Thyroid nodule core needle biopsy - current approach.

Fine needle aspiration biopsy (FNAB) guided by ultrasonography is routinely used to identify thyroid nodules prior to surgery. Although FNAB has great diagnostic accuracy and safety, it is limited by its relatively low diagnostic accuracy in follicular lesions, such as non-diagnostic or atypia of unclear significance (AUS)/follicular lesion of uncertain significance (FLUS). Additional diagnostic tests are required to overcome these challenges in evaluating thyroid nodules. Thyroid nodules can now be diagnosed with spring-activated single- or double-action needles following the introduction of core needle biopsy (CNB). CNB has the ability to address the limitations of FNAB by obtaining a sizeable tissue sample with more details on the histological structure supporting the capsule and fewer non-diagnostic effects brought on by the absence of follicular cells. Compared to repeated FNAB, CNB has been demonstrated to produce fewer ambiguous results, such as non-diagnostic or AUS/FLUS results. The Korean Endocrine Pathology Thyroid CNB Working Group issued its first set of guidelines for "Pathology Reporting of Thyroid Core Needle Biopsy" in 2015. In 2017, the Korean Society of Thyroid Radiology (KSThR) published "Core Needle Biopsy of Thyroid: 2016 Consensus Statement and Recommendations from the Korean Society of Thyroid Radiology". The main objectives of thyroid CNB are to detect individuals with thyroid illness who require surgery and to obtain a significant number of thyroid lesions with low morbidity.

Comparison of the Effectiveness of Ethanol and Radiofrequency Ablation in the Treatment of Thyroid Nodules and Their Effects on Cosmetic Scoring.

PURPOSE: In this study, we aimed to retrospectively evaluate the volumes and cosmetic scores of mixed-type and spongy-type thyroid nodules treated with ethanol and radiofrequency (RF) ablation before and after treatment. In addition, the safety and efficacy of ethanol and RF ablation treatment methods were compared. METHODS: In the radiology department, mixed-type and spongy-type benign thyroid nodules undergoing ethanol and RF ablation between February 2015 and March 2020 were evaluated retrospectively. Consequently, 50 patients who received ethanol ablation therapy and 46 patients who received RF ablation therapy were included in the study. Nodule volumes obtained in pretreatment, third-month, and sixth-month control ultrasounds were noted. Similarly, the cosmetic scores obtained pretreatment and at the sixth-month follow-up were recorded for all patients. RESULTS: All of the patients had a single nodule, and 46 patients (47.9%) received RF ablation, and 50 patients (52.1%) received ethanol ablation. The mean volume pretreatment in nodules with RF ablation was 21.41 ml, at the third-month control was 5.68 ml, and at the sixth-month control, it was 4.12 ml (p < 0.05). In ethanol ablation therapy, the mean volume pretreatment was 20.52 ml, at the third-month control was 8.76 ml and at the sixth-month control was 6.01 ml (p < 0.05). CONCLUSION: A minimally invasive approach is increasingly used in the treatment of benign thyroid nodules. Our study showed that RF ablation was somewhat more successful in reducing cosmetic scores in patients with biopsy-proven benign mixed-type and spongy-type thyroid nodules, and both techniques were similarly effective in volume reduction.

Effects of soy-containing infant formulas on thyroid gland in rats.

BACKGROUND: Effects of soy-containing infant formulas on the thyroid gland is not clear. We aimed to evaluate the effects of infant formulas with different quantities of soy content on the functional and histopathological characteristics of the thyroid gland. METHODS: Twenty-eight female Sprague-Dawley rats were divided into four groups. Group 1 was fed with standard pellet rat food (8 g/day); group 2 soy-free infant formula (8 g/day); group 3 low-dose (1.12 g/100 mL) soy-containing formula (8 g/day), and group 4 high-dose (2.64 g/100 mL) soy-containing formula (8 g/day). Blood samples were collected from the subjects on day 0, 30, 60, and 90 to evaluate thyroid functions. All subjects were sacrificed on day 90. Thyroid glands were excised and examined histopathologically. RESULTS: Serum levels of free T3, free T4, TSH, anti-TPO, and anti-TG were significantly higher in Group 4 compared to other groups (P<0.001, P<0.01, P<0.001, P=0.002). No differences were found in the histopathological findings between the groups. CONCLUSIONS: Infant formulas with high soy content induce hyperthyroidism with high TSH levels. High levels of anti-TPO and anti-TG suggest that observed changes might have occurred via inflammatory mechanism.

Effects of glycerol and sodium pentaborate containing new formulation on sleeve gastrectomy model in rats.

