E-ISSN 2587-0610
Laparoscopic Endoscopic Surgical Science (LESS) - Laparosc Endosc Surg Sci : 27 (2)
Volume: 27  Issue: 2 - 2020
1.Are morbid obese (class–III) patients at high risk for postoperative complications after robotic ventral hernia repair? A propensity score matching analysis
Fahri Gokcal, Omar Yusef Kudsi
doi: 10.14744/less.2020.04274  Pages 37 - 47
INTRODUCTION: Extreme obesity is an independent risk factor for many perioperative complications, as well as the development of ventral hernias. Many surgeons consider extreme obesity as a prohibitive factor for minimally invasive ventral hernia repair (VHR). To investigate whether robotic VHR (RVHR) has value in these high–risk patients, in this study, we aim to compare outcomes between class–III obese (BMI ≥40 kg/m2) patients and non–obese (BMI <30 kg/m2) patients.
METHODS: A retrospective analysis of a database collected between 2012 and 2020 was performed. A 1: 2 propensity score match (PSM) analysis was implemented to obtain two balanced patient groups. Univariate analyses, in unmatched and matched samples, were performed between the two groups concerning preoperative, intraoperative, and postoperative variables. Postoperative complications and morbidity (up to 90–days) were assessed using the Clavien–Dindo classification and comprehensive complication index (CCI®) score system.
RESULTS: Our initial cohort consisted of 598 patients, in which 287 unmatched patients were included. After 1: 2 PSM, 86 and 43 patients were assigned to the non–obese and class–III obese groups, respectively. Differences in unmatched patient demographics, hernia characteristics, and intraoperative variables between the two groups were resolved after matching. In an unmatched comparison, class–III obese patients experienced higher rates of Clavien–Dindo grade–II complications and cellulitis. However, the two matched groups experienced similar postoperative complication rates.
DISCUSSION AND CONCLUSION: This study revealed that class–III obese patients can obtain similar benefits from RVHR as their non–obese counterparts. Surgeons should consider patient and hernia characteristics when planning to perform RVHR in these patients, rather than BMI alone.

2.Comparison of sealers used in laparoscopic cholecystectomy for cystic duct closure: An ex vivo study
Aziz Ahmet Surel, Burak Kavlakoğlu
doi: 10.14744/less.2020.48295  Pages 48 - 52
INTRODUCTION: Comparison of sealers used in laparoscopic cholecystectomy for cystic duct closure:
An ex vivo study
METHODS: In this prospective study, 90 patients with symptomatic gallstone disease were operated using laparoscopic technic. Then gallbladders were divided into three groups (n=30). In all groups, gallbladders were removed with surgical clips. After the gallbladders removed, in first group, cystic ducts remain clipped (SC). In second and third groups, cystic ducts were sealed with HS and PK distally after the surgical clips removed. Then, twenty–gauge catheters were applied to fundic part of gallbladder and gallbladders filled with saline. An increasing pressure was applied through a sphygmomanometer. Bursting pressures were measured using invasive arterial blood pressure measurement device and measured systolic pressures were accepted bursting pressure. After bursting pressures were measured in three groups, results were written down to the SPSS table. Differences between HSvsSC, HSvsPK and SCvsPK groups were calculated using paired–samples t–test.
RESULTS: In this study, the mean cystic duct bursting pressures were 332.46±4.62 mm Hg with SC, 326.56±4.53 mmHg with PK and 343.06±4.28 mm Hg with HS. Differences in the mean cystic duct bursting pressures between HS vs. SC and HS vs. PK groups were indicated HS’s superiority (p=0.046 and p=0.026, respectively). On the contrary, SC vs. PK group was not indicated PK’s advantage; however, PK was found safely as much as SC.
DISCUSSION AND CONCLUSION: HS and PK sealer could be an alternative and safe method for cystic duct closure, avoiding the clip displacement and migration of the clip. Single device usage was one of the most important advantages of this technique. Thus, intraabdominal organ injuries will be lessened.

