Effect of the COVID-19 pandemic on surgery for indeterminate thyroid nodules (THYCOVID): a retrospective, international, multicentre, cross-sectional study.

BACKGROUND: Since its outbreak in early 2020, the COVID-19 pandemic has diverted resources from non-urgent and elective procedures, leading to diagnosis and treatment delays, with an increased number of neoplasms at advanced stages worldwide. The aims of this study were to quantify the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic; and to evaluate whether delays in surgery led to an increased occurrence of aggressive tumours. METHODS: In this retrospective, international, cross-sectional study, centres were invited to participate in June 22, 2022; each centre joining the study was asked to provide data from medical records on all surgical thyroidectomies consecutively performed from Jan 1, 2019, to Dec 31, 2021. Patients with indeterminate thyroid nodules were divided into three groups according to when they underwent surgery: from Jan 1, 2019, to Feb 29, 2020 (global prepandemic phase), from March 1, 2020, to May 31, 2021 (pandemic escalation phase), and from June 1 to Dec 31, 2021 (pandemic decrease phase). The main outcomes were, for each phase, the number of surgeries for indeterminate thyroid nodules, and in patients with a postoperative diagnosis of thyroid cancers, the occurrence of tumours larger than 10 mm, extrathyroidal extension, lymph node metastases, vascular invasion, distant metastases, and tumours at high risk of structural disease recurrence. Univariate analysis was used to compare the probability of aggressive thyroid features between the first and third study phases. The study was registered on ClinicalTrials.gov, NCT05178186. FINDINGS: Data from 157 centres (n=49 countries) on 87 467 patients who underwent surgery for benign and malignant thyroid disease were collected, of whom 22 974 patients (18 052 [78·6%] female patients and 4922 [21·4%] male patients) received surgery for indeterminate thyroid nodules. We observed a significant reduction in surgery for indeterminate thyroid nodules during the pandemic escalation phase (median monthly surgeries per centre, 1·4 [IQR 0·6-3·4]) compared with the prepandemic phase (2·0 [0·9-3·7]; p<0·0001) and pandemic decrease phase (2·3 [1·0-5·0]; p<0·0001). Compared with the prepandemic phase, in the pandemic decrease phase we observed an increased occurrence of thyroid tumours larger than 10 mm (2554 [69·0%] of 3704 vs 1515 [71·5%] of 2119; OR 1·1 [95% CI 1·0-1·3]; p=0·042), lymph node metastases (343 [9·3%] vs 264 [12·5%]; OR 1·4 [1·2-1·7]; p=0·0001), and tumours at high risk of structural disease recurrence (203 [5·7%] of 3584 vs 155 [7·7%] of 2006; OR 1·4 [1·1-1·7]; p=0·0039). INTERPRETATION: Our study suggests that the reduction in surgical activity for indeterminate thyroid nodules during the COVID-19 pandemic period could have led to an increased occurrence of aggressive thyroid tumours. However, other compelling hypotheses, including increased selection of patients with aggressive malignancies during this period, should be considered. We suggest that surgery for indeterminate thyroid nodules should no longer be postponed even in future instances of pandemic escalation. FUNDING: None.

Appendiceal neoplasms: Suspected findings and reports of 14 cases.

Background: Neoplastic lesions of the vermiform appendix are still considered to be rare, some studies suggest that appendix cancer may be on the rise, with an estimated incidence of 0.08-0.1% of all appendiceal specimens. The lifetime incidence of malignant appendiceal tumors ranges from 0.2 to 0.5%. Patients and Methods: Our study is applied at the Department of General Surgery at tertiary training and research hospital; 14 patients who had appendectomy or right hemicolectomy between December 2015 and April 2020 were evaluated. Results: The mean age of the patients was 52.3 ± 15.1 (range, 26-79) years. Gender of the patients were: five (35.7%) men and nine (64.3%) women. The clinical diagnosis was appendicitis without suspected findings in 11 (78.6%), appendicitis with suspected findings (appendiceal mass, etc.) in three (21.4%) of the patients, and there is no patient with asymptomatic or other rare findings. Surgeries applied for the patients were: nine (64.3%) underwent open appendectomy, four (28.6%) underwent laparoscopic appendectomy, and one (7.1%) underwent open right hemicolectomy. Histopathologic results were as follows: five (35.7%) neuroendocrine neoplasm, eight (57.1%), noninvasive mucinous neoplasm, and one (7.1%) adenocarcinoma. Conclusion: While diagnosis and management of appendiceal pathology, surgeons should be familiar with suspected findings of appendiceal tumors and discuss them with patients to the possibility of histopathologic results.

