Arterial blood gas analysis predicts futile recanalization in mechanical thrombectomy-treated acute ischemic stroke patients: a multicenter study

OBJECTIVE: It is known that providing recanalization alone in large vessel occlusions is not sufficient to provide a good 90-day clinical outcome. It is advocated that neuroprotection should be increased before endovascular treatment and that the penumbra should be protected from reperfusion damage after recanalization. However, the effects of blood gas parameters before and after mechanical thrombectomy on clinical outcomes are not clear. The objective of this study is to assess the effectiveness of serial blood gas measures in accurately predicting futile recanalization at an early stage. PATIENTS AND METHODS: This study is a multicenter inquiry that collected data in a prospective manner and analyzed it retrospectively. Patients with a 2b-3 thrombolysis in cerebral infarction (TICI) score after mechanical thrombectomy for recanalization were consecutively analyzed from July 2022 to March 2023. Arterial blood gas parameters, including pH, oxygen saturation (SaO2), partial carbon dioxide pressure (PaCO2), partial oxygen pressure (PaO2), lactate, and bicarbonate (HCO3), were measured at four time points: before mechanical thrombectomy treatment (preoperative), immediately after recanalization (postoperative 1st), during the 3rd hour (postoperative 3rd), and at the 5th hour (postoperative 5th). The patients were categorized into groups based on their modified Rankin Scale (mRS) scores. RESULTS: The study included 136 patients with an average age of 69.71±11.22. The postoperative 1st-hour SaO2 values were lower in the mRS 3-6 group (p=0.038). The postoperative pH and lactate mean were greater in the mRS 3-6 group than in the 0-2 group (p=0.038 and 0.018, respectively). In logistic regression, a unit rise in lactate increased poor functional outcomes 1,632 times (p=0.024). Early neurological recovery was associated with decreased postoperative 3rd-hour lactate (p=0.014). The mean postoperative PaO2 (average of 1, 2, 3 PaO2) was higher in those with symptomatic cerebral bleeding (p=0.044). CONCLUSIONS: Monitoring lactate and pH levels in AIS patients who have had mechanical recanalization can be utilized to predict mortality and morbidity, especially in the first five hours after the procedure.

Graphical Abstract

https://www.europeanreview.org/wp/wp-content/uploads/Graphical-abstract-8.jpg.

The relationship between albumin and its proportion to other markers in predicting mortality in severe COVID-19 patients

OBJECTIVE

The aim of the present study was to investigate the relationship between albumin, blood urea nitrogen (BUN)/albumin ratio (BAR), D-dimer/albumin ratio (DAR), C-reactive protein (CRP)/albumin ratio (CAR), and neutrophil/albumin ratio (NAR) levels and prognosis in severe COVID-19 cases.

PATIENTS AND METHODS

A total of 619 patients diagnosed with severe COVID-19 in the emergency department were retrospectively analyzed. BAR, DAR, CAR, and NAR values were obtained by dividing BUN, neutrophil, CRP, and D-dimer by albumin. All patients were divided into groups [survived and deceased patients, and those who received and did not receive mechanical ventilation (MV) assistance]. These groups were statistically compared with regard to albumin, BAR, DAR, CAR, and NAR.

RESULTS

While 350 out of 619 patients survived, 269 patients died. A statistically significant difference was determined between survived and deceased patient groups with regard to BUN, neutrophil, lymphocyte, CRP, D-dimer, albumin, BAR, NAR, DAR, and CAR levels (p<0.001 for all). Also, BAR, NAR, DAR, and CAR were significantly higher in those who received MV support, while albumin was found to be low (p<0.001). According to receiver operating characteristic (ROC) analysis, NAR, BAR, CAR, albumin, and DAR had the highest area under the curve (AUC) values compared to the other parameters (0.825, 0.815, 0.806, 0.772, and 0.770, respectively) (p<0.001 for all). According to logistic regression analysis, BAR, NAR, DAR, and CAR levels were determined as important risk factors for mortality.

CONCLUSIONS

Low serum albumin levels can be used for severity as an additional tool in severe COVID-19 patients. Moreover, the NAR, BAR, and CAR levels were found to be more valuable than albumin levels in predicting prognosis in these patients.

A randomized controlled trial examining the impact of low vs. moderate-intensity aerobic training in post-discharge COVID-19 older subjects

OBJECTIVE

Post-COVID-19 patients complained of pain, fatigue, breathlessness, and reduction in quality of life which required planned intervention. This study aimed to compare the impact of 10 weeks of low vs. moderate-intensity aerobic training on physical fitness, psychological status, and quality of life in post-COVID-19 older subjects.

PATIENTS AND METHODS

72 patients were randomized into 3 equal groups, moderate-intensity exercise (MIG, n = 24), low-intensity exercise (LIG, n = 24), and control group (CG, n = 24). The exercise was done 40 min/4 times per week for 10 weeks. We measured exercise capacity using the six-minute walking test, 1 min sit-to-stand test, post-COVID-19 functional scale (PCFS), and quality of life using the SF-36 questionnaire and HAMILTON Anxiety and Depression Scale (HADS).

RESULTS

There was no difference between groups regarding the demographic and most clinical characteristics of the subjects. Compared with CG there were statistically significant improvements in studying groups (MIG and LIG) with (p < 0.05) in most outcomes and the improvement was higher in MIG than in LIG in most outcomes.

CONCLUSIONS

10-week moderate-intensity and low-intensity aerobic training programs are effective with superior effect to moderate-intensity. Moderate-intensity aerobic exercise is more effective and feasible in post-discharge COVID-19 older subjects regarding exercise capacity, quality of life, and psychological status than low-intensity aerobic exercise.

