Evaluation of the correlation of neutrophil/lymphocyte ratio with prognostic classification systems in papillary thyroid carcinoma patients.

We aimed to evaluate the use of cost-effective NLR (Neutrophil Lymphocyte Ratio) in determining the prognosis and recurrence risk of thyroid papillary carcinoma patients. This retrospective, cross-sectional and single-center study was carried out in the Department of General Surgery, Istanbul Gaziosmanpasa Training and Research Hospital. Between 2018 and 2021, who were diagnosed with papillary thyroid cancer and underwent total thyroidectomy, and patients who underwent total thyroidectomy due to multinodular goiter were analyzed. For patients in the malignancy group, the NLR cutoff value was determined as 1.73, the sensitivity was calculated as 51.77% and the specificity as 86.15%. NLR in the malignant group was found to be 9.5 times higher than the NLR in the control group (Odds Ratio: 9.5). A statistically significant difference was found between NLR and papillary thyroid carcinoma prognostic classification systems (AJCC/TNM, AMES, and MACIS). NLR medians differ according to ATA recurrence risk classification (P = .020). According to the results we obtained in our study, we believe that cost-effective NLR can be a useful indicator in terms of predicting malignancy in a patient with thyroid nodule and in determining the prognosis and risk of recurrence in patients with thyroid papillary carcinoma.

The effect of the Covid 19 pandemic on the number of patients treated for acute and complex acute appendicitis.

AIM: The aim of this study was to compare the increase in the number of complicated cases in patients who underwent surgery for acute appendicitis during the COVID-19 pandemic and the previous year. MATERIAL AND METHODS: A retrospective examination was made of the files of patients who presented at the Emergency Department and were diagnosed with acute appendicitis and underwent surgery within 24 hours or were followed up between 11 March and 1 June 2020 during the COVID-19 pandemic, and in the same period in the previous year. The patients in the pandemic period were named the pandemic group (PG) and the patients from the previous year, the control group (CG). The definition of complicated appendicitis included peri-appendicular abscess and perforated appendix. RESULTS: The number of patients in the PG was 38.33% lower than in the CG. The duration of symptoms was 2 days in the PG and 1 day in the CG, and the difference was statistically significant (p=0.001). The mean neutrophil count was determined to be higher in the PG than in the CG (p=0.018). The rate of perforated appendix was determined to be 10.9 higher in the PG than in the CG. CONCLUSION: The number of patients presenting at the Emergency Department reduced during the pandemic, especially during periods of lockdown, and it was seen that fewer but more complicated patients presented at our centre. KEY WORDS: Acute appendicitis, COVID-19, Perforation.

Open abdomen technique used in complications of major gynecological oncology surgery.

OBJECTIVE: To evaluate the open abdomen technique (laparostomy) used in complications of major gynecological oncology surgery. METHODS: We analyzed retrospectively the surgical database of all patients who had undergone major open surgery by the same gynecologic oncologist over a 5-year period. All patients who had had open abdomen procedure were identified; demographic data and indications of primary surgery, temporary abdominal closure procedure details, fascia closure and morbidity, mortality rates were evaluated. Intraabdominal infection and intraoperative massive hemorrhage were the major indications for all open abdomen cases. Mannheim Peritonitis Index was used perioperatively to determine open abdomen decision in intraabdominal infections. Vacuum Assisted Abdominal Closure system and Bogota Bag were used for temporary abdominal closure techniques. RESULTS: Out of the total 560 patients who had undergone major oncological surgery, 19 patients (3.3%) had open abdomen procedure due to surgical complications. Eleven patients had intraabdominal infection, six patients had hemodynamic instability due to peri and postoperative hemorrhage, two patients had gross fecal contamination during posterior pelvic exenteration surgery. The fascia was closed totally in 15 (78%), partially in 3 (15%) and could not be closed in 1 patient who had died secondary to multiorgan failure. Total morbidity and mortality rates were 26% (5/19) (two intrabdominal abscess, one pulmonary embolism, one skin necrosis, one enteroatmospheric fistula) and 5.2% (1/19) respectively. CONCLUSION: Open abdomen is a life-saving procedure when applied with correct indications and timing. Gynecological oncologic surgeries are candidates to serious complications and gynecologic oncologists dealing with such surgery should be as experienced as general surgeons in this regard.

