Concomitant thyroid lesions in patients with primary hyperparathyroidism.

BACKGROUND: Concomitant thyroid pathologies in patients with primary hyperparathyroidism (PHPT) present a challenge in the clinical and surgical decision-making for these patients. In this study, we aimed to evaluate concomitant thyroid pathologies in patients who underwent operations for PHPT to determine the sensitivity (Sn) of neck ultrasonography (US) and Tc99m sestamibi scintigraphy in detecting parathyroid adenoma. We also aimed to determine the clinical impact of preoperative neck US in patients with PHPT. METHODS: One hundred thirty-eight patients with PHPT were included in this retrospective study. All patients underwent preoperative Tc99m sestamibi scintigraphy and/or thyroid US. Nodules of ≥1 cm or <1 cm with suspicious US features underwent fine needle aspiration biopsy (FNAB). RESULTS: Preoperative thyroid US revealed that 93.5% of patients with PHPT had thyroid abnormalities and 66.7% of patients had at least one thyroid nodule. Postoperative histopathology results showed that 79.2% of patients had benign thyroid disease and 20.8% of patients had malignant thyroid disease. In the detection of parathyroid adenoma, US had 89.1% Sn and Tc99m sestamibi scintigraphy had 82.6% Sn. CONCLUSION: We recommend the routine use of US in combination with Tc99m sestamibi scintigraphy, especially in endemic goiter regions, to detect any concomitant thyroid disease and thus determine the best surgical strategy for patients with PHPT.

Elastosonography scoring and strain index of thyroid nodules with Hurthle cells.

BACKGROUND: This study evaluated the effectiveness of elastosonography (ES) scoring and strain index (SI) in diagnosing patients with thyroid nodules composed primarily of Hurthle cells. METHODS: This study retrospectively analyzed 57 patients with thyroid nodules composed predominantly of Hurthle cells on fine needle aspiration cytology (FNAC). Patients were evaluated by thyroid ultrasonography (US), ES scoring, SI, US guided FNAC, and histopathology. RESULTS: Histopathologically, 12 (21.1%) nodules were malignant and 45 (78.9%) were benign. Mean age, sex distribution, thyroid function tests, and morphologic features on US were similar in the malignant and benign groups. Mean SI (40.98±31.28 vs 21.24±25.47, p=0.027) and thyroid peroxidase antibody (anti-TPOab) positivity (p=0.004) were significantly higher in malignant than in benign nodules. Receiver operating curve (ROC) analysis showed that an SI cutoff of 10.326 had a sensitivity of 91.7% and a specificity of 49%, and an SI cut-off of 64.807 had a specificity of 91.1% and a sensitivity of 25%. The optimal SI cut-off value, 17.877, had a sensitivity of 66.7%, a specificity of 66.7%, a positive predictive value (PPV) of 34.8%, a negative predictive value (NPV) of 88.2%, and an area under the ROC curve of 73.1±0.074% (95% CI: 58.7-87.6.5%). The sensitivity, specificity, PPV, NPV and diagnostic accuracy of ES scoring were 41.6%, 91.1%, 55.5%, 85.4% and 80.7%, respectively. CONCLUSIONS: This is the first study to investigate ES scoring and SI in nodules composed predominantly of Hurthle cells on FNAC. ES scoring and SI may add some contribution to ultrasonography in the characterization of thyroid nodules with Hurthle cells.

The diagnostic accuracy of ultrasound-guided fine-needle aspiration biopsy for thyroid nodules three centimeters or larger in size.

BACKGROUND AND PURPOSE: Whether under ultrasonography (US) guidance or not, fine-needle aspiration biopsy (FNAB) has some limitations, particularly in larger nodules. In this study, we aimed to evaluate the diagnostic value of US-guided fine-needle aspiration biopsy (US-FNAB) in thyroid nodules equal to or larger than 3 cm. MATERIALS AND METHODS: Data of 267 patients operated for nodular goiter in the period of January 2006 and March 2012 were reviewed retrospectively. The study group (40 males, 104 females; mean age 42.3 ± 12.3, between 17 and 71) consisted of patients with nodules with a diameter of 3 cm or larger. Patients with nodules less than 3 cm in diameter were considered as the control group (27 males, 96 females; mean age 44.4 ± 11.9, between 18 and 71). RESULTS: For nodules smaller than 3 cm, US-FNAB had an accuracy rate of 60% and a false negativity rate of 21.9%. In nodules equal to or larger than 3 cm, the accuracy rate of US-FNAB was 80%, with a false negativity rate of 6.7%. Malignancy was observed in 16% of the study group and 42.3% of the control group. CONCLUSION: This study showed that increased nodule diameter is not associated with limitations in the diagnostic value of US-FNAB. We also found that the malignancy rate was smaller for larger nodules. This finding reflects the importance of accurate and rational diagnostic work-up and clinical management for detecting malignancy and surgical decision-making.

