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.     

Perioperative Allogeneic Blood Transfusion Is Associated With Surgical Site Infection After Abdominoperineal Resection—a Space for the Implementation of Patient Blood Management Strategies

Allogeneic blood transfusion (ABT) has been reported as a major risk factor for surgical site infection (SSI) in patients undergoing colorectal surgery. However, the association of ABT with SSI in patients undergoing abdominoperineal resection (APR) and total pelvic exenteration (TPE) still remains to be evaluated. Here, we aim to elucidate this association. The medical records of all patients undergoing APR and TPE at our institution in the period between January 2000 and December 2012 were reviewed. Patients without SSI (no SSI group) were compared with patients who developed SSI (SSI group), in terms of clinicopathologic features, including ABT. In addition, data for 262 patients who underwent transabdominal rectal resection at our institution in the same period were also enrolled, and their data on differential leukocyte counts were evaluated. Multivariate analysis showed that intraoperative transfusion was an independent predictive factor for SSI after APR and TPE (P = 0.004). In addition, the first–operative day lymphocyte count of patients undergoing APR, TPE, and transabdominal rectal resection was significantly higher in nontransfusion patients compared with transfusion ones (P = 0.026). ABT in the perioperative period of APR and TPE may have an important immunomodulatory effect, leading to an increased incidence of SSI. This fact should be carefully considered, and efforts to avoid allogeneic blood exposure while still achieving adequate patient blood management would be very important for patients undergoing APR and TPE as well.Key words: Colorectal cancer, Abdominoperineal resection, Surgical site infection, Allogeneic blood transfusion, Patient blood managementPostoperative surgical site infection (SSI) is one of the most frequent complications associated with various surgical procedures, and it results in adverse outcomes, including longer hospital stay, higher health care costs, and increased surgical mortality.¹ It is one of the most frequent nosocomial complications, accounting for almost one fifth of all health care–associated infections.² Colon surgery and rectal surgery are associated with higher SSI rates compared with most other abdominal procedures, with 5% to 25% of colon and rectal surgery patients developing incisional and organ/space SSI.^3–5 Moreover, the incidence of overall SSI was reported to be higher in rectal surgery patients (17%–28%) than in colonic surgery patients (9%–23%),^3,5,6 with especially higher overall SSI rates observed in patients undergoing abdominoperineal resection (APR; 12%–51%).^7–9 These are attributed to the high infection rates of the perineal wound, reported to be as high as 21%.¹⁰ Thus, the incidence of SSI associated with APR should be the highest among the various abdominal operative procedures.Various risk factors for postoperative SSI in colorectal surgery were reported previously. Open surgery,^10–12 perioperative allogeneic blood transfusion (ABT),^4,10,12 and prolonged operation time^4,9 have been found to be risk factors for SSI in a number of studies. Although several preceding reports have investigated the risk factors for SSI associated with APR, the reported independent risk factors varied among the studies. Although a number of studies have reported on the role of ABT as a strong risk factor for incisional SSI in colorectal surgery,^13,14 only one study has investigated on its relevance to the onset of incisional SSI after APR procedure; but this study failed to demonstrate a significant association. Presently, therefore, the role of ABT as a potential risk factor for incisional SSI in APR remains to be elucidated, and doing so will be very important for the implementation of measures to achieve patient blood management in this group of patients.In this study, we aimed to elucidate the risk factors for SSI in patients receiving APR, especially focusing on ABT.     

Medullary Carcinoma of the Thyroid With Axillary Metastasis: A Case Report

We report a case of axillary lymph node metastasis as a consequence of medullary thyroid carcinoma (MTC) in a 42-year-old man. On January 2009, the patient was referred to us for the management of right cervical lymph node enlargement. Total thyroidectomy was performed with right-sided functional neck dissection. Postoperative histopathology revealed MTC in the right lobe of the thyroid, with extrathyroidal extension and right-sided neck metastases. Multiple left cervical, mediastinal, and right axillary lymphadenopathies were detected at the third year follow-up exam. Left-sided functional neck dissection, axillary lymph node dissection, and mediastinal lymph node dissection were performed, and the pathologic outcomes revealed as the metastatic dissemination of MTC. After a disease-free term for 1 year, multiple metastatic lesions were detected in the patient.Key words: Medullary thyroid cancer, Lymph node metastasis, Axillary involvementMedullary thyroid cancer (MTC) is a rare tumor originating from the parafollicular C cells of the thyroid gland. MTC accounts for approximately 3% to 5% of all thyroid cancers.¹ The frequently used prognostic markers in the follow-up period of MTC patients are serum calcitonin and carcinoembryonic antigen (CEA) levels. Calcitonin hormone is a specific and sensitive biomarker for parafollicular C-cell disorders. The CEA produced by neoplastic C cells is generally considered a marker of dedifferentiation and is associated with worse prognosis for MTC.^2,3 MTC may occur sporadically or may be inherited. Hereditary forms of this cancer account for 25% of all cases and include familial MTC and multiple endocrine neoplasia syndromes (MEN 2A, MEN 2B). Seventy-five percent of cases are sporadic.⁴ The overall prognosis of MTC is affirmative, with a 10-year overall survival rate of approximately 95% for patients with tumors confined to the thyroid gland. However, for patients with distant metastasis at presentation, the 10-year overall survival rate is estimated to be only 40%.⁵ For metastatic cases, lymph node involvement is very common throughout the clinical course. During initial staging, the incidence of pathologically proven cervical lymph node metastasis has been reported as 71% to 80%^6–8; the corresponding value for mediastinal involvement is 36%.^6,8 Whereas, distant metastases have been reported in 20% of MTC patients.⁹ Considering the spectrum of MTC, axillary lymph node metastasis (LNM) is rare, and there are reports of isolated cases.^10–12     

