Diagnostic and therapeutic value of ductoscopy in nipple discharge and intraductal proliferations compared with standard methods.

BACKGROUND: Fiberoptic ductoscopy is a practical and direct approach that allows the visualization of intraductal breast disease. The aim of this study was to assess the efficacy of ductoscopy in the diagnosis and management of intraductal lesions. METHODS: Data on 357 ductoscopic investigations from patients with nipple discharge were collected prospectively. Seventy-five patients were diagnosed as having intraductal papillary lesions and these cases were evaluated by final histopathology (55 solitary, 14 multiple papillomatosis, 6 premalignant or malignant lesions). Results of classical diagnostic studies using ultrasonography, mammography, and galactography were compared with those of ductoscopy and pathology. RESULTS: The sensitivities of investigation methods for papillomas in this study were 72 % in ultrasonography, 62.9 % in mammography, 81.4 % in galactography, and 86.6 % in ductoscopy. With ductoscopic papillomectomy (DP), almost 30 % of patient with solitary papilloma did not require further extensive surgery. CONCLUSION: Since there is an increased risk of malignancy, surgical excision is recommended for multiple, larger papillomas and for papillomas with atypia and in addition for papillomas where diagnostic tools produce suspicious findings. On the other hand DP is a minimally invasive intervention and can aid in the follow-up of lesions proven to have no atypia.

Gamma Probe Guided Minimally Invasive Parathyroidectomy without Quick Parathyroid Hormone Measurement in the Cases of Solitary Parathyroid Adenomas.

OBJECTIVE: In this study, our aim was to study the efficiency of gamma probe guided minimally invasive parathyroidectomy (GP-MIP), conducted without the intra-operative quick parathyroid hormone (QPTH) measurement in the cases of solitary parathyroid adenomas (SPA) detected with USG and dual phase 99mTc-MIBI parathyroid scintigraphy (PS) in the preoperative period. MATERIAL AND METHODS: This clinical study was performed in 31 SPA patients (27 female, 4 male; mean age 51±11years) between February 2006 and January 2009. All patients were operated within 30 days after the detection of the SPA with dual phase 99mTc-MIBI PS and USG. The GP-MIP was done 90-120 min after the iv injection of 740 MBq 99mTc-MIBI. In all cases, except 1 patient, the GP-MIP was performed under local anesthesia; due to the enormity of size of SPA, then general anesthesia is chosen. RESULTS: The operation time was 30-60 min, mean 38,2±7 min. In the first postoperative day, there was a more than 50% decrease in PTH levels in all patients and all but one had normal serum calcium levels. Transient hypocalcemia was detected in one patient. CONCLUSION: GP-MIP without intra-operative QPTH measurement is a suitable method in the surgical treatment of SPA detected by dual phase 99mTc-MIBI PS and USG. CONFLICT OF INTEREST: None declared.

Penetrating cardiac injury: factors affecting outcome.

BACKGROUND: Penetrating cardiac injuries are rare but represent a high mortality. Early recognition of the injury and rapid intervention are necessary. We analyzed the characteristics of patients with penetrating injury and the factors affecting the outcome, including the experience of the general surgeon. METHODS: Twenty-three patients suffering penetrating cardiac injury were retrospectively evaluated in the Istanbul Okmeydani Training and Research Hospital, Department of General Surgery between 1995 and 2009. Patients with no sign of life on admission were excluded. RESULTS: All patients were male, and the median age was 25 years. Fifteen patients had left ventricular, 4 had right ventricular and 4 had right atrial injuries; in addition, 2 patients had accompanying intra-abdominal injuries. No coronary vascular injury was reported, and pericardial tamponade did not statistically influence the outcome. Ten of 23 patients suffering of penetrating cardiac injury were lost, and in 6 of the 10 cases, the patient represented the first experience for the operating surgeon. CONCLUSION: The characteristics of the penetrating cardiac injuries seen in our institution are consistent with the literature. However, we believe that the surgeon's experience is another prognostic factor. Dedicated level 1 emergency services and trained trauma surgeons are invaluable.

Ductoscopy in the evaluation and management of nipple discharge.

BACKGROUND: Nipple discharge is a relatively common complaint among patients visiting specialized outpatient clinics for disease of the breast. With advancing technology, it became possible to diagnose and manage nipple discharge using minimally invasive procedures. The aim of this study is to report our experience with ductoscopic evaluation of patients with nipple discharge. MATERIALS AND METHODS: Between September 2005 and February 2009, 236 patients with complaint of nipple discharge were admitted prospectively into the study. All patients were evaluated with ductoscopy. Data concerning age, ductoscopic and postsurgical diagnosis, duration, and complications with the procedure were statistically analyzed. RESULTS: For 236 patients evaluated, there were 249 ductoscopic investigations. Of these, 39 patients were found to have intraductal solitary papilloma of which 24 were excised ductoscopically. Of the 24 ductoscopically excised solitary papillomas, it was possible to remove 17 completely, but 7 papillomas could be removed partially. For 13 patients with solitary papillomas large enough or unfavorably localized so that they could not be snare-excised and for 14 patients with multiple papillomas, we offered surgical removal of the lesions by limited excision of the ducts with the help of ductoscopic localization and marking. There were 35 patients who had debris within the canalicular system, and the debris was washed out. Ductoscopy revealed atypical ductal hyperplasia in 3 patients, ductal carcinoma in situ in 6 patients, and invasive carcinoma in 3 patients; all patients underwent surgery. CONCLUSIONS: We believe that, as the technology quickly improves, ductoscopy will become more widely accepted and applied for breast disorders, not only as a diagnostic tool but also as a privileged therapeutic option for certain pathologies.

