Feasibility of Magnetic Technique for Axillary Staging after Neoadjuvant Therapy in Breast Cancer Patients.

PURPOSE: Optimal axillary staging after neoadjuvant chemotherapy (NAC) in node-negative breast cancer is an area of controversy. Sentinel node biopsy with Technetium-sulphur colloid (99m Tc) alone or with blue dye is the recommended technique for evaluating axilla in these patients. However, this technique has drawbacks such as limited access to nuclear departments and timing limitations related to Tc injection exposing patients to unnecessary radiation. Superparamagnetic iron oxide nanoparticles (SPIO) may represent a valid option for SLN biopsy. In this study, we assessed the feasibility of the magnetic technique (Sentimag) with combination of isosulfan blue dye in breast cancer patients who received NAC. METHODS: The study sample consisted of 54 female breast cancer patients who received NAC. Sentinel node localization was performed using magnetic technique and blue dye. Sentinel node identification rate (IFR) of magnetic technique was calculated and postoperative complications were assessed. RESULTS: Sentinel lymph node was detected in 52 patients with Sentimag method (identification rate = 96.3%, 95% CI: 87.4-98.9%). Blue dye was successful to find SLN in 38 patients (identification rate = 70%). The most common histologic type was invasive ductal (n = 51; 94.4%). Mean tumor size was 2.1 cm after NAC. Most of patients had T2 (n = 30; 55.5%) and HER2 + positive (n = 49; 90.7%) cancer. CONCLUSION: Sentimag which is a magnetic technique appears to be safe, easy to perform with minimal adverse effects, may be an alternative and accurate technique in patients with NAC, especially in breast units where nuclear medicine unit is not available.Supplemental data for this article is available online at https://doi.org/10.1080/08941939.2022.2038737 .

Identification of the recurrent laryngeal nerve during thyroidectomy can affect the complication rate.

AIM: Identification of recurrent laryngeal nerve (RLN), performed via different techniques, decreases nerve injury during thyroidectomy. We aimed to evaluate the effect of different anatomic levels at which RLN was identified on postoperative complications. MATERIAL AND METHODS: The patients underwent total thyroidectomy or lobectomy without lymph node dissection were included. Two different surgical methods were performed: thyroidectomy identifying RLN at level of inferior thyroid artery (ITA) (Group 1); at level of Berry's ligament (Group 2). Patients were evaluated with indirect laryngoscopy on 3rd postoperative day, if nerve damage was determined, at each six months. Nerve damage and postop hypocalcemia were accepted transient up to 6th month, permanent after 6th month. Total serum calcium levels were postoperatively measured on 24th and 48th hours, and then monthly. RESULTS: Unilateral and bilateral RLN damage were detected as 4.4% and 2.2% in Group 1; and 8% and 2.67% in Group 2, respectively. The frequency of RLN damage was similar (p=0.62). Postoperative hypocalcemia was significantly higher in Group 1 (p=0.04); hypocalcemia was similar (p=0.149). One patient in Group 1, and 2 patients in Group 2 had f superior laryngeal nerve (SLN) injury. Three patients from each group showed permanent hypocalcemia. One patient in Group 1, and two in Group 2 developed permanent hoarseness. DISCUSSION: RLN injury was similar in both groups, however, temporary hypocalcemia was more frequent in patients undergone thyroidectomy with RLN identification at ITA level. CONCLUSIONS: Devascularization of parathyroid glands may be accused. Future studies are needed. KEY WORDS: Recurrent laryngeal nerve, Thyroidectomy.

Isolated Penile Fournier's Gangrene: A Rare Case.

Fournier's gangrene is necrotizing fasciitis involving the penis, scrotum, or perineal region. This condition is associated with a high mortality rate and requires aggressive debridement of necrotic tissues. It is mainly seen in elderly, immune-suppressed, diabetic patients, or patients with long-term urinary catheterization. Isolated penile involvement is very rare due to the rich blood supply of the organ and is thought to be induced by penile trauma with partial involvement of the urethra. In this study, we present a patient with isolated penile and urethral necrosis rather than scrotum and perineum and emphasize its gastrointestinal source.