PURPOSE: The development of cutting surface leakage and postoperative peritoneal adhesions (PPA) after sleeve gastrectomy (SG) are the most serious operative complications. We investigated the effectiveness of the newly developed glycerol and sodium pentaborate containing formulation on the prevention of these complications. METHODS: Sixteen Sprague Dawley rats (mean weight 310 ± 50 g, mean age 3 months old) were divided into two groups, consisting of eight rats in each. SG and a double-layer suture technique were performed for each group. In study group, there was the mixture of 2 mL 3% glycerol plus 3% sodium pentaborate formulation, and in the control group 2 mL 0.9% NaCl was injected into the peritoneal cavity. Rats were sacrificed after 30 days, then macroscopic adhesion grade scoring and histopathological evaluations were assessed. RESULTS: Macroscopic PPA scores in the control and study groups were 2.75 ± 0.16 and 1.50 ± 0.327, respectively (p = 0.004). Histopatologic fibrosis scores in the control and study groups were 0.87 ± 0.125 and 2.00 ± 0.26, respectively (p = 0.002). CONCLUSIONS: In SG operation model, glycerol plus sodium pentaborate compound decreased PPA formation and also increased stomach cut surface line fibrosis. This new formulation is hopeful for more safe SG operations.

Number of cells in parathyroid tissue in primary hyperparathyroidism cases and its relationship with serum calcium value.

BACKGROUND: The relationship between serum calcium (Ca) level to serum parathyroid hormone (PTH), phosphorus (P) levels and tissue properties of the parathyroid gland is unknown in primary hyperparathyroidism cases. Revealing this relationship may be useful for understanding the etiopathogenesis of primary hyperparathyroidism and determining the time of treatment. METHODS: Ninety patients (71 females, 19 males, age range; 27-73 years, average age; 46) who underwent single gland excision with the diagnosis of primary hyperparathyroidism were studied. The patients were divided into 2 groups as serum Ca level <12 and serum Ca level ≥12. Age and sex of the patients, mean cell number of the gland, mean volume of the gland, serum levels of PTH, P, and histopathologic type of hyperplasia were evaluated. RESULTS: The mean cell number per cubic centimeter is 22.9 (10-220 range) million in all glands. Serum Ca level was <12 in 82 (91.1%) of the patients, and ≥12 in 8 (8.9%) cases. Mean cell number of the gland, mean volume of the gland, existence of cystic hyperplasia of the gland, serum levels of PTH and P were statistically significant between the 2 groups (P < .001, P < .001, P < .05, P < .001, P < .05 respectively). CONCLUSION: In primary hyperparathyroidism cases serum Ca level is not related to age and sex but directly related to proportionals to the cell number and volume of the gland and serum levels of PTH, inversely related to cystic hyperplasia and serum levels of P. Early surgical intervention should be planned since the serum Ca level will be high in large adenomas with a noncystic radiological appearance.

Clinical and functional results of radiofrequency ablation and microwave ablation in patients with benign thyroid nodules.

OBJECTIVES: To determine how well ultrasound-guidance percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) performed for benign symptomatic thyroid nodules in terms of clinical and functional outcomes. METHODS: Patients who had a thyroid nodule-linked symptoms acting as dysphagia, cosmetic issues, pain, a foreign body sense, hyperthyroidism secondary to autonomous nodules, or concern of malignancy were involved in the study. The primary was the comparison in symptom scores obtained at 1, 3, and 6 months after RFA and MWA. The volume alterations in nodules and alterations in thyroid gland functions were secondary objectives. RESULTS: This prospective study carried out from November 2014 and January 2017 at the General Surgery Department, Marmara University, Faculty of Medicine, Istanbul, Turkey included a total of 100 nodules (50% MWA, 50% RFA). There were statistically significance in pain scores, dysphagia scores, and foreign body sensation scores at 1, 3, and 6 months after therapy in both ablation groups (p=0.0006, p=00004, p=0.0005). At the same time, there were statistically significant reductions in size and volume of the nodules for RFA and MWA (p=0.0004, p=0.0003). There was no significant difference between the RFA and MWA groups' cosmetic scoring and volume changes (p=0.68, p=0.43). CONCLUSIONS: Alternative therapies for benign symptomatic thyroid nodules include RFA and MWA. The findings of this research revealed that both approaches are safe and effective.

Measurement of hiatal surface area and other hiatus oesophageal diameters at computed tomography imaging in patients with gastroesophageal reflux disease and its relationship with hiatal hernia.