A rare location of papillary carcinoma: Thyroglossal duct cyst

The inadequate closure of the thyroglossal tract paves the way for a thyroglossal cyst. Thyroglossal duct cyst (TDC) malignancy is quite rare. A thirty-nineyear-old female patient was admitted to the polyclinic with a complaint of palpable mass in the neck. Findings compatible with TDC were determined in the patient's neck screening and it was considered to be malignant due to irregular margins, apparent vascularization and punctual calcifications. Fine needle aspiration biopsy was unremarkable. TDC was excised by Sistrunk procedure and frozen examination was performed. Total thyroidectomy was performed additionally since the result of the frozen examination was found to be compatible with the primary papillary carcinoma of TDC. If preoperative biopsy does not provide a diagnosis, frozen section study will be beneficial in terms of both providing the early diagnosis and directing the operation strategy during the surgery in clinically or radiologically suspected patients.

Coexistence of Colon Perforation and Congenital Lipodystrophy

Lipodystrophy (LD) is an acquired or congenital rare condition consisting of hyperlipidaemia, glucose intolerance/ insulin resistance, and almost complete absence and storage of adipose tissue. Colon perforations can be observed in type 4 congenital LD. Here, we aimed to present a case of sigmoid colon perforation which developed in a young woman with the diagnosis of LD. Extensive purulent peritonitis, significant wall thickening, and oedema in the sigmoid colon were detected during surgical exploration. Anterior resection with end colostomy procedure was then performed. Although bowel perforation has been theoretically reported to occur in LD, the presented case is the first adult patient in the literature. These individuals tend to develop colon perforation as a result of histological changes in their gastrointestinal tract. This situation should always be taken into consideration in order to avoid delay in diagnosis, especially in patients who present with abdominal pain and have a history of LD. Key Words: Intestinal perforation, Congenital lipodystrophy, Peritonitis, Sigmoid colon.

Predictive value of systemic immune-inflammation index for cerebral reperfusion and clinical outcomes in patients with acute ischemic stroke undergoing endovascular treatment

OBJECTIVE

The systemic immune inflammation (SII) index has been an excellent prognostic indicator in patients with acute ischemic stroke (AIS). In this study, we assessed the utility of the SII in predicting the prognosis and reperfusion status of patients with AIS who underwent endovascular treatment (EVT).

PATIENTS AND METHODS

123 consecutive AIS patients were enrolled in our study. The receiver-operating characteristics (ROC) curve was used to determine the cut-off value of SII for predicting unsuccessful cerebral reperfusion. Multivariate logistic regression analysis analyzed the association between SII and unsuccessful reperfusion rate after EVT.

RESULTS

The median value of SII was significantly higher in patients with unsuccessful reperfusion compared to patients with successful reperfusion [2,029 (1,217-2,771) vs. 1,172 (680-2,145) respectively, p=0.003)]. A ROC curve analysis showed that the best cut-off value of SII for predicting unsuccessful reperfusion status was 1,690, with sensitivity and specificity of 71% and 69%, respectively. The area under the curve (AUC) was 0.673 (95% CI; 0.552-0.793). Multivariate analysis demonstrated that SII ≥ 1,690 value was an independent predictor of unsuccessful cerebral reperfusion and unfavorable clinical outcome after EVT (Hazard ratio - H.R.=3.713, 95% CI: 1.281-10.76, p=0.016, HR=2.28, 95% CI: 1.06-4.88, p=0.035, respectively).

CONCLUSIONS

We suggested that SII is a potential indicator to predict the unsuccessful cerebral reperfusion and unfavorable clinical outcome for patients with AIS undergoing EVT.

Comparison of COVID-19 patients who underwent thrombectomy with those in the pre-pandemic period in terms of etiology and prognosis

OBJECTIVE

We aimed at determining the effectiveness of mechanical thrombectomy (MT) in patients with major vessel occlusion and infected with COVID-19, evaluating its clinical outcome and comparing it with non-COVID patients.

PATIENTS AND METHODS

During the pandemic, 729 patients who underwent MT in stroke centers due to Acute Ischemic Stroke (AIS) with large vessel occlusion were evaluated. This study included 40 patients with a confirmed COVID-19 diagnosis by a positive PCR test between March 11, 2020, and December 31, 2020. These patients were compared to 409 patients who underwent MT due to major vessel occlusion between March 11, 2019, and December 31, 2019.

RESULTS

Of the patients with AIS who are infected with COVID-19, 62.5% were males, and all patients have a median age of 63.5 ± 14.4 years. The median NIHSS score of the COVID-19 group was significantly higher than that of the non-COVID-19 groups. Dissection was significantly more in the COVID-19 group. The mortality rates at 3 months were higher in the COVID-19 groups compared to non-COVID-19 groups.

CONCLUSIONS

This study revealed an increased frequency of dissection in patients with COVID-19. COVID-19-related ischemic strokes are associated with worse functional outcomes and higher mortality rates than non-COVID-19 ischemic strokes.

How childhood trauma and emotions influence essential tremor and its severity in Sakarya Province

OBJECTIVE

Essential tremor (ET) is among the most common central nervous system disorders. It is characterised by symmetrical and bilateral postural tremor, usually affecting the hands. Alongside such motor symptoms, psychiatric symptoms, such as anxiety and depression, often occur. This study aimed to investigate how anxiety, depression and childhood trauma influence ET patients' tremor frequency and severity.

