Does the intraoperative parathormone monitoring really affect surgical success in primary hyperparathyroidism?

BACKGROUND: Surgery is the only curative treatment option for primary hyperparathyroidism (PHPT). The intraoperative parathormone (IOPTH) monitoring is recommended to confirm that all pathological glands have been removed. This study aimed to evaluate the effect of IOPTH monitoring on the surgical success of parathyroidectomy performed for PHPT. METHODS: The demographic, biochemical, operative and pathological data of patients who underwent parathyroidectomy for PHPT in a single institute over a three-year period were retrospectively analyzed. RESULTS: The total number of patients included in the study was 182. The IOPTH monitoring had been performed in 92 patients (50.5%). The IOPTH monitoring had a clinical accuracy of 89.2%, sensitivity of 89.8%, and specificity of 75%. The rate of surgical success was 95.7% in the group with IOPTH monitoring and 91.1% in the group without this monitoring (p = .21). Of the 40 patients who underwent minimally invasive parathyroidectomy (MIP), 25 patients had IOPTH monitoring, and the surgery was successful for all these patients (100%). Surgical success was achieved in 14 (93.3%) patients who underwent MIP without IOPTH monitoring (p = .37). CONCLUSION: The IOPTH monitoring is a reliable test with high accuracy. The lack of IOPTH monitoring may result in lower than acceptable surgical success rates. Even though preoperative localization studies are compatible with surgical findings, the IOPTH monitoring should also be undertaken, especially in patients scheduled for MIP for PHPT.

The Effect of Primary Surgery in Patients with De Novo Stage IV Breast Cancer with Bone Metastasis Only (Protocol BOMET MF 14-01): A Multi-Center, Prospective Registry Study.

BACKGROUND: More evidence shows that primary surgery for de novo metastatic breast cancer (BC) prolongs overall survival (OS) in selected cases. The aim of this study was to evaluate the role of locoregional treatment (LRT) in BC patients with de novo stage IV bone only metastasis (BOM). METHODS: The prospective, multicenter registry study BOMET MF14-01 was initiated in May 2014. Patients with de novo stage IV BOM BC were divided into two groups: those receiving systemic treatment (ST group) and those receiving LRT (LRT group). Patients who received LRT were further divided into two groups: ST after LRT (LRT + ST group) and ST before LRT (ST + LRT group). RESULTS: We included 505 patients in this study; 240 (47.5%) patients in the ST group and 265 (52.5%) in the LRT group. One hundred and thirteen patients (26.3%) died in the 34-month median follow-up, 85 (35.4%) in the ST group and 28 (10.5%) in LRT group. Local progression was observed in 39 (16.2%) of the patients in the ST group and 18 (6.7%) in the LRT group (p = 0.001). Hazard of death was 60% lower in the LRT group compared with the ST group (HR 0.40, 95% CI 0.30-0.54, p < 0.0001). CONCLUSION: In this prospectively maintained registry study, we found that LRT prolonged survival and decreased locoregional recurrence in the median 3-year follow-up. Timing of primary breast surgery either at diagnosis or after ST provided a survival benefit similar to ST alone in de novo stage IV BOM BC patients.

A scoring system for preoperative assessment of resectability in periampullary neoplasms.