Our Contrivances to Diminish Complications After Pylorus-Preserving Pancreaticoduodenectomy

The objective of this study is to diminish postoperative complications after pylorus-preserving pancreaticoduodenectomy. Pylorus-preserving pancreaticoduodenectomy is still associated with major complications, especially leakage at pancreatojejunostomy and delayed gastric emptying. Traditional pylorus-preserving pancreaticoduodenectomy was performed in group A, while the novel procedure, an antecolic vertical duodenojejunostomy and internal pancreatic drainage with omental wrapping, was performed in group B (n = 40 each). We compared the following characteristics between the 2 groups: operation time, blood loss, time required before removal of nasogastric tube and resumption of food intake, length of hospital stay, and postoperative complications. The novel procedure required less time and was associated with less blood loss (both P < 0.0001). In the comparison of the 2 groups, group B showed less time for removal of nasogastric tubes and resumption of food intake, shorter hospital stays, and fewer postoperative complications (all P < 0.0001). The novel procedure appears to be a safe and effective alternative to traditional pancreaticoduodenectomy techniques.Key words: Pylorus-preserving pancreaticoduodenectomy (PPPD), Internal stent, Omental wrapping, Postoperative stayPylorus-preserving pancreaticoduodenectomy (PPPD) has replaced conventional pancreaticoduodenectomy (PD) as the standard operation for both benign and malignant conditions.^1,2 Pylorus-preserving pancreaticoduodenectomy was first reported by Watson in 1944 and popularized by Traverso in 1978. Mortality related to PD has been reduced, or even eliminated^3–5; however, in comparison with other abdominal operations such as gastrectomy and rectal surgery, PPPD has a high morbidity rate.^6–9 Pancreatic fistula is one of the most difficult complications to eradicate in both PD and PPPD. In addition, delayed gastric emptying is a specific complication of PPPD. These complications may extend the duration of hospital stay required after the operation.Sugiyama et al¹⁰ first reported that delayed gastric emptying can be prevented by a vertical duodenojejunostomy. Since then, antecolic reconstruction and vertical stomach reconstruction have also been reported to be useful procedures for minimizing the adverse effects in both pancreaticojejunostomy and pancreaticogastrostomy.^11,12 The likelihood of a pancreatic fistula can also be reduced, by a duct-to-mucosa pancreaticojejunostomy^3,13,14 and by the use of omental wrapping.¹⁵ However, none of the studies have examined whether the complications after PPPD would be diminished if vertical reconstruction, antecolic reconstruction, internal drainage, and omental wrapping were simultaneously performed.To address this problem, we developed a new reconstruction method for preventing delayed gastric emptying and pancreatic fistula. Here, we describe this new technique for the first time, and compare the efficacy of this technique with that of our classical method.     

Mean Platelet Volume: Is It a Predictive Parameter in Diagnosis of Acute Mesenteric Ischemia?

