Objective: This study presents the causes of death-censored graft loss among kidney transplant recipients. Materials and Methods: Medical records of the patients, who had undergone kidney transplantation at a tertiary center between November 2010 and December 2018, were retrospectively reviewed. Death-censored graft loss was described as an irreversible graft failure signified by return to long-term dialysis (or re-transplantation). Inclusion criteria were: patients who had undergone kidney transplantation, and subsequently lost their first graft, and a follow-up of more than one year after kidney transplantation. Results: Of 269 kidney transplant recipients, 33 recipients with a mean age of 33.54 ± 15.37 years (17 male and 16 female) were included in the study. The rate of death-censored graft loss was 12.26%. Of graft failures, 3.03% occurred in the hyperacute phase, 18.18% in the acute phase, and 78.78% in the chronic phase. Chronic allograft nephropathy was the leading cause of graft failure (48.48%). Other causes were medical problems (18.18), immunological problems (18.18%) and surgical complications (15.15%). Conclusion: Identification of the true causes of graft failure described under the heading chronic allograft nephropathy is noteworthy. Comprehensive biochemical, physiological, pathological, immunological, and genetic research should be implemented to remove the obstacles in kidney transplantations.

BACKGROUND:There are some difficulties regarding the evaluation of the post-splenectomy state.OBJECTIVE:The objective of the study is to compare the post-splenectomy blood changes of immune thrombocytopenia (ITP) patients with those of trauma patients, 1 month and ≥ 6 months after surgery.METHODS:Medical records of patients, who had undergone total splenectomy for ITP and trauma at a tertiary center between January 2009 and December 2019, were retrospectively reviewed.RESULTS:The current study included 52 patients, who had undergone splenectomy for ITP (57.7%), and trauma (42.3%). Splenectomy, irrespective of the indications, resulted in an increase in hemoglobin concentration, hematocrit, and platelet levels. Neutrophils were responsible for the preoperative leukocytosis in ITP patients, and neutrophilia was ameliorated by splenectomy and also withdrawal of the steroid therapy in some patients. Decreased neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio supported the finding that splenectomy ameliorated inflammation in ITP patients. Splenectomy resulted in a change in percentages of leukocytes in favor of basophils in ITP patients.CONCLUSIONS:Splenectomy, irrespective of the indications, resulted in an increase in hemoglobin concentration, hematocrit and platelet levels, lymphocyte, monocyte, and eosinophil counts. Splenectomy ameliorated inflammation in ITP patients and resulted in a change in percentages of leukocytes in favor of basophils.

OBJECTIVES:In the past decade, advances in immunological therapy have increased the survival of kidney recipients and their grafts. However, it has not achieved the desired level of improvement. This study aims to reveal the mortality among kidney recipients.METHODS:Medical data of the patients, who had undergone kidney transplantation (KT) between November 2010 and December 2020, were retrospectively reviewed. Inclusion criteria were adult kidney recipients, who had died. Exclusion criteria were pediatric recipients, recipients of en bloc and dual KT, recipients with missing data, and recipients with a primary non-functioning graft. The recipients were grouped according to their donor type; Group 1 (from a living donor) and Group 2 (from a deceased donor). Subgroup analyses were done for mortality by time-period post-transplant and for infectious causes of mortality.RESULTS:Of 314 recipients, 35 (11.14%) died. Twenty-nine recipients were included in the study (Group 1: 17 and Group 2: 12). The most common cause of mortality was infection (58.6%), and the second was cardiovascular disease (CVD) (24.1%). Sepsis developed in 29.4% of infection-related deaths, while COVID-19 constituted 23.5% of infection-related deaths.CONCLUSION:Early diagnosis and treatment of infectious and CVD are important to improve survival in kidney recipients.

