Publications by authors named "Ismail Hamzaoglu"

55 Publications

Does Obesity Impact Surgical and Pathological Outcomes in Robotic Complete Mesocolic Excision for Colon Cancer?

J Laparoendosc Adv Surg Tech A 2021 Jan 8. Epub 2021 Jan 8.

Department of General Surgery, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey.

Obesity is one of the contributing factors to technical difficulties in minimally invasive colorectal surgery. However, there are no data regarding the outcomes for obese patients undergoing robotic complete mesocolic excision (CME) for colon cancer. In this study, we aimed to investigate whether robotic CME in obese patients can be performed with similar morbidity and pathological results compared with nonobese patients. Patients who underwent robotic CME between 2014 and 2019 were classified into obese and nonobese groups. Obesity was defined as body mass index ≥30 kg/m. Demographic data, perioperative outcomes and pathological results were compared between the groups. There were 42 and 105 patients in the obese and nonobese group, respectively. The groups were comparable regarding preoperative characteristics. There were no significant differences with respect to operative times (244 ± 64 versus 304 ± 75 minutes,  = .29), blood loss (median, 50 versus 80 mL,  = .20), intraoperative complications (0% versus 3.8%,  > .99), and conversions (0% versus 1.9%,  > .99). No differences were detected in length of hospital stay (6 ± 1 versus 6 ± 2 days,  = .73), anastomotic leak (2.4% versus 1.9%,  > .99), septic complications, reoperations (2.4% versus 3.8%), and readmissions (2.4% versus 2.9%) ( > .05). The mean number of harvested lymph nodes (33 ± 11 versus 34 ± 13,  = .79), resection margin status, and mesocolic fascia grading were similar. Robotic CME in obese patients can be performed with a similar morbidity and pathological profile compared with nonobese patients. The Clinical Trial Registration number is not applicable for this study.
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http://dx.doi.org/10.1089/lap.2020.0824DOI Listing
January 2021

Metastasis to lymph nodes around the vascular tie worsens long-term oncological outcomes following complete mesocolic excision and conventional colectomy for right-sided colon cancer.

Tech Coloproctol 2021 03 5;25(3):309-317. Epub 2021 Jan 5.

Department of General Surgery, VKF American Hospital, Guzelbahce Street, No: 20, Sisli, Istanbul, Turkey.

Background: Oncologic outcomes after complete mesocolic excision (CME) in colon cancer are under investigation. The aim of our study was to compare CME and conventional colectomy (CC) in terms of pathological and oncological outcomes for right colon cancer and to evaluate the impact of lymph node metastasis around the vascular tie on survival.

Methods: Consecutive patients with right colon cancer who had CME or CC between January 2011 and August 2018 at two specialized centers in Turkey were included. Statistical analyses were performed with respect to demographic characteristics, operative and pathologic outcomes, harvested and metastatic lymph nodes around the vascular tie (LNVT), recurrences, and survival.

Results: There were 91 patients in the CME group (58 males, mean age 64 ± 16 years) and 192 patients in the CC group (96 males, mean age 66 ± 14 years). The mean number of harvested lymph nodes (CME: 42 ± 15 vs CC: 34 ± 13, p = 0.01) and LNVT were higher in the CME group (CME: 3.2 ± 2.2 vs CC: 2.4 ± 1.6, p = 0.001). LNVT metastases were 7.7% and 8.3% in the CME and CC groups, respectively (p = 0.85). Three-year overall and disease-free survival rates were 96.4% and 90.9% in the CME group and 90.4% and 87.6% in the CC group in stage I-III patients (p > 0.05). In stage III patients, the 3-year overall survival (92.5% vs 63.5%, p = 0.03) and disease-free survival (85.6% vs 52.1%, p = 0.008) were significantly better in LNVT-negative patients than in LNVT-positive patients.

Conclusion: LNVT metastasis seems to be the key factor associated with poor disease-free and overall survival in right colon cancer regardless of the radicality of surgery.
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http://dx.doi.org/10.1007/s10151-020-02378-4DOI Listing
March 2021

Learning curve analysis of robotic transabdominal preperitoneal inguinal hernia repair.

Int J Med Robot 2020 Dec 8;16(6):1-5. Epub 2020 Sep 8.

Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey.

Background: The purpose of this study was to assess the learning curve (LC) for inguinal hernia repair with robotic transabdominal preperitoneal (R-TAPP) approach.

Methods: Between April 2016 and October 2019, patients who underwent R-TAPP were retrieved. Patient demographics, operative variables and postoperative outcomes were assessed. The moving average method and cumulative sum of operation times (OT) were used to evaluate the LC. The surgeon (BB) in this study had completed his laparoscopic (Lap) TAPP experience.

Results: There were 50 (two females) consecutive patients (mean age was 51.7 ± 16.9 years). The first phase (learning phase) included initial 35 operations. The second phase included the next 15 operations. It was observed that, with increasing experience, a statistically significant shortening in the average OT by about 25 min was achieved (p = 0.041).

Conclusion: The LC phase for R-TAPP, for surgeon with previous experience in Lap TAPP, seems to be very quick without compromising the operative morbidity.
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http://dx.doi.org/10.1002/rcs.2150DOI Listing
December 2020

Operative and long-term oncological outcomes in patients undergoing robotic versus laparoscopic surgery for rectal cancer.

Int J Med Robot 2020 Dec 24;16(6):1-10. Epub 2020 Sep 24.

Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.

Background: This study aimed to compare short- and long-term outcomes after robotic versus laparoscopic approach in patients undergoing curative surgery for rectal cancer.

Methods: Patients undergoing elective robotic and laparoscopic resection for rectal cancer were included. Perioperative clinical characteristics, postoperative short- and long-term outcomes were compared between groups.

Results: There were 72 and 44 patients in robotic (RG) and laparoscopic (LG) groups respectively. No differences were detected regarding patients' demographics, histopathologic outcomes, conversion rates and 30-day overall postoperative complication rates. Operative time was longer in the RG (341 ± 111.7 vs. 263 ± 97.5 min, p = 0.001) and length of stay was longer in the LG (4.4 ± 1.9 vs. 6.4 ± 2.9 days, p = 0.001). The 5-year overall and disease-free survival rates were similar (97.1% and 94.9%, p = 0.78; 86.2% and 82.7%, p = 0.72) between the groups.

Conclusion: This study showed both short and long-term outcomes of a limited number of included patients between the robotic and laparoscopic surgery were similar. However, future studies and randomized trials are necessary to establish these findings.
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http://dx.doi.org/10.1002/rcs.2168DOI Listing
December 2020

Totally minimally invasive radical gastrectomy with the da Vinci Xi robotic system versus straight laparoscopy for gastric adenocarcinoma.

Int J Med Robot 2020 Dec 2;16(6):1-9. Epub 2020 Sep 2.

Department of General Surgery, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.

Background: Data regarding the outcomes of pure minimally invasive techniques of radical gastrectomy are scarce. We aimed to compare short-term post-operative outcomes in patients undergoing totally minimally invasive radical gastrectomy with the da Vinci Xi robotic system versus straight laparoscopy for gastric adenocarcinoma.

Methods: Between December 2013 and March 2018, robotic and laparoscopic radical gastrectomy performed in two centres were included. Both groups were compared with respect to perioperative short-term outcomes.

Results: Ninety-four patients were included in the study. Anticoagulant and neoadjuvant chemotherapy use were higher in the robotic group (p = 0.02, p = 0.02). There were conversions in the laparoscopy group whereas no conversions occurred in the robotic group (p = 0.052). Operating time in the robotic group was longer (p = 0.001). The number of harvested lymph nodes in the laparoscopic group was higher (p = 0.047).

Conclusion: Totally robotic technique with the da Vinci Xi robotic system provides similar short-term results compared to laparoscopic surgery in radical gastrectomy.
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http://dx.doi.org/10.1002/rcs.2146DOI Listing
December 2020

Impact of Prolonged Neoadjuvant Treatment-surgery Interval on Histopathologic and Operative Outcomes in Patients Undergoing Total Mesorectal Excision for Locally Advanced Rectal Cancer.

Surg Laparosc Endosc Percutan Tech 2020 Dec;30(6):511-517

Acibadem Mehmet Ali Aydinlar University School of Medicine.

Background: This study primarily aimed to assess the impact of prolonged neoadjuvant treatment-surgery interval (PNSI) on histopathologic and postoperative outcomes. Impacts of the mode of neoadjuvant treatment (NT) and surgery on the outcomes were also evaluated in the same patient population.

Patients And Methods: Between February 2011 and December 2017, patients who underwent NT and total mesorectal excision for locally advanced rectal cancer were included. PNSI was defined as >4 and >8 weeks after short-course and long-course NT modalities, respectively.

Results: A total of 44 (27%) patients received short-course NT (standard interval: n=28; PNSI: n=16) and 122 (73%) patients received long-course NT (standard interval: n=39; PNSI: n=83). Postoperative morbidity was similar between the standard interval and PNSI in patients undergoing short-course [n=3 (11%) vs. n=3 (19%), P=0.455] and long-course [n=6 (15%) vs. n=16 (19%), P=0.602] NT. PNSI was associated with increased complete pathologic response in patients receiving short-course NT [0 vs. n=5 (31%), P=0.002]. Compared with short-course NT, long-course NT was superior in terms of tumor response based on the Mandard [Mandard 1 to 2: n=6 (21%) vs. 6 (38%), P=0.012] and the College of American Pathologists (CAP) [CAP 0 to 1: n=13 (46%) vs. n=8 (50%), P=0.009] scores. Postoperative morbidity was similar after open, laparoscopic, and robotic total mesorectal excision [n=1 (14.2%) vs. n=21 (21%) vs. n=6 (12.5%), P=0.455] irrespective of the interval time to surgery and the type of NT.

Conclusions: PNSI can be considered in patients undergoing short-course NT due to its potential oncological benefits. The mode of surgery performed at tertiary centers has no impact on postoperative morbidity after both NT modalities.
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http://dx.doi.org/10.1097/SLE.0000000000000836DOI Listing
December 2020

Predictors of endoscopic recurrence in resected patients with Crohn's disease in a long-term follow-up cohort: History of multiple previous resections and residual synchronous disease in the remnant intestine.

Turk J Gastroenterol 2020 04;31(4):282-288

Department of Gastroenterology, İstanbul University-Cerrahpaşa, Cerrahpaşa School of Medicine, İstanbul, Turkey.

Background/aims: This study aimed to determine the predictors of endoscopic recurrence in a cohort of patients with Crohn's disease (CD) with prior intestinal resections.