Insidious Onset of Localised Small Intestinal Perforation by Ingested Plastic Fork.

Ingestion of a foreign body is generally observed in the psychiatric patients and children. Healthy adult individuals may also swallow a foreign body unintentionally. Here, we report a case of a patient who swallowed a plastic fork and treated with laparoscopic repair. A 46-year man was admitted to the emergency room with the abdominal pain. His physical evaluation and diagnostic imaging revealed free air in the abdomen. Further imaging with CT scan showed a foreign body in the proximal ileum. On taking details of his swallowing history, he remembered swallowing a broken part of a plastic fork unwittingly during dinner. Following the removal of the foreign body, the perforation area was primarily repaired in double layers. The postoperative course was uneventful. An accurate diagnosis of the small intestinal perforation caused by the ingested foreign bodies, particularly in cases where the patient is unaware of the ingestion, can be difficult. CT scan is a useful tool when available to establish the diagnosis before the surgical intervention. Key Words: Small intestine, Perforation, Foreign body, Laparoscopic surgery.

Cecal Diverticulitis: A Diagnosis to Keep in Mind When Evaluating Acute Appendicitis.

Cecal diverticulitis is a rare cause of right lower-quadrant abdominal pain. As its symptoms mimic those of acute appendicitis, the final diagnosis in the patients is generally confirmed after surgery. Herein, we report a 45-year man who was admitted to the department of emergency with lower right abdominal pain. Cecal diverticulitis was diagnosed on computed tomography (CT) images, and a conservative treatment approach was recommended. He was hospitalised, and intravenous antibiotics and hydration were administered immediately. Oral feeding was interrupted. After five days of intensive medical care, the patient was discharged without any further complications. Based on my experience, I advise that CT can be used to differentiate cecal diverticulitis from the acute appendicitis. In uncomplicated cases, conservative approaches are advised. Key Words: Cecal diverticulitis, Computed tomography, Acute appendicitis, Conservative treatment.

Minimally Invasive Parathyroidectomy: Are Auxiliary Methods Necessary?

OBJECTIVE: To determine the success rate of minimally invasive parathyroidectomies (MIPs) with preoperative scintigraphy and ultrasonography, and to assess whether these imaging modalities are sufficient. STUDY DESIGN:  Observational study. PLACE AND DURATION OF STUDY:   Department of General Surgery, University of Health Sciences, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey between March 2017 and December 2019. METHODOLOGY: Medical records of 61 patients, who underwent MIP to treat primary hyperparathyroidism, were examined. Age, gender, and pre- and postoperative calcium, parathormone, and phosphorus levels were obtained from patient records. For all patients, the parathyroid (PT) glands were localised, using ultrasonography and Tc-99m methoxyisobutylisonitrile (MIBI) scintigraphy. RESULTS:  The average patient age was 56.89 ± 13.47 years. Of the patients, 83.6% (n = 51) were females. Localisation of the PT glands with preoperative scintigraphy had an accuracy rate of 100%. However, ultrasonographic localisation was unsuccessful in five patients. Adenomas were noted in 44 patients (72.1%), hyperplasia in 15 patients (24.6%), and neoplasia in two patients (3.3%). Serum parathormone and calcium levels were measured 24 hours after surgery, and were found to be significantly reduced compared to the corresponding preoperative levels (p <0.001). Hypocalcaemia developed in four patients (6.6%), two (3.3%) of which were symptomatic. After three months, persistent hyperparathyroidism developed in five patients (8.2%). CONCLUSION: Parathyroid scintigraphy has been demonstrated to be the gold standard for the preoperative localisation of PT glands. In the absence of scintigraphy, ultrasound guidance is the next useful technique for PT gland localisation. Key Words: Minimal invasive parathyroidectomy, Parathyroid scintigraphy, Ultrasonography, Parathormone.

Factors effecting cecal intubation time during colonoscopy.

