The impact of intraoperative neural monitoring during papillary thyroid cancer surgery on completeness of thyroidectomy and thyroglobulin response: a propensity-score matched study.

BACKGROUND: Intraoperative neural monitoring (IONM) has been utilized for a variety of thyroid pathologies, including papillary thyroid carcinoma (PTC). Remnant thyroid tissue following total thyroidectomy (TT) in patients with PTC is associated with increased recurrence. The aim of this study is to investigate whether the use of IONM in PTC surgery has an impact on the completeness of thyroidectomy. METHODS: Retrospectively, patients with preoperative diagnosis of PTC, who underwent TT in a tertiary center were reviewed. They were grouped based on the IONM usage, and 1:1 propensity-score match was performed. Primary outcome was the completeness of thyroidectomy, determined by measuring postoperative stimulated thyroglobulin levels (sTg). RESULTS: Among 274 clinically node-negative PTC patients who underwent TT and ipsilateral prophylactic central lymph-node dissection, a total of 170 patients (85:85) were matched. Postoperative sTg levels were significantly lower in the IONM group (1 ng/dL vs. 0.4 ng/dL; p < 0.01) with higher percentage of the patients with sTg levels <1 ng/ml (50.6% vs. 69.4%; p = 0.01). More patients in the no-IONM group received RAI ablation with significantly higher doses (mean mci: 120 vs. 102; p = 0.02). CONCLUSION: The use of IONM during thyroidectomy provides improvement in the completeness of thyroidectomy and reduction in postoperative sTg levels which can be used as a guide by clinicians to avoid RAI ablation in selected PTC patients and to adjust low ablative doses in patients who are scheduled for remnant ablation.

DICER1 Mutations Do Not Always Indicate Dismal Prognosis in Pediatric Poorly Differentiated Thyroid Carcinomas.

Progress in the field of pediatric thyroid pathology has linked DICER1 mutations to benign follicular cell-derived thyroid tumors (e.g., follicular adenoma with papillary architecture, follicular nodular disease), low-risk follicular cell-derived differentiated thyroid carcinomas and PDTCs enriched in fatal or recurrent/progressive disease. The dismal outcome of DICER1-harboring pediatric PDTCs stems from a limited number of reported patients' data given the rarity of pediatric PDTCs. In light of the former observations, the current study assessed clinicopathological variables of a series of 5 pediatric (≤ 18 years old) PDTCs using the Turin criteria (WHO 2022) and also examined the status of DICER1 and TERT promoter mutations. Five PDTCs (3 males, 2 females) were included in the study. The mean age at the time of diagnosis was 15.4 years. No patients had a history of DICER1 syndrome-related tumors or other clinicopathological diagnostic features of DICER1 syndrome. The mean tumor size was 3.9 cm. All tumors were completely submitted for microscopic examination. There was increased mitotic activity ranging from 3 to 10 mitoses per 2 mm2. Tumor necrosis was present in two cases. No PDTC harbored TERT promoter mutation. DICER1 hot spot mutation was identified in one (20%) tumor. The DICER1-mutant tumor had neither associated differentiated thyroid carcinoma component nor other pathological findings in the adjacent thyroid parenchyma. The DICER1-mutant PDTC showed widely invasive growth confined to the thyroid parenchyma. Despite the widely invasive growth, the tumor lacked vascular invasion. Two DICER1 wild-type PDTCs had lymphocytic thyroiditis and another one had underlying follicular nodular disease and/or follicular adenomas. Three DICER1 wild-type PDTCs also had an associated differentiated thyroid carcinoma component with no high-grade features. No abnormal p53 expression (overexpression or global loss) was recorded in all tested tumors. Four patients had follow-up data with a mean follow-up time of 60.25 months (range: 18-86 months). One patient with no evidence of disease recurrence died of an unrelated cause after 18 months of the initial surgery, all remaining patients were alive with no distant metastasis at their last visit. Of the 4 patients with lymph node (LN) dissection, one DICER1 wild-type PDTC had recurrent nodal disease. During the follow-up period (72 months), no local recurrence or distant metastases was detected in the DICER1-mutant PDTC. Taken together all reported findings from earlier series, DICER1 mutations alone may not necessarily indicate dismal outcome in a subset of pediatric PDTCs. The occurrence of additional genomic alterations as discussed in some earlier reports may be contributing to tumor progression or aggressivity of pediatric PDTCs. The lack of vascular invasion in the current DICER1-mutant pediatric PDTC may also explain an indolent biologic outcome. The risk escalation of DICER1 mutations should integrate the status of additional genetic events and well-established pathologic variables in order to ensure predictive dynamic risk stratification in DICER1-mutant pediatric PDTCs. Additional studies are needed to corroborate the findings of this study and advance our knowledge in pediatric thyroid neoplasia.

