Özer Makay

Traumatic diaphragmatic rupture: look to see

OBJECTIVE Traumatic diaphragmatic rupture (TDR) is a rare but potentially life threatening clinical entity with a high incidence of associated injuries. In this article, our experience with this challenging diagnosis is presented. METHODS In this study, a total of 68 patients with TDR, were operated in our center between July 1994 and September 2005. Study group was analyzed retrospectively. The etiological factors, management and outcomes were discussed. RESULTS The mean age was 32.9 years with a female to male ratio of 9/59. TDR was right-sided in 16.2% (n=11) and left-sided in 83.8% (n=57). The cause of the rupture was penetrating trauma in 51 (75%), and blunt trauma in 17 (25%). Only three patients (4.4%) had late diagnosis. Associated injuries were seen in 91% (n=62) of the patients. The most common used incision was a laparotomy incision (89.6%). Morbidity and mortality were encountered in 13.1% (n=9) and 16.2% (n=11) patients, respectively. CONCLUSIONS Although rare, diaphragmatic rupture must be suspected in any patient with thoracoabdominal injury. Early diagnosis of TDR is sometimes difficult and depends on a high index of suspicion. Surgical repair is necessary even for small tears. The most common approach is the transabdominal approach, which allows a complete exploration of the abdominal organs for associated injuries. The transthoracic approach might be used in most cases with latent diaphragmatic rupture.

The recurrent laryngeal nerve and the inferior thyroid artery--anatomical variations during surgery.

Background and aimsRecognition of variations of the inferior laryngeal nerve is essential. We aimed to investigate the relationship of the inferior laryngeal nerve with the inferior thyroid artery.Materials and methodsA study was undertaken between August 2005 and August 2006. A total of 253 adult patients undergoing thyroid surgery were included in this prospective, non-randomized study. Both sides of the thyroid gland were considered separately.ResultsSixteen variations of the nerve were clarified. In the most observed variation, the nerve was deep to the artery. Two and three nervous branches were seen in 22.5% and 1.6% of the patients, respectively. Bifurcation of the nerve was mostly observed on the left side. No non-recurrent laryngeal nerve was found.ConclusionTo avoid the risk of nerve damage during thyroid surgery, a good knowledge of the variations of the inferior laryngeal nerve is essential. This is important to achieve an undisturbed quality of life for the thyroid patient.

Clinical Characterization of the Pheochromocytoma and Paraganglioma Susceptibility Genes SDHA, TMEM127, MAX, and SDHAF2 for Gene-Informed Prevention

Importance Effective cancer prevention is based on accurate molecular diagnosis and results of genetic family screening, genotype-informed risk assessment, and tailored strategies for early diagnosis. The expanding etiology for hereditary pheochromocytomas and paragangliomas has recently included SDHA, TMEM127, MAX, and SDHAF2 as susceptibility genes. Clinical management guidelines for patients with germline mutations in these 4 newly included genes are lacking. Objective To study the clinical spectra and age-related penetrance of individuals with mutations in the SDHA, TMEM127, MAX, and SDHAF2 genes. Design, Setting, and Patients This study analyzed the prospective, longitudinally followed up European-American-Asian Pheochromocytoma-Paraganglioma Registry for prevalence of SDHA, TMEM127, MAX, and SDHAF2 germline mutation carriers from 1993 to 2016. Genetic predictive testing and clinical investigation by imaging from neck to pelvis was offered to mutation-positive registrants and their relatives to clinically characterize the pheochromocytoma/paraganglioma diseases associated with mutations of the 4 new genes. Main Outcomes and Measures Prevalence and spectra of germline mutations in the SDHA, TMEM127, MAX, and SDHAF2 genes were assessed. The clinical features of SDHA, TMEM127, MAX, and SDHAF2 disease were characterized. Results Of 972 unrelated registrants without mutations in the classic pheochromocytoma- and paraganglioma-associated genes (632 female [65.0%] and 340 male [35.0%]; age range, 8-80; mean [SD] age, 41.0 [13.3] years), 58 (6.0%) carried germline mutations of interest, including 29 SDHA, 20 TMEM127, 8 MAX, and 1 SDHAF2. Fifty-three of 58 patients (91%) had familial, multiple, extra-adrenal, and/or malignant tumors and/or were younger than 40 years. Newly uncovered are 7 of 63 (11%) malignant pheochromocytomas and paragangliomas in SDHA and TMEM127 disease. SDHA disease occurred as early as 8 years of age. Extra-adrenal tumors occurred in 28 mutation carriers (48%) and in 23 of 29 SDHA mutation carriers (79%), particularly with head and neck paraganglioma. MAX disease occurred almost exclusively in the adrenal glands with frequently bilateral tumors. Penetrance in the largest subset, SDHA carriers, was 39% at 40 years of age and is statistically different in index patients (45%) vs mutation-carrying relatives (13%; P < .001). Conclusions and Relevance The SDHA, TMEM127, MAX, and SDHAF2 genes may contribute to hereditary pheochromocytoma and paraganglioma. Genetic testing is recommended in patients at clinically high risk if the classic genes are mutation negative. Gene-specific prevention and/or early detection requires regular, systematic whole-body investigation.

