Post-ERCP Pancreatitis Risk Factors: Is Post-Sphincterotomy Bleeding Another Risk Factor?

BACKGROUND: Despite advancements in technology and expertise, ERCP carries risks of significant complications, such as pancreatitis, bleeding, and perforation. Post-ERCP pancreatitis is the most common and important complication following ERCP. In our study, we aimed to examine the relationship between patient and procedure-related parameters and the development of pancreatitis. METHODS: Four hundred patients who underwent ERCP between January 1, 2019 and December 31, 2020, at the General Surgery Clinic of the Bakirköy Dr. Sadi Konuk Health Application and Research Center of the University of Health Sciences Faculty of Medicine were retrospectively evaluated. Patient and procedure-related factors were analyzed statistically through univariate and multivariate analyses. RESULTS: Age, urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, pancreatic cannulation, pancreatic stent, and bleeding were statistically significant risk factors for post-ERCP pancreatitis (+). In multivariate analysis, the effects of urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, and pancreatic cannulation on post-ERCP pancreatitis were statistically significant risk factors ( P <0.05). DISCUSSION: This study demonstrates that emergency indication, ERCP history, cholangitis, precut sphincterotomy, and pancreatic cannulation are significant risk factors for the development of post- ERCP pancreatitis. One notable contribution of our study to the existing literature is the unique analysis of post-sphincterotomy bleeding as an independent factor.

Comparison of DaVinci Si and Xi robotic platforms for adrenal surgery. Effects on short term outcomes.

OBJECTIVES: To evaluate our experience and short term surgical outcomes between two robotic systems. METHODS: The present study retrospectively analyzed 38 cases, who underwent robotic adrenalectomy between 2012-2019 at our center. The patients were divided into Group Si (n=11) and Group Xi (n=27), and the results of these two groups were compared. RESULTS: Demographic characteristics of both groups were similar between two groups. While, 42% of the patients had Cushing syndrome, 22% had Pheochromocytoma and 22% had Conn syndrome in the Xi group, 72% of the patients were non-secreting adrenocortical adenoma in Si group (p=0.005). The mean docking time in Group Xi was shorter than Si group (p=0.027). Console and total operation times were similar in both groups (p=0.312 and p=0.424; respectively). The intraoperative complication rate (p=0.500) and hospital stay (3.2±1.0 vs. 2.52±1.42 days, respectively, p = 0.077) were similar in both groups. Postoperative 4th and 12th hour Visual Analog Scale (VAS) scores were similar (p=0.213 and p=0.857; respectively). The average cost of robotic consumables was $210 higher in Xi group (p=0.495). CONCLUSION: Our study shows that; the Xi robotic system is as safe as the Si system for adrenalectomy operations. KEY WORDS: Adrenal gland surgery, Minimally invasive adrenalectomy, Robotic surgery.

Risk factors affecting benign anastomotic stricture in anterior and low anterior resections for colorectal cancer: a single-center retrospective cohort study.

PURPOSE: Although not as life-threatening as anastomotic leakage, anastomotic stricture reduces the quality of life. The risk factors for such an important life complication have not been revealed. This article examines the risk factors affecting anastomotic strictures due to colorectal cancers. METHODS: Patients who underwent anterior and low anterior resection for colorectal cancer under elective conditions between 2015 and 2021 were included in the study. The patients were divided into two groups, those who developed anastomotic stricture and those who did not. The parameters determined between the two groups were compared, and multivariate analysis of statistically significant parameters was performed. RESULTS: A total of 375 patients were included in the study. The anastomotic stricture was detected in 36 (9.6%) patients. In the multivariate analysis, non-mobilization of the splenic flexure and a proximal clean surgical margin of < 10 cm and a distal surgical margin of < 2 cm were identified as risk factors affecting anastomotic stricture. The risk factor with the highest odds ratio in the development of anastomotic stricture is the non-mobilization of the splenic flexure (p = 0.001, OR 11.375). CONCLUSION: It is recommended that the mobilization of the splenic flexure to reduce the development of strictures. In addition, a clean surgical margin of 10 cm proximally and 2 cm distally and high ligation of the inferior mesenteric artery may reduce the development of stricture.

Comparison of urgent and elective thyroidectomy complications in Graves' disease.

