Alp Bozbora

Evaluation of the Cardiovascular Risk in Patients with Subclinical Cushing Syndrome Before and After Surgery

BackgroundThe widespread use of ultrasound, computerized tomography, and magnetic resonance imaging has led to an increase in the number of incidental adrenal masses identified. Asymptomatic incidentally discovered adrenal masses may indicate that subclinical Cushing syndrome (SCS) is not uncommon. We aimed to evaluate the cardiovascular risk of patients with SCS before and after surgery.MethodsAn autonomous cortisol-producing tumor was detected in 11 of 94 patients with adrenal incidentaloma between 1995 and 2005. Twenty-eight patients suffering from classical Cushing syndrome (CS) associated with unilateral adrenocortical adenoma, who were treated at our department in the same period, served as a control group. Cardiovascular risk factors such as blood pressure, body mass index, and lipid profile were evaluated before and 1 year after surgery.ResultsThe frequency of hypertension (61% versus 63%), obesity (46% versus 55%), diabetes mellitus (50% versus 36%), hypercholesterolemia (39% versus 36%), and low HDL cholesterol (28% versus 36%) were not significantly different between CS and SCS patients, respectively. Adverse cardiovascular risk profile improved 1 year after adrenalectomy in both groups, although the changes were not significant with respect to body mass index, frequency of diabetes, and hyperlipidemia in SCS patients. But frequency of systolic/diastolic hypertension decreased significantly in this group.ConclusionsThese findings indicate that the increased incidence of cardiovascular risk factors commonly observed in classical CS, is also present in SCS. Unilateral adrenalectomy does not always lead to significant improvements in cardiovascular risk profile in SCS.

A Rare Complication of Adjustable Gastric Banding:Wernicke's Encephalopathy

Background:Wernickesencephalopathy is an uncommon complication seen after morbid obesity surgery. Neurological and cardiac symptoms can occur. Early and adequate replacement of thiamin is crucial. Methods: A patient, who was operated by adjustable silicone gastric banding had severe vomiting 1 week after the operation. Physical examination showed no abnormalities except neurological signs consisting of ataxia, disorientation and diplopia. All radiological and biochemical parameters were in the normal range. Result: After replacement of vitamin B1 (thiamin) intravenously 20 mg twice daily, all the neurological signs regressed day by day. Oral thiamin pills have been continued. Conclusion: Wernickes encephalopathy which occurs as a result of thiamin deficiency is a rare complication that has serious morbidity with rapidly progressing neurologic symptoms, and must be treated immediately. Surgeons who treat morbidly obese patients must follow the metabolic and nutritional status of the patient.

Impact of Gland Morphology and Concomitant Thyroid Nodules on Preoperative Localization of Parathyroid Adenomas

Objectives: Primary hyperparathyroidism (pHPT) is a common endocrine disease. The aim of this study was to assess the effect of the presence of thyroid nodules, adenoma weight, and ectopic localization on the sensitivity of different imaging studies in patients with hyperparathyroidism.

The impact of age, vitamin D3 level, and incidental parathyroidectomy on postoperative hypocalcemia after total or near total thyroidectomy

BACKGROUND Hypocalcemia caused by transient or definitive hypoparathyroidism is the most frequent complication after thyroidectomy. We aimed to compare the impact of incidental parathyroidectomy and serum vitamin D(3) level on postoperative hypocalcemia after total thyroidectomy (TT) or near total thyroidectomy (NTT). PATIENTS Two hundred consecutive patients with nontoxic multinodular goiter treated by TT and NTT were included prospectively in the present study. Group 1 (n = 49) consisted of patients with a postoperative serum calcium level < or =8 mg/dL, and group 2 (n = 151) had a postoperative serum calcium level greater than 8 mg/dL. Patients were evaluated according to age, preoperative serum 25-hydroxy vitamin D (25-OHD) levels, postoperative serum calcium levels, incidental parathyroidectomy, and the type of thyroidectomy. RESULTS Patients in group 1 (n = 49) were hypocalcemic, whereas patients in group 2 (n = 151) were normocalcemic. Preoperative serum 25-OHD levels in group 1 were significantly lower than in group 2 (P < .001). The incidence of hypoparathyroidism was significantly higher following TT (13.5%) than following NTT (2.5%) (P < .05). The risk for postoperative hypocalcemia was increased 25-fold for patients older than 50 years, 28-fold for patients with a preoperative serum 25-OHD level less than 15 ng/mL, and 71-fold for patients who underwent TT. Incidental parathyroidectomy did not have an impact on postoperative hypocalcemia. The highest risk of postoperative hypocalcemia was found in the patients with all of the above variables. CONCLUSIONS Age, preoperative low serum 25-OHD, and TT are significantly associated with postoperative hypocalcemia. Patients with advanced age and low preoperative serum 25-OHD levels should be placed on calcium or vitamin D supplementation after TT to avoid postoperative hypocalcemia and decrease hospital stay.

