Rectal prolapse is a circumferential, full-thickness protrusion of the rectum through the anus. It is a rare condition, and only affects 0.5% of the general population. Multiple treatment modalities have been described, which have changed significantly over time. Particularly in the last decade, laparoscopic and robotic surgical approaches with different mobilization techniques, combined with medical therapies, have been widely implemented. Because patients have presented with a wide range of complaints (ranging from abdominal discomfort to incomplete bowel evacuation, mucus discharge, constipation, diarrhea, and fecal incontinence), understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure. It is crucial to assess these additional symptoms and their severities using preoperative scoring systems. Additionally, radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders. However, there is no consensus on or standardization of the optimal extent of dissection, type of procedure, and materials used for rectal fixation; this makes providing maximum benefits to patients with minimal complications difficult. Even recent publications and systematic reviews have not recommended the most appropriate treatment options. This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.

OBJECTIVE: Post-operative adhesion is a common problem in abdominal surgery. Especially, foreign materials are strong stimulus for the development of adhesions. The aim of this study was to investigate whether drug release material coated prosthetic mesh decreases intra-abdominal adhesion formation or not. METHODS: 5-Fluorouracil (5-FU) releasing "chitosan gels" were loaded to polypropylene and polyglactin-910 grafts. Polypropylene, polyglactin-910 grafts, chitosan gel, and 5-FU-loaded polyglactin 910, polypropylene grafts were used to cover abdominal defects of rats which were created under sterile conditions (n=84). Each group was divided into two subgroups (n=6). Subgroups were sacrificed on the 7(th) and 30(th) days. RESULTS: The 7(th) day macroscopic examinations were similar. Polypropylene group was most adhesive group on the 30(th) day. There were less adhesions in chitosan gel and 5-FU-loaded groups. Capsule and capsule margins showed no difference on both the 7(th) and 30(th) days. Polypropylene-5-FU group and polypropylene-chitosan gel group showed significantly less macroscopic adhesions than polypropylene control group. Furthermore, polyglactin-910-chitosan gel group was less adhesive than polypropylene control group. CONCLUSION: This study showed that 5-FU decreases the adhesions but the dosage and release kinetics need further investigations.

Anorectal malformations are common congenital anomalies but diagnosis and treatment in adulthood are quite rare. Treatment during adulthood may be challenging due to anatomic and physiologic changes. Posterior sagittal anorectoplasty may provide good cosmetic and functional results even in adult patients. KEY WORDS: Congenital malformations, Rectovaginal fistula, Rectovestibular fistula.

An incisional herniaIncisional hernia after an abdominal operation develops in approximately 10% of the cases. However, incarceration of an incisional hernia is relatively low. On the other hand presence of an inflamed appendix, in one hernia sac is a rare entity which may cause mis or delayed diagnosis. This case is an example of acute appendicitis which is atypically located in an incisional hernia sac and mimick incarceration. KEY WORDS: Appendicitis, Incisional hernia, Perforation.

Amaç: Sağ hemikolektomi sonrasında anastomoz kaçağı diğer gastrointestinal sistem anastomozlarına oranla göreceli olarak daha az olsa da hayatı tehdit edici önemli bir komplikasyondur. Bu çalışmanın amacı sağ hemikolektomi sonrasında anastomoz kaçağına ve mortaliteye etki eden faktörleri araştırmaktır. Gereç ve Yöntemler: 1-1-2016 / 31-12-2020 tarihleri arasında sağ kolon tümörü ön tanısı ile ameliyat edilen 18 yaş üzerindeki tüm hastalar çalışmaya dahil edildi. Hastaların demografik verileri, eşlik eden hastalıkları, ameliyat öncesi laboratuar tetkikleri, perioperatif transfüzyon durumu, ameliyatı yapan sorumlu cerrah, ameliyat zamanlaması, anastomoz tekniği ve tümör evresi değişkenleri retrospektif olarak değerlendirildi. Bulgular: Toplam 141 hasta çalışmaya dahil edildi. Ortanca yaş 62 ( min 30—max 92) idi. Anastomoz kaçağı oranı % 9.2 ( n= 13) , mortalite oranı % 5 ( n=7) idi. Anastomoz kaçağına etki eden başlıca faktörün ameliyat zamanlaması olduğu ve acil şartlarda ameliyat edilen hastalarda anastomoz kaçağı riskinin anlamlı şekilde arttığı tespit edildi. İleri yaş ve düşük albümin düzeyi anastomoz kaçağı ve mortalite üzerine etki eden diğer risk faktörleri olarak tespit edildi. Sonuç: Bu çalışma sonucunda ameliyat zamanlaması, hasta yaşı ve düşük albümin düzeyi sağ hemikolektomi sonrasında anastomoz kaçağına etki eden faktörler olarak tespit edilmiştir. Acil ameliyat gerektiren ileri yaştaki, beslenme bozukluğu olan hastalarda sağ hemikolektomi sonrası anastomoz yapılması yerine diversiyonun tercih edilmesi uygun bir yaklaşım olacaktır.