An unusual finding after adrenal surgery: a case series of adrenal schwannomas.

Adrenal schwannomas are rare benign tumors with no specific imaging and laboratory findings to diagnose preoperatively. Due to the limited number of cases in the literature, clinical, imaging, and pathological findings are presented in this study. Case 1 is a 61-year-old woman patient who has a 31-mm mass in the right adrenal gland. This mass was nonfunctional; in imaging studies, this mass had a cystic necrotic component, and high 18-fluorodeoxyglucose (FDG) uptake was seen. There was no metaiodobenzylguanidine (MIBG) uptake. Laparoscopic transabdominal right adrenalectomy was performed, and the pathology result was consistent with adrenal schwannomas. Case 2 is a 63-year-old man patient who presented with a 38-mm mass in the left adrenal gland. This mass was nonfunctional and similar to that in Case 1; this mass had a cystic component. Laparoscopic transabdominal left adrenalectomy was performed. The diagnosis of adrenal schwannoma with degeneration was revealed. Case 3 was a 72-year-old woman patient admitted to the hospital for a 125-mm left adrenal mass. Similar to Case 1, this mass also had a cystic necrotic component in imaging studies. High FDG uptake was seen, and the patient underwent conventional adrenalectomy due to the suspicion of malignancy. After pathological evaluation, a diagnosis of adrenal schwannoma was made. A main diagnostic challenge in adrenal schwannomas is the preoperative diagnosis. These masses have no pathognomonic finding or specific hormonal function. Imaging findings of these masses may increase the suspicion of malignancy, which may affect decisions for surgery and the surgical technique.

Artificial Intelligence in Minimally Invasive Adrenalectomy: Using Deep Learning to Identify the Left Adrenal Vein.

BACKGROUND: Minimally invasive adrenalectomy is the main surgical treatment option for the resection of adrenal masses. Recognition and ligation of adrenal veins are critical parts of adrenal surgery. The utilization of artificial intelligence and deep learning algorithms to identify anatomic structures during laparoscopic and robot-assisted surgery can be used to provide real-time guidance. METHODS: In this experimental feasibility study, intraoperative videos of patients who underwent minimally invasive transabdominal left adrenalectomy procedures between 2011 and 2022 in a tertiary endocrine referral center were retrospectively analyzed and used to develop an artificial intelligence model. Semantic segmentation of the left adrenal vein with deep learning was performed. To train a model, 50 random images per patient were captured during the identification and dissection of the left adrenal vein. A randomly selected 70% of data was used to train models while 15% for testing and 15% for validation with 3 efficient stage-wise feature pyramid networks (ESFPNet). Dice similarity coefficient (DSC) and intersection over union scores were used to evaluate segmentation accuracy. RESULTS: A total of 40 videos were analyzed. Annotation of the left adrenal vein was performed in 2000 images. The segmentation network training on 1400 images was used to identify the left adrenal vein in 300 test images. The mean DSC and sensitivity for the highest scoring efficient stage-wise feature pyramid network B-2 network were 0.77 (±0.16 SD) and 0.82 (±0.15 SD), respectively, while the maximum DSC was 0.93, suggesting a successful prediction of anatomy. CONCLUSIONS: Deep learning algorithms can predict the left adrenal vein anatomy with high performance and can potentially be utilized to identify critical anatomy during adrenal surgery and provide real-time guidance in the near future.

Left Adrenal Venous Drainage into the Inferior Vena Cava in a Pheochromocytoma Patient with Ectopic Pelvic Kidney.

In this report, we describe a very rare variant adrenal venous anatomy in a left-sided pheochromocytoma case with left adrenal vein draining into the inferior vena cava (IVC). A 66-year-old female with an incidentally discovered left adrenal mass was referred to our clinic for further diagnostic work up. She had hypertension for the past three years. Abdominal magnetic resonance imaging which has been performed for essential thrombocytopenia revealed a left adrenal mass. She was diagnosed as pheochromocytoma by further laboratory workup. Pre-operative imaging with computed tomography (CT) angiography showed that left kidney was ectopically localized in pelvis, and left adrenal vein was draining directly into the IVC. A laparoscopic transabdominal left adrenalectomy was performed. Final pathology result was consistent for pheochromocytoma. Variant adrenal venous anatomy is rare. There are only few case reports on patients with left adrenal vein draining into the IVC. Although there are handful of autopsy studies, these studies were performed on normal adrenal glands. The number of clinical reports on variant adrenal venous anatomy is limited. Clinical studies revealed that most commonly seen variant adrenal venous anatomy was number based and were associated with larger tumor size and pheochromocytoma. Pre-operative CT imaging could be used to improve the identification of venous anatomy. In this report, we present a very rare case of an adult patient with left ectopic kidney who had undergone laparoscopic adrenalectomy for left adrenal pheochromocytoma and had left adrenal vein draining into the IVC. To the best of our knowledge, it is a first in the literature. Pre-operative CT imaging identified the variant adrenal venous anatomy in this patient.