BACKGROUND: Surgical treatment of Graves' disease (GD) has increased risk for bleeding, hypothyroidism and recurrent laryngeal nerve (RLN) palsy compared to other benign thyroidectomy indications. Nevertheless, it can be done safely in high volume centers. In some particular cases (i.e., anti-thyroid drug intolerance or thyrotoxicosis), urgent surgical treatment might be needed. In this study, we aimed to compare the complications of thyroidectomy in urgent and elective management of Graves' disease. METHODS: The patients, who underwent total thyroidectomy due to Graves' disease between 2012-2019 (n=113) were evaluated retrospectively in terms of demographics, pre-operative laboratory results, management, hospital admissions, operative and post-operative short-term outcomes, morbidity and mortality. Patients who were hospitalized to endocrinology department due to uncontrollable hyperthyroidism and related complications and who were prepared for surgery with Lugol's solution, plasmapheresis and steroids were considered as Urgent Group (n=12). Remaining 101 patients who underwent elective surgery considered as Elective Group. Surgical short-term outcomes, morbidity and mortality rates were compared. RESULTS: Of the 113 patients who were operated for GD, 92 were female and 21 were male. In urgently operated group, FT4 and FT3 levels were significantly higher (p<0.001 and p=0.001, respectively). There was no significant difference in transient or permanent hypocalcemia (p=0.821 and p=0.501, respectively), transient or permanent RLN palsy (p=0.356, p=0.634, respectively) and post-operative bleeding (p=0.338), between elective surgery and rapid optimization groups. CONCLUSION: Emergency surgery for Graves' disease can be performed safely with the application of effective pre-operative treatment protocols. KEY WORDS: Graves' Disease, Thyroidectomy complications, Urgent thyroidectomy.

Risk Factors for Conversion in Laparoscopic Totally Extraperitoneal Inguinal Hernioplasty.

BACKGROUND: Conversion is a surgical concern because the surgical technique can change during surgery. Surprisingly, there is no study in the literature on the causes and risk factors leading to conversion in laparoscopic total extraperitoneal inguinal repair (TEP). There is also no consensus on the prevention and causes of this condition in TEP. The aim of this study was to evaluate the risk factors underlying the development of conversion during TEP. MATERIALS AND METHODS: We recruited 962 consecutive patients who underwent TEP between May 2016 and May 2021. All data were collected retrospectively. The outcomes of patients who converted to open surgery were compared with those without conversion. Multivariate analysis identified independent risk factors for conversion. RESULTS: The overall incidence of conversion was 4.05% (n=39). The median age was 42 years (18 to 83) and body mass index was 25.2 kg/m2 (15.67 to 32.9). Significant clinical factors associated with conversion included old age, American Society of Anesthesiologists (ASA) score, large peritoneal tear (PT), Charlson comorbidity index, previous surgery, large hernial defects, presence of scrotal hernia, and the defect size of inguinal hernia. Multivariate analysis identified independent risk factors for conversion: large hernial defect, large PT, previous lower abdominal surgery, previous hernia surgery, and scrotal hernia. CONCLUSION: Conversion is a minor complication seen during TEP and its incidence varies depending on many factors. Previous lower abdominal surgery and a large PT carries a 6-fold increased risk for conversion from laparoscopic to open surgery during TEP.

Partial cecum resection using endostapler in acute complicated appendicitis with appendiceal base necrosis.

INTRODUCTION: The method of stump closure is controversial in complicated patients, especially with appendix base necrosis or perforation. AIM: To evaluate the efficacy and safety of partial cecum resection technique with an endostapler in patients with appendix base necrosis or perforation. MATERIAL AND METHODS: Thirty-six patients who underwent laparoscopic partial cecum resection due to appendix base necrosis or perforation between 2015 and 2020 were retrospectively analyzed. In acute complicated appendicitis with appendiceal base necrosis or perforation, it was performed by laparoscopic partial cecum resection using an endostapler within a safe surgical margin. Demographic characteristics, duration of operation, days of hospital stay, and intra- and post-operative complications were evaluated. RESULTS: The mean age of the patients is 42.72 ±16.69, female/male ratio was 19/17 (52.8%/47.2%). No intraoperative complications developed. Mean operative time and hospital stay were 104.75 ±34.96, 4.58 ±2.82 days, respectively. Post-operative complications developed in 5 (13.7%) patients. One of them was wound infection (2.7%), 2 of them were ileus (5.5%) and 2 patients had an intraabdominal abscess (5.5%). Stapler line leak was not observed in any of the patients. CONCLUSIONS: The use of an endostapler in laparoscopic appendectomy is a safe and effective technique in cases where appendix base necrosis, appendix perforation or severe inflammation affects the base of the cecum.

