Orhan Agcaoglu

Evaluation of recurrent laryngeal nerve monitoring in thyroid surgery

AIMnThyroidectomy creates a potential risk for all parathyroid glands and nerves. Nerve identification has decreased the rates of nerve injury during thyroidectomy. Intraoperative nerve monitoring (IONM) has been used as an adjunct to the visual identification of the nerve. The aim of this clinical trial is to evaluate the effect of the identification time of RLN during thyroidectomy using IONM.nnnMETHODnTwo hundred and thirty seven patients and 409 nerves at risk were enrolled in this prospective study. The nerves in Group 1 (n=210) were identified with IONM, whereas the nerves in Group 2 (n=199) were identified without IONM.nnnRESULTnThe identification time of RLN and the operating time in patients of Group 1 were significantly lower than patients of Group 2. There was not any significant difference between postoperative complications of the groups. According to logistic regression analysis, the use of IONM was found to be the only determinant of the decrease of identification time of RLN.nnnCONCLUSIONnAlthough the operating time was lower with IONM than with visualization alone, the shortened surgical time may not seem to have great clinical relevance. However, the shorter the nerve is identified the lower is the surgeons level of stress. We think that it is important to use IONM to decrease the identification time of RLN in the course of thyroidectomy.

Determinants of postoperative hypocalcemia in vitamin D–deficient Graves’ patients after total thyroidectomy

BACKGROUNDnThe etiology of postoperative hypocalcemia after total thyroidectomy appears to be multifactorial, that is, postoperative transient hypoparathyroidism, low 25-hydroxy vitamin D (25-OHD) concentrations, aging, and hyperthyroidism with increased bone turnover. Our aim was to evaluate the factors responsible for postoperative hypocalcemia in euthyroid vitamin D-deficient/insufficient Graves patients who underwent total thyroidectomy at our institution.nnnMETHODSnThirty-five consecutive patients with Graves disease treated by total thyroidectomy were included in the present study. All patients were vitamin D deficient/insufficient (ie, 25-OHD concentrations of <20/<30 ng/mL, respectively). Patients were divided into 2 groups according to postoperative serum albumin corrected calcium concentrations: group 1 (n = 13) patients had postoperative serum calcium concentrations of 8 mg/dL or less; group 2 (n = 22) patients had serum calcium concentrations greater than 8 mg/dL. Bone turnover markers (deoxypiridinoline, bone-specific alkaline phosphatase) and 25-OHD were determined the day before surgery.nnnRESULTSnIn group 1 patients, disease duration was significantly longer, 25-OHD and postoperative parathyroid hormone concentrations were significantly lower, and bone turnover markers were significantly higher. Logistic regression analysis revealed that a postoperative parathyroid hormone concentration less than 10 pg/mL was the most powerful parameter to predict postoperative hypocalcemia (odds ratio, 23; 95% confidence interval, 3.3-156).nnnCONCLUSIONSnIn Graves patients with vitamin D deficiency/insufficiency, postoperative (transient) hypoparathyroidism is the most significant parameter to determine the development of postoperative hypocalcemia.

Radio-Guided Excision of Metastatic Lymph Nodes in Thyroid Carcinoma: A Safe Technique for Previously Operated Neck Compartments

BackgroundBetter follow-up of patients with papillary thyroid cancer (PTC) and more sensitive detection leads to detection of recurrences in the neck. Despite excellent outcomes, the major challenge is controlling locoregional recurrence. We aimed to investigate whether the radio-guided excision of metastatic lymph nodes makes it possible to find the affected lymph nodes in patients with previously operated neck compartments.MethodThis prospective study included 46 patients with recurrent/persistent PTC who had previously undergone operation of the neck compartment. Prior to operation, the pathologic node was localized by ultrasound (US) and radiotracer (99mTc-labeled rhenium colloid) was injected directly into the pathologic node. Careful dissection was carried out following the area of maximum radioactivity until the metastatic lymph node(s) were identified and excised.ResultOne affected lymph node was removed in 17 patients, and more than one lymph node (affected or additional nodes) was removed in 29 patients. The median count from the lesion was significantly higher than values from the lesion bed (background activity) (16,886 counts/20xa0s versus 52 counts/20xa0s; pxa0<xa00.001). During follow-up, four patients were lost to follow-up and 27 patients had negative US and basal thyroglobulin (Tg). Five patients had suspicious lymph nodes on the operated side. Although the basal Tg level remained above the normal limit, moderately high in 8 patients, no metastases were detected in the neck.ConclusionsRadio-guided excision of metastatic lymph nodes can be performed safely for the detection and excision of recurrent thyroid cancer in the central and lateral neck.