Magnesium and dexmedetomidine combination reduces sodium nitroprusside requirement in laparoscopic pheochromocytoma.

BACKGROUND: Anesthesia management of pheochromocytoma excision surgery is associated with severe hemodynamic fluctuations. The objective of this study is to compare the number of hypertensive crisis requiring sodium nitroprusside (SNP) administration between the groups treated with magnesium (Mg)-dexmedetomidine (Dex) and conventional group in pheochromocytoma. METHODS: This retrospective cohort study included patients who underwent pheochromocytoma surgery between 2011 and 2020. Patients were examined into two groups: 1-Conventional group (GC) included patients who were operated between 2011 and 2015 under standard anesthesia care and who did not receive perioperative additional medication. 2- Mg-Dex therapy group (GMD) comprised the patients who were operated between 2015 and 2020 and who had received 300 mg Mg per oral daily 1 week before the surgery and Mg-Dex infusion intraoperatively. Blood pressure, heart rate (HR), and SNP requirement were recorded throughout surgery as well as demographics and operative data. Hypertensive crisis was defined as systolic blood pressure (SBP) >180 mmHg, and tachycardia was defined as HR >110 bpm. RESULTS: A total of 78 patients' data were analyzed from 108 patients' documentary. (38 in GC, 40 in GMD) SNP requirement was significantly higher in GC (39.5%) comparing GMD (7.5%) (p=0.001). SBPs during tumor manipulation period were statistically higher in GC than in GMD at 10th, 15th, 20th, 25th, 30th, and 35th min. HR values were significantly higher in GC compared to GMD at 10th and 15th min of tumor manipulation period (p<0.05). CONCLUSION: Combination of Mg-Dex seems to be an alternative therapy for reducing vasodilator requirement in perioperative management of pheochromocytoma.

Is craniocaudal dissection of recurrent laryngeal nerve safer than lateral approach: a prospective randomized study comparing both techniques by using continuous intraoperative nerve monitoring.

Purpose: This study was performed to compare the real-time electromyographic (EMG) changes and the rate of recurrent laryngeal nerve (RLN) injury in craniocaudal and lateral approaches for RLN during thyroidectomy. Methods: One hundred twelve and 86 patients were prospectively randomized to receive lateral (group 1) or craniocaudal (group 2) approach to RLN, respectively, under continuous intraoperative nerve monitoring. Results: Loss of signal (LOS) occurred in 7 (2.0%) of 356 nerves at risk (NAR). LOS was significantly associated with repeated adverse EMG changes and presence of RLN entrapment at the ligament of Berry (LOB), which was accompanied by other clinicopathological or anatomical features, such as tubercle of Zuckerkandl (TZ), extralaryngeal branching, hyperthyroidism, autoimmune thyroid disease (ATD), or thyroid lobe volume of >29 cm3 (P = 0.001 and P = 0.030, respectively). The rate of repeated adverse EMG changes and LOS in the NARs with LOB entrapment accompanied by other clinicopathological and anatomical features was higher in group 1 vs. group 2 (11.1% vs. 2.2%, respectively and 9.7% vs. 0%, respectively; P = 0.070). The total rate of vocal cord palsy (VCP) was significantly higher in group 1 than in group 2 (P = 0.005). The rate of permanent VCP showed no significant difference between the 2 groups. Conclusion: The craniocaudal approach to the RLN is safer than the lateral approach in the RLNs with entrapment at the LOB accompanied by other features, such as TZ, extralaryngeal branching, hyperthyroidism, ATD, or high thyroid lobe volume.

DICER1 Mutations Occur in More Than One-Third of Follicular-Patterned Pediatric Papillary Thyroid Carcinomas and Correlate with a Low-Risk Disease and Female Gender Predilection.