Cytomorphologic features and ultrasonographic characteristics of thyroid nodules with Hurthle cells.

This study was designed to evaluate the ultrasonographic and histopathologic features of nodules composed predominantly of Hurthle cells detected during cytological examination. Fifty-seven patients with thyroid nodules composed predominantly of Hurthle cells on fine needle aspiration cytology were retrospectively analyzed. Patients were evaluated by thyroid ultrasonography (US), and biopsy samples taken by US-guided fine needle aspiration cytology were assessed histopathologically. There were 57 patients and 57 nodules with Hurthle cells in cytological examination; 49 (86%) were classified as Bethesda 1, and 8 (14%) were classified as Bethesda 3. Histopathologically, 45 (78.9%) nodules were benign and 12 (21.1%) were malignant. Nuclear groove, transgressing blood vessel, and absence of colloid were observed with a higher frequency in malignant nodules compared to benign nodules (P < .05). There were no specific morphological features (nodule echogenity, presence of microcalsification, presence of cystic areas, absence of halo, margin irregularity, and increased blood flow) predicting malignancy in the US evaluation of nodules including Hurthle cells. Nuclear groove, transgressing blood vessel, and absence of colloid on cytomorphological evaluation are indicative of malignancy in nodules containing Hurthle cells.

Malignancy rate of thyroid nodules defined as follicular lesion of undetermined significance and atypia of undetermined significance in thyroid cytopathology and its relation with ultrasonographic features.

Fine-needle aspiration biopsy (FNAB) has been widely accepted as the most accurate, safe, and cost-effective method for evaluation of thyroid nodules. The most challenging category in FNAB is atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS). The Bethesda system (BS) recommends repeat FNAB in that category due to its low risk of malignancy. In our study, we aimed to investigate the malignancy rate of thyroid nodules of AUS and FLUS and whether there were different malignancy rates among the different patterns in this category, and to evaluate the presence of biochemical, clinical, and echographic features possibly predictive of malignancy related to AUS and FLUS. Data of 268 patients operated for AUS and FLUS cytology were screened retrospectively. Ultrasonographic features and thyroid function tests, thyroid antibodies, scintigraphy, and histopathological results were evaluated. Of the 268 patients' results, 276 nodules are evaluated. Malignancy rates were 24.3 % in the AUS group, 19.8 % in the FLUS group, and 22.8 % in both groups. In the evaluation of all nodules, the predictive features of malignancy are hypoechogenicity and peripheral vascularization of the nodule. We determined that the malignancy rates in these nodules are higher than that in the literature rate. This high ratio may be due to the fact that we studied only patients who underwent surgery. The ultrasonographic features alone may be insufficient to predict the malignancy; therefore, all the clinical and ultrasonographic features must be considered in the evaluation of the thyroid nodules. In addition, we think that the recommended management of repeat FNAB in these groups must be reconsidered with the clinical and ultrasonographic features.

A single-surgeon, single-institute experience of 59 sinotomies for sacrococcygeal pilonidal disease under local anesthesia.

BACKGROUND: The sacrococcygeal pilonidal disease affects relatively young people, causing much nuisance and many lost working days. The ideal treatment should be simple, allowing a speedy recovery with short hospitalization while affording a permanent cure. Currently, many treatment options are available; unfortunately, none of them is ideal and each has its own recurrence rate. In this study, we wanted to emphasize the effectiveness of sinotomy in sacrococcygeal pilonidal sinus disease by single-surgeon's experience. METHODS: Single-surgeon's experience of 59 pilonidal sinus patients was reviewed at single-institute between July 2005 and December 2006. 2% Prilocaine was injected for local anesthesia and sinotomy technique was performed. All patients were discharged at postoperative second hour and were followed up for a minimum 1 year. RESULTS: Median age of the 59 patients was 24 (14-56) years. Forty-six (77.96%) of them were male and 13 (22.03%) of them were female. Healing completed in 1 month and almost all the patients were able to return to work the following day. We proudly have no recurrence at our mean follow up time of 16 months (range: 12-24 months). Our complication rate was 1.69%. CONCLUSION: Sinotomy has the advantages of simplicity, the possibility to operate under local anesthesia with excellent recurrence rate of 0% (Ref. 9). Full Text (Free, PDF) www.bmj.sk.

A very rare localisation of pilomatrixoma.

Pilomatrixoma is a rare skin neoplasm which is usually localized on face, neck and lower extremites and its etiology is still unknown. We report a case of a 32-year-old male patient with a rare localisation of pilomatrixoma on the right shoulder. The presumed diagnosis was sebaceous cyst. Excision biopsy was performed (Fig. 1, Ref. 8). Full Text (Free, PDF) www.bmj.sk.

