Preoperative Therapeutic Plasma Exchange and Surgical Treatment in Thyrotoxicosis Patients: A Single-Centre Retrospective Cohort Study

Context

Therapeutic plasma exchange (TPE) provides time for thyroidectomy in thyrotoxic patients.

Objective

TPE is indicated in cases where antithyroid medications cannot be used due to the side effects or attain no adequate hormonal suppression response at the highest dosage and in cases of rapid onset of clinical symptoms. This study presents the treatment results of patients who underwent TPE and were subsequently operated for thyrotoxicosis.

Design

The patients who underwent thyroidectomy and TPE between January 1999 and February 2019 were retrospectively analyzed.

Subjects and Methods

The files of 27 patients with thyrotoxicosis who performed TPE prior to surgery were analyzed in relation to the demographic and clinical features.

Results

We included 15 (55.6%) females, 12 (44.4%) males with a mean age of 44 (23-82) years. The pre-TPE mean free thyroxine (fT4) level was 12 (5-46) pmol/L while free tri-iodothyronine (fT3) level was 34 (17-141) pmol/L. The post-TPE fT4 level was 6 (3-10) pmol/L while the fT3 level was 21 (12-41). There was one case of an allergic reaction during the procedure. In the postoperative follow-up, there was transient hypocalcemia in 8 (29%) patients, permanent hypocalcemia in 1 (3.7%) patient, and surgical site infection in 1 (3.7%) patient.

Conclusion

Preoperative TPE is an alternative treatment option for thyrotoxic patients. This is an especially effective treatment for patients with inadequate response or adverse reaction to antithyroid drugs or patients who need urgent surgery for thyroid storm.

Hand-made Extracorporeal Knotting versus Hem-o-Lok Clip for Stump Closure in Laparoscopic Appendectomy

OBJECTIVE

To compare hand-made extracorporeal knotting and hem-o-lok clip for the closure of appendix stump regarding safety, complications and cost-effectiveness.

STUDY DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

Baskent University Adana Teaching and Research Center, between January 2010 and December 2016.

METHODOLOGY

A total of 287 patients, who underwent laparoscopic appendectomy, were enrolled in this study. Patients were divided into hand-made extracorporeal knotting and hem-o-lok clip groups. Patients were compared according to age, gender, duration of symptoms, serum leukocyte count, American Society of Anesthesiologists (ASA) score, intraoperative findings, operation time, hospital stay, pathology report and complications.

RESULTS

Of 287 patients, 149 (51.9%) were female and 138 (48.1%) were male. The mean age was found 34.9 years. No statistical difference was observed between groups according to age, gender, duration of symptoms, serum leukocyte count, ASA score, operation time and hospital stay. Intraoperative findings were different between groups (p<0.05). Overall postoperative complication rate was 6.6%. No statistical difference was observed regarding complications Conclusion: Both hand-made extracorporeal knotting and hem-o-lok clips can be used for stump closure in laparoscopic appendectomy. Hand-made extracorporeal knotting is an effective, safe and costeffective method alternative to hem-o-lok clips.

Outcomes of Total Parathyroidectomy with Autotransplantation versus Subtotal Parathyroidectomy Techniques for Secondary Hyperparathyroidism in Chronic Renal Failure

OBJECTIVE

To compare the safety and the effectiveness of total parathyroidectomy with autotransplantation versus subtotal parathyroidectomy for refractory secondary hyperparathyroidism in patients with chronic kidney disease.

STUDY DESIGN

A comparative study.

PLACE AND DURATION OF STUDY

Baskent University, Adana Medical and Research Center, Adana, Turkey, from January 2012 to November 2018.

METHODOLOGY

Patients operated upon for refractory secondary hyperparathyroidism by the general surgery team were inducted. Overall, 25 (40%) patients underwent total parathyroidectomy with autotransplantation (Group 1), whereas 37 (60%) patients underwent subtotal parathyroidectomy (Group 2). Patient files were retrospectively analysed for recurrence or persistence of hyperparathyroidism.

