Akif Enes Arikan

Effects of Ankaferd on Anastomotic Healing of Colon

ABSTRACT Background: Ankaferd (Ankaferd blood stopper®, ABS) is a recently developed topical hemostatic agent. ABS is a standardized mixture of the plants Thymus vulgaris, Glycyrrhiza glabra, Vitis vinifera, Alpinia officinarum, and Urtica dioica. Through its effects on the endothelium, blood cells, angiogenesis, cellular proliferation, vascular dynamics, and cell mediators; Ankaferd plays a part in inflammation and hemostasis processes. The aim of this experimental study is to assess the effects of ABS on the left colonic anastomoses under normal, septic, and ischemic conditions. Methods: Forty-eight Wistar Albino male rats were divided into six weight-matched equal groups: A, anastomosis in normal condition (n = 8); AA, anastomosis with ABS in normal condition (n = 8); AS, anastomosis in septic condition (n = 8); AAS, anastomosis with ABS in septic condition (n = 8); AI, anastomosis in ischemic condition (n = 8); and AAI, anastomosis with ABS in ischemic condition (n = 8). Blood and tissue samples were taken for the histopathological and biochemical studies after the anastomotic bursting pressures were measured. Results: Higher hydroxyproline levels (p = .048) and angiogenesis (p = .038) were observed in the sepsis-induced rats compared to the control group. The inflammatory activity, fibrosis, and granulation were comparable in all experimental groups. Ankaferd improved the angiogenesis under septic conditions (AAS) when compared to the control group (AI; p = .038). Conclusions: ABS may support anastomotic healing in septic conditions. Topical ABS application controlling the mucosal bleeding at the cut ends of the colon may also improve the anastomotic wound healing by means of increasing mechanical strength and positively affecting angiogenesis. Further studies shall focus on the clinical importance of those findings.

Effect of energy-based devices on voice quality after total thyroidectomy

Voice alteration is an important complication of thyroid surgery and is closely related to patients’ quality of life. There are no studies analyzing effect of energy-based devices (EBD) on voice quality (VQ). Aim of this prospective study is to evaluate impact of sutureless total thyroidectomy performed with EBDs on objective voice parameters of patients without recurrent laryngeal nerve (RLN) and/or external branch of superior laryngeal nerve (EBSLN) injury. Sixty patients underwent total thyroidectomy with meticulous dissection of EBSLN. Patients were assigned to Group L (Ligasure™), Group H (Harmonic), or Group C (Conventional) through random ballot. For analysis of alteration in VQ, digital videolaryngostroboscopy (VLS), voice handicap index (VHI), multidimensional voice program (MDVP), and electroglottography (EGG) were used. VLS was performed by 70°-angled indirect laryngoscopy and evaluation was standardized by VLS scale and laryngeal function scoring. This study is registered on clinicaltrials.gov with number NCT01865006. Forty eight patients were female. There was no difference on demographic data. On post-operative laryngoscopic examination, none of the patients had vocal fold palsy. When mean VHI scores at post-operative 1st week and 2nd month were compared to pre-operative values for each groups, groups L and H demonstrated a significant increase in VHI in the early post-operative evaluation, while there was no significant increase for group C. No significant increase was seen in late post-operative period compared to pre-operative period for any groups. In the early post-operative period, VQ is better with the conventional technique than EBDs; however, in late post-operative period, VQ is detected better in EBDs (especially in Group L) than the conventional technique, but no statistical difference was observed.

Bupivacaine application reduces post thyroidectomy pain: Cerrahpasa experience

BACKGROUND We aimed to evaluate the impact of bupivacaine administration into the surgical field after total thyroidectomy on post-operative pain and analgesic requirement with a double-blind, prospective, clinical and randomized study. METHODS The study was performed between 2010 and 2011. Pain assessment was performed with the visual analog score (VAS). Patients were pre-operatively, randomly divided into two groups to receive either bupivacaine or saline. One group received a 10-mL of bupivacaine solution while the other group was treated with the same volume of 0.9% NaCl through the drain after completion of total thyroidectomy procedure. All patients were anesthetized and operated with the same anesthesia and surgical team. RESULTS Ninety-one patients (20 males) were included in the study. No patient dropped out of the study during the procedures. No mortality was seen. The VAS scores were significantly lower in the bupivacaine administered group at post-operative minute 30 (3.7±3.2 vs. 5±2.9; P=0.03), hour one (3.04±2.4 vs. 4.2±2.8; P=0.04), and hour eight (1.8±2.04 vs. 3.2±2.1; P=0.005). Thirteen patients required analgesia during their hospital stay in the bupivacaine group while this number was twenty-two in the saline group (P=0.005). CONCLUSIONS Local bupivacaine administration into the surgical field after total thyroidectomy reduces pain and analgesic requirement during the hospital stay.

