MANAGEMENT PRINCIPLES OF INCIDENTAL THYROID 18F-FDG UPTAKE IDENTIFIED ON 18F-FDG PET/CT IMAGING.

Purpose: The purpose of this study is to determine the clinical significance of incidental thyroid 18F-FDG PET/CT uptake in oncology patients with the focus achieving the most appropriate management of this challenging situation. Materials and method: Two thousand five hundred and eighty 18F-FDG PET/CT studies performed at our institute in the past 4 years were retrospectively reviewed. Patients with incidental FDG uptake in the thyroid gland were further analysed. Results: The prevalence of incidental FDG uptake in thyroid gland was 7.6% (129 patients). 26 patients (20.1%) had diffuse 18F-FDG PET/CT uptake, 103 patients (79.1%) had nodular uptake in thyroid gland. All diffuse uptake patients who were further examined diagnosed to be a benign condition. 53 patients in the nodular uptake group were further examined and the final histopathology examinations revealed an 18.8% malignancy rate. SUV max values ranged from 2 to 21.8 with a significant highness in malignant lesions. Conclusion: 18F-FDG PET/CT uptake in the thyroid gland may be diffuse or nodular. Diffuse uptake needs no further examination as it usually accompanied by benign thyroid disorders. Patients with nodular uptake whose general condition is good should be further examined due to high rates of malignancy.

Timing of laparoscopic cholecystectomy in acute cholecystitis.

BACKGROUND: Timing of laparoscopic cholecystectomy (LC) in acute cholecystitis (AC) is still debated. AIMS: The aim of this study was to investigate the effect of timing on operative results; from the first appearance of symptoms to the operation. METHODS: The study included 57 sequential patients operated laparoscopically for AC. Patients operated within the first 3 days of admission (Group 1), those operated between 4th and 7th days (Group 2) and those operated after 7th day (Group 3) were evaluated and compared with respect to demographics, time from admission to operation, duration of operation, adhesion score, complications, conversion rates, duration of hospital stay, morbidity and mortality rates, bile culture results, and histopathological evaluation. RESULTS: A total of 63% of the patients were female and 21 (37%) were male. The mean age was 48 years (range, 21-74). There was no significant difference among the groups with respect to demographics (P > 0.05, for each). The duration of operation was significantly shorter in Group 1 than both Groups 2 and 3 (P < 0.05 and P < 0.001, respectively). Duration of operation was also significantly shorter in Group 2 than Group 3 (P < 0.001). Group 1 had significantly fewer adhesions compared to Group 2 and Group 3 (P < 0.05 and P < 0.001, respectively), and no significant difference was found between Group 2 and Group 3 (P > 0.05). Duration of hospital stay was significantly shorter in Group 1 compared to Group 2 and Group 3 (P < 0.001) and also was significantly shorter in Group 2 than Group 3 (P < 0.05). Group 1 had significantly lower rate of culture proliferation than Group 3 (P < 0.001), whereas no significant differences were evident in other inter-group analyses (P > 0.05, for each). CONCLUSION: LC can safely be performed within 7 days of admission in cases of AC.

The effect of polyethylene glycol adhesion barrier (Spray Gel) on preventing peritoneal adhesions.

The prominent cells in the late phase of wound healing during proliferation and matrix deposition are fibroblasts. Foreign materials in the operation site like prosthesis prolong the inflammation and induce fibroblast proliferation (8). 3 different prostheses used in this study induced chronic inflammation and fibrosis and provided an effective repair. Dense and thick adhesions due to fibrosis also induced strong adhesions to omentum and small intestine if only polypropylene mesh used for hernia repair. However, there was no difference between SprayGel treated polypropylene mesh and Sepramesh when compared for fibrosis. It also prevents the intraabdominal adhesion formation. It is nontoxic, sticky adherent, non- immigrant and easy to use both in open and laparoscopic surgeries. This experimental study revealed that polyethyleneglycol applied polypropylene mesh accomplishes hernia repair with significantly less adhesion formation than polypropylene mesh alone while securing a remarkable economy than adhesion barrier coated dual meshes (Tab. 6, Fig. 7, Ref. 23). Text in PDF www.elis.sk.

A new prognostic strategy for gastric carcinoma: albumin level and metastatic lymph node ratio.