The short term effects of infected gallstones lost intraperitoneally.

In this experimental study, an animal model was set up to evaluate what sort of complications may cause intraperitoneal retained bile stones. Forty rats were divided into 4 groups. The first group was assigned as the control group and the subjects had only laparatomy. In the 2nd group, during laparotomy, sterile bile and bile stones were placed within the peritoneal cavity. In the 3rd group, contaminated bile and bile stones were placed within the peritoneal cavity. In the 4th group, again contaminated bile and bile stones were placed and prophylactic antibiotic (Ceftriaxon) was used for 7 days. After a 4 week interval, survivors were subjected to laparatomy and necropsy. As a conclusion, the peritoneal adhesion difference between the infected bile and stone inooculation group without antibiotic and the other group with antibiotic usage may show that antibiotics might prevent further complications in case of abdominal contamination. Available clinical and experimental data is not enough to recommend laparatomy to collect stones. We conclude that more detailed studies with larger series are necessary to clarify the issue (Tab. 1, Fig. 1, Ref. 26).

Giant primary synchronously bilateral mesenteric dedifferentiated liposarcoma with hyperparathyroidism, hyperthyroidism, type-2 diabetes mellitus and hypertension.

Liposarcomas represent the single most common type of soft tissue sarcoma, occurring most commonly in the extremities and retroperitoneum. There is no relation between liposarcomas and multiple endocrine syndromes. We presented a 61-year old woman with giant primary synchronously bilateral mesenteric dedifferentiated liposarcoma with hyperparathyroidism, hyperthyroidism, Type-2 diabetes mellitus (T2DM) and hypertension. The mesenteric liposarcoma was reported neither synchronously bilateral nor with endocrine disorders. We must note if the patients' presentation was a co-incidence or an undescribed syndrome, waiting to be discovered.

Surgical interventions in patients with chronic constipation refractory to intensive medical treatment.

INTRODUCTION: Management of patients with chronic constipation (CC), irresponsive to medical treatment, is very difficult. There are some surgical approaches reported for the treatment. In this study we aimed to assess the results of different surgical procedures in patients with severe CC who were refractory to intensive medical treatments. METHODS: Fifteen patients with refractory chronic constipation underwent surgical management between 1998 and 2003 in Ankara University School of Medicine Department of General Surgery. RESULTS: Median age of the patients was 40 years (range, 24-77), female/male ratio was 11/4, median duration of symptoms was 13 years (range, 4-35 years) and median interval of two subsequent bowel movements was 15 (range, 5-30) days. Preoperative evaluation including barium enema, colonoscopy, colonic transit time, and cinedefecography and balloon expulsion test were done in all patients. Clinical analysis of constipation with these tests indicated a simple slow transit colon in three patients but more complicated variations of combined anatomical functional disorders in the rest of the cases. Surgical procedures consisted of total colectomy, Frykman-Goldberg procedure, Wells procedure and appendisostomy, laparoscopically in 8 of them. Deep vein thrombosis developed in the postoperative period after rectopexy and pelvic floor repair in one case. The median follow-up time was 5.5 years. Fourteen (93.3%) patients had an excellent bowel movement and were highly satisfied with the surgical management. CONCLUSION: Surgical interventions may be beneficial in selected patients with refractory chronic constipation (Tab. 2, Ref. 13). Full Text (Free, PDF) www.bmj.sk.

A single-surgeon, single-institute experience of 115 Lichtenstein hernia repairs under local anesthesia.

BACKGROUND: Repair of an inguinal hernia is one of the most common operations performed in general surgery with significant costs to health care and society. Lichtenstein mesh repair has been the most widely performed groin hernia repair. In this study, we wanted to emphasize the effectiveness of local anesthesia in groin hernia repair by single-surgeon's experience. METHODS: One-hundred and fifteen inguinal hernia patients were reviewed between July 2005 and July 2007. 2% Prilocaine was injected for local anesthesia and Lichtenstein polypropylene mesh repair technique was performed. Pain was assessed after operation by using a visual analogue scale (VAS). All patients were controlled at postoperative first week, first month and end of first year. RESULTS: 113 (98.26%) of 115 patients were discharged at postoperative 8th hour. The other 2 patients (1.739%) were discharged at postoperative second day. They were followed up two days, because of seroma and pain, individually. Mean VAS score was 3.2 (2.7-4.0 95% CI). There was no statistically significant difference between groups, according to Nyhus classification, right/left inguinal hernia and gender. CONCLUSION: Lichtenstein mesh repair under local anesthesia is an effective day case technique, particularly in the elderly and medically unfit patients. The economic benefits are enhanced by low morbidity and low recurrence rates (Ref. 5). Full Text (Free, PDF) www.bmj.sk.

The PlasmaKinetic tissue management system in thyroid surgery.

