BACKGROUND
Red blood cell distribution width (RDW), a component of an electronic complete blood count, is a measure of heterogeneity in the size of circulating erythrocytes. In patients with symptomatic cardiovascular disease (CVD), RDW is associated with mortality. However, it has not been demonstrated that RDW is a predictor of mortality independent of nutritional deficiencies or in the general population.


METHODS
Red blood cell distribution width was measured in a national sample of 8175 community-dwelling adults 45 years or older who participated in the 1988-1994 National Health and Nutrition Examination Survey; mortality follow-up occurred through December 31, 2000. Deaths from all causes, CVD, cancer, and other causes were examined as a function of RDW.


RESULTS
Higher RDW values were strongly associated with an increased risk of death. Compared with the lowest quintile of RDW, the following were adjusted hazard ratios (HRs) for all-cause mortality (and 95% confidence intervals [CIs]): second quintile, HR, 1.1 (95% CI, 0.9-1.3); third quintile, HR, 1.2 (95% CI, 1.0-1.4); fourth quintile, HR, 1.4 (95% CI, 1.2-1.8); and fifth quintile, HR, 2.1 (95% CI, 1.7-2.6). For every 1% increment in RDW, all-cause mortality risk increased by 22% (HR, 1.22; 95% CI, 1.15-1.30; P < .001). Even when analyses were restricted to nonanemic participants or to those in the reference range of RDW (11%-15%) without iron, folate, or vitamin B(12) deficiency, RDW remained strongly associated with mortality. The prognostic effect of RDW was observed in both middle-aged and older adults for multiple causes of death.


CONCLUSION
Red blood cell distribution width is a widely available test that is a strong predictor of mortality in the general population of adults 45 years or older.

Red Blood Cell Distribution Width and the Risk of Death in Middle-aged and Older Adults.

Summary Background Lateral pelvic lymph-node metastases occur in 10–25% of patients with rectal cancer, and are associated with higher local recurrence and reduced survival rates. A meta-analysis was undertaken to assess the value of extended lateral pelvic lymphadenectomy in the operative management of rectal cancer. Methods We searched Medline, Embase, Ovid, Cochrane Library, and Google Scholar for studies published between 1965 and 2009 that compared extended lymphadenectomy (EL) with standard rectal resection. 20 studies, which included 5502 patients from one randomised, three prospective non-randomised, and 14 retrospective case–control studies published between 1984 and 2009, met our search criteria and were assessed. 2577 patients underwent EL and 2925 underwent non-EL for rectal cancer. Random and fixed-effects meta-analytical models were used where indicated, and between-study heterogeneity was assessed. End-points evaluated included peri-operative outcomes, 5-year survival and recurrence rates. Findings Operating time was significantly longer in the EL group by 76·7 min (95% CI 18·77–134·68; p=0·0096). Intra-operative blood loss was greater in the EL group by 536·5 mL (95% CI 353·7–719·2; p Interpretation Extended lymphadenectomy does not seem to confer a significant overall cancer-specific advantage, but does seem to be associated with increased urinary and sexual dysfunction. Funding The National Institute for Health Research Biomedical Research Centre, London, UK.

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(09)70224-4.pdf

Extended lymphadenectomy versus conventional surgery for rectal cancer: a meta-analysis

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)00276-7.pdf

Perforated peptic ulcer

Breast cancer (BC) is the most common female malignancy within the spectrum of human cancer. One promising way to reduce the mortality and morbidity of BC is to explore novel diagnostic markers for early diagnosis and prognostication. The neutrophil lymphocyte ratio (NLR) is a good reflection of inflammation, which plays an important role in tumor progression and metastasis. However, the association between NLR and BC prognosis remains unclear. The aim of this meta-analysis is to explore the prognostic value of NLR in BC. Among the screened references in the database, 12 eligible studies were identified in this study. Patients with a higher NLR had a shorter disease-free survival (hazard ratio =1.46, 95% confidence interval: 1.12-1.90, P=0.044) and overall survival (hazard ratio =2.03, 95% confidence interval: 1.41-2.93, P<0.001). In the subgroup analysis of NLR and disease-free survival, the studies from Eastern countries had a positive result with perfect homogeneity (I (2)=0); however, this homogeneity has not been achieved in studies from Western countries. In the subgroup analysis of the NLR and overall survival, the results of the univariate and multivariate analyses were completely different, with different heterogeneity. In the luminal A and luminal B subtypes, we found that there was no association between the NLR and overall survival in the BC patients. Positive results were obtained in the analyses of the human epidermal growth factor receptor 2 (HER2)-positive and triple-negative BC subtypes. In conclusion, this meta-analysis suggests that NLR is a good prognostic marker for BC, and patients with a higher NLR have poorer prognoses. Future studies should perform more detailed investigations to decrease heterogeneity and determine the appropriate cut-off values for different races.

