A survey of current approaches to thyroid nodules and thyroid operations.

INTRODUCTION: Thyroid nodules are commonly seen. Our aim is to learn the behaviors and operational attitudes of surgeons approaching the thyroid nodules. In a literature search, our study is the first and only study performed merely on surgeons. MATERIALS- METODS: This cross-sectional study was done between June 2014-January 2015. The questionnaire consists of 25 questions. Initially, general questions consisting of demographic findings were asked. In step 2, questions consisting of the index case and case variants were asked. Results were compared with American Thyroid Association, European Thyroid Association guidelines, and Australia survey results. In the last step, questions about thyroid operations were asked. RESULTS: A total of 301 surgeons responded to the survey. The response rate was approximately 20%. Thirty nine were female and 262 were male. For the question that asks the diameter of the thyroid nodule that will require a thyroid fine needle aspiration biopsy (TFNAB), 47.5% of the surgeons will require a TFNAB for 1-2 cm solid nodules. 40.15% of the surgeons required a TFNAB regardless of size. 46.1% of the surgeons who required a TFNAB between 1 and 2 cm solid nodules also required scintigraphy at diagnosis of suppressed TSH case variant. CONCLUSION: In this survey, we identified differences from up-to-date guidelines about approaching thyroid nodules and perioperative thyroid surgery. From our perspective, surgeons need updated training requirements. This can be done with updated seminars across the country. Thereby approaches may become standard and consequently patients may have qualified services.

Correlation of Bowel Wall Thickening Seen Using Computerized Tomography With Colonoscopies: A Preliminary Study.

PURPOSE: Bowel wall thickening (BWT) is a common finding in abdominal computerized tomography imaging (CTi). The purpose of the present study was a prospective assessment and management of patients who have BWT in abdominal CTi. MATERIALS AND METHODS: This study was conducted between January 2012 and July 2014 at Erzincan University Hospital, Turkey, with 64 patients who were admitted to the emergency and general surgery department. All of the patients had received colonoscopies due to BWT seen in abdominal CTi. RESULTS: Twenty-three (36%) female and 41 (64%) male patients were included in the study. The mean age was 56.2 years (range, 14 to 84 y). The positive predictive value of CTi for BWT was 87.5%. The positive predictive value of a CTi diagnosis of the disease according to a radiologist's report was 78.1%. Common pathologies detected by colonoscopy included neoplasia and inflammatory bowel disease. CONCLUSIONS: Diagnosis of BWT by abdominal CTi reveals pathologies in many cases. Colonoscopies will be helpful in the differential diagnosis.

Metalloproteinases and Their Inhibitors in Patients with Inguinal Hernia.

AIM: The aim of this prospective study is to investigate if there is a relationship between inguinal hernia, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinases (TIMPs). MATERIALS AND METHODS: This case control study was performed on patients admitted to the general surgery department of Erzincan University Hospital. Four groups were created: control, indirect hernia, direct hernia, and bilateral hernia. All groups were comprised of 11 patients. Serum and tissue levels of MMP-1, MMP-2, MMP-9, MMP-13, TIMP-1, TIMP-2, TIMP-3, and hydroxyproline were evaluated. RESULTS: MMPs values were significantly high at hernia groups, especially at bilateral hernia group (p < 0.05), whereas TIMPs values were significantly low at bilateral hernia group (p < 0.05). MMPs values were increasing at hernia groups in an order as control, indirect, direct, and bilateral. TIMPs values were decreasing at hernia groups in an order as control, indirect, direct, and bilateral. CONCLUSION: Increased levels of MMP-1-2-9-13 and decreased levels of TIMP-1-2-3 may have played role in the formation of inguinal hernia. Hernia is not only a local defect, but a reflection of systemic disease. This is even more significant for bilateral hernias.

Use of Ozone to Treat Ileostomy Dermatitis in an Experimental Rat Model.