BACKGROUND: The oesophageal hiatus is a long and oblique opening in the diaphragm where the thoracic section of the oesophagus passes into the abdomen. Enlarged hiatal surface and insufficiency are considered to be associated with gastroesophageal reflux disease (GERD) and hiatal hernia (HH). In this study, we aimed to retrospectively evaluate the relationship and the presence of GERD with HH by performing hiatal surface area (HSA) and other hiatal measurements at the thorax and abdominal computed tomography (CT) images in cases without any intra-abdominal or oesophageal surgery history. PATIENTS AND METHODS: A total of 192 patients of GERD+ and 173 cases with GERD- as a control group were included in the study. In CT examinations of 365 patients included in the study, measurements and comments were made by an experienced radiologist in abdominal radiology. In CT scans, the following were evaluated for each case; HSA, hiatus anterior-posterior (A-P) diameter, hiatus transverse diameter, and HH types. The HSA measurement was made with the freehand region of interest in the picture archiving and communication system. RESULTS: A total of 365 cases were included in this study; there was a significant difference between the median HSA, A-P diameter, and transverse diameter measurements between GERD- and GERD+ groups (P < 0.001). A statistically significant difference was found between the presence of GERD and HH types (P < 0.001). CONCLUSIONS: CT imaging helps investigate the presence of HH at GERD+ patients. In addition, pre-operative valuable data can be obtained from the detection of HH types and HSA measurements in cases with HH.

The role of ultrasound measurements and cosmetic scoring in evaluating the effectiveness of ethanol ablation in cystic thyroid nodules.

BACKGROUND: A minimally invasive approach has been adopted to treat benign cystic nodules in recent years, with ethanol ablation (EA) being used as a more common method in routine treatment. For this study, we aimed to investigate the change of nodule volumes and cosmetic scores before and after EA in benign thyroid nodules and the effectiveness of treatment. Therefore, ultrasound data and cosmetic scores of pure cystic, mixed-type and spongy-type benign thyroid nodules undergoing EA in the last two years were reviewed retrospectively. METHODS: Archive scanning was performed for all cases that were proven benign by fine-needle aspiration biopsy (FNAB) and who underwent EA. In all 46 patients included in the study, thyroid FNAB was performed. Ultrasound images were available to assess the size and volumes at pretreatment and 3 and 6 months after EA. The cosmetic scores obtained before the procedure and at 6 months after EA were compared. RESULTS: There was a statistically significant difference when the sizes and volumes of the nodules were compared at pretreatment, 3 and 6 months follow-up (P < .001). The mean pretreatment cosmetic score was 3.09, and at 6 months, it was 1.20, with a statistically significant difference (P < .001). CONCLUSIONS: Recently, a minimally invasive approach has been adopted in the treatment of benign cystic nodules, with ethanol ablation becoming more common in routine treatment. Therefore, ethanol ablation is very valuable in minimising complications that may arise from surgery.

The importance of the Moskowitz artery as a lesser-known collateral pathway in the medial laparoscopic approach to splenic flexure mobilisation and its evaluation with preoperative computed tomography.

INTRODUCTION: The collateral pathways between the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) play an important role in colonic surgery. The most well-known are the Drummond marginal artery and Riolan's arch. The Moskowitz artery, also known as the meandering mesenteric artery, is a lesser-known collateral pathway and represents another link between SMA and IMA. The Moskowitz artery runs along the colonic mesentery floor and represents the link between the proximal segment of the middle colic artery and the ascending branch of the left colic artery. AIM: To comprehend the presence and importance of the Moskowitz artery (meandering mesenteric artery) in preoperative patients by using computed tomography (CT) studies. MATERIAL AND METHODS: We retrospectively reviewed all abdominal CT images performed using intravenous contrast for any reason at the Radiology Department of Yeditepe University Hospital between April 2015 and September 2018. Patients older than 18 years with intravenous contrast (arterial and venous phases with a cross-section thickness of 0.625 mm), who underwent abdominal CT scan, and patients without any abdominal surgery were included in the study. As a result of the screening, 109 CT scans with eligibility criteria were included in this study. RESULTS: There were 109 cases in this study; 50 (45.9%) of them were male and 59 (54.1%) were female. Moskowitz artery was found in 18 (16.5%) cases; 8 were males and 10 were females. Riolan's arch was present in 30 cases, of whom 15 were male and 15 were female. In our study Moskowitz artery and Riolan's arch were monitored as separate vascular structures, and in all cases with Moskowitz artery, Riolan's arch was also present. There was a statistically significant difference (p < 0.05) between the combined MCA emerging type and the presence of MA, and 12 cases with combined branch and 6 cases with single branch had Moskowitz artery. There was a statistically significant difference (p < 0.05) between LCA types and the presence of MA, and the Moskowitz artery was the most common seen at type 1 LCA. CONCLUSIONS: Knowledge of the relationship between Riolan's arch and the Moskowitz artery is valuable, and preoperative evaluation of this artery may be beneficial in the presence of Riolan's arch. In addition, preoperative radiological evaluation and its importance are prominent in minimising intraoperative bleeding during splenic flexure mobilisation with a medial laparoscopic approach and reducing the risk of colorectal anastomosis leakage.