Association between Acute Pancreatitis and COVID-19: Could Pancreatitis Be the Missing Piece of the Puzzle about Increased Mortality Rates?

BACKGROUND: The COVID-19 pandemic caused by SARS-CoV-2 commenced in Wuhan China in 2019 and soon spread worldwide. SARS-CoV-2 enters the cell by binding to the ACE II receptor and begins viral replication. The effects and clinical findings of SARS-CoV-2 on the liver, kidney, heart, gastrointestinal (GI) system and especially lungs have been widely discussed. However, the effects on the pancreas-another organ that also expresses ACE II-have not been studied. METHODS: This work prospectively evaluated data from 316 patients who were admitted with a diagnosis of COVID-19 pneumonia. The patients were categorized into three according to the severity of pneumonia (mild, severe, critical). Demographic data, rate of pancreatitis, biochemical parameters, and radiological images from each group were analyzed. The patients were divided into two groups and outcomes were compared: COVID-19 patients with acute pancreatitis (Group P) and without acute pancreatitis (Group C). RESULTS: The median age was 54 (18-87), and the median age for patients with acute pancreatitis was 55 (26-84). As an expected finding, we found a positive correlation between advanced age and mortality (p = 0.0003). 12.6% of the patients had acute pancreatitis. While pancreatitis was not seen in patients on mild status, the rate of pancreatitis was 32.5% in critical patients. Hospitalization and mortality rates were higher in patients with COVID-19 accompanied by acute pancreatitis (p = 0.0038 and p < 0.0001, respectively). C-Reactive Protein (CRP) and ferritin were significantly higher in those who had pancreatitis (p < 0.0001). D-Dimer and procalcitonin levels had only a small difference (p = 0.1127 and p = 0.3403, respectively). CONCLUSION: Acute pancreatitis alone is a clinical condition that can lead to mortality and may be one of the reasons for the exaggerated immune response developing in the progression of COVID-19. Our results point out that the presence of pancreatic damage triggered by SARS-CoV-2 can deteriorate the clinical condition of patients and the mortality rate may increase in these patients.

Clinical adaptation of auxiliary methods and multidisciplinary approach to changing trends in parathyroid surgery.

ABSTRACT: To examine the effects of multidisciplinary approach and adjunct methods, on the surgical strategy, complications and treatment success of parathyroid surgery.Patients, who were operated for primary hyperparathyroidism (n = 411) at our institution between 2012 and 2019 were reviewed retrospectively. Preoperative imaging studies, surgical method, additional diagnostic methods used during surgery, frozen section results, and histopathology findings, complications, persistence, and recurrence were examined.Localization was determined by first-line examinations in 79.9% (n = 348). Four-dimensional computed tomography was used with an 83.3% success rate. Lateralization success for angiographic selective venous sampling was 80.3% and exact localization success was 65.1%. Bilateral neck exploration was performed in 10.6% (n = 37) of the patients, and in the remaining 89.4% (n = 311), minimally invasive parathyroidectomy (MIP) was performed. While the complication rate was higher in the bilateral neck exploration group (P = .019), persistence and recurrence rates were similar between 2 groups. During the study period, annual case volume increased from 9 cases to 103 cases (P < .001) and the rate of MIP increased from 44.4% to 92.8% over the years (P < .001).Effective use of adjunct techniques has increased the rates of MIP. The multidisciplinary approach has also provided low complication rates with the increasing number of cases.

Hormonally Active Adrenal tumors; Challenges and Outcomes for Different Surgical Approaches.