AIM: We evaluated the prognostic significance of preoperative serum albumin value and metastatic lymph node ratio for gastric cancer patients. METHODS: We studied patients diagnosed with gastric carcinoma in the first Department of Surgery, Bezmialem Vakif Gureba Training and Research Hospital between January 2004 and December 2010; the patients were studied retrospectively. RESULTS: A total of 67 patients with a mean age of 58.7 ± 11.4 years were included in the study. The majority of patients were male (N.=53 male; N.=14 female). Most patients were in an advanced stage of the disease (stage III-IV) on admission (67.2%). We classified patients according to albumin value as "normal" Group 1 (83%) and "hypoalbuminemic" Group 2 (17%). With albumin, age, resection type, perineural invasion, and ratio of metastatic lymph nodes, T and TNM stages were significant predictors of cancer-specific survival. CONCLUSION: As a result, irrespective of mechanism, pre-operative evaluations of albumin and metastatic lymph node ratio should be performed to stratify the patients for risk analysis and prognosis. A level less than 3.5 g/dL is a negative prognostic factor for resectable gastric cancers.

"Diagnostic value of MRCP in biliary pancreatitis: result of long-term follow-up".

AIM: Magnetic resonance cholangiopancreatography (MRCP) has increasingly been used to evaluate the common bile duct. This study was to determine the role of MRCP instead of endoscopic retrograde cholangiopancreatography (ERCP) in the management of patients with acute biliary pancreatitis. METHODS: A total of 81 patients with mild or moderate biliary pancreatitis who underwent MRCP and were treated in our department with selective ERCP between May 2001 and July 2007 were entered into a prospective database. RESULTS: MRCP was considered abnormal in 13 patients. Ten patients underwent ERCP. Three patients did not undergo ERCP due to protocol violations. In nine patients, stone extraction was performed. The remaining patient who had dilatation of the CBD underwent ES. The false positive rate of MRCP was 10%. The median follow-up of overall patients was 36 months (range 23-99 months). The patients with normal MRCP had a median follow-up of 39.5 months (range 23-99 months). During the follow-up period in the normal MRCP group, five patients were diagnosed with recurrent biliary pancreatitis, of which three underwent ERCP (7.4%). There was no disease-related mortality during this period. CONCLUSION: In conclusion, the use of MRCP in acute biliary pancreatitis is safe and may be recommended as a tool to aid in the selective use of ERCP.

Restoration of the growth suppression function of mutant p53 by a synthetic peptide derived from the p53 C-terminal domain.

We demonstrate here that synthetic 22-mer peptide 46, corresponding to the carboxy-terminal amino acid residues 361-382 of p53, can activate specific DNA binding of wild-type p53 in vitro and can restore the transcriptional transactivating function of at least some mutant p53 proteins in living cells. Introduction of peptide 46 in Saos-2 cells carrying a Tet-regulatable His-273 mutant p53 construct caused growth inhibition and apoptosis in the presence of mutant p53 but not in its absence, confirming that the effect of the peptide is mediated by reactivation of mutant p53. Moreover, peptide 46 caused apoptosis in mutant as well as wild-type p53-carrying human tumor cell lines of different origin, whereas p53 null tumor cells were not affected. These findings raise possibilities for developing drugs that restore the tumor suppressor function of mutant p53 proteins, thus selectively eliminating tumor cells.

Lymphocyte-C-reactive protein ratio: a putative predictive factor for intestinal ischemia in strangulated abdominal wall hernias.

PURPOSE: The purpose of this study was to investigate whether it is possible to estimate systemic inflammation and intestinal ischemia in incarcerated hernias using the lymphocyte-C-reactive protein ratio (LCR). METHODS: A total of 116 patients who underwent an emergency operation due to incarcerated abdominal wall hernia were investigated retrospectively. The patients with incarcerated hernias were divided into two groups: those who did not undergo intestinal resection and those who underwent intestinal resection due to strangulation. The two groups were analyzed based on sex, surgical operation (open, laparoscopic), length of stay, complications and mortality rates as well as preoperative period laboratory analyses, such as white blood cell, neutrophil, thrombocyte, and lymphocyte counts and C-reactive protein (CRP), neutrophil-lymphocyte ratio (NLR) and LCR values. RESULTS: Twenty-five patients (21.6%) underwent intestinal resection due to strangulated hernia. Neutrophil count, lymphocyte count, CRP, platelet count, NLR, and LCR were significantly different in the strangulated hernia group. Receiver operating characteristic (ROC) analysis results showed that an LCR level below 0.02 had 80% sensitivity (58-92%) and 80.2% specificity (70-87%) for the diagnosis of strangulation. CONCLUSION: A low preoperative LCR level in incarcerated hernias could be used as a bioindicator that helps to estimate the intestinal ischemia.