PATIENTS AND METHODS

The participants comprised 85 patients and 70 control volunteers. Participating patients have been admitted to our clinic for hand tremor complaints and diagnosed with ET, according to the Washington Heights Inwood Genetic Study of Essential Tremor (WHIGET) diagnosis criteria, and they returned for follow-up for at least one year after their initial treatment. Patients with thyroid dysfunction, Parkinson's disease, central nervous system pathology, a history of smoking or alcohol use or a history of drug use that may cause tremor were excluded from the study. Patients' demographic data, such as their age and gender, age at disease onset, disease duration, family history and tremor severity were recorded. The Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI) and Childhood Trauma Questionnaire (CTQ) were applied to all patients.

RESULTS

Statistically significant differences were found in BDI score averages and BAI score averages between the patient and control groups (p = 0.002; p = 0.001) and physical abuse, emotional neglect and sexual abuse scores on the CTQ scale (p = 0.001, p = 0.007 and p = 0.001, respectively).

CONCLUSIONS

Childhood mental trauma and emotional mood disorders are more common among ET patients. However, these disorders do not appear to affect ET severity.

Should coronary catheter laboratories be used in the treatment of ischemic stroke? Endovascular treatment in acute ischemic stroke performed by interventional cardiologists

OBJECTIVE

The aim of this study was to investigate the technical success and in-hospital outcomes of endovascular thrombectomy (ET) in acute ischemic stroke (AIS) patients performed by interventional cardiologists.

PATIENTS AND METHODS

ET for AIS provides fast, effective and safe recanalization. Insufficient number of catheter laboratories for stroke interventions and experienced interventional neurologists are limiting the widespread application of such a promising treatment method.

RESULTS

123 patients with AIS and eligible for ET were evaluated retrospectively. 65 patients were female (52.8%) and the mean age of the patients was 71.5 ± 11.9 years. Most of the patients had a middle cerebral artery (MCA) occlusion (112 patients, 91%). Successful recanalization (thrombolysis in cerebral infarction grading 2b or higher) was achieved in 109 patients (88.6%). Access site complication was observed only in 3 patients (2.4%). Intracranial bleeding was observed in 17 patients (13.8%) and only 8 of them were symptomatic (6.5%). In-hospital death occurred in 19 patients (15.4%). The initial National Institutes of Health Stroke Scale (NIHSS) was 16.8±3.3 (median 18) which improved significantly to 10.4±7.2 (median 11) at 24 hours (p<0.001). Dramatic neurologic improvement was observed in 60 of 123 patients (48.8%). The modified rankin score of the patients was significantly lower at discharge compared to admission (4.2±0.7 vs. 2.9±2, p<0.001).

CONCLUSIONS

ET in AIS can be performed safely with high success rates by trained interventional cardiologists within the stroke team. Until the number of stroke centers is sufficient, endovascular treatment of AIS can be supported by experienced interventional cardiologists.

Comparison of laparoscopic and open resections for gastric gastrointestinal stromal tumors (GISTs)

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are the most common mesencyhmal tumors of the gastrointestinal tract. Today surgical resection is still the treatment of choice for primary gastric GISTs. This study compares the laparoscopic versus open surgical resection approaches of gastric GISTs.

METHODS

A retrospective chart review was conducted from our database, and 68 primary gastric GIST resections were found to be performed in our center between 2008- 2020. Of these 68 patients, 57 were included for the study. Open resection was performed in 32 patients, and laparoscopic resection was performed in 25 patients. The medical records were examined and compared for clinical, pathologic and surgical results according to preferred surgical method of choice.

RESULTS

Fifty-seven patients were qualified for the study. The average diameter of the tumor was 4.8   1.91 cm in the laparoscopic group, and 6,8   4,27 cm in open group. Estimated blood loss during the surgery was significantly lower in laparoscopic group patients (100.7 ml vs 287.5 ml) (p< 0.001) and also length of stay was shorter compared with open at 4.4 versus 11.9 days (p < 0.001). Laparoscopic group patients needed less pain medication, and they had quicker return to daily life.

CONCLUSIONS

Laparoscopic approach is safe and feasible with acceptable oncologic outcomes and certain benefits like decreased length of stay, less complication rates and better comfort. The preference of laparoscopic resection should be decided not only on tumor location or diameter but also surgeon's laparoscopic surgical experience.

KEY WORDS

Laparoscopic, Gastric resection, GISTs.

Specialist physicians battle against the COVID-19 pandemic: the relationship between specialist physicians working conditions and levels of burnout during the COVID-19 pandemic

OBJECTIVE

This study was planned to determine the burnout levels of physicians during the COVID-19 pandemic, and to contribute to taking the necessary measures by determining the associated factors.

MATERIALS AND METHODS

This research was designed via Google Online Form as an online survey with questions of Sociodemographic Data Form, Maslach Burnout Inventory and Beck Anxiety Inventory and was conducted with 40 specialist physicians actively working at the Sakarya University Training and Research Hospital. The same questionnaire was re-applied online after two months, and 24 out of 40 physicians were accessed. The SPSS 25 (IBM, Armonk, NY, USA) program was used for the analysis of the data.

RESULTS

According to the Maslach Burnout Inventory applied in the pre-test, it was found that the feeling of personal accomplishment was high, emotional burnout was normal, and depersonalization was low. Anxiety and burnout were found to be positively correlated, and there were no statistically significant differences in the average values of the pre-and post-test Maslach Burnout Inventory and Beck Anxiety Inventory scores.

CONCLUSIONS

Detecting possible burnout in physicians working in a pandemic, identifying associated factors and taking required measures can be beneficial both for physicians and society from a biopsychosocial perspective.

Clinical outcome of gallstone ileus; a single-centre experience of case series and review of the literature

BACKGROUND

Gallstone ileus (GI) is a rare entity which is seen in 0.5% of patients with cholelithiasis. In this study, we aimed to share our clinical approach to GI, to present our long-term results and to draw clinicians' attention to this rare entity.

