Doppler ultrasonography (Dop-US) has been used as an effective method for detecting the presence of potential bleeders.^25,26 However, Dop-US-assisted intraoperative identification and tracking of critical vessels for pancreatic surgery has not been reported to date.The objective of the present study was to evaluate the potential of intraoperative Dop-US for detection of critical vessels relative to that of preoperative MD-CT, including MPR and 3D angiography, and to clarify the efficacy of vessel navigation surgery using Dop-US-guided tracking for the reduction of intraoperative bleeding.     

Effect of 4% Chlorhexidine Gluconate Predisinfection Skin Scrub Prior to Hepatectomy: A Double-Blinded,Randomized Control Study

This trial was designed to compare the efficacy of 4% chlorhexidine gluconate (CHG) with normal saline (NS) as a predisinfection skin-scrub solution prior to standard presurgical skin preparation. Data was collected at a single transplantation center where patients electing resection of hepatic tumors were recruited between October 2011 and September 2012. In total, 100 patients were consecutively enrolled for random assignment to either 4% CHG or NS as a predisinfection skin-scrub solution prior to surgery. Our aim was to assess the comparative antiseptic efficacy of CHG in this setting, focusing on cutaneous microbial colonization (at baseline, preoperatively, and postoperatively) and postsurgical site infections as primary outcome measures. Positivity rates of baseline, preoperative, and postoperative cultures were similar for both groups, showing significant declines (relative to baseline) after skin preparation and no significant postsurgical rebound. Rates of surgical site infection were also similar in both groups (CHG, 6.0%; NS, 4.1%; P = 1.0). For patients with hepatic tumors undergoing hepatectomy, the effect of 4% CHG as a predisinfection scrub solution was similar to that of NS in terms of skin decontamination and surgical site infections.Key words: Chlorhexidine gluconate, Predisinfection scrub, Surgical site culture, Surgical site infection, HepatectomySurgical site infections (SSIs) are the most common type of hospital-acquired infection in surgical departments.¹ They delay wound healing, prolong postoperative hospitalization, increase costs, promote antibiotic use, inflict unwanted pain, and in extreme cases cause fatalities.² Due to recent advances in surgical technique and perioperative management, hepatic resection has evolved from a risky endeavor to a safe and effective therapy for many liver diseases.^3,4 However, SSI rates after hepatic resection remain high, ranging from 4.6% to 25.2%.^4–6Following elective procedures, SSI usually results from colonization by the patient''s native skin flora.⁷ The most common pathogens, thus, are Staphylococcus aureus and coagulase-negative Staphylococci.^1,8,9 As such, preoperative disinfection of the surgical site to decrease skin microbial counts prior to incision is standard practice before any surgical intervention¹ as an important step in limiting surgical wound contamination and preventing infection.A variety of skin-preparation agents and methods are available for SSI prevention, and techniques for preoperative skin cleansing vary among hospitals and surgeons. In Taiwan, the standard preoperative skin preparation used by many hospitals includes a scrub with chlorhexidine gluconate (CHG), followed by painting with alcoholic povidone-iodine (P-IO). There is currently a pressing need to determine the actual contribution of CHG toward preventing SSI when used in this way. Studies comparing CHG with P-IO for cutaneous disinfection have shown that CHG cleansing before intravascular insertions substantially reduces the incidence of related infection and that CHG aids in postinfection site care.^10–12 Hence, this study was conceived to test whether a CHG scrub prior to routine disinfection would reduce microbial growth in surgical site cultures and lower infection rates after resection.     

Recurrent Cholangitis by Biliary Stasis Due to Non-Obstructive Afferent Loop Syndrome After Pylorus-Preserving Pancreatoduodenectomy: Report of a Case

We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.Key words: Nonobstructive afferent loop syndrome, Biliary stasis, Hepaticojejunostomy, Hepatobiliary scintigraphy, Double-balloon enteroscopyIt has been reported that cholangitis occurs in between 6.7% and 14.3% of postoperative pancreatoduodenectomy (PD).¹ Most cases of cholangitis originate due to biliary stasis, which is broadly caused by either anastomotic or nonanastomotic stenosis. In many cases, anastomotic stenosis is accompanied by intrahepatic biliary duct dilatation and obstructive jaundice, making early diagnosis and treatment possible.^2–3 On the other hand, nonanastomotic stenosis, including those of afferent loop syndrome, is performed as a conservative treatment for unexplained fever and cholangitis. However, in many cases, the cause remains unidentified, thereby causing this condition to repeat itself. Since cholangitis can at times be fatal, it is therefore important to identify the cause.It has been reported that afferent loop syndrome occurs in around 13% of postoperative PD patients.⁴ Afferent loop syndrome is generally caused by mechanical occlusion due to the recurrence or metastasis of cancer,^4–6 adhesion,^7–8 torsion,⁹ internal hernia,¹⁰ enterolithiasis,^11–12 etc., and thereafter, leads to a syndrome associated with acute abdominal symptom or acute cholangitis. On the other hand, nonobstructive afferent loop syndrome may also be caused by biliary stasis due to jejunal motility failure or the length of the blind end or jejunum, and thereafter, leads to acute cholangitis, liver abscess, and the formation of enterolithiasis and intrahepatic stones. Nonobstructive afferent loop syndrome occurs in around 37% of all of the afferent loop syndrome,^12–13 but few cases have actually been reported.We herein report a rare case in which the patient experienced recurrent cholangitis and liver abscess by biliary stasis due to nonobstructive afferent loop syndrome after pylorus-preserving pancreatoduodenectomy (PPPD) for cholangiocarcinoma.     

