Effects of weight intervention-induced changes in pathological fat mass of patients with extreme obesity and anorexia nervosa on adipokines and visceral adipocyte functions: a prospective, comparative, observational study.

OBJECTIVE: Adipose tissue is the largest endocrine organ in the human body, and as its mass changes, the serum levels of the molecules it secretes also change. Visceral adipose tissue index (VAI) is a simple surrogate marker of visceral adipose tissue dysfunction. This study evaluated the effects of changes in fat mass on adipocytokine behavior and VAI in patients with anorexia nervosa (AN) and extreme obesity (EO). PATIENTS AND METHODS: The study group consisted of three subgroups: Group 1, patients with EO who were candidates for obesity surgery with BMI≥50 kg/m2 (n=20). Group 2, newly diagnosed patients with AN (n=12). Group 3 controls with BMI 20-25 kg/m2 (n=20). The AN and EO groups were followed until at least a 10% weight change before and after the intervention. RESULTS: Prior to the intervention, EO patients exhibited the lowest levels of apelin, omentin, and adiponectin, while AN patients demonstrated the highest levels of these markers. Leptin and IL-6 were elevated in EO and reduced in AN patients. After treatment, all adipokines and VAI increased in AN patients, and omentin, adiponectin, and IL-6 increased in EO patients, while apelin, leptin, and VAI decreased. The change in each adipocytokine (∆) was positively correlated with the other adipocytokines (p<0.050) and negatively correlated with metabolic and VAI changes (p<0.050). The regression analysis determined that the following variables were associated with the change in adipose tissue mass: Δapelin (OR: 1.061; p=0.028) and Δadiponectin (OR: 1.057; p=0.036). CONCLUSIONS: In individuals with pathological adipocyte mass, the change in adipocytokine levels in response to weight change is not as expected. The fact that these changes are not seen in the early period of the weight intervention treatment indicates that these patients have compensatory physiological mechanisms to protect them. In addition, using VAI instead of BMI, whose reliability is increasingly questioned because it does not reflect body fat mass, can be considered an alternative. However, there may be modeling errors in the early stages of weight change and in AN and EO patients where metabolic parameters reach extreme values. Therefore, it should be tested in studies where larger patient groups are followed for a more extended period.

Is belching increasing after bariatric bypass surgery in the long term period?

BACKGROUND AND AIMS: Gastric bypass surgery effectively treats obesity; however, its association with belching, which occurs in other bariatric surgeries, remains unclear. Hence, we aimed to evaluate belching occurrence after gastric bypass surgery. METHODS: We enrolled 12 healthy volunteers and 17 patients (12 and 5 underwent Roux-en-Y gastric bypass and mini-gastric bypass surgeries 24 (18-54) months prior, respectively). Gastrointestinal symptoms were assessed. Gastroscopy was performed, followed by the 24-hour pH-impedance analysis. RESULTS: Age and sex were not statistically different between the two groups (P > 0.05). Patients had a significantly higher mean DeMeester score than the healthy controls (9.11 ± 19.40 vs. 6.04 ± 5.60, P = 0.048), but the pathologic acid reflux (DeMeester score > 14) rate was similar in both groups (11.8% vs. 8.3%). Regarding the impedance, symptom-association probability was positive in 11.8% of patients. The patients also had higher alkaline reflux rates (6% vs. 0%); additionally, 50% of them experienced belching based on the questionnaire, and 25% had esophagitis based on gastroscopy. Furthermore, patients had a significantly higher number of gas reflux (123.24 ± 80 vs. 37.2 ± 21.5, P = 0.001) and supragastric/ gastric belches (182 ± 64/228 ± 66.69 vs. 25.08 ± 15.20/12.17 ± 17.65, P = 0.001). Supragastric belching was more frequent than gastric belching in the controls, whereas gastric belching was more frequent in the patients. CONCLUSION: Belching increases after gastric bypass surgery in a long-term period. Gastric belching was more frequent than supragastric belching in these patients.