MATERIALS AND METHODS

This study included 11 patients with GI whose medical records were evaluated retrospectively.

RESULTS

Majority of the 11 patients were female (63.7%, n:7) and the mean age was 71.9 ± 14.10 (range: 50-91). Most common presenting complaints were vomiting (n: 9) and abdominal pain (n: 9). The mean interval from the onset of symptoms to the hospital admission was 3.8 ± 0.75 (range 3-5) days. Rigler triad in abdominal computed tomography (CT) was detected in all cases. Enterolithotomy, one-step procedure and conservative treatment were performed in five (45.4%), four (36.3%) and two (18.1%) patients, respectively. Enterolithotomy group was found to have higher risk according to American Society of Anesthesiologists (ASA) classification, shorter operation time and less intraoperative blood loss.

CONCLUSION

Although enterolithotomy is the first choice for patients with GI, one-step procedure should be kept in mind as a more advantageous technique in low-risk patients.

Do tumor localization, microsatellite instability and mismatch repair deficiency have an impact on the prognosis of colorectal cancer?

Background

Recent reports have shown that left-and right-sided colon cancers display different clinical and biological features. Chromosomal instability, epigenetic alterations, and defects in the deoxyribonucleic acid (DNA) mismatch repair (MMR) system may lead to the development of colorectal cancer (CRC). Besides microsatellite instability (MSI) caused by DNA MMR activity degradation increases the risk for CRC.

Aim

We aimed to show the differences between CRCs in different locations, to research the cause of these differences, to present whether there is a relation between MMR and MSI, and to evaluate their effects on prognosis.

Patients and Methods

641 CRC cases were divided into three groups: Group 1 (right-sided), Group 2 (left-sided), and Group 3 (rectum). Demographics, cancer stages, location of the tumors, number of the lymph nodes removed, MMR deficiency or proficiency, MSI status, and survival were assessed by retrospective review of the patients.

Results

Among 641 patients, 64.9% were males. Group 1, 2, and 3 comprised 31.2%, 45.7%, and 23.1% of all the cases, respectively. There was a significant difference in terms of survival and location only in stage II tumors. Stage II left colon cancer (LCCs) had a statistically significant lower survival rate. There was no significant difference in survival between both MSI and MMR statuses. In addition, cases were also stratified by stages. According to this data, 10.1, 45.7, and 44.2% of the patients had stages I, II, and III disease, respectively.

Conclusions

Although it was not statistically significant, tumors with MMR deficiency (dMMR) and high microsatellite instability (MSI-H) are more common in right-sided colon tumors.

Is subtotal cholecystectomy safe and feasible? Short- and long-term results

BACKGROUND

Cholecystectomy is one of the most commonly performed surgical procedures. However, it may result in some unpleasant conditions such as bile duct injury (BDI), bile leak, and vessel injury. Subtotal cholecystectomy (SC), which has been introduced as an alternative method for reducing the complication rates, has been reported to have lower risk of BDI when compared to total cholecystectomy. This study aimed to evaluate the indications for SC, its early and late complications and their management, and the risk factors affecting the bile leak.

METHODS

Fifty-seven patients who underwent SC were included in the study, and their medical records were retrospectively reviewed.

RESULTS

Thirty-three patients were male (57.9%) and the mean age was 64.84 ± 11.35 (range: 29-86). All patients had at least one episode of cholecystitis. Forty-seven (82.5%) patients underwent surgery under emergency conditions. Postoperative bile leak/fistula, surgical site infection, and fluid collection were developed in 12 (21.1%), eight (14%), and six (10.5%) patients, respectively. Leaving the remnant tissue pouch open, presence of comorbidity and emergency operative condition were found to increase the risk of leak development (P < .001). During the average follow-up of 49 months (range: 13-98), symptomatic choledocholithiasis, symptomatic gallstones in the remnant tissue, and incisional hernia were detected within the first year of surgery in three (5.3%), four (7%), and seven (12.3%) patients, respectively.

CONCLUSIONS

Although SC is not an equivalent to total cholecystectomy, its vital benefit of lowering the risk of BDI should be considered in difficult cases.

The factors that affect the mortality of emergency operated ASA 3 colon cancer patients

Introduction

colorectal cancers take third place among cancer-related deaths and 10-28% of these patients are admitted with the necessity of emergency surgical intervention. The main propose of this study was to investigate the factors affecting mortality in ASA 3 colorectal cancer patients who undergo emergency surgery.

Methods

between 2010 and 2017 ASA 3 patients who underwent emergency colon cancer surgery were included in the study. All of the study group was evaluated within the first 30-day time-frame. The results were obtained by a statistical comparison of the data of patients with and without mortality.

Results

one hundred and twenty eight patients included in the study. There was no statistical difference in the demographic data of the groups and the indications of the operation. The differences and durations of surgery also did not make any statistical difference. The complication rate was the same according to the Clavien-Dindo classification.

Conclusion

despite the screening programs applied in colorectal cancers, applications to emergency services and procedures performed under emergency conditions are still at high levels. Surgical operations, which have to be performed in patients with impaired metabolic status, carry major risks for patients, but their outcomes are also satisfactory for them.

Comparative efficacy of medical treatment versus surgical sphincterotomy in the treatment of chronic anal fissure

Background

Anal fissure which is defined as a longitudinal tear in anoderm below the dentate line is one of the most common benign diseases of anorectal area. Severe pain during the defecation and emotional stress that it causes may reduce people's quality of life.

Aims

In this randomized clinical trial, we aimed to compare the efficiency of the topical ointment with medical treatment and surgical lateral internal sphincterotomy.