Some pediatric papillary thyroid carcinoma (PPTC) cohorts have suggested a preliminary correlation with respect to DICER1 mutation status and histomorphology in both benign and malignant follicular cell-derived nodules; however, the data regarding correlates of DICER1-related sporadic PPTCs subtyped based on the 2022 WHO classification criteria are largely unavailable. The current study investigated the status of hotspot DICER1 mutations with clinical, histological and outcome features in a series of 56 patients with PPTCs with no clinical or family history of DICER1-related syndromic manifestation. Fifteen (27%) PPTCs harbored BRAF p.V600E. Eight (14%) cases of PPTCs harbored DICER1 mutations with no associated BRAF p.V600E. DICER1 mutations were identified in exons 26 and 27. A novel D1810del (c.5428_5430delGAT) mutation was also detected. We also confirmed the absence of hotspot DICER1 mutations in the matched non-tumor tissue DNA in all 8 DICER1-related PPTCs. The mean age of DICER1-harboring PPTCs was 15.1 (range: 9-18) years whereas the rest of this cohort had a mean age of 14.8 (range 6-18) years. With the exception of one PPTC, all DICER1-related PPTCs were seen in females (female-to-male ratio: 7). The female to male ratio was 3.8 in 48 DICER1-wild type PPTCs. In terms of histological correlates, 5 of 8 (63%) DICER1-mutant PPTCs were invasive encapsulated follicular variant papillary thyroid carcinomas (FVPTCs) including 4 minimally invasive FVPTCs and 1 encapsulated angioinvasive FVPTC, whereas the remaining 3 PPTCs were infiltrative classic papillary thyroid carcinomas (p < 0.05). The incidence of DICER1 mutations was 19.5% in BRAF p.V600E-wild type PPTCs. Sixty-three percent of DICER1 hotspot mutations occurred in invasive encapsulated FVPTCs, and this figure represents 38% of invasive encapsulated FVPTCs. Only one (12%) patient with DICER1-related disease showed a single lymph node with micro-metastasis. Unlike DICER1-wild type patients, no distant metastasis is identified in patients with DICER1-related PPTCs. The current series expands on the surgical epidemiology of somatic DICER1-related PPTCs by correlating the mutation status with the clinicopathological variables. Our findings underscore that female gender predilection and enrichment in low-risk follicular-patterned PTCs are characteristics of DICER1-related PPTCs.

Comparison of Single-Dermatome Laparoscopic Appendectomy With Standard Laparoscopic Appendectomy in Terms of Postoperative Pain and Patient Satisfaction: A Randomized Controlled Trial.

BACKGROUND: Laparoscopic appendectomy (LA), used since 1980, is a common surgical technique for acute appendicitis (AA) treatment. Laparoscopic surgical techniques can achieve higher patient satisfaction than conventional open surgery techniques. However, many patients complain of severe pain after laparoscopic abdominal surgeries. In this study, we compared single-dermatome laparoscopic appendectomy (SDLA), wherein all trocars were placed at the same dermatome field, with standard laparoscopic appendectomy (SLA), wherein trocars were placed at multiple dermatome sites, in terms of postoperative pain and patient satisfaction. MATERIALS AND METHODS: The study was designed as a double-blind randomized controlled trial. Patients who underwent LA for AA between May 2019 and December 2019 were included in the study and randomized into 2 groups, wherein patients were included sequentially. The first group was operated with SLA surgery, whereas the second group was operated with SDLA surgery. All patients were assessed in terms of visual analog scale (VAS) scores, hemodynamic parameters, and patient satisfaction at postoperative 1, 2, 4, 6, 12, and 24 hours. RESULTS: In the SLA technique, VAS values at postoperative 1, 2, and 4 hours were significantly higher than in the SDLA ( P =0.009; P <0.05). No significant difference was observed between the surgical techniques in terms of VAS levels at postoperative 6, 12, and 24 hours ( P >0.05). In the SDLA group, patient satisfaction was significantly higher than in the SLA group ( P =0.024; P <0.05). CONCLUSIONS: In our study, SDLA caused less pain in AA cases during postoperative period than SLA. Further, the SDLA method achieved higher patient satisfaction during the postoperative period than the SLA method.