The use of Ligasure vessel sealing system in axillary dissection; effect on seroma formation.

BACKGROUND: Seroma formation is the most frequent postoperative complication after axillary dissection for breast surgery with an incidence of 10 - 50 %. This prospective clinical randomized study was carried out to evaluate the Ligasure vessel sealing system and its effect on seromaformation and other complications for axillary dissection. METHODS: Between January 2006 and November 2007, the patients with histopathological diagnosis of breast cancer were analysed prospectively. The patients with positive sentinel lymph node biopsy or clinical axillary involvement were included in the study, and the patients who underwent neoadjuvant therapy or using anticoagulants have been excluded from the study. Patients were divided into two study groups.Axillary dissection was performed in the first group by LigaSure and in the second group by linking and electrocautery. RESULTS: There were a total of thirty three patients with a mean age of 51.4 +- 13.7. In group one, mean age of patients was 54.1 +- 13.2 and 48.68 +- 14.1 in group two. There was no significant statistical difference between the groups regarding age, body mass index, excised tissue weight,tumour size and number of excised lymph nodes. The use of Ligasure reduced drainage amount and duration of drain till removal, but increased operative time. CONCLUSION: There were no significant differences between study groups regarding the complications. LigaSure electrothermal bipolar vessel sealing system can be safely used in axillary dissection as an alternative to traditional methods.

How to prevent intraoperative risks and complications in laparoscopic splenectomy.

Since its introduction in 1992 laparoscopic splenectomy (LS) has become the technique of choice for surgical removal of the spleen in several centres. The procedure, however, is associated with risks and complications, either during surgery or in the postoperative phase. Although the incidence of intraoperative complications is unknown, intraoperative risks in patients undergoing laparoscopic splenectomy are not uncommon. In this article, we reviewed the literature on risks and complications during LS, and we point out, based on our personal series and on the experiences reported by other Authors, how to prevent, whenever possible, these complications.

Electrocautery for cutaneous flap creation during thyroidectomy: a randomised, controlled study.

BACKGROUND: Although electrocautery has been used widely in surgery, the fear of delayed wound healing and infection persists. We aimed to evaluate the risk factors for wound complications and the rate of wound complications, comparing the use of electrocautery or scissors in cutaneous flap creation during thyroidectomy. DESIGN: The study group comprised 239 consecutive patients scheduled for thyroidectomy. SUBJECTS: Patients were randomly assigned to cutaneous flap dissection by either electrocautery (group one, n = 126) or scissors (group two, n = 113). Age, gender, body mass index, American Society of Anesthesiology score, tissue weight, operating time, incision length, cutaneous tissue depth, thyroid function and surgeon experience were recorded and compared with the rate of post-operative wound complications in both groups. RESULTS: There were no significant differences between the overall rate of post-operative wound complications, comparing groups one and two (7.9 vs 10.6 per cent, respectively; p = 0.74). Significant positive correlations were found between wound complication and age (Spearman's rank coefficient (rs) = 0.135, p = 0.036), body mass index (rs = 0.379, p = 0.0001), cutaneous tissue depth (rs = 0.677, p = 0.0001) and tissue weight (rs = 0.643, p = 0.0001). According to logistic regression analysis, a body mass index of more than 27.5 kg/m2 was associated with a 13.7-fold increased rate of post-operative wound complications. CONCLUSION: When creating cutaneous flaps during thyroidectomy, the use of electrocautery is as safe as the use of scissors. Such electrocautery does not increase the risk of wound complications in thyroid surgery.

Graves' disease, with and without nodules, and the risk of thyroid carcinoma.

