Intraoperative Parathyroid Hormone Monitoring-Guided Subtotal Parathyroidectomy is an Effective and Valid Surgical Procedure for Secondary Hyperparathyroidism.

Objectives: Secondary hyperparathyroidism (sHPT) is a prevalent complication of end stage renal disease in which serious morbid conditions and mortality can be encountered. Although the best solution of this severe problem is renal transplantation, because of the huge demand and limited resources, this cannot be possible most of the time. Initial treatment alternative is medical treatment in patients with sHPT and parathyroidectomy (PTX) should be applied if does not help. Subtotal PTX, total PTX and total PTX together with autotransplantation are the current surgical options preferred for sHPT. Intraoperative parathyroid hormone (IO PTH) monitoring can increase surgical success in sHPT. We aimed to determine the ideal surgical technique and relation of IO PTH monitoring with surgical success in patients with sHPT through our study. Methods: We analyzed all the data of the 35 patients who had PTX and follow up between January 2001 and December 2021 because of sHPT at General Surgery Department of Akdeniz University Medical Faculty Hospital in retrospective manner. Results: Twenty-seven of the patients had been applied subtotal PTX while six of the cases had experienced limited surgery and two of them had undergone total PTX. Persistance happened to be present in the follow-up of nine patients and recurrence in one of them. Four persistant and one recurrent cases were present in 23 patients with IO PTH monitoring (78.3% surgical success), while there were persistences in each of the three patients with no IO PTH monitoring (0% success of surgery) (p=0.022). IO PTH monitoring data of nine patients could not be reached. In this study, 20 patients had IO PTH decline of 80% or more (90% surgical success) and three patients had IO PTH decline below 80% (0% surgical success) (p=0.006). Subtotal PTX was applied to 17 (94.1% surgical success) of these 20 patients. Conclusion: In surgical treatment of patients with sHPT, IO PTH monitoring should be maintained and operation should not be finished until 80% or more decline in IO PTH level had been detected. Among the surgical alternatives for sHPT, subtotal PTX appears as an effective and valid method when performed together with IO PTH monitoring, provided that there is a decline in PTH level of 80% or more.

Utility of immature granulocyte in severity of helicobacter pylori infection.

Introduction: Helicobacter pylori infection is a chronic bacterial infection associated with some extragastric diseases as well as gastric involvements that occur most commonly worldwide. In our study, we aimed to investigate the usability of immature granulocytes as a basic indicator that can reflect the severity of helicobacter pylori inflammation, to the best of our knowledge, for the first time. Materials and Methods: Patients who underwent upper gastrointestinal endoscopy between April 2019 and April 2020 and were diagnosed with antral gastritis were included in this study. The relationship between helicobacter infection and its severity detected in gastric biopsies of patients and immature granulocyte count (IGC), immature granulocyte percentage (IG%), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and mean platelet volume (MPV) were investigated. Results: Of the 868 patients, 210 were HP negative, 658 were HP positive (218 mild HP positive, 293 moderate HP positive, and 147 severe HP positive). There were statistically significant differences between the HP negative and HP positive groups in terms of IGC, IG%, NLR, and PLR. However, IG% and IGC were not clinically useful because the median IG% (0.3 vs 0.3) and IGC (0.02 vs 0.02) were the same in the HP negative and total HP positive groups. Conclusion: In our study, IGC and IG% were not found useful to detect H. pylori intensity and severity of inflammation.

Idiopathic granulomatous mastitis and steroid use during the pandemic of COVID-19.