Materials And Methods: The charts of the patients with CD were reviewed in a retrospective manner. Eighty-three patients were eligible for the final analysis. Demographic features of these patients and time between resection and colonoscopy, presence of any macroscopic residual disease in the remnant intestine, and postoperative medications were noted. Rutgeerts score was used to define postoperative endoscopic recurrence.

Results: The patients' mean age±SD at their final colonoscopy was 42.81±11.99 yr; and 37 of 83 patients (45%) were female. The mean follow-up time between resection and the final colonoscopy was 51.16±51.08 months. A total of 51 of 83 patients (61%) were in endoscopic remission (i0, i1); whereas 32 (39%) had an endoscopic recurrence (i2, i3, i4). History of multiple resections (χ2=6.12; p=0.013) and the presence of any postoperative residual disease in the remnant intestine (χ2=5.86; p=0.015) were risk factors; whereas the regular use of azathioprine (AZA) was significantly more common among patients without recurrence (χ2=4.515; p=0.034). In an age-sex adjusted Cox regression analysis history of multiple resections, presence of any postoperative residual disease proved to be independent risk factor for endoscopic recurrence, whereas the regular use of AZA proved to be ineffective.

Conclusion: In a retrospective long-term follow-up cohort of resected patients with CD, having multiple resections for CD and the presence of any residual synchronous disease after ileocolonic resection were identified as risk factors for endoscopic recurrence; the latter was never reported in previous studies.
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http://dx.doi.org/10.5152/tjg.2020.136680DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236643PMC
April 2020

Totally Robotic Autonomic Nerve-Preserving Total Mesorectal Excisions: Step-by-Step Technical Tips and Tricks.

Dis Colon Rectum 2020 04;63(4):562

Department of General Surgery, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey.

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http://dx.doi.org/10.1097/DCR.0000000000001477DOI Listing
April 2020

Live surgical demonstrations for minimally invasive colorectal training.

Langenbecks Arch Surg 2020 Feb 31;405(1):63-69. Epub 2020 Jan 31.

Department of General Surgery, School of Medicine, Koc University, Istanbul, Turkey.

Purpose: Live surgical demonstrations are considered an effective educational tool providing a chance for trainees to observe a real-time decision-making process of expert surgeons. No data exists evaluating the impact of live surgical demonstrations on the outcomes of minimally invasive colorectal surgery. This study evaluates perioperative and short-term postoperative outcomes in patients undergoing minimally invasive colorectal surgery in the setting of live surgical demonstrations.

Methods: Patients undergoing minimally invasive colorectal surgery which was performed as live surgical demonstrations (the study group) performed between 2006 and 2018 were reviewed. These patients were case-matched with those undergoing operations in routine practice (the control group). The study and control group were compared for intraoperative and short-term postoperative outcomes.

Results: Thirty-nine live surgery cases in the study group were case-matched with its thirty-nine counterparts as the control group. Operating time was longer (200 vs 165 min; p = 0.002) and estimated intraoperative blood loss was higher in the study group (100 vs 55 ml; p = 0.008). Patients in the study group stayed longer in the hospital (6 vs 5 days; p = 0.001). While conversion (n = 4 vs n = 1, p = 0.358) and intraoperative complications (n = 6 vs n = 2, p = 0.2) were more frequent in the study group, these outcomes did not reach statistical significance. Overall complications were higher in the study group (n = 22 vs n = 9, p = 0.003). One patient underwent a reoperation due to postoperative bleeding, and one mortality occurred in the live surgery group.

Conclusions: Live surgical demonstrations in minimally invasive colorectal surgery seem to be associated with increased risk of operative morbidity.
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http://dx.doi.org/10.1007/s00423-020-01858-3DOI Listing
February 2020

Management of Complicated Ostomy Dehiscence: A Case Study.

J Wound Ostomy Continence Nurs 2020 Jan/Feb;47(1):72-74

Ismail Ahmet Bilgin, MD, Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.

Background: Stoma creation is a common procedure in colorectal surgery. Despite improved surgical techniques, ostomy-related wound complications may prolong the recovery period and impair health-related quality of life. Negative pressure wound therapy (NPWT), autolytic debridement agents, and silver dressings are often used for managing complex wound infection and dehiscence. These applications have the potential to increase patient comfort and accelerate recovery.

Case: We report our experience in a 66 year old female who had a wound dehiscence involving the ostomy after robotic abdominoperineal resection. Her medical history was significant for a rectovaginal fistula which occurred after a low anterior resection for rectal cancer 5 years ago. Interventions for treatment of the dehiscence were use of NPWT, autolytic debriding agent, and silver dressing.

Conclusion: Combined use of these interventions for dehiscence of an ostomy can minimize patient discomfort and accelerate wound healing.
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http://dx.doi.org/10.1097/WON.0000000000000611DOI Listing
September 2020

Totally laparoscopic and totally robotic surgery in patients with left-sided colonic diverticulitis.

Int J Med Robot 2020 Feb 7;16(1):e2068. Epub 2020 Jan 7.

Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.

Background: Introduction of the da Vinci Xi system has facilitated the use of robotics in colorectal surgery. Nevertheless, data on the outcomes of robotic surgery for the treatment of colonic diverticulitis have remained scarce.

Methods: Patient demographics, clinical characteristics, and perioperative outcomes of the patients undergoing totally robotic with the da Vinci Xi system or laparoscopic surgery for left-sided colonic diverticulitis (LCD) were compared.