Neoadjuvant chemoradiotherapy (CRT) followed by surgical resection is the standard treatment for locally advanced rectal adenocarcinoma. In this study we evaluate our treatment results in patients treated with neoadjuvant radiotherapy (RT). Medical records of 144 patients treated between January 2009 and February 2019 were retrospectively evaluated. Most of the patients had (76%) MRI as a part of initial staging. Patients received either short course (25 Gy/5 fractions) (8%) or long course RT (92%) (median 50.4 Gy/28 fractions) +/- chemotherapy (ChT). Median age was 56 years (range, 24-90 years) and 131 patients received CRT. Most common concomitant ChT regime was oral capecitabine (48%). 26 patients refused the surgery. For rest of the patients, median time to surgery was 8 weeks. Sphincter was preserved in 19 patients (38%) who underwent surgery for distal tumors. With a median follow-up of 28 months, 19 patients had local recurrence and 30 patients had distant metastases. Two and five year estimated overall survival (OS), locoregional control (LRC) and distant metastases free survival (DMFS) rates were 88-67%, 78-62% and 74-57%, respectively. Presence of surgery significantly affect OS (HR= 0.147, 95% CI: 0.67-0.32, p< 0.001) , LRC (HR= 0.10, 95% CI: 0.05-0.2, p< 0.001) and DMFS (HR= 0.25, 95% CI: 0.13-0.49). Patients tolerated the treatment well with no grade 3 acute or late gastrointestinal and genitourinary system toxicities. Regardless of the schema neoadjuvant RT seems to be an efficient and safe treatment for patients with rectal adenocarcinoma. We found that surgery is the sole prognostic factor for better OS, LC and DMFS.

Background: Sudden change in general surgery practice during pandemic caused a detrimental effect on residency training. The main objective of this study is to reveal the effect of Covid-19 pandemic on general surgery practice and surgical residency education. Methods: This retrospective observational study included all patients operated at a tertiary university hospital , general surgery department between 11-March 2019/ 11- January-2019 (Pre-Covid 19 Period) and 11-march 2020- 11- January -2020 (Covid 19 period). Two period compared in terms of case volume and distrubition, timing of operation , complication rate, hospital length of stay, resident's operation volume and distribution of operations among residents. Results: Overall 2740 cases included to study. Elective case volume significantly decreased during pandemic (p=0.001). This decrease is much more obvious for B-C category operations. Intermediate seniority resident's case volumes and complexity of the cases they performed decreased during pandemic. Conclusion: Due to pandemic case volume significantly decreased and this decreasement effected residents' training. Surgical residency programs must be revised urgently in order to provide adequte training especially for intermediate seniority residents.

Objective: Acute mesenteric ischemia is a surgical emergency. During the course of treatment, most of the patients require nutritional treatment. However, achieving nutritional goals may not be always possible. This study aimed to investigate nutritional management of the patients who were operated on for acute mesenteric ischemia. Materials and Methods: Patients who were diagnosed and hospitalized for acute mesenteric ischemia between 2015 and 2018 were retrospectively analyzed. Nutritional management of patients was studied in terms of hospital length of stay, mortality rate and achieving of nutritional goals. Results: Thirty patient were included in the study and 18 patient received nutritional treatment. Median length of stay was 28.5 (range:9-220) days. Target nutrition goals were only achieved in 11 patients (61%). Overall mortality rate for nutritional treatment group was 50%. There was no significant difference between the patients whose treatment objectives were achieved or failed in terms of length of stay (p=0.375) or mortality [(p=0.630 (95% CI0,237-10,809)]. Conclusion: The management of nutritional treatment of acute mesenteric ischemia patients is challenging. Achieving the nutritional goals may not be possible in many patients.

