Regional Clinical and Biochemical Differences among Patients with Primary Hyperparathyroidism.

BACKGROUND: Environmental habitat may play a role in clinical disparities of primary hyperparathyroidism (pHPT) patients. AIMS: To compare preoperative clinical symptoms and associated conditions and surgical findings in patients with pHPT, living in different geographical regions from the Black Sea, Mediterranean and Anatolia regions. STUDY DESIGN: Retrospective, clinical-based multi-centric study of 694 patients with pHPT. METHODS: Patients from 23 centers and 8 different geographical regions were included. Data related to baseline demographics, clinical, pathologic and treatment characteristics of 8 regions were collected and included age, gender, residential data, symptoms, history of fracture, existence of brown tumor, serum total Ca and p levels, serum parathormone (PTH) levels, serum 25-OH vitamin D levels, bone mineral density, size of the resected abnormal parathyroid gland(s), histology, as well as the presence of ectopia, presence of dual adenoma, and multiple endocrine neoplasia (MEN)- or familial-related disease. RESULTS: The median age was 54. Asymptomatic patient rate was 25%. The median PTH level was 232 pg/mL and serum total Ca was 11.4 mg/dL. Eighty-seven percent of patients had an adenoma and 90% of these had a single adenoma. Hyperplasia was detected in 79 patients and cancer in 9 patients. The median adenoma size was 16 mm. Significant parameters differing between regions were preoperative symptoms, serum Ca and p levels, and adenoma size. All patients from South-East Anatolia were symptomatic, while the lowest p values were reported from East Anatolia and the largest adenoma size, as well as highest Ca levels, were from Bulgaria. CONCLUSION: Habitat conditions vary between geographical regions. This affects the clinicopathological features of patients with pHPT.

Vacuum-assisted stereotactic biopsy for isolated BI-RADS 4 microcalcifications: evaluation with histopathology and midterm follow-up results.

PURPOSE: The aim of this study was to evaluate the 10-gauge vacuum-assisted stereotactic biopsy (VASB) of isolated Breast Imaging Reporting and Data System (BI-RADS) 4 microcalcifications, using histology and follow-up results. METHODS: From January 2011 to June 2013, VASB was performed on 132 lesions, and 66 microcalcification-only lesions of BI-RADS 4 were included into our study. VASB was performed using lateral decubitis stereotaxy for all patients. Pathologic results of VASB and further surgical biopsies were reviewed retrospectively. Patients who were diagnosed to have benign lesions by VASB were referred for follow-up. VASB and surgical histopathology results were compared to determine the underestimation ratios. RESULTS: Fifteen out of 66 lesions from 63 patients (median age, 47 years; range, 34-88 years) were identified as malignant by VASB. Pathological results after surgery revealed three cases of invasive ductal carcinoma among the 12 VASB-diagnosed ductal carcinoma in situ (DCIS) lesions, for a DCIS underestimation rate of 25%. The atypical ductal hyperplasia underestimation rate was 0% for the three lesions. The follow-up period was at least 10 months, with an average of 22.7 months for all patients and 21.2 months for patients with VASB-diagnosed benign lesions. None of the patients had malignancy during the follow-ups. The false-negative rate was 0% in the follow-up of 48 patients. CONCLUSION: VASB should be the standard method of choice for BI-RADS 4 microcalcifications. This method obviates the need for a surgical procedure in 73% of BI-RADS 4 microcalcification-only patients.

The comparison of single incision laparoscopic cholecystectomy and three port laparoscopic cholecystectomy: prospective randomized study.

PURPOSE: Laparoscopic techniques have allowed surgeons to perform complicated intra-abdominal surgery with minimal trauma. Single incision laparoscopic surgery (SILS) was developed with the aim of reducing the invasiveness of conventional laparoscopy. In this study we aimed to compare results of SILS cholecystectomy and three port conventional laparoscopic (TPCL) cholecystectomy prospectively. METHODS: In this prospective study, 100 patients who underwent laparoscopic cholecystectomy for gallbladder disease were randomly allocated to SILS cholecystectomy (group 1) or TPCL cholecystectomy (group 2). Demographics, pathologic diagnosis, operating time, blood loss, length of hospital stay, complications, pain score, conversion rate, and satisfaction of cosmetic outcome were recorded. RESULTS: Forty-four SILS cholesystectomies (88%) and 42 TPCL cholecystectomies (84%) were completed successfully. Conversion to open surgery was required for 4 cases in group 1 and 6 cases in group 2. Operating time was significantly longer in group 1 compared with group 2 (73 minutes vs. 48 minutes; P < 0.05). Higher pain scores were observed in group 1 versus group 2 in postoperative day 1 (P < 0.05). There was higher cosmetic satisfaction in group 1 (P < 0.05). CONCLUSION: SILS cholecystectomy performed by experienced surgeons is at least as successful, feasible, effective and safe as a TPCL cholecystectomy. Surgeons performing SILS should have a firm foundation of advanced minimal access surgical skills and a cautious, gradated approach to attempt the various procedures. Prospective randomized studies comparing single access versus conventional multiport laparoscopic cholecystectomy, with large volumes and long-term follow-up, are needed to confirm our initial experience. (ClinicalTrials.gov Identifier: NCT01772745.).

