Omer Yoldas

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.

Comparison and Validation of Scoring Systems in a Cohort of Patients Treated for Biliary Acute Pancreatitis

Objectives: There are a few prospective studies assessing the severity of acute pancreatitis with exclusive criteria for biliary etiology. The aim of this study was to assess the reliability of prediction of the severity and mortality of acute biliary pancreatitis by using the Ranson, Acute Physiology And Chronic Health Evaluation II and III, Simplified Acute Physiology Score II, and Mortality Probability Model (MPM) II systems. Methods: Fifty-eight patients with acute biliary pancreatitis were studied prospectively. Disease severity scores and mortality predictions were calculated using the collected data in the first 24 hours of admission and for Ranson score in the first 48 hours. Discrimination and calibration characteristics of each system were determined by using area under receiver operating characteristics curve and Hosmer-Lemeshow goodness-of-fit test, respectively. Results: Among 58 patients included, there were 4 mortalities (6.8 %). Fifteen patients (25.8 %) had severe disease, and 5 patients (8.6 %) had systemic and local complications. All systems had reliable power of discrimination and calibration. Among systems tested MPM II was the best performing as far as discrimination, and calibration characteristics are considered. The items of MPM II that were positive in patients with severe pancreatitis were those related to systemic perfusion. Conclusions: Mortality Probability Model II predicted mortality at admission is better than the other systems in predicting the severity of pancreatitis. Results also indicate the important role of systemic perfusion at the early phases of acute pancreatitis in the progression of disease.Abbreviations: AUC - area under curve, ROC - receiver operating characteristic, APACHE - Acute Physiology and Chronic Health Evaluation, SAPS - Simplified Acute Physiology Score, MPM - Mortality Probability Model, ABP - acute biliary pancreatitis

Comparison of short-term results of modified Karydakis flap and modified Limberg flap for pilonidal sinus surgery

The aim of this study was to compare and analyze the short term results of modified Karydakis flap reconstruction (MKF) and modified Limberg flap reconstruction (MLF). This is a retrospective analysis of 81 patients operated for pilonidal sinus disease. There were 46 patients in MLF group and 35 patients in MKF group. We compared patients age, BMI, operation time, removal time of suction drain, time of feeling completely healed, type of presentation, complications, postoperative 1., 3., 5. Days VAS scores, time to stop analgesic drugs and time to sit on chair or throne without pain. Complication rate, analgesic drug stopping time, postoperative 5. days VAS score were lower in MLF group and there were significant difference between groups. MLF group patients feel better (P: 0.010), they recommended this operation to other pilonidal sinus patients (P: 0.010) and 36 of them rated their satisfaction excellent and 10 of them good (P: 0.010). MLF procedure was more comfortable for patients. Lesser pain, lower complication and recurrence rates and higher patient satisfaction were detected in MLF group.

Effects of tamoxifen citrate on postoperative intra-abdominal adhesion in a rat model

