Is total thyroidectomy more difficult in Hashimoto's thyroiditis?

AIM: Hashimoto's thyroiditis (HT) is accepted as a difficult thyroidectomy for surgeons in practice, but there is not enough data in the literature to support this. The aim of this study was to evaluate whether HT belongs to difficult thyroidectomy class or not. MATERIAL AND METHODS: 614 patients who undergoing total thyroidectomy were evaluated. 270 patients with factors that prolong the operation were excluded from the study. Group 1 consisted of 132 patients reported as benign diseases accompanied by HT. Group 2 consisted of 212 patients reported as other benign diseases with no HT as a result of pathology. Patients were statistically analyzed for age, sex, finding for (Recurrent Laryngeal Nerve) RLN, time for reaching RLN, time for operation, transient or permanent RLN injury and other postoperative complications. RESULTS: There were statistically significant differences in terms of age, sex, time for operation and time for reaching RLN (respectively; p=0.01, p=0.007, p<0.001 and p<0.001). There was no significant difference between the groups in terms of finding for RLN rates, transient or permanent RLN injury and other postoperative complications (p>0.05). CONCLUSION: The mean time for operation and mean time for reaching RLN in patients with HT was significantly longer than in patients with other benign pathology results. It has been scientifically shown that HT should be among the causes of difficult thyroidectomy. This result can provide a legal advantage for surgeons who face such a sad complication. KEY WORDS: Hashimoto thyroiditis, Recurrent laryngeal nerve, Thyroiditis.

The factors of pancreatic fistula development in patients who underwent classical pancreaticoduodenectomy.

AIM: Pancreatic fistula (PF) and anastomotic leakage are significant complications of the pancreaticoduodenectomy (PD). The PF is considered as the root cause of other major complications of PD. The aim of the study was to investigate the risk factors underlying PF that occurred after PD and the effects of the PF on postoperative morbidity. MATERIAL AND METHODS: In this study, fifty patients who underwent classic PD were evaluated, retrospectively. Patients were divided into two groups as patients with PF and patients without PF. The following demographical, clinical and operative parameters were collected to evaluate the PF; age, gender, preoperative biochemical parameters, resection type, duration of the operation, patient's comorbidities, amount of perioperative transfusion, localization of the tumour, texture of the residual pancreas, type of the anastomosis and the diameter of the pancreatic duct. RESULTS: A statistically significant relation was found between the texture of the remnant pancreatic parenchyma and PF (p<0.001). A significant relation was determined between PF and preoperative ALP, GGT, AST, ALT, hemoglobin levels and length of the hospitalization (p<0.05). In this study, we found that mortality, abdominal bleeding, bile leakage, intra-abdominal abscess were associated with reoperation and prolonged hospitalization. CONCLUSION: The lack of internationally accepted definition of a fistula is an important issue. Preoperative high ALP, ALT, AST, GGT values, low hemoglobin values and soft texture of remnant pancreatic tissue were found to be related with PF that occurs after PD. Residual pancreatic tissue has been shown as an independent risk factor. KEY WORDS: ISPGF, Pancreaticoduodenectomy, Pancreatic fistula, Risk factors.

Omentopexy versus falciformopexy for peptic ulcer perforation.