An electron microscopy study of liver and kidney damage in an experimental model of obstructive jaundice.

With this experimental study we investigated the consequences of ligation of the common bile duct (CBD) on hepatic cells and on the renal ultrastructure by electron microscopy and also determine the effects after liberation of the ductus joint in order to clarify the mechanisms of renal failure commonly observed in cholestatic liver disease. The study was conducted on 53 Wistar albino rats divided into 4 subgroups. In the comparison group (sham) we proceeded to the simple laparotomy. After preparation of the common bile duct of all the rats of the four groups, and ligation of the duct at the level of the distal third, eight rats in each group were sacrificed on the 3rd, 7th, 10th and 14th day after surgery, taking blood samples to measure the serum levels of ALP and bilirubin, and liver and renal tissue samples for histological evaluation. In four rats of each group the common bile duct was unligated at the same deadlines to obtain free drainage of the bile for a week. At the end of this week, the rats were sacrificed by collecting blood and liver and kidney tissue samples. RESULTS: after CBD ligation in both groups, the ALP value, total and direct bilurubin levels were proportionally increased. After duct release, bilurubin levels decreased significantly. In group II, while large lipid granules were observed to indicate oxidative damage, mitochondrial swelling and crystals were observed after duct liberation. Areas of glycogen and normal mitochondria were observed in group IV. After duct release in this group, increases in Ito granules, lipid granules and normal mitochondria were observed, which may reflect the evolution of hepatic regeneration. When renal tissue was examined in group II, fusion processes in the feet, thickening of the basement membrane and mesengium were observed, and mitochondrial crystals were observed in renal tissue as well as in the liver after duct release. Damage in group III and group IV was increased parallel to prolongation of jaundice and after loosening persistent damage with mitochondrial crystals. CONCLUSION: Ultrastructural changes in rat liver tissue in conditions of obstructive jaundice may be reversible after restoration of drainage. On the other hand, ultrastructural changes in renal tissue in cases of prolonged jaundice are irreversible even if the internal drainage is restored. KEY WORDS: Bile Duct, Liver, Kidney, Obstructive Jaundice.

Association between Tumor Size and Malignancy Risk in Hormonally Inactive Adrenal Incidentalomas.

Introduction Adrenal incidentalomas (AI) are adrenal masses that are discovered during radiological examinations conducted for other reasons. In this study, we focused on the pathological and radiological properties of nonfunctional AI(NFAI) and the association with malignancy risk in our clinical series. Methods A total of 186 patients underwent adrenalectomy between 2010 and 2017; of these, 76 (40.8%) patients with non-functional AI were included in the current study. The radiological and pathologic characteristics of these AIs were retrospectively analyzed to determine the malignancy rate. Results There were 22 (28.9%) male and 54 (71.1%) female patients with nonfunctional AI included in this study. The median age was 55 (range: 24-85) years. Of the patients included, 37 (48.6%) had AI on the left and 39 (51.3%) had AI on the right adrenal gland. Sixty-one (80.2%) cases were treated laparoscopically, four (5.3%) required conversion to open surgery due to intraoperative difficulties such as bleeding and adhesions, and 11 (14.4%) were managed with open adrenalectomy. The rate of malignancy in the tumors with diameters of <4 cm, 4-6 cm, and >6 cm was found to be 0%, 2.9%, and 13.6%, respectively. Conclusions Determining the ideal cutoff value for surgical indication in an NFAI is challenging. Besides the malignancy risk, the rate of silent pheochromacytomas must be taken into account in the surgical decision.

High C-reactive protein level as a predictor for appendiceal perforation.

