Familial pancreatic cancer: who should be considered for genetic testing?

BACKGROUND: Determining how many female patients who underwent breast imaging meet the eligibility criteria for genetic testing for familial pancreatic cancer (FPC). METHODS: A total of 42,904 patients seen at the Newton-Wellesley Hospital between 2007 and 2009 were retrospectively reviewed. The first four categories were based on pancreatic cancer-associated syndromes: (1) hereditary breast and ovarian cancer (HBOC), (2) Lynch syndrome (LS), (3) familial atypical multiple mole melanoma (FAMMM), and (4) family history of FPC (FH-FPC). PancPRO (5) and MelaPRO (6) categories were based on risk scores from Mendelian risk prediction tool. RESULTS: Exactly 4445 of 42,904 patients were found to be in at least one of the six risk categories. About 5.7% of patients were classified as being at high risk for HBOC, 2.3% as being at high risk for LS, 0.1% as being at high risk for FAMMM, 0.1% as being at high risk for FH-FPC, 2.7% as being at high risk based on PancPRO, and 0.2% as being at high risk based on MelaPRO. CONCLUSION: About 10.4% of the female patients were classified as being at high risk for FPC. This finding emphasizes the importance of applying criteria to the general population, in order to ensure that individuals with high risk are identified early.

A Case of Clostridioides difficile Infection of a Pregnant Woman Treated with Colectomy.

Clostridioides difficile-associated pseudomembranous colitis (PMC) is a life-threatening inflammatory bowel disease. Here, we aimed to present a 40-year-old woman at 25 weeks of gestation whose pregnancy was terminated earlier than expected. Unfortunately, despite fidaxomicin and oral vancomycin, the patient's diarrhea did not improve, and she had to undergo a subtotal colectomy. C. difficile infections developing in pregnant women can be catastrophic for both baby and maternal health. Also, antibiotic stewardship is crucial in the prevention of PMC. Therefore, unnecessary and prolonged use of antibiotics should be avoided.

Intraoperative Neuromonitoring in Thyroid Surgery: An Efficient Tool to Avoid Bilateral Vocal Cord Palsy.

OBJECTIVES: This study aimed to analyze the effects of intraoperative neuromonitoring (IONM) on the prevalence of vocal cord palsy (VCP) in thyroid surgery. METHODS: Data from 493 patients (839 nerves at risk [NAR]) who underwent thyroid surgery between July 2014 and May 2016 were retrospectively evaluated. The patients were divided into 2 groups: Group 1 (G1) consisted of patients who underwent surgery without IONM, whereas group 2 (G2) consisted of patients who underwent surgery with IONM. The surgical techniques were identical, and experienced surgeons performed the procedures in both groups. Intraoperative neuromonitoring was performed in compliance with the International Neural Monitoring Guidelines. RESULTS: In total, 211 patients (170 female, 41 male) with 360 NAR were included in G1, and 282 patients (220 female, 62 male) with 479 NAR were included in G2. The number of VCP per NAR in G1 and G2 was 33 (9.2%) and 27 (5.6%), respectively (P = .005). The number of transient VCP per NAR in G1 and G2 was 27 (7.5%) and 23 (4.8%; P = .230), respectively. The number of permanent VCP per NAR in G1 and G2 was 6 (1.7%) and 4 (0.8%; P = .341), respectively. Bilateral VCP was detected in 4 (2.7%) patients in G1, whereas there was no patient with bilateral VCP in G2 (P = .033). CONCLUSIONS: Intraoperative neuromonitoring may decrease the incidence of total VCP and prevent the development of bilateral VCP, which has unfavorable results for both patients and health-care professionals.

The Impact of Micropapillary Component Ratio on the Prognosis of Patients With Invasive Micropapillary Breast Carcinoma.