BACKGROUND: Steroid therapy is an immunosuppressive treatment and may have possible side effects in a pandemic period. However, the number of studies on the use corticosteroids for the treatment of idiopathic Granulomatous Mastitis (IGM) especially during the pandemic is almost negligible. METHODS: The data of patients with the diagnosis of IGM between January-December 2020 in the General Surgery Clinic were retrospectively analyzed. The patients were explained in detail that steroid therapy is an immunosuppressive treatment and it may have possible side effects. Prednisolone 0.5-1 mg/kg/day was given as steroid therapy. The treatment was planned for 4-6 months according to the severity of the symptoms and was completed by reducing it to a total dose of 10 mg/month. RESULTS: Eleven patients were included in the study. Five patients had completed steroid treatment and continued their follow-up. In our study, a total of six patients were receiving steroid therapy. CONCLUSIONS: There is no consensus yet on the use of the steroid in the COVID-19 pandemic. Low doses Corticosteroids (<1 mg/kg/day) don't have an effect on increase mortality in patients with severe COVID-19. We can think that low-dose corticosteroids used by many centers in IGM treatment do not have a negative effect on mortality.

Crystallized phenol treatment vs excision and primary closure in pilonidal sinus disease: A randomized clinical trial in adolescent patients.

INTRODUCTION: Pilonidal sinus is a chronic inflammatory disease seen in the intergluteal sulcus. A wide variety of treatment modalities have been described for the management of this disease, however optimal therapy remains controversial. The study aims to compare phenol treatment, a minimally invasive method used in the treatment of pilonidal sinus disease, with the commonly practiced surgical methods of excision and primary closure in the adolescent age group. PATIENTS AND METHODS: Adolescent patients who presented with pilonidal sinus disease between January 2018 and December 2018 were randomized into 2 groups as phenol treatment and surgical treatment (after obtaining consent for the study). Early complications and recurrence rates after 24 months of follow-up were the two main endpoints of the study. RESULTS: A total of 100 patients (phenol group n = 50, surgery group n = 50) were included in the study. Both groups were similar in terms of age, gender, and BMI. The mean duration of the procedure was 12.4 ± 2.84 min in the phenol group and 42.3 ± 7.22 min in the surgery group (p = 0.00). There was no difference in postoperative complications between the groups (p = 0.22). After 24 months of follow-up, recurrence was found in 8% (n = 4) of the cases in the phenol group and 10% (n = 5) of the cases in the surgery group (p = 0.5). CONCLUSION: In our study, phenol treatment and excision/primary closure methods for pilonidal sinus disease have similar complication and recurrence rates. However, phenol treatment seems to be the method of choice in the adolescent age group as it has the advantage of being a minimally invasive method and it does not affect subsequent surgical treatments. LEVEL OF EVIDENCE: Level II treatment study.

A Novel Transabdominal Preperitoneal Hernioplasty Technique in the Repair of Large Inguinal Hernias: The use of Polypropylene Mesh in the form of Plug-patch.

OBJECTIVE: To describe the outcome of modified transabdominal laparoscopic preperitoneal (TAPP) hernioplasty repair with plug-patch of polypropylene mesh. STUDY DESIGN:  A descriptive study. PLACE AND DURATION OF STUDY: Alanya Alaaddin Keykubat University Training and Research Hospital, Alanya, Turkey from December 2017 to December 2019. METHODOLOGY: Patients aged 18-70 years, who underwent TAPP hernioplasty at this clinic between December 2017 and 2019 were evaluated retrospectively. Those with a defect diameter of 3 cm and above, which were measured intraoperatively, were considered as large inguinal hernias. A modified TAPP procedure that includes the plug-patch technique, using polyester mesh, similar to that of open inguinal hernia repair, was performed on these patients. Complications and recurrences frequency was noted. RESULTS: This modified TAPP procedure was applied to 35 patients (24 men, 11 women). The defect size was 3-4 cm in 24 patients, and 4 cm in 11 patients. None of the patients developed chronic pain. Five patients had a feeling of fullness in the inguinal region where the repair was performed, and their complaints subsided at the first month of follow-up. Seroma developed in 2 patients, but resolved spontaneously. During the follow-up period, no chronic complications or recurrences were observed. CONCLUSION: This technique is simple and does not create a serious cost burden on TAPP technique. Furthermore, it can be applied routinely with the advantages of low pain, rapid recovery and acceptable complication rates as well as the reduction of pseudo-recurrence rates. Key Words: Hernia, Laparoscopic repair, Plug-patch technique, Modified TAPP, Mesh.