Is the use of a drain for thyroid surgery realistic? A prospective randomized interventional study.

Background. The use of a suction drain in thyroid surgery is common practice in order to avoid hematomas or seromas. The aim of this study was to determine the efficacy of routine drainage after thyroid surgery. Methods. In this prospective randomized trial, 400 patients who underwent either a total thyroidectomy or lobectomy for thyroid disorders were randomly allocated to either the nondrainage (group 1) or the drainage (group 2) group. The volume of fluid collection in the operative bed, postoperative pain, complications, and length of hospital stay were then recorded. Results. Both groups were homogeneous according to age, gender, thyroid volume, type of procedure performed, and histopathological diagnosis. After assessment by USG, no significant difference was found between the groups in the fluid collection of the thyroid bed (P = 0.117), but the length of hospital stay was significantly reduced in group 1 (P = 0.004). Conclusions. In our experience, the use of drain for thyroid surgery is not a routine procedure. However, it should be used in the presence of extensive dead space, particularly when there is retrosternal or intrathoracic extension, or when the patient is on anticoagulant treatment. This trial was registered with clinical Trials.gov NCT01771523.

Bilateral nipple leiomyoma.

Cutaneous leiomyomas are benign smooth muscle neoplasms of the skin. They arise from vascular, arrector pili, genital, and areolar smooth muscles. The most common localizations of cutaneous leiomyomas are the extensor surfaces of the extremities and the trunk. To our knowledge, only few cases of one-sided nipple leiomyomas have been reported, but two-sided nipple leiomyomas have not been presented. For the first time, here, we report a bilateral nipple leiomyoma.

Primary hyperparathyroidism as an extremely rare cause of secondary myelofibrosis in childhood.

Primary hyperparathyroidism (PHP) and myelofibrosis are rare entities in childhood. Myelofibrosis secondary to PHP is also extremely rare. We report a 15-year-old boy presented with generalized weakness, vomiting, and pallor. A parathyroid adenoma was detected on the left distal parathyroid gland. PHP was diagnosed together with hepatosplenomegaly and pancytopenia. Bone marrow biopsy revealed grade 3-4 reticulin fibrosis. As early as 2 months after the left distal parathyroidectomy, hematologic parameters improved without any other intervention. His liver and spleen also gradually decreased in size. We concluded that the pancytopenia was as a result of myelofibrosis from PHP.

Pure SILS Floppy Nissen Fundoplication with Hiatal Repair: A Case Report.

Background. Single-incision laparoscopic surgery has recently became popular on behalf of inventing less invasive procedures. In this paper, we present a case of Pure SILS Nissen Fundoplication. Patient and Methods. In February 2010 a 29-year old male patient with a 4 cm sliding hiatus hernia presenting with reflux symptoms had undergone a standard floppy Nissen Fundoplication with a hiatus repair via single 2 cm incision in umbilicus. Results. The procedure had obeyed the standard natural orifice surgery rules, and no needlescopic assistance for any stage of the operation was used so to be a pure single-incision procedure. The operation lasted for 120 minutes without any need of conversion, and the patient was discharged the following day of operation. Conclusion. In the recent time, hybrid single incision laparoscopy techniques have been defined with the use of extra-abdominal supplements for retraction of liver or stomach for Nissen procedure. In addition the main issue in single-incision upper GI and/or hiatus surgery is still the retraction of liver. We succeeded to retract the left lobe of liver through the incision and completed the operation without any need for supplemental access besides the umbilical incision till the end. SILS Hiatus Surgery can be safely and effectively done but the issue needs further clinical studies to state the efficacy when compared to standard laparoscopy.

N-butyl cyanoacrylate versus conventional suturing for fixation of meshes in an incisional hernia model.

