Trocar Site Location in Laparoscopic Appendectomy-A Prospective Randomized Study.

INTRODUCTION: Laparoscopic appendectomy has been used in the treatment of appendicitis, which is among the most common emergency pathologies worldwide. There is no consensus on the best trocar entry sites. The purpose of the present study was to compare various trocar entry sites in the literature and to find the localization with the optimal usage area. METHODS: Patients who underwent laparoscopic appendectomy between 2021 and 2022 were randomized into 4 groups and included in the study. The demographic data, perioperative, and postoperative findings of the patients were evaluated. RESULTS: A total of 200 patients participated in the study and 73% were male. No differences were detected between the groups in terms of demographic data, preoperative findings, length of stay, and complications of the patients. However, when the mean surgery times of the groups were examined (47.2±26.9, 58.4±23.1, 54.5±18.3, 55.8±18.6 min), it was observed that this period was less in Group 1 ( P =0.02). When the postoperative Visual Analogue Scale values were analyzed (4.8±2.2, 6.2±1.7, 5.5±2.0, and 5.8±1.9), Group 1 was found to be less painful ( P =0.00001). CONCLUSION: When the surgical procedure is optimized and environmental factors are homogenized, Group 1 trocar entry sites seem advantageous for the procedure in terms of postoperative patient pain scale and operation times.

Role of digital infrared thermal imaging in diagnosis of acute appendicitis.

BACKGROUND: Acute appendicitis (AA) is one of the most common diseases requiring emergency surgery. Today, diagnosis of AA is made through anamnesis, physical examination along with advanced imaging methods. Thermal imaging confers advantages over conventional techniques for being portable, non-invasive, easily conducted, ionization radiation-free, and inexpensive. Digital infrared thermal imaging (DITI) has been the subject of research in various clinical scenarios. In this prospective randomized controlled study, diagnostic potential of DITI in AA was investigated. METHODS: Totally, 224 volunteers (112 healthy volunteers and 112 patient volunteers) were enrolled and divided into two groups; control group and patient group. All subjects were assessed by DITI. Steady-state images of both lower quadrants and sternum were taken. Thermal images were transferred to computer software and analyzed. Potential of thermal imaging as a diagnostic method was evaluated. RESULTS: Regarding temperature differences between the quadrants, statistical analysis delivered significant difference between the both groups (p<0.001). As a result of the analysis, the cutoff value for the diagnosis of AA was found to be 0.4°C difference between the average lower quadrant temperatures. CONCLUSION: This study has enlarged the application of DITI to abdominal pain, especially within context of AA. Thermal evaluation of patients with abdominal pain seems promising.

Comparison of Patients with and Without Hiatal Hernia Repair during Laparoscopic Sleeve Gastrectomy: Single-centre Experience.

OBJECTIVE:  To evaluate whether the concomitant repair of hiatal hernias during laparoscopic sleeve gastrectomy has an effect on the outcome of the surgery in patients with hiatal laxity and gastroesophageal reflux disease (GERD) symptoms during preoperative preparations. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of  General Surgery, Kayseri City Training and Research Hospital, Health Science University, Kayseri, Turkey, from 2016 to 2020. METHODOLOGY: Reflux symptom index questionnaire (RSI) is used in patients with GERD symptoms and in cases where hiatal hernia is detected in routine endoscopy. Preoperative and postoperative periods can be compared with this non-invasive and short-term test. RESULTS:  Thirty-five patients were included in the study. The mean age of the included patients was 36.0 ± 9.8 (range, 21- 54) years, 80% of them were female. The preoperative median BMI was 43.9 (IQR, 41-50.7), and the postoperative mean BMI was 31.3 ± 5.1 (range, 23.2-40.6) Kg/m2. The median calculated RSI of the patients in the preoperative period was 8 (IQR, 2-13), and the postoperative median was 5.1 (IQR, 0-8) (p = 0.028). It was observed that 24 (68.6%) of the patients had improvement in their symptoms, 7 (20%) patients had worsening, 3 (8.6%) patients did not experience a change, and only one (2.9%) patient developed de novo GERD symptoms.  Conclusion: No statistically significant difference was observed in individuals undergoing LSG and known to have GERD, hiatal hernia repair and cruroraphy in addition to LSG regarding reduction of  GERD symptoms. Key Words: Sleeve gastrectomy, Reflux symptom index score, Gastroesophageal reflux disease.