Is it necessary to perform prophylactic cholecystectomy for all symptomatic gallbladder polyps diagnosed with ultrasound

OBJECTIVE The main aim of this study is to determine the necessity of cholecystectomy in patients with ultrasound diagnosed symptomatic polypoid lesions of the gallbladder. MATERIAL AND METHODS The data of 82 patients with polypoid lesions of the gallbladder who had cholecystectomy between 2000 and 2012 were analyzed retrospectively with preoperative ultrasound and histopathology results. RESULTS The mean age was 48.05±11.18 years (range 25-74 years). All patients underwent preoperative ultrasound examination. Eighteen (22%) of the 82 patients were asymptomatic; their polypoid lesions of the gallbladder were detected with ultrasound during a check-up or other reasons. In 45 (55%) of cases pathology reported no polypoid lesions of the gallbladder. Right upper quadrant or epigastric pain was the most common symptom (41.46%) that led to hepatobiliary ultrasound, the other symptom was dyspepsia (36.59%). On preoperative ultrasound evaluation, 22 patients had multiple polyps, and 9 of these 22 patients had at least 3 polyps. CONCLUSION There is an inaccuracy of ultrasound to detect polypoid lesions of the gallbladder. After diagnosing polypoid lesions of the gallbladder by using standard ultrasound, further pre-operative diagnostic tests are needed to help discriminating benign lesions from malignant ones, which may prevent unnecessary surgery regardless of symptoms.

A rare case of non-surgical vocal cord paralysis: Vocal cord hematoma

Although vocal cord paralysis (VCP) following thyroidectomy is primarily associated with surgical trauma, it is not the sole etiology. Vocal cord paralysis following thyroidectomy can be caused by a vocal cord hematoma with an incidence of 1.4% due to direct injury during orotracheal intubation. In this article, we present a case of VCP caused by vocal cord hematoma. A 32-year-old male patient who has been receiving propylthiouracil treatment for toxic multinodular goiter since 10 years was admitted to our hospital to be operated because of persisting complaints. The patient was hospitalized for sutureless thyroidectomy after he became euthyroid. Preoperative fiberoptic laryngoscopy performed by the ear, nose, and throat department revealed bilaterally motile vocal folds and a completely open airway. Patient underwent sutureless total thyroidectomy with a vessel sealing device (LigasureTM LF1212, Covidien, CO), and a minivac drainage system was placed in the thyroid lodge. On the morning of the first postoperative day, 50 mL of serosanguinous fluid was drained. The patients voice was normal, and there was no ecchymosis. Postoperative fiberoptic laryngoscopy revealed a hematoma near the right vocal fold and paralysis of the right vocal fold; however, the airway was open. It should be kept in mind that VCP is not solely due to surgery but can also result from intubation, as observed in this case.

The effect of thyroid gland weight on early complications in total thyroidectomy: Cerrahpasa experience

In this study we aimed to show whether thyroid gland weight has an effect on early and late complications in thyroidectomy done in an experienced center. 721 patients in Istanbul University Cerrahpaşa Medical Faculty General Surgery Department, in whom sutureless total thyroidectomy with vessel sealing devices were done, were retrospectively evaluated from January 2012 to December 2015. Reoperations, plonjan goiter, patients with capsule invasion and lymph node metastases who were operated due to thyroid cancer were excluded in the study. Demographic data, operation indications, operation duration, incision length, postoperative complications of the patients were recorded. The complications were recurrent nerve paralysis, hypocalcemia, hematoma and wound infection. These complications were compared according to the thyroid gland weight separately. Also, each complication group was divided into four groups, according to thyroid gland weight, as below 30 grams, 30-60 grams, 60-90 grams and heavier than 90 grams. The effect of thyroid gland weight on postoperative complications was evaluated. 22.2 % of the patients (n=160) were males and 77.8 % (n=561) were females. Mean age of the patients was 48,58±SD (18-85) years. Recurrent laryngeal nerve paralysis was seen in 5.68% (n=82) of the 721 patients, to whom vocal cord examination was done. Hypocalcemia symptoms in 5.54% of the patients (n=40), wound infections in 0.97% (n=7) of the patients and hemorrhage in 0.69% (n=5) of the patients were seen. Mean thyroid gland weight in patients with thyroid surgery complication was 56.1±SD (15-315) grams, while it was 56,94±SD (20-795) grams for noncomplicated thyroid surgery. The complications were divided into four groups. When these groups were compared according to thyroid gland weight separately, it was seen that thyroid gland weight does not affect early complications (p >0,5). Total thyroidectomy, when done in an experienced center, is the suggested surgery, which has 1% complication rate and the least recurrence rate. In our study, there was no statistically significant difference. This may be due to lighter thyroid gland weights in our study.