BACKGROUND: Open or laparoscopic Graham's omentopexy is frequently used in the treatment of peptic ulcer perforation (PUP). The technical difficulty of applying the omental plug, especially in patients with previous omentum resection, has led to the use of falciform ligament for the PUP, and some studies have reported that PUP may even be a more advantageous technique than omentopexy. Here, in this study, we aimed to compare the retrospective results of patients who underwent falciformopexy or omentopexy for PUP. METHODS: Between 1999 and 2018, 303 patients who were followed-up and treated for PUP were included in this study. Patients who had malignancy, gastric resection, definitive ulcer surgery, laparoscopic surgery and nonoperative treatment were excluded from this study. In the remaining patients, either open ometopexy or falciformopexy were applied based on the surgeon's choice. These two techniques were compared for intraoperative and postoperative outcomes. RESULTS: Falciformopexy (n=46) and omentopexy (n=243) groups had similar demographics, but ASA scores were lower in the falciformopexy group. For ulcer size and localization, duration of operation, no difference was found between the groups. There was no significant difference between the groups concerning general postoperative morbidity and mortality. However, atelectasis was more frequently observed in the omentopexy group, whereas the pexia failure was more frequent in the falciformopexy group (2.6% and 8.7%, p=0.04). CONCLUSION: Falciformopexy is an alternative technique that can be used in situations where it is not possible to use the omentum. Falciformopexy is not superior to omentopexy for the repair of the PUP.

The value of hematological parameters in acute pancreatitis.

BACKGROUND: Acute pancreatitis (AP) is a common inflammatory disease in the emergency department (ED). This study aims to assess the role of CRP and hematologic parameters in mild/severe AP patients and biliary/nonbiliary AP at the time of admission to the ED. METHODS: 168 patients who were diagnosed as AP in the ED, and as a control group, 100 patients were included in this study. At the time of application to the ED, the demographic information (age, sex) and the amylase, lipase, CRP, hematological parameters (WBC, MPV, RDW, PLT, NLR) of all patients and the control group were recorded and compared. According to the etiology of the patients, the patients were divided into biliary and nonbilary AP groups and according to the severity, they were divided into mild and severe AP groups, then, the same parameters were evaluated. RESULTS: Significant differences were found out between WBC, CRP, NLR, MPV and PLT values between patient and the control group (p<0.001). The length of hospitalization and the parameters were not significant between the biliary and the nonbiliary group. Ranson and APACHE II scores were correlated with WBC, CRP and NLR. There was a statistically significant difference between the mild and severe AP groups in terms of duration of the hospital stay, CRP, WBC and NLR values (p=0.003 for CRP, p<0.001 for the others). In severe AP, the cut-off value of NLR was found to be 8.05, sensitivity %93.48, specificity %86.89 and AUC 0.937 (p<0.001). CONCLUSION: The use of parameters, such as WBC, CRP, and NLR, in combination with other diagnostic and prognostic tools in emergency service can provide convenience to clinicians at the time of admission and prognosis.

A practical scoring system to predict mortality in patients with perforated peptic ulcer.

INTRODUCTION: The mortality rate of perforated peptic ulcer is still high particularly for aged patients and all the existing scoring systems to predict mortality are complicated or based on history taking which is not always reliable for elderly patients. This study's aim was to develop an easy and applicable scoring system to predict mortality based on hospital admission data. METHODS: Total 227 patients operated for perforated peptic ulcer in two centers were included. All data that may be potential predictors with respect to hospital mortality were retrospectively analyzed. RESULTS: The mortality and morbidity rates were 10.1% and 24.2%, respectively. Multivariated analysis pointed out three parameters corresponding 1 point for each which were age >65 years, albumin ≤1,5 g/dl and BUN >45 mg/dl. Its prediction rate was high with 0,931 (95% CI, 0,890 to 0,961) value of AUC. The hospital mortality rates for none, one, two and three positive results were zero, 7.1%, 34.4% and 88.9%, respectively. CONCLUSION: Because the new system consists only age and routinely measured two simple laboratory tests (albumin and BUN), its application is easy and prediction power is satisfactory. Verification of this new scoring system is required by large scale multicenter studies.

Polycystic liver transplant: a case report.