Comparison of stage III mucinous and serous ovarian cancer: a case-control study.

BACKGROUND: The purpose of this case-control study was to compare the prognoses of women with stage III mucinous ovarian carcinoma (MOC) who received maximal or optimal cytoreduction followed by paclitaxel plus carboplatin chemotherapy to those of women with stage III serous epithelial ovarian cancer (EOC) treated in the similar manner. METHODS: We performed a multicenter, retrospective review to identify patients with stage III MOC at seven gynecologic oncology departments in Turkey. Eighty-one women with MOC were included. Each case was matched to two women with stage III serous EOC in terms of age, tumor grade, substage of disease, and extent of residual disease. Survival estimates were measured using Kaplan-Meier plots. Variables predictive of outcome were analyzed using Cox regression models. RESULTS: With a median follow-up of 54 months, the median progression-free survival (PFS) for women with stage III MOC was 18.0 months (95% CI; 13.8-22.1, SE: 2.13) compared to 29.0 months (95% CI; 24.04-33.95, SE: 2.52) in the serous group (p = 0.19). The 5-year overall survival rate of the MOC group was significantly lower than that of the serous EOC group (44.9% vs. 66.3%, respectively; p < 0.001). For the entire cohort, presence of multiple peritoneal implants (Hazard ratio [HR] 2.39; 95% confidence interval [CI], 1.38-4.14, p = 0.002) and mucinous histology (HR 2.28; 95% CI, 1.53-3.40, p < 0.001) were identified as independent predictors of decreased OS. CONCLUSION: Patients with MOC seem to be 2.3 times more likely to die of their tumors when compared to women with serous EOC.

Evaluation of Factors Affecting Lymph Node Metastasis in Clinical Stage I-II Epithelial Ovarian Cancer.

BACKGROUND: Systematic lymphadenectomy is useful for accurate staging of early-stage ovarian cancer and has obvious prognostic value. Accurate staging may prevent unnecessary postoperative chemotherapy. The aim of this study was to evaluate the rate of lymph node involvement and factors affecting it in clinically early-stage epithelial ovarian cancer (EOC; stages I, II). PATIENTS AND METHODS: The study included 163 patients who underwent surgery at our hospital between January 2004 and April 2017 and who were diagnosed with early-stage EOC based on preoperative and intraoperative examination. Patient data were retrospectively analyzed. The rate of lymph node involvement and factors affecting it were analyzed. RESULTS: Of 163 patients, 21 (12.9%) had lymph node metastasis, whereas 16 (16.3%) of 98 patients who underwent comprehensive lymphadenectomy had lymph node metastasis. According to the univariate results for patients undergoing any type of lymphadenectomy, the rate of positive lymph nodes was significantly higher (37.1%) in those with bilateral ovarian involvement (p < 0.001). The rate was significantly higher in patients with positive intraabdominal fluid cytology (25.9%; p < 0.001), serous histology (20.5%; p = 0.02), and grade 3 disease (33.3%; p < 0.001). In multivariate logistic regression analysis, the rate was significantly higher in patients with bilateral adnexal involvement (p = 0.012). The risk of positive lymph nodes was significantly higher in patients with grade 3 disease (p = 0.016). CONCLUSION: Comprehensive lymphadenectomy increases the detection rate for metastatic lymph nodes in patients with clinically early-stage EOC. The rate of lymph node involvement is significantly higher in grade 3 tumors, serous cytology, bilateral adnexal involvement, and positive intraabdominal fluid cytology.

Is It Necessary to Specifically Define the Cause of Surgically Treated Biliary Tract Infections? A Rare Case of Raoultella planticola Cholecystitis and Literature Review.