BACKGROUND/AIMS The aim of this study was to evaluate the effects of oral tamoxifen citrate on postoperative intra-abdominal adhesions. MATERIALS AND METHODS Forty five rats were randomly separated in to 3 groups. Group 1: Control group (15 rats), Group 2: tmx 1 group (15 rats) and Group 3: tmx 10 group (15 rats). The cecum was abraded with a sterile gauze until subserosal hemorrhage had developed. Full- thickness 4-0 silk sutures were also placed in the traumatized anterior cecal wall to increase the adhesive reaction. In Group 1 (control group), adhesion induction was performed and no treatment was given. In Group 2 (tmx 1 group), after adhesion induction, 1 mg/kg/day tamoxifen citrate was given by orogastric gavage. In Group 3 (tmx 10 group), adhesion induction was performed and 10 mg/kg/day tamoxifen citrate was given by orogastric gavage. Rats were sacrificed on postoperative day 30. At the time of second surgery, after the abdominal fascia had been opened blood samples were collected to evaluate serum TGFβ-1 levels and following the macroscopic adhesion scoring, tissue specimens of the bowel and adhesions were subjected to histopathological investigation. RESULTS In group 1 and group 2 we detected higher scores for the macroscopic classification (2.25 ± 1.13 vs. 1.53 ± 0.77) and histopathological scores (2.72 ± 0.64 vs. 2.53 ± 0.87) for fibrosis and serum TGFβ-1 levels (42000 ± 2935 vs. 32988 ± 10804). In group 3 we have detected decreased scores for macroscopic classification (0.91 ± 0.51) and histopathological scores (1.58 ± 0.90) for fibrosis and serum TGFβ-1 levels (22847 ± 4976). There were no significant differences between group 1 and group 2 according to the macroscopic classification and pathological scores for fibrosis. There were statistically significant difference between tamoxifen 10 mg/kg group and the other groups according to macroscopic classification ( P: G1-3: 0.004; G2-3: 0.046), pathological scores for fibrosis (P: G1-3: 0.004; G2-3: 0.011) and serum TGFβ-1 levels (P: G1-3:<0.001). CONCLUSIONS In conclusion tamoxifen citrate seems to be useful for preventing postoperative intra-abdominal adhesions. Its effects are in a dose and time dependent manner. Further studies must be carried out to use tamoxifen for preventing intra-abdominal postoperative adhesions in clinical practice.

Prediction of clinical outcomes using artificial neural networks for patients with acute biliary pancreatitis.

To the Editor: Gallstones and alcohol have been implicated as etiologic factors in 80% of acute pancreatitis cases. Acute biliary pancreatitis (ABP) range from a mild, self-limited disease to severe, and sometimes fatal, disorder. Early identification of patients at greater risk of complications may determine a more rational use of diagnostic studies and prompt treatment, leading to decreased mortality rates. Inquiry in prediction of severity of acute pancreatitis dates back to the 19th century, when Reginald Heber Fitz first reported a classification scheme based on autopsy studies. After this publication, detailing pathology of acute pancreatitis, many different scoring systems have been evaluated for predicting severity of pancreatitis on which treatment decisions can be based. These systems can be grouped into two, the first group including those systems that attempts to correlate laboratory and clinical markers specific to pancreatitis with subsequent outcome and disease severity, Ranson score being an example. The second type of scoring systems, such as the Acute Physiologic and Chronic Health Evaluation System (APACHE) II and III, Simplified Acute Physiology Score (SAPS) II, and the Mortality Probability Models (MPM) II were developed to quantify the severity of illness and the likelihood of hospital survival for a general intensive care unit (ICU) population. In the last 10 years, a class of techniques inspired by the workings of biologic neurons, artificial neural networks (ANNs), have been proposed as a supplement or alternative to standard statistical techniques for predicting complex biologic phenomena. Briefly, ANNs are a class of nonlinear mathematical models that are characterized by a complex structure of interconnected computational elements, the neurons. These computational elements aggregate a series of inputs (factors that influence the outcomes of ABP) by using a summation operation and produce an output, such as the severity of ABP. The aim of this study was to evaluate a novel ANN for the prediction of severity and mortality in patients with ABP and to compare it with the results of the other scoring systems. This prospective study has been conducted in a cohort of patients with ABP admitted to the Ankara Numune Hospital between August 2005 and September 2006. Diagnosis of ABP was based on clinical (acute abdominal pain in upper quadrants associated with nausea and vomiting), laboratory (increase in serum amylase at least 3 times to normal) and ultrasonographic data (cholelithiasis, choledocholithiasis, or biliary sludge). Cases with alcoholic or metabolic causes of pancreatitis and those admitted more than 24 hours later than onset of symptoms were excluded from the study. The main outcomes measured in this study were mortality and severity. We determined severity of the disease according to clinically based classification of Atlanta. An outcome was defined as severe if it was associated with organ failure and/or local complications, whether or not the patient was admitted to the ICU. Organ failure was established if one or more of the following factors were present: shock (systolic blood pressure G90 mm Hg), pulmonary insufficiency (PO2 G60 mm Hg), renal failure (creatinine levels 92.0 mg/dL after rehydration), and gastrointestinal bleeding (9500 mL/24 h). Local complications include the development of pancreatic necrosis, abscess, or pseudocyst. Mortality was calculated as the number of patients dying during hospital admission with pancreatitis. All patients were managed conservatively unless a complication had arisen. Cholangitis was treated with intravenous antibiotics and endoscopic retrograde cholangiopancreatography with sphincterotomy where appropriate. Pancreatic necrosis, abscess, acute fluid collection, or pseudocysts were managed by either radiologically guided percutaneous fineneedle aspiration or surgery. Data related to calculations of Ranson score, APACHE II, and score at admission and 48 hours for Ranson score were collected by a physician unaware of the study end points within the first 48 hours of admission, and calculations were performed by using clinical calculators of the Muavenet Intensive Care Information System (http://www.icu.hacettepe.edu.tr/ micis.html). The optimum variables used to construct the ANN were selected previous literature. Three demographic and/or physical data points (age, presence of other illness, temperature) and 8 laboratory data points (white blood cell count, serum amylase level, lactate dehydrogenase level, calcium level, creatinine level, glucose level, serum urea nitrogen level, and base deficit) were used in the final assessment. Three-layered, multilayer perceptron ANN models, with back propagation circuit, were constructed using Neuro-Solutions version 5 neural network software (NeuroDimension, Inc, Gainesville, Fla). This is a simple neural network design in which the neurons are arranged in parallel layers, and each layer is connected fully to the previous layer through synaptic connections, leading to a single predictive outcome. The ANNs were trained through back propagation of error, which is a process by which the error of prediction is minimized by adjusting the weights associated with the synaptic connections in the hidden layers of the ANN. The training was stopped when the predictive error reached a minimum on this set. One third of the data were used to train the ANN, one third to improve it, and one third for testing the system. Discrimination and calibration describe the overall predictive power of a model. Model discrimination was measured by the area under the receiveroperator characteristic curve (AUC) to evaluate how well the model distinguished patients experienced the events LETTERS TO THE EDITOR