Endoscopic Ultrasound-Guided Fine Needle Aspiration Using a 22-G Needle for Hepatic Lesions: Single-Center Experience.

BACKGROUND/AIMS: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been accepted as a reliable tool in diagnosing and staging intra-abdominal tumors. In this study, we aimed to investigate the performance of EUS-FNA in the evaluation of liver masses and its impact on patient management and procedure-related complications retrospectively. METHODS: Data of patients who underwent EUS-FNA biopsies due to liver masses between November 2017 and July 2018 were retrieved retrospectively. Biopsies were performed using 22-G needles. The demographics, EUS-FNA results, sensitivity and specificity of the procedure, negative predictive value, positive predictive value, and specimen sufficiency rates were assessed. RESULTS: A total of 25 patients (10 females) were included in the study. The mean age was 62.73±15.2 years. The mean size of the masses was 34.50±16.04 mm. The technical success rate was 88%. During the EUS-FNA procedure, each patient had only one pass with 94.45% of aspirate sufficiency rate and 86.3% of biopsy sufficiency rate. The diagnostic accuracy rate was 86.3%. There were no complications. CONCLUSION: For the evaluation of liver masses, EUS-FNA using a 22-G needle with even one pass had high aspiration and biopsy success rates accompanied with high diagnostic accuracy rates.

Evaluation of the Bethesda System and the ACR TIRADS in an Endemic Goiter Region.

BACKGROUND: Various factors can affect incidence of thyroid disorders and disease profiles may show abrupt changes in endemic goitrous areas. In this study, it was aimed to analyze the American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) and the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) in terms of risk of malignancy and general recommendations in an endemic goiter region (EGR). METHODS: In this retrospective study, a total of 500 patients who had thyroidectomy following thyroid fine needle aspiration biopsy were enrolled. For the assessment of thyroid cytology, BSRTC was used and for the evaluation of ultrasound features of thyroid nodules, ACR TIRADS lexicon was adopted. For the assessment of thyroid cytology, Bethesda classification was used and for the evaluation of ultrasound features of thyroid nodules, ACR TIRADS lexicon was adopted. RESULTS: In the EGR setting, benign category of BSRTC had a cancer risk of 6.2% which was two times more than the 2017 BSRTC revision reported. Nodules 10-14.9 mm in diameter had nearly 4 times higher malignancy risk than nodules >15 mm. In this group of patients, the risk of malignancy for TIRADS level 1, 2, 3, 4 and 5 was 1.16%, 2.94%, 7%, 45.64% and 94.44%, respectively. The malignancy rates for Bethesda system category I, II, III, IV, V and VI were as follows: 14.43%, 6.2%, 19.05%, 36.73%, 75.68% and 100%. CONCLUSIONS: There are slight differences between the common set of standards and this study results regarding risk of malignancy. This brings up the question whether there is need for revision for the use of categories and the appropriate management in endemic goiter regions.

The detection of occult CO poisoning through noninvasive measurement of carboxyhemoglobin: A cross-sectional study.

OBJECTIVES: Carbon monoxide (CO) poisoning is one of the leading causes of preventable death in the world. Our primary objective was to identify and treat individuals who are unaware of their exposure to carbon monoxide in emergency departments (EDs). Our secondary goal was to reduce the costs of diagnosis and treatment by preventing unnecessary diagnostic testing in EDs. METHODS: In this cross-sectional study, carboxyhemoglobin (COHb) levels of patients presented with the signs of CO poisoning to the Emergency Department of Kayseri Training and Research Hospital between November 2012 and May 2013 were noninvasively measured during triage. Patients with elevated COHb levels were suspected of CO poisoning and subjected to further investigation. RESULTS: A total of 4073 patients were enrolled in the study, and 106 (2.6%) of them were diagnosed with CO poisoning. Initial evaluation revealed headache to be the most common presenting complaint in patients with occult CO poisoning. Further evaluations to determine the accuracy of noninvasive measurements showed that noninvasive pulse CO-oxymeter and arterial blood gas (ABG) measurement were compatible. CONCLUSIONS: The use of noninvasive pulse CO-oxymeter might reduce the morbidity and mortality associated with occult CO poisoning in patients presented with suspected CO poisoning in emergency settings.