Background and Objectives: Invasive micropapillary carcinoma (IMPC) of the breast is a rare and aggressive variant of invasive ductal carcinoma characterized by high-grade lymphovascular invasion and high rates of nodal metastasis. The prognostic significance of the micropapillary component (MC) ratio that constitutes this aggressive variation is controversial. In this study, we aimed to investigate the effect of the MC ratio on the prognosis of these patients. Methods: The data of 47 patients with IMPC were retrospectively reviewed. Patients were divided into two groups: MC ratio of 10-75% (Group 1) and greater than 75% (Group 2). The demographic characteristics of the patients, histopathologic features of the tumors, and survival rates were compared. Results: We detected no significant difference in demographic characteristics between groups 1 and 2 (p = 0.21). No significant difference was detected in terms of tumor diameter, lymph node metastasis, lymphovascular invasion, histologic grade, multicentricity, local recurrence, distant metastasis, and overall survival. Conclusion: In the micropapillary subgroup of invasive ductal carcinoma, although positive receptor characteristics are directly proportional to the increase in MC ratio, recurrence and survival rates are not affected by micropapillary component level.

Colostomy reversal after a Hartmann's procedure Effects of experience on mortality and morbidity.

AIM: Hartmann's procedure (HP) is mostly lifesaving procedure especially for obstructive colorectal carcinomas, but remains bothersome requiring staged operation and subsequent reversal colostomy. We aimed to investigate risk factors for unfavorable surgical outcome after Hartmann's reversal. MATERIALS AND METHODS: Between September 2003 and September 2014, all patients who underwent colostomy reversal surgery after HP were enrolled into the study. Retrospective data collection included demographics (age, gender, body mass index (BMI), ASA scores) primary pathologies, interval period, surgeon who performed procedure [general surgeon (GS)/colorectal specialty (CRS)], postoperative complications and hospital stay. RESULTS: There were 72 patients (49M/23F) with a median age of 64 (range: 29-83) years. The median BMI was 24 (21-44). Most of the patients (82%) had ASA score 3-4. Colorectal cancer was the primary diagnosis in 79% while others included diverticular perforation, volvulus, trauma and Crohn disease. Hartmann's procedure was performed as an emergency in three-fifths of patients. Median interval period between index surgery and reversal colostomy was 7 (1-24) months. The morbidity and mortality rates for colostomy reversal surgery were 34% and 8.3%, respectively. The most common postoperative complication was surgical site infection (22%) followed by anastomotic leak 5%. Mortality and morbidity rates were significantly higher in patients with higher BMI (p=0.031), higher ASA scores (p=0.028) and patients who underwent procedure not by a CRS. CONCLUSION: Reversal colostomy procedure resulted in significant morbidity and mortality, particularly in those with high BMI and ASA scores. Efforts to improve risk management and specialization in colorectal surgery may help to improve the outcome in reversal colostomy after Hartmann's procedure. KEY WORDS: Colorectal surgery, Experience, Hartmann's procedure, Reversal colostomy, Morbidity.

Atypical ductal hyperplasia in men with gynecomastia: what is their breast cancer risk?

PURPOSE: Atypical ductal hyperplasia (ADH) significantly increases the risk of breast cancer in women. However, little is known about the implications of ADH in men. METHODS: Review of 932 males with breast pathology was performed to identify cases of ADH. Patients were excluded if ADH was upgraded to cancer on excision, or if they had contralateral breast cancer. Cases were reviewed to determine whether any male with ADH developed breast cancer. RESULTS: Nineteen males were diagnosed with ADH from June 2003 to September 2018. All had gynecomastia. Surgical procedure was mastectomy in 8 patients and excision/reduction in 11. One patient had their nipple areola complex removed, and 1 required a free nipple graft. Median patient age at ADH diagnosis was 25 years (range 18-72 years). Of the 14 patients with bilateral gynecomastia, 10 had bilateral ADH and 4 had unilateral. Five cases of ADH were described as severe, bordering on ductal carcinoma in situ. No patient reported a family history of breast cancer. No patient took tamoxifen. At a mean follow-up of 75 months (range 4-185 months), no patient developed breast cancer. CONCLUSION: Our study is the first to provide follow-up information for males with ADH. With 6 years of mean follow-up, no male in our series has developed breast cancer. This suggests that either ADH in men does not pose the same risk as ADH in women or that surgical excision of symptomatic gynecomastia in men effectively reduces the risk of breast cancer.

Clinicopathologic Differences Between Micropapillary and Papillary Thyroid Carcinoma.