Correlations between Vitamin D Status and Biochemical/Clinical and Pathological Parameters in Primary Hyperparathyroidism

BackgroundTo determine the prevalence of vitamin D deficiency and the effects of vitamin D status on parathyroid adenoma weight, clinical and biochemical indices in patients with primary hyperparathyroidism (pHPT) were studied.MethodsEighty patients with pHPT who underwent surgical treatment and in whom the presence of parathyroid adenoma were confirmed histopathologically were studied retrospectively from recorded data files. Patients were divided into three groups: patients with 25-hydroxyvitamin D (25-OHD) concentrations < 15 ng/ml (group 1, n = 44), patients with 25-OHD concentrations > 15–25 ng/ml (group 2, n = 9), and patients with 25-OHD concentrations > 26 ng/ml (group 3, n = 27). Serum calcium, phosphate, alkaline phosphatase, creatinine, and albumin levels and urinary calcium excretion were determined by auto-analyzer. Plasma 25-OHD and parathyroid hormone (PTH) levels were determined by immunoradiometric assay using commercially available kits.ResultsNo statistically significant differences were observed with respect to serum calcium, phosphorus, albumin, and creatinine concentrations between these groups. Serum PTH, alkaline phosphatase concentrations, urinary calcium excretion, parathyroid adenoma weight, and postoperative sixth month PTH concentrations were significantly higher in group 1 patients than in group 2 and group 3 patients. Significant correlations were observed between parathyroid adenoma weight and serum 25-OHD concentrations (r = −0.348, P = 0.020); parathyroid adenoma weight and urinary calcium excretion (r = 0.348, P = 0.021). Multiple regression analysis revealed that parathyroid adenoma weight, serum 25-OHD, and preoperative PTH concentrations correlated independently and significantly with postoperative sixth month PTH concentrations.ConclusionsVitamin D deficiency leads to more severe bone disease, increased parathyroid tumor growth, and delayed postoperative recovery of parathyroid function in patients with primary hyperparathyroidism.

Surgical Management of Substernal Goiters: Clinical Experience of 170 Cases

PurposeTo discuss the presentation, diagnosis, treatment, histopathological findings, and complications of patients who underwent thyroidectomy for substernal goiter in our surgical clinic.MethodsWe retrospectively analyzed 170 patients with substernal goiters among 2650 patients undergoing surgical treatment for various thyroid diseases between 1990 and 2003. We evaluated the clinical data, preoperative diagnostic findings, surgical treatments, histopathological results, and postoperative complications.ResultsThe most common symptoms were a cervical mass (88%) and dyspnea (35%), but 26% of the patients were asymptomatic. Chest radiography provided the first evidence of a substernal goiter in 77% of the patients. We performed total or near total thyroidectomy and operated through a cervical incision in all but 12 of the patients. There was no operative mortality but 12 (7%) patients suffered temporary hypoparathyroidism and 4 suffered transient vocal cord paralysis (2%). Malignancy was diagnosed by histopathological examination in 22 (13%) patients.ConclusionWe think that the diagnosis of a substernal goiter is an indication for thyroidectomy, which is associated with very low postoperative morbidity.

The use of LigaSure in patients with hyperthyroidism

BackgroundThyroidectomies of hyperthyroidic patients are known to be more blood-spattered than the operations performed for euthyroid nodular diseases and require careful hemostasis. Our purpose was to evaluate the efficacy of the use of LigaSure in patients with hyperthyroidism.Materials and methodsBetween January 2004 and October 2005, 100 patients underwent total or near-total thyroidectomy. Bipolar vessel ligation system (LigaSure) was the choice of modality for hemostasis in half of these patients, and the conventional suture ligation technique was used for the rest. The following data were evaluated non-randomized and prospectively in this study: patients demographics, thyroid pathology, operative duration, presence of complications, and the duration of the hospital stay. Comparisons of the data were evaluated by the Wilcoxon and chi-square tests.ResultsAmong the patients of the LigaSure group, 14 patients were detected to have hyperthyroidism (seven patients with Graves’ disease and another seven patients with multinodular toxic goiter), while 36 patients were found to be euthyroidic. The durations of the operation time and of the hospital stay of the patients in the LigaSure group were significantly lower than the conventional thyroidectomy group (p<0.05). The complication rates of the LigaSure and conventional thyroidectomy groups were 4 and 6%, respectively (p>0.05).ConclusionsThe use of LigaSure as an operative technique in the treatment of Graves’ disease and toxic goiter is a safe and effective modality that provides a shorter hospital stay and a shorter operation time as well.