Our objective for this study was to discuss the usability of mean platelet volume, which is associated with numerous vascular pathologies, in the early diagnosis of acute mesenteric ischemia. Acute mesenteric ischemia is an uncommon, life-threatening clinical condition mostly seen in the elderly. Early diagnosis of acute mesenteric ischemia and correction of blood circulation before necrosis occurs are important factors affecting prognosis. A total of 95 patients who underwent emergency surgery for acute mesenteric ischemia and 90 healthy volunteers as control group were included in this study. Age, gender, hemoglobin values, white blood cell counts, mean platelet volume, and platelet counts are recorded for evaluation. The mean platelet volume values were significantly higher in patients with acute mesenteric ischemia than in the controls (9.4 ± 1.1 fL and 7.4 ± 1.4 fL, respectively; P < 0.001). Receiver-operating characteristic analysis demonstrated a cutoff value of mean platelet volume as 8.1 fL (area under the curve, 0.862), a sensitivity of 83.2%, and a specificity of 80%. As a result, in the patients who are admitted to the hospital with acute nonspecific abdominal pain and suspected of having acute mesenteric ischemia, high mean platelet volume values in routine hemograms support the diagnosis of acute mesenteric ischemia.Key words: Acute mesenteric ischemia, Mean platelet volume, DiagnosisAcute mesenteric ischemia (AMI) is an infrequent, life-threatening clinical condition mostly seen in the elderly. Despite advances in the diagnosis of and therapy for AMI, mortality rates remain high and show dissimilarity (30%–97%) in the literature. Atypical symptoms, cases frequently being elderly patients with cardiovascular diseases, and diagnostic difficulties all cause delays in surgical intervention and ultimately high mortality rates.^1,2 AMI, as a result of mesenteric vascular insufficiency, causes damage in other vital organs besides the intestines. AMI may progress due to obstruction of mesenteric vessels as a result of embolism or thrombosis, or for nonobstructive reasons, such as hypotension or cardiac insufficiency. AMI is frequently seen in patients with serious concomitant diseases.^3–5 Early diagnosis of AMI and correction of blood circulation before necrosis occurs are important factors affecting prognosis.⁶ In every patient, platelets show heterogeneity in size and density. Mean platelet volume (MPV) is a blood parameter used for measuring platelet size and can be determined in routine blood tests. It is cost-effective and yields results in a short amount of time.⁷ Larger platelets are more active metabolically and enzymatically,⁸ and their prothrombotic potential is greater than that of smaller ones.⁹ Elevated MPV is associated with other markers of platelet activity, including increased platelet aggregation, increased thromboxane synthesis, increased β-thromboglobulin release, and increased expression of adhesion molecules.¹⁰ This suggests a common mechanism by which these factors may increase the risk of cardiovascular disease.⁷ In patients with a myocardial infarction or cerebrovascular disease,^7–12 platelet volume has been found to be increased, and MPV is independently associated with peripheral artery disease.¹³ However, data in mesenteric vascular disease are lacking. Our objective in this study is to discuss the usability of MPV, which is associated with numerous vascular pathologies, in the early diagnosis of AMI.     

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.     

High Expression of DARPP-32 in Colorectal Cancer Is Associated With Liver Metastases and Predicts Survival for Dukes A and B Patients: Results of a Pilot Study

The purpose of this study was to investigate prognostic significance of Dopamine and cAMP-Regulated neuronal Phosphoprotein 32 (DARPP-32) expression in primary colorectal cancer. The study material consisted of clinical and histopathological data of 100 patients operated for colorectal cancer between 1994 and 1997. For immunohistochemical analysis, specific rabbit antibodies for DARPP-32 were used and the percentage of stained tumor cells was calculated under gross magnification (400 times) on a sample of 500 tumor cells. DARPP-32 expression in the primary tumor was significantly greater in patients with distant metastases compared to patients with no distant metastases (p=0.002). In multivariate regression analysis, DARPP-32 expression in the primary tumor was a significant predictor of distant metastases. With a cut-off point of 76.5%, DARPP-32 expression in the primary tumor significantly influenced both overall and disease free survival, especially for Dukes A and B patients (p=0.037). The results of this study indicate that DARPP-32 may be a potential marker of worse prognosis and a valuable tool for managing further adjuvant treatment in patients with stages Dukes A and B colorectal cancer.Key words: Colorectal neoplasms, Dopamine and cAMP-regulated phosphoprotein 32, Humans, Nerve tissue proteins, Liver metastasesColorectal cancer is the second most common cause of cancer related death in Western Europe and the United States, with the incidence of 50/100,000 population.¹ In spite of significant developments in surgery and new chemotherapy drugs and protocols as well as radiotherapy regimens, this malignancy still has high mortality.²The 5-year survival rate of colorectal cancer patients with Dukes A cancer ranges from 74 to 93%. Patients with Dukes B cancer have a 5-year survival of 40 to 82%, and those with positive lymph nodes (Dukes C) have a 5-year survival rate of 30 to 59%.^3,4 Recurrences are observed in as much as 34% of patients with Dukes A and B stage, compared with 59% in patients with lymph node metastases.⁵Liver metastases are a well proven major determinant of survival in patients with colorectal cancer.^2,6 Therefore, better selection of patients with potential to develop liver metastases or those having occult metastases may increase the survival of those patients in whom adjuvant therapies would not otherwise be indicated.^2,5,7Recently, overexpression of dopamine and 3′5′-cyclic adenosine monophosphate regulated neuronal phosphoprotein 32 (DARPP-32) has been found in several gastrointestinal adenocarcinomas.⁸ Although most of the research on this protein focused on its role in the central nervous system,^9–11 the finding of overexpression of this protein in cancer tissues brought up the hypothesis of its role in carcinogenesis.^8,12 Genetic studies led to the discovery of frequent 17q DNA amplifications in gastric cancer.⁸ Subsequently, the gene located at this site, called PPP1R1B, has been sequenced and found to encode DARPP-32 molecule, that was brought into connection with several malignancies.^8,13–18 The DARPP-32 molecule is a protein with molecular mass of 32 kDa, consisting of 204 amino acids and 4 phosphorylation sites: Thr34, Thr75, Ser102, and Ser137. Depending on the phosphorylation of 1 of these 4 amino acids, the DARPP-32 molecule is acting as the signal integrator and as the regulator of the phosphorylase and kinase activities in eukaryotic cells.¹⁹Basic research indicates that DARPP-32 may be associated with worse prognosis in some carcinomas.²⁰ However, it is remains unknown if evaluation of DARPP-32 expression in colorectal cancer patients may aid to evaluate prognosis.The purpose of this study was to investigate possible associations of DARPP-32 expression in primary colorectal cancer with known prognostic determinants of colorectal cancer and therefore set the basis for further clinical research.     