A liver from a donor with brain death due to a ruptured cerebral aneurysm was transplanted. The liver had multiple bilobar simple cysts; the largest was less than 3 cm in diameter. The noncystic liver volume was greater than 50%, and the liver had neither fibrosis nor venous congestion. The donor surgery was performed in accordance with the standard protocol without rupture of the cysts. The recipient was a 40-year-old man with cirrhosis associated with hepatitis B. The recipient operation was done by using the piggyback method with no complications. Excessive drainage of chylous ascites (10 000 mL/d) started in the first days after surgery and continued, gradually decreasing until the end of the second month. The patient was discharged with no complications at the end of the third month. No growth in the cysts was observed on follow-up computed tomography scans. Excluding this particular case, a total of 7 other patients have received a polycystic liver transplant. In all 7 cases, the fact that the donor had polycystic liver disease was not known but was encountered by coincidence during procurement. The case reported here is the first case where the polycystic liver disease was diagnosed before procurement and the transplant was still carried out. It appears that, if the donor liver has enough healthy noncystic volume, polycystic livers can be transplanted.

Clinicopathological characteristics of hepatocellular carcinoma in Turkey.

BACKGROUND: Hepatocellular carcinoma (HCC), the main malignant tumor of the liver, is very common and highly lethal. The aim of this study was to determine its clinicopathologic characteristics and risk factors in Turkey. MATERIALS AND METHODS: In this study, patients who were diagnosed as suffering from HCC in the period between August 2004 and December 2011 were evaluated retrospectively. RESULTS: A total of 98 patients were included, with a median age 61 (range: 16 to 82). Seventy nine (80.6%) were male 59 (60.2%) were infected with hepatitis B virus (HBV) and 15 (15.3%) with HCV, another 15 (15.3%) being alcohol abusers. Seventy two (73.5%) were at advanced stage and 54 (55.1%) had elevated serum alpha-fetoprotein (AFP). Surgery, chemoembolization, systemic chemotherapy and application of the tyrosine kinase inhibitor sorafenib were the major treatment options. CONCLUSIONS: According to our findings HCC is mostly diagnosed in advanced stage and age, being five times more common in males than females. Main risk factors of HCC are HBV infection, HCV infection and alcohol abuse. Elevation in AFP may facilitate early diagnosis of HCC in high risk groups.

T-tube bridging for the management of biliary tree injuries.

BACKGROUND: Injuries of the biliary tree, which mainly occur as a complication of laparoscopic cholecystectomy, are a potentially life threatening cause of high morbidity and mortality. The reported frequency of biliary injuries after laparoscopic cholecystectomy is from 0.5-0.8%. Such injuries may sometimes become too complicated for surgical repair. Presented here is the case of a patient with a major bile duct injury for whom bile duct continuity was achieved using a T-tube. CASE REPORT: A 53-year-old man, who developed bile duct injury following a laparoscopic cholecystectomy performed in another center for cholelithiasis, was referred to our clinic. A Roux-en-Y hepaticojejunostomy was performed in the early postoperative period. However, ensuing anastomotic leakage prompted undoing of the hepaticojejunostomy followed by placement of a T-tube by which bile duct continuity was achieved. CONCLUSIONS: For injuries with tissue loss requiring external drainage, T-tube bridging offers a feasible option in that it provides bile duct continuity with biliary flow into the duodenum, as well as achieving external drainage, thus alleviating the need for further definitive surgery.

Reversal of the Hartmann procedure through only a stomal orifice.

We performed reversal of the Hartmann procedure only through the stoma site and we did not use either any other incision nor laparoscopic assistance. A total of 8 patients (7 males), ages between 23 and 80 years, were treated by means of a defined technique. The indications of the Hartmann procedure were sigmoid volvulus (4), sigmoid cancer obstruction (2), rectal trauma (1), and Fournier gangrene (one). The duration from the first procedure was a mean of 5 months (range, 2 to 8 months). The length of the rectal stump was at least 5 cm over the pelvic peritoneum and the body mass indices of all patients were less than 30 kg/m². The diameter of the stoma opening was a mean of 50 mm (range, 40 to 55 mm). Incision extensions from the stomal orifice (accepted as conversion) were needed for two cases as a result of injury on the intestine and inability to identify the distal bowel stump (25%). The mean operative blood loss and duration of operation were 50 mL (range, 30 to 100 mL) and 65 minutes (range, 45 to 80 minutes), respectively. Fecal discharge of all patients was weighed before hospital discharge and the length of postoperative hospital stay was a mean of 5.5 days (range, 4 to 9 days). Neither anastomosis leakage nor surgical site infections were observed in any of the patients and all had an uneventful postoperative course. The described technique can be the least invasive one than the previously described techniques for the reversal of the Hartmann procedure by only using the stoma site, particularly for nonobese patients with a long distal rectal stump.