OBJECTIVES: The aim of this study is observing the clinicopathologic features of thyroid papillary microcarcinomas (PTMs) and comparing these features with papillary thyroid carcinoma (PTC). METHODS: A total of 86 surgically treated patients suffering from PTC were evaluated retrospectively. Group 1 (G1) included patients with a tumor <1 cm, while Group 2 (G2) included patients with a tumor >1 cm. The two groups were compared in terms of the preoperative thyroid-stimulating hormone (TSH) level, anti-thyroid peroxidase antibody (anti-TPO) and antithyroglobulin antibody (TgAb) values, multicentricity, the lymphovascular invasion rate, the presence of extrathyroidal extension, and central and/or lateral lymph node metastasis. RESULTS: There was no statistically significant difference observed between the groups in terms of the preoperative TSH level, anti-TPO, and TgAb values. The rate of multicentricity of the tumor in G2 was 66%, while it was 36% in G1 (p<0.001). The lymphovascular invasion rate in G1 was 14.2%, while it was 61% in G2 (p<0.001). The extrathyroidal extension rate of the tumor cells in G1 was 21.4%, while it was 63.6% in G2 (p<0.001). The central lymph node metastasis rate in G2 was 38.6%, while it was 4.8% in G1 (p<0.001). The lateral lymph node metastasis rate in G2 was 20.5%, while it was 0% in G1 (p<0.001). CONCLUSION: PTMs are generally associated with good prognostic factors with high survival rates. However, the risk factors such as multifocality, extrathyroidal extension, and lymphovascular invasion increasing the recurrence risk are not rare in PTM. Thus, the patients having these histopathological features of the tumor should be followed more carefully.

Emergency computed tomography for the diagnosis of acute appendicitis: How effectively we use it?

BACKGROUND: Technological developments support using ultrasonography (US) in all patients, if available, and advanced diagnostic methods such as abdominal computed tomography (CT) in case of clinical suspicion during diagnostic process of acute appendicitis. We aimed to investigate whether CT was appropriately and efficiently used in the diagnosis of acute appendicitis. METHODS: Between May 2013 and February 2016, 811 patients who underwent appendectomy were retrospectively reviewed from an IRB-approved database, and those who underwent a preoperative CT were enrolled into the study. Results of Alvarado scores and US were recorded in addition to which clinic requested the CT (general surgery or emergency department). RESULTS: The frequency of CT use in the diagnostic process was 25% (n=208/811). Ultrasound was negative for appendicitis in 53% of these patients. The mean Alvarado score was 5±1.5 (range: 3-8). General surgeons requested 57% of CTs. Alvarado scores were significantly higher in patients whose CT was requested by general surgery than in those whose CT was requested by the emergency clinic (5.6 vs. 4.7, p=0.013). Regarding histopathological results, age and Alvarado scores were significantly lower (p=0.015 and 0.037, respectively), whereas the frequency of negative CT was significantly higher (p=0.042) in those with negative appendectomy (n=29, 14%). CONCLUSION: Most patients who underwent CT in the diagnostic process had an Alvarado score between 5 and 8 and negative ultrasound for appendicitis preoperatively. These findings may provide efficient use of CT in the diagnosis of appendicitis with an acceptable rate of 25% compared with the findings in current literature. However, further research is needed to ensure more efficient use of CT because negative appendectomy has been a concern in our series despite promising results of this study.

A comparative study of two techniques in the treatment of condyloma acuminata.

OBJECTIVES: Condyloma acuminata (CA) is mainly caused by human papillomavirus (HPV) types 6 and 11. Clinicians use many different methods to treat analcondyloma acuminate ( CA). In this study, we aimed to compare electrocautery ablation (ECA) and argon plasma coagulation (APC) techniques in terms of postoperative bleeding, pain, scar development, loss of sexual sensation, and recurrence rates. METHODS: A retrospective analysis of collected data was performed for 49consecutive patients with CA, who underwent surgery between July 2011 and July 2014. Patients were grouped and evaluated according to surgical technique, including an ECA group and an APC group. Postoperative bleeding was determined by the number of dressings used in the first postoperative week. Scar severity in the perianal region following ablation therapy was evaluated by scar diameter. A visual analog scale (VAS) was used to measure pain and loss of sexual sensation. All patients were followed for 9 months. RESULTS: There were statistically significant differences between the ECA and APC groups in terms of postoperative bleeding, pain, scar development, and loss of sexual sensation. No difference in recurrence rate was observed. CONCLUSIONS: APC is a safe and effective alternative for the surgical treatment of patients with CA. Although it appears to be more comfortable than ECA techniques, more randomized controlled trials are necessary to reinforce this claim. KEY WORDS: Argon plasma coagulation, Condyloma acuminata, Electrocautery ablation, Human Papilloma Virus, Surgical treatment.