BACKGROUND: To identify the preoperative factors predicting resectability in periampullary neoplasms. METHODS: Twenty-three different parameters representing the clinical, laboratory and radiological data of 65 patients, who were operated for periampullary neoplasms, were analyzed to determine their value in assessing neoplasm resectability. Coefficients were calculated by Cox regression analysis for significant factors. A scoring system was designed for resectability. All patients were divided into 4 groups according to their scores. RESULTS: Twenty-six patients who had a resectable neoplasm underwent pancreatico-duodenectomy and surgical palliation was performed in the remaining 39 patients. After multivariate analysis, neoplasms larger than 4.5 cm, low leukocyte count (<9500/mm3), high bilirubin levels (>137.5 micromol/L) and tomographic findings indicating neoplasm invasion were found to be independent factors predicting resectability. The score range was between 0 and 12. Patients were grouped as Group-1 (total score 0-2), Group-2 (total score 3-5), Group-3 (total score 6-8), and Group-4 (total score 9 and higher). Resectability rates were 100% in Group 1 (n=13), 44% in Group-2 (n=23), 21% in Group-3 (n=14), and 0% in Group-4 (n=15), respectively. Mean score was 3.3 in patients with resectable lesions and 7.2 in patients with unresectable lesions (p<0.001). CONCLUSION: This simple scoring system can be a guide in the management plans of patients with periampullary neoplasms. By using this scoring system, patients with an unresectable neoplasm can be predicted and most unnecessary laparotomies can be avoided (Tab. 3, Fig. 2, Ref. 27). Full Text (Free, PDF) www.bmj.sk.

The significance of pulmonary nodule in breast cancer patients.

BACKGROUND: Pulmonary nodule in patients with breast cancer is a difficult problem and constitutes a therapeutic challenge. This study questioned the significance of solitary pulmonary nodule in breast cancer patients and compared the survival with patients who had normal thorax tomography. METHODS: There were 58 breast cancer patients included in the study. From these, 28 patients had normal preoperative tomography (group 1), and 30 patients had pulmonary nodule less than 1 cm on thorax tomography (group 2). Chi-square and Fisher tests were used for comparisons and Kaplan-Meier test for survival. RESULTS: Stage, tumour size, treatment, histology, lymph node involvement, adjuvant therapy, were similar in both groups. We did not find a significant difference in disease-free and overall survival rates, between two groups. CONCLUSIONS: For the nodules that show benign properties at tomography, there is no need to do further investigation and no need to change treatment plan in breast cancer patients (Tab. 2, Fig. 2, Ref. 12). Full Text (Free, PDF) www.bmj.sk.

The Effect of BRAF V600E Mutation on Lymph Node Involvement in Papillary Thyroid Cancer.

OBJECTIVES: Papillary thyroid cancer (PTC) is the most common well-differentiated thyroid cancer. Lymph node (LN) metastasis is frequently seen in PTC. The effect of BRAFV600E mutation on PTC-associated LN metastasis has not been clearly established. Therefore, we aimed to evaluate the effect of the BRAFV600E mutation in patients with PTC on regional LN metastasis. MATERIAL AND METHODS: Between January 2013 and 2017, sixty-three PTC patients who underwent central lymph node dissection were included into the study. The patients were divided into two groups according to the pathology results of the LN dissection, and these groups were compared for positive BRAFV600E mutations and other clinicopathological findings. RESULTS: BRAFV600E mutation was found to be more significant in the pLN1 group (p= 0.005). Multivariate analysis revealed that nodule size, microcalcifications, and BRAFV600E mutation were associated with lymph node metastasis independent of other parameters. ROC analysis also evaluated the adequacy of the BRAFV600E mutation in predicting the presence of LN involvement. AUC: 0.738 (95%CI:0.6110.866,p: 0.002). CONCLUSION: In our study, independent of other parameters, BRAFV600E gene mutation was found to be effective on lymph node involvement.

Associated Features with Non-Sentinel Lymph Node Involvement in Early Stage Breast Cancer Patients who Have Positive Macrometastatic Sentinel Lymph Node.

OBJECTIVE: The main goal of this study is to determine the clinico-pathological factors that correlate non-sentinel lymph nodes (LNs) involvement in clinically node negative breast cancer (BC) patients with positive macrometastatic sentinel lymph node (SLN) in order to derive future evidence to define a subgroup where completion axillary lymph node dissection (cALND) might not be recommended. MATERIALS AND METHODS: Total 289 SLN biopsies were performed in clinically node negative BC patients between March 2014 and April 2017. Seventy patients who performed cALND due to positive macrometastatic SLN were retrospectively selected and classified into two groups, according to non-SLN involvement (NSLNI). Clinico-pathological features of patients were examined computerized and documentary archives. RESULTS: Extracapsular extension (ECE) of SLN, number of harvested SLNs, metastatic rate of SLNs, absence of ductal carcinoma in situ (DCIS) and presence of multilocalization were significantly associated with the likelihood of non-SLN involvement after univariate analysis (p<0,05). Absence of DCIS and presence of multilocalization were found to be significant after multivariate analysis. CONCLUSION: Careful examination of clinico-pathological features can help to decide avoiding cALND if enough LNs are removed and the rate of SLN metastases is low, particularly in case DCIS accompanying invasive cancer in patients without multi localized tumour.

