Turkish Ministry of Health, 2nd Turkish Medical General Assembly Clinical Oncology Study Group Report.

OBJECTIVE: There is an increase in the incidence of cancer, and consequently in mortality rates, both in the world and in Turkey. The increase in the incidence and mortality rate of cancer are more prominent in our country as well as in other developing countries. The aim of this workshop was to determine the current status on prevention, screening, early diagnosis and treatment of cancer in our country, to identify related shortcomings, specify solutions and to share these with health system operators, and to aid in implementation of these systems. Developments on palliative care were also evaluated. MATERIALS AND METHODS: The current situation in the practice of clinical oncology, related drawbacks, problems encountered during multidisciplinary approach and their solutions were discussed under several sub-headings during a 3-day meeting organized by the Turkish Ministry of Health (Türkiye Cumhuriyeti Saglik Bakanligi-TCSB) with participation of 16 scientists from Turkey and 6 from abroad, and the conclusions were reported. RESULTS: It is expected that the newly established Turkish Health Institutes Association (Türkiye Saglik Enstitüleri Baskanligi-TÜSEB) and the National Cancer Institute (Ulusal Kanser Enstitüsü) will provide a new framework in the field of oncology. The current positive findings include the increase in the number of scientists who carry out successful trials in oncology both in Turkey and abroad, the implementation of the national cancer registry program by the Cancer Control Department and the breast cancer registry program by the Turkish Federation of Breast Diseases Societies (Türkiye Meme Hastaliklari Dernekleri Federasyonu-TMHDF), and introduction of Cancer Early Diagnosis, Screening, and Training Centers (Kanser Erken Tani, Tarama ve Egitim Merkezi-KETEM) for the application of community-based cancer screening programs. In addition to these, obvious shortcomings related to education, implementation, management and research issues were also determined, and policy and project proposals to address these issues were presented. Collaboration with relevant organizations in the implementation of these studies was supported. CONCLUSION: Both the incidence and mortality rates of cancer are increasing in Turkey. The widespread deficiencies in population-based screening and in effective treatment lead to an increase in delay in diagnosis and mortality. Despite improvements in data recording, screening and treatment over the last 10 years, extensive, organized, population-based screening programs and fully equipped early diagnosis and treatment centers are required. Enhancement of basic cancer epidemiologic, translational, genetic and molecular research studies is essential in our country. Improvements on pain treatment and palliative care of patients with chronic and terminal cancer are also required.

Mag-5: a magnificent approach to upper and midfacial "magic".

MAG-5 is an operation with five surgical components: (1) a lateral emphasis frontal lift with (2) corrugator resection, (3) lower blepharoplasty, (4) extended two-layered canthopexy, and (5) a full (or partial) subperiosteal malar release and midcheek lift assisted by an absorbable suture securing the malar tuft periosteum and fibrous tissue to the orbital rim. The procedure rejuvenates and restores the face or transforms it when, and if, transformation is the desire.

The open coronal approach to forehead rejuvenation.

The coronal or frontal lift is a simple operation and the most effective tool for brightening and refreshing facial appearance. It becomes even more effective when combined with canthopexy, midcheek lifting, and lower lid surgery. Its rejuvenation and beauty-enhancing effects are awesome, and much of its benefit is transferable to endoscopic lifts or lateral juxta-brow, temple excisions, if one takes the time to master the details.

When should we order a CT scan and when should we rely on the results to diagnose an acute appendicitis?

OBJECTIVE: The objective of this study was to retrospectively analyze the last 100 consecutive emergency appendectomies performed in the authors' institution, which is a community-based teaching hospital, and look at the accuracy of the CT scan in the diagnosis of acute appendicitis. DESIGN: Retrospective clinical study. SETTING: A 600-bed community-based teaching hospital. METHODS: The last 100 consecutive emergency appendectomies, which were performed at New York Methodist Hospital in 2004, were retrospectively analyzed. The collected data included the demographics of the patients, relevant history, physical examination, laboratory and radiological tests, and pathology results. The statistical analyses were performed using the JMP version 3.2 software (SAS Institute Inc., Cary, North Carolina). An alpha value of 0.05 was used in all statistical analyses, and p values were considered as being statistically significant at or below the alpha value of 0.05. RESULTS: There was no statistically significant correlation between the acute appendicitis and some of the typical presenting symptoms and signs of acute appendicitis (rebound tenderness, low-grade fever, elevated white blood cell count, and anorexia). The sensitivity, specificity, positive predictive value, and negative predictive value of the CT scan in this retrospective analysis were 96%, 75%, 98.5%, and 50%, respectively, with an overall efficiency of 95%. However, the sensitivity, specificity, positive predictive value, and negative predictive value of the CT scan increased after reevaluation of the false-positive, false-negative, and inconclusive CT results by an experienced radiologist in a blind fashion (97%, 100%, 100%, and 71%, respectively). The correlation between the CT scan and the pathology result was statistically significant when the CT result was positive or negative (p = 0.0001). CONCLUSION: The CT scan is indicated when the clinical presentation is equivocal, and it will be helpful if the result is positive or interpreted as negative only by an experienced radiology attending.