Local thrombolytic therapy in acute mesenteric ischemia.

BackgroundThe aim of the study was to evaluate the local thrombolytic therapy (LTT) in combination with laparoscopy, in management of acute mesenteric ischemia (AMI).MethodsFrom January 2000 to January 2010, patients who were admitted to the hospital with AMI due to acute arterial occlusion were analysed retrospectively. Patients presenting with acute abdomen with a suspicion of AMI were evaluated with computerized tomography angiography (CTA). Patients who had findigs of AMI on CTA, were underwent selective mesenteric angiography and LTT eventhough without peritoneal signs. LTT was carried out before or after laparoscopy or laparotomy, and initiated with recombinant plasminogen activator.ResultsLTT was performed in 13 (17.1%), out of 76 patients. From the remaining patients, 56 underwent necrotic bowel resection and 7 underwent tromboembolectomy. The median age was 62 years (45–87). The median duration of symptoms was 24 h. Four (30.7%) patients presented within 24 h onset of symptoms, whilst 9 (69.3%) patients presented after 24 h onset of symptoms. There were 5 (39.5%) patients, who presented with abdominal pain without peritoneal signs on physical examination and 8 (61.5%) patients, who had peritoneal signs. The mortality rate was 20% (1/5) in the first group who presented without peritoneal signs, whilst it was 62.5% (5/8) in the remaining.ConclusionEarly intervention in AMI is the key to better results. CTA combined with early laparoscopy and LTT may have beneficial effects at this setting.

The Effect of Retroperitoneal Fat Mass on Surgical Outcomes in Patients Performing Laparoscopic Adrenalectomy: The Effect of Fat Tissue in Adrenalectomy

Background: Obesity and visceral fat are thought to be the most important factors influencing the technical difficulty during open and laparoscopic surgery. The authors aimed to investigate the effect of retroperitoneal fat mass on surgical outcomes in patients undergoing laparoscopic adrenalectomy. Patients and methods: This prospective study included 51 consecutive patients who underwent lateral transabdominal laparoscopic adrenalectomy. Body mass index (BMI) and retroperitoneal fat area (RFA)/adrenal mass area (AMA) ratio were calculated. Results: There was a positive correlation between BMI and operating time and postoperative complications and hospital stay. According to 2-way analysis of variance, only RFA/AMA ratio (P = .0001) was found to significantly correlate with operating time, whereas BMI did not significantly correlate with operating time (P = .51). In patients with high BMI, high RFA indicated longer operating time and higher complication rate, whereas low RFA was associated with significantly shorter operating time and decreased risk of complications. Conclusion: Retroperitoneal fat mass is a more useful parameter than BMI for predicting the surgical outcomes of laparoscopic adrenalectomy.

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

INTRODUCTIONnNeurofibromatosis 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.nnnPRESENTATION OF CASEnA 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.nnnDISCUSSIONnIn patients with NF1, pheochromocytomas and GISTs are well known neoplasms seen with increased incidence than the general population.nnnCONCLUSIONnIn patients with NF1, any symptoms with other systems should be managed carefully for underlying malignity.