3.An agent to improve gastrointestinal recovery after laparoscopic cholecystectomy: Nicotine gum
Yalın Işcan, Iksan Taşdelen, Yetkin Özcabı, Engin Ölçücüoğlu, Birol Ağca, Anıl Ergin, Ahmet Çakmak, Bora Karip, Ender Onur, Kemal Memişoğlu
doi: 10.14744/less.2020.65668  Pages 53 - 60
INTRODUCTION: This study aims to investigate the gastrointestinal recovery effects of the nicotine gum after laparoscopic cholecystectomy.
METHODS: In this study, 119 patients were randomized into three groups as follows: Sugar–free gum, nicotine gum and control. After laparoscopic cholecystectomy, within an interval of two hours, the gum was chewed for 15 minutes by the gum groups. Demographic features, postoperative first flatus time, first hunger feelings, first defecation time, constipation scores, smoking, and drain usage were recorded.
RESULTS: The first flatus time of the Nicotine Gum group was significantly lower than those of the Control group (p=0.018). There was no statistically significant difference between the Sugar–Free Gum and the control group (p=0.992). The nicotine gum group was the first to have defecation in a significantly shorter period than the other two groups (p=0.036, p=0.008, p<0.05). According to smoking in all patients, the first flatus time was found to be significantly lower in smokers than in non–smokers (p=0.004). The findings showed that the time of the first defecation was statistically significantly earlier in the smoker patient group (p=0.015).
DISCUSSION AND CONCLUSION: Nicotine gum used as a sham feeding after laparoscopic cholecystectomy accelerated the recovery of the gastrointestinal system motility. Also, independently of sham feeding, the time of first postoperative gas and defecation were found to have occurred in the earlier period in the patient group of smokers.

4.The effectiveness of routine drain placement in laparoscopic sleeve gastrectomy: Single–center results
Hakan Seyit, Sina Ferahman, Fahri Gökçal, Kıvanç Derya Peker, Mehmet Karabulut, Halil Alış
doi: 10.14744/less.2020.66933  Pages 61 - 66
INTRODUCTION: Routine drainage of the abdominal cavity has been widely accepted in the diagnosis and treatment of complications, but many studies have questioned the usefulness of drainage. In complications after laparoscopic sleeve gastrectomy (LSG), the value of routine drainage is unknown. To determine whether routine drainage is required after LSG, we aimed to compare clinical data and complications between groups.
METHODS: This study included a retrospective analysis of LSGs from January 2017 to November 2019. Groups were defined as (Group D) with and without a drain (Group U). Complication diagnosis was confirmed using computed tomography (CT) or endoscopy after suspicion. Clear fluid was administered at the 6th postoperative hour. Data included age, height, body weight, BMI, mean operative time, length of hospital stay, and complications. Data between groups were compared.
RESULTS: The mean age of 744 patients (female=570, male=174) was 38 years (18–63), and the mean preoperative BMI was 47.9 kg/m2 (40–76). The hospitalization time was 4.03 days (2–23), and the operations were performed at an average of 83 minutes (30–225). There were Group D=547, Group U=197 patients. The complication rate was 6.7%. Sixteen of the 17 patients who were on the run were in group D and one in Group U. In Group D, 14 of the leaks were treated with stents, and 15 of them were treated with a percutaneous catheter, while in Group U, only one patient was treated using stents. The decrease in hemoglobin value was 3.07 g/dl on average, and bleeding was detected in 33 patients (Group D=22, Group U=11). Percutaneous catheter was applied to five patients in Group D.
DISCUSSION AND CONCLUSION: Routine drainage is not required after LSG. Neglected drainage can contribute to faster recovery, shortened hospital stay, and reduced cost without causing additional surgical complications.