RESULTS

A total of 62 patients, 32 (52%) of whom were females, with a mean age of 41.4 ±15.8 years for group 1; and 30 patients were males with a mean age of 43.1 ±16.7 years for group 2 were assessed in this study. The presenting complaints were bone pains and malaise supported by laboratory values that showed consistently elevated parathyroid hormone levels (>200 pg/ml). In the postoperative follow-up, 29 patients (46.8%) had transient hypocalcemia, while 3 (5%) had persistent hypoparathyroidism. In Group 1, one (4%) patient had a recurrence, while 4 (16%) patients had persistent hyperparathyroidism. In contrast, two (5.6%) patients in Group 2 had recurrence, whereas 8 (22%) patients had persistent hyperparathyroidism.

CONCLUSION

Both surgical options can be safely utilised in the management of refarctory secondary hyperparathyroidism. Moreover, regardless of the procedure used, all the parathyroid glands must be explored. However, due to high morbidity and failure rates of subsequent surgeries, the surgeon should be keen and thorough in the initial procedure.

Comparison of the Early-Term Complications and Patency Rates of the Standard (Parachute) and Diamond-Shaped End-To-Side Anastomosis Techniques in Arteriovenous Fistulas Created for Hemodialysis

OBJECTIVE

To compare the early-term patency and complication rates of the end-to-side anastomosis techniques parachute and diamond-shaped techniques in arteriovenous fistulas.

STUDY DESIGN

Prospective randomised study.

PLACE AND DURATION OF STUDY

Department of General Surgery, Adana Baskent University Application and Research Hospital, Adana, Turkey, between October 2014 and January 2015.

METHODOLOGY

Patients with end stage renal disease who underwent arteriovenous fistula creation for hemodialysis were grouped into two according to the anastomosis technique performed. Group 1 was composed of the patients undergoing the standard parachute technique and Group 2 consisted of the patients operated with the diamond-shaped anastomosis technique. The two groups were compared with each other with respect to clinical and demographic data, operative and postoperative variables, and complication and patency rates.

RESULTS

A total of 56 patients underwent arteriovenous fistula creation. The overall complication rate was 12.5%. The early-term patency rate was higher in the diamond-shaped anastomosis technique than the standard parachute end- to-side anastomosis technique. Effective dialysis was established after 4 weeks in 48 (85.7%) patients in the overall study group, 23 (82.1%) in Group 1, and 25 (89.2%) in Group 2. However, there was no significant difference between both the techniques with respect to effectiveness of dialysis.

CONCLUSION

Both end-to-side anastomosis techniques have their own advantages and disadvantages. Using a patient- specific suitable technique rather than a standard technique would be more appropriate in arteriovenous fistulas formation.

Is there a correlation between the severity of Idiopathic Granulomatous Mastitis and pre-treatment Shear-Wave Elastography Findings? Original research

AIM

The aim of this study was to analyze the correlation between the severity of idiopathic Garulomatous Mastitis (IGM) and the pre-treatment Shear-Wave Elastography (SWE) findings.

MATERIAL AND METHODS

A total of 39 patients diagnosed with granulomatous mastitis were included in the study between the dates of December 2014 and February 2017. The patients were divided into two groups. Group 1 was treated using a conservative protocol and steroids. Group 2 was treated surgically. Pre-treatment SWE findings of both groups were compared.

RESULTS

The mean ages of the patients in group 1 and 2 were 38.44±9.6 and 36.05±7.44 years, respectively. There were not any significant differences between the groups with regard to frequency of BI-RADS categories and Virtual touch tissue imaging (VTI) patterns. The mean Shear-Wave Spead (SWS) were 1.98 ± 1.02 m/sec and 2.82± 1.66 m/sec in group 1 and 2 respectively. The difference was not significant (p ≥ 0.05). The BI-RADS categories and VTI patterns did not show significant difference when the recurrent and non-recurrent patients were compared.

CONCLUSION

There may not be a correlation with the pre-treatment SWE findings and severity of the IGM.

KEY WORDS

Breast, Elasticity Imaging Techniques, Granulomatous mastitis, Ultrasonography.

