Nihat Aksakal

Endothelial function and endothelial nitric oxide synthase intron 4a/b polymorphism in primary hyperparathyroidism.

Background and aim: Patients with symptomatic primary hyperparathyroidism (pHT) have increased cardiovascular morbidity and mortality. Endothelial nitric oxide synthase (eNOS) intron 4a/b polymorphism is associated with coronary artery disease and hypertension in various populations. Our aim is to evaluate endothelial function in patients with pHT during pre-operative hypercalcemic and post-operative normocalcemic periods and to determine whether intron 4a/b polymorphism of eNOS gene influences endothelial function. Subjects and Methods: Forty patients with pHT (age 48.48±11.64 yr) were examined pre-operatively and reexamined 5.8±1.9 months after parathyroidectomy. Forty-three healthy subjects (age 47.13±8.14 yr) were served as control group. Endothelial function was determined by flow-mediated dilation of brachial artery (FMD). eNOS4a/b polymorphism was detected by polymerase chain reaction. Results: FMD was significantly lower in patients pre-operatively compared with controls (8.48±1.78% vs 19.49±2.34%, p<0.001). FMD improved significantly after parathyroidectomy (16.19±2.16%, p<0.001 compared with pre-operative measurements), but was still significantly lower than controls (p<0.001). The distribution of eNOS4a/b genotype frequencies was not significantly different between patients and controls. Logistic regression analysis showed that increased serum calcium (>2.47 mmol/l) and PTH concentrations (>7.75 pmol/l) were significant independent predictors of lower FMD (<16.7%). ENOS4a/b polymorphism did not enter in this model. Conclusion: Impaired endothelial function in patients with pHT improves after successful parathyroid surgery. No compelling data are evident to suggest that eNOS4a/b polymorphism modifies the endothelial function in patients with pHT.

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.

Factors That Affect the False-Negative Outcomes of Fine-Needle Aspiration Biopsy in Thyroid Nodules

Background. The purpose of this study was to assess the factors that affect the false-negative outcomes of fine-needle aspiration biopsies (FNABs) in thyroid nodules. Methods. Thyroid nodules that underwent FNAB and surgery between August 2005 and January 2012 were analyzed. FNABs were taken from the suspicious nodules regardless of nodule size. Results. Nodules were analyzed in 2 different groups: Group 1 was the false-negatives (n = 81) and Group 2 was the remaining true-positives, true-negatives, and false-positives (n = 649). A cytopathologist attended in 559 (77%) of FNAB procedures. There was a positive correlation between the nodule size and false-negative rates, and the absence of an interpreting cytopathologist for the examination of the FNAB procedure was the most significant parameter with a 76-fold increased risk of false-negative results. Conclusion. The contribution of cytopathologists extends the time of the procedure, and this could be a difficult practice in centres with high patient turnovers. We currently request the contribution of a cytopathologist for selected patients whom should be followed up without surgery.

Laparoscopic surgery of the splenic artery and vein aneurysm with spontaneous arteriovenous fistula.

Visceral artery aneurysms are rare and important vascular entities due to the quarter of all cases presented as surgical emergency. Nevertheless, splenic artery aneurysm (SAA) is the most common visceral and third most common intra-abdominal artery aneurysm after aorta and iliac artery. SAA accompany splenic vein aneurysm because arteriovenous fistula communication between them is a very rare entity. Location and size of the SAA determine the likelihood of rupture. Women of child-bearing age who have SAAs are at particularly high risk of death as a result of aneurysm rupture and should be treated with elective repair. Herein, we report a case of a splenic artery and vein aneurysm with arteriovenous fistula in a 25-year-old young female patient who presented with left upper quadrant pain. Diagnosis was established by computerized tomography angiogram. The patient underwent laparoscopic resection of splenic artery and vein, as well as with splenectomy. Laparoscopic therapy for SAA should be considered for the patient with a low periprocedural morbidity at experienced surgical clinics.