Hypovolemic shock due to giant ovarian tumor rupture after minor trauma: A case report.

Rupture of gynecologic tumors secondary to trauma rarely occurs. Rupture can lead to acute abdominal pain due to hemorrhage from the ruptured area and organs; rupture can also lead to peritonitis, depending on the size of the tumor. We describe the case of giant epithelial ovarian tumor rupture exhibiting due to minor trauma and the development of hypovolemic shock. A 69-year-old female patient was admitted to the emergency room with complaints of acute abdominal pain and subsequent clouding of consciousness after falling down while walking. Emergency abdominal computed tomography scan revealed widespread hemorrhagic free fluid in the abdominal cavity and a mass measuring 27.5 cm × 21 cm × 15 cm, extending from the right quadrant of the abdomen to the left. The patient underwent an emergency operation due to hypovolemic shock. During surgery, a totally ruptured mass lesion arising from the right ovary was seen; the mass contained cystic components and measured approximately 30 cm × 20 cm × 15 cm. Hemostasis was achieved in the bleeding areas, and the right ovarian mass was totally resected. The patient was discharged as cured on the 6th post-operative day. Gynecologic tumor rupture due to trauma is a rare event. However, it is a clinical condition that should be kept in mind regardless of the type of trauma. This is especially true in patients who experienced trauma and were radiologically found to have intra-abdominal hemorrhage with normal-appearing solid organs, such as liver and spleen, that frequently cause bleeding.

A Collision Tumor with Squamous Cell Carcinoma of Skin Overlying Breast and Invasive Breast Carcinoma.

Invasive breast cancer is the most common carcinoma in women. Invasive ductal carcinoma, not otherwise specified (NOS), is the largest group of invasive breast cancers. The second most common cancer of skin is squamous cell carcinoma (SCC). Collision tumor is a very rare and unusual tumor. It is defined as the concrescence of two distinct primary neoplasms at one site. Herein, we report a 56-year- female patient who had a collision tumor in the right breast, composed of moderately differentiated squamous cell carcinoma (SCC) and invasive breast carcinoma NOS. In the literature, collision tumors in the breast are very rare and reported in various combinations, but there is only one reported case with SCC and invasive breast cancer, the same as in our case. Key Words: Collision tumor, Squamous cell carcinoma, Invasive breast carcinoma.

What Should be Done for Perforation of the Gallbladder During Laparoscopic Cholecystectomy: Prophylaxis or Treatment?

Background: Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy (LC) is one of the most common intraoperative complications, and there is no clear consensus among surgeons on this issue and there are studies reporting the antibiotic treatment. The aim of this study is to determine the effect of type and duration of antibiotic use on infective complications between iatrogenic perforations of the gallbladder during LC patients. Methods: Patients who developed iatrogenic perforation of gallbladder during LC were subdivided into three groups according to antibiotic treatment; single dose intravenous (i.v.) antibiotic group, prophylactic antibiotic + additional dose i.v. antibiotic group, and prophylaxis + additional dose i.v. antibiotic + oral antibiotic group. Results: A total of 577 patients who underwent LC were included in the study, and 114 patients (19.8%) had iatrogenic perforation of gallbladder. No statistically significant difference was found in wound infection and surgical site infection in all three groups (P > .05). Conclusions: We suggest that single dose antibiotic use is sufficient to prevent infectious complications in patients who had iatrogenic perforation of the gallbladder during LC. Adding intravenous and/or oral antibiotics does not contribute to prevention of infective complications in these patients.

The Role of Serum Laboratory Biomarkers for Complicated and Uncomplicated Appendicitis in Adolescents.