OBJECTIVE: The aim of this study is to compare the intraoperative and short-term outcomes of different surgical approaches for hormone active and non-functional adrenal masses. METHODS: The data of 206 patients who underwent adrenal gland surgery in our clinic between 2012 and 2020 were retrospectively analyzed. Pre-operative outpatient clinic records of the patients, imaging methods, laboratory results and surgery records, operation time (OT), amount of bleeding, duration of hospital stay, and complications were evaluated. Patients were divided into two groups as those with non-functional mass (n=80) and those with hormoneactive mass (n=126). RESULTS: The median age of the patients was 52 (range 19-83) and 77.2% of them were female. Tumor size was larger in hormone active group (p=0.311), and the difference was more pronounced in the pheochromocytoma subgroup (p=0.088). The rate of transition to open surgery was similar in both groups (0.959), and no conversion to laparoscopy or conventional open surgery was performed in robotic cases. The duration of surgery (p=0.669), mean amount of blood loss (p=0.834), and mean hospital stay (p=0.195) were also similar between the two groups. Intraoperative and post-operative complications were similar between two groups (p=0.573 and p=0.415, respectively). Considering the subgroup analysis of the patients in hormone active group; the duration of hospital stay was longer in patients with Cushing syndrome (p=0.001), while there was no difference in OT and estimated blood loss between patients who were operated for Conn, Cushing, and pheochromocytoma (p=0.086 and p=0.099; respectively). CONCLUSION: Surgical results of hormone active adrenal masses were found to be similar to non-functional masses. Although the hormonal condition of the mass does not change the difficulty level of the surgical procedure, it may be recommended that the robotic approach be preferred to facilitate manipulation in these masses.

Comparison of General, Epidural, and Spinal Anesthesia in Laparoscopic TEP (Total Extraperitoneal Repair) for Inguinal Hernia.

PURPOSE: Laparoscopic total extraperitoneal repair (TEP) is one of the most preferred minimally invasive methods for inguinal hernia repair. In our study, we aimed to compare the advantages and disadvantages of general anesthesia (GA), spinal anesthesia (SA), and epidural anesthesia (EA) for TEP operations. MATERIALS AND METHODS: This is a retrospective study involving 221 patients who underwent TEP surgery for inguinal hernia between January 2018 and July 2020. Patients were divided into 3 groups as GA (n=77), SA (n=70), and EA (n=74). Demographic data of the patients, duration of anesthesia and surgery, perioperative and postoperative complications, postoperative pain, anatomical delineation, hospital stay and quality of life were evaluated. RESULTS: Anesthesia time was the longest in the EA group (23.1±2.32 min) and significantly prolonged the operation time (P<0.001). When the visual analog scale scores were compared, it was observed that the patients in the GA group felt significantly more pain (P<0.001). While the rates of hypotension and headache were higher in regional anesthesia (P<0.001 and P<0.002), there was no significant difference in urinary retention, postoperative nausea/vomiting, and shoulder pain (P=0.274, 0.262, and 0.314, respectively). SA and EA groups were found to be superior compared with the GA group in terms of patient satisfaction (P<0.001). CONCLUSION: Regional anesthesia (SA and EA) can be safely performed in TEP surgeries, gives results similar to the anatomical delineation satisfactory and complication rates of GA, and results in less postoperative pain.

Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience.

PURPOSE: Colonoscopic detorsion (CD) is the first treatment option for uncomplicated sigmoid volvulus (SV). We aim to examine the factors affecting the failure of CD. METHODS: The files of patients, treated after diagnosis of SV between January 2015 and September 2020, were retrospectively reviewed. Patients' demographic data, comorbidities, endoscopy reports, and surgical and other treatments were recorded. Patients were divided into two groups, as the successful CD group and unsuccessful CD group. The data were compared between the groups, and multivariate analysis of statistically significant variables was performed. RESULTS: There were 21 patients in the unsuccessful CD group and 52 patients in the successful CD group. The unsuccessful CD rate was found to be 28.76%; this is likely a function of more neuropsychiatric disease, more accompanying sigmoid diverticulum, previous abdominal surgery, abdominal tenderness, onset of symptoms for more than 48 h, higher mean intra-abdominal pressure (IAP), IAP over 15 mmHg, larger mean diameter of the cecum, the cecum diameter over 10 cm, and higher mean C-reactive protein (CRP) values as statistically significant. In the multivariate analysis, previous abdominal surgery and cecum diameter over 10 cm were seen as predictive factors for failure of CD (p=0.049, OR=0.103, and p = 0.028, OR=10.540, respectively). CONCLUSIONS: CD failure rate was significantly associated with previous abdominal surgery and a cecum diameter over 10 cm. We found that patients with these factors will tend to need more emergency surgery.

The role of selective venous sampling in patients with non-localized primary hyperparathyroidism.

