Does the intraoperative parathormone monitoring really affect surgical success in primary hyperparathyroidism?

BACKGROUND: Surgery is the only curative treatment option for primary hyperparathyroidism (PHPT). The intraoperative parathormone (IOPTH) monitoring is recommended to confirm that all pathological glands have been removed. This study aimed to evaluate the effect of IOPTH monitoring on the surgical success of parathyroidectomy performed for PHPT. METHODS: The demographic, biochemical, operative and pathological data of patients who underwent parathyroidectomy for PHPT in a single institute over a three-year period were retrospectively analyzed. RESULTS: The total number of patients included in the study was 182. The IOPTH monitoring had been performed in 92 patients (50.5%). The IOPTH monitoring had a clinical accuracy of 89.2%, sensitivity of 89.8%, and specificity of 75%. The rate of surgical success was 95.7% in the group with IOPTH monitoring and 91.1% in the group without this monitoring (p = .21). Of the 40 patients who underwent minimally invasive parathyroidectomy (MIP), 25 patients had IOPTH monitoring, and the surgery was successful for all these patients (100%). Surgical success was achieved in 14 (93.3%) patients who underwent MIP without IOPTH monitoring (p = .37). CONCLUSION: The IOPTH monitoring is a reliable test with high accuracy. The lack of IOPTH monitoring may result in lower than acceptable surgical success rates. Even though preoperative localization studies are compatible with surgical findings, the IOPTH monitoring should also be undertaken, especially in patients scheduled for MIP for PHPT.

External validation of the AppendistatTM score and comparison with CRP levels for the prediction of complicated appendicitis.

BACKGROUND: In acute appendicitis, the treatment approach may vary depending on the age and comorbidities of the patient and whether the appendix is complicated. In this study, we validated the appendistatTM score, including the logistic regression model of complicated appendicitis, and compared the efficacy of this scoring with C-reactive protein in predicting complicated appendicitis. METHODS: Demographic characteristics, pathology, and laboratory results of patients who underwent appendectomy for acute appendicitis were retrospectively screened, those over 18 years of age were included in the study. The appendistatTM scores, including the logistic regression model of complicated appendicitis, were obtained. RESULTS: Complicated appendicitis was present in 13 (10.1%) patients and non-complicated appendicitis in 116 (89.9%). Two (15.4%) of the complicated appendicitis cases were female and 11 (84.6%) were male. The mean age of complicated appendicitis cases was 44 (20-77) years, and their median value of C-reactive protein was 41.00 mg/L. In the ROC curve analysis, the cut-off value for C-reactive protein was 23.5 mg/L and that of the appendistatTM as 9.6. The area under the curve values of the appendistatTM score and C-reactive protein were 0.787 and 0.750, respectively. CONCLUSION: AppendistatTM is a successful scoring system that contains appropriate parameters. However, C-reactive protein detecting or excluding complicated appendicitis at a similar rate to AppendistatTM suggests that the latter does not have a significant advantage in clinical practice.

Associated Features with Non-Sentinel Lymph Node Involvement in Early Stage Breast Cancer Patients who Have Positive Macrometastatic Sentinel Lymph Node.

OBJECTIVE: The main goal of this study is to determine the clinico-pathological factors that correlate non-sentinel lymph nodes (LNs) involvement in clinically node negative breast cancer (BC) patients with positive macrometastatic sentinel lymph node (SLN) in order to derive future evidence to define a subgroup where completion axillary lymph node dissection (cALND) might not be recommended. MATERIALS AND METHODS: Total 289 SLN biopsies were performed in clinically node negative BC patients between March 2014 and April 2017. Seventy patients who performed cALND due to positive macrometastatic SLN were retrospectively selected and classified into two groups, according to non-SLN involvement (NSLNI). Clinico-pathological features of patients were examined computerized and documentary archives. RESULTS: Extracapsular extension (ECE) of SLN, number of harvested SLNs, metastatic rate of SLNs, absence of ductal carcinoma in situ (DCIS) and presence of multilocalization were significantly associated with the likelihood of non-SLN involvement after univariate analysis (p<0,05). Absence of DCIS and presence of multilocalization were found to be significant after multivariate analysis. CONCLUSION: Careful examination of clinico-pathological features can help to decide avoiding cALND if enough LNs are removed and the rate of SLN metastases is low, particularly in case DCIS accompanying invasive cancer in patients without multi localized tumour.