Effect of montelukast and MK-886 on hepatic ischemia-reperfusion injury in rats.

BACKGROUND: Hepatic ischemia-reperfusion injury (I/R) may occur in transplantation, trauma, and elective hepatic resections. Leukotrienes have been shown to play a major role in hepatic I/R injury. Five-lipoxygenase enzyme is an important enzyme in the production of leukotrienes from arachidonic acid. MK-886 is an inhibitor of 5-lipoxygenase, and montelukast is a cysteinyl leukotriene receptor antagonist. The aim of this study was to investigate whether MK-886 and montelukast are effective in preventing hepatic I/R injury. MATERIALS AND METHODS: Rats were divided into five groups consisting of seven rats in each: (1) Control I/R, (2) Control-montelukast, (3) Control-MK-886, (4) I/R+montelukast, and (5) I/R+MK-886. Thirty min of total hepatic vascular occlusion and then 60 min reperfusion were performed to animals in groups 1, 4, and 5. In groups 2 and 4, montelukast, and in groups 3 and 5, MK-886 was applied intraperitoneally before and during the surgical procedures. RESULTS: Apoptosis in the liver and intestine decreased significantly in the I/R+montelukast and I/R+MK-886 groups compared with the I/R group. Tissue malondialdehyde levels and glutathione consumptions also decreased significantly in the I/R+montelukast and I/R+MK-886 groups compared with the I/R group. The difference in serum alanine aminotransferase and aspartate aminotransferase levels between the groups did not reach significance. CONCLUSIONS: Montelukast and MK-886 were found to be effective in prevention of liver and intestine injury by reducing apoptosis and oxidative stress in a hepatic I/R model. Anti-inflammatory properties and inhibition of lipid peroxidation by montelukast and MK-886 could be protective for these organs in I/R injury.

Stratifying the risk factors for hypoparathyroidism after total thyroidectomy. A single Center study.

BACKGROUND: Post-operative hypoparathyroidism is a complication in patients who undergo thyroid surgery. Our study aimed to evaluate the incidence and causes of post-operative transient and permanent hypoparathyroidism in patients undergoing thyroid surgery. MATERIALS AND METHODS: The data of 933 consecutive patients who underwent total thyroidectomy in a single center were retrospectively evaluated. The rate of post-operative hypoparathyroidism, clinicopathological features, and laboratory parameters during the post-operative first day, first month, and first year of patients with and without hypoparathyroidism were analyzed. Patients with hypoparathyroidism were classified as transient or permanent cases. RESULTS: The incidence of post-operative hypoparathyroidism was 22.7%, including transient (20.6%) and permanent (2.1%). In multivariable analysis, independent predictors of permanent hypoparathyroidism were as follows: surgery due to malignant thyroid disease, tumor multifocality, and pre-operative vitamin-D deficiency (VDD) (p<0.001, 0.047, and 0.002, respectively). During the post-operative first month, the mean serum PTH levels were found to be 7.58 pg/mL, and they remained low on the post-operative first year in patients with permanent hypoparathyroidism. CONCLUSION: Surgery due to thyroid malignancy and VDD should be considered risk factors for permanent hypoparathyroidism in patients who undergo thyroid surgery. The post-operative first month is important in the prediction of permanent hypoparathyroidism. KEY WORDS: Hypoparathyroidism, Permanent, Transient.

A rare cause of primary hyperparathyroidism: Parathyroid lipoadenoma.