The Role of American Thyroid Association Pediatric Thyroid Cancer Risk Stratification and BRAFV600E Mutation in Predicting the Response to Treatment in Papillary Thyroid Cancer Patients ≤18 Years Old

Objective: This study aimed to evaluate the role of risk stratification by the American Thyroid Association (ATA) pediatric thyroid cancer risk levels and BRAFV600E mutation to predict the response to treatment in papillary thyroid cancer (PTC) patients ≤18 years old. Methods: Clinical outcomes during a median period of 6 (2-21.8) years were assessed in 70 patients, according to ATA pediatric risk stratification, BRAFV600E mutation status, and dynamic risk stratification (DRS) at final follow-up. Results: Of 70 patients, 44 (63%), 14 (20%), and 12 (17%) were classified initially as low-, intermediate-, and high-risk, respectively. BRAFV600E mutation analysis data was available in 55 (78.6%) patients, of whom 18 (32.7%) had the BRAFV600E mutation. According to the final DRS, 61 (87%), two (3%), six (9%), and one (1%) patients were classified as an excellent, incomplete biochemical, incomplete structural, and indeterminate response, respectively. All ATA low-risk patients showed excellent response to treatment, whereas the rate of excellent response was 65.4% in intermediate- and high-risk levels (p<0.001). The rates of excellent response in BRAFV600E positive and negative patients were 83% and 92%, respectively (p=0.339). The rate of locoregional recurrence was significantly higher in BRAFV600E positive vs negative patients (33.3% vs 2.7% respectively, p=0.001). Conclusion: ATA pediatric risk stratification is effective in predicting response to treatment in PTC patients ≤18 years old. The presence of BRAFV600E mutation was highly predictive for recurrence but had no significant impact on the rate of excellent response to treatment at final follow-up.

Impact of the Coronavirus Disease Pandemic on the Annual Thyroid, Parathyroid, and Adrenal Surgery Volume in a Tertiary Referral Endocrine Surgery Center in 2020.

OBJECTIVE: The purpose of the study was to evaluate the impact of the coronavirus disease (COVID-19) pandemic on endocrine surgical volumes. METHODS: There were periodic surgical restriction sin our country in 2020 due to the pandemic. Endocrine surgery volumes at the Division of Endocrine Surgery, Istanbul Medical Faculty were compared between 2019 and 2020. RESULTS: The surgical volume reduction in 2020 compared to 2019 was 20%, 54.5%, and 40% for thyroid, parathyroid, and adrenal surgery, respectively. Surgical volume for thyroidectomy for benign nodular goiter and parathyroidectomy significantly decreased, whereas adrenal surgery showed no significant difference in 2020 compared to 2019. No significant difference was found in the rates of thyroid cancer and adrenocortical cancer surgery in 2020compared to 2019. CONCLUSION: The COVID-19 outbreak led to a significant reduction in the annual rates of parathyroidectomy and thyroidectomy for benign goiter, whereas the volume of thyroid cancer and adrenal surgeries were similar to the previous year.

Endocrine Surgery during the COVID-19 Pandemic: Recommendations from the Turkish Association of Endocrine Surgery.

The 2019 novel coronavirus disease (COVID-19) was initially seen in Wuhan, China, in December 2019. World Health Organization classified COVID-19 as a pandemic after its rapid spread worldwide in a few months. With the pandemic, all elective surgeries and non-emergency procedures have been postponed in our country, as in others. Most of the endocrine operations can be postponed for a certain period. However, it must be kept in mind that these patients also need surgical treatment, and the delay time should not cause a negative effect on the surgical outcome or disease process. It has recently been suggested that elective surgical interventions can be described as medically necessary, time-sensitive (MeNTS) procedures. Some guidelines have been published on proper and safe surgery for both the healthcare providers and the patients after the immediate onset of the COVID-19 pandemic. We should know that these guidelines and recommendations are not meant to constitute a position statement, the standard of care, or evidence-based/best practice. However, these are mostly the opinions of a selected group of surgeons. Generally, only life-threatening emergency operations should be performed in the stage where the epidemic exceeds the capacity of the hospitals (first stage), cancer and transplantation surgery should be initiated when the outbreak begins to be controlled (second stage), and surgery for elective cases should be performed in a controlled manner with suppression of the outbreak (third stage). In this rapidly developing pandemic period, the plans and recommendations to be made on this subject are based on expert opinions by considering factors, such as the course and biology of the disease, rather than being evidence-based. In the recent reports of many endocrine surgery associations and in various reviews, it has been stated that most of the cases can be postponed to the third stage of the epidemic. We aimed to evaluate the risk reduction strategies and recommendations that can help plan the surgery, prepare for surgery, protect both patients and healthcare workers during the operation and care for the patients in the postoperative period in endocrine surgery.

Fallopian tube herniation from trocar-site after laparoscopic appendectomy.