OBJECTIVE: Thyroid nodules are frequently present in Graves' disease. The aim of this study was to evaluate the risk of thyroid carcinoma in Graves' disease patients, with and without ultrasonographically identified nodules, who subsequently underwent surgical treatment. DESIGN: The study group included 150 consecutive patients with diagnosed Graves' disease who subsequently underwent surgery. SUBJECTS: The patients were divided into two groups according to whether the pre-operative ultrasound scan showed diffuse parenchyma (group one; n = 70) or nodules (group two; n = 80). RESULTS: Of the 150 patients, 18 (12 per cent) were found to have papillary thyroid carcinoma. Papillary carcinoma was found in seven patients (10 per cent) in group one and in 11 patients (1.7 per cent) in group two. After evaluating the overall groups, the incidence of carcinoma in the parenchyma outside a nodule was 67 per cent, whereas the incidence of carcinoma in a nodule was 33 per cent. CONCLUSION: Carcinoma can occur in Graves' disease patients without nodules, and the absence of nodules on ultrasonographic examination does not reduce the risk of malignancy.

Determination of remnant thyroid volume: comparison of ultrasonography, radioactive iodine uptake and serum thyroid-stimulating hormone level.

PURPOSE: We aimed to evaluate the accuracy of ultrasonography, radioactive iodine uptake and serum thyroid-stimulating hormone level in predicting the volume of remnant thyroid gland. METHODS: Sixty-six thyroidectomy patients were divided into two groups according to their functional status, i.e. those operated upon for nontoxic multinodular goitre (group one) and those operated upon for hyperthyroidism (group two). Ultrasonography, radioactive iodine uptake and thyroid-stimulating hormone assay were performed in all patients during the first post-operative month. The two groups were subdivided according to the amount of remnant thyroid volume detected on ultrasonography: <2 ml, 2-5 ml and >5 ml. RESULTS: The remnant thyroid volume was positively correlated with the radioactive iodine uptake (rs = 0.684, p = 0.0001). The increase in remnant thyroid tissue radioactive iodine uptake was significantly greater in the patients operated upon for hyperthyroidism compared with those operated upon for nontoxic multinodular goitre (p = 0.0001). There was a negative correlation between remnant thyroid volume and post-operative serum thyroid-stimulating hormone level (rs = -0.865, p = 0.0001) and between remnant thyroid tissue radioactive iodine uptake and post-operative serum thyroid-stimulating hormone level (rs = -0.682, p = 0.0001). CONCLUSION: Ultrasonography is a more accurate measure of remnant thyroid volume than radioactive iodine uptake in patients operated upon for hyperthyroidism, compared with those operated upon for nontoxic multinodular goitre.

Synchronous carcinoid tumour of the small intestine and appendix in the same patient.

Carcinoid tumours have been reported in a wide range of organs but most frequently involve the gastrointestinal tract. Many of these carcinoid tumours are associated with metachronous and synchronous lesions of another histological type. Primary carcinoid tumours of the different organ in the same patient is rare. In this paper, the authors present a case with synchronous carcinoid tumour of the small intestine and appendix in the same patient.

Laparoscopic treatment of splenic lymphangiomas: report of three cases.

BACKGROUND AND AIM: Since 1991, laparoscopic splenectomy has been performed in many different pathologies of the spleen. Although it is a rare lesion, splenic lymphangiomas are cystic lesions of the spleen requiring splenectomy. Herein, we present three females who have undergone laparoscopic splenectomy with the diagnosis of cystic splenic lymphangioma. PATIENTS AND METHODS: In the last four years, in Istanbul Medical School, Department of General Surgery (Turkey) and in University of Catania Medical School, Department of Surgery (Italy), we performed laparoscopic splenectomy in three cases of splenic lymphangioma. RESULTS: These three female patients, with the age of 26, 30 and 40, had nonspecific abdominal pain requiring abdominal CT scan and magnetic resonance imaging, which showed incidental cystic lesions in the spleen, associated with cholelithiasis in one case. Preoperative laboratory tests and physical examinations were normal. Laparoscopic splenectomy was performed successfully with three 10 mm trocars in two patients in less than 1 hour, and with an Hasson trocar, two 5 mm trocars and one 10-12 mm trocar in the last case, who required simultaneous cholecystectomy. No peroperative and postoperative complications has occurred. Histopathological examinations confirmed the preoperative diagnosis. CONCLUSION: Laparoscopic splenectomy is the best treatment for patients with suspected cystic lymphangioma. It permits a total pathological examination of the spleen, and it should be preferred to partial splenectomy because of possible multiple lesions. In conclusion, minimal invasive treatment of this rare pathology is an effective and safe procedure.

