Halit Ziya Dündar

Management of hepatorenal syndrome.

Hepatorenal syndrome (HRS) is defined as development of renal dysfunction in patients with chronic liver diseases due to decreased effective arterial blood volume. It is the most severe complication of cirrhosis because of its very poor prognosis. In spite of several hypotheses and research, the pathogenesis of HRS is still poorly understood. The onset of HRS is a progressive process rather than a suddenly arising phenomenon. Since there are no specific tests for HRS diagnosis, it is diagnosed by the exclusion of other causes of acute kidney injury in cirrhotic patients. There are two types of HRS with different characteristics and prognostics. Type 1 HRS is characterized by a sudden onset acute renal failure and a rapid deterioration of other organ functions. It may develop spontaneously or be due to some precipitating factors. Type 2 HRS is characterized by slow and progressive worsening of renal functions due to cirrhosis and portal hypertension and it is accompanied by refractory ascites. The only definitive treatment for both Type 1 and Type 2 HRS is liver transplantation. The most suitable bridge treatment or treatment for patients who are not eligible for transplantation is a combination of terlipressin and albumin. For the same purpose, it is possible to try hemodialysis or renal replacement therapies in the form of continuous veno-venous hemofiltration. Artificial hepatic support systems are important for patients who do not respond to medical treatment. Transjugular intrahepatic portosystemic shunt may be considered as a treatment modality for unresponsive patients to medical treatment. The main goal of clinical surveillance in a cirrhotic patient is prevention of HRS before it develops. The aim of this article is to provide an updated review about the physiopathology of HRS and its treatment.

Non-recurrent laryngeal nerve

Injury to the recurrent laryngeal nerve is a serious complication in thyroid and parathyroid surgery. The anatomy of the recurrent laryngeal nerve is variable. Non-recurrent nerve is a very rare variation of the inferior laryngeal nerve. Because of the anatomical variations of the nerve, preservation of the nerve is the optimal strategy during surgery. In this case report, we present a non-recurrent laryngeal nerve abnormality in a patient who underwent parathyroidectomy, thyroidectomy and functional neck dissection for malignant parathyroid disease. A non-recurrent laryngeal nerve was identified during nerve exploration.

Outcomes of Parathyroid Autotransplantation During Total Thyroidectomy: A Comparison with Age- and Sex-Matched Controls

ABSTRACT Purpose: To determine the effect of parathyroid autotransplantation (PA) on postoperative hypocalcemia in cases of total thyroidectomy. Materials and Methods: Cases undergoing total thyroidectomy and PA were compared with age and sex-matched controls who had not undergone PA. The postoperative percentage changes (PC) of parathyroid hormone (PTH) and calcium (Ca+2) in the first 12–24 hours (12–24hr→preop), between the 1st-3rd weeks (1-3wk→preop) and at the 6th month (6mo→preop), the rates of hypocalcemia (Ca+2< 8mg/dL) and low PTH level (PTH< 15 pg/mL), permanent hypocalcemia, inadvertent parathyroidectomy in both groups were compared. Results: The number of patients with PTH12-24hr<15 pg/mL was significantly higher (n:34,(55.7%)) than the number of patients in the control group (n:16(26.2%)), (p=0.001). The rate of decrease in the blood Ca+2 median PC (6mo→preop) was significantly higher in the PA group (4.2%) than the control group (1.1%), (p=0.008). There was no significant difference between the 2 groups in terms of the postoperative frequency of hypocalcemia (p>0.05). In the PA&age≤50 group, the rate of inadvertent parathyroidectomy was higher than that of cases over age 50 (p=0.029). Conclusion: In spite of the presence of an increased postoperative hypocalcemia trend in cases requiring PA during total thyroidectomy, the rates of transient and permanent hypocalcemia were not different to the control cases. But the frequency of cases with low PTH level in cases undergoing PA was higher than that of the control cases. In cases of 50 years of age and under, who had undergone PA, the possibility of inadvertent parathyroidectomy increased.

Choosing the appropriate side for subcutaneous port catheter placement in patients with mastectomy: ipsilateral or contralateral?