BACKGROUND: Dermatitis associated with ileostomy is an important problem that affects many people, especially children. The aim of this study was to investigate the therapeutic effects of ozone on dermatitis due to ileostomy, and to develop an alternative treatment option. MATERIAL/METHODS: A total of 28 rats were divided into 4 groups: control, ileostomy, ozone, and zinc oxide. Ileostomy was performed in all rats except the control group. After a 1-week waiting time, the ozone group was administered ozone therapy and the zinc oxide group was administered zinc oxide cream locally once a day for a total of 7 days. All rats were sacrificed at the end of this period. The efficacy of treatment was examined by biochemical, histopathological, and immunohistochemical parameters. The levels of malondialdehyde (MDA), total glutathione (tGSH), total antioxidant capacity (TAC), and total oxidant status (TOS) were measured from tissue. Vascular endothelial growth factor (VEGF) and proliferating cell nuclear antigen (PCNA) were examined immunohistochemically. RESULTS: Dermatitis occurred pathologically in all rats that underwent ileostomy surgery. The lowest dermatitis score was in the ozone treatment group (p<0.05). Ileostomy dermatitis caused increased levels of MDA and TOS. Ozone treatment resulted in reduced MDA and TOS levels, while the levels of tGSH and TAC were increased (p<0.05). Both VEGF and PCNA immunostaining were augmented in the ozone treatment group (p<0.05). CONCLUSIONS: Local ozone application may be a good alternative compared to the conventional treatment methods for the prevention of skin lesions that develop after ileostomy.

Relationship among mismatch repair deficiency, CDX2 loss, p53 and E-cadherin in colon carcinoma and suitability of using a double panel of mismatch repair proteins by immunohistochemistry.

Biomarkers such as mismatch repair proteins, CDX2, p53, and E-cadherin are blamed for colon cancers, but the relationships of these biomarkers with each other and with pathological risk factors in colon carcinoma are still not clear. The aim of this study was to evaluate the association of these biomarkers with each other by using immunohistochemical staining and to compare their expression with pathological risk factors for colonic adenocarcinoma. We also aimed to study the usability of a double panel of mismatch repair proteins. One hundred and eleven cases with colonic adenocarcinoma were examined. There was a statistically significant relationship between tumor histological differentiation and perineural invasion, vascular invasion, mismatch repair deficiency, p53, CDX2, and E-cadherin (p < 0.05). PMS2 and MSH6 loss covered 100% of cases with mismatch repair deficiency. Mismatch repair deficiency was correlated with CDX2 loss and E-cadherin expression (p < 0.05). It was also observed that cases with PMS2 loss covered all the cases with CDX2 loss. In conclusion, this double panel may be used instead of a quadruple panel for detecting mismatch repair deficiency. Association of CDX2 and PMS2 in the present study is necessary to conduct further genetic and pathological studies focusing on these two markers together.

How do surgeons approach breast cancer surgery in Turkey? A national survey.

BACKGROUND: The aim of this study was to investigate the experience, practice and approaches of general surgeons in relation to the treatment of breast cancer in Turkey. METHODS: A survey was conducted between November 2012 and February 2013 with 453 general surgeons who claimed to perform breast surgery. Initial and most preferred approaches for breast cancer surgery and demographic features of participants were questioned. Initial approaches of surgeons for a suspected breast mass were assessed with a clinical scenario. RESULTS: A total of 12.6 % of practicing general surgeons in Turkey responded to the survey. A multidisciplinary assessment was employed by 57.2 % of participants. The most frequently used diagnostic tool was needle biopsies (64.9 %) and the most frequently performed surgery for early stage cancers was breast-conserving surgery (72.2 %). The initial approach for locally advanced breast cancer was neoadjuvant chemotherapy (59.8 %) and mastectomy for metastatic cancer (22.7 %). Sentinel lymph node biopsies were utilized by 59.2 % of participants by different methods in appropriate cases. Oncoplastic breast surgery was performed by 9.0 % of participants, frequently or constantly. The surgeons' initial approaches for the clinical scenario were imaging (56.7 %) and biopsy (40.6 %). CONCLUSIONS: Although there are efforts to improve up-to-date approaches towards breast cancer surgery by surgeons, currently there are significant inadequacies for evidence-based medicine practices.