External validation of prognostic models among cancer patients undergoing emergency colorectal surgery

BACKGROUND The aim of this study was to evaluate the predictive accuracy of different scoring systems on patients undergoing emergency colorectal surgery. METHODS The Acute Physiology and Chronic Health Evaluation II or III, the Simplified Acute Physiology Score II, the Mortality Probability Model II, and the Colo-rectal POSSUM scoring systems were applied to 102 patients who underwent colorectal resection for cancer. Validation of scoring systems was tested by assessing calibration and discrimination. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic curve analysis. RESULTS Overall, 17 deaths occurred. The Simplified Acute Physiology Score II showed good calibration (x(2) = 1.079, P = .982) and discrimination (areas under the receiver-operating characteristic curve .83). CONCLUSIONS These data suggest that the SAPS II scoring system was accurate in predicting outcome for patients undergoing emergency colorectal surgery.

Artificial neural networks in the diagnosis of acute appendicitis.

The aim of the study was to assess the role of artificial neural networks in the diagnosis of acute appendicitis in patients presenting with right lower abdominal pain. Data from 156 patients presenting with suspected appendicitis over a 12-month period to a rural hospital were collected prospectively. The sensitivity, specificity, and positive and negative predictive values of the artificial neural network were 100%, 97.2%, 96.0%, and 100% respectively. Artificial neural networks can be an effective tool for accurately diagnosing acute appendicitis and may reduce unnecessary appendectomies.

Diagnosis and Treatment of Multiseptate Gallbladder with Recurrent Abdominal Pain

Laparoscopic cholecystectomy is usually performed for gallstones or polyp of the gallbladder. Multiseptate gallbladder is a rare congenital malformation. Although several asymptomatic cases have been described, patient usually present with right upper abdominal pain. We present a 29-year-old female patient with multiseptate gallbladder, cholecystectomy was performed, and her abdominal pain and gastrointestinal complaints have resolved.