Method

This is a randomized clinical trial of 550 patients who were treated for chronic anal fissure. Patients were randomly divided into 4 groups according to the treatment type they received.

Results

In a vast majority of the patients, the primary complaint was pain (92.3%) and bleeding during defecation (62%). Both pain relief and healing of the fissure, which are the components of response to treatment, had not been observed in 56 (37.3%) patients of topical nitroglycerin ointment group until the second month. Among the recalcitrant patients in both topical nitroglycerin (56) and topical diltiazem ointment (47) groups, 27 (48.2%), and 36 (76.5%) patients underwent surgery, respectively. The best response to treatment was also obtained in lateral internal sphincterotomy group.

Conclusion

LIS is still the gold standard for the treatment of chronic anal fissure when the physicians would like to avoid recurrence and obtain the best pain relief.

Can Magnetic Resonance Imaging Replace Mammography and Ultrasonography for the Detection of Breast Lesions?

Objective We aimed to evaluate the role of magnetic resonance imaging (MRI) in the visualization of breast lesions and to estimate whether MRI can be a reliable alternative to mammography (MG) and ultrasonography (USG) for this purpose. Materials and methods In this retrospective, single-center study, an analysis of medical files of 260 patients with breast masses as breast imaging reports and data system (BI-RADS) 4 and 5 at MRI was performed. The features of the breast lump, such as the side, location, multi foci or multicentricity, histopathological diagnosis, contrast-enhancement characteristics, radiological, and pathological axillary involvement, were noted. Consistency between MRI-BIRADS and MG+USG-BIRADS, as well as the association between lesion characteristics, was sought. Results The agreement ratio between the BI-RADS categories of MRI and MG+USG was 0.654 while consistency between histopathological diagnosis and MRI BI-RADS category was 0.838. The agreement between the BI-RADS category of MG+USG and histopathological diagnosis was 0.819. The consistency between MRI BI-RADS and MG+USG BI-RADS increased remarkably with the advancement of age. Similarly, the consistency between MRI BI-RADS and histopathological diagnosis tends to increase with the advancement of age. Nonmass contrast enhancement yielded the highest agreement ratios between MRI BI-RADS and MG+USG BI-RADS, histopathological diagnosis and MRI BI-RADS, and histopathological diagnosis and MG+USG BI-RADS. Conclusion Dynamic MRI is a useful and reliable method for imaging breast neoplasms. However, it is not devoid of disadvantages such as cost, attainability, and contrast use and it should be reserved as a problem-solving technique to be used in conjunction with conventional methods including MG and USG.

The effect of successful parathyroid surgery on left ventricle function in patients with primary hyperparathyroidism evaluated with strain echocardiography

BACKGROUND

Hyperparathyroidism (PHP) is the most common cause of hypercalcemia in outpatients. It is characterized by many cardiac complications including chronic cardiac arrhythmia, hypertrophy, and diastolic insufficiency. However, there are insufficient data about the cardiac systolic function in PHP. Data regarding the positive effects of surgical treatment on cardiac complications are limited and inadequate. The aim of this study was to evaluate the postoperative changes in the left ventricle functions of patients with PHP using strain echocardiography (STE) instead of traditional echocardiographic evaluation.

METHODS

This prospective study included 29 patients with PHP. Detailed echocardiographic evaluations were made including conventional and STE' ventricle function preoperatively and at 6 months after surgery. Then, preoperative and postoperative STE changes, global longitudinal (GLS) and circumferential strain (GCS), were compared. Patients with recurrent surgery, poor echogenicity, and comorbid conditions affecting STE were excluded.

RESULTS

No significant change was determined in ejection fraction in the period from preoperative to 6 months postoperative (P > .05). The GLS value increased from 18.53 ± 3.06 to 20.25 ± 3.89, to a statistically significant level (P = .004). The other echocardiographic parameters remained unchanged for the same patients.

CONCLUSION

Despite normal 2D echocardiography data, it was determined that the GLS values deteriorated preoperatively and improved by the 6th postoperative month. The detection of early disorders in PHP that cannot be detected on 2D echocardiography, even in asymptomatic patients, may suggest a new treatment indication. For asymptomatic PHP patients, strain echocardiography may be more valuable than 2D echocardiographic evaluation to determine myocardial dysfunction. The recent literature is insufficient, and there is a need for further, more extensive studies with longer follow-up periods.

Torsion of Wandering Spleen: Importance of Splenic Density and Liver-to- Spleen Attenuation Ratio on CT

BACKGROUND

Wandering spleen (WS) is a rare clinical condition which may cause fatal complication like torsion with subsequent infarction. Determination of splenic parenchyma viability is very important in deciding whether splenopexy rather than splenectomy is an option. Contrast- enhanced computed tomography (CECT) is important for the diagnosis of WS and assessment of the viability of spleen.

DISCUSSION

We reviewed the CT studies of four cases with WS. We measured the mean splenic and liver density and calculated liver-to-spleen attenuation ratio (LSAR). We also assessed the CT findings for each patient. Mean splenic density was measured as 40.77 Hounsfield Unit (HU) in cases with infarction, 127.1 HU in case without infarction. LSAR was calculated as 2.55 in cases with infarction, 0.99 in case without infarction. We detected whirlpool sign, intraperitoneal free fluid, splenic arterial enhancement in all patient, parenchymal and splenic vein enhancement in one patient without infarction, fat rim sign in three patients with infarction, capsular rim sign in one patient with infarction.

CONCLUSION

CECT should be obtained for the diagnosis of WS and assessment of the viability of spleen. CECT could suggest the diagnosis of infarction of the spleen with following findings; absence of parenchymal enhancement, very low density of spleen (<45 HU), and LSAR which is greater than 2.