Role of computed tomography tractography in evaluation of back/flank stab wounds.

BACKGROUND: The clinical approach to back/flank wounds has evolved over the years. The aim of this study was to discuss the potential of computed tomography tractography in patients with a stab wound to the back or flank. METHODS: A total of 25 stable patients with stab wounds confined to the back/flank region were enrolled in this retrospective study. After initial resuscitation and physical examination, tractography was performed at the site of the stab wound. The patients subsequently underwent computed tomography with intravenous contrast. RESULTS: Computed tomography tractography helped avoid a laparotomy in 15 (60%) patients and accurately revealed a peritoneal breach in 10 (40%) patients. No missed injuries were reported in the conservatively followed patients. CONCLUSION: The addition of tractography to computed tomography is a safe, fast, and cost- and time-effective technique to evaluate back/flank stab wounds.

Spontaneous rupture of right gastroepiploic artery aneurysm: a rare cause of hemorrhagic shock. case report

ABSTRACT CONTEXT: Aneurysms of the gastroepiploic arteries are seen only rarely. They are usually diagnosed during autopsy or laparotomy in patients with hemodynamic instability. Although the operation to treat this condition is relatively easy, delay in making the diagnosis affects the course of the disease. Case Report: A 57-year-old woman was admitted to the emergency department with abdominal pain and unconsciousness. A computed tomography scan showed extravasation of contrast agent at the headcorpus junction of the pancreas, and the patient underwent exploratory laparotomy under general anesthesia. During laparotomy, aneurysmatic rupture of the right gastroepiploic artery was detected. Control over bleeding was achieved by ligating the right gastroepiploic artery at its origin. The aneurysm was also resected and sent for pathological examination. CONCLUSION: Especially in cases of unidentified shock, splanchnic artery aneurysms should be kept in mind. Moreover, in the light of the data in the literature, the possibility of death should be taken into account seriously and, if feasible, prophylactic aneurysmectomy should be performed.

Spontaneous rupture of right gastroepiploic artery aneurysm: a rare cause of hemorrhagic shock. case report.

CONTEXT: Aneurysms of the gastroepiploic arteries are seen only rarely. They are usually diagnosed during autopsy or laparotomy in patients with hemodynamic instability. Although the operation to treat this condition is relatively easy, delay in making the diagnosis affects the course of the disease. CASE REPORT: A 57-year-old woman was admitted to the emergency department with abdominal pain and unconsciousness. A computed tomography scan showed extravasation of contrast agent at the headcorpus junction of the pancreas, and the patient underwent exploratory laparotomy under general anesthesia. During laparotomy, aneurysmatic rupture of the right gastroepiploic artery was detected. Control over bleeding was achieved by ligating the right gastroepiploic artery at its origin. The aneurysm was also resected and sent for pathological examination. CONCLUSION: Especially in cases of unidentified shock, splanchnic artery aneurysms should be kept in mind. Moreover, in the light of the data in the literature, the possibility of death should be taken into account seriously and, if feasible, prophylactic aneurysmectomy should be performed.

Endoscopic Management of Colonic Perforation due to Ingestion of a Wooden Toothpick.

BACKGROUND Toothpick ingestion is implicated in bowel injuries that may cause violent complications, mimicking diseases causing acute abdomen. CASE REPORT A 18-year-old man was admitted with a 3-day history of a swallowed wooden toothpick. The patient had tenderness in the left flank area. Computed tomography indicated toothpick impaction at the splenic flexura of the colon. It was successfully removed with colonoscopy. After the procedure, abdominal radiography showed free air as a sign of perforation. Along with conservative management, the patient was discharged without surgery. CONCLUSIONS There is need for greater awareness of the hazardous of an ingested toothpick. Endoscopic approach should be considered in the first-line management of toothpick perforations.

Co-occurrence of subacute granulomatous thyroiditis and papillary microcarcinoma.

Subacute thyroiditis, which is most commonly observed after a viral infection and may heal spontaneously, is an inflammatory thyroid disease. The co-occurrence of subacute thyroiditis and papillary carcinoma is quite rare. A 58-year-old male patient who applied to our hospital with the complaints of sore throat and neck swelling was performed total thyroidectomy following physical examination, ultrasound, and laboratory analysis. In histopathological examination, many granuloma structures were observed in both lobes, and a papillary microcarcinoma focus of 2 mm in diameter was seen in the left lobe. The co-occurrence of subacute thyroiditis and papillary carcinoma was deemed worthy of presentation as it is rarely observed.