Skin metastasis on the neck: an unusual presentation of recurrence of papillary thyroid carcinoma

Skin metastasis of papillary thyroid carcinoma (PTC) is rare. Here, two cases of skin metastases of PTC are presented. Both of the patients were females, one is 83 and the other is 65 years old. The patients were admitted to the hospital with a movable skin lesion on anterior neck region. Free T3 and T4 levels were in normal levels and TSH levels were low in both patients. The 83-year-old patient underwent total thyroidectomy due to papillary thyroid cancer and received 131I ablation therapy and then thyroid suppression therapy. After the surgery, the patient lived without evidence of disease for 3 years and then skin metastasis occurred. The 65-year-old patient had a total thyroidectomy 5 years ago due to PTC then neck dissection due to metastasis 3 years later and then received 131I ablation therapy. Thyroid ultrasonography of both patients showed hypoechoic nodules with central vascularization. In the histological examination of both patients, cystic lesions filled with papillary structures were seen. Fine needle aspiration biopsy (FNAB) taken from both patients were papillary carcinoma with solid trabecular pattern. PTC tends to metastasize to regional lymph nodes but distant metastasis is rare. When distant metastasis develops, prognosis of the disease is poor. Therefore, skin metastasis of papillary thyroid cancer is a poor prognostic factor. If the patient does not have a thyroid malignancy history, diagnosis of PTC metastatic to the skin may be difficult since primary skin tumors such as apocrine tumors have similar histopathological features. However, in the presented cases since there was a PTC history, the diagnosis was easier with the help of histopathological examination. Skin metastasis of PTC should be kept in mind when differential diagnosis of atypical skin lesions are made especially in the patients with thyroid malignancy history.

Silk suture reaction in thyroid surgery

Silk suture reaction (i.e., a benign granulomatous inflammatory foreign body reaction) is a rare complication of thyroid surgery. Here, two cases of post-thyroidectomy suture reaction are presented. Both of the patients were female, one is 48 and the other is 34 years old. The patients were presented with neck swelling and leakage of serous fluid from the Kochers incision. Both patients had normal free T4, free T3, and TSH values. The 48-year-old female patient had a right subtotal and left near-total thyroidectomy 6 years ago and the other had bilateral total thyroidectomy 6 years ago. In the physical examination a mobile, painless, red, swelling was palpated in front of neck. In the ultrasound of both patients, a heterogeneous nodule with hypoechoic rim was seen, however, in scintigraphy no radiopharmaceutical involvement was observed in thyroid region. Due to suspicion of thyroid malignancy, a fine needle aspiration biopsy was performed and foreign body reaction was revealed cytologically. A suture reaction can vary from an erythematous swelling to chronic granulomatous reaction. The time interval between the operation and formation of suture reaction was 6 years in both of the cases thus these patients were considered as chronic patients. Foreign body reaction diagnosis was confirmed with fine needle aspiration biopsy. It is important to diagnose these chronic inflammation cases since these cases can mimic recurrence in thyroid malignancies. A post-thyroidectomy suture reaction is diagnosed cytologically with fine needle aspiration biopsy and by surgical removal of suture, this chronic inflammatory reaction can be cured.

Single port thoracoscopic treatment of thoracic duct injury after thyroidectomy with neck dissection

Chylous leakage is a complication of thyroidectomy accompanied by bilateral neck dissection with incidence of 0.5-6.2%. A 51-year-old female patient underwent total thyroidectomy, bilateral and central neck dissection for papillary thyroid carcinoma. In post-operative 4th day, left sided chylous leakage was observed as 1,500 cc/day through neck drain. Leakage did not cease after 1-month conservative treatment so single port thoracoscopic intervention was performed. Under general anesthesia, patient was placed in left lateral decubitus position. An Alexis® retractor was placed through sixth intercostal space. Thoracic cavity was visualized with 30º scope. Posteroinferior edge of lower lobe was retracted superior posteriorly with a Foerster clamp to display inferior pulmonary ligament, which was then divided with electrocautery. Posterior mediastinal pleura between azygous vein and chest wall was incised to mobilize the vein. After that, mediastinal pleura between azygous vein and esophagus was cut longitudinally and esophagus was retracted anteriorly to dissect towards aorta. By dissection, thoracic duct was revealed as a thin tubular structure with occasional peristalsis. After isolation of the duct, it was clipped using Hem-o-lok®. Finally, fibrin sealant was applied to decrease risk of recurrence. One chest tube was placed to ensure adequate drainage of thoracic cavity and complete re-expansion of lung. Neck drain and chest tube was extracted in postoperative second and fourth day respectively and patient was discharged at 8th day. Single port thoracoscopy is a safe choice for treatment of chylous leakages due to cervical ductus thoracicus injury with faster recovery.