Dermafascial fixation suture: a technique for a more durable projection with short-scar (vertical) reduction mammaplasty.

BACKGROUND: Short-scar reduction mammaplasty has several advantages over the traditional technique, mainly reduced scarring and superior long-term breast shape. Multiple modifications of the short scar reduction mammaplasty technique have been made in an effort to decrease the learning curve while improving the results. The authors present another modification of the short-scar technique for a more durable projection without reliance on a skin envelope. METHODS: The perimeters of the medial pedicle and the nipple-areola complex are marked, and the medial pedicle is deepithelialized. A 2 x 5-cm skin area at the inferior border of the pedicle is further deepithelialized, then pexied to the pectoralis fascia in a superomedial direction using a nonabsorbable monofilamanet suture with a horizontal mattress suturing technique. RESULTS: Taking the suture bites from the dermis rather than the breast parenchyma for the pexy aims to spare the pedicle's circulation. This durable internal rearrangement of the breast parenchyma with dermafascial pexy further decreases the tension at the nipple-areola complex because the final breast shape no longer relies on the skin closure. Suture spitting at the nipple-areola complex also is prevented with elimination of the purse-string suture because there is no need for a further decrease in the tension with the purse-string suture after the dermafascial pexy. CONCLUSIONS: The authors believe that the dermafascial pexy is a concept more than a technique. It incorporates the two strongest structures, the dermis and the fascia, to achieve more durable results not only with reduction mammaplasty, but also with any aesthetic breast surgery that uses the pedicles.

Correlation between complication rate and tissue resection volume in inferior pedicle reduction mammaplasty: a retrospective study.

BACKGROUND: The inferior pedicle technique is the most common breast reduction procedure performed in the United States today. Traditionally, it has been recommended that pedicle techniques not be used for large volume breast reduction (>1000 gm/breast), as the complication rate may be unacceptably high. OBJECTIVE: We conducted a retrospective study to determine whether any correlation could be found between complication rate and tissue resection volume in breast reduction procedures when the inferior pedicle technique was used. METHODS: One hundred twenty-two patients underwent inferior-pedicle reduction mammaplasty by a single surgeon between January 1998 and December 2001. Patients were divided into 2 groups according to the average quantity of tissue resection: 500- to 1000-gm breast reduction, and >1000-gm breast reduction. Complications were analyzed. Rates in each group were determined and assessed for statistical significance. RESULTS: The average reduction was 673 gm/breast (range, 502-964 gm) in the small volume group (n = 73), and 1326 gm/breast (range, 1005-2175 gm) in the large-volume group (n = 49). Twenty-nine complications occurred. No patient experienced more than 1 complication. Eight different complications were identified. Hypertrophic scarring was most common, occurring in 11 patients. One major complication, an expanding hematoma, occurred. There were no cases of nipple-areolar complex or skin flap necrosis. The overall complication rate was 23.7%. There were 18 complications in the >1000-gm group (24.6%) and 11 complications in the <1000-gm group (22.4%). This difference was not statistically significant (P = .77). CONCLUSIONS: The inferior pedicle technique can be safely used in reduction mammaplasty for resection volume exceeding 1000 gm/breast, without added complications.

Finding the best abdominal closure: an evidence-based review of the literature.

BACKGROUND: Despite advances in surgical technique and materials, abdominal fascial closure has remained a procedure that often reflects a surgeon's personal preference with a reliance on tradition and anecdotal experience. The value of a particular abdominal fascial closure technique may be measured by the incidence of early and late wound complications, and the best abdominal closure technique should be fast, easy, and cost-effective, while preventing both early and late complications. This study addresses the closure of the vertical midline laparotomy incision. DATA SOURCES: A MEDLINE (National Library of Medicine, Bethesda, Maryland) search was performed. All articles related to abdominal fascia closure published from 1966 to 2003 were included in the review. CONCLUSIONS: Careful analysis of the current surgical literature, including 4 recently published meta-analyses, indicates that a consistent conclusion can be made regarding an optimal technique. That technique involves mass closure, incorporating all of the layers of the abdominal wall (except skin) as 1 structure, in a simple running technique, using #1 or #2 absorbable monofilament suture material with a suture length to wound length ratio of 4 to 1.

Peeling orange: rapid deepithelialization in reduction mammaplasty.

The authors contend that "peeling orange" deepithelialization, a technique of scalpel deepithelialization for reduction mammaplasty, is fast and simple to master. It facilitates more rapid deepithelialization than en bloc deepithelialization, particularly with long pedicles.

The septic abscess wall: a cytokine-generating organ associated with portal venous cytokinemia, hepatic outflow fibrosis, sinusoidal congestion, inflammatory cell sequestration, hepatocellular lipid deposition, and focal cell death.