Benefits of CT tractography in evaluation of anterior abdominal stab wounds.

INTRODUCTION: The study aimed to identify the presence of peritoneal penetration in management of anterior abdominal stab wound by using computed tomography (CT) tractography. MATERIAL AND METHODS: Hemodynamically stabile, CT tractography-performed patients who were admitted to our emergency clinic with anterior abdominal stab wounds between the years 2012 and 2014 were included in this study, and all images were evaluated in terms of peritoneal penetration and possible intra-abdominal injury. RESULTS: In the study CT tractography identified necessity of laparotomy accurately in 90% of the patients, and none of the patients without peritoneal penetration needed surgical treatment in their follow-up. CONCLUSION: The procedure may be used for some selected cases of hemodynamically stable patient with anterior abdominal stab wounds to abstain from local wound exploration.

Intact parathormone measurement 1 hour after total thyroidectomy as a predictor of symptomatic hypocalcemia.

OBJECTIVE: Postoperative iPTH assay may predict significant hypocalcemia after thyroid surgery. The present study aimed to evaluate the ability of iPTH assay to monitor parathyroid function and to identify the risk of postoperative hypocalcemia in patients underwent thyroid surgery. MATERIALS AND METHODS: One hundred patients participated in the study (7 male and 93 female). Hypocalcemia was defined as a serum calcium concentration less than 8.0 mg/dL and symptoms of hypocalcemia. Concomitant serum calcium and iPTH levels were measured before operation and at 1(st) h for iPTH, 24(th) h for calcium after thyroidectomy. RESULTS: Postoperative hypocalcemia was observed in 31 patients. The mean postoperative serum calcium concentration in normocalcemic patients was 8.8 ± 0.5 mg/dL, whereas it was 7.6 ± 0.3 mg/dL in hypocalcemic patients. The mean postoperative 1(st) hour iPTH of patients in the hypocalcemia group was 9.1 ± 4.9 pg/mL, whereas patients of the normocalcemia group had a mean postoperative iPTH of 35.8 ± 20.2 pg/mL. CONCLUSION: Postoperative 1(st) hour iPTH < 8 pg/mL with drop in iPTH level ≥ 81.5% together showed the highest diagnostic accuracy in predicting postoperative hypocalcemia.

Bilateral ductal carcinoma in situ of the breast after radiation therapy for Ewing's sarcoma of the vertebra in a young woman: report of a case.

Thoracic radiation in the early years of life is a known risk factor for breast cancer later in life. A 21-year-old woman who had received thoracic radiation therapy for Ewing's sarcoma of the vertebra 9 years earlier was referred to our hospital for investigation of a palpable mass in her left breast. Ultrasonography and excisional biopsy showed ductal carcinoma in situ (DCIS) of the left breast, with no detectable pathology in the right breast except that it was more hypoplastic than the left breast. Considering the known risk factors for invasive breast cancer in both breasts, we performed bilateral skin-sparing mastectomy with immediate breast reconstruction using subpectoral implants. The final histopathological diagnosis was bilateral DCIS.

Can biliary-cyst communication be predicted before surgery for hepatic hydatid disease: does size matter?

BACKGROUND: The aim of this study was to determine if there is any predictive factor indicating the risk of bile leakage before surgery for hepatic hydatid disease in clinically asymptomatic patients. METHODS: The data of 116 patients who underwent surgery for hepatic hydatid disease were reviewed retrospectively. There were 43 men (37%) and 73 women (63%) with a mean age of 45 +/- 15 years. Because of high preoperative serum bilirubin and liver function test levels, 12 patients were excluded from the study. These patients underwent preoperative endoscopic retrograde cholangiopancreatography. In addition, 2 medically treated patients were excluded from the study. The following variables were analyzed as potential predictors of biliary-cyst communication: age, sex, physical examination findings, leukocyte count, liver function test results, and ultrasonographic cyst features (type, diameter, number, and localization). RESULTS: Bile leakage was detected in 24 out of 102 patients. There were no differences in age, sex, cyst type, alkaline phosphatase level, gamma-glutamyl transpeptidase level, alanine aminotransferase level, aspartate aminotransferase level, bilirubin level, and number of cysts and cyst locations between the patients with and without bile leakage. The mean cyst size in patients with biliary leakage was 10.2 cm as compared with 6.1 cm in patients with no biliary leakage (P < .05). When the cut-off value of cyst diameter was accepted as 7.5 cm, the specificity and sensitivity for biliary-cyst communication were 73% and 79%, respectively. CONCLUSIONS: These data suggest that cyst diameter is an independent factor that is associated with a high risk of biliary-cyst communication in clinically asymptomatic patients. Preoperative endoscopic retrograde cholangiopancreatography should be performed in these asymptomatic patients to reduce the incidence of postoperative complications.