BACKGROUND: Thyroid surgery involves meticulous devascularization of the gland. Although conventional technique being a highly efficient technique for vessel bleeding control, it takes long time. The aim of this study was evaluate the efficacy of PlasmaKinetic to the conventional technique. METHODS: We reviewed the medical records of 86 patients who underwent primary thyroid surgery by the same surgeon at our clinic between June 2006 and January 2008. Total thyroidectomy was performed at all of the patients in the study group. RESULTS: When the incidence of postoperative cord palsy was 2.32%, transient hypoparathyroidism was 4.6%. There was no significant difference in consideration of age, gender, thyroid gland weight, and complication rates between the PlasmaKinetic group and conventional group (p>0.05). Operation time, mean drainage from the suction drain and duration of hospital stay of the patients in PlasmaKinetic group were significantly lower than those in conventional group (p<0.05). CONCLUSION: PlasmaKinetic technique decreases the operation time to a level of less than 50 minutes with no increase at complication rate (Tab. 3, Fig. 3, Ref. 14). Full Text (Free, PDF) www.bmj.sk.

Vascular reactivity in the experimental, simvastatin-treated diabetes with endothelial dysfunction.

BACKGROUND: The aim of this study was to evaluate the effect of simvastatin therapy on general characteristics of diabetes and vascular reactivity in the 14 week-old streptozotosin-diabetic rats. METHODS: Twenty-four Sprague-Dawley male rats were divided into four groups as following: control, control-statin, diabetes and diabetes-statin. RESULTS: We observed that hyperglycemia and weight-loss observed in diabetic rats were partially treated with simvastatin, but were still different from the control group. After thapsigargin, the endothel-mediated acetylcholine releasing responses were decreased; the releasing response in diabetes-statin group differed from the diabetic group. DISCUSSION: Simvastatin treatment in diabetic rats, in addition to the treatment of diabetic dislipidemia, has also partially treated the endothel-mediated releasing response in diabetes. We observed that thapsigargin reduces the response of the aortic rings to the current substance (Fig. 5, Ref. 15).

Castleman's disease of the duodenum.

Castleman's disease is a rare lymphoproliferative disorder of uncertain origin. Just two cases of Castleman's disease of the gastrointestinal tract have been reported. These were found in the stomach. However, as far as we know, Castleman's disease of the duodenum has not been reported. This is the first report of hyaline vascular subtype of Castleman's disease at the duodenum.

Prevention of surgical site infection after open prosthetic inguinal hernia repair: efficacy of parenteral versus oral prophylaxis with amoxicillin-clavulanic acid in a randomized clinical trial.

The aim of this prospective study was to compare the efficacy of oral versus parenteral prophylactic amoxicillin-clavulanic acid for preventing surgical site infection after open prosthetic mesh repair of inguinal hernia. A total of 480 inguinal-hernia patients were randomly assigned to two groups. Group I (n = 240) received 1.313 g oral amoxicillin-clavulanic acid 2 hours before operation, and group II (n = 240) received 1.2 g of the same drug combination intravenously approximately 30 minutes before surgery. Patients were examined four times during 1 year of follow-up (at 7-10 days, 4-6 weeks, 6 months, and 12 months postoperation), and data related to surgical site infections were collected. Seventy-two patients were excluded due to confounding factors during and after the operation. There were no statistically significant differences between group I (final n = 208) and group II (final n = 200) with respect to age, sex distribution, body mass index, American Anesthesiology Association grade, frequencies of different hernia types, duration of surgery, and the experience levels of the principal surgeon in the operations. One of the 208 (0.5%) patients in group I and 3 of the 200 (1.5%) patients in group II developed superficial surgical site infections (p > 0.05). None of the infections required mesh removal. There were no deep surgical site infections in either group, and there was one case of hernia recurrence in each group. For patients undergoing open prosthetic repair of inguinal hernia, oral amoxicillin-clavulanic acid is safe, significantly less costly, and equally effective in preventing surgical site infection as the same dose given parenterally.

Cytomegalovirus infection in a patient with Crohn's ileocolitis.

Cytomegaloviral enterocolitis is an uncommon infection that can complicate inflammatory bowel disease. A case of a patient with a three-year history of Crohn's disease is reported. He had been in a stable condition on mesalamine 4 g/day and methylprednisolone 10 mg/day for three years until four weeks before admission. The patient was admitted with complaints of fever, abdominal pain and watery diarrhea. A diagnosis of an exacerbation of Crohn's disease was established. The radiological examination revealed narrowing of the terminal ileum. Multiple fistulas and abscess-like images were observed. The patient then underwent ileocolic resection and ileostomy. The histopathological examination revealed Crohn's ileocolitis with superimposed cytomegalovirus infection. In patients with rapidly deteriorating inflammatory bowel disease, cytomegalovirus infection should be kept in mind as one of the differential diagnoses.