Innervation of the human posterior cricoarytenoid muscle by the external branch of the superior laryngeal nerve.

BACKGROUND: The posterior cricoarytenoid muscle is the abductor muscle for the vocal cords and is innerved by the recurrent laryngeal nerve (RLN). The purpose of this study was to present our determination if the external branch of the superior laryngeal nerve (SLN) contributes to the motor innervation of the posterior cricoarytenoid muscle. METHODS: We performed electromyographies (EMGs) via needle electrodes on 47 posterior cricoarytenoid muscles from 28 patients during thyroidectomy (9 lobectomies and 19 total thyroidectomies) with intraoperative neural monitoring. The RLN, vagus nerve, and external branch of the SLN were stimulated intraoperatively and the responses were evaluated by EMG. RESULTS: Positive EMG responses were obtained from 16 (34%) of 47 posterior cricoarytenoid muscles after external branch of the SLN stimulation. The EMG of the posterior cricoarytenoid muscle was unilaterally positive in 8 of 19 patients (42%) with total thyroidectomy, and 2 of 19 patients (10.5%) were bilaterally positive. CONCLUSION: The external branch of the SLN contributes to the ipsilateral posterior cricoarytenoid muscle innervation in one-third of the cases. This contribution is usually unilateral, but is occasionally bilateral.

A rare cause of acute abdomen: Chylous ascites.

Chylous ascites, defined as a lipid-rich fluid accumulation in the peritoneal cavity, is a rare pathology of the lymphatic system and is a very rare cause of acute abdomen. It is generally associated with diseases such as cancer, cirrhosis, inflammatory diseases, surgery, or trauma. In this study, we report a patient with chylous ascites, which mimics acute appendicitis. Diagnosis and treatment procedures were discussed.

How to avoid negative appendectomies: Can US achieve this?

BACKGROUND: Clinical diagnosis of acute appendicitis is based primarily on symptoms and physical findings. However, diagnosis of appendicitis is not always straightforward. The aim of this study was to demonstrate the diagnostic effectiveness of ultrasonography (US) in these cases in combination with white blood cell count (WBC) and C-reactive protein (CRP) level. METHODS: Retrospective analysis of data collected on 470 consecutive patients who underwent appendectomy at the same institution between January 2014 and January 2016 was conducted. Data included demographic features, preoperative WBC and CRP levels, and US measurement of diameter of appendix. Patients were divided into 3 groups: lymphoid hyperplasia (LH), non-complicated acute appendicitis (NCAA), and complicated acute appendicitis (CAA), according to postoperative histopathological examination results. RESULTS: There were 331 male and 139 female patients with mean age of 32.29±11.44 years included in the study. Mean WBC level was 12.31103/µL (±4.47 103/µL), 13.3 103/µL (±3.87 103/µL) and 14.08 103/µL (±4.11 103/µL) in LH, NCAA, and CAA groups, respectively (p=0.016). Mean CRP level was 14.2±19 mg/L, 36.9±59 mg/L, and 40.8±66 mg/L in LH, NCAA, and CAA groups, respectively (p=0.008). Mean outer diameter of the vermiform appendix on US was 4.8 mm (±3.9 mm), 6.9 mm (±4.08 mm) and 7.6 mm (±3.92 mm) in LH, NCAA, and CAA groups, respectively (p<0.01). When all variables were compared with each other, there were statistically significant differences in US findings according to group. CONCLUSION: WBC count and CRP level were higher in patients with acute appendicitis, but these findings alone were insufficient for definitive diagnosis. US findings were effectual both in diagnosis and demonstration of severe inflammation. US should be combined with laboratory tests and used as standard initial imaging in diagnostic pathway of patients with clinically suspected appendicitis. The authors of this study believe that this diagnostic pathway will reduce negative appendectomy rate.