The effect of ozone and naringin on intestinal ischemia/reperfusion injury in an experimental model.

BACKGROUND: The aim of the study was to evaulate the effect of ozone and naringin on the intestine after intestinal ischemia-reperfusion(II/R) injury. METHODS: Thirty five rats divided into 5 groups of 7 animals: control, II/R, ozone, naringin and naringin + ozone. Only laparotomy and exploration of the superior mesenteric artery (SMA) were done in control group. In the experimental groups, SAM was occluded for 1 h and reperfused for 1 h. 15 min after ischemia, ozone (25 µg/ml, 0.5 mg/kg), naringin (80 mg/kg) and naringin + ozone(80 mg/kg + 25 µg/ml, 0.5 mg/kg) were infused intraperitoneally to each groups. Ileum tissues were harvested to determine intestinal mucosal injury and oxidative stress markers. For SMA occlusion, different than literature, silk suture binding was used. RESULTS: Oxidative stress markers were significantly low in experimental groups compared with II/R group (p < 0.05). Histopathologically, the injury score was significantly low at experimental groups compared with II/R group (p < 0.05). The lowest injury score was encountered at naringine + ozone group. CONCLUSIONS: Ozone alone or combined with naringin has a protective effect for mesenteric ischemia. Instead of using instruments such as clamps in the II/R rat model, silk binding may be used safely.

Diagnostic evaluation and treatment of patients with rectus abdominis hematoma.

PURPOSE: To identify clinical characteristics, treatment modalities, and course of spontaneous rectus sheath hematoma (SRSH). In the literature, there is no prospective clinical trial that is intended for treatment in clinical research. METHODS: Seventeen SRSH patients diagnosed and treated between March 2012 and March 2014 at the general Surgery Department of Erzincan University Training and Research Hospital were included. Age, sex, weight, height, predisposing factors, comorbid diseases, Charlson index, current medical treatment, physical examination signs, imaging methods, lowest hemoglobin value, blood type, SRSH type, INR/Factor V Leiden mutation/Factor VII/Factor VIII/Factor X/Protein S/Protein C values, treatment method, transfusions hospitalization duration, and outcome were studied. RESULTS: Thirteen patients were female. The mean age was 63.3 ± 18.7 years (range, 22-87 years), and the mean BMI was 27.8 ± 3.5 (range, 20.9-33.7). Six patients had Grade I SRSH, 5 had Grade II SRSH, and 6 had Grade III SRSH. Thirteen were hospitalized for a mean duration of 9.3 ± 8.1 days (range, 1-30 days). The death rate attributable to SRSH was 5.8%. CONCLUSION: Early diagnosis of SRSH by ultrasonography and/or computerized tomography is important for a low mortality rate. Even though medical treatments are important, arterial embolization by interventional radiology, or more radical interventions such as surgery, may be required.

Surgeons' Approaches and Professional Perspectives on Breast Masses: A National Survey in Turkey.

OBJECTIVE: General surgeons' approaches to breast masses in their daily practices and their perspectives for issues on breast diseases and breast surgery are investigated through a survey. MATERIALS AND METHODS: Answers of 524 general surgeons for the survey "Approach to breast diseases and breast surgery" between November 2012 and February 2013 were assessed. Demographic features, approaches to the breast masses, and answers for the clinical scenerios of surgeons were questioned. Surgeons were asked about management of breast cancer and the future role of surgeons for oncoplastic breast surgery and breast diseases. RESULTS: Participants were representing 14.6% of all general surgeons in Turkey. The survey revealed that breast diseases are the most common cause for admission in general surgery outpatient clinics. Needle biopsies were employed by 241 (60%) respondents. Three hundred and seventy-one (71%) participants indicated that breast cancer management could be accurately conducted by the general surgeons. Two hundred and seventy-three (52%) respondents think that oncoplastic breast surgery should be performed by a general surgeon and 241 (41%) respondents predict that the role of general surgeons for breast diseases and breast surgery will decrease in the future. CONCLUSION: Basic approaches towards breast masses need to be improved in our country despite the highest frequency of breast diseases in outpatient admissions. The views and opinions of surgeons on breast diseases and the course of breast surgery in different regions and different communities need to be defined and clarified.