Ramadan Fasting Increases Socialization in Patients Who Underwent Sleeve Gastrectomy: An Observational Study.

PURPOSE: The prevalence of obesity is increasing along with the number of sleeve gastrectomies. Patients' mental health and social life, along with their physical health, should be considered. Their cultural and religious values are an important part of treatment. Fasting is an important act of worship in all religions. Ramadan fasting is one of the five pillars of Islam. In this study, we aimed to investigate the effect of Ramadan fasting on quality of life in patients who underwent sleeve gastrectomy. MATERIALS AND METHODS: Data regarding the demographic characteristics, weight, the time elapsed after surgery, and the amount of liquid and solid food consumed during fasting were collected with two surveys, one of which was carried out at the beginning and the other at the end of Ramadan. In addition, the SF-36 health survey questionnaire was administered to evaluate the impact of Ramadan fasting on patients' quality of life. RESULTS: Fifty-one people participated in the first survey, but the second survey included 19 of them. While the median weight of the patients was 86.52 ± 17.78 kg before fasting, the median weight after 25 days of fasting was 83.31 ± 17.06 kg. A significant decrease was observed in weight after 25 days of fasting (p < 0.001). A comparison of the SF-36 scores for quality of life revealed a significant increase in the social functioning (p = 0.032). CONCLUSION: Ramadan fasting caused significant weight loss in patients who underwent sleeve gastrectomy. Besides, it did not adversely affect the quality of life, but rather increased social functioning.

Colonic Wall Thickening Reported in Abdominal CT: Does It Always Imply Malignancy?

AIM/BACKGROUND: Early diagnosis of patients with colon cancer is one of the most important parameters affecting the survival of patients. In this study, we aimed to examine the effect of the age, hemoglobin (Hb), albumin, neutrophil lymphocyte ratio (NLR), thrombocyte lymphocyte ratio (PLR), and mean platelet values (MPV) on the separation of benign and malignant diseases in patients with suspected colon wall thickness (CWT) observed in abdominal computed tomography (CT) examination. METHOD: The study included 116 patients between the ages of 18 and 95 who had CT examination where the colon wall could be evaluated and who also had colonoscopy. Patients suspected for CWT in CT with difficulties in differential diagnosis were divided into two groups according to colonoscopic-histopathological evaluations. Normal or benign pathological causes were included in the first group, while malignant causes constituted the second group. Whether the two groups differed in terms of CWT, Hb, age, albumin, NLR, PLR, and MPV values was investigated with descriptive statistics. RESULTS: One hundred and sixteen patients (74 males, 42 females) with CT examinations and colonoscopic sampling were included in the study. After colonoscopic and histopathological evaluations, there were 64 cases in the first group and 52 in the second group. According to the results of the univariate analysis and multivariate logistic regression, CWT, Hb, NLR, and MPV were identified to be independent variables for determining colon cancer. CONCLUSION: A combined evaluation of Hb, NLR, and MPV values in patients with CWT in abdominal CT examination may contribute to the separation of benign and malignant pathologies.

Significance of Gastric Wall Thickening Detected in Abdominal CT Scan to Predict Gastric Malignancy.