Giant parathyroid adenoma associated with severe hypercalcemia in an adolescent patient.

BACKGROUND: The objective of this study is to bring attention to the importance of differential diagnosis in adolescent patients with skeletal involvement and hypercalcemia. CASE: A 17-year-old male patient with a complaint of severe leg pain was admitted to our hospital. Seven months before he had a fracture of his distal humerus after falling on to his left shoulder and was treated conservatively. Five months previously, he had a rupture of his quadriceps tendon. Magnetic resonance imaging (MRI) was performed for the quadriceps tendon rupture and was evaluated as polyostotic fibrous dysplasia (PFD). Doctors decided to operate for the ruptured tendon but they detected severe hypercalcemia in the pre-operative blood tests and noticed that the main disease was primary hyper-parathyroidisim (PHPT) which was caused by a giant parathyroid adenoma. Conclusions Giant parathyroid adenoma can present in adolescent patients with multiple bone lesions and severe hypercalcemia. PHPT should be considered in the differential diagnosis of pathological bone fractures and benign bone tumors in every age. This may prevent patients from miss or delayed diagnosis of PHPT.

Is intraoperative neural monitoring necessary for exploration of the superior laryngeal nerve?

BACKGROUND: We aimed to evaluate the contribution of intraoperative neuromonitoring to the visual and functional identification of the external branch of the superior laryngeal nerve and the effect on postoperative voice changes. METHODS: The prospective data of 221 patients (183 women, 38 men) who underwent thyroid operation with intraoperative neuromonitoring for exploration of the external branch of the superior laryngeal nerve were evaluated retrospectively. The surface endotracheal tube-based Medtronic NIM3 (Medtronic, Jacksonville, FL) intraoperative neuromonitoring device was used. The function of the external branch of the superior laryngeal nerve was evaluated by cricothyroid muscle twitch. Additionally, the contribution of the external branch of the superior laryngeal nerve to vocal cord adduction was evaluated using electromyographic records. RESULTS: A total of 374 (95.2%) of 393 external branch of the superior laryngeal nerves were identified; 145 (36.9%) external branch of the superior laryngeal nerves were identified visually before being stimulated with a probe, and 130 (33.1%) external branch of the superior laryngeal nerves were identified visually after being identified with a probe. Although 99 (25.2%) external branch of the superior laryngeal nerves were identified with a probe, they were not visualized. Intraoperative neuromonitoring provided meaningful contributions to visual (P = .001) and functional (P = .001) identification of the external branch of the superior laryngeal nerve. Positive electromyographic responses were recorded from 257 external branch of the superior laryngeal nerves (68.7%). After the patients with recurrent laryngeal nerve palsy were excluded, voice changes were detected in 6 (3.3%) of 184 patients with identified external branch of the superior laryngeal nerves and 3 (20%) of 15 patients in whom at least 1 external branch of the superior laryngeal nerve could not be identified with intraoperative neuromonitoring. CONCLUSION: Intraoperative neuromonitoring provided an important contribution to the visual and functional identification of the external branch of the superior laryngeal nerve. Intraoperative neuromonitoring is a helpful adjunct for identifying the external branch of the superior laryngeal nerve.

Contribution of intraoperative neural monitoring to preservation of the external branch of the superior laryngeal nerve: a randomized prospective clinical trial.