Trocar site hernias are a type of incisional hernias and may occur within a variable time shift after surgery. A mean incidence of 1.85% was reported, and the first trocar site hernia was narrated by Maio et al. in 1991 describing small bowel obstruction due to trocar site herniation after laparoscopic cholecystectomy. The 10-mm-trocar port is more frequently problematic, and a trocar site hernia in 5 mm port is very rare. This report unveils a 5mm trocar site herniation of right fallopian tube following laparoscopic appendectomy. In this case study, a 19-year-old female patient applied to the emergency department because of a discharge in the right lower quadrant was reported. She explained that she had undergone laparoscopic appendectomy two days before and discharged the next day uneventfully. The surgical report described a suction drain in the right lower quadrant where the patient was suffering from the discharge. The physical examination revealed no tenderness, but an abdominal CT disclosed an edematous tubular structure herniating from the 5 mm trocar site where the drain was put. She was re-operated laparoscopically due to early trocar site hernia, and the right fallopian tube was observed herniating through the defect. After the reduction into the abdomen, the fallopian tube was observed fine, and the defect was closed using 2/0 polypropylene suture. Trocar site hernias are rare but may cause serious complications after laparoscopic surgery. They may occur early after the surgery, but the time shift is variable. Although mechanical bowel obstructions are more frequent endpoint, it should be remembered that any organ within the abdominal cavity may herniate.

Robotic versus laparoscopic sphincter-saving total mesorectal excision for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of long-term outcomes.

The aim of our study was to compare long term outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision (TME) in male patients with mid-low rectal cancer (RC) after neoadjuvant chemoradiotherapy (NCRT). The study was conducted as a retrospective review of a prospectively maintained database, and we analyzed 14 robotic and 65 laparoscopic sphincter-saving TME (R-TME and L-TME, respectively) performed by one surgeon between 2005 and 2013. Patient characteristics, perioperative recovery, postoperative complications and pathology results were compared between the two groups. The patient characteristics did not differ significantly between the two groups. Median operating time was longer in the R-TME than in the L-TME group (182 min versus 140 min). Only two conversions occurred in the L-TME group. No difference was found between groups regarding perioperative recovery and postoperative complication rates. The median number of harvested lymph nodes was higher in the RTME than in the L-TME group (32 versus 23, p = 0.008). The median circumferential margin (CRM) was 10 mm in the R-TME group, 6.5 mm in the L-TME group (p = 0.047. The median distal resection margin (DRM) was 27.5 mm in the R-TME, 15 mm in the L-TME group (p = 0.014). Macroscopic grading of the specimen in the R-TME group was complete in all patients. In the L-TME group, grading was complete in 52 (80%) and incomplete in 13 (20%) cases (p = 0.109). Median follow-up 87 months (1-152). Whereas local recurrence was seen in eight cases (10.12%) and distant metastasis was seen in 18 cases (22.7%). Overall, 5 years survival was 83.3% in R-TME, 75% in L-TME groups. R-TME is a safe and feasible procedure that facilitates performing of TME in male patients with mid to low RC after NCRT.

Multicentricity Is More Common in Thyroid Papillary Microcancer with a Preoperative Diagnosis Compared to Incidental Microcancer.

OBJECTIVE: Although multicentricity is a common feature of thyroid papillary microcancer, it might be difficult to predict this histopathological feature preoperatively. METHODS: The records of 306 papillary microcancer patients who underwent thyroidectomy were evaluated. Papillary microcancer was diagnosed as an incidental histopathological finding in 242 (group 1), and by preoperative fine-needle aspiration biopsy in 64 (group 2). Demographic data and histopathological features were compared between the two groups. RESULTS: Age (44 ± 11.4 vs. 43 ± 14 years) and male/female ratio (44/193 vs. 12/52) showed no significant difference between groups 1 and 2 (p > 0.05). Mean tumor size was significantly larger in group 2 (5.2 ± 2.8 mm) compared to group 1 (3.7 ± 2.4 mm) (p = 0.004). The frequency of thyroid capsule invasion (44 vs. 19%, p = 0.0001), microscopic extrathyroidal invasion (25 vs. 10%, p = 0.004) and multicentricity (44 vs. 29%, p = 0.04), and bilateral lobar involvement (22 vs. 10%, p = 0.0001) was significantly higher in group 2 compared to group 1. CONCLUSION: Multicentricity with bilateral lobar involvement and aggressive histopathological features are more frequent in papillary microcancer patients diagnosed with preoperative fine-needle aspiration biopsy compared to papillary microcancer diagnosed as postoperative incidental histopathological finding.

Strangulated inguinal hernia accompanied by paratesticular leiomyosarcoma.