'Use of electrothermal vessel sealing with LigaSure device during laparoscopic splenectomy'.

PURPOSE: Main causes of conversion to open surgery are uncontrolled bleeding from splenic hilum and capsular injury of spleen during laparoscopic splenectomy (LS). We present the use of LigaSure in laparoscopic splenectomy for hemostasis. MATERIAL & METHOD: Between January 2005 and May 2006, LS was performed in a total of 29 patients (6 male and 23 female) with a mean age of 35.44 +/- 13.63. Indications for splenectomy were idiopathic thrombocytopenic purpura (ITP) in 20 patients, thrombotic thrombocytopenic purpura (TTP) in 2, hereditary spherocytosis (HS) in 3, lymphangioma in 2, hodgkin lymphoma in 1 and splenic cyst in one patient. LS was performed in the right semilateral position with three 10 mm trocars. LigaSure was used in dissection and division of splenic ligaments and hilar vascular structures. RESULTS: Conversion to open surgery was necessary in one patient due to peroperative bleeding. The mean duration of the operation was 71.3 +/- 19.8 minutes and the estimated blood loss was 85 +/- 23 ml. The diameter and the weight of the spleen were 10.7 +/- 2.68 cm and 250 +/- 90 g, respectively. There was no mortality. Postoperative complications included pancreatic fistula, trocar site infection and deep venous thrombosis that were encountered in three patients. These were managed without morbidity. The overall complication rate was 10.3% (n = 3). The mean duration of postoperative hospital stay was 2.86 +/- 1.59 days. CONCLUSION: LigaSureTM use in LS had easy application, provided sufficient hemostasis, and shortened the operative time.

Synchronous carcinoid tumour of the small intestine and appendix in the same patient / Tumor carcinoide sincrónico del intestino delgado y el apéndice en el mismo paciente

Carcinoid tumours have been reported in a wide range of organs but most frequently involve the gastrointestinal tract. Many of these carcinoid tumours are associated with metachronous and synchronous lesions of another histological type. Primary carcinoid tumours of the different organ in the same patient is rare. In this paper, the authors present a case with synchronous carcinoid tumour of the small intestine and appendix in the same patient.

Se han reportado tumores carcinoides en una amplia variedad de órganos, pero el lugar de detección más frecuente ha sido el tracto gastrointestinal. Muchos de estos tumores carcinoides se hallan asociados con lesiones metacrónicas y sincrónicas de otro tipo histológico. La presencia de tumores carcinoides primarios de un órgano diferente en el mismo paciente es rara. En este trabajo, los autores presentan un caso con tumores carcinoides sincrónicos del intestino delgado y el apéndice en el mismo paciente.

Predictive factors for recurrent laryngeal nerve palsy and hypoparathyroidism after thyroid surgery.