Total Versus Subtotal Gastrectomy for Signet Ring Cell Carcinoma of the Stomach

OBJECTIVE

To determine the adequate surgery type for the treatment of signet ring cell of stomach in terms of postoperative complications and survival.

STUDY DESIGN

Comparative analytical study.

PLACE AND DURATION OF STUDY

Baskent University Adana Teaching and Research Center, Adana, Turkey, between 2006 and 2015.

METHODOLOGY

Atotal of 46 patients with the diagnosis of gastric signet ring cell, who underwent total or subtotal gastrectomy, were enrolled in this study. Patients were compared according to age, gender, tumor location, TNM stage, survival and mortality rates, operation time, complication and recurrence. Comparisons between groups were performed by using Mann-Whitney U-test for the data not normally distributed. The categorical data were analyzed by using the Chisquare test or Fisher's exact test, where applicable. Kaplan-Meier test was used for survival curve and Long-rank test was used for survival differences between groups. Values of p < 0.05 were considered statistically for all tests.

RESULTS

Of the 46 patients, 29 (63.0%) were male. The mean age was 56.6 ±13.2 years. The median tumor size was 5.0 cm (IQR: 3.0-6.6). Twenty-six (56.5%) patients were in total gastrectomy, whereas 20 (43.5%) were in subtotal gastrectomy group. Five-year cumulative survival rate was 0.487. Five-year overall survival rate for early and advanced signet ring cell carcinoma was 0.830 and 0.164, respectively (p<0.001). Five-year overall survival rate for total and subtotal gastrectomy groups were 0.422 and 0.582, respectively (P=0.417). Complications were observed in 17.4% (n=8) of all 46 patients.

CONCLUSION

Subtotal gastrectomy can be performed safely for patients with gastric signet ring cell carcinoma and is equal to total gastrectomy with respect to prognosis and complication rates.

Long-term results of retromuscular hernia repair: a single center experience

INTRODUCTION

Incisional hernia (IH) is one of the most frequent postoperative complications after abdominal surgery. There are multiple surgical techniques described for IH repair. The aim of the study is to evaluate the effect of primary fascial closure on long-term results in retromuscular hernia repair (RHR) for incisional hernias.

METHODS

A total of 132 patients underwent RHR for IH were included in our study. 109 patients were evaluated in 2009 and 55 patients in 2015 for short and long-term results.

RESULTS

Among 132 patients perfromed RHR, fascia was closed in 107 (81%) and left open in 25 (19%) patients. The mean age of patients was 57.9 ± 11.8 years. Average mesh area was 439.8 ± 194.6 cm², hernia area was 112 ± 77.5 cm² and open area after repair was 40.8 ± 43.3 cm². Mean follow-up of 104 patients regarding postoperative complications evaluated in 2009 was 30.7 ± 14.1 months. Recurrent IH was observed in 6 (4.5%) patients according to data collected in 2009. Long-term results were; mean follow-up period was 91 ± 20.2 months (20-112 months) and recurrent IH was observed in 4 (7.3%) patients.

CONCLUSION

Retromuscular repair for incisional hernia regardless of the fascial closure gives high patient satisfaction, less recurrence rates and complications in long-term follow-up.

Prophylactic oral calcium supplementation therapy to prevent early post thyroidectomy hypocalcemia and evaluation of postoperative parathyroid hormone levels to detect hypocalcemia: A prospective randomized study

BACKGROUND

Postoperative hypocalcemia is the most common complication after total thyroidectomy. Postoperative parathyroid hormone (PTH) measurement is one of the methods to detect or prevent postoperative hypocalcemia. Prophylactic oral calcium supplementation is another method to prevent early postoperative hypocalcemia. The aim of this study is to detect the accurate timing of PTH and evaluate efficacy of routine oral calcium supplementation for postoperative hypocalcemia.

METHODS

A total of 106 patients were performed total thyroidectomy. Rotuine oral calcium supplementation was given to group 1 and no treatment to group 2 according to randomization. Serum calcium and PTH level of patients in group 2 at postoperative 6, 12 and 24 h and patients in both groups at postoperative day 7 were evaluated. Patients were compared according to age, sex, operation findings, serum calcium and PTH levels and symptomatic hypocalcemia.