Endoscopic resection for giant oesophageal fibrovascular polyp

A fibrovascular polyp is a rare benign pseudotumour of the oesophagus and hypopharynx. Although patients usually present with dysphagia, aspiration related mortality may occur. If the tumour is too large and/or located in the proximal oesophagus, it may protrude from the mouth. The general approach to treatment is complete reconstruction with cervicotomy. We present our experience of a giant oesophageal fibrovascular polyp that was protruding from the mouth and treated with endoscopic resection. A 55-year-old man was admitted to our outpatient clinic complaining of a mass protruding from his mouth when he coughed. Endoscopy and bronchoscopy both revealed a 15-18cm long polypoid mass originating from the proximal oesophagus (at the level of the hypopharynx). Complete resection was performed via endoscopy.

House advancement flap anoplasty for severe post-hemorrhoidectomy anal stenosis

Anal stenosis (AS), which is a very rare but serious complication, usually develops after hemorrhoidectomy. It may be mild, moderate or severe depending on the grade of stenosis. While mild and moderate types can be monitored with conservative treatment, most of the severe type require advancement flap anoplasty. There are several commonly used flap types such as Y-V, diamond and house-type flaps, but the best results belong to house-type flaps. In this paper, we aimed to present a case of severe post-hemorrhoidectomy AS, in which we performed house advancement flap anoplasty, with its video demonstrating the procedure step by step.

The Characteristic Clinical and Pathological Features of Incidental and Non-Incidental Papillary Microcarcinoma of the Thyroid

Abstract- The incidence of papillary microcarcinoma (PMC) keeps raising due to fine needle aspiration (FNA) biopsies and the pathologic evaluation of thyroid specimens of cases operated for benign thyroid disorders. The files of 78 patients who underwent surgery between January 2006 and May 2013 in our department and were diagnosed with PMC were analyzed, retrospectively.Cases were grouped as incidental and non-incidental depending on the preoperative diagnosis. The diameter of the nodules in the preoperativeultrasonographic examination, pathological parameters such as tumor size, bilaterality, multifocality,and capsular invasion were found significantly high in non-incidental group(P<0.05). No significant difference was detected between the two groups’ age, sex, and vascular invasion.Preoperative radiologic examination by experienced radiologists and FNA performed for suspicious nodules may increase the rate of early and correct diagnosis. In our opinion, determining the most useful criteria for malignancy will help to detect incidental PMC in cases followed up for multinodular goiter

A Rare Complication of Anticoagulant Therapy: Intramural Hematoma of the Small Bowel

BACKGROUND

Non-traumatic intramural hematomas of the small bowel (IHSB) are rare conditions which occur due to anticoagulant therapy. In this study, we aimed to explain our clinical approach to non-traumatic IHSB due to anticoagulant overdose and to present the long-term outcomes of the cases who were hospitalized.

METHODS

Sixteen patients with non-traumatic IHSB were included and their medical records were retrospectively reviewed.

RESULTS

Our patients included ten women and six men, with a mean age of 77.5 ± 8.4 (range: 65-95) years. All patients had been using oral anticoagulants (OACs) due to various cardiovascular and cerebral comorbidities. Common complaints at the time of admission included abdominal pain, vomiting and weakness. Ten patients (62%) had anemia, fifteen (94%) had leukocytosis and all patients (100%) had high levels of C-reactive protein (CRP). Abdominal computed tomography (CT) established the final diagnosis of IHSB in all patients. Fourteen patients (87%) were followed up with conservative therapy. Since the clinical course did not improve in two patients (12%), surgery was mandated. The mean duration of hospitalization was 10.25 ± 3.6 days (range: 3-17 days). Mortality occurred in two patients (12%).

CONCLUSION

IHSB should be considered in patients presenting with abdominal complaints and increased levels on coagulation tests. The diagnosis should be confirmed by abdominal CT scan, if possible. Accurate and timely diagnosis allows patients to be successfully treated without need for surgery.

Minimally invasive parathyroidectomy using intraoperative ultrasonographic localization for primary hyperparathyroidism in pregnancy: report of two cases

Primary hyperparathyroidism (pHPT) in pregnancy is a rare entity associated with increased maternal and fetal mortality and morbidity. Diagnosis of pHPT is challenging in pregnancy. Approximately 80% of the cases are asymptomatic, while the most common symptoms are nausea, vomiting, polyuria, polydypsia, and cloudy vision in symptomatic patients. Since the most common cause of pHPT in pregnancy is adenoma, such in the general population, focused anterior or lateral approach is recommended due to shorter operation time, less risk for the fetus, and lower complication risk. Performing intraoperative ultrasonography to do the incision just over the adenoma provides quicker access to the adenoma and intraoperative parathormone assay confirms the surgical cure. Laryngeal mask anesthesia causes lesser sore throat, laryngospasm, coughing, and rapid recovery as compared to endotracheal intubation anesthesia. This study aimed to present the management of two pregnant patients diagnosed with pHPT and who underwent minimally invasive parathyroidectomy under intraoperative ultrasonography and laryngeal mask anesthesia at the second trimester of gestation. To the best of our knowledge, parathyroidectomy under laryngeal mask anesthesia in pregnancy has never been described before.

