Technological Advances Have Improved Surgical Outcome in Thyroid Surgery: Myth or Reality?

AIM: In this study, we aimed to investigate the effects of Ultrasonic Coagulation (UC), Bipolar Energy Sealing System (BESS), Intra Operative Nerve Monitoring (IONM) and surgical experience on the complications of thyroid surgery. METHOD: The data of 1627 patients who underwent thyroid surgery for various indications in our department between 2009 and 2018 were analyzed retrospectively and the effects of different technological devices on complications were investigated. RESULTS: Transient recurrent laryngeal nerve (RLN) palsy was higher between 2009 and 2013, when IONM was not in routine use (p=0.029). There were no significant differences between two energy devices (UC and BESS) in terms of transient or permanent RLN palsy, bleeding, and transient or permanent hypocalcemia. Multivariate analysis showed that young age (0.006), female gender (0.016), surgery type (p<0.001), and lateral neck dissection (p=0.026) are independent risk factors for transient hypocalcemia. CONCLUSION: The results indicate that there is no superior hemostatic device. IONM and specific branching decrease transient RLN palsy. Female gender, young age, completion thyroidectomy, and lateral neck dissection were independent risk factors for the development of transient hypocalcemia.

Analysis of general surgery outpatient clinic admissions and operations during COVID-19 pandemic in Turkey: Reactions of 12728 patients.

Covid-19 pandemic is spreading rapidly in Turkey. We aimed to examine the numbers and demographic data of patients who applied to the general surgery outpatient clinics and operated in this process. Our primary outcome is to reveal the response of general surgery patients to the Covid-19 pandemic.The first Covid-19 case in Turkey has appeared in March 11, 2020. Patients who were operated on due to a surgical emergency or trauma were evaluated separately. Patients in 3 periods were compared with each other. A total of 12728 patients were examined in general surgery outpatient clinics in 26 working days. It is seen that patients come to the outpatient clinic after the first time the Covid-19 patient is seen. All patients reduced hospitalization after the first death due to Covid-19. Women had reduced going to the hospital earlier than men. There was no change in the number of emergency surgeries. Rapid decrease was observed in the number of elective surgeries.It is not easy to control the entrance and exit of these busy hospitals. The remote diagnosis (mail, phone or video-call) and treatment methods that can be expected in the near future may be even closer with the Corona virus (Tab. 3, Fig. 4, Ref. 15). Keywords: general surgery, Covid-19, outpatient clinics, operation, reaction of patients.

Pregnancies achieved by testicular sperm recovery in male hypogonadotrophic hypogonadism with persistent azoospermia.

Hypogonadotrophic hypogonadism is characterized by oligospermia or azoospermia and low testosterone, FSH and LH concentrations. In such cases, treatment with gonadotrophins is required to produce or increase spermatozoa in the ejaculate but few achieve normal spermatogenesis. After long periods of medical treatment, if the patients still have a low sperm count or azoospermia, assisted reproductive technologies in addition to hormone administration can be offered. Four cases of hypogonadotrophic hypogonadism with persistent azoospermia after at least 10 months of medical treatment are reported. In all four cases, spermatozoa retrieved by testicular sperm extraction and intracytoplasmic sperm injection (ICSI) were used to achieve fertilization. Excess spermatozoa were frozen in all cases. Six ICSI cycles using fresh testicular spermatozoa in four and thawed testicular spermatozoa in two were performed. Although there was no pregnancy in cycles where thawed spermatozoa were used, three clinical pregnancies were achieved in four cycles using fresh testicular spermatozoa. One of them ended with spontaneous abortion at 10 weeks of gestation and the two others resulted in the delivery of three normal offspring. If azoospermia persists after medical treatment, spermatozoa can be obtained surgically from testes and can be used successfully to achieve pregnancy in cases of hypogonadotrophic hypogonadism.

Single-dose GnRH agonist administration in the luteal phase of GnRH antagonist cycles: a prospective randomized study.