OBJECTIVE: To investigate if serum biomarkers could differentiate complicated and uncomplicated appendicitis in adolescents. STUDY DESIGN: An cross sectional study. PLACE AND DURATION OF STUDY: Department of General Surgery, Faculty of Medicine, Alanya Alaaddin Keykubat University, Alanya, Turkey, between January 2016 and December 2018. METHODOLOGY: Patients operated for acute appendicitis, aged between 10 and 19 years, were retrospectively evaluated. Patients were divided according to the negative appendectomy (group 1), uncomplicated appendicitis (group 2A) and complicated appendicitis (group 2B). White blood cell count (WBC), neutrophil count (NEU), lymphocyte count (LC), neutrophil/lymphocyte ratio (NLR), mean platelet volume (MPV), red cell distributions width (RDW), C-reactive protein (CRP), and length of hospital stay (LoHS) were analysed by ROC curve, one-way and Mann-Whitney U-tests. RESULTS: There were 277 adolescents (group 1=30, group 2A=205 and group 2B=42). There were statistically significant differences between the groups in WBC, NEU, LYM, NLR, CRP, LoHS. The cut-off values of NLR, WBC, and NEU were 4.1, 10.6x109/L, and 8.17x109/L, respectively for uncomplicated appendicitis, and 7.32, 11.5x109/L, and 10.3x109/L, respectively for complicated appendicitis. The cut off value of CRP was 1.3 mg/dl for complicated appendicitis. CONCLUSIONS: Elevated WBC, NEU, CRP and NLR may be considered useful biomarkers in assisting physical examination and other diagnostic methods in distinguishing severity of acute appendicitis. Key Words: Adolescent, Appendicitis, Neutrophil-to-lymphocyte ratio, C-reactive protein, Length of hospital stay.

Comparison of laparoscopic and open appendectomy on wound infection and healing in complicated appendicitis.

The aim of this study was to investigate the effects of laparoscopic and open surgery on the development of postoperative surgical wound infection and wound healing between complicated appendicitis patients. Patients with complicated appendicitis were divided into those underwent laparoscopic and open surgical procedures according to the surgical method. Patients were followed up with regard to development of any postoperative wound infection, and medical, radiological, and surgical treatment methods and results were recorded. A total of 363 patients who underwent appendectomy were examined, of which 103 (28.4%) had complicated appendicitis. Postoperative wound infection rate in patients who underwent open surgery was 15.9%, while it was 6.8% in the laparoscopic surgery group. There was no statistically significant difference between the two groups in terms of infection development rates (P > .05). The rate of surgical drainage use and rehospitalisation was significantly higher in the group with wound infection than in the group without wound infection. (P < .05). We suggest that in terms of wound infection and wound healing, laparoscopic surgery should be the method of choice for patients with complicated appendicitis. In order to reduce the frequency of wound infection, drains should not be kept for a long time in patients undergoing appendectomy.

Non-healing wounds: Can it take different diagnosis?

Wound healing is a complex cellular and biochemical process and can be affected by several systemic and local factors. In this study, we aimed to discuss the aetiologic factors of non-healing wounds and the management of this complicated process with current information. The medical data of the patients who were admitted to our clinic due to non-healing or chronic wounds were analysed retrospectively. A total of 27 patients were evaluated retrospectively during the 14 months of the study. The data of 6 patients who were followed up for chronic wound that developed after abdominal incisional hernia repair and pilonidal sinus surgery were not included in the study as their data could not be reached. A total of 21 patients were included in the study. Malignancy was diagnosed in two patients and granulomatous disease was found in four patients. The aetiology of the other cases included foreign body reaction, infection, and mechanical causes. Non-healing wounds are a serious social and economic problem for patients. Further studies on the pathophysiology of various aetiologies in non-healing wounds in both clinical settings and experimental animal models would be a useful step in treatment.

Burnout syndrome should not be underestimated.

