İsmail Cem Sormaz

The rate of operative success achieved with radioguided occult lesion localization and intraoperative ultrasonography in patients with recurrent papillary thyroid cancer

BACKGROUND To investigate the rate of operative success in excision of nonpalpable lymph nodes with metastatic disease achieved with radioguided occult lesion localization (ROLL) and intraoperative ultrasonography (IOUS) in patients with papillary thyroid cancer (PTC). METHODS Twenty consecutive PTC patients with nonpalpable lymph nodes with metastatic disease localized in previously operated fields were randomized to receive ROLL (n = 11) or IOUS (n = 9). Nodes were excised along with adjacent soft tissue to accomplish a compartment-oriented dissection. The duration of operation, rate of postoperative complications, pre- and postoperative serum thyroglobulin (Tg) levels, and the findings of postoperative neck ultrasonography and postablation scan were recorded in all patients. Measures of operative success included a postoperative Tg level <50% of preoperative Tg level and no abnormal lesions on postoperative imaging. RESULTS Histopathologic examination confirmed the excision of all preoperatively identified metastatic nodes. Additional nodes also were excised (2.3 ± 3.3 per specimen in the ROLL group and 1.6 ± 1.8 per specimen in the IOUS group), 23% of which were metastatic. No postoperative complications occurred in either group. The duration of operation was similar in the 2 groups (P = .4). Postoperative imaging confirmed the clearance of suspicious nodes in all patients. The rate of operative success in ROLL and IOUS group were 100% and 89%, respectively. CONCLUSION In patients with recurrent PTC, a high rate of operative success in excision of nonpalpable metastatic lymph nodes was achieved by both ROLL and IOUS. We recommend compartment-oriented dissection; this approach may maximize the removal of metastatic nodes not identified by preoperative imaging.

The Value of Preoperative Volumetric Analysis by Computerized Tomography of Retrosternal Goiter to Predict the Need for an Extracervical Approach

Background: A thyroidectomy can be performed via a cervical incision in most patients with retrosternal goiter. Aims: To investigate the correlation between the volume of the mediastinal portion of the thyroid gland and the need for an extra-cervical approach for retrosternal goiter. Study Design: Diagnostic accuracy study. Methods: The measurement of craniocaudal length and the volume of the mediastinal component of the thyroid gland on computerised tomography images was performed in 47 patients with retrosternal goiter. Of these 47 patients, 8 (17%) required an extra-cervical approach and were classified as group 1, and 39 (83%) patients that required a cervical incision were classified as group 2. Receiver operating characteristic analysis was performed to determine the cut-off value for the craniocaudal length and the volume of the mediastinal thyroid mass, which significantly correlated with an extra-cervical approach for retrosternal goiter. Results: Reoperative surgery was significantly more frequent in group 1 than in group 2 (50% vs 13%; p=0.03). The craniocaudal length of the mediastinal thyroid gland was significantly longer in group 1 than in group 2 (77±11 mm vs 31±21 mm, respectively; p=0.0001). The volume of the mediastinal component was significantly larger in group 1 compared to group 2 (264±106 cm3 vs 40±41 cm3, respectively; p=0.0001). The receiver operating characteristic curve of craniocaudal length and the volume of the mediastinal component identified ≥66 mm and ≥162 cm3 as the cut-off values with the maximum accuracy, respectively. The craniocaudal length of the thyroid mass below the thoracic inlet ≥66 mm or a volume of the mediastinal portion ≥162 cm3 were significantly associated with an extra-cervical approach (p=0.0001). For predicting an extra-cervical approach, the sensitivity, positive predictive value and negative predictive value of the cut-off value for craniocaudal length was 87.5%, 64% and 97%, respectively. For predicting an extra-cervical approach, the sensitivity, positive predictive value and negative predictive value of the cut-off values for the mediastinal volume were 100%, 89% and 100%, respectively. Conclusion: A thyroid volume of ≥162 cm3 extending below the thoracic inlet was a significant determining factor for an extra-cervical approach, with a negative predictive value for the extra-cervical approach of 100% for retrosternal goiter with smaller volumes. Further studies with an increased number of patients are needed to determine the value of volumetric analysis of retrosternal goiter to predict the need for an extra-cervical approach in retrosternal goiter.