This study was designed to evaluate the effect of luteal-phase administration of single-dose gonadotrophin-releasing hormone (GnRH) agonist on pregnancy, implantation and live birth rates in patients who received GnRH antagonist for pituitary suppression. The study population consisted of 164 patients who underwent intracytoplasmic sperm injection (ICSI) after ovulation induction by gonadotrophins and GnRH antagonist for the prevention of a premature LH surge. For luteal-phase support, all the cases received intravaginal 600 mg micronized progesterone. In this prospective study, patients were randomly assigned to two groups. In one group, patients received an additional single dose of GnRH agonist (0.5 mg leuprolide acetate) subcutaneously on day 6 after ICSI, whereas the patients in the other group did not. Although the number of embryos transferred and the grade of the embryos were similar in the two groups, the patients in the luteal-phase agonist group had significantly higher rates of implantation and clinical pregnancy rates ( P < 0.05). When the two groups were compared, there were also statistically significant differences in multiple pregnancy and live birth rates ( P < 0.05). Administration of single-dose GnRH agonist as a luteal-phase support in ovarian stimulation-GnRH antagonist cycles in addition to standard luteal support seems to be effective in all cycle outcome parameters.

Serum nectin-2 levels are diagnostic and prognostic in patients with colorectal carcinoma.

INTRODUCTION: Nectins are a family of integral protein and immunoglobulin-like cell adhesion molecules involved in the formation of functioning adherence and tight junctions. Aberrant expression is associated with cancer progression, apoptosis and cell proliferation but little is known how these effects change in cell behavior. The objective of this study was to evaluate the serum levels of nectin-2 with regard to diagnostic, predictive and prognostic value in colorectal cancer (CRC) patients. MATERIALS AND METHODS: One-hundred and forty CRC patients were enrolled in this study. Serum nectin-2 levels were determined by enzyme-linked immunosorbent assay method. Age- and sex-matched 40 healthy controls were included in the analysis. RESULTS: Median age of patients was 60 years old, range 24-84 years. The localization of tumor in majority of the patients was colon (n = 81, 58 %). Non-metastatic (stage II and III) and metastatic patients' baseline serum nectin-2 levels were significantly higher than those in the healthy control group (p < 0.001; for two group). However, known clinical variables including response to CTx (chemotherapy) were not found to be correlated with serum nectin-2 concentrations (p > 0.05). While non-metastatic group patients with elevated serum nectin-2 levels showed significant adverse effect on PFS, metastatic group patients with elevated serum nectin-2 levels showed no significant adverse effect on PFS (p = 0.05 and p = 0.29, respectively). On the other hand, our study results did not show statistically significant serum nectin-2 concentrations regarding overall survival rates. CONCLUSION: Serum levels of nectin-2 may have diagnostic roles for CRC patients. Moreover, our study results show the prognostic role of nectin-2 in non-metastatic group patients.

Hemodynamic assessment in pelvic inflammatory disease by transvaginal color Doppler ultrasonography.

One of the major signs of inflammation is a change in vascular flow and caliber. It is possible to detect these changes with the help of transvaginal color Doppler velocitometry. The purpose of this study was to evaluate the changes in pelvic circulation in cases with pelvic infection and to correlate these findings with other infectious parameters. The study group consisted of 20 cases who had the diagnosis of pelvic inflammatory disease (PID). Resistance index (RI) and pulsatility index (PI) were measured with transvaginal color Doppler ultrasonography in the uterine and ovarian arteries as well as at the tubouterine junction three times in a one-month period. At the same time the body temperature, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and leukocyte counts were recorded. Infectious parameters declined to normal values, following a pattern parallel to clinical improvement from the first until day 30. Infectious parameters revealed significant differences between days 1-7, 1-30 and 7-30. On the other hand, low resistance in all three measurement points exhibited a rapid increase on the day 7 day and plateaued until the day 30 day. Color Doppler velocitometry measurements revealed significant differences between days 1-7 and 1-30 but not between days 7-30. These findings demonstrate that as the infection subsides, the changes in vascular flow return to normal before infectious parameters do. In conclusion, it is possible to detect decreased vascular resistance in acute infection with the help of transvaginal color Doppler ultrasonography. Furthermore, color Doppler ultrasonography can accurately detect regression of the infectious process before body temperature and acute phase reactants do.

Is Hashimoto's thyroiditis a prognostic factor for thyroid papillary microcarcinoma?