A Diagnostic Dilemma: Skip Metastasis in Papillary Thyroid Cancer.

The frequency, pattern, and predictive factors for skip LN metastasis in patients with papillary thyroid carcinoma (PTC) remain controversial. In this study, we evaluated predictive factors of skip LN metastasis in these patients. We reviewed the medical records of 68 PTC patients who underwent total thyroidectomy, central neck dissection, and lateral neck dissection at the initial operation. The relationships between skip LN metastasis and clinicopathologic factors were analyzed. After careful examination of electronic medical records of patients, 19 patients were excluded from the study. Of the remaining 49 patients, 9 (18.4%) had skip LN metastasis. Multivariate analysis showed that tumor size <1 cm was an independent risk factor for the presence of skip metastasis (P = 0.035, odds ratio: 3.78, 95% confidence interval: 1.09-13.15). The rate of positive LN was relatively higher in micro-PTC patients than PTC patients. This finding is clinically significant and should be considered in routine clinical practice.

Clinical course of percutaneous cholecystostomies: A cross-sectional study.

BACKGROUND: Although cholecystectomy is the standard treatment modality, it has been shown that perioperative mortality is approaching 19% in critical and elderly patients. Percutaneous cholecystostomy (PC) can be considered as a safer option with a significantly lower complication rate in these patients. AIM: To assess the clinical course of acute cholecystitis (AC) in patients we treated with PC. METHODS: The study included 82 patients with Grade I, II or III AC according to the Tokyo Guidelines 2018 (TG18) and treated with PC. The patients' demographic and clinical features, laboratory parameters, and radiological findings were retrospectively obtained from their medical records. RESULTS: Eighty-two patients, 45 (54.9%) were male, and the median age was 76 (35-98) years. According to TG18, 25 patients (30.5%) had Grade I, 34 (41.5%) Grade II, and 23 (28%) Grade III AC. The American Society of Anesthesiologists (ASA) physical status score was III or more in 78 patients (95.1%). The patients, who had been treated with PC, were divided into two groups: discharged patients and those who died in hospital. The groups statistically significantly differed only concerning the ASA score (P = 0.0001) and WBCC (P = 0.025). Two months after discharge, two patients (3%) were readmitted with AC, and the intervention was repeated. Nine of the discharged patients (13.6%) underwent interval open cholecystectomy or laparoscopic cholecystectomy (8/1) within six to eight weeks after PC. The median follow-up time of these patients was 128 (12-365) wk, and their median lifetime was 36 (1-332) wk. CONCLUSION: For high clinical success in AC treatment, PC is recommended for high-risk patients with moderate-severe AC according to TG18, elderly patients, and especially those with ASA scores of ≥ III. According to our results, PC, a safe, effective and minimally invasive treatment, should be preferred in cases suffering from AC with high risk of mortality associated with cholecystectomy.

Differences in the Clinical Course of Acute Appendicitis in Geriatric Patient Groups.

OBJECTIVE: To compare the differences in the clinical course of acute appendicitis between early elderly (60-79 years) and late elderly patients (≥80 years). METHOD: The sample consisted of 177 patients aged over 60 that underwent surgery at the emergency service with the diagnosis of acute appendicitis between January 2010 and May 2018. Patients' data were retrospectively obtained from electronic records. Patients that had undergone appendectomy or negative appendectomy or had an appendix tumor were excluded from the study. The patients were divided into two groups by age; early elderly (60-79 years) and late elderly (≥80 years). RESULTS: Of the 177 patients included in the study, 162(91%) were 60-79 years old and 15 (9%) were over 80. A statistically significant difference was found between the early and late elderly groups in terms of perforation, requirement for intensive care (p =0.001), red cell distribution width (p =0.025), the Clavien-Dindo classification (p =0.020), and the Charlson comorbidity index (p =0.005). The mean hospital stay was four and 11 days for early and late elderly groups, respectively. Multivariate analysis revealed that age alone was an independent factor with a statistically significant effect on mortality (OR=Odds Ratio: 53, 95% CI: 16.91-166.08; (p<0.001)). CONCLUSION: In particular, in the elderly patients over 80 years old, the clinical manifestation of acute appendicitis at hospital admission is in the form of perforation. Therefore, in this age group, a careful, precise and prompt diagnosis is crucial.