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).     

Is the Male Gender an Independent Risk Factor for Complication in Patients Undergoing Laparoscopic Cholecystectomy for Acute Cholecystitis?

This paper was designed to investigate the gender dependent risk of complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. Laparoscopic cholecystectomy is the standard procedure for benign gallbladder disorders. The role of gender as an independent risk factor for complicated laparoscopic cholecystectomy remains unclear. A retrospective single-center analysis of laparoscopic cholecystectomies performed for acute cholecystitis over a 5-year period in a community hospital was performed. Within the period of examination, 1884 laparoscopic cholecystectomies were performed. The diagnosis was acute cholecystitis in 779 cases (462 female, 317 male). The male group was significantly older (P = 0.001). Surgery lasted significantly longer in the male group (P = 0.008). Conversion was done in 35 cases (4.5%). There was no significant difference in the rate of conversion between both groups. However the rate of conversion was significantly higher in male patients > 65 years (P = 0.006). The length of postoperative hospital stay was significantly longer in the male group (P = 0.007), in the group > 65 years (P = 0.001) and following conversion to open surgery (P = 0.001). The male gender was identified as an independent risk factor for prolonged laparoscopic cholecystectomy on multivariate analysis. The male gender could be an independent risk factor for complicated or challenging surgery in patients undergoing laparoscopic cholecystectomy for acute cholecystitis.Key words: Acute cholecystitis, Gallbladder disease, Laparoscopic cholecystectomy, Cholecystolithiasis, GallstonesGallbladder disorders represent common medical problems for which surgery is usually indicated. With about 1 million procedures performed worldwide per year and close to 170,000 in Germany alone, laparoscopic cholecystectomy (LC) belongs to one of the most commonly performed surgical procedures.¹ Over the last decades this procedure has grown to be the standard procedure for the management of benign gallbladder disease.^2–4 The surgical challenges in LC, especially converting from laparoscopic to open surgery has been a matter of concern.^5–9 The gender-associated risk of complication in laparoscopic cholecystectomy has not been clearly defined.^2,10–11The aim of this study was to investigate whether the male gender is an independent risk factor for complication in patients undergoing laparoscopic cholecystectomy for acute cholecystitis (AC).     