OBJECTIVES: To evaluate the incidence and risk factors of recurrent laryngeal nerve palsy and hypoparathyroidism following thyroidectomy. DESIGN: Retrospective case-control study. SETTING: Tertiary clinic. PARTICIPANTS: From September 1990 to September 2005, 3250 consecutive patients who had a thyroidectomy for treatment of various thyroid diseases. MAIN OUTCOME MEASURES: The rates of nerve palsy and hypoparathyroidism were evaluated based on thyroid pathology, the choice of operative procedure, whether the nerve was identified, and the experience of the surgeon. RESULTS: Overall, the rate of nerve palsy was 1.8% and that of hypoparathyroidism was 6.6%. On univariate analysis the rates of complications were siginificantly higher in the patients who had an extended thyroidectomy, identification of the recurrent laryngeal nerve during surgery, repeat surgery and patients older than 50 years of age. Complications were no commoner in operations performed by trainees under supervision than experienced surgeons. On multivariate analysis extended thyroidectomy had a 12 fold (95% CI 1.7, 92) increased risk of nerve palsy. Repeat surgery had a 3 fold (95% CI 2.1, 4.7) increased risk of postoperative hypoparathyroidism. CONCLUSION: Extentended thyroidectomy and repeat surgery had a significant effect on the incidence of recurrent laryngeal nerve palsy and postoperative hyperparathyroidism respectively following thyroid surgery.

The comparison of laparoscopic and open ventral hernia repairs: a prospective randomized study.

BACKGROUND: The laparoscopic approach has emerged in the search for a surgical technique to decrease the morbidity associated with conventional repair of ventral hernias. In this study we aimed to compare the results of our open and laparoscopic ventral hernia repairs prospectively. METHODS: Between January 2001 and October 2005, a total of 46 patients diagnosed with ventral hernias (primary and incisional) who were admitted to our surgical unit and accepted to be included in this study group were examined. All patients were divided into laparoscopic repair (n = 23) and open repair (n = 23) subgroups in a randomized fashion. The patients' demographic characteristics, operation times, body mass indices, sizes of fascial defects, hernia locations, durations of hospital stay, presence and degrees of postoperative pain, and postoperative minor and major complications were analysed and compared. All the data were expressed as means +/- SDs. Chi-square and Wilcoxon tests were used for statistical analysis, and P < 0.05 was accepted as a significant statistical value (SPSS 11.0 for Windows). RESULTS: The demographic characteristics of both groups were similar. Women predominated, especially in the laparoscopy group (P < 0.05). The comparison of the results revealed that the major advantage of laparoscopy was the shortened postoperative hospital stay and the reduced incidence of mesh infection (P < 0.05, P < 0.05). On the other hand, operation time was significantly longer in the laparoscopy group (P < 0.05). The major complications encountered in the laparoscopy group were ileus and a missed enterotomy. The most frequent minor complication was seroma, which was significantly more frequent in the laparoscopy group (P < 0.05). Postoperative pain assessment revealed similar results in both groups (P > 0.05). CONCLUSIONS: The laparoscopic approach appears to be as effective as open repairs in the treatment of ventral hernias. Advanced surgical skill, laparoscopic experience and high technology are mandatory factors for successful ventral hernia repair.

Gamma probe-guided surgery for revision thyroidectomy: in comparison with conventional technique.

Reoperative thyroid surgery may be required in patients who undergo any procedure less than total or near total thyroidectomy. The aim of this study was to investigate advantages of gamma-probe guided revision thyroidectomy (GGRT) over conventional revision thyroidectomy (CRT) in patients with differentiated thyroid carcinoma (DTC). GGRT was assessed according to the TSH values, complication rates and the incidence of carcinoma in residual thyroid tissue. In this randomised prospective clinical trial, 25 patients with differentiated thyroid carcinoma who had previously undergone surgery for benign multinodular goiter were included in the study. GGRT was performed in 11 (44%) patients (Group 1) and CRT in 14 (65%) (Group 2). The intraoperative mean ratio of thyroid activity to background activity (T/B) was detected as 5.1 +/- 1.4 and the mean ratio of thyroid bed activity to background activity after excision (Tbed/B) was 1.3 +/- 0.3, (p < 0.01). Although the incidence of carcinoma in residual thyroid tissue was higher in group 1 (4/11) in comparison to group 2 (1/14), it was not statistically significant. The elevation of the TSH concentration at the first post-operative month was significantly higher in group 1 in comparison with group 2 (18 +/- 25 5 +/- 3 mlU/l), (p < 0.02). These results indicate that intraoperative gamma probe application may be beneficial to detect and remove residual thyroid tissue in revision thyroidectomy.