Is Vocal Cord Assessment before Total Thyroidectomy Required for All Patients?

We investigated whether laryngoscopy should be performed before total thyroidectomy on all patients without a history of neck surgery. A total of 2523 patients who underwent total thyroidectomy between January 1, 2013, and March 18, 2018, were retrospectively examined. Preoperative vocal cord examination was performed on 2070 of these patients by the otorhinolaryngology department using indirect laryngoscopy. Patients with a history of neck or thyroid surgery were not included in the study. The patients were evaluated in terms of age, gender, symptom (hoarseness/dyspnea), comorbidity, surgical history, biopsy, nodule diameter, pathological diagnosis, and tracheal deviation. Preoperative vocal cord paralysis was detected in 0.8 per cent of the patients (17/2070). Four patients (23.5%) were male and 13 patients (76.5%) were female. The mean age was 62 (range, 25-82) years. Seven of the 17 patients (41%) were symptomatic, with complaints of dyspnea in five and hoarseness in two. The univariate analysis revealed that a nodule diameter >30 mm and the presence of dyspnea were associated with vocal cord damage. Furthermore, the multivariate analysis showed that dyspnea alone was an independent variable (P = 0.011). It is recommended that preoperative vocal cord evaluation should be performed only in patients with severe symptoms, such as dyspnea.

A novel simplified scoring system for predicting mortality in emergency colorectal surgery: prediction model development.

BACKGROUND: Despite advances in surgical approaches, emergency colorectal surgery has high mortality and morbidity. OBJECTIVE: We aimed to create a simple and distinctive scoring system, for predicting mortality among patients undergoing emergency colorectal surgery. DESIGN AND SETTING: Prediction model development study based on retrospective data-gathering. METHODS: Patients who underwent emergency colorectal surgery between March 2014 and December 2016 at a single tertiary-level referral center were included in our study. Patient demographics, comorbidities, type of surgery, etiology and laboratory and radiological findings were collected retrospectively and analyzed. A new clinical score (named the Numune emergency colorectal resection score) was constructed from the last logistic regression model, in which one point was assigned for the presence of each predictive factor. RESULTS: 138 patients underwent emergency colorectal surgery. These comprised 64 males (46.4%) and 74 females (53.6%), with a mean age of 64 years. Multivariate analysis revealed that blood urea nitrogen level > 65 mg/dl (odds ratio, OR: 8.03; 95% confidence interval, CI: 2.16-15.77), albumin level < 0.7 -mg/-dl (OR: 4.43; 95% CI: 1.96-14.39) and American Society of Anesthesiologists score ≥ 3 (OR: 3.47; 95% CI: 0.81-9.18) were associated with postoperative complications. The Numune score was graded from I to III. The risk of mortality was found to be 63.2% in the group with grade III, which accounted for 35.2% of the subjects. There were 37 postoperative deaths. CONCLUSIONS: Surgeons need scoring systems, especially to predict postoperative mortality. We propose the Numune emergency colorectal resection score for emergency surgical procedures as a practical, usable and effective system for predicting postoperative morbidity.

A novel simplified scoring system for predicting mortality in emergency colorectal surgery: prediction model development

ABSTRACT BACKGROUND: Despite advances in surgical approaches, emergency colorectal surgery has high mortality and morbidity. OBJECTIVE: We aimed to create a simple and distinctive scoring system, for predicting mortality among patients undergoing emergency colorectal surgery. DESIGN AND SETTING: Prediction model development study based on retrospective data-gathering. METHODS: Patients who underwent emergency colorectal surgery between March 2014 and December 2016 at a single tertiary-level referral center were included in our study. Patient demographics, comorbidities, type of surgery, etiology and laboratory and radiological findings were collected retrospectively and analyzed. A new clinical score (named the Numune emergency colorectal resection score) was constructed from the last logistic regression model, in which one point was assigned for the presence of each predictive factor. RESULTS: 138 patients underwent emergency colorectal surgery. These comprised 64 males (46.4%) and 74 females (53.6%), with a mean age of 64 years. Multivariate analysis revealed that blood urea nitrogen level > 65 mg/dl (odds ratio, OR: 8.03; 95% confidence interval, CI: 2.16-15.77), albumin level < 0.7 ­mg/­dl (OR: 4.43; 95% CI: 1.96-14.39) and American Society of Anesthesiologists score ≥ 3 (OR: 3.47; 95% CI: 0.81-9.18) were associated with postoperative complications. The Numune score was graded from I to III. The risk of mortality was found to be 63.2% in the group with grade III, which accounted for 35.2% of the subjects. There were 37 postoperative deaths. CONCLUSIONS: Surgeons need scoring systems, especially to predict postoperative mortality. We propose the Numune emergency colorectal resection score for emergency surgical procedures as a practical, usable and effective system for predicting postoperative morbidity.