5.Helicobacter pylori incidence in upper gastrointestinal endoscopy biopsies
Hüseyin Kerem Tolan, Tolga Canbak
doi: 10.14744/less.2020.68878  Pages 67 - 70
INTRODUCTION: The incidence of Helicobacter pylori (HP) has been investigated in several studies. The bacteria can cause many diseases, such as atrophic gastritis, ulcers, dyspepsia, and gastric adenocarcinoma. Therefore, it is important to look for HP even in individuals who do not have any macroscopic findings on endoscopy and pursue eradication in positive cases. The aim of this study was to assess the clinical and pathological association of HP in gastric biopsies.
METHODS: Patients who underwent an upper gastrointestinal endoscopy at the general surgery clinic between January 2014 and January 2015 were included in the study. Hospital registry system data of demographic details, admission complaints, and endoscopic findings were evaluated retrospectively. Patients who had a malignancy or who underwent an emergency endoscopy for gastrointestinal bleeding were excluded from the study.
RESULTS: A total of 325 patients were included in the study. In the group, 185 (56.9%) were female and 140 (43.1%) were male. The mean age was 58 years (range: 18–89 years). The most common complaint was epigastric pain. Biopsies were taken from the gastric antrum in 295 of the patients. The mean number of biopsies was 1.5 (range: 1–5). Active gastritis was present in 245. In 111 of the patients, HP was moderately or strongly positive, in 91 cases it was mild, and in 43 of the patients, the result was negative. Of the 80 patients without any gastritis, 4 had mild positive staining results in the final pathology reports, while 2 had moderate or severe findings (p<0.0001).
DISCUSSION AND CONCLUSION: Upper gastrointestinal endoscopy revealed a high probability of HP positivity in patients examined for gastritis. Routine biopsy may not be advisable in high–risk patients. Prospective studies are needed to further investigate these findings.

6.Acute necrotizing pancreatitis treatment: Endoscopic sphincterotomy and minimal invasive step–up approach of liver hydatid cysts
Murat Akaydın, Tamer Akay, Okan Demiray
doi: 10.14744/less.2020.46547  Pages 71 - 77
INTRODUCTION: Hydatid disease is a zoonosis that generally arises from echinococcus granulosus. Abdominal pain, cholangitis and jaundice may develop as a result of spontaneous rupture of the liver cyst into the biliary tract. Rarely, in some of these cases, pancreatitis may develop as a complication of hydatid cysts and there is no clear consensus on treatment options in patients with diffuse bile duct obstruction that occurs with a necrotizing pancreatitis clinic. The present study aims to establish a common consensus in patients presenting with liver cyst hydatid pancreatitis and jaundice clinic.
METHODS: In a retrospective, clinical–based multicenter study, ERCP and minimally invasive approaches are presented in the treatment of four patients who developed liver bile duct obstruction and necrotizing pancreatitis from the liver hydatid cyst.
RESULTS: All patients had abdominal pain and jaundice. Acute pancreatitis was detected in all cases using computed tomography. All patients underwent endoscopic sphincterotomy. Infected cystic material and germinal membranes were removed from the biliary tract. With endoscopic sphincterotomy, necrotizing pancreatitis clinic improved rapidly in three patients, while one patient progressed to necrotizing pancreatitis. All patients underwent laparoscopic cystectomy and cholecystectomy in combination. In patients who were followed up for necrotizing pancreatitis, the wall formation (encapsulation) period of necrosis was waited, and four weeks later, percutaneous drainage was applied to the walled necrosis areas. While the patients were discharged, Andazol® treatment was applied during the 6–month follow–up period.
DISCUSSION AND CONCLUSION: One of the complications of ERCP is that it may increase the severity of pancreatitis. However, ERCP is the most important endoscopic intervention for the treatment of pancreatitis filled with common bile duct hydatid cyst to ensure safe and effective biliary tract drainage in the early period. In addition, percutaneous drainage provides safe and rapid recovery in necrotizing pancreatitis complications when the wall of necrosis phenomenon is expected.

7.Our six years experiences about percutaneous endoscopic gastrostomy in surgical endoscopy unit
Erdoğan Mütevelli Sözüer, Muhammet Akyüz, Fatih Dal, Uğur Topal, Tutkun Talih, Mustafa Gök
doi: 10.14744/less.2020.12499  Pages 78 - 83
INTRODUCTION: Percutaneous Endoscopic Gastrostomy (PEG) is the preferred method of nutrition for patients that are in need of long term enteral feeding. In this study, we aim to convey a six–year experience of a surgical endoscopy unit in the light of the literature.