ERCP without radiation during pregnancy in the minimal invasive world

BackgroundThe current guidelines recommend endoscopic retrograde cholangiopancreatography (ERCP) procedures in pregnant women with minimal radiation exposure. Regarding the safety of ERCP during pregnancy, data are limited in the literature. In this study, we report our experience with five ERCP procedures performed in five pregnant women without radiation at a single tertiary health center.MethodsBetween May 2007 and February 2012, five pregnant patients underwent ERCP without radiation, analyzed retrospectively. Clinical disease was confirmed with either pre-procedure ultrasonography and magnetic resonance cholangiopancreatography in all patients. In all cases, selective deep cannulation was performed and confirmed by the aspiration and/or direct visualization of the bile. The data regarding laboratory, ultrasonography, magnetic resonance imaging, endoscopic findings, and clinical course of the patients were analyzed. Fetal complications were noted at delivery and 30xa0days postdelivery follow-up.ResultsThe mean patient age was 26xa0years (22–33) and the mean duration of pregnancy was 20xa0weeks (12–32). In all cases, no secondary ERCP procedures were needed. Also, no maternal and fetal adverse events and complications were determined after the procedures or on follow-up. All stages of the procedure including cannulation, sphincterotomy, and stone extraction were performed without the use of fluoroscopy.ConclusionAs far we know, there is no report in the literature regarding the failure of endoscopic retraction of stones without fluoroscopy during pregnancy. Our series notes that ERCP is safe and prevents recurrent biliary pancreatitis during pregnancy. Unfortunately, due to the small limited number of patient data, our study notes the requirement of further large randomized and controlled series.

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.

Curative surgery for locally advanced retroperitoneal mature teratoma in an adult. Case report

INTRODUCTIONnPrimary teratomas of retroperitoneum are not usual in the adult population. These tumors most commonly seen at the gonadal and sacrococcygeal regions. Herein we describe a case of an 18-year-old female who had a benign cystic teratoma at the retroperitoneum.nnnPRESENTATION OF CASEnThe patient underwent an operation at another hospital following a misdiagnosis of hydatid cyst. The patient was referred to our hospital because of the detection of an unresectable tumor during her operation. A computerized tomography (CT)-angiography revealed a cystic mass, with a diameter of 14cm which was invaded into the retrohepatic suprarenal inferior vena cava and also extended to the posterior aspect of the liver. Additionally the mass invaded the posterior wall of the inferior vena cava and the right renal vein. The tumor was completely resected with a vascular resection. The inferior vena cava was reconstructed with a 12cm Dacron(®) graft and the renal vein was implanted. The patients postoperative period was uneventful.nnnDISCUSSIONnGerm cell tumors of retroperitoneum are usually seen in children, but there are also some reports of adult cases in the literature. Adult cases are especially seen in females. Imaging studies are paramount for diagnosis, preoperative strategy and safe surgical excision. CT scans and MRIs can identify various components of these tumors.nnnCONCLUSIONnEven though primary retroperitoneal teratomas are quite rare in adults. Preoperative radiology imaging and strategy is critical for performing a safe surgery. The gold standard treatment strategy for this neoplasm is the surgical resection.

Safety and feasibility of laparoscopic adrenalectomy: What is the role of tumour size? A single institution experience.

Background: Although, there are studies in the literature having shown the feasibility and safety of laparoscopic adrenalectomy, there are still debates for tumour size and the requirement of the minimal invasive approach. Our hypothesis was that the use of laparoscopy facilitates minimally invasive resection of large adrenal tumours regardless of tumour size. Materials and Methods: Within 7 years, 149 patients underwent laparoscopic adrenalectomy at one institution. The patients were divided into two study groups according to tumour size. Group 1 included patients with adrenal tumours smaller than 5 cm and group 2 included larger than 5 cm. Patient demographics and clinical parameters, operative time, complications, hospital stay and final pathology were analysed. Statistical analyses of clinical and perioperative parameters were performed using Student′s t-test and Chi-square tests. Results: There were 88 patients in group 1 and 70 in group 2. There were no significant differences between study groups regarding patient demographics, operative time, hospital stay, and complications. Estimated blood loss was significantly higher in group 2 (P = 0.002). The conversion to open rate was similar between study groups with 5.6% versus 4.2%, respectively. Pathology was similar between groups. Conclusion: Our study shows that the use laparoscopy for adrenal tumours larger than 5 cm is a safe and feasible technique. Laparoscopic adrenalectomy is our preferred minimally invasive surgical approach for removing large adrenal tumours.