A comparison of total thyroidectomies carried out through LigaSure and Harmonic Scalpel: a retrospective study.

AIM: Both LigaSure (LS) and Harmonic Scalpel (HS) are new surgical technologies that have been used to secure hemostasis in various fields of surgery. There is little information in the literature about the use of LS and HS in thyroid surgery. The aim of this study was to report our experience with LS and HS in thyroid surgery. MATERIALS AND METHODS: In this nonrandomized retrospective study 326 consecutive patients who underwent primary thyroid surgery were reviewed. HS was used in 136 patients and LS was used in 126 patients. A conventional technique was used in 64 patients. The were 42 male patients (12.9%) and 284 female patients (87.1%); their ages varied between 19 and 72 years (mean 42.8 + 12.4). Data regarding each patient's demographics, thyroid pathology, operation time, and complications were collected throughout the study. RESULTS: The 3 study groups-had similar demographics (age, female/male ratio) and thyroid pathology. Permanent hypocalcemia developed in 2 (1.6%) patients in the patient group operated on through LS, of which 1 was male and the other was female. In the HS group, postoperative hematoma developed in 2 (1.5%) patients. CONCLUSION: The results of this retrospective clinical study showed that LS and HS thyroidectomy can be a useful and fast alternative for conventional thyroidectomy. The main advantage of these devices is that they simplify the procedure and eliminate the need for clips and suture ligations while achieving efficient hemostasis.

Familial multiple lipomas coexisting with celiac disease: a case report.

INTRODUCTION: Gluten enteropathy (celiac disease) is a chronic disease and presents as diarrhea, weight loss and anemia. CASE PRESENTATION: A 35-year-old Caucasian man with gluten enteropathy, familial multiple lipomas and seborrheic keratosis was seen in our clinic. After confirmation of the diagnosis, he was advised to follow a gluten-free diet. His clinical improvement was evaluated and confirmed with biopsy. CONCLUSION: Celiac disease is known to be associated with many systemic diseases and skin lesions but its association with familial multiple lipomas has not yet been reported.

Importance of metastatic lymph node ratio in non-metastatic, lymph node-invaded colon cancer: a clinical trial.

BACKGROUND: The aim of this study was to evaluate the prognostic importance of the metastatic lymph node ratio for stage III colon cancer patients and to find a cut-off value at which the overall survival and disease-free survival change. MATERIAL/METHODS: Patients with pathological stage III colon cancer were retrospectively evaluated for: age; preoperative values of Crp, Cea, Ca 19-9, and Afp; pathologic situation of vascular, perineural, lymphatic, and serosal involvement; and metastatic lymph node ratio values were calculated. RESULTS: The study included 58 stage III colon cancer patients: 20 (34.5%) females and 38 (65.5%) males were involved in the study. Multivariate analysis was applied to the following variables to evaluate significance for overall survival and disease-free survival: age, Crp, Cea, perineural invasion, and metastatic lymph node ratio. The metastatic lymph node ratio (<0.25 or ≥0.25) is the only independent variable significant for overall and disease-free survival. CONCLUSIONS: Metastatic lymph node ratio is an ideal prognostic marker for stage III colon cancer patients, and 0.25 is the cut-off value for prognosis.

Application of fasciocutaneous V-Y advancement flap in primary and recurrent sacrococcygeal pilonidal sinus disease.