Breast hamartoma: a case report.

Breast hamartoma is a benign and rare tumour consisting of glandular fat and fibrous tissue. A 36-year old woman was admitted to our clinic, complaining of a mass in her right breast since two months. Ultrasonographic and mammographic examinations revealed a 10 cm mass diagnosed as fibroadenolipoma. Total excision of the mass was performed without any complication. Histopathological examination revealed fibroadenomatous hamartoma.

Appendicitis in incarcerated femoral hernia.

BACKGROUND: Femoral hernia can rarely present with the content of appendicitis. We report on an elderly female who was admitted to our emergency department with a painful groin mass. METHODS: An 85-year-old woman presented with a 7-day history of right groin pain and swelling. She also had complaints of nausea, vomiting, and right lower quadrant abdominal pain. Physical examination revealed a right groin mass in the femoral region, which was painful on examination. Abdominal examination ended with normal findings except bilateral lower quadrant tenderness. Ultrasonographic examination revealed a hernia sac containing suspected aperistaltic bowel segment with edematous wall. RESULTS: The patient underwent surgery. During exploration of the right groin region, a strangulated femoral hernia sac containing appendicitis was detected. CONCLUSION: Surgeons should be aware of the existence of this kind of atypical presentation of appendicitis.

Do vitamin E and selenium have beneficial effects on trinitrobenzenesulfonic acid-induced experimental colitis.

The balance between oxidant and antioxidant systems may be important in the pathogenesis and/or maintenance of tissue injury in ulcerative colitis. This study was designed to evaluate the effects of vitamin E and selenium supplementations on tissue injury and oxidative stress in trinitrobenzenesulfonic acid-induced ulcerative colitis in rats. Trinitrobenzenesulfonic acid administration severely changed the normal architecture of the colon and significantly increased the levels of malondialdehyde, protein carbonyl, and xantine oxidase (P < 0.001) in the colon homogenates of these rats. Supplementation of selenium to the trinitrobenzenesulfonic acid-treated rats neither improved the histopathological findings nor decreased the levels of malondialdehyde and protein carbonyl. Vitamin E supplementation reduced the levels of malondialdehyde and protein carbonyl but did not improve the colonic lesions. Supplementation of vitamin E + selenium significantly reduced both the severity of colonic lesions and the levels of malondialdehyde and protein carbonyl. In conclusion, we suggest that antioxidants and specific micronutrients may have beneficial effects in the treatment of ulcerative colitis.

Effects of pneumoperitoneum created through CO2 insufflation and parameters of mechanical ventilation (PEEP application) on systemic dissemination of intraabdominal infections.

