ARE THYROID NODULES AN OBSTACLE TO MINIMAL INVASIVE PARATHYROID SURGERY? A SINGLE-CENTER STUDY FROM AN ENDEMIC GOITER REGION.

CONTEXT: Minimally invasive parathyroidectomy (MIP) procedure has become a widely accepted alternative to the standard four-gland exploration nowadays. OBJECTIVE: The aim of this study was to evaluate patients with primary hyperparathyroidism (PHPT), who had been treated with thyroidectomy and bilateral neck exploration (BNE), rather than MIP alone, due to coexisting thyroid nodules and to determine the benefits of simultaneous thyroidectomy and the possible negative outcomes of not performing this additional procedure. DESIGN: There were 185 patients who were operated for PHPT at our clinic from January 2014 to November 2016. SUBJECTS AND METHODS: 50 patients meet inclusion criteria: have thyroidectomy at the same time of parathyroid surgery, have concordant findings of parathyroid adenoma localization at preoperative MIBI-SPECT and the cervical US and have not had malignancy on fine needle aspiration biopsy (FNAB). RESULTS: The mean age of the patients was 55.3±10.4, and female to male ratio was 7:1. All patients had parathyroidectomy with BNE and thyroidectomy: 11 (22%) patients had micropapillary thyroid cancer (mPTC), 2 (4%) had papillary thyroid cancer (PTC). CONCLUSION: The results were inconclusive in clearly demonstrating which patients presenting with coexisted thyroid nodules should undergo thyroidectomy, rather than MIP, and which should be monitored for thyroid nodules after MIP. However, we consider that in cases who are not clearly indicated for thyroidectomy, MIP followed by monitoring of thyroid nodules can be the treatment approach.

Effectiveness of breast electrical impedance imaging for clinically suspicious breast lesions.

OBJECTIVES AND BACKGROUND: This study was designed to compare the usefulness of the breast electrical conductivity measures performed in a surgical examination room against conventional breast screening modalities for identifying the symptomatic lesions of the breast tissue. METHODS: A group of 181 patients were examined with Ultrasonography (USG), Mammography (MG), Electrical Impedance Scanning (EIS) modalities and were followed-up 24 months to clarify in terms of the lesion tumour progression relationship. Tumour biopsy was determined as an endpoint of the study. RESULTS: According to USG, 13 (7.2 %) lesion were suspicious, where as EIS was reported 22 (12.2 %). 2 of these 9 patients were presented as BI-RADS 4 and histopathologic result was proven as malignant disease during 6 months short-interval follow-up. EIS exhibited compatible sensitivity (81.2 %), accuracy (84.6 %) and PPV (81.8 %) rates with USG in BI-RADS 4 subgroup, combination of these modalities raised sensitivity rates to 92.31 %, accuracy and PPV to 100 %. EIS results in BI-RADS 3 subgroup were pointed out 77.8 % specificity and 87.5 % NPV rates. CONCLUSION: Breast electrical impedance measures should be useful to reduce the number of the unnecessary follow-up and biopsy rates in the clinical setting (Tab. 2, Fig. 2, Ref. 39).

Clinical determinants of suppurative cholangitis in malignant biliary tract obstruction.

BACKGROUND: The purpose of this study was to find the factors predicting the supurative cholangitis in malignant biliary tract obstruction. METHODS: During the period of 1992-2003, 107 patients were operated on for malignant obstruction of the biliary tract. Obstructions were due to gall bladder cancer (n = 4), cholangiocarcinoma (n = 21) or periampullary tumor (n = 82). Sixteen patients were found to have suppurative cholangitis at laparotomy. Among the patients with suppurative cholangitis, eight were males and eight were females with a mean age of 62 (range 42-85) years. The chi-square analysis and student-t test were employed for correlation of individual risk factors with cholangitis. Stepwise logistic regression analysis was then used to identify independent risk factors. RESULTS: Only seven patients with supurative cholangitis (43.8 %) had the Charcot's triad of symptoms and one had the Reynold's pentad. Six of 16 patients survived postoperatively and were discharged from hospital while nine patients died during the first hospital admission. There were five cases of death due to biliary sepsis, two cases of anastomotic leakage, one acute renal failure, and one case of intra-abdominal hemorrhage and sepsis. Multivariate logistic regression analysis showed that a number of variables can serve as independent predictors of suppurative cholangitis, namely the fever, leukocytosis, high bilirubin level and ERCP performed in preoperative period. CONCLUSION: Identification of these risk factors may be worthwhile in the early diagnosis and treatment of the disease. Fever, high bilirubin level, leukocytosis and ERCP performed in the preoperative period were independently associated with suppurative cholangitis (Tab. 3, Ref. 20).

Intrabiliary rupture of a hepatic hydatid cyst: associated clinical factors and proper management.