/pdf/the-neutrophil-lymphocyte-ratio-is-associated-with-breast-42rag7ugtc.pdf

The neutrophil lymphocyte ratio is associated with breast cancer prognosis: an updated systematic review and meta-analysis.

Emergency repair of complicated abdominal wall hernias may be associated with worsen outcome and a significant rate of postoperative complications. There is no consensus on management of complicated abdominal hernias. The main matter of debate is about the use of mesh in case of intestinal resection and the type of mesh to be used. Wound infection is the most common complication encountered and represents an immense burden especially in the presence of a mesh. The recurrence rate is an important topic that influences the final outcome. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013 with the aim to define recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel. In 2016, the guidelines have been revised and updated according to the most recent available literature.

/pdf/2017-update-of-the-wses-guidelines-for-emergency-repair-of-51ge4wj3bx.pdf

2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias

Anomalous biliary opening especially the presence of the ampulla of Vater in the duodenal bulb is a very rare phenomenon. We report clinical implications, laboratory and ERCP findings and also therapeutic approaches in 53 cases. The data were collected from the records of 12.158 ERCP. The diagnosis was established as an anomalous opening of the common bile duct (CBD) into the duodenal bulb when there is an orifice observed in the bulb with the absence of a papillary structure at its normal localization and when the CBD is visualized by cholangiography through this orifice without evidence of any other opening. A total of 53 cases were recruited. There was an obvious male preponderance (M/F: 49/4). Demographic data and ERCP findings were available for all, but clinical characteristics and laboratory findings could be obtained from 39 patients with full records. Thirty – seven of 39 cases had abdominal pain (95%) and 23 of them (59%) had cholangitis as well. Elevated AP and GGT were found in 97.4% (52/53). History of cholecystectomy was present in 64% of the cases, recurrent cholangitis in 26% and duodenal ulcer in 45%. Normal papilla was not observed in any of the patients and a cleft-like opening was evident instead. The CBD was hook shaped at the distal part that opens to the duodenal bulb. Pancreatic duct (PD) was opening separately into the bulb in all the cases when it was possible to visualize. Dilated CBD in ERCP was evident in 94% and the CBD stone was demonstrated in 51%. PD was dilated in four of 12 (33%) cases. None of them has a history of pancreatitis. Endoscopically, Papillary Balloon Dilatation instead of Sphincterotomy carried out in 19 of 27 patients (70%) with choledocholithiazis. Remaining eight patients had undergone surgery (30%). Clinical symptoms were resolved with medical treatment in 16(32%) patients with dilated CBD but no stone. Perforation and bleeding were occurred only in two patients, which stones extracted with sphincterotomy (each complication in 1 patient). The opening of the CBD into the duodenal bulb is a rare event that may be associated with biliary and gastric/duodenal diseases. To date, surgical treatment has been preferred. In our experience, sphincterotomy has a high risk since it may lead to bleeding and perforation by virtue of the fact that a true papillary structure is absent. However, we performed balloon dilatation of the orifice successfully without any serious complication and suggest this as a safe therapeutic modality.