Sarcomas that arise from the spermatic cord constitute 2.1% of soft tissue sarcomas and are observed at a rate of 1% to 2% in the genitourinary system. A 74-year-old patient presented at the emergency department with complaints of groin pain and swelling persisting for 3 days. On physical examination, a firm mass that was approximately 5x5 cm in size and could not be reduced was observed at the right inguinal area as well as a right inguinal hernia. Computed tomography revealed a large hernia sac in the right inguinal area and a mass that was 77x55 mm in size within the hernial sac. A radical orchiectomy and hernia repair were performed. A diagnosis of leiomyosarcoma was made based on the pathological evaluation of the mass. At the 7-month postoperative follow-up, no local relapse or distant metastasis was found. To conclude, although paratesticular leiomyosarcoma is rare, it should be kept in mind as one of the possible diagnoses for older patients presenting with an inguinal mass.

Early results of comparison of polypropylene mesh and 75% resorbable mesh (monofilament polypropylene and poly-L-lactic acid (PLLA) mesh) for laparoscopic total extraperitoneal (TEP) inguinal hernia repair.

OBJECTIVE: Laparoscopic totally extraperitoneal (TEP) hernia repair has become increasingly widespread. Faster recovery than conventional open methods shortens the return to work. Polypropylene (PP) mesh is still in use in hernia surgery because it is an inexpensive and easily accessible patch. The post-operative chronic pain and foreign body sensation are the disadvantages of these PP patches. Poly-L-lactic acid and polypropylene (PLLA) were used in this study because of the good biocompatibility and low tissue inflammation response. We compared the early clinical outcomes of PP patch and PLLA patches. METHODS: Between January 2013 and April, 2018,469 patients with inguinal hernia underwent TEP procedure. Patients were divided into two groups. PP mesh (n=211) in group 1, PLLA mesh (n=258) in group 2. Patients were compared regarding age, gender, hernia side, ASA scores, the duration of operation, pain, time to return to work, the sensation of foreign body, seroma and hematoma. RESULTS: A total of 469 patients were analyzed retrospectively (426 male, 43 female). The mean age was 52.23±13.66 years. The operative times of the patients were 40.92±8.9 minutes in group 1, and 38.82±8.5 minutes in group 2 (p<0.05). The time to return to work was 10.2±1.47 days in Group 1 and 8.4±1.0 days in Group 2 (p<0.05). Visual Analog Scale (VAS) in group 2 was lower than in group 1 (p<0.005). In group 2, the feeling of the organic body decreased in the early and late period (p<0.005). Seroma and hematoma were less in Group 2 than in Group 1 (p<0.005). The mean follow-up period of the patients was 18 (3-63) months, two patients in Group 1, two patients in Group 2 recurred. CONCLUSION: The PLLA patch used in the TEP method is thought to be a herniated patch that can be safely used because of its ease of application and less postoperative complication rates and more rapid return to work.

[Ultrasound-guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy: comparison of efficacy of bupivacaine and levobupivacaine on postoperative pain control]. / Bloqueio do plano abdominal transverso guiado por ultrassom em pacientes submetidos à colecistectomia laparoscópica: comparação da eficácia de bupivacaína e levobupivacaína no controle da dor pós­operatória.

BACKGROUND AND OBJECTIVE: The use of transversus abdominis plane block with different local anesthetics is considered as a part of multimodal analgesia regimen in laparoscopic cholecystectomy patients. However no studies have been published comparing bupivacaine and levobupivacaine for transversus abdominis plane block. We aimed to compare bupivacaine and levobupivacaine in ultrasound-guided transversus abdominis plane block in patients undergoing laparoscopic cholecystectomy. METHODS: Fifty patients (ASA I/II), undergoing laparoscopic cholecystectomy were randomly allocated into two groups. Following anesthesia induction, ultrasound-guided bilateral transversus abdominis plane block was performed with 30mL of bupivacaine 0.25% in Group B (n=25) and 30mL of levobupivacaine 0.25% in Group L (n=25) for each side. The level of pain was evaluated using 10cm visual analog scale (VAS) at rest and during coughing 1, 5, 15, 30min and 1, 2, 4, 6, 12 and 24h after the operation. When visual analogue scale>3, the patients received IV tenoxicam 20mg. If visual analogue scale remained >3, they received IV. tramadol 1mg.kg-1. In case of inadequate analgesia, a rescue analgesic was given. The analgesic requirement, time to first analgesic requirement was recorded. RESULTS: Visual analogue scale levels showed no difference except first and fifth minutes postoperatively where VAS was higher in Group L (p<0.05). Analgesic requirement was similar in both groups. Time to first analgesic requirement was shorter in Group L (4.35±6.92min vs. 34.91±86.26min, p=0.013). CONCLUSIONS: Bupivacaine and levobupivacaine showed similar efficacy at TAP block in patients undergoing laparoscopic cholecystectomy.