Results: Laparoscopic and robotic groups included 22 and 20 patients, respectively. There were no significant differences between the two groups in terms of patient demographics, clinical characteristics, operative time, and postoperative complications. There were three conversions in the laparoscopy group and no conversion in the robotic group (P = 0.23). Conversion to open surgery was associated with postoperative morbidity (P = 0.02).

Conclusion: Robotic surgery is an applicable alternative for the treatment of LCD. Robotic approach may potentially lower the risk of operative morbidity by reducing the requirement of conversion.
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http://dx.doi.org/10.1002/rcs.2068DOI Listing
February 2020

Fully robotic total gastrectomy with D2 lymphadenectomy for gastric cancer.

Surg Oncol 2020 Mar 3;32:48. Epub 2019 Nov 3.

Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey.

Purpose: Robotic surgery with technical advantages was shown to make complex maneuvers easier and more precise for gastric surgery [1]. This video demonstrates our technique on robotic total gastrectomy with the da Vinci Xi platform for gastric cancer.

Methods: 68-year-old female was presented with persistent epigastric abdominal pain and underwent upper endoscopy showed ulcerated mass extended from the cardia to the lesser curvature. Histopathology showed gastric adenocarcinoma. After patient received neoadjuvant chemotherapy, decision was made to proceed with surgery.

Results: Initially, greater curvature dissection was started by division of the gastrocolic ligament with entering the lesser sac with monopolar scissors and bipolar forceps. The right gastroomental vessels were identified and divided at their root along with lymph nodes. After ligation of the right gastric vessels, dissection was extended to retrieve lymph nodes around the left gastric vessels. Duodenum was circumferentially dissected and transected 2 cm distal to the pylorus. Subsequently, extended lymphadenectomy was started with suprapancreatic lymph node dissection to retrieve lymph nodes around the common hepatic artery and celiac axis. Spleen-preserving dissection of the lymphatic tissue of the distal splenic artery and the splenic hilum was performed. The distal esophagus was divided with robotic stapler. Fully robotic end-to-side esophagojejunal anastomosis was constructed. For the reconstruction of gastrointestinal continuity after total gastrectomy, side-to-side jejuno-jejunal anastomosis was performed. Total operative time was 5 hours and estimated blood loss was 20 cc.

Discussion: Totally robotic gastrectomy with D2-lymphadenectomy is a safe technique for gastric cancer and provides intracorporeal suturing in reconstructing the anatomy.
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http://dx.doi.org/10.1016/j.suronc.2019.11.001DOI Listing
March 2020

Totally robotic ivor-Lewis esophagectomy with intrathoracic robot-sewn anastomosis for cardio-esophageal cancer with the da VINCI XI.

Surg Oncol 2019 Sep 29;30:139-140. Epub 2019 Jul 29.

Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey.

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http://dx.doi.org/10.1016/j.suronc.2019.07.010DOI Listing
September 2019

Complete response after neoadjuvant treatment for rectal cancer.

Lancet 2019 04;393(10182):1694

Department of Surgery, Division of Colon and Rectal Surgery, New York University Langone Health, New York, NY, USA.

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http://dx.doi.org/10.1016/S0140-6736(18)33203-3DOI Listing
April 2019

Robotic Complete Mesocolic Excision Versus Conventional Laparoscopic Hemicolectomy for Right-Sided Colon Cancer.

J Laparoendosc Adv Surg Tech A 2019 May 26;29(5):671-676. Epub 2019 Feb 26.

Department of General Surgery, Koc University School of Medicine, Istanbul, Turkey.

Robotic technique has been proposed to overcome the limitations of laparoscopic surgery. In this study, we aimed at determining whether robotic complete mesocolic excision (CME) for right-sided colon cancer can be safe and effective as conventional laparoscopic right hemicolectomy (CLRH). Between February 2015 and September 2017, patients undergoing robotic right CME and CLRH with curative intent for right-sided colon cancer were included. Patient characteristics, short-term and histopathological outcomes were compared between the groups. Ninety-six patients (robotic,  = 35) were included in this study. The operative time (286 ± 77 versus 132 ± 40 minutes,  = .0001) was significantly longer in the robotic group. There were no conversions in either group. No significant differences existed between the groups regarding the mean estimated blood loss, time to first flatus, length of hospital stay (6 ± 3 versus 6 ± 3 days,  = .64), and follow-up times (robotic 15 ± 8 versus laparoscopic 16 ± 10 months  = .11). Overall complication rates ( = 10 [29%] versus  = 15 [25%],  = .67) were similar. In the robotic group, vascular injury occurred in 2 patients, and both were repaired robotically. The mean number of harvested lymph nodes was significantly higher (41 ± 12 versus 33 ± 10,  = .04) and length between the vascular tie and colonic wall was longer (13 ± 3.5 versus 11 ± 3,  = .02) in the robotic group. Although robotic right CME seems equally safe to CLRH in terms of short-term morbidity, future prospective randomized trials are needed to define its role for treatment of right colectomy.
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http://dx.doi.org/10.1089/lap.2018.0348DOI Listing
May 2019

Short-term Results After Totally Robotic Restorative Total Proctocolectomy With Ileal Pouch Anal Anastomosis for Ulcerative Colitis.

Surg Laparosc Endosc Percutan Tech 2020 Feb;30(1):40-44

Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.