HYPOTHESIS: The prediction of an intrabiliary rupture of a hepatic hydatid cyst using associated clinical factors is important for early diagnosis and proper management. DESIGN: Case series of patients with hepatic hydatid cysts treated between January 1, 1992, and January 1, 2000, in a single institution. SETTING: A tertiary care teaching hospital. PATIENTS: The clinical findings in 116 patients with a hepatic hydatid cyst were reviewed. Of the 116 patients, 24 (21%) had a cyst-biliary communication: 15 (13%) had an occult rupture, and 9 (8%) had a frank rupture. MAIN OUTCOME MEASURES: The following variables were analyzed as potential predictors of an intrabiliary rupture: age, sex, type and duration of symptoms, findings on physical examination, leukocyte count, liver function test results, serologic test results, suggestive ultrasonographic findings, ultrasonographic cyst features (type, diameter, number, and localization), and whether the cyst is primary or recurrent. RESULTS: The independent clinical factors for the presence of an occult rupture were a history of nausea and vomiting (P = .004), alkaline phosphatase level greater than 144 U/L (P = .004), total bilirubin level greater than 0.8 mg/dL (>13.5 micromol/L) (P< .001), and cyst diameter greater than 14.5 cm (P< .001) in multivariate analysis. Multivariate analysis also showed that history of jaundice (P< .001), jaundice found on physical examination (P = .05), cyst diameter greater than 10.5 cm (P = .009), a type IV cyst (P< .001), and suggestive ultrasonographic findings (P< .001) were the independent clinical predictors for the presence of a frank intrabiliary rupture. Patients with cyst-biliary communications had increased morbidity rates (13 [54%] of 24 patients vs 13 [14%] of 92 patients; P< .001) and longer mean postoperative hospital stays (13.7 vs 9.4 days; P = .03) compared with others. CONCLUSION: Clinical predictors should be considered for early diagnosis and proper management of intrabiliary ruptures in patients with hepatic hydatid cysts.

Factors affecting post-operative mortality in malignant biliary tract obstruction.

BACKGROUND/AIMS: Although malignant obstruction, itself, is a significant risk factor associated with post-operative mortality, factors affecting mortality in the surgery of malignant obstruction have not been thoroughly studied in the literature. METHODOLOGY: In order to identify independent risk factors which might be associated with an increase in post-operative mortality in patients with malignant biliary obstruction, 24 clinical and laboratory parameters in 52 patients undergoing biliary tract surgery were analyzed retrospectively. RESULTS: Simple regression revealed 24 factors with prognostic significance, but multivariate analysis detected only 3 factors with independent significance in predicting mortality (cholangitis, weight loss of 10 kg or more and operative or post-operative blood transfusion). The presence of 2 of these risk factors identified a group of patients with an 37% mortality rate. CONCLUSIONS: The results of this study show that the presence of pre-operative cholangitis, marked weight loss, and operative and post-operative blood transfusion are associated with high post-operative mortality. The major challenge is the prevention of cholangitis in high-risk patients, improvement of the nutritional status of the patients, and avoidance of unnecessary blood transfusions.

Effect of 5-lipoxygenase inhibition on Kupffer cell clearance capacity in obstructive jaundiced rats.

BACKGROUND: Obstructive jaundice is a common surgical problem. It may cause hepatic and Kupffer cell dysfunction. Previous studies demonstrated that 5-lipoxygenase inhibition prevents hepatic injury. However, its effect on Kupffer cell clearance capacity has not been determined yet. MATERIALS AND METHODS: Rats were divided into four groups. In group 1 (sham control group), only bile duct dissection was performed. In other groups bile ducts were ligated and divided. In groups 1 and 2 saline, in group 3 ethanol, and in group 4 a 5-lipoxygenase inhibitor AA-861 was given intraperitoneally to the animals. Rats were sacrificed 14 days after the operations. Serum alkaline phosphatase, total bilirubin, and alanine aminotransferase levels were determined. Kupffer cell clearance capacity was measured using an in situ isolated hepatic perfusion technique. Hematoxylin-eosin-stained liver samples were evaluated under light microscope for histopathologic scoring. RESULTS: Rats in the sham control group had significantly lower serum ALP and bilirubin values than those in the experimental groups with biliary obstruction. AA-861 administration significantly decreased serum ALT levels and histopathologic scores. There was no significant difference in ALT levels and histopathologic scores between the sham control and AA-861 groups. Kupffer cell clearance capacity was found to be significantly increased in the AA-861 group compared to other experimental groups with obstructive jaundice. CONCLUSIONS: This study shows that leukotriene synthesis inhibition using AA-861 prevents hepatic damage and improves Kupffer cell clearance capacity in obstructive jaundiced rats. This may have significant implications for the management of patients with obstructive jaundice.