Multiple gastrointestinal stromal tumors and pheochromocytoma in a patient with von Recklinghausen's disease

INTRODUCTION Neurofibromatosis type 1 is a genetic disease characterized by neoplastic and non neoplastic disorders involving tissues of neuroectodermal and mesenchymal origin. Herein, we present a case with von Recklinghausens disease, right adrenal heochromocytoma and multiple gastrointestinal stromal tumors. PRESENTATION OF CASE A forty-eight year old male patient was admitted to our Emergency Department with melena. His physical examination revealed multiple neurofibromas all over the skin, kyphosis, multiple cafe au lait spots and Lisch nodules on the eye and, melena on digital rectal examination. Abdominal computerized tomography scan showed a mass on right adrenal gland and multiple soft tissue mass lesions between distal part of pancreas and small bowel. Adrenal mass was determined as a pheochromocytoma and small bowel lesions were verified as stromal tumors. DISCUSSION In patients with NF1, pheochromocytomas and GISTs are well known neoplasms seen with increased incidence than the general population. CONCLUSION In patients with NF1, any symptoms with other systems should be managed carefully for underlying malignity.

Complete Versus Partial Mobilization of Splenic Flexure During Laparoscopic Low Anterior Resection for Rectal Tumors: A Comparative Study

BACKGROUND The aim of the current study is to compare the results after partial and complete splenic flexure mobilization (SFM). SUBJECTS AND METHODS The records of laparoscopic and hand-assisted laparoscopic procedures for primary rectal tumor patients were abstracted from a prospectively designed database. The phrenicocolic and splenocolic ligaments were divided via a four-trocar technique in the partial SFM group, and dissection was continued with the separation of gastrocolic and pancreaticomesocolic attachments via a five-trocar procedure in the complete SFM group. The following data were compared between the groups: Demographics, intra- and postoperative information, and pathological features. RESULTS In total, 122 cases (77 [63.1%] male, 58.2±13.2 years old) who underwent a partial (n=36, 29.5%) or a complete (n=86, 70.5%) SFM were included. Reservoir creation (48.8% versus 19.4%, P=.003) was more common and conversion (8.1% versus 22.2%, P=.039) was less frequent in the complete SFM group, but there were significantly more T4 tumors in the partial group (16.7% versus 2.3%, P=.008). Demographics, other intra- and postoperative parameters, and pathological features were identical. CONCLUSIONS In our study, complete SFM decreased conversion rates, but this finding may be related to the higher rate of T4 tumors in the partial SFM group. Complete SFM assures an increase in reservoir creation in patients receiving a low anterior resection. Because other parameters are identical, the decision for the level of SFM is better left to the surgeon in cases undergoing a low anterior resection, but complete SFM may be preferred in cases who are candidates for a reservoir formation.

Laparoscopic and Conventional Resections for Low Rectal Cancers: A Retrospective Analysis on Perioperative Outcomes, Sphincter Preservation, and Oncological Results

BACKGROUND This study aims to compare the results of laparoscopic and conventional techniques in patients with low rectal cancers. SUBJECTS AND METHODS A retrospective data analysis was initiated in patients underwent laparoscopic or conventional surgery for cancers located in the low (<6 cm) rectum. Patient and tumor-related information, outcomes of operations, and survival were compared between the groups. RESULTS Among 142 patietns (91 men [64.1%]; mean±standard deviation age, 57.7±14.6 years) who had tumors located <6 cm from the dentate line, 92 (64.8%) were operated on with the laparoscopic technique. Demographics, tumor stage, and localization (2.9±2.0 versus 2.9±2.1 cm from the dentate line in laparoscopic and conventional arms, respectively; P=.968) were similar. However, there were more patients in the laparoscopic group who received neoadjuvant chemoradiation therapy (92.4% versus 80.0%; P=.03), since there were significantly fewer cases with stage I tumors in this group (3.3% versus 14%; P=.33). The conversion rate was 14.1% (n=13). The amount of bleeding and the requirement for transfusion decreased (P<.05 for both), and the possibility of sphincter-saving procedures (66.3% versus 34.0%; P<.001) increased, in the laparoscopy group. Other parameters were identical. In the laparoscopy group, the number of harvested lymph nodes (10.2±5.4 versus 12.4±6.0; P=.025) and the rate of vascular invasion (27.5% versus 47.8%; P=.021) were less, and Kaplan-Meier analysis revealed an improved survival (P=.042), although the follow-up period was significantly shorter in this group (P<.001). CONCLUSIONS Laparoscopic surgery for low rectal cancers may be technically feasible and oncologically safe. Laparoscopy may increase the possibility of sphincter preservation.