Papillary Thyroid Carcinoma with Central Lymph Node Metastases

Lymph nodal involvement in papillary thyroid carcinoma (PTC) is very common. Preoperative neck ultrasonography (USG) allows for the early detection of nonpalpable cervical lymph node metastasis prior to thyroidectomy in patients with FNAB-proven or suspected thyroid cancer. In patients with clinically involved central nodes, therapeutic central compartment (level VI) neck dissection should be performed. Lateral neck dissection performed for macroscopic PTC metastases should be the selective neck dissection of levels IIa, III, IV, and Vb. We present a 38-year-old female patient of unilateral PTC with central and ipsilateral lateral lymph node metastasis who underwent total thyroidectomy and bilateral central and ipsilateral lateral lymph node dissection followed by radioactive iodine ablation (RAI) treatment. Postoperative RAI adjuvant therapy should be considered in ATA intermediate-/high-risk level patients. In PTC patients, no biochemical, clinical, or radiological evidence of tumor during the follow-up after total thyroidectomy and RAI treatment is defined as excellent response to treatment. The rate of recurrence ranges between 1 and 4% in patients with excellent response. In intermediate-risk patients who are subsequently reclassified into excellent response category, non-stimulated thyroglobulin assays and neck USG at 12–24-month intervals are considered to be appropriate in the follow-up.

Papillary Thyroid Carcinoma

Although most thyroid nodules are a result of a benign disease process (>90%), the possibility of thyroid cancer is always a consideration. Ultrasonography can help for differential diagnosis of thyroid nodules. Fine needle aspiration biopsy is the traditional diagnostic test to determine malignancy in thyroid nodules. We present a 58-year-old female patient with low-risk papillary thyroid carcinoma (PTC) who was treated by total thyroidectomy. Although the recent ATA guideline recommends that the extent of initial surgery can be a total or near-total thyroidectomy or lobectomy in low-risk unilateral PTC >1 cm and <4 cm, the extent of thyroidectomy in such patients should be decided according to the judgment of the treatment team and postoperative histopathological findings. In low-risk PTC patients, a suppressed or stimulated Tg <1 ng/mL by 3–4 weeks postoperatively and no evidence of disease by imaging further confirm classification of these patients as being at low risk. RAI (radioactive iodine) remnant ablation is not routinely recommended after thyroidectomy for ATA low-risk PTC patients.

Pinch-Off Syndrome, a Rare Complication of Totally Implantable Venous Access Device Implantation: A Case Series and Literature Review

Background Pinch-off syndrome (POS) is a rare complication after totally implantable venous access device (TIVAD) implantation. In cancer patients, it is important to prevent this rare complication and to recognize it early if it does occur. We present a case series of POS after TIVAD implantation and the results of a literature search about this complication. Methods From July 2006 to December 2015, 924 permanent implantable central venous catheter implantation procedures were performed. The most common indication was vascular access for chemotherapy. Results POS occurred in 5 patients in our clinic. Two patients experienced POS within 2 weeks, and the other 3 patients were admitted to department of surgery, Istanbul Faculty of Medicine at 6 to 14 months following implantation. The catheters were found to be occluded during medication administration, and all patients complained of serious pain. The transected fragments of the catheters had migrated to the heart. They were successfully removed under angiography with a single-loop snare. Conclusion POS is a serious complication after TIVAD implantation. It is important to be aware of this possibility and to make an early diagnosis in order to prevent complications such as drug extravasation and occlusion events.

Bilateral patterns and motor function of the extralaryngeal branching of the recurrent laryngeal nerve