Common Bile Duct Exploration in an Elderly Asian Population

Common bile duct exploration (CBDE) is an accepted treatment for choledocholithiasis. This procedure is not well studied in the elderly population. Here we evaluate the results of CBDE in elderly patients (>70 years) and compare the open (group A) with the laparoscopic group (group B). A retrospective review was performed of elderly patients with proven common bile duct (CBD) stones who underwent CBDE from January 2005 to December 2009. There were 55 patients in group A and 33 patients in group B. Mean age was 77.6 years (70–91 years). Both groups had similar demographics, liver function tests, and stone size—12 mm (range, 5–28 mm). Patients who had empyema (n = 9), acute cholecystitis (n = 15), and those who had had emergency surgery (n = 28) were more likely to be in group A (P < 0.05). The mean length of stay for group A was 11.7 ± 7.3 days; for group B, 5.2 ± 6.3 days; the complication rate was higher in group A (group A, 38.2%; group B, 8.5%; P = 0.072). The overall complication and mortality rate was 29.5% and 3.4%, respectively. CBDE can be performed safely in the elderly with accepted morbidity and mortality. The laparoscopic approach is feasible and safe in elective setting even in the elderly.Key words: Common bile duct exploration, Elderly, LaparoscopyThe treatment of common bile duct (CDB) stones varies, and the optimal management is still a matter of debate.¹ The treatment options include pre- or postoperative endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic cholecystectomy (LC) or common bile duct exploration (CBDE) with LC or open cholecystectomy (OC). LC is necessary, as up to 47% of patients will develop recurrent symptoms from cholelithiasis.² However, in the former approach (ERCP with LC), patients will have to undergo 2 procedures and be exposed to the risks of ERCP. ERCP has a mortality and morbidity rate of up to 1% and 15.9%, respectively.^3,4 Furthermore, patients who opt for preoperative ERCP may still require CBDE if stone clearance is not achieved and may eventually end up having multiple procedures.^5–7Although laparoscopic common bile duct exploration (LCBDE) is an accepted treatment, the technical difficulties associated with this procedure have made it slower to gain widespread acceptance.⁸ Nonetheless, as surgeons gain more expertise and experience in laparoscopic biliary surgery, LCBDE is fast becoming part of the armamentarium for dealing with CBD stones. The safety and efficacy of LCBDE is well studied in the general population. In the literature, the ductal stone clearance rate for all comers is approximately 85% to 97.3% and has an associated mortality rate of 0.3% to 0.8% and morbidity of 3.7% to 33%.^9–13 The overall length of stay is shorter in LCBDE compared with the 2-stage approach.¹⁴ With all these advantages, it has even been suggested that LCBDE is the preferred treatment, especially in patients who are fit and young.¹⁵ Of interest, the incidence of CBD stones is higher in the elderly; however, this procedure is not well studied in this group of patients.^16,17 There are also concerns regarding the safety of biliary tract surgery in elderly patients especially in the acute setting.¹⁸ With this in mind, this retrospective study aimed to evaluate and analyze the results of CBDE in elderly patients and to compare the results between the open and laparoscopic groups.     

Fecoflowmetric Analysis of Anorectal Motor Function in Postoperative Anal-Preserving Surgery Patients With Low Rectal Cancer Comparison With the Wexner Score and Anorectal Manometry

The aim of this study was to elucidate whether fecoflowmetry (FFM) could evaluate more detailed evacuative function than anorectal manometry by comparing between FFM or anorectal manometric findings and the clinical questionnaires and the types of surgical procedure in the patients who received anal-preserving surgery. Fifty-three patients who underwent anal-preserving surgery for low rectal cancer were enrolled. The relationships between FFM or the manometric findings and the clinical questionnaires and the types of procedure of anal-preserving surgery were evaluated. There were significant differences between FFM markers and the clinical questionnaire and the types of the surgical procedure, whereas no significant relationship was observed between the manometric findings and the clinical questionnaire and the types of the surgical procedure. FFM might be feasible and useful for the objective assessment of evacuative function and may be superior to manometry for patients undergoing anal-preserving surgery.Key words: Anorectal manometry, Anal-preserving surgery, Fecoflowmetry, Incontinence, Rectal cancerSphincter preservation has been one of the key issues of rectal cancer surgery. Low anterior resection (LAR)¹ and internal and external sphincter resection (ISR and ESR) are anal-preserving surgeries.^2,3 The aim of these procedures is to restore the normal process of defecation, along with its function, and to improve the quality of life of patients by avoiding permanent colostomy. However, anal-preserving surgery is often associated with evacuative dysfunction and various degrees of incontinence.^4–7Most studies that have assessed the evacuation function have used clinical questionnaires, which are subjective and may vary according to the patient perception.⁷ There are many factors that can affect the evacuative function, such as the stool consistency, rectal capacity, anal sphincters, pelvic floor muscles, and intra-abdominal pressure. Although manometry with or without the clinical score has also commonly been used, fecoflowmetry (FFM) has been reported to be more accurate and useful for assessing the postoperative anorectal motor function.^8–13 FFM was first introduced by Shafik and is a dynamic method for examining the anorectal motor activity that simulates the natural act of defecation.¹⁴ Some studies have shown its usefulness in postoperative patients with anorectal disease,^8–11 but only a few studies have been performed to examine the evacuative function following anal-preserving surgery.^12,13 The aim of this study was to evaluate the evacuative function in the postoperative period following anal-preserving surgery in patients with low rectal cancer using FFM, and to compare the results with the Wexner score and anorectal manometry.¹⁵     

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.     