PURPOSE: The purpose of this study was to evaluate the effect of intraoperative neuromonitoring (IONM) on the injury rate of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy. METHODS: A total of 133 consenting patients (98 female, 35 male; mean age, 45.6 ± 11.7 years) undergoing thyroidectomy were randomly assigned to 2 groups. In group 1 (n = 65 patients, 105 nerves), superior thyroid pole dissection was performed with no attempt to identify the EBSLN; in group 2 (n = 68 patients, 106 nerves), IONM was used to identify the EBSLN during surgery. EBSLN function was evaluated by intraoperative electromyography of the cricothyroid muscle. The EBSLN Voice Impairment Index-5 (VII-5) was conducted preoperatively and at 1, 3, and 6 months postoperatively. The primary outcome was the prevalence of EBSLN injury. The secondary outcomes were the identification rate of the EBSLN using IONM and changes in postoperative voice performance. RESULTS: EBSLN injury was detected in eight (12.3%) patients and nine (8.6%) nerves in group 1 and in one (1.5%) patient and one (0.9%) nerve in group 2 (patients, p = 0.015; nerves, p = 0.010). IONM contributed significantly to visual (p < 0.001) and functional (p < 0.001) nerve identification in group 2. The VII-5 indicated more voice changes in group 1 than 2 at 1, 3, and 6 months postoperatively (p = 0.012, p = 0.015, and p = 0.02, respectively). CONCLUSION: IONM contributes to visual and functional identification of the EBSLN and decreases the rate of EBSLN injury during superior pole dissection. Routine use of IONM to identify the EBSLN will minimize the risk of injury during thyroidectomy.

Laparoscopic adrenalectomy in a patient with situs inversus totalis.

Situs inversus totalis(SIT) is a relatively rare condition involving transposition of both the abdominal and thoracic viscera. SIT typically presents as left to right reversal of the viscera combined with dextrocardia, while the individual organs function is normal. Although there are no obvious abnormalities in the function of transposed organs, anatomical irregularity causes important technical difficulties in the surgical treatment of these patients. In this study, we aim to report surgical challenges in laparoscopic adrenalectomy in a patient with SIT.

Inflammatory myofibroblastic pancreas tumor: a case report.

Inflammatory myofibroblastic tumor (IMT) histologically characterized by fibroblastic and myofibroblastic proliferation with inflammatory infiltrate. The therapy adopted was Whipple's pancreaticoduodenectomy with a histological diagnosis of the inflammatory myofibroblastic tumor. The disease that should be considered as the differential diagnosis is pancreatic cancer. The diagnosis and treatment of IMT is surgical resection.

Laparoscopic versus open surgery for hydatid disease of the liver. A single center experience.

BACKGROUND: Cystic Echinococcosis is a chronic parasitic infection, which is still an important problem in rural areas. Due to the development in technology, laparoscopic surgery has been introduced for the surgical treatment of hydatid disease of the liver (HD-L). The present study aimed to evaluate the clinical outcomes of laparoscopic versus open surgery for HD-L in a comparative analysis. METHODS: Between January 2010 and March 2014, medical records of 83 patients who underwent surgery for HD-L were retrospectively analyzed. Patients' demographic data, cystic features, operative details and postoperative outcomes were reviewed from the database. All patients were divided in two groups regarding the surgical approach; Group A (open surgery, n= 69) and Group B (laparoscopic surgery, n= 14) RESULTS: Both groups were similar regarding demographic variables and cystic features. In group B, mean operative time was significantly lower when compared to Group A (89±28 minutes vs. 144±19 minutes, respectively p<0,01). Hospital stay was also lower in laparoscopic group (3.38±0.7 vs 8.81±5.4 p<0,01). Overall postoperative complication was 19% and it was similar between groups. incidence of biliary fistula was 15% (n=13). CONCLUSION: Laparoscopic approach in the treatment of HD-L is safe and feasible. Additionally, it has some advantages including shorter operative time and hospital length of stay. KEY WORDS: Conventional surgery, Hydatid disease of the liver, Laparoscopic approach, Surgical treatment.

Can 4-port laparoscopic cholecystectomy remain the gold standard for gallbladder surgery?

UNLABELLED: Since the first laparoscopic cholecystectomy (LC), laparoscopic approach has been the focus of surgical authorities and continued its technical revolution. With increasing surgical experience, a trend toward even more minimally invasive approaches has led to laparoscopic surgery to new inovations. Current surgical procedures are: four ports (4PLC), still the gold standart technique, three ports (3PLC), two ports (2PLC) and single port laparoscopic cholecystectomy (SPLC). Robotic cholecystectomy (RC) and natural orifice translumenal endoscopic surgery (NOTES) are the other new techniques for performing cholecystectomy. This article aims to make an objective comparision between different types of laparoscopic cholecystectomies by using available medical literature. KEY WORDS: Cholecystectomy, Laparoscopic, Technique.