External validation of anastomotic leakage risk analysis system in patients who underwent colorectal resection

Background/aim: One of the most feared complications after colon resection for carcinoma is anastomotic leakage. Prediction of anastomotic leakage can alter pre- and perioperative management of patients. This study validates an anastomotic leakage prediction system. Materials and methods: Ninety-five patients who underwent colonic resection between 1 January 2016 and 30 January 2017 were included in the study. Patient records and electronic charting system data were used to calculate anastomotic leakage risk on the http://www.anastomoticleak.com/ website. Results: Fifty-six (58.9%) patients were male and thirty-nine (41.1%) were female. The mean age was 61.7 (min: 33, max: 90). Six (6.3%) patients had anastomotic leakage. According to the ROC analysis, the area under curve for the prediction system was 0.767. Conclusion: The prediction system for anastomotic leakage produced significant results for our patient population. It can be effectively utilized in preoperative and perioperative measures to prevent anastomotic leakage.

Long-term results of the patients who were applied laparoscopic adjustable gastric banding.

OBJECTIVES: The most effective treatment step in morbid obesity is surgical treatment. The purpose of the present study was to investigate the long-term follow-up results and success rates in laparoscopic adjustable gastric banding. MATERIAL AND METHODS: The change in body mass index, percentage of excess weight loss, comorbidities, and resulting complications were investigated in 220 patients who were morbidly obese and applied laparoscopic adjustable gastric band between April 2006 and February 2012, throughout the 6-year follow-up period. Forty-six patients who did not show up for their routine follow-ups were excluded from the study. RESULTS: In the present study, band removal percentage was 35.63%. The percentage of excess weight loss in patients who were followed up without removal of the band was 46.03%. Complications were observed in 46.5% of the patients. The most frequently observed complication among the major complications was band intolerance, which is also the most common cause of band removal. Band removal was considered as a failure in laparoscopic adjustable gastric band operations, and patients were referred to other surgical methods. CONCLUSION: When improved patient compliance and careful and close patient follow-up are provided in the early stages of laparoscopic adjustable gastric band application, it may be possible to reach percentage of excess weight loss results that would be the nearest to those achieved by gastric bypass or sleeve gastrectomy methods. However, high complication rates and necessity to perform other bariatric surgical procedures in the majority of the patients in the long-term follow-up suggest that the laparoscopic adjustable gastric band operation is not the first choice in bariatric surgery.

A comparison of logistic regression and artificial neural networks in predicting central lymph node metastases in papillary thyroid microcarcinoma.

OBJECTIVE: Prophylactic central lymph node dissection(CLND) is a controversial issue in papillary thyroid microcarcinoma( PTMC) patients without lymphatic metastasis. Artificial neural network(ANN) has been proposed as an alternative statistical technique for predicting complex biologic phenomena. Our aim is to develop an ANN model in predicting central lymph node metastases(CLNM) in patients with PTMC, in comparison to traditional logistic regression(LR) analysis. STUDY DESIGN: Eighty patients who underwent total thyroidectomy plus CLND for PTMC were included in the study. The factors associated with CLNM were determined by using both ANN model and LR analysis. The predictive performances of these two statistical models were compared. RESULTS: Twenty (25%) patients had CLNM. In univariate analysis, age >45 years, tumor diameter >7 mm, and multifocality were the associated parameters with CLNM. These parameters were used to create LR and ANN models. LR test revealed tumor diameter >7 mm and multifocality as independent factors for CLNM. ANN (AUC: 0.786) had a higher predictive value for CLNM, in comparison to LR model (AUC: 0.750). CONCLUSIONS: Tumor diameter >7 mm and multifocality are the independent prognostic indicators of CLNM in patients with PTMC. ANN model has higher predictive value for determining central metastasis, in comparison to LR analysis. KEY WORDS: Artificial neural networks, Central lymph node metastasis, Logistic regression, Papillary thyroid microcarcinoma.