BACKGROUND: Early diagnosis of gastric cancer is one of the most important parameters affecting the survival of the disease. In this study, we aimed to stress the importance of antrum wall thickness in CT examination. METHOD: The study included 111 patients between ages of 18 and 95 who had antral wall thickening in computed tomography and also had endoscopic evaluation performed in the same clinic. The patients were divided into two groups as benign and malignant according to the pathology results. The thickness of the antrum wall in computed tomography, hemoglobin and albumin levels, and age was compared among these two groups. Parameters with significant differences were further analyzed by multivariate analysis using logistic regression analysis. RESULTS: Of the 111 patients included in the study, 57 were male and 54 were female. Mean age was 65 years. Fifty-one patients were classified as benign and 60 patients as malignant. Mean age of the malignant patients was 70, while that of benign patients was 59 (p < 0.05). Antrum wall thickness was 13.68 ± 3.27 mm in malignant patients and 9.22 ± 2.17 mm in benign patients (p < 0.05). Similarly, hemoglobin level was significantly different in malignant and benign patients (10.78 ± 1.57 g/dl and 12.64 ± 1.43 g/dl, respectively; p < 0.05). Albumin levels were 3.36 ± 0.57 mg/dl in malignant patients and 3.97 ± 0.57 mg/dl in benign patients (p < 0.05). CONCLUSION: Evaluation of antrum wall thickness, age, hemoglobin, and albumin values together may contribute to distinguishing the benign and malignant pathologies involving this region in patients with suspected stomach wall thickening in abdominal CT scan.

Risk factors of morbidity and mortality in patients with perforated peptic ulcer.

PURPOSE: Peptic ulcer perforation is a serious problem that leads to high complication and mortality rates. The aim of this prospective clinical study was to evaluate complications and possible risk factors for peri-operative morbidity and mortality in patients with perforated peptic ulcer (PPU). MATERIAL AND METHODS: Ninety-seven patients hospitalized for PPU at the Department of Surgery, Vakif Gureba Training and Research Hospital, between March 1998 and December 2004 were analysed. RESULTS: The mean age of patients was 38.6 years. Ten patients had 19 co-morbidities. The mean hospitalisation time was 7.1 days. Twenty-one complications in 15 patients occurred. Overall morbidity and mortality rates were 15.5% and 5.2% respectively. Multivariate logistic regression analysis of 97 patients revealed that age (p < 0.006) and late admission (p < 0.001) were linked to morbidity. The mortality rate tended to be associated with advanced age, therapeutic delay and co-morbidities. CONCLUSIONS: Increased patients' age and the therapeutic delay, predicted outcome after surgical treatment of PPU. Morbidity and mortality could be reduced by avoiding delays in diagnosis and treatment, especially in older patients, and by instituting proper treatment of any coexisting medical illness.

Idiopathic abdominal cocoon: report of a case.

The abdominal cocoon is a rare disease in which there is total or partial encapsulation of the small bowel by a fibrous membrane. A correct diagnosis is not often made pre-operatively. Awareness of this rare cause of surgical emergency may prevent delay in treatment and avoid unnecessary procedures for the patient, such as bowel resection. We report a patient diagnosed with abdominal cocoon who was subsequently treated.

Association between angiographic coronary stenosis morphology and acute coronary syndrome manifestation in patients with ischemic heart disease.

AIM: Patients with acute coronary syndrome (ACS) often show complex morphology of coronary stenosis at angiography. In the present study we evaluated the association between different clinical forms of manifestation of acute coronary syndrome and the angiographic morphological patterns of coronary stenosis. PATIENTS AND METHODS: A total of 112 patients with angiographically verified single vessel coronary artery disease were divided into two groups: a control group of 44 patients with simple coronary stenosis at angiography and a study group of 66 patients with complex coronary stenosis. Angiographic analysis was performed using a modified Ambrose classification. The two groups were compared according to the manifestation and distribution of the acute coronary syndrome based on Braunwald classification. RESULTS: There were no statistically significant differences between the mean values of stenosis severity in the group with simple stenosis (79.8% +/- 10.7%) and the group with complex stenosis (82.7% +/- 8.2%) (P > 0.05). The incidence of current acute coronary syndrome - unstable angina or myocardial infarction - was higher in the group with complex stenosis (30.00% +/- 8.37% vs. 52.00% +/- 7.07%, P < 0.05). Patients with previous ACS were prevailing in the group with simple stenosis (70.00% +/- 8.37% vs. 48.00% +/- 7.07%, P < 0.05). CONCLUSION: Complex coronary stenosis is associated with higher prevalence of acute coronary syndrome in acute clinical stage while simple coronary stenosis is associated with higher prevalence of previous acute coronary syndrome. A possible metamorphosis of coronary stenoses is taken into consideration.

Endoscopic stenting for selected cases of biliary fistula after hepatic hydatid surgery.