RESULTS

Half of the patients (50%) were in group 1. Most of the patients were female (83%). The most common etiology of thyroid disease was multinodular goiter (64.1%). Oral calcium supplementation was given to 18 (33.9%) patients in group 2. Symptomatic hypocalcemia for group 1 and 2 was found to be 1.9 and 33.9% respectively (p < 0.05). No statistical difference can be observed regarding the timing of serum biomarkers.

CONCLUSION

Serum PTH levels at postoperative 12 and 24 h can predict early post-thyroidectomy hypocalcemia. Prophylactic oral calcium supplementation therapy can prevent early post-thyroidectomy hypocalcemia with advantages of being cost effective and safe.

Rupture of an Aneurysm of a Small Branch of the Superior Mesenteric Artery: A Case Report

Background

Superior mesenteric artery aneurysm (SMAA) is an uncommon vascular disorder. Complications such as rupture have been reported. Once complication has been encountered both surgical and endovascular treatment techniques can be considered.

Case Report

We present a case of 68-year old male patient with SMAA rupture treated by endovascular modality.

Conclusions

Endovascular therapy is an effective and less invasive option for rupture of superior mesenteric artery aneurysm.

Unusual location of median raphe cyst presenting as perianal polyp: a case report

Median raphe cysts (MRC) are uncommon, benign congenital lesions that may present anywhere in the midline between the urinary meatus and the anus, with the shaft of the penis and the glans penis being the most common sites. We report a 52-year-old man with median raphe cyst unusually located in perianal region and treated by surgical excision.

Anastomotic Leakage in a Patient with Acute Intestinal Obstruction Secondary to Appendiceal and Ileal Endometriosis: A Case Report

Endometriosis is a commonly encountered problem in women of reproductive age. It usually causes chronic abdominal pain. However, it rarely causes complications such as intestinal obstruction. The most commonly performed procedure for these patients is bowel resection and anastomosis. Unless it is complicated with anastomotic leakage. We present a 39-year-old woman presented with intestinal obstruction due to appendiceal and ileal endometriosis complicated with anastomotic leakage after surgery.

The type of specimen retrieval in laparoscopic appendectomy affects wound infection

AIM

To evaluate the role of laparoscopy in appendicitis and importance of wound protection in this sense.

MATERIALS AND METHODS

Data of 506 patients operated on by either open or laparoscopic appendectomy within the last four years were evaluated retrospectively for wound infection rates. Those had laparoscopic surgery were also subgrouped and analyzed in terms of retrieval type of the specimen.

RESULTS

Wound infection rate was 5.7% for open appendectomy and zero for laparoscopic appendectomy in minimal or non-inflamed cases. For suppurative appendicitis and gangrenous or perforated cases wound infection rates were 9.1% versus 17.6% for open appendectomy versus laparoscopy. Laparoscopy without wound protection increased these rates to 17.9% versus 50%, where as wound protection reduced both to zero.

DISCUSSION

Laparoscopy itself was protective for wound infection in non-inflamed or minimally inflamed appendectomy cases with respect to open surgery. However, for suppurative, gangrenous or perforated appendicitis, laparoscopy protects from wound infection only when contact of the specimen with incisions was avoided.

CONCLUSION

Laparoscopy reduces wound infection rates in appendectomy. This advantage is prominent especially wound contamination with the specimen is prevented anywise. Using a glove finger, as a tissue bag for the retrieval of the specimen has been our favorite method that we defined as "reverse cover-up technique".

KEY WORDS

Glove bag, Glove finger, Laparoscopic appendectomy, Specimen retrieval, Tissue bag, Wound protection.

The effect of subcutaneous suction drains on surgical site infection in open abdominal surgery A prospective randomized study

AIM

Surgical site infection (SSI) is a major problem associated with open abdominal surgery and related to increased morbidity and mortality rates, healthcare costs and also incisional hernia. A negative pressure subcutaneous drain reduces dead space in subcutaneous tissue by preventing accumulation of fluid. The aim of current study was to establish the efficacy of a subcutaneous drainage system for preventing SSI after open abdominal clean-contaminated surgery.