/pdf/anomalous-opening-of-the-common-bile-duct-into-the-duodenal-537w613no6.pdf

Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment

Aims The aim of the current study is to demonstrate whether the effects of extended systematic lymph-node dissection (ESLND) on urinary dysfunctions differ from those of curative radical surgery (CRS) only for rectal cancer. Methods We present data about our patients who underwent rectal resection for rectal cancer over 5 years. One hundred and seventy patients with rectal cancer were reviewed with respect to surgical procedures and post-operative urinary problems. Results We performed CRS on 146 patients and CRS+ESLND on 24 patients, and analysed the incidence of post-operative urinary dysfunction in both groups. Urinary incontinence rates were 39 and 58%, urinary retention rates were 4 and 16%, for the patients from CRS group and CRS+ESLND group, respectively. Conclusions We conclude that the addition of ESLND to CRS does not increase the frequency of post-operative urinary dysfunction, apart from an increased risk of urinary retention.

The assessment of urinary function following extended lymph node dissection for colorectal cancer

Background/Aims: The incidence and prevalence of peptic ulcer disease has decreased in recent years, but it is not so easy to make the same conclusion when complications of peptic ulcer are taken into consideration. The aim of this study is to determine the time trends in complicated peptic ulcer disease and to state the effects of H2 receptor blockers, proton pump inhibitors (PPI), and H. pylori eradication therapies on these complications. Materials and Methods: This study retrospectively evaluated the patients who were operated on for complications (perforation, bleeding, and obstruction) of peptic ulcer for the last 50 years. Patients were grouped into four groups (G1-G4) according to the dates in which H2 receptor blockers, PPIs, and eradication regimens for H. pylori were introduced The time periods that were studied were: (G1) 1962-1980, (G2) 1981-1990, (G3) 1991-1997, and (G4) 1998-2012. Results: In total, 2953 patients were operated on for complications of peptic ulcer disease, of which 86% of the patients were male. In G1, perforation and obstruction were significantly the most frequent complications (p<0.001), followed by bleeding. In groups G2 and G3, obstruction was still the most frequent complication requiring surgery (p<0.001). In G2 and G3, obstruction was followed by perforation and bleeding, respectively. In G4, perforation was significantly the most frequent complication (p<0.001). Conclusion: From 1962 to 1990 obstruction was the most common complication requiring surgery. In the last decade, perforation became the most common complication. In contrast to reports in the literature, bleeding was the least common complication requiring surgery in Turkey.

Peptic ulcer complications requiring surgery: what has changed in the last 50 years in Turkey.

In the preoperative period, simple methods to identify the tumor stage of colorectal cancer patients are needed. In recent years, the neutrophil-lymphocyte ratio (NLR) has been used as a predictive parameter for systemic inflammatory response in many different clinical entities. This study aims to determine if the NLR predicts the tumor stage in colorectal cancer patients in the preoperative period. Materials and methods: A total of 206 patients diagnosed with colorectal cancer and admitted for surgical treatment over a 6-year period were identified from a retrospectively maintained database. NLR was calculated from preoperative full blood counts. NLRs were compared with the tumor stages as determined in histopathological reports and scanning tests to determine the extent of metastasis. Results: We found NLRs to be statistically higher in patients with T3 and T4 tumors than in patients with T1 and T2 tumors (mean: 5.261 vs. 4.499, respectively, P = 0.010). Similarly, we found statistically higher NLR values in the N1 and N2 groups than in the N0 group (mean: 6.597 vs. 4.501, respectively, P < 0.001). Additionally, NLRs were statistically higher in M1 patients than in M0 patients (mean: 8.261 vs. 5.158, respectively, P = 0.004). Conclusion: In the preoperative period, NLR was found to be a valuable predictive parameter for tumor staging in patients with colorectal cancer, thus informing us as to the kind of tumor we will meet when we open the abdomen.

https://journals.tubitak.gov.tr/medical/issues/sag-14-44-3/sag-44-3-3-1305-33.pdf

Hakan Güzel

Papers

Anomalous opening of the common bile duct into the duodenal bulb: endoscopic treatment

The assessment of urinary function following extended lymph node dissection for colorectal cancer

Peptic ulcer complications requiring surgery: what has changed in the last 50 years in Turkey.

Neutrophil-lymphocyte ratio as a predictive factor for tumor staging in colorectal cancer

The role of proton MR spectroscopy and apparent diffusion coefficient values in the diagnosis of malignant thyroid nodules: preliminary results