An acute septic inflammatory response with access to the portal circulation was created in a rat model using an intra-abdominal abscess composed of a sterile agar pellet, or one contaminated with 102 Escherichia coli (E. coli) and 109 Bacteriodes fragilis (B. fragilis). After 3 days postimplantation, a well-formed intra-abdominal abscess occurred whose wall showed IL-6 DNA by PCR and IL-6 mRNA by in situ hybridization. Portal venous blood draining into the liver from the intra-abdominal abscess had increased levels of TNF-alpha, IL-1beta, and IL-6 in both sterile and septic groups compared with a control normal animal group. Increased levels of these cytokines were also found in suprahepatic inferior vena caval blood, but were correlated with the higher portal vein levels, suggesting a gradient from abscess wall to portal vein into the systemic circulation via the liver. Liver histology demonstrated sinusoidal congestion centering on the central vein, growing worse with progression from normal in control, to sterile, to septic. Similarly, the degree of intrahepatic myeloperoxidase-positive inflammatory cell infiltration and hepatocellular lipid deposition and apoptosis also increased from control, to sterile, to septic. Gene expression by in situ hybridization demonstrated a significant increase in IL-6 and fibrinogen mRNAs in cells surrounding the central vein in sterile and septic animals, being greatest in animals with sepsis, associated with an increased deposition of collagen in the central vein area, most prominent in the septic liver. The pericentral vein cells with IL-6 and fibrinogen mRNA increases paralleled the increases in cells containing IL-6 and fibrinogen mRNAs in the abscess walls of sterile and septic animals, respectively. The data suggest that an intra-abdominal abscess, especially when contaminated with gram-negative bacteria, induces mRNA-generated cytokine responses in the abscess wall that are related to increased portal venous levels of the inflammatory cytokines TNF-alpha, IL-1beta, and IL-6 perfusing the liver. These, in turn, induce localized production of IL-6 and fibrinogen mRNAs in cells at the central vein area with resultant outflow fibrosis and increased inflammatory cell sequestration within the liver lobular sinuses. This is associated with a generalized inflammatory response and intrahepatic portal sinusoid congestion. There is also increased hepatocellular lipid deposition and apoptosis. Thus, the cytokine production of the abscess wall itself appears to be a major mediator of the septic hepatic response.

"Tear-drop augmentation mastopexy": a technique to augment superior pole hollow.

Breast ptosis classification systems focus on the inferior descent of the nipple, as well as the descent and distribution of the breast parenchyma below the inframammary fold. Common problems, such as development of a superior pole hollow and an excessive width of the superior pole, extending into the axilla, are not addressed. Few procedures specifically address these deficiencies, and even less information is available in terms of preventative maneuvers when augmentation is desired as an adjunct. Round implants worsen the problem by creating a superior pole shelf, and anatomic implants are unreliable alternatives. Here, we present a technique-"tear-drop" augmentation mastopexy-that addresses superior pole hollow, excess superior pole width, as well as breast ptosis and hypomastia. Patients with moderate to severe breast ptosis (Regnault's classification), tubular breast deformity, and deformities secondary to previous breast surgery are included in the study. Skin is deepithelialized through a circumareolar incision, and a skin-fat flap is elevated completely encircling the breast. A 2-cm area of parenchyma is left attached to the skin in the lower half of the breast. Breast parenchyma in the superior half of the breast is then advanced and plicated in a superiomedial direction to move the nipple areolar complex to the desired new position. Care is taken to redefine the pectoralis major muscle at its axillary border. A 3-cm incision is then placed in the inferior part of the parenchyma at the 6 o'clock position to create a subpectoral pocket for placement of the implant. The tunnel is then closed to separate the implant pocket from the subcutaneous dissection. Residual dermal flap is used to define, and add durability to the parenchyma reshaping procedure. A 3-0 mersiline (Ethicon, Somerville, NJ) blocking suture is used for a uniform circumareolar skin closure. Patients (n:35), ages 17-48, underwent "tear-drop" augmentation mastopexy between January 1999 and September 2002 for correction of the breast ptosis, tubular breast deformity, and deformities secondary to previous aesthetic breast surgery. The average follow-up was 2 years. All patients displayed type 1 or 2 (Baker classification) capsules. One subcutaneous hematoma and one subcutaneous seroma were seen, which were both treated by percutaneous aspiration. No submuscular hematomas, infections, skin or nipple losses, or hypertrophic scars were noted. Patient satisfaction was high. A more natural "tear-drop" breast shape was created with an improvement in the superior pole hollow and narrowing of the superior breast. The smallest breasts did not benefit from this technique for elimination of the superior pole shelf, as correction was proportional to the amount of breast tissue available for superior advancement. The "tear-drop" augmentation mastopexy is a novel technique for correction of the breast ptosis with augmentation, avoiding problematic development of superior pole hollow and excess superior width. This technique is also well applied to tubular breast deformity as well as to secondary breast procedures. Long-term follow-up demonstrates a safe and reproducible result with high patient satisfaction. This technique may solve several problems associated with breast ptosis surgery, which before were not specifically addressed, and the technique warrants further investigation.

Delayed post-operative pneumoperitoneum.

We present a case of post-operative pneumoperitoneum (PP), which persisted for eight weeks. Postoperative retained air is the most common cause of PP. It does not require a surgical intervention and thus is defined as a 'non-surgical PP'. The etiological factors contributing to the duration of the postoperative PP are controversial but the longest time described in the literature is 24 days. We review the relevant literature and discuss factors contributing to the duration of postoperative PP.