PurposeTo evaluate the bilateral patterns and motor function of the extralaryngeal branches (ELB) of the recurrent laryngeal nerve(RLN).MethodsThis study included 500 consecutive patients who underwent total thyroidectomy. Intraoperative nerve monitoring (IONM) was used in 230 patients. Demographic data, indications for surgery, the bilateral patterns of ELB of the RLN, electromyographic activity of the ELB, distance between the branching point to the entrance into the larynx, and the rate of postoperative morbidity were analyzed.ResultsThe overall rate of ELB was 27.6% (276/1000). A single trunk of the RLN on both sides was found in 269 (54%) patients, whereas ELB on both sides was observed in 45 (9%) patients. The rates of ELB on the left and right sides were 26.6 and 28.6%, respectively. Of the 89 branched nerves which were dissected using IONM, an evoked motor response was present in 100% of the anterior branches and 5.6% of the posterior branches. The mean branching distance of the RLN was significantly greater in female patients than in male patients on the left side (p = 0.031). The patterns of ELB showed no significant difference in male and female patients. The rates of postoperative transient and permanent hypoparathyroidism and unilateral RLN palsy were 21.6 and 2.8%, and 3.2 and 0.8%, respectively. The rate of RLN palsy was higher in branched nerves compared to those with a single trunk (0.75 vs 0.3%; p = 0.2).ConclusionUnilateral ELB of the RLN might be observed in approximately 1/4 of the patients, while bilateral branching is rare. A few number of posterior branches of the RLN can have motor function. The RLN’s with ELB might have a higher risk of injury compared to those with a single trunk.

Preoperative adrenal artery embolization followed by surgical excision of giant hypervascular adrenal masses: report of three cases

Abstract Background: Transcatheter arterial embolization (TAE) is an effective minimally invasive adjunct to surgery for the management and/or palliation of adrenal tumors. Methods: In this case study, we reported three patients who underwent preoperative TAE before adrenalectomy for large hypervascular adrenal tumors. All patients underwent preoperative embolization 24 h before the operation and were then followed up at the intensive care unit surgery. Results: The largest diameter of the adrenal lesions ranged between 8 and 17 cm. Hypertensive attack occurred in one patient with pheochromocytoma during embolization. No other complications associated with the procedure was noted. The adrenal tumors were totally excised in all patients. The major intraoperative findings associated with preoperative embolization were marked reduction in hypervascularity and the decrease in the size of collateral vessels. No major hemorrhage necessitating blood transfusion were noted during surgery. Conclusions: Preoperative embolization of large hypervascular adrenal masses could reduce perioperative blood loss by reducing tumor vascularity.

The mechanisms of recurrent laryngeal nerve injury during thyroidectomy and the impact of continuous intraoperative nerve monitoring on surgical strategy

Objective: To evaluate the mechanisms of recurrent laryngeal nerve (RLN) injury during thyroidectomy and the impact of continuous intraoperative nerve monitoring (C-IONM) on surgical strategy. Material and Methods: The data of 364 consecutive patients who underwent total or hemithyroidectomy between June 2014 and January 2016 were evaluated prospectively. All patients underwent thyroidectomy by using C-IONM. The mechanisms of RLN injury and the outcomes of the patients with combined events (CE) and loss of signal (LOS) were evaluated. Results: Combined events (CE) occurred in 6 (1.6%) of these 364 patients. The reduced electromyographic (EMG) amplitude and prolonged latency recovered in all patients intraoperatively by the reversal of the medial traction maneuver. Loss of signal (LOS) occurred in 7(1.9%) patients. The mechanisms of LOS was ligation of the anterior branch of the nerve in 1 (14.3%) patient and traction in 4(57%) patients. The probable mechanism of LOS was traction or transection in 2 (28.6%) patients in whom LOS occurred during the dissection of the intrathoracic portion of large substernal goiter. Of these 7 patients, LOS recovered intraoperatively after 20 minutes of waiting in 1(14.3%) patient. In the remaining 6 (85.7%) patients, unilateral vocal cord paralysis (VCP) was verified on the postoperative laryngoscopic examination. The overall temporary and permanent unilateral VCP rates were 1.6% (n=6) and 0.8% (n=3), respectively in these 364 patients. No bilateral VCP was recorded. Continuous intraoperative nerve monitoring (C-IONM) prevented bilateral VCP in 1 (0.3%) patient. Conclusion: The major advantage of C-IONM is to alert the surgeon for imminent RLN injury. Combined event (CE) is a pathognomonic sign of impending nerve injury that may progress to LOS. This situation enables the surgeon to adverse (reverse) the surgical maneuver before permanent damage to the nerve sets in. Continuous intraoperative nerve monitoring (C-IONM) can also immediately spot RLN injury during thyroidectomy. This property of C-IONM gives the surgeon the opportunity for an early corrective action to release the affected nerve promptly. In case of permanent LOS, staged thyroidectomy could be planned to prevent bilateral VCP.

