Mehmet Keskek

A prospective randomized trial comparing the harmonic scalpel with conventional knot tying in thyroidectomy

Currently, thyroidectomies are performed with very little morbidity. This study was undertaken to investigate whether the use of the harmonic scalpel during thyroid surgery has any advantage over the conventional technique. Eighty patients were randomly assigned to 2 groups. The patients in group 1 (n=40) underwent thyroidectomy performed with conventional knot tying and the electrocautery technique; in patients in group 2 (n=40), the harmonic scalpel was used for the procedure. Significant differences were observed between these 2 surgical techniques in terms of operative time, number of ligatures used, amount of bleeding, average length of incision, total amount of drainage fluid, and cosmetic satisfaction (P<.05). With the harmonic scalpel technique, there was a nearly 18% reduction in operative time. No significant differences were noted between mean hospital stay and postoperative pain (P>.05). No patient in either group had permanent recurrent laryngeal nerve palsy or hypoparathyroidism. The harmonic scalpel significantly shortens the duration of thyroidectomies; it can be used safely and effectively in thyroid surgery with no additional morbidity.

Receiver operating characteristic analysis of leukocyte counts in operations for suspected appendicitis.

STUDY OBJECTIVE There has been no clear-cut value of the white blood cell (WBC) count in differential diagnosis of acute appendicitis in emergency medicine. Therefore, the aim of this study was to assess the preoperative WBC counts in 3 groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendectomy: uninflamed appendix, uncomplicated acute appendicitis, or complicated acute appendicitis. METHODS The medical records of 540 patients who underwent appendectomy for suspected acute appendicitis during a 17-month period were retrospectively reviewed. Data for 3 groups of patients were analyzed to calculate the sensitivity and specificity of the WBC count in the diagnosis of acute appendicitis, and we calculated likelihood ratios for 2 cut-points with either high sensitivity or high specificity. Receiver operating characteristic curves were used to evaluate the WBC count in relation to the true diagnosis and severity of acute appendicitis. RESULTS We were able to identify patients with appendicitis on a statistically significant level using receiver operating characteristic curves of WBC counts (area under the curve = 0.756, P < .001), but the WBC count had no diagnostic value in differentiating between uncomplicated and complicated groups (area under the curve = 0.55, P = .086). Likelihood ratio ranged from 1.79 (95% confidence interval, 1.17-2.3) for WBC count of more than 10,500 cells/mm(3) to 3.20 (95% confidence interval, 2.72-3.24) for WBC count of more than 14,300 cells/mm(3). CONCLUSION White blood cell count is helpful in the diagnosis and exclusion of appendicitis. However, there is no value to differentiate advanced appendicitis.

Can biliary-cyst communication be predicted before surgery for hepatic hydatid disease: does size matter?

BACKGROUND The aim of this study was to determine if there is any predictive factor indicating the risk of bile leakage before surgery for hepatic hydatid disease in clinically asymptomatic patients. METHODS The data of 116 patients who underwent surgery for hepatic hydatid disease were reviewed retrospectively. There were 43 men (37%) and 73 women (63%) with a mean age of 45 +/- 15 years. Because of high preoperative serum bilirubin and liver function test levels, 12 patients were excluded from the study. These patients underwent preoperative endoscopic retrograde cholangiopancreatography. In addition, 2 medically treated patients were excluded from the study. The following variables were analyzed as potential predictors of biliary-cyst communication: age, sex, physical examination findings, leukocyte count, liver function test results, and ultrasonographic cyst features (type, diameter, number, and localization). RESULTS Bile leakage was detected in 24 out of 102 patients. There were no differences in age, sex, cyst type, alkaline phosphatase level, gamma-glutamyl transpeptidase level, alanine aminotransferase level, aspartate aminotransferase level, bilirubin level, and number of cysts and cyst locations between the patients with and without bile leakage. The mean cyst size in patients with biliary leakage was 10.2 cm as compared with 6.1 cm in patients with no biliary leakage (P < .05). When the cut-off value of cyst diameter was accepted as 7.5 cm, the specificity and sensitivity for biliary-cyst communication were 73% and 79%, respectively. CONCLUSIONS These data suggest that cyst diameter is an independent factor that is associated with a high risk of biliary-cyst communication in clinically asymptomatic patients. Preoperative endoscopic retrograde cholangiopancreatography should be performed in these asymptomatic patients to reduce the incidence of postoperative complications.