OBJECTIVE: The main cause of primary hyperparathyroidism is a single parathyroid adenoma. Parathyroid lipoadenomas contain abundance of fat cells. Because of these histological features, they can mimic normal parathyroid tissue at the histopathologic examination and radiological imaging could be difficult to localize lipoadenomas. CLINICAL PRESENTATION: In this case report, we present three cases of functional parathyroid lipoadenomas. CONCLUSION: Preoperative imaging modalities often can't localize lipoadenoma. In our cases, SPECT has seen more successful than ultrasonography or CT. There may not be gender predominance at parathyroid lipoadenomas. Intraoperative pathology consultation and rapid biochemical workup can help the surgeon in difficult cases.

Thyroid incidentalomas: prediction of malignancy and management.

The treatment strategy of an incidentally detected thyroid nodule is controversial. The aim of this study was to establish management criteria for thyroid incidentalomas by defining and formulating the risk factors predicting thyroid malignancy. A prospective database containing 815 consecutive patients who underwent a thyroidectomy for nodular thyroid disease, between January 1992 and May 2003, was studied. Multivariate analyses demonstrated that the independent clinical predictors of malignancy were a fixed nodule and cervical lymphadenopathy on palpation, a euthyroid patient, and a patient age <23 years or >45 years; and independent nodule features significantly associated with malignancy were punctuate calcifications, irregular nodule margin, solid appearance on ultrasonography, and solitary nodule in an euthyroid patient. Using the regression coefficients of four independent ultrasound (US) features, a malignancy risk score of a nodule was calculated as follows. Depending on the score of a thyroid nodule, a simple follow-up, a US-guided fine needle aspiration biopsy or a thyroidectomy, may be offered for management.

Phyllodes Tumor of the Breast: Analysis of 48 Patients.

OBJECTIVE: Phyllodes tumor (PT) is a rare biphasic breast neoplasm that accounts for less than 1% of all breast tumors. The aim of this study was to evaluate the clinicopathologic features, diagnostic difficulties, and therapeutic outcomes of patients with PT. MATERIALS AND METHODS: A total of 48 female patients who underwent surgery for PT were included in the study. Patient characteristics, clinicopathologic features of tumors, diagnostic findings, surgical outcomes, adjuvant therapies, and follow-up findings were retrospectively evaluated. RESULTS: The mean age of patients was 35 years. Painless breast mass was the most common (85.4%) presenting symptom. Total excision with at least 1 cm macroscopic clear margins was the most frequently performed (87.5%) surgery. Most patients (n=34, 70.8%) had benign PT; however, borderline and malignant tumors were found in 9 (18.8%) and 5 (10.4%) patients, respectively. During the mean follow-up period of approximately 30 months, local and distant recurrence was detected in three (6.3%) patients and one (2.1%) patient, respectively. Patients with malignant PT had larger tumors than those with benign and borderline PTs (p=0.010). No significant difference in other clinical, diagnostic, and pathologic characteristics was found between the groups. CONCLUSION: PT can be easily confused with other breast masses such as fibroadenoma due to the non-specific clinical and radiologic findings. Surgical excision with at least 1 cm clear margins is of great importance to reduce the risk of local recurrence. However, recurrence can develop even after appropriate surgery, thus patients should be closely followed up after surgery.

[Importance of lumbar vertebra transverse process fractures in multitrauma patients who had undergone emergent laparotomy]. / Acil laparotomi yapilan multitravmali hastalarda lomber vertebra transvers çikinti kiriklarinin önemi.

BACKGROUND: To evaluate the incidence and importance of lumbar vertebra transverse process fractures in polytraumatized patients who had undergone emergent laparatomy, and to find out the relevant risk factors. METHODS: The medical records of 312 laparotomized trauma patients who referred to our emergency department between January 2001 and January 2002 were retrospectively assessed. Hundred and six cases who met inclusion criteria were investigated. Data relevant to the trauma, demographics, hemoglobine levels, additional system traumas, complications were recorded. Correlations between collected data and the fractures were investigated. Results were evaluated statistically using SPSS 11,0 software package program. RESULTS: Lumbar vertebra transverse process fractures were detected in 58,5 % of the cases. They were more frequently encountered in women, elderly and after falls or traffic accidents.. Abdominal organ injuries were more common in these cases. These fractures are associated with hepatic and splenic injuries. Their presence also increases the risk of vertebra corpus fractures seven fold. CONCLUSIONS: Lumbar vertebra transverse process fractures usually occur after higher energy traumas They must be evaluated as serious findings which might lead to potential organ injuries. Once these fractures were detected in trauma patients, every attempt should be made to exclude probably fatal and more serious additional organ injuries.