Buttressing the Stapler Line in Laparoscopic Sleeve Gastrectomy; Is It Really Necessary?

Materyal ve Metot: Kliniğimizde Ocak 2014 ve Aralık 2015 tarihleri arasında morbid obezite nedeniyle laparoskopik sleeve gastrektomi uygulanan ve rezeksiyon hattına güçlendirme süturu konulmayan 16 ardışık hastanın dosyası incelendi. Hastaların demografik özellikleri, vücut kitle indeksi (VKİ), ameliyat süreleri, ameliyat öncesi ve ameliyat sonrası 3. gündeki hemoglobin (Hb) değerlerindeki değişim ve ameliyat sonrası gelişen komplikasyonları değerlendirildi. Giriş Morbid obezite günümüzün en sık karşılaşılan sağlık sorunlarından birisidir. Cerrahi tedavi, özellikle de laparoskopik sleeve gastrektomi (LSG) en çok uygulanan yöntemlerden bir tanesidir. LSG’nin ameliyat sonrası yüz güldürücü sonuçları olmasına rağmen başta stapler hattından oluşan kaçak ve kanama gibi ciddi komplikasyonları mevcuttur. Bu komplikasyonların büyük oranda cerrahi teknikle ilişkili olduğu iyi bilinmektedir. Dikiş ve fibrin-yapıştırıcı ile stapler hattını güçlendirme gibi yöntemler önerilse de kesin olarak kabul edilen ve üstünlüğü kanıtlanmış bir yöntem yoktur. Literatürde dikiş hattını güçlendirecek yöntemler kullanılmasına rağmen kaçak oranının %71, kanama oranının ise %8,7’ye2 ulaştığı bildirilmektedir. Ayrıca maliyeti arttırdığı ve ameliyat süresini de uzattığı bir gerçektir3,4. Bu çalışmamızda, LSG esnasında yeni nesil stapler ile rezeksiyon yapılan ve sonrasında hiçbir güçlendirici yöntem kullanmayan hastaların sonuçlarını değerlendirdik. Bulgular: Çalışmaya katılan hastaların ortalama yaşı 44,1±7,2, K/E oranı 12/4 idi. Hastaların ortalama VKİ 49±9 kg/m2 olarak hesaplandı. Ortalama ameliyat süresi 87,9±16,1 dakika olarak hesaplandı. Ameliyat öncesi ortalama Hb değerleri 14,41±0,77 gr/dL, ameliyatın 3. gününde ortalama Hb değerleri 13,91±0,82 gr/dL olarak hesaplandı. Ameliyat sonrası hiçbir hastada major komplikasyon, stapler hattında kaçak veya kanama görülmedi. Tüm ameliyatlar açık cerrahiye geçilmeden laparoskopik olarak sonlandırıldı.

The impact of postoperative percent change of parathormone level from baseline value on the rate of hypocalcemia after total thyroidectomy

Background: To investigate the impact of the percent change of postoperative parathormone (PoPTH) level from baseline value (∆PTH) on the rate of hypocalcemia after total thyroidectomy. Methods: Assays of serum PTH and calcium (Ca) were performed preoperatively and at 24 hours postoperatively in 222 consecutive patients who underwent total thyroidectomy. Postoperative hypocalcemia was defined as serum calcium level corrected for albumin concentration (cCa) <8.5mg/dl. Patients with postoperative hypocalcemia were classified as group1 (n=100) and those with normal Ca levels as group 2 (n=122). The PoPTH levels and ∆PTH were compared between the two groups. ROC analysis was performed to determine the cut off values for PoPTH and ∆PTH. Results: The mean PoPTH level was significantly lower in group 1 compared to group 2 (18.6±15.3 pg/ml vs 32.3±15.6 pg/ml, respectively; P<0.0001). PoPTH values were within normal range in 54% of the patients with hypocalcemia and 35% of those with symptomatic hypocalcemia. PoPT...