METHODS: Patients that underwent PEG in our clinic between the years 2015 and 2020 were included in this study. Demographic and clinical data, indications, early and late complications, and long term results of the patients were analyzed retrospectively. PEG was employed using the standard pull method.

RESULTS: One hundred six patients participated in our study. The age average was 61, and the male sex was predominant (71%). The findings obtained in this study showed that 81.2% of the patients had comorbidities. Eight patients had an abdominal operation history. The most frequent indications were chronic neurological disease (36.8%), prolonged coma after head trauma (11.3%), and head and neck cancers (10.4%). The incidence of catheter–related early complications was observed to be 17.9%, and the most frequent complication was the leakage in the catheter insertion site. The incidence of general complications was observed as early complications (<30 days) (4.7%) and late complications (>30 days) (0.9%), respectively. Catheter dysfunction developed in eight patients during their follow–up examinations. Recurrent medical interventions were performed on five patients. The incidence of catheter–related unplanned arrivals at the hospital was 8.5%.
DISCUSSION AND CONCLUSION: PEG is a safe, minimally invasive, effective, well–tolerated practice with a low incidence of complications and is used in the provision of nutritional support enterally. The most frequent complications are related to the care of the catheter insertion site. To reduce such complications, emphasis should be placed on training related to catheter care.

8.Percutaneous endoscopic gastrostomy: Single–center experience
Durmuş Ali Çetin, Mehmet Patmano
doi: 10.14744/less.2020.46873  Pages 84 - 87
INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is a method used for long–term enteral feeding in patients with normal gastrointestinal function and who cannot be fed orally. In this study, we aimed to present the demographic and clinical features of our patients who underwent PEG.
METHODS: The records of patients who had PEG tube inserted in the endoscopy unit or intensive care units in our hospital between August 2017 and December 2019 were reviewed retrospectively.
RESULTS: A total of 108 patients underwent a PEG catheter between August 2017 and December 2019. 58 (53.7%) of the cases were male, and 50 (46.2%) were female. It was observed that the PEG procedure was performed most frequently in patients with cerebrovascular disease. No major complications were observed in any case after the procedure. Early complications were observed in 15 (13.8%) patients and late complications in seven (6.4%) patients.
DISCUSSION AND CONCLUSION: PEG is a safe and effective enteral feeding method. It is the type of nutrition that should be applied for long–term enteral nutrition in appropriate patients.

9.Missing intrauterine devices, laparoscopic and a conventional management: A single–center experience
Barış Mantoğlu, Fatih Altintoprak, Hilal Uslu Yuvacı, Muhammet Burak Kamburoğlu, Mehmet Aziret, Emre Gönüllü, Emrah Akın
doi: 10.14744/less.2020.40326  Pages 88 - 91
INTRODUCTION: Intrauterine contraception devices (IUCD) are frequently and safely used in pregnancy control. Migration related complications, such as adhesions and perforations, can be encountered as the most important but rare circumstances. In such cases, the laparoscopic approach is beneficial with the least harm principle.
METHODS: This study included ten patients who were admitted to our hospital between 2015–2019 with chronic abdominal pain, induced by migrated intrauterine devices. Patients’ complaints, radiological methods used in diagnosis, IUCD insertion timing, migration of IUCD and time interval to diagnosis, intra–abdominal migration points, and types, as well as surgical interventions, were evaluated retrospectively.
RESULTS: While all patients were diagnosed with abdominal ultrasonography and gynecological examination, some patients underwent computed tomography 60% and plain radiogram 20% as additional imaging. While the intra–abdominal migration site of IUCD was ascertained as the most common localization in the lower right quadrant of the omentum (30%), the placement in the umbilical hernia site was the rarest and the only one in the literature. Three different types of IUCD were detected; Copper–T (80%) was the most common, while IUCDs were laparoscopically removed in all patients except for the patient who underwent open surgery due to acute cholecystitis. All patients who had laparoscopic surgery were discharged the next day.
DISCUSSION AND CONCLUSION: In conclusion, the IUCD’s frequency of use is increasing as the current method of contraception, dislocation of the device may be encountered if the required conditions are not taken into consideration during the application. In such a situation, laparoscopic removal of a dislocated IUCD is a safe, feasible, and less invasive method.