BACKGROUND: Pilonidal sinus disease is a common disease of young adults, which most frequently occurs in the sacrococcygeal region on the skin's midline. Various procedures, ranging from simple incision and curettage to complex flaps for natal cleft obliteration, have been described in the literature. MATERIAL/METHODS: We aimed to present the dermographic characters, post-operative complications, length of stay in hospital, time of return to daily activities, and recurrence rates of the patients in which we applied sinus excision and fasciocutaneous V-Y advancement flap due to primary complicated or recurrent sacrococcygeal pilonidal sinus disease. RESULTS: Patients with primary complicated and recurrent pilonidal sinus received a fasciocutaneous V-Y advancement flap in the general surgery service of our hospital. Eleven patients had recurrent disease. Thirty-seven patients received a unilateral V-Y flap and 8 patients received a bilateral V-Y flap. None of the patients had post-operative flap necrosis or wound opening. Two of the patients had a self-draining simple seroma and 3 of the patients had delayed wound healing in the perianal region of the incision, which was treated with dressing. The mean time required to return to daily activities was 7 days, and return to work took 17 days. In the mean 25-month follow-ups of the patients, no recurrences were detected. CONCLUSIONS: We think that fasciocutaneous V-Y advancement flap is an easily learned and practicable method that reduces the recurrences in the patients with primary complicated and recurrent pilonidal sinus, length of stay in hospital, and time to return to daily activities and work in the post-operative period.

How could such a wide piece of tree root pass through the narrow pyloric orifice? An extremely rare case.

PATIENT: Female, 30 FINAL DIAGNOSIS: Phytobezoar Symptoms: Nausea • vomiting MEDICATION: - Clinical Procedure: - Specialty: - OBJECTIVE: Rare disease. BACKGROUND: Phytobezoars are a common type of bezoar known to accumulate in the gastrointestinal system. CASE REPORT: A 30-year-old mentally retarded woman was operated on due to small bowel obstruction. A piece of tree root was extracted from the ileum. The patient was discharged from the hospital on postoperative day 7. CONCLUSIONS: Due to difficulties in determining the nature of the bezoar preoperatively, small bowel obstruction due to a phytobezoar is not a common diagnosis. For bezoars, prevention is considered preferable to treatment.

Clear cell variant of follicular thyroid carcinoma with normal thyroid-stimulating hormone value: a case report.

INTRODUCTION: Clear cell carcinomas of the thyroid gland with normal thyroid-stimulating hormone value are very rare, but clear cell changes are described in most reported cases of thyroidal lesions. CASE PRESENTATION: In this report, we describe the case of a 50-year-old Caucasian woman with a normal thyroid-stimulating hormone level who underwent surgery to treat a multi-nodular goiter. The pathology was a clear cell variant of follicular thyroid carcinoma. The tumor was 1cm in diameter and consisted of pure clear cells. CONCLUSION: Clear cell variants of follicular thyroid carcinoma are rarely seen, especially it is misdiagnosed with metastatic renal cell carcinoma. In this report, we describe the case of a patient with a clear cell variant of follicular thyroid carcinoma with an interesting pathology.

A case report of esophageal perforation: Complication of nasogastric tube placement.

PATIENT: Male, 70 FINAL DIAGNOSIS: Esophageal perforation Symptoms: Abdominal pain • nausea • vomiting MEDICATION: - Clinical Procedure: - Specialty: Surgery. OBJECTIVE: Unusual clinical course. BACKGROUND: Esophageal perforation is a well-defined and severe clinical condition. There are several etiologies of esophagus perforation. CASE REPORT: We report the case of a 70-year-old Caucasian man who underwent an emergency cholecystectomy due to acute cholecystitis. Two days after surgery, his condition deteriorated. Thorax computerized tomography revealed an esophageal perforation. CONCLUSIONS: Esophageal perforation due to nasogastric application is relatively rare but the consequences are potentially serious. The anatomy of the upper gastrointestinal system should be understood by all healthcare professionals involved in the treatment.