In this study, we aimed to present our initial experience on totally robotic total restorative proctocolectomy in ulcerative colitis (UC) patients. Patients undergoing a totally robotic restorative total proctocolectomy with ileal J-pouch anal anastomosis for UC between January 2015 and November 2017 were included. The da Vinci Xi was used for the operations. Patient demographics, perioperative and short-term operative outcomes were evaluated. Ten patients were included. The median operative time was 380 minutes(range, 300 to 480 min). The median blood loss was 65 mL (range, 5 to 400 mL). No conversion to open surgery was needed. The median time to flatus was 1 day (range, 1 to 2) and length of stay was 6 (4 to 12) days. Short-term complications (≤30 d) were superficial wound infection (n=3), anal bleeding (n=1), pouchitis (n=1). No mortality was observed during the study period. Our study, which is the largest series so far, reveals that totally robotic restorative proctocolectomy is a safe and feasible option for the surgical treatment of UC.
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http://dx.doi.org/10.1097/SLE.0000000000000645DOI Listing
February 2020

Portal vein ligation and in situ liver splitting in metastatic liver cancer.

Turk J Surg 2018 Dec 1;34(4):327-330. Epub 2018 Dec 1.

Department of General Surgery, Acıbadem University School of Medicine Maslak Hospital, İstanbul, Turkey.

The most serious complication after major liver resection is liver failure. Depending on preoperative liver function, a future liver remnant of 25%-40% is considered sufficient to avoid postoperative liver failure. A new technique known as portal vein ligation combined with in situ splitting has been developed to obtain rapid liver hypertrophy. Herein, we present a case where we performed portal vein ligation combined with in situ splitting. A 37-year-old male patient with a diagnosis of sigmoid adenocarcinoma and liver metastasis underwent anterior resection because of an obstructing sigmoid tumor and received palliative chemotherapy. After chemotherapy, abdominal computed tomography revealed a lesion, 50 mm in diameter, localized between segments 5-8 of the liver on the bifurcation of the anteroposterior segmental branch of the right portal vein. Computed tomography volumetric assessments of the liver were performed in the preoperative period, and it was found that the remnant left liver volume was less than 25%. In the first stage, portal vein ligation and in situ splitting of the liver parenchyma were performed. On the second and sixth postoperative days, computed tomography revealed hypertrophy of the left liver lobe. On the sixth day, a right hepatectomy was performed. Portal vein ligation combined with in situ splitting has been used by surgeons worldwide to obtain rapid and adequate liver hypertrophy. This new approach yields hope for patients with locally advanced liver tumors and may increase the number of curative resections for primary or metastatic liver tumors.
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http://dx.doi.org/10.5152/turkjsurg.2017.3507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6340668PMC
December 2018

Dealing with the gray zones in the management of gastric cancer: The consensus statement of the İstanbul Group.

Turk J Gastroenterol 2019 Jul;30(7):584-598

Acıbadem Mehmet Ali Aydınlar University School of Medicine, İstanbul, Turkey.

The geographical location and differences in tumor biology significantly change the management of gastric cancer. The prevalence of gastric cancer ranks fifth and sixth among men and women, respectively, in Turkey. The international guidelines from the Eastern and Western countries fail to manage a considerable amount of inconclusive issues in the management of gastric cancer. The uncertainties lead to significant heterogeneities in clinical practice, lack of homogeneous data collection, and subsequently, diverse outcomes. The physicians who are professionally involved in the management of gastric cancer at two institutions in Istanbul, Turkey, organized a consensus meeting to address current problems and plan feasible, logical, measurable, and collective solutions in their clinical practice for this challenging disease. The evidence-based data and current guidelines were reviewed. The gray zones in the management of gastric cancer were determined in the first session of this consensus meeting. The second session was constructed to discuss, vote, and ratify the ultimate decisions. The identification of the T stage, the esophagogastric area, imaging algorithm for proper staging and follow-up, timing and patient selection for neoadjuvant treatment, and management of advanced and metastatic disease have been accepted as the major issues in the management of gastric cancer. The recommendations are presented with the percentage of supporting votes in the results section with related data.
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http://dx.doi.org/10.5152/tjg.2018.18737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6629281PMC
July 2019

En-Bloc Excision of the High-ligated Inferior Mesenteric Vein Pedicle With the Specimen in Patients Undergoing Minimally Invasive and Open Sphincter Saving Rectal Resections for Cancer.

Surg Laparosc Endosc Percutan Tech 2019 Feb;29(1):13-17

Departments of General Surgery.

Although high-ligated pedicle of the inferior mesenteric artery is usually kept in the resected specimens, the value of preserving high-ligated pedicle of the inferior mesenteric vein within the resected specimens of the sphincter saving rectal resections for cancer is not well defined. In the current study, patients undergoing open, laparoscopic, and robotic sphincter saving rectal resection for cancer were prospectively included. Lymph node invasion and presence of lymph nodes along the IMV pedicles were analyzed. In total 100 patients were included. There were lymph nodes in 63 patients at the IMV and 71 patients at the IMA pedicles. En-bloc removal of the high-ligated IMV pedicle with the resected specimen significantly increased the number of harvested lymph nodes(P<0.001) regardless of surgical modality (P=0.36). Although it increases the number of harvested lymph nodes with acceptable operative morbidity, no oncological benefits were found related to preservation of high-ligated pedicle of the inferior mesenteric vein within the resected specimen of the rectum.
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http://dx.doi.org/10.1097/SLE.0000000000000615DOI Listing
February 2019

Adoption of robotic technology in Turkey: A nationwide analysis on caseload and platform used.