Raoultella planticola is an aquatic and soil organism that does not notoriously cause invasive infections in humans. Infections in the literature are limited only in case reports. We present a very rare case of R. planticola cholecystitis. A 71-year-old female patient with abdominal pain was diagnosed with acute cholecystitis. Patient received intravenous antibiotic treatment, but the treatment failed and the patient underwent an open cholecystectomy. The final pathological result was gangrenous cholecystitis complicated with R. planticola. Eventually, the patient recovered with appropriate antimicrobial therapy. Patients with acute cholecystitis are usually treated without any microbiological sampling and antibiotic treatment is started empirically. To date, there have only been 5 reported biliary system related R. planticola infections in humans. We believe that Raoultella species might be a more frequent agent than usually thought, especially in resistant cholecystitis cases. Resistant strains should be considered as a possible causative organism when the patient's condition worsened despite proper antimicrobial therapy. It should be considered safe to send microbiological samples for culture and specifically define the causative microorganisms even in the setting of a cholecystectomized patient.

A modified technique for the laparoscopic management of large gastric bezoars.

Bezoar is an intraluminal mass formed by the accumulation of undigested material anywhere in the gastrointestinal system. Most of small bezoars are removed by gastrointestinal endoscopy, while the best approach for the larger ones is surgical removal. Currently, laparoscopic technique is successfully used in the treatment of bezoars, which are used to be managed by open surgery. In the laparoscopic treatment of bezoars, contamination of peritoneal cavity is a major problem. We describe a modified laparoscopic technique in which an endobag is placed in the stomach instead of the peritoneal cavity in order to avoid spillage of the bezoar during laparoscopic removal.

The clinical value of leucocyte count and neutrophil percentage in diagnosing uncomplicated (simple) appendicitis and predicting complicated appendicitis.

BACKGROUND: The aim of this study was to establish the diagnostic value of leucocyte count and neutrophil percentage in both diagnosing simple appendicitis and predicting complicated appendicitis. METHODS: The patients who underwent appendectomy with a clinical diagnosis of acute appendicitis (AA) between January 2011 and December 2012 were studied retrospectively. The data of total WBC count, neutrophil ratio, and physical findings were analyzed. Sensitivities and specificities of leucocyte count and neutrophil ratio were calculated. RESULTS: One hundred and fifty-nine patients, diagnosed with acute appendicitis, were operated. Simple appendicitis was detected in 82.4% of the patients and complicated appendicitis in 17.6%. Leucocyte count had low sensitivity and specificity for diagnosing acute appendicitis (67.5% and 36.3%, respectively). Neutrophil ratio had a sensitivity rate of 60.1% and specificity rate of 90.9%. Complicated appendicitis was more common in male patients. Leucocyte count was statistically higher in patients with complicated appendicitis. CONCLUSION: Two inflammatory markers, leucocyte count and neutrophil ratio, were evaluated for diagnosing acute appendicitis. Neutrophil ratio had higher sensitivity and specificity for acute appendicitis. On the other hand, increased leucocyte count and male gender was found to be a risk factor for complicated appendicitis.

Prolene mesh migration into the rectum after sacral colpopexy presented with frozen pelvis.

INTRODUCTION: Pelvic organ prolapse (POP) is a common gynecological problem. Repair with synthetic materials such as prolene mesh has become a popular approach in prolapsus surgery. Migration of synthetic materials can cause serious complications. PRESENTATION OF CASE: A 69-year-old woman was admitted to the hospital with a complaint of sensation of fullness and a feeling of a foreign material protruding during defecation. The patient underwent exploratory laparotomy. Prolene mesh was detected in sacral region but resection of the mesh could not be conducted because of dense adhesions causing frozen pelvis. The migrated prolene mesh was resected transanally. DISCUSSION: Genital prolapse or genital hernia is described as the protrusion of pelvic organs along the vagina. It is one of the common gynecological conditions that affect the quality of life in women. Mesh migration is a well-known clinical pathology. CONCLUSION: Mesh migration is a serious complication after sacral colpopexy. Surgical resection of migrated mesh can be difficult due to dense adhesions.

Anatomic localization of the popliteal artery at the level of the knee joint: a magnetic resonance imaging study.