The impact of combined interpretation of localization studies on image-guided surgical approaches for primary hyperparathyroidism.

BACKGROUND: The impact of single and combined interpretations of ultrasonography and sestamibi scintigraphy to select the appropriate surgical approach in patients with primary hyperparathyroidism were evaluated retrospectively. METHODS: A total of 183 patients with primary hyperparathyroidism who were evaluated preoperatively using both ultrasonography and sestamibi scintigraphy were included in the study. The results of preoperative localization studies were correlated with intraoperative findings and postoperative histopathological results. The localization rates of individual and combined interpretations of ultrasonography and sestamibi scintigraphy were evaluated. RESULTS: The overall sensitivity and the positive predictive value of ultrasonography and sestamibi scintigraphy were 76% and 90%, and 81% and 91%, respectively. Both imaging studies were concordant for the same localization(s) in 121 (66%) of 183 patients. The prevalence rates of single-gland and multiglandular disease were 90% (N.=109) and 10% (N.=12), respectively, in patients with concordant results (P=0.0001). The overall rate of localization was 91% (N.=110) in these patients. In these patients with concordant results, the sensitivity and the positive predictive value of imaging were 91% and 100%, respectively. The localization rates were 96% and 42% for single-gland and multiglandular disease, respectively (P=0.0001). Of the remaining 62 patients, 50 had negative imaging with either ultrasonography (N.=29) or MIBI (N.=21). Of the 29 patients with negative ultrasonography results, sestamibi scintigraphy was positive in 23. Of the 21 patients with negative sestamibi scintigraphy imaging, ultrasonography was positive in 15. Thus, 38 patients had a single positive imaging result. The majority (95%) of these 38 patients had single-gland disease, and the rate of multiglandular disease was 5% (P=0.0001). The rate of localization was 95% (36/38) in patients with a single positive imaging study. Eighteen patients had discordant imaging results. CONCLUSIONS: The overall rate of localization in primary hyperparathyroidism is greater than 90% if ultrasonography and sestamibi scintigraphy are concordantly positive for the same localization, and the prevalence of multiglandular disease is low in patients with concordant imaging. An image-guided surgical approach and selective parathyroidectomy exhibit high cure rates in the setting of concordantly positive sestamibi and ultrasonography results, even if intraoperative parathormone monitoring is not used.

Effect of Triclosan-Coated Suture and Antibiotic Prophylaxis on Infection and Recurrence after Karydakis Flap Repair for Pilonidal Disease: A Randomized Parallel-Arm Double-Blinded Clinical Trial.

BACKGROUND: Pilonidal sinus disease was first described by Mayo in 1833 as "a cyst that contains hair." Although surgical treatment of the lesions can have successful outcomes, it also can be associated with relatively high rates of post-operative infectioins and recurrence. Many studies have demonstrated that triclosan-coated sutures (TCS) decrease surgical site infections. OBJECTIVE: The goal of this randomized parallel-arm double-blind clinical trial was to investigate the ability of antibiotic prophylaxis, and secondarily of antibiotic-coated sutures, to prevent post-operative infections in the surgical management of pilonidal sinus disease. PATIENTS AND METHODS: The initial trial protocol aimed to compare early infections in patients who did and did not undergo antibiotic prophylaxis (AP(+) vs. AP(-)). A secondary goal was to compare the effects of TCS and conventional sutures (CS) on early infectious complication rates in the two groups. The AP(-) arm had to be terminated prematurely because of an unacceptably high rate of infectious complications. RESULTS: A total of 80 micro-organisms were recovered from 74 patients (69.8%). Methicillin-susceptible coagulase-negative staphylococci were the most common isolates (30%). The most frequently detected anaerobic micro-organism was Actinomyces israelii (7.5%). The TCS and CS groups had similar rates of micro-organism growth (65.8% vs. 75.0%). There was no significant difference in the occurrence of wound dehiscence. Over the six-month follow-up, there were two recurrences, both in the TCS group. The difference was not significant. CONCLUSIONS: We believe that antibiotic prophylaxis is necessary in patients scheduled for Karydakis flap repair. In our study, TCS tended to be associated with a lower rate of infection, but this trend did not achieve statistical significance. Anaerobic micro-organisms dominated the infective isolates.