The change in the principle of performing laparoscopic adrenalectomy from small to large masses

BACKGROUND Laparoscopic adrenalectomy has become the gold standard in most patients with adrenal tumors. It is unclear; however, at what size an adrenal neoplasm should be resected by means of an open or a laparoscopic approach. The aim of the present study was to compare the outcomes of laparoscopic adrenalectomy for large tumors with smaller tumors. METHODS A prospective study of patients who underwent adrenalectomy during the period 2006-2009 was undertaken. The patients were divided into 2 groups according to the tumor size. Group 1 (n=29) consisted of patients presenting tumors smaller than 5 cm in diameter; group 2 (n=31) consisted of patients with tumors larger than 5 cm in diameter. RESULTS Two of the 29 tumors in group 1 (6.8%) were malignant at final histology. However, 11 of the 31 tumors in group 2 (35.4%) were malignant. There were no significant differences between operating time and complications of groups 1 and 2. The intra-operative blood loss was significantly lower in group 1 than in group 2. CONCLUSION Laparoscopic adrenalectomy is a reasonable procedure for selected large adrenal tumors when a complete resection is technically feasible and there is no evidence of local invasion.

Adjustable Gastric Banding in a Multicenter Study in Turkey

Background: Adjustable gastric banding (AGB) is a minimally-invasive approach which allows adjustment of gastric restriction. Methods: The AGB was evaluated retrospectively in a consecutive series at 3 centers. From October 1998 to October 2001, 70 patients (49 women), mean age 34.3 years (18-59) with morbid obesity (preoperative mean BMI 45.2 kg/m2) underwent AGB The open approach was employed in the first 35 patients. Laparoscopic placement was used in the second 35 patients. Complete follow-up has been obtained in all patients. Results: Mean postoperative follow-up has been 18 months (12-39). Mean operative time was 120 minutes in the open approach and 150 minutes in the laparoscopic AGB. Mean hospital stay was 5 days after the open approach and 1.7 days after the laparoscopic surgery. The excess weight loss after 18 months was 59%. Incidence of early postoperative complications was 27.1%, including nausea and vomiting in 8 patients (5 in open approach, 3 in laparoscopic placement), wound infection in 10 patients (all 10 in open approach), and Wernickes encephalopathy in 1 patient (open approach). Incidence of late complications was 28.5%, and included band migration in 2 patients (both by laparoscopic placement), pouch dilatation in 10 patients (6 in open approach, 4 in laparoscopic placement), incisional hernias in 4 patients (all by open approach), and port infections in 4 patients (all 4 in open approach). Conclusion: AGB has been effective in achieving good weight loss to 3 years follow-up. The ability to adjust the degree of gastric restriction has enabled progressive weight loss.

Predictive factors for recurrent non-toxic goitre in an endemic region.

AIMS We aimed to determine the risk factors for recurrence and to assess the complication rate associated with surgery for benign, recurrent goitre. METHODS We studied 125 consecutive patients with recurrent goitre who underwent re-operative thyroid surgery (group one). Patients in the control group were randomly selected from those undergoing their first procedure during the same period (group two). Age, initial surgery, presence of multinodular goitre, presence of carcinoma in the resected thyroid tissue, interval between initial operation and re-operation, and complications were analysed and compared for the two groups. RESULTS The mean age (+/- standard deviation) was found to be significantly greater in group one compared with group two. The mean age at the time of primary thyroid operation was found to be significantly less in group one compared with group two. The interval between the initial and the re-operative procedures was a mean of 15.8+/-eight years. Initial surgery was conservative. Papillary thyroid carcinoma was found in 14/125 (11 per cent) of group one patients. The incidence of complications was found to be significantly higher in group one compared with group two. CONCLUSION The incidence of recurrent goitre has been directly related to conservative thyroid surgery and to the retention of large amounts of remnant tissue. To avoid recurrent goitre and possible re-operative complications, total or near-total thyroidectomy should be performed in all patients with bilateral, multinodular goitre, especially in endemic regions.