Parathyromatosis: a very rare cause of recurrent primary hyperparathyroidism - case report and review of the literature

Parathyromatosis is a rare entity and usually appears as a consequence of the seeding on previous parathyroid surgery which was applied for the secondary hyperparathyroidism. A 63-year-old woman presented with a history of subtotal thyroidectomy 20 years ago and parathyroidectomy due to primary hyperparathyroidism (PHPT) four years ago. Imaging methods revealed multiple parathyromatosis foci on subcutaneous tissue of the neck. En-bloc resection was performed and pathological examination confirmed the diagnosis of parathyromatosis. After an uneventful 10 months, biochemical and radiological tests revealed recurrence on bilateral thyroid lodges. En-bloc resection was performed. The patient has remained well for 24 months after the second operation and has been followed-up with normal parathormone and serum calcium values. To the best of our knowledge, this report describes the twenty-first case of parathyromatosis in PHPT setting in the literature. It should be kept in mind that parathyromatosis may recur at different sites in the neck even in patients with PHPT.

Carcinoma Showing Thymus-Like Elements: A Rare Malignant Tumor of the Thyroid Gland

Carcinoma showing thymus-like elements (CASTLE) is a rare tumor arising in the thyroid gland. Fewer than 100 patients with this tumor, those predominantly from Eastern Asia, have been reported before. We present the first CASTLE case from Turkey. A 51-year-old male was admitted with a complaint of a neck mass and hoarseness. A laryngoscopic examination revealed left vocal cord paralysis. Neck ultrasonography showed a tumor which was compressing the esophagus and had invaded the left recurrent laryngeal nerve (RLN). The patient underwent a total thyroidectomy, a unilateral central-compartment neck dissection, and following adjuvant radiotherapy. Intraoperative nerve monitoring was performed during the operation to preserve the contralateral nerve. He completed a 3-year follow-up period after the completion radiotherapy, and no recurrence was observed. The treatment is controversial, although surgery with or without adjuvant radiotherapy appears to be the best choice. In cases of RLN destruction due to tumor invasion, we recommend using intraoperative nerve monitoring to preserve the contralateral RLN to avoid devastating complications, such as a tracheostomy.

Role of endoscopic interventions and electroincision in benign anastomotic strictures following colorectal surgery

BACKGROUND/AIMS

The anastomotic strictures are one of the most common colorectal surgery complications, and various endoscopic techniques have been defined. Balloon dilation is the most well-known and the simplest procedure. In this article, we aimed to present our series of endoscopic interventions and electroincision management for anastomotic strictures.

MATERIALS AND METHODS

The files of 59 patients, who underwent colorectal surgery between January 2010 and September 2017 in our hospital and were diagnosed during the follow-up with anastomotic stricture, were analyzed. The outcomes of endoscopic interventions such as balloon dilation and electroincision were compared and reported.

RESULTS

The mean age of the 59 patients included in the study was 59.5±16.26 years. The primary operative indications were colorectal cancer in 46, inflammatory bowel disease in 7, diverticulum in 5, and penetrating trauma in one patient. Single- or multiple-balloon dilations were successful in 48 patients. Electroincision was performed in 11 patients because of the balloon dilation failure. None of the patients needed a secondary surgery. During the mean 33.75 months of the follow-up, the stricture recurred in seven patients who had undergone balloon dilation. Repeated balloon dilation was successful in these patients without any need for an additional surgical intervention.

CONCLUSION

Balloon dilation can be performed safely as the primary treatment option, because of its easy access and noninvasive application. Electroincision is also a safe and effective endoscopic technique that can be preferred especially when the balloon dilation fails.

Chest wall metastasis of endometrial cancer: case report and review of the literature

Introduction: Endometrial cancer is the fourth most common female cancer and also distant metastases to the chest wall associated with these tumors are seen less common. Surgical treatment options for metastases of endometrial cancer are limited. Case: A 57-year-old patient who underwent total abdominal hysterectomy + bilateral salpingo oophorectomy and received adjuvant chemotherapy for endometrioid-type adenocarcinoma of the endometrium and tuba is presented. The patient initially presented with pleural effusion 8 years ago and the tumor was detected while during etiologic screening. The patient had no problems after adjuvant chemotherapy and had been living in another city when she presented with a mass on the chest wall measuring 20 × 15 × 12 cm 8 years after the initial diagnosis and distant organ metastasis due to the first surgery was detected. The mass was first thought to be a sarcoma and the tru-cut biopsy revealed a metastatic lesion that was immunohistochemically similar to the first surgical specimen. The mass was resected with a wide radical excision and 'no touch' technique. The patient was then discharged with no postoperative complications. Conclusion: Here in, a case with a distant organ metastasis due to an endometrioid-type adenocarcinoma is presented accompanied by literature data.

Intraoperative nerve monitoring during thyroidectomy: evaluation of signal loss, prognostic value and surgical strategy

INTRODUCTION

Intraoperative neural monitoring of the recurrent laryngeal nerve has been widely used to avoid nerve injury during thyroidectomy. We discuss the results of the change in surgical strategy after unilateral signal loss surgeries using intermittent intraoperative neural monitoring in a high-volume referral centre.

MATERIALS AND METHODS

Details of consecutive patients who underwent thyroidectomy with intermittent intraoperative neural monitoring between January 2014 and December 2017 were prospectively recorded and retrospectively reviewed. Loss of signal was defined as recurrent laryngeal nerve amplitude level lower than 100 μV during surgery. The rate of loss of signal and change in surgical strategy during the operation were evaluated.

RESULTS

Loss of signal was detected in 25 (5.4%) of 456 patients for whom intermittent intraoperative neural monitoring was performed. Four patients had anatomic nerve disruption and surgery was completed by an experienced endocrine surgeon making use of intraoperative neural monitoring with continuous vagal stimulation. Staged thyroidectomy was performed on 16 patients with unilateral loss of signal in whom the nerves were intact visually. Postoperative vocal cord paralysis was encountered in 18 of 21 (85.7%) patients with loss of signal, and 16 of 18 (88.8%) were improved during the follow-up period. Patients' voices were subjectively normal to the surgeon postoperatively in 9 of 21 (42.8%) patients who were found to have loss of signal with intact nerves.