Using a risk score for conversion from laparoscopic to open cholecystectomy in resident training.

BACKGROUND: We previously developed a risk score for conversion from laparoscopic to open cholecystectomy (RSCLO). The aim of this study is to validate this scoring system in a new patient population and test its use in case selection for resident training. METHODS: The data of 1,000 laparoscopic cholecystectomies (LC) that had been performed in our clinic between 1992 and 1999 were analyzed retrospectively, and RSCLO was developed. Scores take values between -20 and 41; values below -3 represent low risk, and values over -3 represent high risk. Analyses in this group of patients showed that at least 15 cases have to be performed for adequate LC training. The current study is a clinical prospective study based on data of the previous study and evaluates RSCLO in a new patient population of 400 LCs. All patients were scored preoperatively; surgeons who had performed 15 or fewer LCs previously operated only patients with a score below -3. Patients with high scores (>values of -3) were operated only by surgeons who had performed at least 16 LCs. Results of the first 1,000 cases and later 400 cases (new patient population of the current study) were compared in terms of conversion to open cholecystectomy, complications, and operation times. RESULTS: Both in the first 1,000 patients and later in 400 patients, increasing scores resulted with higher conversion rates and complication rates and longer operation times (P<.05). In the later 400 patients, conversion rate (4.8% vs 3.0%, P=.08), complication rate (5.5% vs 3.5%, P=.07), and mean operation time (56.8 min vs 52.5 min, P=.004) were decreased when compared with the first 1,000 patients. In resident training cases, conversion and complication rates decreased to 0%, and mean operation time was shortened by nearly 10 minutes. In high-score difficult cases, conversion and complication rates decreased, and mean operation time was shortened by nearly 20 minutes. CONCLUSIONS: This risk score can predict the difficulty of LC cases reliably. Scoring patients preoperatively can decrease the problems in training cases, and management of difficult cases may be left to experienced surgeons.

Effect of topically applied charged particles on healing of colonic anastomoses.

HYPOTHESIS: Various forms of electrical stimulation can improve wound healing in different tissues, but their application to gastrointestinal tract healing has not been investigated. We assumed that positively charged diethylaminoethyl cross-linked dextran bead (diethylaminoethyl Sephadex [DEAE-S]) particles would have a beneficial effect on the healing of colonic anastomoses. DESIGN: Experimental animal study. SETTING: Animal research laboratory of a university hospital. ANIMALS: Forty female Wistar albino rats. INTERVENTIONS: Right colonic transection and anastomosis was performed in 5 animal groups. The control group received no treatment; the placebo group, methylcellulose gel; and the DEAE-S group, DEAE-S in methyl cellulose gel applied topically around the anastomoses. The fecal peritonitis (FP) group underwent cecal ligation and perforation simultaneously with the anastomosis to cause FP; the FP + DEAE-S group also received DEAE-S applied around the anastomoses. MAIN OUTCOME MEASURES: After the completion of postoperative day 4, all rats were killed. Anastomotic bursting pressures and hydroxyproline concentrations in perianastomotic tissue were measured and compared. RESULTS: Mean bursting pressures were 115.1 mm Hg in the control group, 113.6 mm Hg in the placebo group, 159.4 mm Hg in the DEAE-S group, 62.8 mm Hg in the FP group, and 121.1 mm Hg in the FP + DEAE-S group (P =.001, 1-way analysis of variance [ANOVA]). The differences between the control vs DEAE-S groups, placebo vs DEAE-S groups, and FP vs FP + DEAE-S groups were significant (P<.05, t test). Mean hydroxyproline concentrations were 5.2 microg/mg in the control group, 4.9 microg/mg in the placebo group, 5.6 microg/mg in the DEAE-S group, 4.5 microg/mg in the FP group, and 5.4 microg/mg in the FP + DEAE-S group (P =.09, 1-way ANOVA). The difference between the FP and FP + DEAE-S groups was significant (P =.04, t test). CONCLUSIONS: A positively charged particle, DEAE-S, improves healing of colonic anastomoses in healthy rats and in rats with FP. This inexpensive, nontoxic material is easily applied and deserves further evaluation in gastrointestinal tract healing.