PurposeTo evaluate long-term clinical follow-up results of implanting subcutaneous port catheters (SPCs) on ipsilateral or contralateral with mastectomy side in patients with axillary lymph node dissection.MethodsA total of 73 patients composed of ipsilateral (34 catheters) and contralateral (39 catheters) groups, with SPCs were included. All patients had lumpectomy or modified radical mastectomy for breast cancer. Ipsilateral and contralateral groups had similar patient characteristics.ResultsFive late complications were seen in the ipsilateral group and 2 late complications in the contralateral group. No statistical significant difference was seen between two groups in regard to late complications. Four complications of the ipsilateral group were classified as major group C and 1 as major group D, while 1 complication of the contralateral group was classified as minor group B and 1 as major group C according to Society of Interventional Radiology (SIR) classification. No statistical significant difference was seen between complication rates of two groups in regard to SIR classification.ConclusionsSPC related complications do not differ in regard to ipsilateral or contralateral side selection on mastectomized patients with breast cancer and lymph node dissection. SPCs can be implanted on ipsilateral or contralateral sides of the operation in these patients.

Primary thyroid lymphoma.

Primary thyroid lymphoma is an uncommon thyroid malignancy. The treatment modalities significantly differ from other thyroid malignancies. Frequently it is accompanied by Hashimotos thyroiditis, and it may be difficult to differentiate the two entities histologically. Patients typically present with suddenly growing mass in the thyroid gland. Discrimination between primary and secondary lymphoma is important due to variations in diagnostic tools, treatment modalities and prognosis. Surgery, chemotherapy, radiotherapy or combinations of these modalities may be applied in treatment. In this report, three cases with primary thyroid lymphoma in which three different treatment modalities have been applied are presented.

The Relationship between Marginal and Non-Marginal Kidney Transplants

Objective The retrospective evaluation of graft loss, living status and 1-month, 3-month, 6-month and 12-month creatinine values of post-transplant recipient recipients in kidney transplants transplanted from cadaveric marginal kidney donors to non-marginal and marginal cadaver kidney donors, it is aimed to find the relationship between donors. Method The brain death notification form made in the Bursa Organ and Tissue Transplantation Coordination Center in 2011-2015 was obtained from donor information forms of family donations and organ donors. Demographic data and etiology of donors were determined. Serum creatinine> 1.5 mg / dL, HbsAg - Anti - HCV - HIV positive patients, BMI 40, Intensive Care Unit> 5 days, Cold ischemia time> 30 hours, Active infection status, Marginal renal donor criteria were determined. Findings During the research period, brain death was reported in 748 cases in Bursa Organ and Tissue Transplant Coordination Center. the number of brain deaths donated was 249 (33.3%). Uludag University Health Practice and Research Center Directorate Organ transplantation center was evaluated with 161 kidney donors using kidney. There are 128 marginal and 33 non-marginal cases from these donations. There were no cases with a BMI> 40 or more. 36 of the cases were> 60 ages (22.3%). There was no HBsAg (+) anti-HCV (+) and HIV (+) donor. Intensive care time hospital stay> 5 days 42 (26 %). Active infection was detected in 22 (13,66 %). The amount of serum creatinine was> 1.5 mg / dL in 59 (36,6%). 128 cases marginal in. and 31 cases died. The number of cases that died after 1 year from marginal donor donors is 17. 17 cases of the marginal cadaver kidney donors was lost grafts within one year. There is no graft loss in non-marginal cases, no significant correlation was found when p> 0,05 in the mann - whitney test of 6 - month creatinine values of renal transplant recipients from marginal donors and from non-marginal cases. This suggests that there is no difference between kidney transplants made from marginal donor donors and made from non-marginal kidney donors. Conclusion The rate of organ donation in Turkey is below the national average in the brain death declaration. However, the marginal donor utilization rate is satisfactory. This may be due to broad marginal criteria. The fact that there is no difference between marginal and non-marginal cases of the cases can be explained by applications that increase the number of marginal donors in Turkey.