BACKGROUND: To examine whether CO2 pneumoperitoneum and positive end expiratory pressure (PEEP) in mechanical ventilation affect the systemic spread of intraabdominal infection. METHODS: Sprague-Dawley male rats weighing 200-300 g were allocated to three groups of 12 animals in each. All rats received mechanical ventilation under general anesthesia. An intraabdominal infection model was established by injecting with 1 ml of Escherichia coli (10(9) CFU/mL) intraperitoneally. Half of the animals in each group were exposed to PEEP (10 cmH2O). CO2 pneumoperitoneum at 13 mmHg was applied to the rats in group 1. Group 2 rats underwent laparotomy. Group 3 served as controls. In addition, TNF-alpha serum levels were measured at baseline and 3 h. A peritoneal specimen for histopathological examination were obtained after the rats were killed at the end of 3 h. For the assessment of data, descriptive statistical methods (mean, standard deviation) as well as Friedman test for repeated measurements in multiple groups, Kruskal-Wallis test for intergroup comparisons, Dunn's multiple comparison test for subgroup comparisons, Mann-Whitney U test for comparisons between paired groups, chi-square and Fisher's exact test for comparison of qualitative data, and McNemar's test for assessment of changes in group variables over time were used. The results were considered statistically significant if probability (p) values were <0.05. RESULTS: Grades of peritonitis in group 1 and 2 were seen to differ nonsignificantly. In group 1, baseline blood cultures were not included in the assessment between the subgroups that received PEEP or not, as there was no growth in any of the subgroups. No significant difference was detected between growth in blood cultures at 1, 2, and 3 h ( p > 0.05). Application of PEEP in subgroups did not alter the blood culture results ( p > 0.05). Significant differences were seen between the initial and final TNF-alpha values of groups (KW: 18.94, p < 0.0001). The values in control group were observed to be significantly lower than those in groups 1 and 2 ( p < 0.01, p < 0.001). Bacteremia and systemic spread of the intraabdominal infection did appear to be different according to the PEEP application. After the assessments of ventilation parameters in our study, significant reductions in pH and HCO3 levels were detected in group 1 as a result of pneumoperitoneum, which was consistent with the literature. There is a significant difference between pH values at baseline and at the end of 1 h because of pneumoperitoneum (Fr: 10.01, p < 0.05). PEEP application in subgroups did not create significant differences in terms of respiratory parameters ( p < 0.01). CONCLUSION: No difference was found between the applications of CO2 pneumoperitoneum and laparotomy with regard to bacteremia and infection-induced peritonitis. It was determined that pneumoperitoneum along with PEEP application had neither a positive nor a negative impact on intraabdominal infection.

Color Doppler sonography in cold thyroid nodules for malignancy prediction.

The aim of the present study was to assess the usefulness of thyroid nuclear medicine studies, fine needle aspiration biopsy (FNAB) and color doppler sonography in the evaluation of thyroid nodules. Our study group consists of 81 patients with a solitary hypoactive thyroid nodule or with multinodular goiter having dominant nodule. Perinodular and intranodular blood flow, diameter of inferior thyroid artery and its flow velocity were the parameters measured by color doppler sonography. Also estimation of arterio-venous (A-V) shunt formation was another important parameter indicating the angioneogenesis. Results were not significant to distinguish the malignant and benign thyroid nodules (p > 0.05); 66% (n: 14) of 21 patients who had A-V shunt, had the final diagnosis of thyroid carcinoma. These data revealed sensitivity, specificity, negative and positive predictive values of color doppler sonography in carcinoma diagnosis among the patients with solitary hypoactive nodules or multinodular goiters having dominant nodule, as corresponding: 66%, 100%, 83% and 100%. In conclusion, arterio-venous shunt detected with color doppler sonography was the only parameter having high predictive value for malignancy. Recent studies on this topic imply that color doppler sonography will take place in algorithm of thyroid nodule evaluation.

Dieulafoy's lesion of esophagus.

Dieulafoy's lesion is a rare arterial malformation that can cause massive gastrointestinal hemorrhage. The lesion occurs most commonly in the proximal stomach. The esophagus is not a common location for this lesion. We present the case of a 25-year-old woman who was admitted to our emergency unit with the findings of hematemesis and melena. Early upper gastrointestinal endoscopic examination revealed a Dieulafoy's lesion, which was located in the distal esophagus. Endoscopic band ligation stopped the bleeding successfully. The patient was discharged 3 days after the band ligation without any complications. Dieulafoy's lesion may cause severe, life-threatening bleeding. Endoscopic diagnosis can be difficult because of the small size and obscure location of the lesion. An abnormally dilated artery that penetrates through the mucosa constitutes the etiology. Endoscopy plays an important role in the diagnosis and treatment of this pathology. Despite widespread awareness of this entity, it may present a real challenge for the endoscopist due to the small size and hidden location of the lesion. The endoscopic approach to occult gastrointestinal bleeding for the diagnosis of vascular malformations is accepted as a quick and safe diagnostic method.