Robotic TAMIS: A Technical Note Comparing Si® versus Xi®.

Transanal minimally invasive surgery (TAMIS) can be performed robotically assisted (R-TAMIS) for easier rectal defect suture closure particularly on the anterior rectal wall. The surgical technique described in this technical note emphasizes three safety points: 1) decreased likelihood for rectal injury when the ports are inserted into the GelPOINT® Path Transanal Access Platform (Applied Medical, Rancho Santa Margarita, California) on the back table rather than being inserted into the rectum; 2) decreased external collision between ports when using ports of different length; and 3) increased stabilization of pneumorectum when insufflating with an AirSeal™ port (Intelligent Flow System, ConMed, Utica, New York). Although R-TAMIS can be safely performed with the da Vinci® Si® or Xi® (Intuitive Surgical Inc., Sunnyvale, California) patient cart, the following differences are noteworthy: a) the Si® vertically-mounted arms design forces the patient in an uncomfortable position with asymmetrical hip flexion as opposed to the Xi® boom-mounted horizontal arm design; b) the 28cm circumference of each Si® patient cart arms operating between the patient's legs offer decreased maneuvering freedom as opposed to the 19cm circumference of the Xi® counterparts; and c) the abduction pattern of movement of the Si® arms potentially increases the risk of external collision with the patient's legs as opposed to the Xi® "jack-knife" pattern of movement.

The effectiveness of ethanol ablation in the treatment of thyroglossal duct cysts in adult cases and evaluation with cosmetic scoring.

PURPOSE: The purpose of this study was to evaluate thyroglossal duct cyst (TGDC) volumes before and after treatment with ultrasound (US) in patients who underwent ethanol ablation (EA). Besides, the usability of cosmetic scoring in TGDC cases was investigated by comparing cosmetic scores pre-treatment and after EA. MATERIALS AND METHODS: 28 TGDC cases who had EA in one session and had complete US data and cosmetic scores were included in the study. US data including TGDC diameters and volumes obtained at the pre-treatment, 3rd, 6th, and 12th month after EA were noted, respectively. Cosmetic scoring was performed pre-treatment and after EA using the WHO grading system simultaneously with US. RESULTS: At the 12th month after EA, there was 85.2% reduction in mean diameter and 95.1% reduction in mean volume in TGDC cases (p < 0.001). The mean cosmetic score pre-treatment was 2.7 ± 0.8 and the mean cosmetic score at the 12th month was 1 (p < 0.001). When the changes in TGDC volumes and cosmetic scoring after EA were compared according to gender and age, there was no statistically significant difference (p > 0.05). CONCLUSION: The current study demonstrated that EA can be used safely to reduce TGDC sizes and is an alternative treatment option to surgery.

Does the learning curve in robotic rectal cancer surgery impact circumferential resection margin involvement and reoperation rates? A risk-adjusted cumulative sum analysis.

BACKGROUND: The aim of this study was to evaluate the impact of surgeons' learning curve in robotic surgery for rectal cancer on circumferential resection margin (CRM) involvement and reoperation rates. METHODS: Learning curve data were prospectively collected from four centers. Patients undergoing robotic proctectomy for resectable rectal cancer were included. CRM was involved when ≥1 mm. TME quality was classified as complete, nearly complete, or incomplete. T-test and χ2 tests were used to compare continuous and categorical variables, respectively. Risk-adjusted cumulative sum (RA-CUSUM) analysis was utilized to evaluate the effect of the learning curve on primary endpoints. Univariate analysis of potential risk factors for CRM involvement and reoperation was performed. Factors with the P value ≤0.2 were included in the multivariate logistic regression model for further RA-CUSUM analysis. RESULTS: A total of 221 patients (80, 36, 62, and 43 patients operated on by surgeons 1, 2, 3, and 4, respectively) who underwent robotic surgery for rectal cancer during the surgeons' learning curves were included. CRM involvement rate was 0%, 11%, 3%, and 5% in surgeons 1, 2, 3, and 4, respectively. Reoperation rate was 3.7%, 8.3%, 4.8%, and 11.6%, respectively. RA-CUSUM analysis of CRM involvement (R2=0.9886) and reoperation (R2=0.9891) found a statistically significant decreasing trend in aggregate CUSUM values throughout the learning curve. CONCLUSIONS: This study found a continued significant decrease in CRM involvement and reoperation rates throughout the learning curve in robotic rectal cancer surgery.