The diagnostic importance of matrix metalloproteinase-7 and nestin in gastrointestinal stromal tumors.

BACKGROUND: The importance of the matrix metalloproteinase-7 (MMP-7) and nestin immunomarkers, C-kit proto-oncogene (CD117), and the efficiency of the Ki-67 proliferation index for gastrointestinal stromal tumors were evaluated. MATERIAL AND METHODS: This study was conducted by examining the microscope slides of 72 patients with gastrointestinal stromal tumors that were sent to the pathology laboratory between 2007 and 2012. Immunohistochemical staining for CD117, MMP-7, nestin, and marker of proliferation Ki-67 was performed. The correlations between the positive results for Ki-67, CD117, MMP-7, and nestin were evaluated relative to the tumor characteristics of size, localization, grade, cellular type, cellularity, cytology type, growth pattern, ulceration, necrosis, hemorrhage, invasion depth, and lymph node metastasis. RESULTS: The tumor was localized in the stomach in 42 of the patients, the intestines in 19, the colon in 7, and the rectum in 4. Comparisons among the groups showed that MMP-7 was correlated with the tumor grade (p<0.001), cellularity (p<0.009), cytologic atypia (p<0.001), ulceration (p=0.002), necrosis (p<0.001), and tumor size (p=0.001). Nestin was correlated with the tumor grade (p=0.013), and tumor size (p=0.024). Correlations among CD117, MMP-7, nestin, and Ki-67 were examined. Nestin and Ki-67 were both significantly correlated with CD117 and MMP-7 [(r=0.279, p=0.018), (r=0.322, p=0.006), (r=0.386, p=0.001), (r=0.386, p=0.002)], respectively. CONCLUSIONS: MMP-7 and nestin may be beneficial as markers, given their sensitivity to gastrointestinal stromal tumors.

Multifocal tumoral calcinosis in a 4-year-old girl.

PATIENT: Female, 4 FINAL DIAGNOSIS: Tumoral calcinosis Symptoms: Hard immobile mass Medication: - Clinical Procedure: - Specialty: Surgery. OBJECTIVE: Congenital defects. BACKGROUND: Tumoral calcinosis is an uncommon condition associated with the deposition of painless calcific masses. It is more common in childhood or early adolescence of African-American females. CASE REPORT: We present a case of a 4-year-old girl with tumoral calcinosis treated surgically. The case is rather rare in terms of the age of the patient and the localization of the masses (gluteal site). In our patient, the biochemical findings were normal, except for hyperphosphatemia and elevated alkaline phosphatase. CONCLUSIONS: Total excision appears to lead to a good clinical outcome and a low incidence of local relapse.

The effect of lateral internal sphincterotomy on resting anal sphincter pressures.

BACKGROUND/AIM: Anal fissures are one of the most common proctologic disorders. This study aimed to investigate alterations in anal sphincteric resting pressures after lateral internal sphincterotomy, which was performed for chronic anal fissure treatment. MATERIALS AND METHODS: Fifty-six (68.3%) male and 26 (31.7%) female patients were included in this study. Patients complicated with fistula-in-ano, abscess, cancer, inflammatory bowel disease, dermatitis, poor general condition, allergy to any of the standard medications, previous history of anal trauma, previous anal surgery, or diagnosis of a neurological disease and patients who did not give consent to the trial were excluded from the study. Two groups were formed: a control group with 41 healthy volunteers and a study group with 41 chronic anal fissure patients. Preoperative and postoperative manometric anal measurements were compared. RESULTS: Preoperative mean resting anal sphincter pressure was 51.29 mmHg for the control group and was 59.99 mmHg for the patient group. Although resting anal sphincteric pressures of the patient group remained within the physiological range, when compared with the control group there was a statistically significant difference. Postoperative mean resting anal sphincteric pressures of the patient group was 32.43 mmHg. CONCLUSION: Lateral internal sphincterotomy decreases resting anal sphincter pressures effectively in chronic anal fissure patients.