CONCLUSIONS

Intraoperative neural monitoring can be used safely in thyroid surgery to avoid recurrent laryngeal nerve injury. It enables the surgeon to diagnose recurrent laryngeal nerve injury intraoperatively to estimate the postoperative nerve function and to modify the surgical strategy to avoid bilateral vocal cord paralysis.

Approach to primary thyroid lymphoma: case series

Primary thyroid lymphomas are rare thyroid neoplasms. Mucosa Associated Lymphoid tissue (MALT) lymphoma and diffuse large B-cell Non-Hodgkin lymphoma are the most common types. It is more common in the elderly, and especially in women. Patients usually present with a rapidly growing mass in the neck. This article aimed to present the epidemiological features, treatment and prognostic factors of thyroid lymphomas by retrospectively reviewing 4 patients with thyroid lymphoma. Four patients were treated for primary thyroid lymphoma, two of whom were women and two were men, with a mean age of 63.7 (51-74) years. Common complaint of those patients was the sudden swelling of the neck. Two patients were diagnosed with fine needle aspiration biopsy (FNAB) and the other two patients were diagnosed with surgical excision. Chemotherapy and radiotherapy were applied to all four patients. While one patient died in the second year of follow-up, the other three patients are still being followed. Primary thyroid lymphomas are not aggressive tumors, and the most effective treatment is radiotherapy.

Chronic visceral ischemia: An unusual cause of abdominal pain

Chronic visceral ischemia is described as postprandial abdominal pain caused by intestinal hypoperfusion. Chronic visceral ischemia arising from the stenosis of major mesenteric arteries can cause death. Chronic abdominal pain, weight loss, and sitophobia are the major symptoms. The main cause of chronic visceral ischemia is atherosclerosis; Doppler ultrasonography, tomographic angiography, and magnetic resonance angiography can be used for diagnosis. The gold standard method is mesenteric catheterized angiography. Surgical bypass or endovascular balloon angioplasty and stent replacement can also be performed to prevent serious complications and death. A total of three patients, two male and one female, applied to emergency services with blunt abdominal pain lasting a few hours that started after meals and was located in the epigastric and periumblical regions. The patients were diagnosed with chronic visceral ischemia after screening tests and physical examination. Mesenteric catheterized angiography was performed immediately in all the cases. Balloon angioplasty and stent replacement were performed on the stenoses, and occlusions were detected. Mesenteric catheterized angiography may be preferred in cases with strong clinical suspicion; balloon angioplasty and stent replacement can also be used as treatments with lower rates of complications.

Importance of informed consent defined by General Surgery Associations in Turkey

Objective

Informed consent is a term based on the idea that every individual has the right to know every medical intervention that is going to be performed on their own body and to learn the issues that she/he may encounter in case of refusal of intervention, and it also defines the protection of personal rights under the guarantee of law.

Material and Methods

The website of Turkish Surgical Association and 25 different websites of surgical associations were evaluated according to general surgery association guide, which was published by the Turkish Surgical Association in 2011.

Results

Four websites of those surveyed include informed consent sections and these were evaluated. A total of 44 informed consent forms were included in this study. Of these, 29 were in Turk Colon and Rectum Surgery Association, 8 were in Turkish Surgery Association, 5 were in Turk Hepatopancreaticobilier Surgery Association, and 4 were in Endocrine Surgery Association. These informed consent forms were evaluated with regard to the aforementioned criteria. The results and also the distribution according to the associations were summarized. A common feature of the informed consent forms was that all of them included the risks of the intervention/operation and complications to be carried out. On the contrary, none of them included approximate time of surgery, information about surgeons, issues that patients should care about before surgery, the section that permits the use of data for scientific purpose, and the time of signing the informed consent form.

Conclusion

We believe that in this context the regulation of informed consent by sub-specialization associations under the flag of Turkish Surgical Association is a very important matter and will standardize informed consents; websites of the associations will be easier to access, and this will be as beneficial for physicians as the patients and also will protect the physicians in probable trials.

Coeliac trunk and common hepatic artery variations in children: an analysis with computed tomography angiography

BACKGROUND

Understanding the coeliac trunk (CeT) and hepatic artery anatomy is important not only in preventing iatrogenic injuries but also in planning surgical procedures in children. Therefore, the aim of this study is to analyse the prevalence of CeT and common hepatic artery (CHA) variations in the paediatric population.

MATERIALS AND METHODS

One hundred and seventy-four children who underwent abdominal multidetector computed tomography (MDCT) angiography, either because of trauma or liver transplantation, were analysed retrospectively. The patterns of CeT, CHA and their variant branches were revealed and compared with previous studies involving adults.

RESULTS

A total of 157 (90.2%) of the 174 patients had normal CeT anatomy, whereas 17 (9.8%) had variations. Five types of CeT variations were identified according to Song's classification in which 'hepatosplenic trunk + left gastric artery + superior mesenteric artery' was the most prevalent. One hundred-twelve (64.4%) of the 174 patients had normal CHA anatomy; however, 62 (35.6%) had variations. Six types of CHA variations were identified according to Michel's and Hiatt's classification. The most common was 'replaced left hepatic artery originating from left gastric artery'.

CONCLUSIONS

The prevalences of CeT and hepatic artery variations are high in children, as they are in older patients. Awareness of these variations is important in terms of avoiding iatrogenic injury and in promoting surgical procedure planning for liver transplantation or abdominal tumour surgery.