Background/aim Gastrointestinal (GI) system cancers are frequent among older adults and it is still difficult to predict which are at increased risk for postoperative complications. Frailty and sarcopenia are increasing problems of older population and may be associated with adverse outcomes. In this study we aimed to examine the effect of sarcopenia and frailty on postoperative complications in older patients undergoing surgery for GI cancers. Materials and methods Forty-nine patients admitted to general surgery clinic with the diagnosis of gastrointestinal system cancers were included in this cross-sectional study. Frailty status was assessed using the Edmonton Frail Scale (EFS). Sarcopenia was defined due to the EWGSOP2 criteria and ultrasonography was used to evaluate muscle mass. Results The median age of the patients was 70 (min-max: 65–87). Fourteen (28.6%) patients were found to be sarcopenic and 16 (32.7%) patients were frail, and 6 (37.5%) of these patients were also severe sarcopenic (p = 0.04). When the postoperative complications were assessed, time to oral intake, time to enough oral intake, length of hospital stay in the postoperative period were found to be longer in frail patients (p = 0.02, p = 0.03, p = 0.04 respectively). Postoperative complications were not different due to the sarcopenia. Conclusion Frailty, but not sarcopenia was associated with adverse outcomes in older adults undergoing GI cancer surgery. Comprehensive geriatric assessment before surgical intervention may help to identify patients who are at risk.

Bile duct injuries during cholecystectomy are not rare and may have significant long-term morbidity. Treatment of these injuries is complex and needs a multidisciplinary approach. This study aims to evaluate the results of revisional surgery performed for recurrent biliary strictures that developed after a prior repair. Patients who had been surgically treated for a major biliary injury during open or laparoscopic cholecystectomy and operated on for recurrent stricture in our institute were reviewed retrospectively. A total of 11 patients who were referred to the surgery clinic were included. The median length of stay after revisional surgery was 9 days (range 5–30 days). Five patients (45%) had experienced at least one postoperative complication. The median follow-up period was 36 months (range 5–69 months). Terblanche clinical scores of all patients were 1 or 2 at their last clinical visit. None of the 11 patients required reoperation and no mortality was seen during the postoperative period. Although revisional biliary surgery for recurrent biliary strictures is a challenging procedure, these revisions can be performed with favorable results. Meticulous preoperative evaluation and implementation of precise surgical technique are essential to achieve long-term success.

Introduction: this pilot study aimed to document our results of treating anorectal abscesses with drainage plus loose seton for possible coexisting high fistulas or drainage plus fistulotomy for low tracts at the same operation. Methods: drainage plus fistulotomy were performed only in cases with subcutaneous mucosa, intersphincteric, or apparently low transsphincteric fistula tracts. For all other cases with high transsphincteric fistula or those with questionable sphincter involvement, a loose seton was placed through the tract. Drainage only was carried out in 17 patients. Results: twenty-three patients underwent drainage plus loose seton. Drainage plus fistulotomy were performed in four cases. None of the patients developed recurrent abscess during a follow-up of 12 months. Not surprisingly, the incontinence scores were similar pre and post-operatively (p=0.564). Only minor complications occurred in 4 cases (14.8 percent). Secondary interventions following loose seton were carried out in 13 patients (48.1 percent). At 12 months, drainage only was followed by 10 recurrences (58.8 percent; p<0.0001, compared with concomitant surgery). Conclusion: concomitant loose seton treatment of high fistula tracts associated with anorectal abscess prevents abscess recurrence without significant complications or disturbance of continence. Concomitant fistulotomy for associated low fistulas also aids in the same clinical outcome. Concomitant fistula treatment with the loose seton may suffice in treating the whole disease process in selected cases. Even in patients with high fistula tracts, the loose seton makes fistula surgery simpler with a mature tract. Abscess recurrence is high after drainage only.

Anorectal sepsis usually presents with anal abscesses, which may evolve to become anorectal fistulas. Most of these cases are either of cryptoglandular origin, or they develop secondary to inflammatory bowel diseases. A 32-year-old male patient applied to our Proctology Unit with severe anal pain and swelling. Three days before admission, leeches were applied to the hemorrhoidal swellings in a medical center. The abscess was drained with appropriate unroofing and search for any compartments. The patient recovered rapidly. The abscess culture and microscopy revealed mix flora with predominant Escherichia coli. After 6 months, he has been symptom-free with perfect healing of the surgical site. We need to check up on possible handicaps in our modern patient care policies that divert people to such methods. Nevertheless, such alternative methods should be regarded as nonscientific and out of context unless their efficacy and safety are documented.

Conventional therapy modalities for advanced breast cancer are problematic, whereas checkpoint blockade immunotherapy has been considered as a promising approach. This study aims to determine programmed death-ligand 1 (PD-L1) expression and methylation status of PD-L1 promoter in primary tumor tissue and metastatic foci of patients with stage IV breast cancer. Clinicopathological data and survival rates of 57 breast cancer patients, who were initially staged IV, and operated for intact tumors, were retrospectively analyzed. Immunohistochemical analysis of PD-L1 using 57 primary tumors, 33 paired metastatic lymph nodes, and 14 paired distant metastases was performed. Additionally, the methylation rate of the PD-L1 gene promoter region was determined with real-time polymerase chain reaction (PCR) analysis in 38 samples. Overall PD-L1 expression in primary tumors was 23.1% (12/52). PD-L1 positivity was reduced in lymph nodes by 15.2% (5/33) and in distant metastases by 21.4% (3/14). PD-L1 expression diverged between primary and metastatic foci in a subset of cases (18.2% for lymph node and 33.3% for distant metastasis). In general, the PD-L1 promoter was not methylated, and mean methylation rates were low (min. 0%-max. 21%). We observed no correlation between PD-L1 expression, promoter methylation, and survival. Neither the expression nor the methylation status of PD-L1 in patients, who were presented with stage IV breast cancer and operated for an intact primary tumor, had a statistically significant relation with survival. Discordance in PD-L1 expression between primary tumor and metastasis should be considered during pathological and clinical management of patients who would undergo checkpoint blockade therapy.