BACKGROUND: Chronic pain and related complications reported after the use of perforating fixation devices in hernia surgery have led to the use of tissue sealants. Fibrin sealant is a feasible option for mesh fixation; however data on cyanoacrylate glues are limited. METHODS: 32 Sprague-Dawley rats were divided into two groups and a 1.5 cm abdominal wall defect was created on each animal. The lesions were then repaired with 2 × 2 cm polypropylene meshes, fixed with n-butyl-cyanoacrylate in the first group and with polypropylene sutures in the second group. The rats were sacrificed on the 21st and 42nd days. The presence of infection, recurrence, and abdominal adhesions were evaluated, followed by biomechanical testing and histological examination. RESULTS: No mesh infection or hernia recurrences were recorded. There was no statistically significant difference between neither the adhesion scores nor the mean broken pressure of the two groups. Cyanoacrylate sealing was found equivalent to suturing in terms of tissue ingrowth, fibrosis, inflammatory infiltration, abscess formation, and necrosis. Furthermore, cyanoacrylate resulted in less foreign body reaction. CONCLUSIONS: Mesh fixation by cyanoacrylate may be considered as an alternative to suture fixation.

The use of LigaSure in patients with hyperthyroidism.

BACKGROUND: Thyroidectomies of hyperthyroidic patients are known to be more blood-spattered than the operations performed for euthyroid nodular diseases and require careful hemostasis. Our purpose was to evaluate the efficacy of the use of LigaSure in patients with hyperthyroidism. MATERIALS AND METHODS: Between January 2004 and October 2005, 100 patients underwent total or near-total thyroidectomy. Bipolar vessel ligation system (LigaSure) was the choice of modality for hemostasis in half of these patients, and the conventional suture ligation technique was used for the rest. The following data were evaluated non-randomized and prospectively in this study: patients demographics, thyroid pathology, operative duration, presence of complications, and the duration of the hospital stay. Comparisons of the data were evaluated by the Wilcoxon and chi-square tests. RESULTS: Among the patients of the LigaSure group, 14 patients were detected to have hyperthyroidism (seven patients with Graves' disease and another seven patients with multinodular toxic goiter), while 36 patients were found to be euthyroidic. The durations of the operation time and of the hospital stay of the patients in the LigaSure group were significantly lower than the conventional thyroidectomy group (p<0.05). The complication rates of the LigaSure and conventional thyroidectomy groups were 4 and 6%, respectively (p>0.05). CONCLUSIONS: The use of LigaSure as an operative technique in the treatment of Graves' disease and toxic goiter is a safe and effective modality that provides a shorter hospital stay and a shorter operation time as well.

The effect of heme oxygenase-1 induction by glutamine on radiation-induced intestinal damage: the effect of heme oxygenase-1 on radiation enteritis.

BACKGROUND: Radiation enteritis is a significant clinical problem in patients receiving ionizing radiation directed at the abdomen or pelvis. The small intestine is the most radiosensitive gastrointestinal organ. Myeloperoxidase (MPO) activity and malondialdehyde (MDA) levels of the small intestine were measured to determine the oxidative damage caused by radiation. In addition, caspase-3 activity of the small intestine was measured to define the degree of apoptosis. The present study was undertaken to investigate the effect of glutamine administration on heme oxygenase-1 (HO-1) expression of the radiation enteritis model. METHODS: Rats received 1 g/kg/d glutamine (HO-1-inducer) for 7 days before irradiation and continued for 3 days after irradiation. Zn-prothoporphyin (Zn-PP) 40 micromol/kg was delivered subcutaneously for 1 day before irradiation. Intestinal MPO activities and MDA levels are indicators of oxidative damage, whereas caspase-3 activities show the degree of apoptosis of the small intestine. At histopathologic examination, terminal ileum tissue was analyzed for morphologic changes. Also, the nuclear factor-kappa (NF-kappa) expression level of the terminal ileum was determined with immunohistochemistry methods to show the mucosal inflammatory process. RESULTS: Irradiation significantly increased the intestinal MPO and caspase-3 activities, MDA levels, and HO-1 expression in comparison with the sham group. Glutamine treatment was associated with increased HO-1 expression, decreased MPO activity, caspase-3 activity, and MDA levels. Inhibition of HO-1 activity by Zn-PP completely eliminated the protective effects of glutamine. Histopathologic examination showed that the intestinal mucosal structure was preserved in the glutamine-treated group. In the irradiation group, NF-kappaB overexpression was detected. NF-kappaB positivity was strongest in the intestine of animals in the radiation alone group and the Zn-PP-treated irradiation group. CONCLUSIONS: Glutamine appears to have protective effects against radiation-induced intestinal damage. This protective effect is mediated in part by the induction of HO-1 activity because inhibition of Zn-PP resulted in the complete abolishment of the protective effect of glutamine.