Leakage tests reduce the frequency of biliary fistulas following hydatid liver cyst surgery.

BACKGROUND AND AIM: Biliary fistulas are the most common morbidity (8.2-26%) following hydatid liver surgery. The aim of our study was to reduce the incidence of postoperative biliary fistulas after the suturing of cystobiliary communications by applying a bile leakage test. PATIENTS AND METHODS: A total of 133 hydatid liver cysts from 93 patients were divided into two groups, according to whether the test was performed. Tests were performed on 56 cysts from 34 patients, and the remaining 77 cysts from 59 patients were treated without the test. In both groups, all visible biliary orifices in the cysts were suture ligated, and drains were placed in all cysts. The visibility of the biliary orifices and postoperative biliary drainage through the drains were recorded. Patients in both groups were also compared with respect to the number of days living with the drains, the length of the hospital stay, and secondary interventions related to biliary complications. RESULTS: Biliary orifices were more visible in the tested cysts (13% vs. 48%; P <0.001). Fewer biliary complications occurred in the tested patients (8.8% vs. 27.7%, P = 0.033). The mean drain removal time (4.1 ± 3.3 days vs. 6.8 ± 8.9 days, P < 0.05) and the length of the hospital stay (6.7 ± 2.7 days vs. 9.7 ± 6.3 days, P,0.01) were shorter for the tested patients. None of the patients in the test group required postoperative Endoscopic retrograde cholangiopancreaticography (ERCP) or nasobiliary drainage (0.0% vs. 8.4%, P = 0.09). There were no long-term biliary complications for either group after three years of follow-up. CONCLUSIONS: Identification of biliary orifices with a bile leakage test and the suturing of cystobiliary communications significantly reduced postoperative biliary complications following hydatid liver surgery.

Radio-guided excision of parathyroid lesions in patients who had previous neck surgeries: a safe and easy technique for re-operative parathyroid surgery.

BACKGROUND: Several methods have been recommended to detect parathyroid lesions in patients who have previously undergone neck surgeries, including radio-guided surgery or intraoperative ultrasounds. In this study, we aimed to investigate whether the radio-guided excision of pathologic parathyroid lesions allowed us to find affected lesions in patients who had previously undergone neck operations. METHODS: This prospective study included 18 patients with primary hyperparathyroidism who had previously undergone neck surgeries. The pathologic parathyroid lesions were localized by ultrasonography, and a radiotracer was injected directly into the lesions. RESULTS: Careful dissections were carried out by following the area of maximum radioactivity until the lesions were identified and excised. Eighteen parathyroid adenomas were removed in 18 patients. The median count from each lesion was significantly higher than the values measured from the adjacent tissues and the lesion beds (12550/20 s, 370/20 s, and 35/20 s, respectively; p < 0.001). CONCLUSION: Radio-guided excision of parathyroid lesions can be performed safely for re-operative parathyroid surgery.

Diagnostic value of thyroglobulin measurement in fine-needle aspiration biopsy for detecting metastatic lymph nodes in patients with papillary thyroid carcinoma.