Is testicular perfusion influenced during laparoscopic inguınal hernia surgery

BackgroundThe influence of laparoscopic inguinal hernia surgery is still unclear. The aim of this study was to compare the possible early effects of laparoscopic and open inguinal hernia repair on testicular perfusion.MethodsIn this prospective trial, 44 patients underwent mesh repair of a primary inguinal hernia assigned to one of two procedures: open anterior mesh repair (n = 29) or a laparoscopic totally extraperitoneal approach (n = 15). Doppler ultrasound was used to determine the hemodynamic characteristics of the testicular blood flow.ResultsNo statistically significant differences were found between the two groups in terms of Doppler flow parameters for the preoperative, very early (day 1), and early postoperative (day 7) periods. When Doppler flow parameters of the testicular artery were compared in the conventional group, statistically significant differences were found between preoperative and very early postoperative values (p < 0.05). Meanwhile, comparison among flow parameters of the testicular, capsular, and intratesticular arteries of the laparoscopic group showed statistically significant differences between preoperative and very early postoperative and between preoperative and early postoperative values (p < 0.05). There were no statistically differences in postoperative complications between the two groups.ConclusionTesticular blood flow is influenced during laparoscopic inguinal hernia surgery. Whether changes in flow parameters remain in the late postoperative period, and whether they have an impact on complications will be evaluated in further studies.

Is D-dimer a predictor of strangulated intestinal hernia?

BackgroundThe goal of this study was to assess the relevance of serum D-dimer measurement as a possible reliable marker for the diagnosis of strangulated intestinal hernia.MethodsConsecutive patients admitted with nontraumatic acute abdominal gastrointestinal disorders were recruited prospectively in a tertiary referral hospital. The study was conducted in 159 patients between August 2002 and April 2004. D-dimer, lactate dehydrogenase, serum amylase, and international normalized ratio (INR) levels were tested in the emergency room prior to surgical intervention. For each patient, 15 variables, including D-dimer, were available for analysis.ResultsThirty-three (20.7%) of the 159 patients had intestinal ischemia, and 28 (85%) of these 33 patients had D-dimer level > 300 ng/ml. Plasma levels of D-dimer in patients with intestinal ischemia were significantly higher than in patients without ischemia (P < 0.05). There were 29 (18.2%) patients in the hernia group with incarceration (n = 22) or strangulation requiring resection (n = 7). D-dimer levels in patients requiring intestinal resection were insignificantly higher than in patients without resection (P > 0.05). Six (85%) of the 7 hernia patients requiring resection had D-dimer levels > 360 ng/ml. The D-dimer variable correlated best with the leukocyte count in patients with hernia requiring resection. Levels of lactate dehydrogenase, serum amylase, and INR did not show any correlation with D-dimer levels.ConclusionsTo help predict ischemic events, the increasing use of the D-dimer assay in clinical practice could be extended to patients presenting with intestinal emergencies. An elevated D-dimer level on admission had a high sensitivity for identifying patients with intestinal ischemia, although it had a low specificity. Whether it is predictive or preventive for resection in strangulated intestinal hernia patients still remains a question.

Leiomyosarcoma of the inferior vena cava: report of a case.

We report a case of leiomyosarcoma of the inferior vena cava, which was successfully treated by surgical en bloc resection and reconstruction of the inferior vena cava, followed by adjuvant radiation therapy. A 39-year-old man presented with nausea, vomiting, epigastric pain, and weight loss. Radiologic examinations showed a mass originating from the inferior vena cava and surgical resection was performed. Histopathological examination of the specimen revealed a moderately differentiated (grade II) leiomyosarcoma arising from the inferior vena cava. We believe that radical resection with clear surgical margins followed by adjuvant radiation therapy is a good curative strategy for achieving any chance of long-term survival.