Thoracoepigastric flap is rarely used for reconstruction of the large chest wall defects due to potential for necrosis and delayed wound healing. This article presents three patients with breast cancer, who underwent mastectomy and chest wall reconstruction with thoracoepigastric flap and subsequently developed distal flap necrosis. The negative pressure wound therapy may eliminate the need for additional graft and/or flap surgery in patients with large necrosis size.

OBJECTIVE To evaluate the effectiveness of F-18-FDG PET/CT for detecting additional tumor foci in breast cancer. MATERIAL-METHOD The data were reviewed retrospectively of 232 women who underwent F-18-FDG PET/CT examination prior to breast cancer surgery between January 2013 and December 2018. RESULTS Additional tumor foci were suspected in 95 cases on F-18-FDG PET/ CT, which were confirmed by histopathological analysis in 81 cases. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of F-18-FDG PET/CT in detection of additional tumor foci were 77.7%, 79.48%, 66.3%, 87.32%, and 79.23%, respectively. The false negative and false positive rates were 22.22% and 20.51%, respectively. In univariate analysis, only the patient's age was positively associated with accuracy of F-18-FDG PET/CT in detecting additional tumor foci. The accuracy was lower in women aged <= 50 years, with a substantial increase in false positive findings in women in that age group. CONCLUSIONS F-18-FDG PET/CT alone cannot replace conventional diagnostic procedures for evaluating additional tumor foci in breast cancer, as a substantial increase in false positive findings is recorded with this method in women aged <= 50 years old.

INTRODUCTION:The efficacy of surgical intervention for perianal infection in patients with hematologic malignancy is not well-established.OBJECTIVE:This article presents a case series of perianal infection progressing to Fournier's gangrene (FG) in patients with hematologic malignancy to guide physicians, because to the author's knowledge, there were no randomized or prospective studies presenting the management strategies reported herein. It was hypothesized that surgery might reduce mortality and morbidity in patients with inflammation spreading beyond the perianal region, in patients with abscess formation, and in those who show no improvement with medical therapy.MATERIALS AND METHODS:The data of 4 adults with hematologic malignancy who developed perianal infection progressing to FG between January 2010 and December 2018 were reviewed retrospectively. Patients younger than 18 years and patients without hematologic malignancies or FG were excluded. The primary outcome was mortality. The secondary outcome was irreversible organ damage.RESULTS:Four male patients with a mean age of 36.75 years ± 13.1 standard deviation (range, 23-52 years) reported fever and dull anal pain during treatment for hematologic malignancy. A broad-spectrum antibiotic regimen was administered as initial empiric therapy at onset of fever and was de-escalated based on the culture results and clinical response. However, FG arose in all cases approximately 8.75 days ± 6.94 (range, 3-17 days) after onset of anal pain. All patients underwent surgical debridement, and diverting ostomy was performed in 3 cases. One patient died of overwhelming sepsis (25%), and 1 patient required orchiectomy (25%).CONCLUSIONS:Clinical suspicion of FG may be effective in reducing mortality in patients with hematologic malignancy, especially in cases with fever accompanied by anal pain. Surgical intervention may improve the prognosis for patients with inflammation spreading beyond the perianal region, patients with abscess formation, those who show no improvement in medical therapy, and those who develop FG. Diverting ostomy may improve survival in patients with FG.

OBJECTIVE To evaluate the predictors of the response to splenectomy in patients with immune thrombocytopenia. METHOD The medical records were reviewed retrospectively of patients who had undergone total splenectomy for immune thrombocytopenia at a tertiary center between January 2009 and December 2019. RESULTS This study included 40 patients (28 females and 12 males) with immune thrombocytopenia. A complete response was obtained in 31 (77.5%) patients, with 9 (22.5%) patients failing to respond to splenectomy. The response was stable in 25 patients (62.5%), and 5 patients (12.5%) had a recurrence. The postoperative mortality rate was 2.5%; one patient developed an ischemic stroke and died. Multivariate analysis demonstrated that an extended time from diagnosis to splenectomy, a lower demand for transfusion of blood components, and a shorter length of hospitalization were positively associated with a complete response. CONCLUSIONS Splenectomy should be considered as the therapeutic approach to immune thrombocytopenia, with a high curative potential in suitable patients. An extended time from diagnosis to splenectomy, lower demand for transfusion of blood components, and shorter length of hospitalization were found to be positively associated with a complete response after splenectomy.