Sentinel lymph node biopsy under fluorescent indocyanin green guidance: Initial experience

Amac: Meme kanserinde sentinel lenf nodu biyopsisi, mavi boya, radyoizotop yontemi veya her iki yontem kom- bine edilerek yapilabilmektedir. Indosiyanin yesili kullanilarak yapilan floresan goruntuleme ise yeni tanimlanan bir metottur. Bu calisma floresan isikla goruntulenen indosiyanin yesili rehberliginde yapilan sentinel lenf nodu biyopsisinin uygulanabilirligini degerlendirmektedir. Gerec ve Yontemler: Goruntuler icin kizil otesini gosteren IC-VIEW sistemi (Pulsion Medical Systems AG, Munih, Almanya) kullanildi. Sentinel lenf nodlarinin goruntulenmesi icin 2 mL indosiyanin yesili enjeksiyonu yapildi. Enjek- siyon sonrasi es zamanli goruntu ile subkutan lenfatikler takip edilerek sentinel lenf nodlarina ulasildi. Floresan isik rehberliginde sentinel lenf nodlari eksize edilerek histopatolojik inceleme yapildi. Sentinel lenf nodunda metastaz saptanan hastalara aksiller diseksiyon yapildi. Bulgular: Calismada meme kanseri nedeniyle sentinel lenf nodu biyopsisi yapilan dort hasta yer aldi. Indosiyanin yesili ile tum hastalarda sentinel lenf nodlari goruntulendi. Indosiyanin yesili ile eksize edilen ortanca sentinel lenf nodu sayisi 2 (2-3) olarak bulundu. Lenf nodu metastazi saptanan iki hastaya aksiller diseksiyon yapildi. Aksiller di- seksiyon yapilan hastalarin sentinel disindaki lenf nodlarinda metastaz gorulmedi. Ameliyat sirasinda ve sonrasinda metoda bagli komplikasyon gorulmedi. Sonuc: Sinirli tecrubemize gore es zamanli goruntuleme avantajina sahip olan indosiyanin yesili rehberliginde yapi- lan sentinel lenf nodu biyopsisi teknik olarak uygulanabilir gorulmektedir. Anahtar Kelimeler: Floresan isik, indosiyanin yesili, sentinel lenf nodu biyopsisi Objective: Sentinel lymph node biopsy can be applied by using either blue dye or radionuclide method or both in breast cancer. Fluorescent imaging with indocyanine green is a new defined method. This study evaluates the applicability of sentinel lymph node biopsy via fluorescent indocyanine green. Material and Methods: IC-VIEW (Pulsion Medical Systems AG, Munich, Germany) infrared visualization system was used for imaging. Two mL of indocyanine green was injected to visualize sentinel lymph nodes. After injection, subcutaneous lymphatics were traced and sentinel lymph nodes were found with simultaneous imaging. Sentinel lymph nodes were excised under fluorescent light guidance, and excised lymph nodes were examined histopatholo- gically. Patients with sentinel lymph node metastases underwent axillary dissection. Results: Four patients with sentinel lymph node biopsy due to breast cancer were included in the study. Sentinel lymph nodes were visualized with indocyanine green in all patients. The median number of excised sentinel lymph node was 2 (2-3). Two patients with lymph node metastasis underwent axillary dissection. No metastasis was detec- ted in lymph nodes other than the sentinel nodes in patients with axillary dissection. There was no complication during and after the operation related to the method. ABSTRACT Ulus Cerrahi Derg 2016; 32: 50-53OBJECTIVE Sentinel lymph node biopsy can be applied by using either blue dye or radionuclide method or both in breast cancer. Fluorescent imaging with indocyanine green is a new defined method. This study evaluates the applicability of sentinel lymph node biopsy via fluorescent indocyanine green. MATERIAL AND METHODS IC-VIEW (Pulsion Medical Systems AG, Munich, Germany) infrared visualization system was used for imaging. Two mL of indocyanine green was injected to visualize sentinel lymph nodes. After injection, subcutaneous lymphatics were traced and sentinel lymph nodes were found with simultaneous imaging. Sentinel lymph nodes were excised under fluorescent light guidance, and excised lymph nodes were examined histopathologically. Patients with sentinel lymph node metastases underwent axillary dissection. RESULTS Four patients with sentinel lymph node biopsy due to breast cancer were included in the study. Sentinel lymph nodes were visualized with indocyanine green in all patients. The median number of excised sentinel lymph node was 2 (2-3). Two patients with lymph node metastasis underwent axillary dissection. No metastasis was detected in lymph nodes other than the sentinel nodes in patients with axillary dissection. There was no complication during and after the operation related to the method. CONCLUSION According to our limited experience, sentinel lymph node biopsy under fluorescent indocyanine green guidance, which has an advantage of simultaneous visualization, is technically feasible.