PURPOSE: We aimed to compare the diagnostic value of fine-needle aspiration cytology (FNAC) and fine-needle aspiration thyroglobulin measurements (FNA-Tg) for detecting cervical lymph node metastases from differentiated thyroid carcinomas. METHODS: This prospective study included 225 patients with neck node metastases or recurrences of papillary thyroid carcinoma. From the 225 patients, 255 lymph nodes were evaluated by FNAC and FNA-Tg. Final diagnoses confirmed by histological examination were compared to preoperative FNAC and FNA-Tg results. RESULTS: FNAC correctly diagnosed 212 metastatic lymph nodes but failed to diagnose 43 of them. FNA-Tg correctly diagnosed 253 metastatic lymph nodes but failed to diagnose two of them. FNA-Tg levels showed 100% sensitivity, 96% specificity, 99% diagnostic accuracy, a 99% positive predictive value (PPV) and a 100% negative predictive value (NPV) with a threshold level of FNA-Tg with a diagnostic accuracy 28.5 ng/ml. The specificity, diagnostic accuracy, PPV and NPV of FNA-Tg were significantly higher than those of FNAC. CONCLUSION: FNA-Tg measurement can be performed safely for the detection of lymph node metastasis in patients with differentiated thyroid carcinomas.

Leakage tests reduce the frequency of biliary fistulas following hydatid liver cyst surgery

BACKGROUND AND AIM: Biliary fistulas are the most common morbidity (8.2-26 percent) following hydatid liver surgery. The aim of our study was to reduce the incidence of postoperative biliary fistulas after the suturing of cystobiliary communications by applying a bile leakage test. PATIENTS AND METHODS: A total of 133 hydatid liver cysts from 93 patients were divided into two groups, according to whether the test was performed. Tests were performed on 56 cysts from 34 patients, and the remaining 77 cysts from 59 patients were treated without the test. In both groups, all visible biliary orifices in the cysts were suture ligated, and drains were placed in all cysts. The visibility of the biliary orifices and postoperative biliary drainage through the drains were recorded. Patients in both groups were also compared with respect to the number of days living with the drains, the length of the hospital stay, and secondary interventions related to biliary complications. RESULTS: Biliary orifices were more visible in the tested cysts (13 percent vs. 48 percent; P <0.001). Fewer biliary complications occurred in the tested patients (8.8 percent vs. 27.7 percent, P = 0.033). The mean drain removal time (4.1±3.3 days vs. 6.8±8.9 days, P<0.05) and the length of the hospital stay (6.7±2.7 days vs. 9.7±6.3 days, P,0.01) were shorter for the tested patients. None of the patients in the test group required postoperative Endoscopic retrograde cholangiopancreaticography (ERCP) or nasobiliary drainage (0.0 percent vs. 8.4 percent, P = 0.09). There were no long-term biliary complications for either group after three years of follow-up. CONCLUSIONS: Identification of biliary orifices with a bile leakage test and the suturing of cystobiliary communications significantly reduced postoperative biliary complications following hydatid liver surgery.

Outcome of surgical treatment of intestinal perforation in typhoid fever.

AIM: To represent our clinical experience in the treatment of intestinal perforation arising from typhoid fever. METHODS: The records of 22 surgically-treated patients with typhoid intestinal perforation were evaluated retrospectively. RESULTS: There were 18 males and 4 females, mean age 37 years (range, 8-64 years). Presenting symptoms were fever, abdominal pain, diarrhea or constipation. Sixteen cases were subjected to segmental resection and end-to-end anastomosis, while 3 cases received 2-layered primary repair following debridement, one case with multiple perforations received 2-layered primary repair and end ileostomy, one case received segmental resection and end-to-end anastomosis followed by an end ileostomy, and one case received segmental resection and end ileostomy with mucous fistula operation. Postoperative morbidity was seen in 5 cases and mortality was found in one case. CONCLUSION: Intestinal perforation resulting from Salmonella typhi is an important health problem in Eastern and Southeastern Turkey. In management of this illness, early and appropriate surgical intervention is vital.

Small Bowel Obstruction due to Mesodiverticular Band of Meckel's Diverticulum: A Case Report.