Endometriosis affects the women during reproductive period and can cause functional disorders. Sometimes general surgical intervention is necessary because of disease boundary. Especially the sigmoid colon and rectum are affected due to the close neighboring. In such a case, treatment must be individualized according to the patient and symptoms. If the lesion has penetrated the entire bowel wall, bowel resection may be inevitable. Laparoscopic resection of the sigmoid colon or rectum can be performed safely in this situation. When laparoscopic resection cannot be possible because of technical difficulties, open resection may be performed for treatment. Here we present two cases, one open and one laparoscopic colon resection performed due to endometriosis.

An improper stoma creation can cause many complications, varying from minor to life-threatening ones. Conversely, a good functioning stoma, at the ideal site improves patient’s quality of life. Most of the stoma complications occur in the early postoperative period and all clinicians must be familiar to these complications. All measures before and during operation must be taken to avoid these complications. Careful follow up after post operative period can help early diagnosis, proper treatment quick recovery of the patient. This review focus on common complications and treatment options of stoma creation.

Objective: Secondary peritonitis or abdominal sepsis and intra-abdominal hemorrhages are associated with high mortality rates and still challenging among surgeons. Planned relaparotomy is underestimated one of the treatment options of these intractable clinical entities. This study aimed to identify mortality and factors affecting mortality in the patient treated by planned relaparotomy for persisting intraabdominal infection and hemorrhage in a single institution. Material and methods: This retrospective study performed by collecting patients’ data from the archive of our university hospital and records of operations performed in our department. Forty-two of sixty-two patients treated with PRL for 19 years were included to study. Indications for PRL were secondary peritonitis and intraabdominal hemorrhage. Results: Overall , secondary peritonitis, and intraabdominal hemorrhage groups mortality rates were 52.4%, 59.3%, and 28.5% respectively (p< 0.05). Factors are Presence of malignancy (p= 0,037), mesenteric ischemia (p=0,029), development of organ failure (p=0,001) and presence of anastomosis (p=0,006) were observed relating to mortality. Conclusion: That high mortality rate could be due to underway infection and repeated surgical trauma-related multiple organ failures, independent factors as the presence of malignancy, and mesenteric ischemia raises the risk of mortality in planned relaparotomy patients. The data from this study and the available literature reveals that the factors which predict mortality in patients who undergo a relaparotomy are related to the severity of the disease.

Von Hippel-Lindau disease is an autosomal dominant disorder occurring in 1 of 36,000 births and associated with various tumors and cysts in the central nervous system and other visceral organs. At present, metastasis from renal cell carcinoma (RCC) and neurologic complications are the most common causes of death from Von Hippel-Lindau disease. We report a case of Von Hippel-Lindau disease diagnosed during a screening and was found to have metastasis of RCC to a focal nodular hyperplasia lesion on the liver. In the literature, misdiagnosis of benign liver lesions as metastases of RCC has been reported, but there has not been a case reported to have a metastasis of RCC within a benign liver lesion. To our knowledge, this is the first case of RCC metastasis to a benign lesion of the liver.

BACKGROUND: Turkey is an endemic region for goiter. The aim of this study was to evaluate the changing factors concerning thyroid disease and thyroid surgery in a referral center in Turkey.METHODS: This study was a retrospective evaluation of reports of patients who underwent surgery for thyroid disease at Hacettepe University Medical School between the years 1970 and 1974, 1980 and 1984, 1990 and 1994, and 2000 and 2004.RESULTS: A total of 1,270 patients were included in the study. There were 140, 141, 402, and 587 patients in the 1970-1974, 1980-1984, 1990-1994, and 2000-2004 groups, respectively In the past decade, the use of ultrasonography has increased significantly; more thyroid cancer cases have been diagnosed and more extensive surgical procedures have been applied.CONCLUSIONS: During the past 40 years, significant changes have occurred in the treatment of thyroid disease, particularly diagnostic tools, pathologies, and surgical procedures. (C) 2009 Elsevier Inc. All rights reserved.