AIM: The relationship between papillary thyroid carcinoma (PTC) and accompanying Hashimoto's thyroiditis (HT) has been investigated extensively. However, there is no agreement among the authors. We aimed with this study to investigate this relationship in a limited subtype of PTC called papillary thyroid microcarcinoma (PTMC). PATIENTS AND METHODS: Between January 1999 and December 2012, 1923 thyroids were surgically resected in two referral centers and thoroughly inspected for evidence of PTMC. Of these patients, 172 who were diagnosed with PTMC had demographic and pathological features recorded. RESULTS: Fourteen patients (8.1%) were found to have CLN metastases. Eleven (78.6%) of the patients with CLN metastases had tumors larger than 5 mm, and 3 (21.4%) patients with CLN metastases had small tumors (≤ 5 mm), but there was no statistical significance (p > 0.05). Accompanying Hashimoto's thyroiditis (HT) was detected in 67 (39%) patients. The CLN metastasis rate was slightly higher in cases with HT in surrounding thyroid tissue. However, there was no statistical significance; the CLN rate was 6.7% (n=7) in patients without thyroiditis and 10.4% (n=7) with Hashimoto's thyroiditis. Insufficient FNA results in patients with thyroiditis were associated with HT (p < 0.05). CONCLUSIONS: Surgeons and other clinicians who play a role in the treatment of thyroid cancers should be aware that some PTMC cases may show a worse course, as with some PTCs, contrary to expectations.

Cerebral haemodynamics in patients with pseudoexfoliation glaucoma.

PURPOSE: To evaluate the cerebral haemodynamics in patients with pseudoexfoliation glaucoma. METHODS: A total of 19 consecutive patients with pseudoexfoliation glaucoma and 19 age- and sex-matched healthy volunteers were recruited in a prospective comparative study. The affected eye in patients with unilateral glaucoma and the eye with more advanced lesions in patients with bilateral glaucoma were included in the study, and the ipsilateral middle cerebral arteries (MCA) were evaluated. While in the controls, the study eye and the ipsilateral MCA were chosen randomly. Measurements included systemic arterial pressure, heart rate, intraocular pressure (IOP), and transcranial colour Doppler parameters, including peak systolic velocity (PSV), end-diastolic velocity (EDV), time-averaged maximum velocity (TAMAX), resistivity index (RI), and pulsatility index (PI). RESULTS: The mean PSV, EDV, and TAMAX were significantly lower in the patients with pseudoexfoliation glaucoma than in healthy controls (P<0.001, <0.001 and <0.001, respectively). Additionally, patients with pseudoexfoliation glaucoma had significantly higher PI and RI than healthy controls (P=0.001 and 0.04, respectively). Systolic and diastolic blood pressures (P=0.19 and 0.91, respectively) and heart rate (P=0.06) were not different between the groups. The mean IOP were significantly higher in the glaucoma patients compared with the controls (P<0.001). CONCLUSION: This study suggests that pseudoexfoliation glaucoma is associated with a reduction in the blood flow velocity and elevation in the resistance of the MCA.

Retinal nerve fiber layer thickness is unaffected in migraine patients.

OBJECTIVES: To search for possible structural effects of migraine on the retina. MATERIALS AND METHODS: The study group included 39 consecutive migraine patients, 15 with visual aura and 24 without aura, and 25 healthy subjects as the control group. Scanning laser polarimetry was used to measure and compare retinal nerve fiber layer (RNFL) thickness between migraine and control groups. RESULTS: The mean age of the patients and the control group were 35.64 +/- 8.3 and 35.96 +/- 9.14 years, respectively (P = 0.92) and the mean duration of migraine in patients with aura and without aura as 4.4 +/- 2.9 and 5.3 +/- 4.3 years, respectively (P = 0.68). Parameters related to RNFL thickness were found to be similar (P > 0.001) in migraine and control subjects. After examining the whole patient group migraine patients with and without aura were compared to each other and the control group individually for RNFL thickness parameters. Briefly no statistical difference was found for any of the test parameters between migraine patients with aura, without aura and controls (P > 0.001). CONCLUSION: Retinal nerve fiber layer thickness was found to be unaffected in migraine patients.

Prediction of perinatal outcome by middle cerebral artery Doppler velocimetry.