Intestinal ischemia-reperfusion injury augments intestinal mucosal injury and bacterial translocation in jaundiced rats.

BACKGROUND/AIMS: The aim of this study was to evaluate local effects and degree of bacterial translocation related with intestinal ischemia-reperfusion injury in a rat obstructive jaundice model. METHODOLOGY: Thirty adult Sprague-Dawley rats (200-250 g) were divided into three groups; including Group 1 (jaundice group), Group 2 (jaundice-ischemia group) and Group 3 (ischemia group). All rats had 2 laparotomies. After experimental interventions, tissue samples for translocation; liver and ileum samples for histopathological examination, 25 cm of small intestine for mucosal myeloperoxidase and malondialdehyde levels and blood samples for biochemical analysis were obtained. RESULTS: Jaundiced rats had increased liver enzyme levels and total and direct bilirubin levels (p<0.05). Intestinal mucosal myeloperoxidase and malondialdehyde levels were found to be high in intestinal ischemia-reperfusion groups (p<0.05). Intestinal mucosal damage was more severe in rats with intestinal ischemia-reperfusion after bile duct ligation (p<0.05). Degree of bacterial translocation was also found to be significantly high in these rats (p<0.05). CONCLUSIONS: Intestinal mucosa is disturbed more severely in obstructive jaundice with the development of ischemia and reperfusion. Development of intestinal ischemia-reperfusion in obstructive jaundice increases bacterial translocation.

Laparoscopic cholecystectomy under spinal anesthesia.

BACKGROUND: Advantages of laparoscopic cholecystectomy (LC) such as less pain and short hospital stay make it the treatment of choice for cholelithiasis. There are limited data about LC under spinal anesthesia. This study was designed to evaluate LC under spinal anesthesia. METHODS: Twenty-nine patients underwent surgery for LC under spinal anesthesia at the 4th Department of Surgery of the Ankara Numune Education and Research Hospital between April 2005 and January 2006. All patients were informed about spinal anesthesia in detail. The patients also were informed about the risk of conversion to general anesthesia, and all patients provided informed consent. The election criteria for spinal anesthesia were as follows: American Society of Anesthesiologists (ASA) risk group 1 or 2; risk score for conversion from LC to open cholecystectomy (RSCO) less than negative 3; and presence of gallstone disease. Standard laparoscopic technique was applied to all patients. Simple questionnaire forms were developed for both patients and surgeons to provide comments about the operation. RESULTS: The operation was completed laparoscopically on 26 patients, while 3 patients needed general anesthesia due to severe right shoulder pain. None of the patients had cardiopulmonary problems other than transient hypotension during surgery. Intravenous fentanyl (25 microg) was needed in 13 patients due to severe right shoulder pain. Five patients still had severe shoulder pain after fentanyl injection. Local washing of the right diaphragm with 2% lidocaine solution was successful in the remaining 5 patients in whom fentanyl injection failed to stop the pain. All of the patients' answers to the questions regarding the comfort of operation were "very well" at the 1-month postoperative evaluation. All surgeons stated that there was no difference from LC under general anesthesia. CONCLUSIONS: All of the patients and surgeons were satisfied with LC under spinal anesthesia. Therefore, LC under spinal anesthesia may be an appropriate treatment choice to increase the number of patients eligible for outpatient surgery.