Electrocautery for cutaneous flap creation during thyroidectomy: a randomised, controlled study

BACKGROUND Although electrocautery has been used widely in surgery, the fear of delayed wound healing and infection persists. We aimed to evaluate the risk factors for wound complications and the rate of wound complications, comparing the use of electrocautery or scissors in cutaneous flap creation during thyroidectomy. DESIGN The study group comprised 239 consecutive patients scheduled for thyroidectomy. SUBJECTS Patients were randomly assigned to cutaneous flap dissection by either electrocautery (group one, n = 126) or scissors (group two, n = 113). Age, gender, body mass index, American Society of Anesthesiology score, tissue weight, operating time, incision length, cutaneous tissue depth, thyroid function and surgeon experience were recorded and compared with the rate of post-operative wound complications in both groups. RESULTS There were no significant differences between the overall rate of post-operative wound complications, comparing groups one and two (7.9 vs 10.6 per cent, respectively; p = 0.74). Significant positive correlations were found between wound complication and age (Spearmans rank coefficient (rs) = 0.135, p = 0.036), body mass index (rs = 0.379, p = 0.0001), cutaneous tissue depth (rs = 0.677, p = 0.0001) and tissue weight (rs = 0.643, p = 0.0001). According to logistic regression analysis, a body mass index of more than 27.5 kg/m2 was associated with a 13.7-fold increased rate of post-operative wound complications. CONCLUSION When creating cutaneous flaps during thyroidectomy, the use of electrocautery is as safe as the use of scissors. Such electrocautery does not increase the risk of wound complications in thyroid surgery.

Mezenter Ven Trombozuna Yaklaşım: Tek Merkez Deneyimi

BACKGROUND Mesenteric vein thrombosis occurs rarely and is responsible for approximately 5-15% of all cases of acute mesenteric ischemia. The aim of this report was to discuss the management of mesenteric vein thrombosis based on our experience with 34 patients. METHODS In the present study, 34 patients who were admitted to our emergency surgery department between January 2007 and January 2010 with a diagnosis of acute mesenteric vein thrombosis were assessed retrospectively. Patients with peritoneal signs first underwent diagnostic laparoscopy to rule out perforation or bowel gangrene. We performed a second-look laparoscopy within 72 hours of the first operation. All patients were administered 100 mg/kg of the anticoagulant enoxaparin twice daily. In the 6th and 12th months of follow up, CT angiography was performed to evaluate recanalization of the veins. RESULTS CT angiography revealed superior mesenteric vein thrombosis in 25 (73%) patients, portal vein thrombosis in 24 (70%) patients, and splenic vein thrombosis in 12 (35%) patients. Eleven patients with peritoneal signs underwent diagnostic laparoscopy; eight of the patients underwent small bowel resection, anastomosis, and trocar insertion. During second-look laparoscopy, small bowel ischemia was found in two patients and re-resection was performed. CONCLUSION Early diagnosis with CT angiography, surgical and non-surgical blood flow restoration, proper anticoagulation, and supportive intensive care are the cornerstones of successful treatment of mesenteric vein thrombosis.

Comparison of single port and three port laparoscopic splenectomy in patients with immune thrombocytopenic purpura: Clinical comparative study.

Aim: Single-port laparoscopic surgery (SILS) has become increasingly popular during the last decades. This prospective study was undertaken to evaluate the feasibility of single-port laparoscopic splenectomy compared with conventional multiport laparoscopic splenectomy. Materials and Methods: Between February 2, 2009 and August 29, 2011, a total of 40 patients with the diagnosis of immune thrombocytopenic purpura were included to study. Patients were alienated into two groups according to the procedure type including SILS and conventional multiport splenectomy. Results: There were 19 patients in group 1, and 21 in group 2. Operative time was significantly shorter in group 1 versus group 2 (112.4 ± 13.56 vs 71.2 ±18.1 minutes, respectively, P < 0.05). One patient in group 1 had converted to laparatomy due to preoperative bleeding. Postoperative pain analyses (VAS Score) revealed superiority of SILS in the early post-operative days (P < 0.05). Conclusions: SILS splenectomy is a safe and effective alternative to standard laparoscopic splenectomy.