Giant Extraluminal Leiomyoma of the Colon: Rare Cause of Symptomatic Pelvic Mass

Leiomyomas (LMs) may appear throughout the entire gastrointestinal tract but are rarely seen in the colon-rectum and only 5 of those measured greater than 15 cm in diameter. Pain and palpable abdominal mass are the most common symptoms. Surgical resection is the treatment of choice for most LMs. We here describe a case of a 46-year-old woman who presented with a 3-month history of abdominal pain associated with worsening constipation and abdominal distension. A pelvic solid, polylobulate, left-sided mass was noted on examination. Preoperative findings revealed a dishomogeneous sigmoid mass with calcified spots compressing small intestine and bladder. At laparotomy, a large polylobulate and well-circumscribed mass arising from the descending colon mesentery and displacing small intestine, uterus, and ovaries. A segmental colon resection was performed. An extraluminal 18- × 12- × 5-cm paucicellular sigmoid colon leiomyoma was histologically diagnosed. Our case is one of the few giant (>15 cm) sigmoid colon LMs reported in the literature. Although rare and benign in nature, LMs of the colon can cause life-threatening complications that could require emergency treatment and they should be included in the differential diagnosis of large abdominopelvic masses. Follow-up after surgery is necessary for tumors with any atypia or mitotic activity.Key words: Leiomyoma, Digestive tract, Bowel obstruction, Pelvic massPrimary leiomyomas (LMs) present most commonly in the female genital tract and skin but they are rarely seen in the colon-rectum. Macroscopically, LMs may be intraluminal, intramural, extramural, or dumbbell.^1,2 The majority of LMs remain asymptomatic until they have reached a large size: most common symptoms are pain and palpable abdominal mass.^1,2 Symptomatic left colon LMs are uncommon and only 5 of those reported in the literature measured greater than 15 cm in diameter.¹ Histologically, most of them arise from the muscularis propria.^1,3 The most important differential diagnoses are malignant leiomyosarcoma and gastrointestinal stromal tumors (GIST).^1,3 Surgical resection is the treatment of choice for large LMs: complete excision should be always attempted and follow up is necessary for tumors with any atypia or mitotic activity.^1,2 Although rare and benign in nature, LMs of the colon can cause life-threatening complications that require emergency treatment.^1–3 We here describe a case of large extraluminal sigmoid colon LM causing pain and worsening bowel obstruction.     

Elevated Platelet Count as Predictor of Recurrence in Rectal Cancer Patients Undergoing Preoperative Chemoradiotherapy Followed by Surgery

The impact of systemic inflammatory response (SIR) on prognostic and predictive outcome in rectal cancer after neoadjuvant chemoradiotherapy (CRT) has not been fully investigated. This retrospective study enrolled 89 patients with locally advanced rectal cancer who underwent neoadjuvant CRT and for whom platelet (PLT) counts and SIR status [neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR)] were available. Both clinical values of PLT and SIR status in rectal cancer patients were investigated. Elevated PLT, NLR, PLR, and pathologic TNM stage III [ypN(+)] were associated with significantly poor overall survival (OS). Elevated PLT, NLR, and ypN(+) were shown to independently predict OS. Elevated PLT and ypN(+) significantly predicted poor disease-free survival (DFS). Elevated PLT was identified as the only independent predictor of DFS. PLT counts are a promising pre-CRT biomarker for predicting recurrence and poor prognosis in rectal cancer.Key words: Platelet, Neutrophil/lymphocyte ratio, Platelet/lymphocyte ratio, Rectal cancer, Prognosis, ChemoradiotherapyPreoperative chemoradiotherapy (CRT) and total mesorectal excision for the management of locally advanced rectal cancer (LARC) have significantly decreased local recurrence rates and improved sphincter preservation and patient survival.^1,2 However, distant recurrence remains the major cause of mortality in patients who undergo preoperative CRT followed by Total Mesorectum Excision (TME). Further improvements in the survival rate cannot be achieved without the control of postsurgical distant recurrence.Postoperative histopathologic features such as surgical margins (achievement of R0 resection) and lymph node metastases are recognized as predictors of local and distant recurrence in rectal cancer patients treated by preoperative CRT.^3–5 However, preoperative serum markers that could predict recurrence and/or poor prognosis⁶ might present a convenient tool to permit intensification of either preoperative neoadjuvant or postoperative adjuvant chemotherapeutic strategies.Aberrant activation of platelets (PLT) and the coagulation pathway are associated with malignancies. Increased PLT count may indicate poor prognosis in cancer patients,^7,8 nearly a third of whom have thrombocytosis at diagnosis and before treatment,⁹ although the mechanisms by which thrombocytosis develops in malignancies remains unknown. Particularly in colorectal cancer, the prognostic significance of thrombocytosis was recently reported by Ishizuka et al and Cravioto-Villanueva et al.^10,11 Pretreatment thrombocytosis is also a predictor for CRT response and local recurrence in rectal cancer patients.¹²However, the systemic inflammatory response (SIR), which is thought to be secondary to hypoxia or tumor necrosis, is associated with anti-apoptotic characteristics in cancer cells¹³ and has been shown to act as a biomarker of outcome in a variety of malignancies.¹⁴ Neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) are two representative indexes of systemic inflammation; their prognostic values have been studied in many cancer types.¹⁵ High NLR or PLR reportedly predicts poor outcomes in colorectal cancer patients who undergo primary resection without lymph node metastases and who undergo hepatectomy for liver metastasis.^16–18 Recently, the clinical significance of NLR in rectal cancer patients undergoing CRT followed by surgery has been demonstrated, showing that it was predictor for recurrence and overall survival.¹⁹In this study, we investigated the correlations between levels of PLT, NLR, and PLR in pretreatment blood tests, and clinicopathologic features in patients who undergo CRT followed by TME for locally advanced rectal cancer, and evaluated and compared their potentials as prognostic biomarkers.     