OBJECTIVES: The aim of this observational clinical study was to evaluate the success of angiographic selective venous sampling (ASVS) in locating parathyroid adenoma in patients with primary hyperparathyroidism (PHPT), in whom the other imaging modalities have failed, and and to evaluate its possible contribution to the applicability of minimal invasive surgery. MATERIAL AND METHODS: Fifty-five patients who were admitted to our hospital's General Surgery department between January 2012 and January 2015 for PHPT in whom ultrasound and sestamibi scintigraphy have failed to localize the diseased gland were included to the study. Patients were divided into two groups: those who underwent ASVS and those who did not. The outcomes of patients were reviewed retrospectively. RESULTS: Among 55 patients, 20 underwent ASVS. ASVS successfully lateralized the diseased gland in 17 (85%) patients, and minimally invasive parathyroidectomy could be performed in 14 (70%) patients. The cut-off value of parathormon gradient was considered 10% for lateralization and the accuracy of ASVS in lateralization was 94.1%. In 11 (59%) patients, the superior-inferior discrimination could be achieved in addition to lateralization. CONCLUSION: ASVS has a high sensitivity in locating the diseased gland in patients with PHPT in whom ultrasound and sestamibi scan have failed, and thereby, rendering the performance of minimally invasive surgery possible. Further studies may reveal the role of ASVS in providing useful information about not only lateralization but also the superior-inferior discrimination.

What is the Treatment Role of Transpapillary Cholecystostomy for Delayed Cholecystectomy in the Coexistence of Acute Cholecystitis and Cholangitis.

INTRODUCTION: This study aims to investigate the role of main bile duct drainage and gallbladder transpapillary drainage in the treatment of patients who diagnosed with acute cholecystitis and acute cholangitis because of choledocholithiasis. MATERIALS AND METHODS: Patients who were admitted to the hospital with the diagnosis of acute cholecystitis between January 2018 and December 2019, have hyperbilirubinemia in their laboratory tests, and who were diagnosed with choledochal stone by magnetic resonance imaging and magnetic resonance cholangiopancreatography imaging because of the findings of cholangitis were included in this study. These patients underwent endoscopic retrograde cholangiopancreatography (ERCP) and choledochus stone extraction procedure and gallbladder drainage with the transpapillary pigtail. The demographic data, success rates, and complications of the patients were evaluated. RESULTS: A total of 19 patients were included in the study. Choledochus was cannulated in all patients, but gallbladder drainage could not be achieved in 2 patients. These 2 patients were recorded under the unsuccessful method use. Although 2 patients could not be operated because of high comorbidity (American Society of Anesthesiologists IV), they underwent percutaneous cholecystostomy because of the development of cholecystitis arising from an obstruction in the pigtail catheter in the 11th and 12th weeks. Treatments of the remaining 15 patients and subsequent cholecystectomy procedures were successful. The mean age of the patients was 54.52 years. Of the patients, 9 were female and 6 were male. In the 6th week of follow-up, 15 patients underwent laparoscopic cholecystectomy with ERCP 1 day after removal of the stent and pigtail catheter. CONCLUSIONS: Transpapillary cholecystectomy with ERCP is a successful method of treatment in patients with acute cholecystitis with the symptoms of cholangitis because of choledochal stone.

Robotic transperitoneal adrenalectomy from inception to ingenuity: the perspective on two high volume endocrine surgery centers.

BACKGROUND: With increased utilization of robotic technology, robotic adrenalectomy (RA) became popular in certain high-volume centers as an alternative to conventional laparoscopic adrenalectomy (LA). The aim of the present study was to evaluate clinical and surgical outcomes of RA in two high-volume centers in Turkey. METHODS: Between 2012 and 2019, consecutive patients who underwent robotic transperitoneal adrenalectomy in two referral centers for surgical endocrine diseases in Turkey were analyzed retrospectively. RESULTS: A total of 111 patients were analyzed. Mean diameter of the tumor in preoperative imaging was 38.6±2.0 mm. Total operation time was 135.4±47.9 min. The analysis of the learning curve period and the post-learning curve period in both centers demonstrated that the total surgery time decreased from 152.68±48.6 to 118.8±37.1 min, and the console time decreased from 113.2±38.9 to 81.6±35.1 min (P<0.0001). In 8 patients, complications arose during the surgery and postoperative complications were observed in 10 patients. Intraoperative complication rate was 28% in patients with a tumor diameter of greater than 50 mm (P<0.0001). There was no mortality. CONCLUSIONS: Our study demonstrated that RA is a safe and effective procedure with low-morbidity and without mortality in high number of cases.