BACKGROUND: Between 18% and 34% of acute appendicitis (AA) patients may have complicated appendicitis. Perforation is the most important complication of AA. Perforation increases morbidity and mortality. In this study, we aimed to investigate the role of basic inflammatory markers in the diagnosis of perforated AA. METHODS: A retrospective chart review was conducted of patients who underwent appendectomy with a diagnosis of AA between January 2014 and October 2019 at Akdeniz University Faculty of Medicine; and between December 2017 and October 2019 at Istinye University Faculty of Medicine Hospital. Markers recorded were as follows: white blood cell count, neutrophils, lymphocytes, platelets, c-reactive protein, mean platelet volume, red cell distribution width and eosinophils. Hematological indices were combined to generate the following three ratios: white cell neutrophil ratio, platelet lymphocyte ratio and neutrophil-lymphocyte ratio. RESULTS: A total of 536 patients with a diagnosis of AA underwent an operation. There were 344 (64.1%) male patients and 192 (35.9%) female patients. The mean age of the patients was 36.7±16.2 (15-88) years. There were 94 (17.5%) patients with perforated AA and 442 (82.5%) patients with non-perforated AA. C-reactive protein (AUC: 0.81, p<0.001) was the most accurate markers in distinguishing the perforated and non-perforated group. CONCLUSION: Elevated CRP level is a nonspecific inflammatory marker in most of the inflammatory diseases. A high CRP level can, therefore, be used as a supplement in the diagnosis of perforated AA.

The Turkish SentiMAG feasibility trial: preliminary results.

BACKGROUND: Sentinel node biopsy (SNB) is the standard of care for staging of the clinically and radiologically negative axillary lymph nodes in breast cancer patients. Sentinel node biopsy, with using Technetium-sulphur colloid (99 m Tc) alone or with blue dye is standard technique for evaluating axillary lymph nodes. This technique has drawbacks such as radiation exposure. Superparamagnetic iron oxide nanoparticles (SPIO) can represent a valid option for SNB. In this study; we tried to evaluate feasibility of new magnetic technique in Turkish early breast cancer patients. MATERIAL AND METHODS: The study sample consists of 143 women affected by early breast carcinoma with clinically negative axillary lymph nodes. Sentinel node localization was performed using magnetic technique. Detection rate of magnetic technique was calculated and postoperative complications were assessed. RESULTS: Results are based on 104 patients. Sentinel node identification rate was 99% (103/104, 95% CI 0.97-1.01) for magnetic technique. A median of two SNs per patient was removed. Major adverse reaction was the permanent skin coloration (7.1%). CONCLUSIONS: The magnetic technique is a feasible method for detecting SN in breast cancer patients with minimal adverse effects. Magnetic technique may be alternative to standard technique especially in breast units, where nuclear medicine unit is not available.

The Usefulness of Inflammation-based Prognostic Scores for the Prediction of Postoperative Mortality in Patients Who Underwent Intestinal Resection for Acute Intestinal Ischemia.

Objective The current study was conducted to clarify whether the neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are clinically useful in predicting postoperative mortality among patients undergoing surgery for acute intestinal ischemia (AII). Materials and methods The study was conducted as a retrospective investigation of 37 consecutive patients operated for AII between January 2014 and September 2019. Data regarding potential prognostic factors, including age, sex, preoperative white blood cell count (WBC), C-reactive protein (CRP), neutrophil, lymphocyte, and platelet counts were obtained from medical records. Results Univariate analysis revealed that age, WBC, and neutrophil count were predictors of postoperative mortality. In multivariate analysis, age (OR =1.14; 95% CI, 1.005-1.303; P=0.02) was found to be the only independent variable predicting postoperative mortality. Conclusions Preoperative NLR and PLR cannot be used as independent variables to predict postoperative 30-day mortality in patients with AII who underwent surgery.

Effect of a new cross-linked hyaluronan gel on the staple line after sleeve gastrectomy in a rat model.