Int J Med Robot 2019 Feb 17;15(1):e1962. Epub 2018 Oct 17.

Department of General Surgery, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, İstanbul, Turkey.

Background: Limited data exist regarding adoption of evolving robotic technology in surgery. This study evaluated trends and the current condition of robotic platforms in surgical specialties and general surgical subspecialties.

Methods: Between January 2013 and December 2017, all robotic operations performed in Turkey were included.

Results: In the study period, 13 760 robotic operations were performed at 32 hospitals. The median numbers of general surgical procedures were 43and eight cases per hospital and per general surgeon, respectively. The high-volume general surgeons performed 1734 (81%) of the cases. Forty-five percent and 55% of the general surgical operations were performed with the Xi and S/Si robots, respectively.

Conclusion: Use of the Xi platform seems to increase caseload in general surgery operations possibly by facilitating robotic colorectal surgery. Targeting the high-volume centres and surgeons for further training and implantation of upcoming robotic technology can be more effective in terms of increasing case volume and improving outcomes.
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http://dx.doi.org/10.1002/rcs.1962DOI Listing
February 2019

Predictive parameters of early postoperative complications in Crohn's disease: Single team experience.

Turk J Gastroenterol 2018 07;29(4):406-410

Department of General Surgery, Acıbadem Mehmet Ali Aydınlar University School of Medicine, İstanbul, Turkey.

Background/aims: Most of the patients with Crohn's disease (CD) may require at least one surgical procedure over their lifetime. However, these patients tend to have a high incidence of postoperative complications. The aim of this retrospective study was to investigate the predictive parameters of postoperative complications in CD.

Materials And Methods: All consecutive patients with CD between March 2001 and March 2016 who underwent bowel resection were included to this study. Postoperative complications were divided as; major complications including anastomotic leakage, ostomy complications, acute mechanical intestinal obstruction and hemorrhage, and minor complications including wound infection.

Results: A total of 147 patients (74 females, 73 males) with a mean age of 36±11.9 years met the inclusion criteria. Behaviors of CD were stricturing in 90 (62%), fistulizing in 45 (30%) and inflammatory in 12 (8%) patients. Minimally invasive approach was applied in 35% (n=51) of the patients. Twentysix (17%) patients had early (≤30 days) postoperative surgical complications including anastomotic leak (n=10), intra-abdominal bleeding (n=2), complications related to ostomy (n=2), acute mechanical intestinal obstruction (n=1) and wound infection (n=11). Only fistulizing disease behavior was associated with early postoperative complications (p=0.014).

Conclusion: This study suggests that postoperative complications are still more common in fistulizing CD. Surgical approach did not affect the complication rate. The decision should be individualized according to the prominent risk factors and surgeons' preference.
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http://dx.doi.org/10.5152/tjg.2018.17687DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6284636PMC
July 2018

Surgery for Intestinal Crohn's Disease: Results of a multidisciplinary approach.

Turk J Surg 2018 Aug 31;34(3):225-228. Epub 2018 Aug 31.

Department of General Surgery, Acıbadem University School of Medicine, İstanbul, Turkey.

Objectives: Crohn's disease is a chronic inflammatory bowel disease that requires lifelong multidisciplinary management. Seventy percent of patients affected by Crohn's disease will require at least one surgical procedure over their lifetime. The aim of this retrospective study was to present our series of patients suffering from Crohn's disease who were scheduled for surgery by a multidisciplinary team.

Material And Methods: The data were retrieved from a review of 950 patients with Crohn's disease treated at our institution between March 2000 and March 2016. Only patients with intestinal Crohn's disease were included into the study. A multidisciplinary team assessed the decision to perform surgery.

Results: There were 203 patients who underwent surgery included in this study. One hundred and sixty-six were intestinal and 37 were perianal Crohn's disease. The mean age was 36±11.5 (range, 12-75) years. Ninety-two were stricturing, 45 were fistulizing, and 12 were inflammatory. The most commonly affected site was the ileocecal region (n=109, 65.7%), and the most common surgical procedure was the ileocecal resection (n=109, 65.6%). Laparoscopic approach was the procedure of choice in 56 (33.7%) patients. Of the patients enrolled, the most common early (<30 days) complications observed were the wound infection as the first (n=11) and anastomotic leak as the second (n=10). The mortality rate was 2.4% (n=4).

Conclusion: Multidisciplinary approach to Crohn's disease may decrease the surgical complications and recurrence rates leading to a better treatment.
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http://dx.doi.org/10.5152/turkjsurg.2017.3885DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173600PMC
August 2018

Totally Robotic Versus Totally Laparoscopic Surgery for Rectal Cancer.

Surg Laparosc Endosc Percutan Tech 2018 Aug;28(4):245-249

Department of General Surgery, School of Medicine, Koç University, Istanbul, Turkey.