Pure transoral robotic thyroidectomy; institutional adaptation and early results from a tertiary endocrine surgery centre.

PURPOSE: Novel thyroidectomy techniques have been described to minimize the visible scar. Hereby, we aim to present our experience with transoral robotic thyroidectomy (TORT) without axillary access. MATERIAL AND METHODS: Between August 2018 and March 2019, six eligible patients were enrolled to undergo TORT. Procedures were performed by using the Da Vinci Xi platform under intermittent intraoperative nerve monitoring. RESULTS: All patients were female, and the mean age was 40.0 ± 14.4 years. Three patients underwent total thyroidectomy, and lobectomy was performed for the remaining three patients. In one patient, the procedure was converted to conventional open thyroidectomy due to bleeding. The mean docking time, console time and total operative time were 22.8 ± 5.2 min, 118.5 ± 48.7 min and 218.29 ± 50.6 min for total thyroidectomy and 21.8 ± 4.1 min, 68.6 ± 6.1 min and 177.6 ± 15.1 min for lobectomy, respectively. All patients were discharged uneventfully. CONCLUSIONS: Pure TORT is a safe procedure, when performed in carefully selected patients by experienced surgeons, but further prospective studies with larger number of patients are required.

Transperitoneal laparoscopic surgery in large adrenal masses.

INTRODUCTION: The laparoscopic adrenalectomy (LA) has become the gold standard since the transperitoneal laparoscopic approach was first reported. AIM: To evaluate the applicability, safety and short-term results of laparoscopic surgery in adrenal masses over 6 cm. MATERIAL AND METHODS: Demographic data, hormonal activities, imaging modalities, operative findings, operation time, conversion rates, complications, duration of hospital stay and histopathologic results of 128 patients who underwent laparoscopic adrenalectomy were evaluated retrospectively. Patients included in the learning curve (n = 23), robotic surgery cases (n = 15) and patients with suspected metastasis (n = 4) were excluded from the study. Six cm mass size was taken as a reference and two groups were formed (group 1: < 6 cm, group 2: ≥ 6 cm). The results of the two groups were compared. RESULTS: There were 64 cases in group 1 and 22 cases in group 2. Functional mass ratio and mass sides were similar between the groups (p = 0.30 and p = 0.17, respectively). The mean mass size in group 1 was 36.4 ±11.2 mm and in group 2 82.4 ±15.5 mm. The conversion rate was similar between the two groups (p = 0.18). The duration of surgery was 135.5 ±8.29 min in group 1, 177.0 ±14.9 min in group 2 (p = 0.014). Morbidity and lengths of hospital stay were similar (p = 0.76, p = 0.34 respectively). Adrenocortical carcinoma was detected in three cases in group 1, which were completed laparoscopically, and in two cases in group 2, which were converted to open surgery (p = 0.46). CONCLUSIONS: Although open surgery is still recommended in the guidelines, studies are now being carried out to ensure that laparoscopy can be safely performed on masses over 6 cm. There was no difference between short-term follow-up and histopathologic results in our study.

Effect of intraoperative neuromonitoring on efficacy and safety using sugammadex in thyroid surgery: randomized clinical trial.

PURPOSE: The use of nondepolarizing neuromuscular blocking agents (NMBAs) may affect intraoperative neuromonitoring (IONM) during anesthesia used during thyroid and parathyroid surgery. METHODS: The use of sugammadex was evaluated in a prospective clinical study during thyroid surgery. Between July 2018 and January 2019, 129 patients were prospectively randomized to either the sugammadex group (group B) or the control group (group A). Group A patients underwent standardized IONM during thyroidectomy, while group B patients used an NMBA-reversal protocol comprised of rocuronium (0.6 mg/kg) in anesthesia induction and sugammadex (2 mg/kg) after first vagal stimulation (V0). A peripheral nerve stimulator was used to monitor the neuromuscular transmission. RESULTS: In our clinical study, it took 26.07 ± 3.26 and 50.0 ± 8.46 minutes to reach 100% recovery of laryngeal electromyography at injection of the sugammadex group (2 mg/kg) and the control group, respectively (P < 0.001). The train-of-four ratio recovered from 0 to >0.9 within 4 minutes after administering 2 mg/kg of sugammadex at the beginning of resection. Surgery time was significantly shorter in group B than in group A (P < 0.001). Transient recurrent laryngeal nerve (RLN) paralysis was detected in 4 patients from group A and in 3 patients from group B (P = 0.681). There was no permanent RLN paralysis in the 2 groups. CONCLUSION: Our clinical study showed that sugammadex effectively and rapidly improved the inhibition of neuromuscular function induced by rocuronium. The implementation of the nondepolarizing neuromuscular block recovery protocol may lead to tracheal intubation as well as favorable conditions for IONM in thyroid surgery.