The Effect of MELD Sodium Scoring System on Waiting List

Aim In Turkey, cadaveric liver distribution is arranged by Health Ministry. During this distribution process a proposal list for 5 people is presented. Waiting lists have been arranged according to MELD sodium scoring system rather than MELD scoring system since 2016. The aim of this study is to investigate the effect of MELD sodium points to the waiting lists before June. Method In this study 50 cadaveric liver transplantation lists before 2016 June were retrospectively investigated. Proposal lists (250 patients totally) were rearranged by adding sodium levels to the MELD scores of patients. Two groups including patients with HCC (they can rise to the top of the list with additional points) and without HCC were formed. Changes in the order and in transplanted patients were analyzed. Results 34% (n = 17) of patients were female and 66% (n = 33) were male. 64% of patients was getting higher points according to the old scoring system. In 28 proposal lists (56%), the order of patients were found to be affected by MELD sodium Points. Besides, in the 42% (21 lists) of proposal lists patients who will undergo liver transplantation, was altered by addition of MELD sodium scores. Among all lists in 68% of patients (34 patients) the diagnosis was HCC. Liver transplantation because of HCC was performed in 16 of patients. When patients with the diagnosis of HCC was omitted from the list the effect of MELD sodium score on the ratio of patients who will undergo liver transplantation was observed to be 46% (23 patients). Conclusion By using MELD sodium scoring system in nearly 50% of patients who will undergo transplantation was found to be altered. References: 1. Machicao V, Model for End-Stage Liver Disease-Sodium Score: The Evolution in the Prioritization of Liver Transplantation.Clin Liver Dis.2017 May;21(2):275–287. 2. Federico Pinero, Sicker Patients for Liver Transplantation: Meld, Meld Sodium, and Integrated Meld’s Prognostic Accuracy in the Assessment of Posttransplantation Events at a Single Center from Argentina.Hindawi Publishing Corporation ISRN Transplantation Volume 2013, Article ID 102590. 3. B. C. Yun, Impact of pretransplant hyponatremia on outcome following liver transplantation, Hepatology, vol. 49, no. 5, pp. 1610–1615, 2009.

Retrospective analysis of clinicopathological features of solid pseudopapillary neoplasm of the pancreas

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare neoplasm that accounts for 2–3% of all primary pancreatic neoplasms. This study aimed to characterize clinicopathological features associated with SPNs and to retrospectively evaluate the relationship of these features with predictive parameters associated with aggressive behavior. We reviewed 16 cases of SPN of the pancreas that had been diagnosed between 2005 and 2014 at our pathology department. A total of 16 cases, 15 female and one male, were evaluated in this study. The patient age ranged from 13 years to 63 years with a median of 35.70 years. The mean tumor diameter ranged from 2 cm to 18 cm with a mean diameter of 5.90 cm. We identified a significant association between the presence of clear cells and perineural invasion (p = 0.019), which was considered to be a predictive factor for aggressive behavior. Other features (i.e., localization, nuclear grooves, central hyalinization, myxoid stroma, eosinophilic bodies, foamy histiocyte aggregates, multinucleated cells, and calcification) were not significantly associated with predictive factors for aggressive behavior. One patient died as a result of a pancreatic fistula that developed as a postoperative complication. The remaining 15 patients are alive and have not demonstrated any signs of recurrence or metastasis. The current study suggested that the presence of clear cells might serve as a possible prognostic indicator of perineural invasion, which is a predictive parameter associated with aggressive behavior in SPN.

Is stoma care effective in terms of morbidity in complicated ileostomies

Background Performing transient or permanent ileostomy is one of the common procedures involved in colorectal surgery. Complication rates up to 40% have been reported in ileostomies. In this report, the effect of specific stoma care unit on ileostomy and its complications were investigated. Methods A total of 141 patients, who were operated and underwent ileostomy, due to different causes, at Department of General Surgery, Uludağ University, Bursa, Turkey, between 2003 and 2006, were examined, retrospectively. Patient records were examined in terms of age, sex, surgery indications, urgent/elective state, benign/malign origin, ileostomy type, complications and stoma care, and education. χ2 test was used to compare the categorical data. Results Among the patients, 95 (67%) were male and 46 (33%) were female. The mean age was 47 years (17–67). Some of the subjects (49%) were operated urgently and some (51%) were under elective conditions. The ileostomy types used included the following: end ileostomy (43%), loop ileostomy (46%), and double-barrel ileostomy (11%). Permanent ileostomy was performed in 23 patients and transient ileostomy was performed in 118 patients. The patients were operated because of either benign (48%) or malign (52%) causes. Complications developed in 37 (26%) patients. The rate of development of complication was markedly higher in ileostomies performed under urgent conditions (61% vs 39%) (P<0.001). The complications included mucocutaneous separation (12 patients), maceration in the peristomal skin (ten patients), retraction (five patients), necrosis (three patients), prolapsus (three patients), and other metabolic complications (four patients). The complications were treated with care (68%) and surgical revision (32%). Conclusion The rate of ileostomy was found to be higher in the male patients compared to female patients. The risk of development of complications was found to be higher in ileostomies performed under urgent conditions. The most common complication observed was mucocutaneous separation. Ileostomy complications can be treated conservatively with professional care and education.