AIM: The aim of this study is to evaluate the factors that has an effect on Cecal Intubation time (CIT), and to define the relationship between quality of bowel preparation and body mass index (BMI). PATIENTS METHODS: The Boston Bowel Preparation Scale (BBPS) was used for the evaluation of bowel cleansing. A total of 346 patients were included. The time from anus to caecum was recorded as the time of the cecal intubation time. Patients were defined under 3 subgroup BMI-1; ≤ 24.9, BMI-2; 25-29.9, BMI-3; ≥30. RESULTS: The mean BMI of women was 29.30 4.25 and men were 26.19 6.14 (p<0,001). Mean Cecal Intubation time was 9.11 6.00 and 10.21 3.45 minutes for women and men (p=0.012). Women with High BMI (≥30) have shorter Cecal Intubation time compared to women with BMI less than 30 (p=0001). When BBPS evaluated, there was a significant difference in BMI-3 due to high scores compared to both BMI-1 and BMI-2 (p<0.001). In BMI-3 group, also women had significantly higher scores in terms of BBPS(p=0.006). Also a negative correlation between BBPS and BMI with CIT has been found (r = - 0.371, p<0.001 / r = -0.191 p<0.001). CONCLUSION: In our study, women gender and increased BMI has a positive impact on the quality of intestinal cleansing that is associated with shortened Cecal Intubation time. KEY WORDS: Body Mass Index, Colonoscopy, Cecal intubation.

An Important Gallbladder Pathology Mimicking Gallbladder Carcinoma: Xanthogranulomatous Cholecystitis: A Single Tertiary Center Experience.

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is an uncommon, focal, or diffuse destructive inflammatory disease of the gallbladder mimicking or being together with the gallbladder carcinoma. This study aimed to evaluate the diagnosis, treatment, and outcomes of patients with XGC as a single tertiary center experience in the light of literature. MATERIALS AND METHODS: Data about 34 patients with XGC identified after evaluating 2212 cholecystectomy specimens between January 2013 and December 2018 in a single tertiary center were documented to determine demographics (sex, age), clinical symptoms and findings, biochemical and imaging clues and operative findings, duration of hospitalization, postoperative complications, and histopathologic results. RESULTS: Thirty-four patients with XGC were evaluated (17 male and 17 female patients with a mean age of 53; range, 25 to 78). Preoperative diagnosis was chronic calculous cholecystitis in 5 patients, cholelithiasis in 12 cases, acute calculous cholecystitis in 16 and emphysematous cholecystitis in 1 patient. Ultrasound was performed in all patients, computerized tomography in 11, contrast-enhanced magnetic resonance imaging in 9, and magnetic resonance cholangiopancreatography in 7 patients. None of the patients were diagnosed preoperatively. All patients received laparoscopic cholecystectomy, among whom 9 were converted to open. Partial cholecystectomy was performed in 1 patient. One patient with gallbladder adenocarcinoma was treated with radical cholecystectomy. XGC has nonspecific clinical and radiologic findings; thus, preoperative diagnosis is generally absent. Open cholecystectomy is the recommended treatment modality. Conversion to open is frequently necessary after laparoscopy. Complete cholecystectomy is the ultimate goal; however, partial cholecystectomy may be preferred to protect the structures of the hepatic hilum. Preoperative imaging studies (ultrasound or computerized tomography) of 34 patients showed a gallbladder stone in 18 patients, microlithiazis in 12 patients, sludge in 10 patients, and gallbladder sclerosis in 5 patients. CONCLUSIONS: Diagnosis of XGC and differentiation from gallbladder carcinoma may be difficult through preoperative or peroperative studies, even imaging is useful; the definitive diagnosis depends exclusively on pathologic examination. The surgeon should be prepared for every possibility.

Surgical treatment of hepatic injury: morbidity and mortality analysis of 109 cases.