OBJECTIVES: Burnout syndrome can be seen among health professionals at every stage of their careers. The incidence of burnout syndrome among health care professionals has increased in recent years and varies between countries and depending on different areas of specialization and work units. It is known that burnout syndrome significantly affects the work and social life of individuals. We aimed to investigate the effect of burnout syndrome on trauma and infection. METHODS: The study was conducted in the Alanya Alaaddin Keykubat University, Faculty of Medicine, Training and Research Hospital. All health professionals working at the hospital were included in the study. The Maslach Burnout Inventory was applied to the participants, who were asked about infective disease and trauma history over the past year. RESULTS: The total burnout rate was 77.8% among participants. We found that the rate of trauma and infective disease history was significantly high in employees who had burnout syndrome (p<0.05). CONCLUSION: Burnout syndrome is a common and important problem among health professionals that also has adverse effects on people's daily life, especially increasing the incidence of infection and trauma.

The effect of antibiotic prophylaxis on wound infections after laparoscopic cholecystectomy: A randomised clinical trial.

The aim of this study was to determine whether the use of prophylactic antibiotics had any effects on the development of postoperative surgical wound infections between laparoscopic cholecystectomy patients. Patients who received a single dose of prophylactic antibiotics prior to surgery were included in the prophylaxis group, and those who did not receive preoperative and postoperative intravenous and/or oral antibiotics were included in the no prophylaxis group. A total of 206 patients who underwent laparoscopic cholecystectomy were examined; the infection rate in patients who received prophylaxis was 4.5%, while it was 4.2% in the non-prophylactic group. There was no statistically significant difference between the groups in terms of infection development rates (P > .05). We suggest that antibiotics should not be given for prophylaxis before low-risk laparoscopic cholecystectomy as there is no statistically significant difference in the rate of postoperative wound infection among patients who were either given or not given prophylaxis.

Coexistence of Papillary Thyroid Cancer and Primary Hyperparathyroidism: Report of Five Cases.

Coincidence of primary hyperparathyroidism and thyroid nodules is quite frequent. This is challenging for clinical diagnosis and treatment. We reviewed the records of patients who underwent surgery for primary hyperparathyroidism. Among 52 such cases, thyroidectomy was performed in seven patients (13%) at the same time. Papillary thyroid cancer was detected in five patients (9.6%) as a result of pathologic examination. Two patients were diagnosed with unifocal micro-papillary cancer and these patients underwent unilateral thyroid lobectomy. The remaining three patients, who had thyroid papillary cancer underwent bilateral total thyroidectomy. Likelihood of thyroid cancer should be considered in cases of primary hyperparathyroidism with coexistent thyroid nodules, and a detailed examination should be performed in preoperative period. These will lead to reduce morbidity and lower cost resulting from a second surgery.

The effects of perioperative antibiotherapy on surgical site infections in sacrococcygeal pilonidal sinus treated with rhomboid excision and Limberg transposition procedure.

Pilonidal sinus disease is a common disorder. We aimed to evaluate the effects of perioperative antibiotherapy on surgical site infections in pilonidal sinus patients who were treated with rhomboid excision with Limberg transposition procedure. A total of 104 patients between 18 and 40 years of age (52 males, 52 females) were included in the study. The patients were divided into two groups and evaluated because of the administration of perioperative antibiotherapy. On the 10th-day, first-month, and third-month follow ups, the status of the wound was recorded. No significant difference was found between the ages, gender distribution, and smoking. Wound dehiscence rate was higher in the non-antibiotic group on the 10th-day, first-month, and third-month follow up, whereas the rate of superficial infection was higher in the antibiotic group. None of the patients had any signs of recurrence. Antibiotic administration did not provide a significant advantage in terms of wound healing, surgical site infection, and recurrence. We think that perioperative antibiotherapy, except for patients with immunosuppression, diffuse cellulitis, or a major coexisting disease who were treated with rhomboid excision with Limberg transposition procedure, does not have any effect on healing surgical site infections and delaying early recurrence.

Morbidity and Mortality in Appendicitis in the Elderly.

