Gokalp Okut

Background/Objectives: While perioperative chemotherapy is standard for locally advanced gastric cancer, no baseline blood marker reliably identifies which patients will respond to treatment. In this retrospective study, we compared eleven inflammatory and nutritional indices against pathological response and survival using data collected between 2020 and 2025. Methods: We analyzed 130 patients with gastric adenocarcinoma receiving perioperative systemic therapy at two centers. Eleven indices—the neutrophil-to-lymphocyte ratio (NLR), systemic immune–inflammation index (SII), Prognostic Nutritional Index (PNI), and eight further indices defined—were assessed against the Mandard tumor regression grade (TRG), overall survival (OS), and disease-free survival (DFS). Results: The median age was 63 years, and the median follow-up was 22.1 months from diagnosis. A Mandard TRG was assigned in 123 patients, 32 of whom achieved a major pathological response (TRG 1–2). The PNI had the highest point estimate of discrimination for major pathological response (AUC 0.618, 95% CI 0.490–0.746; p = 0.070), but its area under the curve did not differ significantly from that of any other index (all p ≥ 0.18), and bootstrap validation incorporating index selection and threshold derivation yielded an optimism-corrected AUC of 0.567. While PNI ≥ 53 was nominally associated with TRG 1–2 (OR 3.823, 95% CI 1.503–9.722; p = 0.005), no association survived correction for multiple comparisons, and the PNI was selected as the best-performing index in only 49% of bootstrap resamples. No index showed a statistically significant association with overall survival, and the event count is insufficient to establish the presence or absence of an association. Conclusions: None of the eleven baseline blood-based indices demonstrated statistically robust or clinically useful discrimination for major pathological response, and none were associated with survival. Although the PNI represented the most promising exploratory signal, its apparent advantage was not statistically distinguishable from the other indices and did not survive internal validation. The threshold of approximately 53 should be regarded as hypothesis-generating only.

Background: Distinguishing benign from malignant gastric outlet obstruction (GOO) remains a major clinical challenge. Despite comprehensive preoperative evaluation, occult malignancy and advanced fibrosis may be overlooked, complicating treatment selection, particularly in the era of minimally invasive and endoscopic bypass techniques. This study aimed to evaluate the clinical and pathological characteristics of clinically benign GOO, focusing on the prognostic significance of intraoperative duodenal wall thickening. Methods: This observational study included adult patients who underwent surgical treatment for clinically benign GOO between September 2023 and December 2025, identified from a prospective institutional gastrectomy database. Preoperative assessment included endoscopy with biopsy, contrast-enhanced computed tomography, tumor markers, and nutritional evaluation. All patients underwent distal subtotal gastrectomy with Roux-en-Y reconstruction using a laparoscopic-first approach. Intraoperative duodenal wall thickening was prospectively recorded, and its association with postoperative outcomes was analyzed. Results: Twenty-two patients were included (median age 58.5 years; 59.1% male). All demonstrated gastric dilatation and normal tumor markers. Helicobacter pylori infection was present in 95.5%, and 54.5% had prior balloon dilatation. Conversion occurred in 27.3%, stump leakage in 13.6%, and 30-day mortality in 9.1%. Occult carcinoma was identified in 4.5%. Duodenal wall thickening was significantly associated with conversion ( P < 0.001), major complications ( P = 0.002), and stump leakage ( P = 0.036). All survivors had durable symptom resolution. Conclusion: In clinically benign GOO, intraoperative duodenal wall thickening is a clinically actionable marker associated with increased surgical complexity, morbidity, and possible occult malignancy, supporting its role in guiding intraoperative decision-making, including conversion, operative caution, and selection between resection and non-resectional strategies.

Background and Objectives: The MATTERHORN study demonstrated that adding durvalumab to perioperative FLOT improves survival in resectable gastric cancer. As immunotherapy enters routine practice, precise patient stratification becomes critical. This study examines whether baseline blood-based inflammatory markers can predict pathological response and long-term outcomes. Materials and Methods: We retrospectively analyzed 130 patients with gastric adenocarcinoma receiving perioperative systemic treatment. Nine inflammatory and nutritional indices (NLR, MLR, NMR, SII, SIRI, HALP, ALBI, PALBI, and PNI) were assessed against Mandard Tumor Regression Grade (TRG), overall survival (OS), and disease-free survival (DFS). Results: Median age was 63 years (range 28–83); median follow-up was 22.2 months. Of all markers assessed, only PNI was significantly associated with major pathological response (TRG 1–2) and DFS on univariable analysis. Multivariable logistic regression identified PNI ≥ 53.125 as the sole independent predictor of TRG 1–2 (OR 4.200, 95% CI 1.631–10.820; p = 0.003). Completing perioperative treatment independently predicted DFS, while post-treatment nodal stage (ypN) and treatment completion independently predicted OS. Optimal cut-offs were PNI ≥ 53.125 for major response (sensitivity 57.1%, specificity 73.6%) and PNI ≤ 48.475 for recurrence risk (sensitivity 59.4%, specificity 68.7%). Conclusions: Among all markers evaluated, PNI showed the most consistent associations with treatment response and survival, and was the only independent predictor of major pathological response. The proposed cut-off values offer a practical, cost-effective approach to patient stratification—helping identify those who may need intensified treatment or closer postoperative surveillance.