PURPOSE: The anatomic localization of the popliteal artery in the mediolateral plane at the level of the joint line was investigated on axial knee magnetic resonance imaging (MRI) scans to study anatomic variations. METHODS: The transverse and central axes were described on axial MRI scans of 334 knees. The distance between the popliteal artery and central axis was measured; the course of the central axis bisected the posterior cruciate ligament in almost all of the cases. The differences in popliteal artery localization according to sex and side were analyzed. RESULTS: Whereas popliteal artery localization was lateral to the central axis in 94.3% of cases, it was on the central axis in 5.7%. The popliteal artery localization was not seen on the medial side of the central axis. There was no significant effect of sex and side. CONCLUSIONS: Arthroscopic surgeons performing posterior cruciate ligament reconstruction or interventions on the posterior horns of the menisci should bear in mind that the risk of arterial complication may be greater for cases having the popliteal artery on the central axis. In conclusion, preoperative evaluation of the popliteal artery with MR axial scans, especially in pericapsular arthroscopic procedures, may prevent popliteal artery injuries. LEVEL OF EVIDENCE: Level III, diagnostic study of nonconsecutive patients.

Importance of identifying the course of the recurrent laryngeal nerve in total and near-total thyroid lobectomies.

In our clinic, near-total thyroidectomy is the principal surgical procedure performed for benign thyroid diseases. We conducted a single-institution study on 176 consecutive patients who underwent near-total thyroidectomy due to various thyroid diseases. We compared the incidence of recurrent laryngeal nerve injury between total and near-total thyroid lobectomy sides in each patient. Our hypothesis was that the incidence of recurrent laryngeal nerve injury after total thyroid lobectomy would be similar to that of near-total thyroid lobectomy when the course of the recurrent laryngeal nerve was identified during surgery. The temporary recurrent laryngeal nerve palsy rates on the total and near-total thyroid lobectomy sides were 3.9 per cent (7 of 176 nerves) and 2.2 per cent (4 of 176 nerves), respectively. The difference was not statistically significant. Permanent recurrent laryngeal nerve palsy did not occur in any of our patients. In conclusion, the incidence of recurrent laryngeal nerve injury in total versus near-total thyroid lobectomy is not different when the course of the recurrent laryngeal nerve is identified during surgery.

Vasculo-Behcet's disease mimicking a metastatic neck mass.

This article presents a case of Behcet's Disease (BD) with vascular involvement of the neck, which mimicks a metastatic neck mass in the initial presentation. A 58-year-old man presented with dysphagia, weight loss, bulging on the lateral wall of the left pyriform sinus, and a firm and fixated neck mass suggestive of metastasis. Computed tomography of the neck demonstrated a solid mass, around the bifurcation of the carotid artery together with a pseudoaneurysm of the left external carotid artery. The mass was about four centimeters in diameter and extended to hypopharynx medially. Biopsy from neck mass and hypopharynx revealed no specific pathology. During follow-up the firm and fixated mass changed into a completely pulsatile one in the following three weeks. Reassessment of the patient's past history in detail revealed that he had had recurrent oro-genital ulcers, arthralgia and recurrent skin lesions. The pathergy test was positive. The patient was diagnosed to be BD and treatment consisting of colchicine 1 mg/day, peroral was started. He had a favorable outcome after treatment and was asymptomatic at follow-up of 24 months. It is unusual for BD to present as a neck mass but yet it must be considered in the differential diagnosis of neck masses. The present case report demonstrates how such a mass may mimic metastatic tumoral involvement and cause diagnostic dilemma.

A randomized prospective study of complications between general surgery residents and attending surgeons in near-total thyroidectomies.

PURPOSE: Recurrent laryngeal nerve palsy and hypoparathyroidism are the most common and serious complications after thyroid operations. Surgeon experience has been defined as a significant factor in the number of complications occurring in thyroid surgery. There has so far been no prospective randomized study that compares the complication rates between residents and the attending surgeon in statistically similar patient groups in which all of the patients undergo the same type of thyroid surgery by the same surgical team. In this prospective study the performances of residents and attending surgeons were evaluated and compared according to the complication rates in near-total thyroidectomies. METHODS: One hundred and fifty-two patients underwent near-total thyroidectomies between April 2001 and May 2003. The number of randomly selected patients operated on by residents at the level of postgraduate year two, under the direct supervision of an attending surgeon, and the number of patients operated on by attending surgeons were 78 and 74, respectively. All patients had preoperative and postoperative videolaryngostroboscopic examinations of the vocal cords and serum calcium level evaluation. RESULTS: The rates of temporary vocal cord paralysis with respect to the nerves at risk for residents and attending surgeons were 3.7% and 2.7%, respectively. The temporary hypoparathyroidism rate was 8.1% for attending surgeons, whereas it was found to be 6.4% for residents. Neither any cases of permanent vocal cord paralysis nor permanent hypoparathyroidism were detected. CONCLUSION: Our results indicate that the complication rates in near-total thyroidectomies performed by residents and attending surgeons are similar. Thyroid surgery can therefore be safely and effectively performed by residents under close supervision.