Gamma probe (99m)Tc-pertechnetate assisted completion thyroidectomy vs conventional thyroidectomy in differentiated thyroid carcinoma.

Patients undergoing partial thyroidectomy for benign diseases may need re-operation if differentiated thyroid carcinoma (DTC) is detected on histopathology. The aim of this study was to determine if using gamma probe during the above surgery in a procedure called: gamma probe completion thyroidectomy (GPCT) could support the diagnosis of DTC tissue and offer an advantage in the surgical treatment of DTC patients. We have studied 100 patients who after bilateral subtotal thyroidectomy for benign disease in several hospitals, were found to have DTC histopathologically and referred to our clinic for subsequent re-operation. Of these, 50 underwent conventional completion thyroidectomy (Group I) and 50 underwent GPCT (Group II). We compared retrospectively Group I and Group II in terms of volume of residual thyroid tissue, thyroid stimulating hormone (TSH) values, complication rates and incidence of tumor found in the residual thyroid. Our results showed that one month postoperatively, TSH was significantly higher in Group II (P<0.001). Volumes of residual thyroid were also significantly less in Group II (P<0.000). Complications and the incidence of tumor cells found in the residual thyroid tissue between the groups were not statistically different (P>0.05). In conclusion, GPCT in patients with DTC significantly increased the success of this operation in localizing and removing residual thyroid tissue.

Systemic inflammatory response after Kugel versus laparoscopic groin hernia repair: a prospective randomized trial.

BACKGROUND: Kugel repair, a minimally invasive technique, has become an alternative to laparoscopic groin hernia repair, but the technique has not been adequately evaluated by assessment of objective parameters. A prospective randomized clinical study was carried out to compare the systemic inflammatory response to surgical trauma and clinical outcomes in patients who underwent groin hernia repair by the Kugel and totally extraperitoneal (TEP) laparoscopic methods. METHODS: Forty consecutive patients admitted for unilateral groin hernia were randomized to Kugel (n = 20) or TEP (n = 20) repair under general anesthesia. Operation time, length of hospital stay, pain severity, time to return to normal activities, cost, and systemic inflammatory and hormone responses to surgical trauma were compared. RESULTS: There were no significant between-group differences in duration of operation, length of hospital stay, time to return to normal activities, or mean visual analogue scale (VAS) score (p > 0.05 for each). Serum cortisol, high-sensitivity C-reactive protein (hsCRP), and interleukin (IL)-6 concentrations before surgery, and 1 and 24 h after surgery, did not differ significantly in the two groups (p > 0.05). There were no recurrences or complications during follow-up. Cost per patient was US $546 lower in the Kugel group. CONCLUSION: Kugel herniorrhaphy is a minimally invasive technique that offers all the advantages of TEP and is more cost-effective.

Scarless endoscopic papillomectomy of the breast.

BACKGROUND: Efforts have been made to improve minimally invasive breast surgery techniques, resulting in less tissue damage and much better cosmetic results. We evaluated the therapeutic value of a new scarless operation, endoscopic papillomectomy (EP), in patients with pathologic nipple discharge (PND). METHODS: Breast ductoscopy was performed on 126 women with PND. These patients underwent a variety of appropriate ductoscopy-assisted (DA) endosurgical interventions, combined with cytologic examinations. Success was determined by recurrence of PND and by standard radiological examinations. RESULTS: Ductoscopy was successfully performed in 102 patients. Of these 102 patients, 26 had solitary papillomas (SP), 5 had multiple papillomas (MP), 11 had intraductal debris, and 1 had a ductal epithelial surface abnormality with positive cytology. Of the 26 polypoid lesions (cytology negative), 22 were excised endoscopically (endoscopic papillomectomy). Patients with MP underwent DA-microdochectomy. Except in one patient, all discharges disappeared. After a mean +/- SD follow-up time of 11.5 +/- 5.8 months (range 2-22 months), there were no recurrences of nipple discharge and no radiological results suggestive of malignancy. Thus, the therapeutic efficacy of EP in our study was 95.4% (21/22). CONCLUSIONS: Ductoscopy is not only a diagnostic procedure, but is also therapeutic for breast papillomas. EP is a new scarless treatment option for patients with PND.

Laparoscopic splenectomy and LigaSure.

Laparoscopic splenectomy (LS) is a preferred choice, especially for hematologic diseases. We present the advantages of the use of LigaSure (energy-based equipment that works by applying a precise amount of bipolar energy and pressure to the tissue, achieving a permanent seal) for achieving a precise hemostasis, thus making the LS easier. We have performed LS using LigaSure on 10 patients (4 female, 6 male; mean age, 36 years [range, 16-58]) between December 2002 and August 2003. All patients had ITP. There were no conversion to open surgery. Mean dimensions of spleens were 99 x 49 mm (range, 85 x 36-118 x 60). Intraoperative blood loss was no more than 100 mL in any patients (range, 20-100; mean, 60). The average operative time was 93 minutes (range, 60-155). There were no complications in the postoperative period. The average postoperative stay was 4.3 days (range, 3-7). LS using LigaSure is a safe and time-sparing procedure with almost no complications in this small initial series.