Background: Emergency laparotomy in older adults is associated with substantial morbidity and mortality, necessitating accurate and rapid preoperative risk stratification. Established risk models such as National Emergency Laparotomy Audit (NELA) and the Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) are widely used, while computed tomography (CT)-derived sarcopenia indices have emerged as potential adjunctive markers of physiological vulnerability. However, the comparative performance of clinical risk scores and paraspinal muscle–based morphometric indices in elderly emergency surgery remains uncertain. The aim of this study was to evaluate the comparative performance of CT-derived morphometric indices, established risk models (NELA and P-POSSUM), and the Prognostic Nutritional Index (PNI) in predicting postoperative morbidity and in-hospital mortality in elderly patients undergoing emergency laparotomy. Methods: This prospective, single-center cohort study included patients aged ≥65 years who underwent emergency laparotomy for acute abdomen between 2022 and 2023. Preoperative risk assessment included the NELA, P-POSSUM, and PNI scores. CT-derived sarcopenia was assessed using the Paraspinal Muscle Index (PSMI) and Fat-to-Muscle Ratio (FMR), measured on contrast-enhanced abdominal CT at the L3 level. Postoperative complications were graded according to the Clavien–Dindo classification. Correlation analyses and receiver operating characteristic (ROC) curve analyses were performed to evaluate associations with postoperative morbidity and in-hospital mortality. Results: A total of 113 patients were included (mean age 74.1 ± 8.1 years; 61.1% male). Major postoperative complications (Clavien–Dindo ≥ 3) and in-hospital mortality were strongly associated with nutritional status. Lower PNI values were significantly associated with major complications, life-threatening complications (Clavien–Dindo ≥ 4), and in-hospital mortality. A PNI cut-off value of approximately 34.5 demonstrated moderate discriminative performance (Area under the curve (AUC) 0.760–0.768), with an AUC of 0.761 (95% CI 0.659–0.851) for mortality prediction. In contrast, PSMI and FMR showed no significant association with postoperative complication severity (PSMI: p = 0.479; FMR: p = 0.614) or mortality and did not correlate with clinical risk scores (all p > 0.05). As expected, NELA and P-POSSUM were significantly associated with postoperative outcomes (all pp =0.77; P-POSSUM vs. P-POSSUM+PNI: ΔAUC=0.032, p =0.17). Conclusions: In elderly patients undergoing emergency laparotomy, established clinical risk scores and nutritional status were strongly associated with postoperative outcomes, whereas CT-derived paraspinal muscle quantity indices did not reflect perioperative risk or complication severity. Future predictive models should integrate nutritional indices, muscle quality measures, functional frailty, and acute physiological parameters to improve risk stratification in elderly emergency surgery.

Background: This study aimed to evaluate the anatomical localization and distribution of parathyroid glands following total parathyroidectomy (TPTx) and bilateral cervical thymectomy (BCTx) in chronic hemodialysis patients with medically refractory secondary hyperparathyroidism (SHPT). Methods: A retrospective study on 154 consecutive SHPT patients with a mean hemodialysis duration of 109.3 ± 63.3 months was conducted.The study focused on the distribution of parathyroid glands within defined anatomical zones identified during surgery. Preoperative imaging methods (ultrasound and technetium-99 m sestamibi scintigraphy) provided limited diagnostic value, successfully localizing glands in only 34.6% and 31% of cases, respectively. Intraoperative parathyroid hormone (iPTH) measurement was not performed in any patient undergoing TPTx and BCTx. Results: Postoperative success was defined by the normalization of iPTH levels, with 76.6% of patients achieving normal iPTH levels on postoperative day one (mean: 12.2 ± 14.1 pg/mL). Persistent SHPT was identified in 36 patients, leading to five complementary parathyroidectomies. The study demonstrated that the anatomical zones defined for parathyroid gland localization are reliable, exhibiting higher accuracy compared to preoperative imaging. Conclusions: The findings support the feasibility of achieving high success rates with TPTx for SHPT, even when preoperative diagnostic tools are limited or ineffective. Knowledge of parathyroid gland distribution within these anatomical zones can significantly assist endocrine surgeons, particularly those who approach this condition with hesitation.