Re-evaluation of Axillary Skip Metastases in the Era of Sentinel Lymph Node Biopsy in Breast Cancer

PurposeTo investigate whether skip axillary metastases are really skip metastases or a continuation of level I micrometastases in invasive breast cancer, and to determine whether there are any factors predisposing to skip metastases.MethodsWe reviewed 568 consecutive patients with breast cancer who underwent complete axillary lymph node dissections (ALND) between January 1998 and December 2004. For patients with skip axillary lymph node metastases, resectioning and immunohistochemical staining of the remaining part of paraffin blocks from level I lymph nodes were done to determine whether there were any micrometastases in this group of lymph nodes.ResultsSkip axillary metastases were found in 27 (10%) of 268 patients with axillary lymph node metastases. Re-evaluation of the level I lymph nodes, both with thin sectioning and immunohistochemical staining, in the patients with axillary skip metastases revealed no micrometastases. No significant correlation was found between the demographic and histopathological variables of the patients with skip metastases and those with regular axillary metastases.ConclusionsThese results suggest that skip axillary metastases are actual skip metastases, not a continuation of undetected level I micrometastases. Moreover, none of the clinical and histopathological measures of primary tumors are predictors of the presence of skip metastases.

Primary echinococcal cyst of the thyroid: Report of a case

A case of primary hydatid disease of the thyroid, a rare location, is presented. The patient was a 50-year-old woman who presented with a neck mass at the thyroid region, which was noticed 2 months before her presentation. Although the clinical impression was of a neoplastic lesion (adenoma or carcinoma), a hydatid cyst was considered intraoperatively and confirmed by a frozen section histology. It was completely removed. No other sites of hydatid disease were found and the patient remained well postoperatively. In patients with a solitary cyst in the thyroid, the possibility of hydatid disease, though rare, should be always kept in mind, because a needle aspiration biopsy is a potentially harmful procedure.

External validation of a US-derived nomogram that predicts individual survival after gastric cancer resection

Dear Sir; Although the incidence of gastric carcinoma is declining in Western Europe, the disease remains the second most common cause of cancer death worldwide. Surgery is the only curative treatment [1, 2]. Kattan et al. established a nomogram derived from 1,039 patients who underwent R0 gastric cancer resection at Memorial Sloan-Kettering Cancer Center, NY. The nomogram combines easily accessible factors: sex, age, tumor location, Lauren histotype, number of histologic positive and negative nodes, as well as depth of invasion, data that should be available in every institution performing gastric cancer surgery [3]. We analyzed the performance of this US-derived nomogram on the patient population from our gastric cancer database by comparing nomogram-predicted 5-year survival with actual survival. Between January 2000 and December 2002, 65 patients had undergone R0 resection for gastric cancer in the Fifth Department of Surgery, Ankara Numune Training and Research Hospital. Depending on the location of the primary lesion, total or distal subtotal gastrectomy was performed. D2 lymphadenectomy was performed on a routine basis. The following prognostic variables were assembled for use in validating the nomogram: age, gender, primary site, Lauren histotype, number of positive lymph nodes resected, number of negative lymph nodes resected, and depth of invasion as defined by the standard nomenclature. Nomogram validation comprised two activities. These are discrimination and calibration. Model discrimination was measured by the area under the receiver–operator characteristic (ROC) curve [4]. Calibration was assessed using the Hosmer–Lemeshow goodness-of-fit test and the corresponding calibration curves [5]. There were 65 eligible patients with all the information available for the nomogram calculation. With a median follow-up of 40 months, 24 of the 65 patients had died of disease. Discrimination of the nomogram was moderate with area under the ROC curve at 0.688 and the nomogram showed poor calibration. For many clinicians, the most important question regarding prognostic scoring systems is: How can they help with individual patient care decisions? Many physicians believe that group statistics do not apply to individuals. Although individual patients have unique characteristics, they also share many common features with other patients, and consideration of these similarities permits us to anticipate the patients’ responses and predict their outcomes. Statistical predictions of outcome produced by prognostic scoring systems or nomograms are apparently at least as accurate as clinical predictions and, in most cases, are more reliable [6]. Performances of the these commonly used disease severity scoring and mortality prediction systems may be effected by the advances in technology and therapeutic strategies, as the system has been described by the differences in the case mix of a specific clinic from an original database and by the differences in admission and discharge policies between different countries and between different clinics. Even Langenbecks Arch Surg (2009) 394:755–756 DOI 10.1007/s00423-008-0426-z