Can we predict severity of acute cholecystitis at admission?

BACKGROUND AND OBJECTIVE: Acute cholecystitis (AC) is an inflammation of the gallbladder. Tokyo Guidelines (TGs) for the diagnosis of AC classified this condition according to severity as mild, moderate and severe. Therapeutic intervention regulated according to the type of severity. This study aimed to determine laboratory parameters that predict the severity of AC at hospital admission. METHODS: One-hundred and ten patients with AC were retrospectively reviewed. These patients were treated in our department of surgery within a one-year period (2015-2016). Three patient groups were formed depending on the severity of Acute cholecystitis. RESULTS: The baseline mean values for white blood cell count (WBC), blood urea nitrogen (BUN), creatinine and international normalized ratio (INR) were higher in the severe patient group at a significant level compared to the mild patient group. The WBC level was also significantly higher in the moderate group than the mild group. However, none of the laboratory parameters differentiated the severe group from the moderate group. CONCLUSION: Acute cholecystitis patients with high WBC, BUN, creatinine and INR levels at admission should be referred to an advanced care center for management.

Long-term results of patients who were applied laparoscopic adjustable gastric banding.

OBJECTIVES: The most effective treatment step in morbid obesity is surgical treatment. The purpose of the present study was to investigate the long-term follow-up results and success rates in patients who were applied laparoscopic adjustable gastric band. MATERIAL AND METHODS: The change in body mass index, percentage of excess weight loss, comorbidities, and resulting complications were investigated in 220 patients who were morbidly obese who were applied laparoscopic adjustable gastric band between April 2006 and February 2012 throughout the 6-year follow-up period. Forty-six patients who did not show up for their routine follow-ups were excluded from the study. RESULTS: In the present study, the band removal percentage was 35.63%. The percentage of excess weight loss in patients who were followed up without removal of the band was 46.03%. Complications were observed in 46.5% of the patients. The most frequently observed complication among the major complications was band intolerance, which is also the most common cause of band removal. Band removal was considered as a failure in laparoscopic adjustable gastric band operations, and patients were referred to other surgical methods. CONCLUSION: When improved patient compliance and careful and close patient follow-up are provided in the early stages of laparoscopic adjustable gastric band application, it may be possible to reach percentage of excess weight loss results that would be the nearest to those achieved by gastric bypass or sleeve gastrectomy methods. However, high complication rates and necessity to perform other bariatric surgical procedures in the majority of the patients in the long-term follow-up suggest that the laparoscopic adjustable gastric band operation is not the first choice in bariatric surgery.

Simplified scoring system for prediction of mortality in acute suppurative cholangitis.

Our objective in this study was to identify the factors contributing to mortality in acute suppurative cholangitis which could be tested easily in every emergency clinic. This is a retrospective study enrolling 104 patients with acute suppurative cholangitis. Demographic and laboratory data were collected for analysis. In univariant analysis red cell distribution width, total bilirubin level, intensive care unit admission was identified as statistically significant (p < 0.05) to predict mortality. Three variables were statistically significant in multivariate analysis: total bilirubin level equal to or more than 6.9 mg/dl, red cell distribution width equal to or more than 14.45%, and admission to intensive care unit. We found a new scoring system for prediction of mortality in acute suppurative cholangitis utilizing only three variables. This would serve as a simplified, rapid way to direct patients for advanced interventions instead of wasting time with more complicated and time consuming multi-variable scoring systems.

A rare cause of primary hyperparathyroidism: Parathyroid lipoadenoma.

OBJECTIVE: The main cause of primary hyperparathyroidism is a single parathyroid adenoma. Parathyroid lipoadenomas contain abundance of fat cells. Because of these histological features, they can mimic normal parathyroid tissue at the histopathologic examination and radiological imaging could be difficult to localize lipoadenomas. CLINICAL PRESENTATION: In this case report, we present three cases of functional parathyroid lipoadenomas. CONCLUSION: Preoperative imaging modalities often can't localize lipoadenoma. In our cases, SPECT has seen more successful than ultrasonography or CT. There may not be gender predominance at parathyroid lipoadenomas. Intraoperative pathology consultation and rapid biochemical workup can help the surgeon in difficult cases.