INTRODUCTION Necrotizing fasciitis results in progressive destruction of the fascia and overlying tissue. Mortality primarily depends upon the timing of medical care and the extent of infection. OBJECTIVE This article presents a case series of thigh abscesses originating from intra-abdominal pathologic conditions and progressing to necrotizing fasciitis due to delayed diagnosis. MATERIALS AND METHODS The data concerning 3 patients with thigh abscess originating from an intra-abdominal pathologic condition and progressing to necrotizing fasciitis are presented. RESULTS All patients had undergone previous colorectal surgery for malignancy and were admitted to the hospital with pain concentrated in the lower back and spreading down to the buttock, sacrum and coccyx, and leg. Patients had received symptomatic therapy, including nonsteroidal anti-inflammatory drugs, and 1 patient had undergone diskectomy for a herniated disk in the lumbar region. All 3 patients subsequently developed thigh abscesses (initially treated by percutaneous and/or surgical drainage) and received antibiotic therapy. One patient underwent percutaneous drainage, and 2 patients underwent abdominal surgery to address the abdominal abscess. During the course of treatment, thigh abscesses progressed to necrotizing fasciitis, which was treated by surgical debridement with or without negative pressure wound therapy. All patients died of overwhelming sepsis. CONCLUSIONS Thigh abscess may spontaneously arise from surrounding soft tissues, or it may be a sign of intraperitoneal, retroperitoneal, or pelvic pathologic conditions. Deep, vague pain in the back or hip area that spreads downward to the buttock and leg may be an early symptom of these pathologic conditions. Clinical suspicion may be effective in reducing mortality by enabling early surgical intervention, especially in the patient with a previous history of abdominal surgery, radiotherapy, or inflammatory or malignant disease.

Background. In the present retrospective study, we analyzed the outcomes of patients transplanted with grafts with multiple renal arteries (MRAs). Patients and Methods. In total, 89 patients were transplanted with renal grafts with MRAs from 2003 to 2018. Demographic characteristics; type of donor; warm and cold ischemia times; arterial anastomosis technique; complications; graft function at first month, first year, and last outpatient clinic visit; and patient and graft survival were all retrospectively evaluated. Results. The mean age of the patients was 40.4 +/- 13.3 years. Fifty-six patients (62.9%) were male. In total, 42 patients (47.2%) received renal grafts from living related donors. In group A (n = 24; 27%), anastomosis was performed separately to the recipient external or internal iliac arteries; in group B (n = 38; 42.7%), the secondary artery was anastomosed to the main artery in a side-to-side fashion to form a single common orifice; in group C (n = 27; 30.3%), secondary arteries were anastomosed to the main renal artery in an end-to-side fashion. Creatinine clearance at the first month was significantly lower for deceased-donor grafts compared to living-donor renal grafts (P < .05). Creatinine clearance in the first postoperative month was significantly lower in group A and creatinine clearance in the first year was significantly lower in group C (P <.05). The best survival was found for anastomosis to the internal iliac artery (P < .05). Conclusion. MRAs can be safely used and the reconstruction technique does not matter if the graft kidney's arterial supply is preserved and the internal iliac artery is chosen for anastomosis.

Hemorrhagic complications in surgical patients with congenital factor VII deficiency are a major concern. Replacement therapy is required, in which recombinant factor VIIa is the first treatment choice, by virtue of its higher efficacy and no risk of infection. Because of the risk of vascular thrombosis, recombinant factor VIIa treatment may result in catastrophic outcomes, including graft loss in transplant patients. We present the case of a 7-year-old male who underwent renal transplantation and who developed renal thrombosis after recombinant factor VIIa substution therapy for factor VII deficiency.