External metallic circle in microsurgical anastomosis of common bile duct

BACKGROUND Biliary stricture development is one of the most serious problems following biliary tract surgery. Here, we present a new technique for biliary tract reconstruction with an external metallic circle, and the results of this new technique in a rat model. METHODS Twelve male Sprague-Dawley rats (250 to 300 g) were divided into two groups. After transection of the bile duct, standard bile duct reconstruction (without the metallic circle) was performed in group 1 and reconstruction with the external metallic (silver) circle was performed in group 2. At the end of the fourth month, clinical, laboratory biochemical, and histopathologic parameters were compared between the groups. RESULTS Serum concentrations of alkaline phosphatase (ALP) and operation time were higher in group 1 than in group 2. Differences were statistically significant. In histopathologic examination, biliary duct stricture was seen in group 1. Foreign body reaction and fibrosis in the bile duct wall were seen in group 2. CONCLUSION An external metallic circle prevents development of biliary stricture after primary end-to-end bile duct anastomosis in this rat model.

Serum chitotriosidase activity in acute appendicitis: preliminary results.

Chitotriosidase is one of the most quantitative proteins secreted by activated macrophages, so its activity has been proposed as a biochemical marker of macrophage accumulation. The clinical importance of the chitotriosidase is still largely unknown. Our aim was to evaluate diagnostic accuracy of serum chitotriosidase activity in acute appendicitis (AA). A total of 34 patients with preoperative AA diagnosis (18 men and 16 women; mean age, 28.8±10.9 years) were enrolled in this study. The appendix specimens were classified as normal appendix (10 patients) and AA (24 patients). The serum chitotriosidase activity was measured preoperatively. Diagnostic value of the preoperative chitotriosidase activity as assessed through the corresponding receiver operating characteristic curve was well (area under the curve, 0.771; 95% confidence interval, 0.647-0.877; P<.05). Preoperative serum chitotriosidase activity may be a useful marker for diagnosis of AA, and future studies are required to confirm the results presented here.

External metallic circle in hepaticojejunostomy

BackgroundBiliary-enteric anastomosis especially Roux-en Y hepaticojejunostomy is frequently used for biliary diversion in benign biliary strictures. In this study, we present the results of hepaticojejunostomy with external metallic circle.MethodsHepaticojejunostomy with external metallic circle were performed in eight male Sprague-Dawley rats. At the end of the third month, anastomoses were analysed for patency and stability of external circles.ResultsRelaparotomy revealed that all the anastomoses were patent and circles were in original places.ConclusionTo provide the patency of narrow hepaticojejunostomy anastomoses, external metallic circle can be a good alternative to use of internal stents in suitable cases.

Bilateral ductal carcinoma in situ of the breast after radiation therapy for Ewing’s sarcoma of the vertebra in a young woman: Report of a case

Thoracic radiation in the early years of life is a known risk factor for breast cancer later in life. A 21-year-old woman who had received thoracic radiation therapy for Ewing’s sarcoma of the vertebra 9 years earlier was referred to our hospital for investigation of a palpable mass in her left breast. Ultrasonography and excisional biopsy showed ductal carcinoma in situ (DCIS) of the left breast, with no detectable pathology in the right breast except that it was more hypoplastic than the left breast. Considering the known risk factors for invasive breast cancer in both breasts, we performed bilateral skin-sparing mastectomy with immediate breast reconstruction using subpectoral implants. The final histopathological diagnosis was bilateral DCIS.