OBJECTIVE: To assess the factors affecting the morbidity and mortality in patients over 65 years of age who underwent appendectomy. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Department of General Surgery, Faculty of Medicine, Ahi Evran University, Kirsehir, Turkey, from November 2014 to March 2017. METHODOLOGY: Medical records of the patients over 65 years of age with the diagnosis of acute appendicitis who underwent appendectomy during the study period were retrospectively analyzed. Age and complications were noted. The reviewed outcome measures were perforation rates, morbidity and mortality. RESULTS: Three hundred and seventy-eight patients over 65 years of age presenting with abdominal pain were hospitalized for diagnosis and treatment. Appendectomy was performed in 112 patients. Laparoscopic appendectomy was performed in 70 of these patients. Perforation rate and morbidity were 40% and 28%, respectively. There was no mortality. CONCLUSION: Elderly patients show a high perforation rate and morbidity after appendectomy.

Granulomatous Mastitis Concurrence with Breast Cancer.

Idiopathic Granulomatous Mastitis (IGM) is a rare, chronic, non-malignant and non-life-threatening breast disease. IGM may mimic carcinoma of the breast. This case report is about concurrence of chronic granulomatous mastitis with breast cancer. The important aspect of this case is that it is the 4th case where IGM and breast cancer are present concurrently.

Follow-up of granulomatous mastitis with monitoring versus surgery.

BACKGROUND: IGM (Idiopathic Granulomatous Mastitis) is a rare, chronic, non-malignant and non-life-threatening breast disease. Clinically and radiologically, it has similar characteristics with other granulomatous diseases and breast carcinomas. METHODS: The patients whom diagnosed IGM according to pathology report were retrospectively evaluated between November 2014 and January 2016. The demographic properties, complaints during admission, diagnosis and treatment methods and clinical results were obtained via investigation of the patient files. The patients were called for follow-up and discussion. RESULTS: The patients whom diagnosed IGM were retrospectively evaluated and total number of patients were 19. The average following period was 11 months (4-13 months). Fourteen patients were in the reproductive period, five patients were in the postmenopausal period. Ultrasound imaging was performed on all patients, mammography was done on 6 patients over 40 years of age. The patients were not imaged by magnetic resonance imaging (MRI). Sixteen patients had IGM in a single breast, only three patient have an IGM history in bilateral breast, one or three years ago. Core biopsy was performed on all patients. One patient with bilateral IGM diagnosis performed a drainage and incisional biopsy due to a twice developing abscess clinic and recurrence. One patient had final diagnosis coexistence IGM and ductal carcinoma. CONCLUSIONS: Patients who followed-up by observation should be explained that IGM is a chronic disease and that it may recur in certain periods. Clinical, radiological and pathological examinations should be performed together for breast cancer developing due to the chronical progresses of IGM or concurrent breast cancer.

The feasibility of bipolar tissue sealer for appendix stump closure.

BACKGROUND: Appendiceal stump closure is a highly important step in laparoscopic appendectomy, especially for post-operative complications. The aim of this study is to compare the effects of suture ligation and bipolar tissue sealer techniques on burst pressure using flesh appendectomy specimens. MATERIAL AND METHODS: Appendectomy specimens of 32 patients with grade I-II disease were included in the study. Perforated or necrotic appendices and specimens ineligible for pressure measurement were excluded from the study. Appendiceal stumps of 16 patients in group 1 were double-ligated with 2/0 polyglactin sutures, then appendectomy was performed between these sutures. In group 2, the management of the stump was performed through single ligation with polyglactin suture, followed by appendectomy using a bipolar tissue sealing device. Burst pressures were recorded for all specimens. RESULTS: There were no differences between groups in terms of age and sex. There was no significant difference between the two groups in terms of burst pressure (p = 0.92). Also, no significant difference was found between groups in terms of localization of the perforation (p > 0.05). CONCLUSION: Bipolar tissue sealer achieves safe stump closure with satisfactory burst pressure values. Based on this, using bipolar tissue sealer for appendiceal stump closure in appendicitis may be safe and reliable.