BACKGROUND: Biliary fistula develops in 4%-28% of patients after hepatic hydatid disease (HHD) surgery. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) are helpful in the treatment of this complication, persistent fistulas may occur. We therefore conducted a study to evaluate the efficacy of endoscopic biliary stenting in the treatment of biliary fistulas after HHD. METHODS: In this study, 84 patients who underwent ERCP for postoperative biliary fistula due to HHD were evaluated. Group I included 70 patients treated with only ES, and group II included 14 patients who underwent biliary stenting as their initial treatment. Demographic data, complications, the results of treatment and the reasons for the failure were compared between two groups. RESULTS: Ninety-five ERCPs were performed. In 63 patients, biliary fistulas were successfully treated with only ERCP and ES. However, 7 patients underwent repeat ERCP and stent placement because of persistent fistula. Biliary stenting was initially performed in 14 patients. The average time for closure of the fistula was 14 +/- 10 days and 7 +/- 3 days in group I (7 patients with repeat ERCP were excluded) and group II, respectively (p = 0.007). There was no statistically significant difference in the complication rates between the groups. CONCLUSIONS: Although ES is effective in the treatment of biliary fistula after HHD surgery, endoscopic biliary stenting may be considered as the initial procedure in patients with biliary stricture, incomplete clearance of hydatid material in the bile duct, and persisting biliary fistulas after treatment with ERCP and ES.

Femoral hernia: a review of 83 cases.

We evaluate the factors that affect morbidity and mortality in patients who underwent surgery due to femoral hernia. The medical records of 83 patients who underwent femoral hernia repair between January 1996 and June 2004 were retrospectively analyzed. The femoral hernias were repaired either with McVay or mesh plug hernioplasty. Sex, age, surgical repair technique, presence of incarceration/strangulation, incarcerated/strangulated organs, postoperative complications, duration of hospitalization, recurrence rate, and factors that affect mortality and morbidity were studied. There were 83 patients with femoral hernia in our study. Patients' age ranged from 10 to 75 years (mean age was 46.84) with a predominance of female (71%). Thirty-six patients (40%) underwent emergency surgery with the diagnosis of strangulation or incarceration of femoral hernia. Seventeen patients had strangulation and underwent resection; eleven of these patients had omentum in the hernial sac, whereas six patients had intestines. Four of these patients underwent laparotomy. The remaining 19 patients had incarceration and underwent simple reduction of hernial sac content without resection. Forty-seven (60%) patients underwent elective surgery. McVay technique was used for 79 patients, while the other four patients were treated with mesh-plug. Twelve patients (15%) developed a variety of complications (nine patients (25%) in emergency, three patients (6%) in elective group). There was one mortality. Recurrences occurred in two patients. Femoral hernia is an important surgical pathology with high rates of incarceration/strangulation and intestinal resection. Emergency surgery can increase morbidity and mortality especially in the elderly. Early elective surgery may reduce complication.

Wild-type p53-triggered apoptosis is inhibited by bcl-2 in a v-myc-induced T-cell lymphoma line.

Using a temperature sensitive p53 construct (ts p53), we have earlier shown that expression of wild-type (wt) p53 triggers apoptosis in a v-myc-induced T-cell lymphoma line that lacks endogenous p53, and in a Burkitt lymphoma line that carries mutant p53. We have suggested that apoptosis is elicited by the contradictory signals emanating from the constitutively activated myc gene and the growth arresting signal of wt p53 (Ramqvist et al., 1993; Wang et al., 1993). Work in other laboratories has shown that constitutive c-myc expression can induce apoptosis when cell proliferation is inhibited due to the lack of growth stimulating factors. Expression of bcl-2 could inhibit apoptosis. In order to test whether p53-induced apoptosis can be prevented by bcl-2, we have introduced a retrovirally driven bcl-2 construct into our v-myc-induced murine T-cell lymphoma line, previously transfected with ts p53. About 90% of the parental ts p53 transfected cells died of apoptosis within 3 days after induction of wt p53 expression at 32 degrees C. Two clones of ts p53/bcl-2 double transfectants that expressed high levels of bcl-2 from the introduced construct were completely protected from apoptosis, following transfer of the cells to 32 degrees C. One clone that expressed the exogenous bcl-2 only at a low level was partially protected from wt p53-induced apoptosis. Clones of the parental ts p53 carrying cells transfected with the puromycin resistance gene vector, without the bcl-2 gene underwent 90% apoptosis. These results suggest that bcl-2 may prevent apoptosis in cells simultaneously exposed to the proliferation-stimulating effect of activated myc and the growth arresting signal of wt p53.