In this study, perioperative and short-term postoperative results of totally robotic versus totally laparoscopic rectal resections for cancer were investigated in a comparative manner by considering risk factors including obesity, male sex, and neoadjuvant treatment. In addition to overall comparison, the impact of sex, obesity (body mass index ≥30 kg/m), and neoadjuvant treatment was assessed in patients who had a total mesorectal excision (TME). Operative time was longer in the robotic group (P<0.001). In obese patients who underwent TME, the mean length of hospital stay was shorter (7±2 vs. 9±4 d, P=0.01), and the mean number of retrieved lymph nodes was higher (30±19 vs. 23±10, P=0.02) in the robotic group. Totally robotic and totally laparoscopic surgery appears to be providing similar outcomes in patients undergoing rectal resections for cancer. Selective use of a robot may have a role for improving postoperative outcomes in some challenging cases including obese patients undergoing TME.
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http://dx.doi.org/10.1097/SLE.0000000000000552DOI Listing
August 2018

Is Robotic Complete Mesocolic Excision Feasible for Transverse Colon Cancer?

J Laparoendosc Adv Surg Tech A 2018 Dec 7;28(12):1443-1450. Epub 2018 Jun 7.

1 Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.

Laparoscopic complete mesocolic excision (CME) for transverse colon cancer is technically challenging. Robotic technology has been developed to reduce technical limitations of laparoscopy. Yet, no data are available on the role of robotic approach for CME of transverse colon cancer. The aim of this study is to evaluate the feasibility and short-term outcomes of robotic CME in this subset of colon cancer. A retrospective review of a prospectively maintained database of 29 consecutive patients undergoing robotic CME for transverse colon adenocarcinoma between December 2014 and December 2017 was performed. Data on demographics, tumor characteristics, postoperative 30-day complications, and oncologic outcomes were analyzed. There were 21 (72%) men and 8 women with a mean age of 62.9 ± 15.6 years and a body mass index of 26.4 ± 4.8 kg/m. Of the 29 robotic CME procedures, 12 patients underwent extended right colectomy, 10 extended left colectomy, 6 subtotal colectomy, and 1 total colectomy. The mean operative time was 321.7 ± 111.3 minutes and estimated blood loss was 106.9 ± 110.9 mL (median, 50; range, 10-400 mL). The intra- and postoperative complication rates were 7% and 24%, respectively. There were no conversions. The mean time to first bowel movement was 3.5 ± 1.3 and length of hospital stay was 7.1 ± 3.0 days. All the resections were R0. The mean number of harvested lymph nodes in extended and subtotal/total colectomy procedures was 36.6 ± 13.1 and 71.0 ± 30.3, respectively. The rate of mesocolic plane surgery was 79%. There were no statistically significant differences between the mesocolic and the intramesocolic/muscularis propria plane resections with respect to clinical characteristics, operative outcomes, and pathology results ( > .05). Robotic CME for transverse colon cancer is feasible and can be a procedure of choice to achieve a good surgical quality.
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http://dx.doi.org/10.1089/lap.2018.0239DOI Listing
December 2018

Totally robotic complete mesocolic excision for right-sided colon cancer.

J Robot Surg 2019 Feb 17;13(1):107-114. Epub 2018 May 17.

Department of General Surgery, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey.

Complexity and operative risks of complete mesocolic excision (CME) seem to be important drawbacks to generalize this procedure in the surgical treatment of right colon cancer. Robotic systems have been developed to improve quality and outcomes of minimal invasive surgery. The aim of this study was to evaluate the feasibility of robotic right-sided CME and present our initial experience. A retrospective review of 37 patients undergoing totally robotic right-sided CME between February 2015 and November 2017 was performed. All the operations were carried out using the key principles of both CME with intracorporeal anastomosis and no-touch technique. Data on perioperative clinical findings and short-term outcomes were analyzed. There were 20 men and 17 women with a mean age of 64.4 ± 13.5 years and a body mass index of 26.8 ± 5.7 kg/m. The mean operative time and estimated blood loss were 289.8 ± 85.3 min and 77.4 ± 70.5 ml, respectively. Conversion to laparoscopy occurred in one patient (2.7%). All the surgical margins were clear and the mesocolic plane surgery was achieved in 27 (72.9%) of the cases. The mean number of harvested lymph nodes was 41.8 ± 11.9 (median, 40; range 22-65). The mean length of hospital stay was 6.6 ± 3.7 days. The intraoperative and postoperative complication rates were 5.4 and 21.6%, respectively. We believe that use of robot for right-sided CME is feasible and appears to provide remarkably a high number of harvested lymph nodes with good specimen quality.
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http://dx.doi.org/10.1007/s11701-018-0817-2DOI Listing
February 2019

Robotic Versus Laparoscopic Stapler Use for Rectal Transection in Robotic Surgery for Cancer.

J Laparoendosc Adv Surg Tech A 2018 May 23;28(5):501-505. Epub 2018 Jan 23.

Department of General Surgery, School of Medicine, Acibadem University , Istanbul, Turkey .

Background: This study was designed to compare the operative and short-term postoperative outcomes of the robotic and laparoscopic staplers in patients undergoing rectal surgery for cancer.

Materials And Methods: Between December 2014 and April 2017, patients consecutively undergoing robotic rectal surgery for cancer were included in this study. Patients were grouped into two according to the type of staplers for rectal transection [Robotic (45-mm) versus Laparoscopic (60-mm) linear staplers]. Patient demographics, pathologic data, perioperative outcomes, and short-term results were compared.