10.Evaluation of our first–year endoscopic retrograde cholangiopancreatography results
Ufuk Arslan, Hacı Murat Çaycı, Ali Tardu, Umut Eren Erdoğdu
doi: 10.14744/less.2020.82712  Pages 92 - 97
INTRODUCTION: In this study, the results of the first year of endoscopic retrograde cholangiopancreatography (ERCP), which has been started to be performed in our center, have been evaluated.
METHODS: A retrospective analysis was carried out with data of 345 patients who underwent ERCP performed by the same team at a single center between April 2019 and April 2020. The patients were assessed for demographic data, indications for the procedure, procedure–related complications, endoscopic findings and interventions.
RESULTS: A total of 345 patients underwent the procedure, with a total of 412 procedures were performed. The patient group comprised 210 women and 135 men, with a mean age of 56.4 (19–86) years. The mean duration of the procedure was 12 (4–48) minutes. The most common (60.4%) indications for ERCP were radiologically detected ductus choledochus stones and elevated liver enzymes and/or hyperbilirubinemia. Successful cannulation was performed using a standard sphincterotome in a total of 370 procedures. The number of procedures performed using a precut needle–knife sphincterotome was 28; however, cannulation was successful only in 16. The total cannulation rate was 93.6%. The most common complication (2.9%) was post–ERCP pancreatitis and 30 (7.2%) patients developed post–ERCP complications.
DISCUSSION AND CONCLUSION: Endoscopic retrograde cholangiopancreatography is an endoscopic method commonly used for the treatment of pancreaticobiliary diseases. We believe that it should be applied as a therapeutic procedure rather than as a diagnostic tool, being an invasive procedure.

11.Mechanical intestinal obstruction due to phytobezoar: Retrospective cohort study
Hüseyin Kerem Tolan, Tolga Canbak, Aylin Acar, Adnan Özpek, Onur Zambak, Suat Aktaş, Ali Kılıç, Ethem Ünal, Fikret Ezberci
doi: 10.14744/less.2020.80775  Pages 98 - 101
INTRODUCTION: In this study, we aimed to look through our patients with intestinal obstruction (IO) due to phytobezoars.
METHODS: Patients with intestinal obstruction due to phytobezoar between April 2013 and January 2017 were evaluated in this study.
RESULTS: There were 13 patients. Seven patients were female; six patients were male, and the mean age was 54.6. Six of the patients had a history of gastric re–section, two patients had severe tooth disturbances, and two patients had diabetes. In four patients, there was a story of eating persimmon (diospyrobezoar). Three of the patients were diagnosed with computerized tomography (CT) and nine of the patients with the laparotomy. Two patients had bezoars in the endoscopy. Two patients were treated nonoperatively. Intravenous (IV) fluid, nasogastric decompression, oral cola beverage and IV metoclopramide were administered. The patients requiring surgery were operated within 72 hours. In the laparotomy, bezoars were found in the ileum and four also in the stomach. In three of the patients, bezoars were crushed manually and then transferred to ileum; in eight of the patients, bezoars were extracted with enterotomy. Two of the patients who had enterotomy, underwent re–laparotomy due to a leak, and these two patients were lost. Superficial wound infection developed in four patients. Specimens were reported as a phytobezoar in pathology reports.
DISCUSSION AND CONCLUSION: Phytobezoars should be kept in mind in differential diagnosis in ileus patients with a gastric operation history and dental problems. Patients’ detailed anamnesis and eating habits should be questioned. CT and endoscopy may help. Patients with partial obstruction may benefit from conservative treatment.