Near-total thyroidectomy could be the best treatment for thyroid disease in endemic regions.

HYPOTHESIS: Near-total thyroidectomy, on the basis of its low morbidity rate, is an appropriate treatment option in the surgical management of various thyroid diseases in an endemic region in Turkey. DESIGN: Single-institution study of patients with various thyroid diseases treated by means of near-total thyroidectomy within 2 years in an endemic region, with comparison of the results vs the complication rates of bilateral subtotal and total thyroidectomy reported in the literature. SETTING: Tertiary academic referral center. PATIENTS: One hundred fifty-two patients who underwent near-total thyroidectomy for various thyroid diseases. MAIN OUTCOME MEASURES: Surgical treatments of various benign thyroid diseases were compared according to the complication rates and the achievable benefits of the procedures. RESULTS: In our clinic, near-total thyroidectomy was the principal surgical procedure performed for benign thyroid disease. The temporary recurrent laryngeal nerve palsy rate with respect to the nerves at risk was 3.3% (10 of 304 nerves), whereas temporary hypoparathyroidism was 7.2% (11 of 152 patients). Neither permanent recurrent laryngeal nerve palsy nor permanent hypoparathyroidism occurred. In 1 patient, wound hematoma developed and required re-exploration. Seroma in another patient needed no medical or surgical intervention. Neither wound infection nor mortality were noted. CONCLUSIONS: Near-total thyroidectomy achieves a lower complication rate of hypoparathyroidism and a similar complication rate of recurrent laryngeal nerve palsy and recurrence when compared with the rates reported in the literature for total thyroidectomy. It is an effective and safe surgical treatment option for various benign thyroid diseases.

Comparison of the measurement methods of bursting pressure of intestinal anastomoses.

BACKGROUND/AIMS: This study was designed to determine whether there exists a difference between in vivo and in vitro measurements of bursting pressure (BP) of experimental intestinal anastomosis studied in Wistar-albino rats. METHODOLOGY: In the first group (n=8), the BP was measured using in vivo method without detaching the adhesions around the anastomosis. BP was determined with digital manometer, and then anastomotic region was removed to measure tissue hydroxyproline (HP) levels. In the second group (n=8), the BP was measured with in vitro method after the segment of intestine including the anastomosis was dissected and isolated. The isolated specimen was then submerged in a normal saline bath. BP was determined with a digital manometer and anastomotic region was removed to measure tissue HP levels. RESULTS: While HP value in the first group was 105.60 +/- 9.43 microg/mg dry tissue, it was found to be 121.11 +/- 16.26 microg/mg dry tissue in the second group and this difference was not statistically significant (p=0.195). The BP was determined as 240.71 +/- 11.65 mmHg in the first group, 144.71 +/- 16.41 mmHg in the second group and the difference was statistically significant (p=0.002). The anastomotic resistances to intraluminal pressure were found to be statistically different whereas tissue HP levels were normal between the groups. CONCLUSIONS: These results make us consider that mechanical changes occur about the isolated anastomotic line and dissection of adhesions weakens the anastomosis.

Comparison of the experimental intestinal anastomoses performed by different surgeons.