Effects of glycerol and sodium pentaborate containing new formulation on sleeve gastrectomy model in rats

ABSTRACT Purpose: The development of cutting surface leakage and postoperative peritoneal adhesions (PPA) after sleeve gastrectomy (SG) are the most serious operative complications. We investigated the effectiveness of the newly developed glycerol and sodium pentaborate containing formulation on the prevention of these complications. Methods: Sixteen Sprague Dawley rats (mean weight 310 ± 50 g, mean age 3 months old) were divided into two groups, consisting of eight rats in each. SG and a double-layer suture technique were performed for each group. In study group, there was the mixture of 2 mL 3% glycerol plus 3% sodium pentaborate formulation, and in the control group 2 mL 0.9% NaCl was injected into the peritoneal cavity. Rats were sacrificed after 30 days, then macroscopic adhesion grade scoring and histopathological evaluations were assessed. Results: Macroscopic PPA scores in the control and study groups were 2.75 ± 0.16 and 1.50 ± 0.327, respectively (p = 0.004). Histopatologic fibrosis scores in the control and study groups were 0.87 ± 0.125 and 2.00 ± 0.26, respectively (p = 0.002). Conclusions: In SG operation model, glycerol plus sodium pentaborate compound decreased PPA formation and also increased stomach cut surface line fibrosis. This new formulation is hopeful for more safe SG operations.

Should Surgeons Evaluate the Anatomy of Drummond Marginal Artery and Riolan's Arch Preoperatively?

INTRODUCTION: The Drummond marginal artery and the Riolan's arch are important links between the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA), which provide collateral flow in case of arterial occlusion or significant stenosis. The Riolan's arch is important in colorectal surgery since it allows for vascularization of the descending colon by the SMA after ligation of the IMA at its origin, especially in cancer patients. In this study, we aimed to evaluate the presence of the Drummond marginal artery and the Riolan's arch. In addition, we assessed anatomic variants of the middle colic artery (MCA) and classified the anatomic relationships between SMA and SMV. MATERIALS AND METHODS: Following screening, 115 abdominal CT scans were included in the study. For all cases, the presence of the Drummond marginal artery and the Riolan's arch, the first diameter of these arterial structures at their origins, the first emerging diameter and anatomic variants of the MCA, and the anatomic relationships between SMA and SMV were evaluated. RESULTS: Drummond marginal artery was present in all participants (100%). The Riolan's arch was observed in 27.8% of all cases and was higher than in other studies. This can be related to the focus of this arch. In addition, we did not find any similar study in the literature that evaluated MCA origin types, SMA-SMV variants with the presence of the Drummond artery and the Riolan's arch, and the first emerging diameters of vascular structures, such as the Drummond marginal artery, the Riolan's arch, and MCA. CONCLUSION: Evaluating and stating whether the Drummond marginal artery and the Riolan's arch are seen in thin section abdominal computed tomography (CT) and CT angiographies preoperatively may help in planning appropriate resections and can reduce unwanted postoperative morbidity.

Factors affecting surgical site infection rate after elective gastric cancer surgery.

OBJECTIVE: Surgical site infection (SSI) is a common complication after surgery and is an indicator of quality of care. Risk factors for SSI are studied thoroughly for most types of gastrointestinal surgeries and especially colorectal surgeries, but accumulated data is still lacking for gastric surgeries. We studied the parameters affecting SSI rate after gastric cancer surgery. MATERIAL AND METHODS: Consecutive patients, who underwent elective gastric cancer surgery between June and December 2013, were included. Descriptive parameters, laboratory values and past medical histories were recorded prospectively. All patients were followed for 1 month. Recorded parameters were compared between the SSI (+) and SSI (-) groups. RESULTS: Fifty-two patients (mean age: 58.87±9.25 [31-80]; 67% male) were included. SSI incidence was 19%. ASA score ≥3 (p<0.001), postoperative weight gain (p<0.001), smoking (p=0.014) and body mass index (BMI) ≥30 (p=0.025) were related with a higher SSI incidence. Also patients in the SSI (+) group had a higher preoperative serum C-reactive protein level (p=0.014). CONCLUSION: We assume that decreasing BMI to <30, stopping smoking at least 3 weeks before the operation, and preventing postoperative weight gain by avoiding excessive intravenous hydration will all help decrease SSI rate after gastric surgery.