Abrogation of p53-induced G1 arrest by the HPV 16 E7 protein does not inhibit p53-induced apoptosis.

Wild type (wt) p53 expressed from a temperature-sensitive construct (ts p53) can induce both G1 cell cycle arrest and apoptosis in the p53-negative J3D mouse T lymphoma line (Wang et al, 1995). The human papillomavirus (HPV) 16 E7 protein has been shown to prevent p53-induced G1 cell cycle arrest following DNA damage. We asked whether inhibition of p53-induced G1 arrest by overexpression of the HPV16 E7 protein in the ts p53-transfected J3D cells would interfere with p53-induced apoptosis. Whereas a majority of the ts p53-expressing J3D cells were arrested in the G1 phase 22 h after induction of wt p53 by temperature shift to 32 degrees C, the E7/ts p53-expressing cells showed only a minor increase in the number of cells in G1 at this time point. In addition, the E7/ts p53-expressing cells showed a much less dramatic reduction in number of cells in S phase than the ts p53-expressing cells. This demonstrates that E7 at least partially rescues the cells from p53-induced G1 arrest. In contrast, overexpression of HPV16 E7 did not have any effect on the kinetics nor the frequency of p53-triggered apoptotic death, as shown by FACS analysis, trypan blue exclusion, and DNA fragmentation analysis. These findings support the notion that p53-induced G1 arrest and p53-induced apoptosis are two separate independent pathways.

Wig-1, a new p53-induced gene encoding a zinc finger protein.

Wild type p53 expressed from a temperature-sensitive (ts p53) construct induces both G1 cell cycle arrest and apoptosis in the p53-negative J3D mouse T lymphoma line (Wang et al., 1995). Using differential display analysis, we have identified one new p53-induced gene, wig-1 (for wild type p53-induced gene 1), whose 7.6 kb and 2.2 kb transcripts are upregulated in ts p53-transfected J3D cells following induction of wild type p53 expression by temperature shift to 32 degrees C. The wig-1 transcripts were also induced in irradiated NIH3T3 and p21-/- fibroblasts but not in irradiated p53-/- fibroblasts. Whole body gamma irradiation caused induction of both wig-1 transcripts in mouse brain, testis, kidney, spleen and lung. A basal wig-1 expression was detected in brain, testis and kidney. The WIG-1 protein contains three zinc finger motifs and a putative nuclear localization signal.

The EBV-encoded LMP1 protein inhibits p53-triggered apoptosis but not growth arrest.

We have previously shown that exogenous wild type p53 induces apoptosis in the Burkitt lymphoma line BL41 that carries endogenous mutant p53, using a temperature sensitive p53 construct expressed as mutant p53 at 37 degrees C and wild type p53 at 32 degrees C (Ramqvist et al., Oncogene, 8, 1495-1500, 1993). We also found that wild type p53-induced apoptosis is blocked by bcl-2 in a mouse T lymphoma line (Wang et al., Oncogene, 8, 3427-3431, 1993) The Epstein-Barr virus (EBV)-encoded latent membrane protein 1 (LMP1) can protect Burkitt lymphoma cells from apoptosis induced by low serum. In order to test if LMP1 can block p53-triggered apoptosis, we infected BL41 cells expressing the ts p53 construct with an LMP1-carrying retrovirus. The LMP1-expressing BL41-ts p53 cells were arrested in G1 upon induction of wild type p53 expression at 32 degrees C, but did not enter apoptosis as shown by the absence of positive TUNEL staining. WAF1/p21 mRNA was induced at 32 degrees C in both the ts p53-expressing and ts p53/LMP1-expressing BL41 cells. Thus, LMP1 prevents p53-induced apoptosis but does not interfere with induction of WAF1/p21. The LMP1-infected cells expressed elevated bcl-2 protein levels. Therefore, our data suggest that LMP1 blocks p53-triggered apoptosis but not G1 arrest by upregulating bcl-2 expression.