BACKGROUND/AIMS: This study was designed to determine the effects of different surgeons on the experimental anastomosis studied in rats. METHODOLOGY: Sixteen Wistar-albino rats were equally separated into two groups. The rats operated on by the first surgeon were coded Group 1 and operated on by the other surgeon were coded Group 2. Both surgeons were trained on the gastrointestinal surgery. The procedure of the study were standardized and dictated to the surgeons. Bursting pressure and tissue hydroxyproline content were determined as parameters of the anastomotic strength and healing on the seventh day postoperatively. RESULTS: The bursting pressures were measured with a digital manometer and anastomotic lines were removed to measure tissue hydroxyproline level. While hydroxyproline value in the first group was 105.60 +/- 9.43 microg/mg dry tissue, it was found to be 104.02 +/- 17.26 microg/mg dry tissue in the second group and this difference was not statistically significant (p=0.521). The bursting pressure was determined as 240.71 +/- 11.65 mmHg in the first group, 190.75 +/- 14.09 mmHg in the second group and the difference was statistically significant (p=0.002). The anastomotic resistances to intraluminal pressure were found statistically different whereas tissue hydroxyproline levels were normal between the groups. CONCLUSIONS: These results make us to consider mechanical differences occur related to the surgeons in the studies performed with the same technical detail.

Effect of sphincter-sacrificing surgery for rectal carcinoma on quality of life in Muslim patients.

PURPOSE: Living with a permanent colostomy significantly diminishes a patient's quality of life. However, little is known about its influence on worship patterns in Muslims. Therefore, the aim of this study was to assess the quality of life in Muslim patients after surgery for rectal carcinoma, especially with respect to religious worship. METHODS: We studied 178 patients who had undergone curative surgery for colorectal carcinoma. The patients fell into three groups based on the type of surgery they underwent: abdominoperineal resection (n = 75), sphincter-saving resection (n = 51), and anterior resection including sigmoid colectomy (n = 52). Quality of life was measured with the Medical Outcomes Study Short Form 36 Health Survey and a questionnaire that asked participants about their work responsibilities, sexual life, and religious worship. RESULTS: The scores for all eight subscales of the Short Form 36 in the abdominoperineal resection group were significantly poorer than those in the sphincter-saving resection and anterior resection groups ( P< 0.001). In addition, social life and work responsibilities were significantly more affected in the abdominoperineal resection group than in the other two groups ( P< 0.001). A significantly ( P< 0.001) greater number of patients in the abdominoperineal resection group stopped praying daily (either alone or in a mosque) and fasting during Ramadan. CONCLUSION: Two aspects of religious worship (praying and fasting) were significantly impaired in the Muslim patients who had a stoma as a result of sphincter-sacrificing surgery. To improve quality of life in these patients, religious issues as they relate to the presence of a stoma should be discussed during preoperative counseling, the informed consent process, and counseling with local religious authorities.

Enteral and intraluminal short-chain fatty acids improves ischemic left colonic anastomotic healing in the rat.

BACKGROUND AND AIMS: This study assessed the effect of short-chain fatty acids (SCFAs) on the healing of ischemic colonic anastomosis and compared the enteral and intraluminal (transrectal) forms of SCFAs in the same study. MATERIAL AND METHODS: Left colonic ischemia was induced and a 1-cm left colon resection 2-4 cm above the peritoneal reflection was performed through a midline incision. In all, 160 rats were divided into eight groups: a control group, an ischemia group, a transrectal SCFAs group, an ischemia + transrectal SCFAs group, an enteral guar gum group, an ischemia + enteral guar gum group, an ischemia + enteral sham group, and a control + enteral sham group. The animals in each group were anesthetized again on day 4 or 7 after the operation for in vivo analytic procedures. Wound complications, intestinal obstructions, and anastomotic complications were recorded. Periperitoneal adhesions were graded. The strength of each anastomosis was assessed by measuring its bursting pressure. RESULTS: There were significantly more dense intra-abdominal adhesions in the ischemic group and ischemia + enteral sham group. Five animals in the ischemia group, six in the ischemia + enteral sham group, and one in each of the control and ischemia + transrectal SCFA groups developed anastomotic dehiscence. The median bursting pressures were significantly lower in the ischemic group and in the ischemia + enteral sham group on the 4 day and 7 days. CONCLUSION: Deleterious effects of ischemia on left colonic anastomotic healing were significantly prevented by the administration of either 7 days' pretreatment with enteral guar gum or the intraluminal instillation of SCFAs. There were no significant differences between enteral and intraluminal SCFA groups.