Surgeon's View on the Limitations of Left-Handedness During Endoscopic Surgery

BACKGROUND The influence of endoscopic surgery on left-handedness is unclear. The aim of this study was to investigate the role of left-handedness during endoscopic surgery. MATERIALS AND METHODS A survey distributed during the 15th Congress of the Turkish Society of Surgery, held in 2006, was conducted to 194 participants. The survey was focused on hand preference and endoscopic surgery. Besides demographic data and use of endoscopy, lateral predominance, questions related to surgical performance (open and endoscopic), training support during residency, and operating room experiences during endoscopic surgery were assessed. RESULTS The laterality preference in performing surgery was left in 9.3% (n = 18). Almost 50% of the left-handed surgeons believed that endoscopic surgery needs to be modified for the left-handed endoscopic surgeon, although 66% reported they had no difficulty while using endoscopic instruments and did not need any modification during surgical endoscopy. Over 86% of all surgeons reported that laterality had no importance for them if they were a patient undergoing endoscopic surgery, while 14% of surgeons refused to be operated on by a left-handed surgeon. CONCLUSION Endoscopic surgery has impact on laterality-related comfort, and technical modifications are warranted for left-handed surgeons. Further research is needed to address questions related to hand dominance in surgical endoscopic skill performance that allows more comprehensive conclusions.

Effects of ropivacaine on pain after laparoscopic cholecystectomy: A prospective, randomized study

Postoperative pain after laparoscopic cholecystectomy is an ongoing problem. To relieve this pain, practitioners have used many anesthetic and analgesic drugs. This study was undertaken to assess the effects of incisional and intraperitoneal administration of ropivacaine on postoperative pain and stress response in patients undergoing laparoscopic cholecystectomy. In this prospective, singleblinded, randomized study, 45 patients with ASA (American Society of Anesthesiologists) scores I and II who were about to undergo laparoscopic cholecystectomy were divided into 3 groups. After cholecystectomy, a total of 40 mL of 3.75% ropivacaine was administered preincisionally and intraperitoneally to patients in group 1 (n=14); preincisionally and intraperitoneally to patients in group 2 (n=17); and intraperitoneally and locally at incision sites to patients in group 3 (n=14). Blood levels of epinephrine and norepinephrine were examined preoperatively, 15 min after insufflation, and at the end of the operation. Visual analog pain scale scores and analgesic requirements were used for 24-h postoperative follow-up of pain levels reported by patients. No statistically significant difference was found among the 3 groups with respect to visual analog pain scale scores, total analgesic requirements, and accompanying pain, nausea, and vomiting. The earliest analgesic requirements were seen in group 2 (P < .005), and less shoulder pain was noted in group 3 (P < .005). Norepinephrine and epinephrine levels showed no statistically significant differences between the 3 groups. Administration of ropivacaine preoperatively and postoperatively for laparoscopic cholecystectomy has similar effects on postoperative pain and the stress response of patients.

Completion thyroidectomy for thyroid cancer.

Abstract Background: Whether thyroid re-operations are associated with an increased complication risk is controversial. The aim of this study was to perform a retrospective analysis of patients undergoing re-operative surgery of the thyroid. We analyzed the safety and the impact of delay on complications before undertaking radicalization thyroidectomy. Material and Methods: From January 1996 to July 2002, 150 consecutive patients with thyroid cancer were treated in our institution. A total of 62 patients underwent completion thyroidectomy. Twenty-seven had undergone their initial operation in our centre. Medical and pathologic data were obtained retropectively. Results: Pathological examination of the specimen after completion surgery revealed malignancy in a total of 35% of 62 patients. The time interval between initial surgery and completion thyroidectomy ranged from 5 days to 24 months (mean 3.1 months). Complications after re-operation were transient recurrent nerve injury in 1.6%, transient hypoparathyroidism in 4.8%, permanent hypoparathyroidism in 1.6% and chylous discharge in 1.6% of the patients. There was no significant difference between complication rates in patients operated on within 90 days or those operated on after this period (p > 0.05). Conclusions: This study suggests that completion thyroidectomy is safe in the hands of experienced endocrine surgeons and the timing of re-operation has no impact on the development of complications.

Foreign bodies in the rectum: An analysis of 30 patients

PurposeA foreign body in the rectum is a rare clinical entity. These foreign bodies can be classified under two major groups: the ones that are inserted from the anus and the ones that are swallowed and thereafter become stuck in the rectum.MethodsData of patients admitted with a foreign body in the rectum between 1988 and 2008 were retrospectively analyzed. A total of 30 patients were reviewed.ResultsThe most common reason for a foreign body in the rectum was insertion for erotic purposes, which was seen in 19 of the 30 patients. All these patients were male. The remaining 11 patients reported nonerotic causes. The most efficient and implemented therapeutic method was simple extraction during the first examination.ConclusionsThe most common reason for a foreign body in the rectum is insertion for erotic purposes. The first target of therapy should be extraction of the foreign body using the simplest method possible. Meanwhile, protecting the integrity of the intestine is of the utmost importance. The care for maintaining the integrity of the rectum should include an evaluation of the patient’s psychological status.