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.     

Prevention of Incisional Surgical Site Infection Using a Subcuticular Absorbable Suture in Elective Surgery for Gastrointestinal Cancer

This study examined whether subcuticular absorbable sutures actually reduce incisional SSI in patients undergoing surgery for gastrointestinal (GI) cancer. Surgical site infection (SSI) is still a source of major complications in digestive tract surgery. Reportedly, incisional SSI can be reduced using subcuticular suturing. We performed subcuticular suturing using a 4-0 absorbable monofilament in patients undergoing elective surgery for GI cancer beginning in 2008. Using an interrupted technique, sutures were placed 1.5-2.0cm from the edge of the wound, with everted subcuticular sutures created at intervals of 1.5-2.0cm. The control group consisted of cases in which the common subcutaneous suture method using clip. One hundred cases were examined in the subcuticular group. The incidence of SSI was 0% in the subcuticular suture group, compared with 13.9% in the control group; this difference was significant. Incisional SSI can be prevented using the devised subcuticular absorbable sutures in patients undergoing elective surgery for GI cancer.Key words: Surgical site infection, Subcuticular suture, Absorbable monofilament, Gastrointestinal cancer surgerySurgical site infection (SSI) is still a source of major complications in digestive tract surgery. The Centers for Disease Control and Prevention (CDC) National Nosocomial Infection Surveillance System (NNIS) risk adjustment index is an internationally recognized method of stratifying the risk of SSI according to three major factors.¹ First, the American Society of Anesthesiologists'' score reflects the patient''s state of health before surgery.² Second, the wound classification reflects the degree of wound contamination. And third, the duration of the operation reflects the technical aspects of surgery. The infection rate increases with an increasing risk index score.^1,3 Excellent surgical technique is widely believed to reduce the risk of SSI.^4–7 In the case of wound closure, such techniques include the maintenance of effective hemostasis while preserving an adequate blood supply, preventing hypothermia, gently handling the tissues, avoiding inadvertent entries into a hollow viscus, removing devitalized (e.g., necrotic or charred) tissues, the appropriate use of drains and suture materials, the eradication of dead space, and the appropriate postoperative management of incisions. Hematoma at the site of a surgical wound is a relatively common complication in elective surgical procedures. In most cases, the hematoma is caused by incomplete preoperative hemostasis, and not the omission of a subcutaneous fat layer suture.^1,8 According to current knowledge, seroma formation is caused by the ultrafiltration of blood serum, lymphatic secretion, the fibrinolytic activity of plasmin (causing the decay of fibrin complexes in the surrounding injured vessels), and tissue exudate formed during early inflammation reactions.^3,9,10 A large dead space also appears to contribute to the formation or a seroma.³ According to some authors, the presence of suturing material (as extraneous material) in tissues can also increase the risk of surgical site infections.^11–13Subcuticular suturing was recently reported to reduce incisional SSI.^14–16 Subcuticular sutures are thought to enable a maintained blood supply and to eradicate dead space in the subcutaneous environment. Therefore, we investigated whether the devised subcuticular suturing actually reduces incisional SSI, compared with the common subcutaneous sutures with clip, in patients undergoing elective surgery for gastrointestinal cancer.     

Effect of Intraoperative Valsalva Maneuver Application on Bleeding Point Detection and Postoperative Drainage After Thyroidectomy Surgeries