MATERIAL AND METHODS

A total of 62 patients underwent abdominal surgery, between November 2014 and March 2015, were enrolled. 48 eligible patients, were randomized into subcutaneous drainage (DG) and no drainage group (NDG). Antibiotic prophylaxis was appiled to each patient. The diagnosis of superficial SSI was made according to the Centers for Disease Control and Prevention's (CDC) definition.

RESULTS

The mean age of patients was 48.77 ± 12.62 years with a male-female ratio of 21:27. No statistical difference between groups was observed for age, sex, comorbidity, incision type, hemoglobin level, blood loss, hospital stay and operation time (P>0.05). 2 (8.7%) patients in DG and 8 (32%) patients in NDG had incisional SSI but no statistical difference was observed (P>0.05).

CONCLUSION

SSI appear to be reduced with subcutaneous suction drains in open abdominal surgery however prospective randomized larger scaled studies should be performed on this topic.

KEY WORDS

Abdominal surgery, Subcutaneous drain, Surgical site infection.

Impact of surgeon factor on radiocephalic fistula patency rates

Introduction

Hemodialysis with arteriovenous fistula (AVF) has been widely accepted treatment modality for patients with chronic renal failure (CRF). Radiocephalic fistulas are considered to be the most desirable for the initial vascular access. The aim of this study is to investigate the surgeon factor on radiocephalic fistula patency rates.

Methods

A total of 186 patients with diagnosis of CRF underwent Radiocephalic fistula for hemodialysis access were included. Patients were divided into 2 groups according to operating surgeon. Patients were evaluated according to demographic characteristics, secondary patency rates, second AVF creation and complications.

Results

Mean age was 57.7 ± 14.8 years. The most common etiology of CRF was idiopathic (66.6%). 40 (75.5%) patients in group 1 and 122 (91.7%) patients in group 2 were pre-dialysis patients (p < 0.05). Overall secondary patency rate was 77.4%. Patients in group 1 and group 2 have secondary patency rates of 83% and 75.2%, respectively (p = 0.458). Second AVF creation was done in 2 (3.8%) patients in group 1 and 23 (17.3%) patients in group 2 (p < 0.05). Postoperative complication rate was 9.6%.

Conclusion

Operating surgeon is not a major factor of secondary patency in radiocephalic arteriovenous fistulas.

•

Overall secondary patency rate was found in 144 (77.4%) patients.

•

No statistical difference was observed according to secondary patency rates.

•

Postoperative complication rate was 9.6%.

•

Operating surgeon is not a major factor on radiocephalic fistula patency rates.

Tension-free primary closure for the treatment of pilonidal disease

AIM

Pilonidal disease (PD) is a common disorder that usually affects young population and generally seen in intergluteal region. Conservative and surgical treatment options have been utilized. Many surgical techniques including primary closure, marsupialization and flap procedures have been described. The present study aims to evaluate the optimal surgical method for the treatment of PD.

MATERIAL AND METHODS

A total of 151 patients underwent pilonidal disease surgery between January 2007 and September 2014 were enrolled in this study. Patients were compared according to age, sex, operation time, length of

RESULTS

A total of 151 patients with a mean age of 25.18 years (range 14-66) presented with pilonidal disease were evaluated. Primary closure (PC) and tension-free primary closure (TFPC) were performed in 105 (69.5%) and 46 (30.5%) patients, respectively. There was no statistical difference between groups according to age, sex, operation time and length of hospital stay. Only 9 patients (8.6%) in PC and 3 patients (6.5%) in TFPC have postoperative recurrent disease. of 17 patients (7.9%) dehiscence was seen, 15 (14.3%) were in PC group and 2 (4.3%) were in TFPC group. Postoperative seroma or wound infection was seen in 16 patients (10.6%).

CONCLUSION

Tension-free primary closure is a method that is effective as primary closure.

KEY WORDS

Modified primary closure, Pilonidal disease, Primary closure.