Emphysematous hepatitis (EH) is a rare and often fatal liver infection characterized by gas within the hepatic parenchyma without abscess formation. Diabetes mellitus and gastrointestinal malignancies are the main predisposing factors. Prompt diagnosis and aggressive treatment are essential due to its fulminant course. A 67-year-old male with uncontrolled type 2 diabetes and a long smoking history presented with abdominal pain, nausea, vomiting, dyspnea, and altered consciousness. Laboratory tests revealed elevated liver enzymes, hyperbilirubinemia, severe hyperglycemia, and increased inflammatory markers. Abdominal CT showed a gas-containing lesion in the left hepatic lobe without fluid collection. Due to rapid clinical deterioration, emergency surgical resection was performed. Despite postoperative intensive care and meropenem therapy, the patient died six hours after surgery. Cultures grew E. coli and Enterobacter hormaechei. Only 19 EH cases have been reported to date. Most patients are elderly and have diabetes. Diagnosis relies on CT imaging, which reveals intrahepatic gas without abscess. Pathogenesis may involve anaerobic bacterial fermentation and microcirculatory impairment in diabetic patients. Despite antibiotics and drainage, mortality remains high. EH should be considered in diabetic patients with sepsis and intrahepatic gas on CT. Early diagnosis and immediate intervention—including antimicrobial therapy and drainage—are critical to improving survival.

Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is a rare autoimmune disease characterized by fibroinflammatory lesions and bile duct strictures, often associated with type 1 autoimmune pancreatitis (AIP). Iso-lated IgG4-SC, occurring without AIP, is particularly uncommon and can clinically and radiologically mimic hilar cholangiocarcinoma, presenting with jaundice and bile duct strictures. Accurate differentiation between these conditions is essential, as surgical resection is the standard treatment for cholangiocarcinoma, whereas steroid therapy is the first-line treatment for IgG4-SC. This case report discusses a 55-year-old female patient who underwent left hepatectomy due to a hilar bile duct stricture initially sus-pected to be cholangiocarcinoma but was ultimately diagnosed as isolated IgG4-SC based on postoperative histopathological and immunohistochem-ical findings. The report highlights the diagnostic challenges of isolated IgG4-SC and emphasizes the importance of integrating histology, imaging, and serology to prevent unnecessary surgical interventions.

The principal aim of this research is to investigate the variables that exert a discernible impact on the overall survival (OS) of individuals afflicted with colorectal cancer (CRC) harboring pathologic stages 2-3, as delineated within the TNM staging schema tailored to CRC, an established framework governed by the American Joint Committee on Cancer (AJCC). Patients with preoperative stages 1 and 4, patients with a history of other organ malignancy, patients who could not undergo curative resection, patients with systemic malignant diseases (leukemia, lymphoma, etc.), patients with synchronous tumors, and patients with positive surgical margins were excluded from the study. Notable pathological parameters, including tumor grade, perforation status, lymphovascular invasion, perineural invasion, the presence of mucinous components, and tumor size, were ascertained through pathological examination of resected specimens. Curative resection was performed on 241 patients. The mean age of all patients was calculated to be 65.67±16.04. The average tumor size was measured as 5.03±2.22 cm. The 1-year survival rate of the patients was found to be 84.3%, 3-year survival rate was 69.0%, and 5-year survival rate was 52.9%. According to the COX regression analysis, the categorical variables that were found to be significantly associated with OS were grade (p=0.046), emergency surgery (p<0.001), and tumor localization (p=0.015). The initial patient and tumor characteristics at baseline have demonstrated substantial predictive capacity regarding patient outcomes following disease recurrence. Survival analyses showed that undergoing emergency surgery, having the tumor located in the rectum, and having a "poor" tumor grade adversely affected survival.

Echinococcus granulosus is predominantly found in the liver and can be effectively managed through antihelminthic therapy, surgical intervention, or interventional radiology. Percutaneous treatment (PT) has gained wide-spread popularity due to its minimally invasive nature. An integral step in surgical and PT procedures involves the utilization of protoscolicidal agents to eliminate the parasites. However, the administration of protoscolicidal agents carries the risk of inducing caustic sclerosing cholangitis (SC) if there is a communication between the cyst and the biliary tract. In this pio-neering study, we present two cases of caustic SC that occurred subsequent to PT for hydatid liver, necessitating further progression of the disease and ultimately leading to liver transplantation.