PURPOSE: To evaluate the effect of a new cross-linked hyaluronan (NCHA) gel on healing of the staple line in an experimental sleeve gastrectomy. METHODS: Eighteen rats were randomly divided into three groups. The control group (n = 6) received no medication. In the saline group (n = 6) and NCHA gel group (n = 6), saline and NCHA gel were respectively administered onto the staple line and intraperitoneally into the abdominal cavity after the standard stapling procedure. RESULTS: The fibroblast activity and collagen deposition were significantly higher in the NCHA gel group than in the control group (p = 0.00, p = 0.017) and saline group (p = 0.004, p = 0.015). The tissue hydroxyproline protein level was significantly higher in the NCHA gel group than in the control group (p = 0.041). Adhesion formation was significantly lower in the NCHA gel group than in the control and saline groups (p = 0.015, p = 0.041). CONCLUSIONS: New cross-linked hyaluronan gel could be an effective approach to improve staple line wound healing and prevent potential leakage after sleeve gastrectomy. Moreover, NCHA gel helps to prevent adhesion formation without compromising healing of the staple line.

Effect of a new cross-linked hyaluronan gel on the staple line after sleeve gastrectomy in a rat model

Abstract Purpose: To evaluate the effect of a new cross-linked hyaluronan (NCHA) gel on healing of the staple line in an experimental sleeve gastrectomy. Methods: Eighteen rats were randomly divided into three groups. The control group (n = 6) received no medication. In the saline group (n = 6) and NCHA gel group (n = 6), saline and NCHA gel were respectively administered onto the staple line and intraperitoneally into the abdominal cavity after the standard stapling procedure. Results: The fibroblast activity and collagen deposition were significantly higher in the NCHA gel group than in the control group (p = 0.00, p = 0.017) and saline group (p = 0.004, p = 0.015). The tissue hydroxyproline protein level was significantly higher in the NCHA gel group than in the control group (p = 0.041). Adhesion formation was significantly lower in the NCHA gel group than in the control and saline groups (p = 0.015, p = 0.041). Conclusions: New cross-linked hyaluronan gel could be an effective approach to improve staple line wound healing and prevent potential leakage after sleeve gastrectomy. Moreover, NCHA gel helps to prevent adhesion formation without compromising healing of the staple line.

Validation of COLA score for predicting wound infection in patients undergoing surgery for rectal cancer.

AIM: The purpose of our study was to estimate the incidence of SSI (Surgical site infection) and the effect of COLA (contamination, obesity, laparotomy and ASA grade) score on SSI in patients undergoing rectal surgical procedures for rectal cancer. MATERIAL OF STUDY: A total of 92 patients who underwent operation for rectum cancer were enrolled in this study. Wound surveillance was performed in all patients by a staff surgeon identified infected wounds during the hospital stay, and collected information for up to 30 days after operation. RESULTS: The overall rate of incisional SSI and organ/space SSI was 22.8% and 7.6% respectively. Surgical site infection rates were 14.2%, 20.58%, 40.7%, 57.1% for COLA 1,2,3 and 4 scores respectively. The area under the receiver/ operator characteristic curve for the score was 0,660. CONCLUSION: COLA scoring systems predict, with reasonable accuracy, the risk of SSI in rectal cancer patients undergoing elective rectal surgery. KEY WORDS: COLA score Rectal surgery, Surgical site infection, Risk prediction, Wound infection.

Incidental midgut malrotation detected during second laparotomy: Case report and literature review.

INTRODUCTION: Intestinal malrotation is defined as intestinal nonrotation or incomplete rotation around superior mesenteric artery (SMA), involving anomalies of intestinal fixation as well. The patients may be recognized incidentally during other surgical procedures or at autopsy. Here in, we present a case of midgut malrotation which was diagnosed incidentally during hepaticojejunostomy procedure for benign biliary stricture. PRESENTATION OF CASE: A 46 years old male patient was referred to our clinic with failed surgery for biliary stricture due to extensive adhesions. Prior to our surgery, intestinal malrotation was not reported and noticed by the diagnostic tools. When the patient underwent relaparotomy, midgut malrotation was observed. DISCUSSION: Distruption in the normal embryological development of bowel is the cause of intestinal malrotation. Various anatomic configurations and anomalies resulting from rotation anomalies of midgut. Adult patients are usually asymptomatic and the anomaly is discovered only at autopsy or incidentally at surgery. The role of additional surgery especially in patients with asymptomatic disease related to malrotation is debated. CONCLUSION: Performing loop hepaticojejunostomy with Braun enteroenterostomy is feasible and acceptable option rather than Roux-N-Y hepaticojejunostomy in case of intestinal malrotation.