Meckel's diverticulum is the most common congenital anomaly of the small intestine. Common complications related to a Meckel's diverticulum include haemorrhage, intestinal obstruction, and inflammation. Small bowel obstruction due to mesodiverticular band of Meckel's diverticulum is a rare complication. Herein, we report the diagnosis and management of a small bowel obstruction occurring due to mesodiverticular band of a Meckel's diverticulum.

Acute acalculous cholecystitis induced by aortic dissection: report of a case.

Acute acalculous cholecystitis (AAC), inflammation of the gallbladder without evidence of calculi, comprises approximately 10% of all cases of acute cholecystitis. Although the mechanism of AAC has not yet been sufficiently clarified, the most commonly postulated theories regarding its pathogenesis are bile stasis, sepsis and ischemia. We present a case of AAC associated with ischemia of the gallbladder caused by aortic dissection Bakey type III.

Investigation of a one-time phenol application for pilonidal disease.

OBJECTIVE: To investigate wound healing rates and postoperative recovery of patients after a one-time phenol application for pilonidal disease. SUBJECTS AND METHODS: A total 30 consecutive patients with chronic pilonidal disease ranging from midline to complex sinuses were enrolled in the study. No preoperative laboratory examinations or bowel preparation were required. No antibiotic prophylaxis or sedation was used. A small incision was made on the midline and hair/debris in the sinuses was removed. A cotton swab with saturated phenol was moved into the cavity and the phenol was left for 2 min. No special dressing was necessary and patients left the hospital immediately afterwards. Patients filled out a daily questionnaire for 7 days. We did not intervene in the wounds with a second phenol application or curettage during the observation period. Wounds were inspected at weekly intervals for 2 months. RESULTS: At the end of the third day, 97% of the patients were pain-free and 100% of the patients were free from analgesics. Time off work was 2 days for most patients (93.3%). Twenty-eight (93.3%) patients were satisfied with the procedure, they found it easy and painless and suggested the procedure to other patients. Twenty-five (83%) patients were asymptomatic at the end of 2 months' observation and the remaining 5 patients had unhealed sinuses. Mean time for wound healing was 25 days (range 10-63 days). There were 4 recurrences after a mean of 14 months' follow-up and the overall success rate was 70%. CONCLUSIONS: A one-time phenol application was an effective treatment for pilonidal disease with acceptable wound healing rates, less postoperative pain and less time off work. Hence it can be an alternative treatment modality.

Tumescent local anesthesia for excision and flap procedures in treatment of pilonidal disease.

PURPOSE: We describe our experience with tumescent local anesthesia for excision and flap procedures in the treatment of pilonidal disease. METHODS: Forty consecutive patients with symptomatic pilonidal disease were treated. Tumescent solution was prepared by mixing one volume of a lidocaine (20 mg/ml) and adrenaline (0.0125 mg/ml) combination with 9 volumes of lactated Ringer's solution. The final solution was infiltrated gradually and liberally, first subcutaneously and then into the skin. The end point was swollen and firm skin. After excision, the area was filled with an advancement flap or a rotational flap. RESULTS: The study group consisted of 37 men (92.5%) and 3 women (7.5%); mean age, 27 (range, 18-61) years. The amount of injected solution ranged from 60 mL to 140 mL (mean, 100 mL; dose interval, 2-4 mg/kg). No additional anesthesia or sedation was needed, and no complications were observed during the procedure. Half of the patients were discharged on the day of the operation, half on the next day. Follow-up ranged from 13 to 37 months. Patients returned to daily activities after a mean of 10.5 (range, 2-30) days. Primary healing occurred uneventfully in 28 patients (70%); wound healing complications occurred in 12 (30%). No flap necrosis was observed. Thirty-seven (92.5%) patients reported satisfaction with the procedure. Recurrence was observed in 3 patients (7.5%). CONCLUSIONS: Excision and flap procedures for sacrococcygeal pilonidal disease can be performed under tumescent local infiltration anesthesia with acceptable results, without requiring regional or general anesthesia.