Simple Diversion by Duodenojejunostomy for a Retroperitoneal Perforation of the Second Portion of the Duodenal Diverticulum

We herein describe that a Roux-en-Y duodenojejunostomy is a simple and secure procedure for perforated diverticulum in the second portion of the duodenum. The surgical technique for perforated duodenal diverticulum can be adaptable when it is difficult to achieve closure of the perforated site easily. Patients who undergo the operation may be able to eat meals, even if duodenal fistula occurs in the postoperative course.Key words: Duodenojejunostomy, Duodenal diverticulum, RetroperitoneumDuodenal diverticula are a relatively common condition. Usually asymptomatic, they may become clinically evident only upon perforation, inflammation, or bleeding. Perforation is a very rare complication, and carries a high mortality of up to 20%.^1,2 As the perforation is usually open to the retroperitoneum, it is possible there will be no sign of peritonitis. After that, a perforated duodenal diverticulum usually leads to retroperitoneal abscess formation and sepsis. The clinical presentation is nonspecific; therefore, it is often difficult to diagnose until the condition of the disease deteriorates.Recently, case reports about successful nonoperative management of the perforated duodenal diverticulum have increased.^3,4 In Thorson''s review article, 14 of 61 patients underwent successful nonoperative management.⁵ Nonoperative management can be performed only in limited cases. Although no surgical guidelines have been published for perforated duodenal diverticulum,⁴ it was demonstrated that operative treatment must be performed in case of deterioration or diagnostic uncertainty.⁵ Surgical procedures depend on the clinical situation and intraoperative findings. If inflammation permits, the treatment of choice is diverticulectomy with single or double-layer duodenal closure. On the other hand, when there is substantial inflammation of the duodenum, it is difficult to achieve closure of the perforated site, and the optimal surgical procedure has been not established.In this article, we report a simple and secure procedure for perforated diverticulum in the second potion of the duodenum. Our simple surgical technique for perforated duodenal diverticulum is the application of Critchlow''s method to the pancreaticobiliary complications of duodenal diverticulum.⁶     

Preoperative Carcinoembryonic Antigen and Prognosis of Colorectal Cancer. An Independent Prognostic Factor Still Reliable

To evaluate whether, in a sample of patients radically treated for colorectal carcinoma, the preoperative determination of the carcinoembryonic antigen (p-CEA) may have a prognostic value and constitute an independent risk factor in relation to disease-free survival. The preoperative CEA seems to be related both to the staging of colorectal neoplasia and to the patient''s prognosis, although this—to date—has not been conclusively demonstrated and is still a matter of intense debate in the scientific community. This is a retrospective analysis of prospectively collected data. A total of 395 patients were radically treated for colorectal carcinoma. The preoperative CEA was statistically compared with the 2010 American Joint Committee on Cancer (AJCC) staging, the T and N parameters, and grading. All parameters recorded in our database were tested for an association with disease-free survival (DFS). Only factors significantly associated (P < 0.05) with the DFS were used to build multivariate stepwise forward logistic regression models to establish their independent predictors. A statistically significant relationship was found between p-CEA and tumor staging (P < 0.001), T (P < 0.001) and N parameters (P = 0.006). In a multivariate analysis, the independent prognostic factors found were: p-CEA, stages N1 and N2 according to AJCC, and G3 grading (grade). A statistically significant difference (P < 0.001) was evident between the DFS of patients with normal and high p-CEA levels. Preoperative CEA makes a pre-operative selection possible of those patients for whom it is likely to be able to predict a more advanced staging.Key words: Colorectal carcinoma, Preoperative carcinoembryonic antigen, Disease-free survival, Independent prognostic factorIn the world today, more than 1 million cases of patients with colorectal neoplasia are identified each year. Forty percent of these will have a poor prognosis for which targeted therapeutic strategies could most likely be more effective.^1–3 For this reason, finding prognostic factors that are early, reliable, and related to the extent of the tumor is of the utmost importance. Among these, the most that are considered even to this day are T and N parameters.^1,2,4,5 Less relied upon, however, is the M parameter, which is often understaged due to inadequate pretreatment diagnostic methods.⁶ However, these parameters, which are available to us only after surgery, do not represent the gold standard. In fact, the prognosis of patients with the same staging is often various and that the need to continually implement ever-changing variables in an already excessively fragmented staging is still present.^2,4,7–9Recently, in light of these needs, great attention has been paid to the study of molecular and genetic markers. At present, these markers still have not found a regular application due to the complexity of their determination, the difficulty of standardization and, last but not least, the low cost-benefit ratio.^1,3,4,9,10With this in mind, in our opinion, the carcinoembryonic antigen (CEA) maintains its position, as for over 30 years it has continued to be the most widely used marker¹¹ and whose validity, with regard to colorectal follow-up, has been sanctioned by leading organizations such as the American Society of Clinical Oncology (ASCO)¹² and the European Group on Tumor Markers.¹³ Moreover, as Herrera¹⁴ and Wanebo¹⁵ had already reported by the end of the ‘70s, the preoperative determination of the CEA (p-CEA) seems to be related both to the staging of colorectal neoplasia and to the patient''s prognosis. However, to date, none of this has been conclusively demonstrated and is still a matter of intense debate both in prestigious scientific journals^{4,7,11,16–21} as well as in different guidelines.²²The American Society of Clinical Oncology itself, if on the one hand suggests using the determination of the CEA in the preoperative staging thus justifying a worse prognosis when increased,¹² on the other, does not validate using the p-CEA in the determination of an adjuvant or neo-adjuvant therapeutic strategy.²³Regarding this issue, we believe it still pertinent to evaluate whether in a sample of patients radically treated for colorectal carcinoma, the determination of the p-CEA may have a prognostic value and constitute an independent risk factor in relation to disease-free survival (DFS).