BACKGROUND/AIMS The goal of the present study was to determine the factors affecting strangulation and necrosis in incarcerated abdominal wall hernias (AWHs). MATERIAL and METHODS This was a retrospective study conducted by reviewing the medical records of 44 patients who underwent surgery for incarcerated abdominal wall hernia at a university hospital between April 2009 and January 2018. RESULTS Of the 44 study patients, 28 were men and 16 were women of mean age 68.95 years. Of all, 30 patients (68.2%) had groin hernias (femoral: 7, inguinal: 23) and 14 (31.8%) had ventral hernias (incisional: 8, umbilical: 5, epigastric: 1). The intraoperative findings were strangulation in 24 (54.5%) and necrosis in 20 (45.5%) cases. Accordingly, omental resection was performed in 4, small bowel resection in 14, and large bowel resection in two patients. The hernia was repaired using a polypropylene mesh in 33 patients (of them 20 were Lichtenstein, 8 were on-lay, and 5 were plug-mesh) and without using a mesh in ten patients. The hernia was not repaired in one patient. The mean duration of hospitalization was 7.43 (range: 1-5) days. The mortality rate was 13.6%. In univariate analysis, the mortality was positively related to necrosis (p=0.045). The duration of these symptoms was the only factor that affected strangulation and necrosis. CONCLUSION The mortality rate was high in incarcerated abdominal wall hernias, while necrosis was the most significant variable associated with mortality. The duration of the symptoms was the most significant factor that affected necrosis; therefore, it is essential to perform surgical intervention within the first 24 h of admission.

ABSTRACT BACKGROUND: There are quite a few studies examining prognostic factors in non-traumatic splenectomies compared to traumatic ones. OBJECTIVE: This study aimed to evaluate the predictors of mortality in patients who underwent splenectomy for non-traumatic spleen diseases. METHODS: Medical records of the patients, who had undergone total splenectomy for non-traumatic spleen diseases at a tertiary center between January 2009 and December 2019, were retrospectively reviewed. Exclusion criteria included patients younger than 18 years of age, partial splenectomies, splenectomies applied to facilitate surgery for malignancy on contiguous organs, and splenectomies performed during liver transplantation. Iatrogenic splenic injuries were regarded as trauma and these cases were also excluded. RESULTS: The current study included 98 patients. Nine (9.2%) patients died. In univariate analysis, age, the presence of hematological neoplasia, hematocrit, hemoglobin, white blood cell counts, neutrophil-to-lymphocyte ratio, indications for splenectomy, application of emergency surgery, surgical technique, and transfusion of blood components were all significantly associated with mortality. In multivariate analysis, the presence of hematological malignancy [P=0.072; OR=7.17; (CI: 0.386-61.56)], the application of emergency surgery [P=0.035; OR=8.33; (CI: 1.165-59.595)] and leukocytosis [P=0.057; OR=1.136; (CI: 0.996-1.296)] were found to be positively associated with mortality. CONCLUSION: Hematologic neoplasia, emergency surgery, and leukocytosis were the independent predictors of mortality in patients, who were operated on for non-traumatic spleen diseases. A thorough preoperative evaluation, early therapeutic intervention, and advanced surgical techniques are important and can serve to minimize complications and mortality in case of inevitable splenectomy. Immunological research can provide new therapeutic opportunities that may impact positively on patients by minimizing morbidity and mortality.