The relationship between pulsatility index (PI) in the middle cerebral artery (MCA) and adverse perinatal outcome was studied in 162 normal and 75 high-risk pregnancies. The intrapartum cardiotocographic (CTG) findings, the mode of delivery, 1 and 5-minute Apgar scores, the pH level of the umbilical artery, admission to the neonatal intensive care unit (NICU) and the incidence of intrauterine fetal growth retardation were recorded. In the low risk group, the PI values in the MCA were only affected in growth retarded fetuses (P = 0.0084). In the high-risk group, there was an association between the MCA PI values and 5-minute Apgar scores (P = 0.0397), umbilical artery pH values (P = 0.0068) and development of IUGR (P = 0.0376). In both groups, an abnormal intrapartum CTG, the 1-minute Apgar score, cesarean section for fetal distress and admission to the NICU were not related to PI values in the MCA. Our present study suggests that Doppler flow measurement of MCA provides useful information about perinatal outcome, especially in the high-risk pregnancies.

The effect of uterine volume on uterine artery Doppler velocimetry in the myomatous state.

This study aimed at testing the hypothesis that lower uterine arterial (UA) Doppler indices are caused by increased uterine volume rather than the presence of myoma. Uterine volumes were calculated and uterine and/or myomal arterial pulsatility index (PI) and resistance index (RI) were obtained by transvaginal color Doppler ultrasonography. The mean uterine volume in the myomatous group (276.2 cm3; range 65-928 cm3, n = 100) was significantly greater than that of the control group (101.4 cm3; range 36-171 cm3; n = 60; p = 0.00). The mean UA PI and RI values in the study group were significantly lower than their corresponding values in the control group (0.77 +/- 0.08 and 1.69 +/- 0.47 vs. 0.82 +/- 0.06 and 1.97 +/- 0.49, respectively, p = 0.01). When the myomatous uterine volumes of the study group were categorized into two subgroups (< 200 and > or = 200 cm2) the UA PI and RI values were lower in the latter group (p = 0.006 and p = 0.015, respectively). However, after analysis of receiver-operator-characteristic curves, none of the UA Doppler indices could differentiate the myomatous uterus from the normal uterus.

Evaluation of intrauterine abnormalities in infertile patients by sonohysterography.

The purpose of this study was to assess the usefulness of sonohysterography in the detection of abnormalities of the uterine cavity in infertile patients, compared with other diagnostic methods. Transvaginal ultrasonography, sonohysterography, hysterosalpingography and finally hysteroscopy were performed in 37 patients with primary and 25 patients with secondary infertility. Suspected uterine anomalies were also confirmed by laparoscopy. Transvaginal ultrasonography and hysterosalpingography were able to detect 36.3 and 72.7% of uterine pathologies respectively. Sonohysterography was able to detect all the anomalies except for a single endometrial polyp (90.3%). However, there was no significant difference between the diagnostic capabilities of these methods. We recommend the use of sonohysterography as an easy, cheap and noninvasive method for the diagnosis of intrauterine pathologies in infertile patients.

Fertility of ejaculated and testicular megalohead spermatozoa with intracytoplasmic sperm injection.

In this study the fertility and outcome of intracytoplasmic sperm injection (ICSI) using megalohead spermatozoa from the ejaculates and testicles was evaluated. Seventeen males with megalohead and pinhead sperm forms in their ejaculate were studied in 22 cycles. A high number of sperm heads without tails and abundant round spermatid forms were commonly observed. Round-headed spermatozoa were seldom accompanied by these severely abnormal spermatozoa. The majority of megalohead spermatozoa were observed to have multiple tails, were predominant in the sample, and were used for ICSI. Ejaculated megalohead spermatozoa were used for ICSI in 15 cycles, while testicular spermatozoa were used in seven cycles where there were no vital spermatozoa or spermatozoa of low vitality in the ejaculate. The same abnormal morphology was observed in the testicles as in the ejaculated spermatozoa in the same males. Mean (+/- SD) low motility 4.7 +/- 5.6% and sperm count (3.8 +/- 4.19 x 10(6)) were common findings in these severely teratozoospermic patients. A low fertilization rate (43.2%) was achieved by using megalohead sperm forms (group I, n = 17) in comparison with the control group (60.2%) which had zero normal sperm morphology according to strict criteria (group II, n = 30) (P <0.01). Furthermore, a low pregnancy rate (9.1%) was obtained in the megalohead sperm group in comparison with the control group (40%) (P <0.05). Low fertilization and pregnancy rates may be due to a high incidence of chromosomal abnormalities from severely defective spermatozoa in the ejaculate. Couples should be counselled and warned about possible low fertilization and pregnancy rates with ICSI when only pinhead and megalohead forms with a high number of sperm heads without tails are present in the ejaculate.