Results: One hundred seven patients met our inclusion criteria. The number of male patients were higher in robotic stapler group than in the laparoscopic stapler group (55% versus 76%, P = .03). Age (59 versus 63 years, P = .40), body mass index (27 versus 27 kg/m, P = .60), American Society of Anesthesiologists score (2 versus 2, P = .20), number of prior abdominal operations (31% versus 20%, P = .22) and number of patients having neoadjuvant chemoradiotherapy (34% versus 36%, P = .86) were comparable between the groups. The numbers of cartridges used were similar regardless of the type of staplers (2 versus 2, P = .58). The overall complication was similar between the groups (24% versus 31%, P = .32). Leak rates were 5% (n = 2) and 3% (n = 2) in the robotic and laparoscopic stapler groups, respectively (p = 1). There was no mortality.

Conclusions: This is the first study evaluating the role of robotic stapler specifically for rectal transection in comparative manner. The use of robotic stapler for rectal transection was safe and feasible in rectal surgery for cancer.
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http://dx.doi.org/10.1089/lap.2017.0545DOI Listing
May 2018

Does Robot Overcome Obesity-related Limitations of Minimally Invasive Rectal Surgery for Cancer?

Surg Laparosc Endosc Percutan Tech 2018 Feb;28(1):e8-e11

Department of General Surgery, School of Medicine, Acibadem University, Istanbul, Turkey.

Background: Adoption of laparoscopic surgery for cancers requiring partial or total proctectomy has been slow due to difficulty of achieving oncologically adequate resection. Obesity is a factor complicating use and outcomes of laparoscopic technique for rectal surgery. Impact of obesity on the outcomes of robotic rectal surgery for cancer is not well defined. This study is designed to assess whether if the robotic technique has potential to overcome the limitations of obesity and to improve outcomes of minimally invasive rectal surgery for cancer.

Patients And Methods: Patients undergoing robotic sphincter-saving radical resection with da Vinci Xi System between December 2014 and December 2016 were included. Patients were divided into 2 groups as obese and nonobese. Patient demographics, perioperative outcomes and short-term results were compared between the groups.

Results: The study included 101 patients (30 were obese). Sex (female: 35 vs. 37%, P=0.89), American Society of Anesthesiologists score (2 vs. 2, P=0.41), number of patients undergoing neoadjuvant chemoradiation (39% vs. 23%, P=0.12) and history of prior abdominal surgery (28% vs. 23%, P=0.62) were comparable between the groups. Operative time was longer in the obese group (311 vs. 332 min. P=0.01). Overall complication rates (27% vs. 23%, P=0.72), length of hospital stay (6 vs. 7, P=0.10) and pathologic outcomes were similar between the groups. Conversion to laparoscopy was not required in any operation. Two nonobese patients required conversion to open surgery.

Conclusion: Robotic rectal surgery for cancer in obese patients is equally safe and effective as in nonobese patients. The new robotic platform can facilitate to overcome obesity-related limitations of rectal surgery.
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http://dx.doi.org/10.1097/SLE.0000000000000500DOI Listing
February 2018

Role of robotic approach for management of complicated jejunoileal diverticulosis - video vignette.

Colorectal Dis 2017 Nov 25. Epub 2017 Nov 25.

Acibadem University, School of Medicine Department of General Surgery, Istanbul, Turkey.

Jejunoileal diverticulosis (JID) is a rare condition with a reported incidence lower than 0.1% (1-3). Surgery is the definitive treatment for JID and can be considered to improve the patient's quality of life and to prevent further occurrence of severe symptoms (3, 4, 5). Minimally invasive approach facilitates postoperative recovery, lowers risks and improves outcomes in JID treatment (6). This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/codi.13975DOI Listing
November 2017

Robotic Complete Mesocolic Excision for Splenic Flexure of Colon Cancer.

Dis Colon Rectum 2016 Nov;59(11):1098

1 Department of Surgery, Acibadem University, School of Medicine, Atakent Hospital, Istanbul, Turkey 2 Department of Surgery, Acibadem University, School of Medicine, Maslak Hospital, Istanbul, Turkey.

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http://dx.doi.org/10.1097/DCR.0000000000000691DOI Listing
November 2016

Is da Vinci Xi Better than da Vinci Si in Robotic Rectal Cancer Surgery? Comparison of the 2 Generations of da Vinci Systems.

Surg Laparosc Endosc Percutan Tech 2016 Oct;26(5):417-423

*Department of General Surgery, Atakent Hospital †Medical Faculty ‡Department of General Surgery, Maslak Hospital, Acibadem University, Istanbul, Turkey.

Background: We aimed to compare perioperative outcomes for procedures using the latest generation of da Vinci robot versus its previous version in rectal cancer surgery.

Patients And Methods: Fifty-three patients undergoing robotic rectal cancer surgery between January 2010 and March 2015 were included. Patients were classified into 2 groups (Xi, n=28 vs. Si, n=25) and perioperative outcomes were analyzed.

Results: The groups had significant differences including operative procedure, hybrid technique and redocking (P>0.05). In univariate analysis, the Xi group had shorter console times (265.7 vs. 317.1 min, P=0.006) and total operative times (321.6 vs. 360.4 min, P=0.04) and higher number of lymph nodes harvested (27.5 vs. 17.0, P=0.008). In multivariate analysis, Xi robot was associated with a shorter console time (odds ratio: 0.09, P=0.004) with no significant differences regarding other outcomes.

Conclusions: Both generations of da Vinci robot led to similar short-term outcomes in rectal cancer surgery, but the Xi robot allowed shorter console times.
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http://dx.doi.org/10.1097/SLE.0000000000000320DOI Listing
October 2016