espanolIntroduccion: En algunos paises la donacion de organos no es suficiente debido a factores medicos, culturales, eticos y socioeconomicos. El donante de rinon vivo constituye la principal fuente de donacion de rinones. Objetivo: Evaluar las causas de cancelacion de los donantes vivos de rinon y mejorar la eficacia de los programas de trasplante. Material y metodos: Registros medicos de posibles donantes y receptores, que fueron evaluados para trasplante de rinon de donante vivo en un centro terciario, entre noviembre de 2010 y septiembre de 2019, fueron revisados ​​retrospectivamente. Resultados: Se evaluaron 364 donantes potenciales y 338 receptores de trasplante de rinon de donante vivo, 207 destinatarios (61,24%) se sometieron a trasplante de rinon de donante vivo. Problemas inmunologicos representaron la mayoria de las cancelaciones (38,84%). A cincuenta y seis donantes (15,38%) se les nego la donacion, principalmente debido a problemas renales (39%). Conclusion: La derivacion oportuna de los pacientes a los centros de trasplante debe garantizarse para superar las barreras inmunologicas. Los centros de trasplante deberian invertir en programas adecuados, tanto por sus recursos como por los pacientes: rinon emparejado intercambio, protocolo de desensibilizacion, investigacion futura, etc. EnglishIntroduction: In some countries, organ donation is not widespread enough due to medical, cultural, ethical and socioeconomic factors. Living-donor kidney transplant constitutes the main source of kidney donation. Aim: To evaluate the causes of cancellation of living-donor kidney transplant and improve the effectiveness of transplant programs. Methods: Medical records of possible donors and recipients who were evaluated for living-donor kidney transplant at a tertiary medical center between November 2010 and September 2019 were reviewed retrospectively. Results: Evaluations were performed on 364 potential donors and 338 living-donor kidney transplant recipients; 207 of the latter (61.24%) underwent living-donor kidney transplant. Immune disorders represented the majority of cancellations (38.84%). Fifty-six donors (15.38%) were rejected mainly due to renal disorders (39%). Conclusion: Timely referral of patients to transplant centers must be guaranteed in order to overcome immune problems. Transplant centers should invest in programs adequate both for their resources and for their patients: paired kidney exchange, desensitization protocols, future research, etc.

OBJECTIVE To evaluate the predictors of mortality in the Fournier's gangrene form of necrotizing fasciitis (NF). METHOD The medical records of patients with anogenital NF who were treated in a tertiary care hospital between January 2010 and December 2018 were reviewed, retrospectively. RESULTS This study included 86 patients, 76 males and 10 females. Perianal abscess (30.2%) was the leading precipitating event causing NF. The scrotum and perineum were the most commonly affected sites, 73.2% and 40.7%, respectively. NF extended beyond the urogenital and or anorectal triangle in 30.2% of cases. Escherichia coli (E. coli) was the most common microorganism isolated in tissue cultures (55.3%), and Klebsiella pneumoniae the second most common (15.3%). Admission to the intensive care unit (ICU) was required for 50 patients (58.1%), and the mortality rate was 23.3%. Older age (>60 years), smoking, and extension of the infection beyond the urogenital and or anorectal triangle were all significantly associated with mortality. CONCLUSIONS Age >60 years, smoking, and extension of the infection beyond urogenital and or anorectal triangle were significantly related with mortality in anogenital NF. Prompt diagnosis and timely intervention are essential to prevent spread of the infection.

Introduction: In some countries, organ donation is not widespread enough due to medical, cultural, ethical and socioeconomic factors. Living-donor kidney transplant constitutes the main source of kidney donation. Aim: To evaluate the causes of cancellation of living-donor kidney transplant and improve the effectiveness of transplant programs. Methods: Medical records of possible donors and recipients who were evaluated for living-donor kidney transplant at a tertiary medical center between November 2010 and September 2019 were reviewed retrospectively. Results: Evaluations were performed on 364 potential donors and 338 living-donor kidney transplant recipients; 207 of the latter (61.24%) underwent living-donor kidney transplant. Immune disorders represented the majority of cancellations (38.84%). Fifty-six donors (15.38%) were rejected mainly due to renal disorders (39%). Conclusion: Timely referral of patients to transplant centers must be guaranteed in order to overcome immune problems. Transplant centers should invest in programs adequate both for their resources and for their patients: paired kidney exchange, desensitization protocols, future research, etc.