The purpose of this paper was to analyze the effect of Valsalva maneuver application before finalizing thyroidectomy operations on the identification of bleeding points and postoperational drainage. One hundred patients (age range, 24–76 years) with multinodular goiter, recurrent multinodular goiter, toxic diffuse multinodular goiter, or papillary thyroid cancer were included in the study and were divided into 2 groups of 50 randomly. Both groups underwent thyroidectomy operation, only 1 group received intraoperative Valsalva maneuver application (twice, 30 seconds of 30-cm PEEP). The size of the thyroid gland, the duration of operation, hospital stay, and drain usage were reported. Postoperational occurrences of drainage, hematoma, reoperation, and additional complications were compared between the groups. Valsalva maneuver application helped to identify minor bleeding points in 32% of the cases. There was no significant difference between the study groups regarding the thyroid gland size, operation duration, hospital stay, and the duration of drain usage (P > 0.05 for all). The amount of drainage as well as the frequencies of hematoma, reoperation, and further complications was not significantly different between the study groups (P > 0.05 for all). Intraoperative application of Valsalva maneuver is only useful to detect minor bleeding points in some patients during thyroidectomy operations, but it had no effect on the duration of postoperative drain usage, the amount of drainage, and risk of hematoma. Therefore, intraoperative application of Valsalva maneuver has no beneficial effect on postoperative hemorrhagic complication after thyroidectomy operations.Key words: Drainage, Hemostasis, Thyroidectomy, Valsalva maneuverThyroidectomy is one of the most commonly performed operations worldwide.¹ Though a series of improvements were introduced to the operation process, still several postoperative complications remain to be faced such as seroma, wound infection, skin flap complications, and hematoma.^2,3Despite the richness of the blood vessels in the thyroid area,⁴ the rate of postoperational bleedings thus hematoma events are low (1–5% of the cases).⁵ However, once not controlled, hematoma can result in airway compression and create a life-threatening situation for the patient.⁶ Hence, preventive measures have been emphasized and employed to avoid postoperational bleedings after thyroidectomy. These approaches range from exercises to avoid Valsalva maneuver kind of forces such as coughing or straining at opening bowel⁷ to the use of drains after the operation. However, recent literature indicates that the drain usage does not have a significant effect on the recovery period or on the duration of the hospital stay.^3,5,8,9 Furthermore, it may cause wound infection and contribute to the discomfort of the patients.^5,8,10,11 Thus a proper hemostasis and an early detection of potential bleeding sites are crucial steps for a successful operation and a steady recovery period.⁴ Several techniques have been used to detect and treat bleeding points immediately after the operation to prevent postoperational hematoma. These techniques involve the use of hydrogen peroxide, water in the wound, Valsalva maneuver, and Trendelenburg tilt.^4,7 Recently, the success of Valsalva maneuver and Trendelenburg tilt application on bleeding point detection was demonstrated by Moumoulidis et al.⁴ However, no further information is provided until now regarding the postoperational evaluation of the patients.In this paper, we aim to analyze the effect of the Valsalva maneuver application on the identification of bleeding points before finalizing the surgery and its influence on the postoperative drainage, complications, and recovery process.     

Emergency Presenting Colon Cancer Is an Independent Predictor of Adverse Disease-Free Survival

Twenty percent of colon cancers present as an emergency. However, the association between emergency presentation and disease-free survival (DFS) remains uncertain. Consecutive patients who underwent elective (CC) and emergent (eCC) resection for colon cancer were included in the analysis. Survival outcomes were compared between the 2 groups in univariate/multivariate analyses. A total of 439 patients underwent colonic resection for colon cancer during the interval 2000−2010; 97 (22.1%) presented as an emergency. eCC tumors were more often located at the splenic flexure (P = 0.017) and descending colon (P = 0.004). The eCC group displayed features of more advanced disease with a higher proportion of T4 (P = 0.009), N2 tumors (P < 0.01) and lymphovascular invasion (P< 0.01). eCC was associated with adverse locoregional recurrence (P = 0.02) and adverse DFS (P < 0.01 ) on univariate analysis. eCC remained an independent predictor of adverse locoregional recurrence (HR 1.86, 95% CI 1.50–3.30, P = 0.03) and DFS (HR 1.30, 95% CI 0.88–1.92, P = 0.05) on multivariate analysis. eCC was not associated with adverse overall survival and systemic recurrence. eCC is an independent predictor of adverse locoregional recurrence and DFS.Key words: Emergency presentation, Colon cancer, Disease free survival, Locoregional recurrenceColorectal cancer (CRC) is a significant cause of mortality, with over 40,000 new cases diagnosed annually in the UK contributing to over 16,000 deaths (Bowel Cancer UK).^1,2 Up to 20% of colon cancers (CC) present as an emergency (eCC) necessitating emergent surgery.^3,4 Although eCC has been shown to be associated with poorer overall survival (OS), much discrepancy exists in the literature regarding its association with disease-free survival (DFS).⁵⁻⁷Studies reporting the oncologic outcomes of CRC presenting as an emergency consist of heterogeneous populations of patients with colon and rectal cancers.^3,5 Colon and rectal cancers are 2 distinct entities with different molecular, clinical, pathologic, and biologic characteristics and treatment modalities.^8,4,9−11 Since the incorporation of combined multimodal treatment and total mesorectal excision the disparity in OS and DFS between colon and rectal cancer has increased.¹²⁻¹⁷ Rectal cancer patients may alter the impression of outcomes in emergency presenting colon cancer. Consequently, previous studies assessing outcomes in eCC may be flawed. Furthermore, the negative impact of eCC has previously been attributed to immediate postoperative complications with an inpatient hospital mortality of approximately 15%. Inclusion of such cases in studies assessing long-term outcomes may have overestimated the negative impact of eCC.¹⁸The aim of the current study was to determine the association between eCC and disease-free/overall survival.