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

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

Recovery of sexual function after scrotal hernia repair.

BACKGROUND: Most of the patients with scrotal hernia have sexual dysfunction to some extent. Therefore, we investigated the recovery of sexual function after scrotal hernia repair by using an internationally approved, patient-administered questionnaire. METHODS: In a prospective follow-up study, 34 patients with scrotal hernia were investigated to assess sexual function before and 3 months after hernia repair by using the International Index of Erectile Function (IIEF) questionnaire. The mean scores obtained on pre- and postoperative visits for all domains of sexual function were analyzed and compared with the Wilcoxon test. Hernia repair was performed by using a standardized Lichtenstein technique. RESULTS: The total mean score of the IIEF-15 was 52.08 before surgery and 56.20 after the procedure, with this difference considered statistically significant (P < .001). Eighty-five percent of the patients improved their scores versus 9% and 6% who showed worsening or no change at all in IIEF scores after surgery, respectively. All of the 5 sexual function domains except the orgasm domain presented statistically significant improvement. CONCLUSIONS: This study showed that scrotal hernia repair caused a positive impact on sexual function after surgery. There was no case of surgery-related erectile dysfunction. Therefore, one of the major indications to repair large scrotal hernias may be to improve the quality of sexual life.

Comparison and validation of scoring systems in a cohort of patients treated for perforated peptic ulcer.

BACKGROUND AND AIMS: The aim of this study is to evaluate the predictive accuracy of different scoring systems on surgery for perforated peptic ulcer referred to an academic department of general surgery in a tertiary reference center. PATIENTS AND METHODS: Seventy-five consecutive patients (Male/female ratio = 64:11; mean age, 44 years; range, 16-85) with perforated peptic ulcer disease were investigated. Disease severity scores and mortality predictions were calculated using the collected data during admission. Discrimination and calibration characteristics of each system, namely, the acute physiology and chronic health evaluation II and III, the simplified acute physiology score II, and the mortality probability models (MPM) II, were determined by using the area under receiver operating characteristics curve and the Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS: Among the 75 patients included, there were eight (10.6%) mortalities. All systems had a reliable power of discrimination and calibration. Among the systems tested, MPM II was the best performing as far as discrimination and calibration characteristics were considered. The parameters of MPM II system that were related to systemic perfusion of the patient were significantly positive in patients who died compared to those who survived. CONCLUSIONS: MPM II that predicted mortality at admission is better than the other systems in predicting mortality. Results also indicate the importance of maintenance of systemic perfusion of the patient at the early phases of peptic ulcer perforation.

A prospective randomized trial comparing the harmonic scalpel with conventional knot tying in thyroidectomy.

Currently, thyroidectomies are performed with very little morbidity. This study was undertaken to investigate whether the use of the harmonic scalpel during thyroid surgery has any advantage over the conventional technique. Eighty patients were randomly assigned to 2 groups. The patients in group 1 (n=40) underwent thyroidectomy performed with conventional knot tying and the electrocautery technique; in patients in group 2 (n=40), the harmonic scalpel was used for the procedure. Significant differences were observed between these 2 surgical techniques in terms of operative time, number of ligatures used, amount of bleeding, average length of incision, total amount of drainage fluid, and cosmetic satisfaction (P<.05). With the harmonic scalpel technique, there was a nearly 18% reduction in operative time. No significant differences were noted between mean hospital stay and postoperative pain (P>.05). No patient in either group had permanent recurrent laryngeal nerve palsy or hypoparathyroidism. The harmonic scalpel significantly shortens the duration of thyroidectomies; it can be used safely and effectively in thyroid surgery with no additional morbidity.

Comparison and validation of scoring systems in a cohort of patients treated for biliary acute pancreatitis.

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