Aim: This study aimed to evaluate clinical, radiological and laboratory (neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios, and mean platelet value) features that may better define the rate of malignancy in order to contribute to the management of thyroid nodules with AUS/FLUS. Material and Methods: The data of patients with histologic findings of AUS/FLUS on FNA, who underwent surgery at General Surgery Department in a tertiary care hospital between January 2012 and December 2019, were reviewed retrospectively. The patients with any other malign and/or inflammatory diseases and continued on corticosteroid therapy and/or chemotherapy were excluded. Results: The current study included 60 patients (73.3% women), who underwent surgery for 62 thyroid nodules classified as AUS/ FLUS. The specimen pathology revealed a thyroid malignancy in 16 patients, including 10 patients with papillary cancer, 5 patients with micro-papillary thyroid cancer, 1 patient with minimally invasive follicular carcinoma. Ten patients had follicular adenoma. The remaining 35 patients (37 nodules) had nodular colloidal hyperplasia and/or chronic lymphocytic thyroiditis. The rates of malignancy (ROM) and neoplasia (RON) were 25.8% and 40.3%, respectively. Nearly half of the cases (41.9%) had chronic lymphocytic thyroiditis. The malignancy rate in cases with chronic lymphocytic thyroiditis was 26.9%, which was similar in cases without (25%). In multivariate analysis, only microcalcifications were found to be positively associated with malignancy (p: 0.1; [OR] 5.185; CI95% 1.4-19.18). Conclusion: Chronic lymphocytic thyroiditis may lead to overestimation of AUS/FLUS results. It was not associated with malignancy in thyroid nodules with AUS/FLUS. Inflammatory values, such as NLR, PLR and MPV, were not useful markers of malignancy. Among all variables only US findings (microcalcifications according to the current study) may be useful in risk-stratification of malignancy in thyroid nodules with AUS/FLUS.

OBJECTIVE To investigate the incidence of major low anterior resection syndrome (LARS), using the LARS score, in patients who underwent sphincter-preserving surgery for rectal cancer, and to explore the factors affecting major LARS development. METHOD The medical records were retrospectively reviewed of patients, who were operated for rectal cancer at a tertiary center between January 2009 and October 2017. The inclusion criteria were: The absence of other colorectal or proctologic diseases, the application of anterior resection (high anterior resection, low anterior resection, extremely low anterior resection), follow-up of more than one year after the primary surgery, and follow-up of more than one year after protective ileostomy closure, and the absence of an unreversed stoma, ongoing treatment with chemotherapy or radiotherapy, recurrence, and metastatic disease. LARS was diagnosed using the LARS score developed by Emmertsen and Laurberg. RESULTS For the study period, 81 patients met the inclusion criteria, including 45 (55.5%) men and 36 (44.4%) women, with a mean age of 60.1 years. Of the 81 patients, 56 (69.1%) underwent chemotherapy and 43 (53%) underwent radiotherapy. Major LARS was detected in 29.6% of the patients. Univariate analysis revealed that radiotherapy, lower tumor location and a short interval after ileostomy closure had an effect on LARS development, and multivariate analysis indicated that incidence of LARS was higher in middle and lower rectal cancer. CONCLUSIONS There appears to be no harm in creating a protective ileostomy for LARS development, with regard to anastomosis safety and the planning of the adjuvant therapy. Neither radiotherapy, nor type of surgery had an effect on major LARS. As was expected, a high rate of major LARS was reported in lower rectal tumors.

Following improvements in immunosuppressive therapy and the reduction of surgical complications, pancreatic transplantation has gained in popularity. The management of peripancreatic fluid collection (PPFC) is a major concern, especially in the case of retroperitoneal implantation. Percutaneous drainage catheters may be ineffective for clearing large pieces of pancreatic debris. The cases are presented here of three patients who were treated successfully with vacuum-assisted closure (VAC) for PPFC after pancreas transplantation.