12.Complications during laparoscopic cholecystectomy performed due to acute cholecystitis
Nizamettin Kutluer, Burhan Hakan Kanat
doi: 10.14744/less.2020.25901  Pages 102 - 106
INTRODUCTION: Today, laparoscopic cholecystectomy is essential in the treatment of acute cholecystitis, particularly in all patients who have applied in the early period and can tolerate surgery. Although the rates of complication and conversion to open surgery tend to decrease over time with the increasing experience, they are still among the important problems today. The most important complications of laparoscopic cholecystectomy in acute cholecystitis are biliary tract injuries and bleeding. In this article, we aimed to retrospectively present the complications that we encountered in laparoscopic cholecystectomy due to acute cholecystitis.
METHODS: The patients, who underwent laparoscopic cholecystectomy with the diagnosis of acute cholecystitis between March 2016 and December 2019, were retrospectively examined. The patients’ age, gender, symptoms–examination findings, laboratory findings, ultrasonography findings and pathology findings were analyzed. Complications and the rate of conversion to open in surgical treatment were evaluated.
RESULTS: Of 70 the patients included in this study, 22 (31%) were male and 48 (69%) were female. The ages of the patients were between 25–70 and the mean age was 46.08±11.8. Open surgery was performed in six patients (9%). Perop–postop complications developed in three (4%) patients in total. Conversion to open was required in one of these patients. Biliary tract injury occurred in one patient, cystic duct stump leak occurred in one patient, and choledochal stenosis occurred in one patient.
DISCUSSION AND CONCLUSION: As a result, early laparoscopic cholecystectomy in acute cholecystitis is an acceptable treatment option with these complications and rates of conversion to open. It should be considered that complications may occur in the interim period and patients will be at a second risk due to the postponed operation. Minimal invasive methods should be preferred as much as possible with developing complications, and if necessary, support should be obtained from more experienced teams.

13.Pneumoperitoneum, pneumoretroperitoneum, pneumothorax, and subcutaneous emphysema findings in a case of perforation after colonoscopy
Mehmet Patmano, Durmuş Ali Çetin, Tufan Gümüş
doi: 10.14744/less.2020.35492  Pages 107 - 110
Colonoscopy is a widely used method for diagnosis and treatment. Endoscopic examination of the colon and rectum is performed for various purposes, including screening for and monitoring of colorectal cancer. Perforation after colonoscopy is rare; the occurrence is reported to be approximately 0.15–0.19%. A 54–year–old male patient presented at the emergency department with abdominal pain 8 hours after a colonoscopy, which had been completed without any known problem. Examination revealed pneumothorax, pneumoretroperitoneum, intraperitoneal air, and subcutaneous emphysema. The patient was hospitalized for observation and treatment, without any signs of peritoneal irritation or leukocytosis. The patient was subsequently discharged without complications. The aim of this study was to analyze the clinical presentation, diagnosis, and treatment of a patient who developed retroperitoneal air, pneumoperitoneum, pneumothorax, and subcutaneous emphysema following a colonoscopy procedure.

14.Laparoscopic surgery for urachal anomalies: Time to shift the paradigm?
Ankit Shukla, Ankur Sharma, Krishan Lal Kapoor, Roshni Shukla, Som Prakash
doi: 10.14744/less.2020.70446  Pages 111 - 113
Urachal anomalies are the result of failure of obliteration of the allantois, which connects the bladder to the umbilicus. These anomalies are usually divided into 5 distinct variants based on the site of residual patency across the urachus. Most often, patients present with umbilical discharge, abdominal pain, or recurrent urinary tract infection. The basic investigation tool for diagnosing a case of a urachal remnant is ultrasonography. The traditional approach for treatment of urachal anomalies is open excision. However, the trend has started to shift toward a laparoscopic approach, which has a promising future for dealing with urachal anomalies. Presently described is a case of symptomatic urachal sinus in a female teenager that was dealt with effectively using a laparoscopic approach at a secondary care hospital.

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