Colonic Stent Use in Patients With Malignant Flexure Tumors Presenting With Obstruction.

BACKGROUND AND OBJECTIVE: Colonic stenting in left-sided tumor is being commonly used. However, placing a stent in the flexure tumors is rare because it is technically more difficult. In this study, we aimed to retrospectively screen patients with flexure tumors admitted to our clinic who were treated using a colonic stent and discuss our findings. METHODS: Patients admitted to the emergency department for obstructive colonic tumors between 2012 and 2017 were retrospectively evaluated, and 21 patients treated using stents were included in the study. The expandable metal stent (Wallflex®, Boston Scientific, Marlborough, MA, USA) was placed at the obstruction through the lead wire. RESULTS: The mean age of the patients was 62 years, and the ratio of females to males was 3:18. Splenic flexure tumors were detected in 18 patients and hepatic flexure tumors in 3 patients. Seven of the patients were stented for palliative purposes. Fourteen of the cases underwent surgery. Three of them underwent laparoscopic surgery and eleven underwent open surgery. CONCLUSIONS: Preoperative stenting in colonic flexura tumors is associated with faster healing, less postoperative complications, lower rates of colostomy, and higher rates of minimally invasive surgery, and can be safely used at experienced centers.

Feasibility of Thyroid Imaging Reporting and Data System Classification in Predicting Thyroid Malignancy.

In this study, we aimed to evaluate the diagnostic value of thyroid imaging reporting and data system (TIRADS) in the estimation of malignancy and assess the concordance between TIRADS and the histopathology results of the postoperative specimens. Consecutive ultrasound imaging records of patients with multinodular goiter from January 2010 to December 2017 who underwent surgery were retrospectively reviewed. The risk of malignancy of each TIRADS category was determined, and correlation with pathology was assessed. The patients with malignant cytology findings (Bethesda 6) who were categorized TIRADS 6 were excluded from the study. The positive and negative predictive values, sensitivity, specificity, and accuracy of the TIRADS classification were calculated on a 2 × 2 table with their own formulas. A total of 1457 patients were evaluated, and 1122 of these were included in the study. The risk of malignancy for nodules evaluated as TIRADS 2 was 0.6 per cent, TIRADS 3 was 13.1 per cent, TIRADS 4a was 20 per cent, TIRADS 4b was 61.1 per cent, TIRADS 4c was 85.7 per cent, and TIRADS 5 was 93.3 per cent. The positive predictive value of TIRADS classification was found to be 43.4 per cent, negative predictive value was found to be 90.7 per cent, sensitivity was found to be 78 per cent, specificity was found to be 68.4 per cent, and accuracy was found to be 70.7 per cent for our institution. The TIRADS classification based on suspicious ultrasound findings is reliable in predicting thyroid malignancy and can be routinely used in daily practice.

Endoscopic repair of rectal perforation due to colonoscopy with a clamp method.

Colon perforation during colonoscopy is a rare complication that usually requires surgical intervention. Traditionally, primary repair by laparoscopy, laparotomy, resection, and anastomosis is performed for such perforations. More recently developed minimally invasive endoscopic instruments have also been used in the repair of these perforations; this is becoming increasingly common. An endoscopic over-the-scope clip clamp was used in a 59-year-old male patient who suffered a rectum perforation in connection with a diagnostic colonoscopy. He was referred to our clinic. A colonoscopy was performed in our clinic to assess the rectal perforation caused by a diagnostic colonoscopy 2 h after the initial colonoscopy, with the concurrent therapeutic purpose of repairing the perforation using an endoscopic clamping method. Oral feeding was started 24 h after the procedure. After three days, the patient was discharged. An endoscopic clamping method in appropriate cases can be a safe and appropriate alternative therapy in the management of colonoscopic perforations.