Cysts of the round ligament simulating inguinal hernia: report of a case.

We report on a 49-year-old woman with cysts of the round ligament causing a nonreducible mass of the groin. Cysts of the round ligament are rare. Physical findings were similar to those of an inguinal hernia. Such cysts are usually not considered in the differential diagnosis of groin hernias and might be identified only at the time of herniorraphy.

A new and simple score for predicting cystobiliary fistula in patients with hepatic hydatid cysts.

BACKGROUND: Hepatic hydatid cysts are common disorders in Turkey. Although most patients are treated by percutaneous drainage, some cases require operative intervention. Biliary fistula is a major complication of hydatid cyst operations. The purpose of this study is to identify preoperative predictors of cystobiliary fistula (CBF) and to develop a scoring system for this disorder. METHODS: Overall, 135 patients with hepatic hydatid cysts were included in this study. The following variables were analyzed as potential predictors of CBF: Age, gender, findings on physical examination, complete blood cell count, liver function tests, and ultrasonographic features of the cysts (type, diameter, number, and localization). RESULTS: CBF was detected in 33 of 135 patients. Univariate analyses showed significant differences in cyst diameter, levels of alkaline phosphatase (ALP) and direct bilirubin, platelet count, and white blood cell (WBC) count between patients with and without CBF. On multivariate analyses, WBC count > 9,000/mm(3) (odds ratio [OR], 4.5), direct bilirubin level > 0.7 mg/dL (OR, 2.76), cyst diameter > 8.2 cm (OR, 5.48), and ALP level > 120 U/L (OR, 3.82) were significant and independent predictors of CBG. One point was given for the presence of each of these factors to develop a new score. The resulting area under the receiver operator characteristic curve was 0.803 (95% confidence interval, 0.726-0.866). CONCLUSION: Preoperative detection and management of CBF are important issues in the treatment of hydatid cysts of the liver. Developing a scoring system based on routinely measured laboratory and radiologic factors will help the clinician to manage patients with hepatic hydatid cysts. External studies are needed to validate this new scoring system in routine clinical practice.

D1 versus D2 dissection in gastric carcinoma: Evaluation of postoperative mortality and complications.

OBJECTIVE: Surgery is the only curative treatment for patients with gastric cancer. However, the extent of lymph node dissection is still debated. The aim of the study was to evaluate complications, postoperative length of hospital stay and postoperative mortality after D1 or D2 lymph node dissection for gastric cancer in a non-specialized hospital. MATERIAL AND METHODS: All patients who underwent surgery for pathologically confirmed gastric cancer at our 3rd General Surgery Department, Ankara Numune Training Hospital between January 1999 and 2007 were retrospectively reviewed. A consecutive series of 71 gastric cancer patients was identified. D1 resection (level 1 lymphadenectomy) was compared with D2 resection (levels 1 and 2 lymphadenectomy). RESULTS: The D2 group had higher postoperative mortality (16% vs. 8%; p<0.005) and morbidity (54% vs. 34%; p<0.005), and their postoperative length of stay was longer. Splenectomy did not have an effect on postoperative morbidity and mortality in either the D1 or the D2 group. CONCLUSION: The D2 procedure was associated with significantly higher postoperative mortality, morbidity, and postoperative length of hospital stay.

Primary hydatid cyst of the axilla: report of a case.

OBJECTIVE: The aim of this work was to report a case of hydatid cyst located in the axilla. CLINICAL PRESENTATION AND INTERVENTION: A 36-year-old female presented with a painless right axillar swelling of 6 months duration. We removed the entire cyst surgically, and macroscopic and histopathological examinations confirmed the diagnosis of axillar hydatid disease. Seventeen months after the operation there was no recurrence. CONCLUSION: This case report showed that in cases of a cystic mass in an endemic zone, the diagnosis of hydatid cyst should be considered.