BACKGROUND/AIMS: We aimed to determine the factors that affect morbidity and mortality in patients that underwent surgery for hepatic injury. METHODOLOGY: Records of 109 blunt or penetrating hepatic trauma patients that underwent surgery in the Third Surgical Clinic of Izmir Atattürk Training and Research Hospital between 1994 and 2004 were reviewed retrospectively. Evaluated parameters were: age, gender, cause of injury, diagnostic procedures, preoperative blood pressure (BP), hemoglobin (Hb) level, amount of intraabdominal blood, associated injuries, the number of involved hepatic segments and anatomic distribution, severity of injury, abdominal trauma index (ATI), amount of blood transfusions, type of surgery, hospital stay, and rates of morbidity and mortality. RESULTS: Median age of the patients was 29 years. The injury was penetrating in 53.2% of the patients and blunt in 46.8%. Abdominal blood was 500cc or less in 70 (64.2%) patients. Isolated hepatic injury was encountered in 29 (26.6%) cases. 22.9% of the patients had major injuries. Hemostasis was achieved by electrocautery, sponge-gel, primary suturing, hepatic resection or perihepatic packing. Morbidity and mortality rates were 40.4% and 14.6% respectively. CONCLUSIONS: Age, type of the injury, BP and Hb levels, amount of intraabdominal blood, degree of injury, ATI, and accompanying organ injuries significantly affect morbidity and/or mortality.

Survival analysis after surgical treatment of gastric cancer: review of 121 cases.

BACKGROUND/AIMS: This study was performed to evaluate major morbidity, early mortality and to analyze survival in our patients that underwent surgical treatment for gastric cancer. METHODOLOGY: Records of 121 patients with gastric adenocarcinoma that underwent surgery between 1997 and 2004 were reviewed retrospectively. Age, gender, tumor site, presence of local invasion, depth of tumor invasion, lymph node metastases, stage of the disease, distant metastases, histological differentiation, type of surgery, and blood transfusions were evaluated in relation to survival. Survival curves were estimated using the Kaplan-Meier method and the differences in survival were compared by the log-rank test. RESULTS: Forty-two cases (34.7%) underwent total gastrectomy, 34 (28.1%) had subtotal gastrectomy, and 45 (37.2%) received palliative surgery. The majority of the patients (61.2%) had stage IV gastric cancer. Total morbidity and mortality were 26.4% and 17.3%, respectively. The factors that influence survival were type of surgery, adjacent organ invasion, existence of metastases, lymph node status, blood transfusions, and stage of the disease in this study. Among the significant prognostic factors in the univariate analysis, only one factor, R0 resection proved to be independently significant in the multivariate analysis. CONCLUSIONS: R0 resection was found to have a significant favorable effect on survival in our study.

Palliative surgery for advanced stage (stage IV) gastric adenocarcinoma.

BACKGROUND/AIMS: The factors that effect resectability, major morbidity, early mortality, and survival in advanced stage gastric adenocarcinoma patients are evaluated. METHODOLOGY: Records of 74 patients that underwent surgery for stage IV gastric adenocarcinoma in the Third Surgical Clinic of Izmir Atatürk Training Hospital between January 1997 and January 2004 were reviewed retrospectively. Two groups (the patients with resectable disease and those with unresectable disease) were compared with regard to age, gender, primary complaint, symptoms, site of the tumor, involvement of adjacent organs, lymph node involvement, distant metastases, differentiation of tumor, surgical procedure, perioperative blood transfusions, and postoperative hospital stay. RESULTS: Mean age of the 74 patients was 58.4 years. Forty-five cases (60.8%) were considered as unresectable and 29 (39.2%) patients underwent a palliative resection. There was a significant relation between resectability and site of the tumor, and severity of invasion. As the number of perioperative blood transfusions increased, morbidity and mortality increased significantly. Although early mortality was high in the palliative resection group, survival (mean 10.4 months, longest 25 months) was better compared to that of the unresectable gastric cancer group (mean 3.5 months, longest eight months). CONCLUSIONS: A palliative gastric surgery may be applied to improve prognosis of advanced gastric cancer patients, even at the presence of peritoneal dissemination, hepatic metastases, N3 lymph node involvement, adjacent organ invasion, or poor differentiation of the tumor.

Gastrointestinal stromal tumors (GISTs): analysis of 20 cases.

BACKGROUND/AIMS: Gastrointestinal stromal tumors (GISTs) are soft tissue sarcomas arising from the mesenchymal tissues in the gastrointestinal tract. Diagnosis, treatment and follow-up protocols of GISTs have not been exactly defined. In this study, twenty cases with GISTs treated in our clinic are examined retrospectively. METHODOLOGY: Twenty cases treated for GISTs in Izmir Atatürk Training and Research Hospital between the years 1999 and 2004 were reviewed retrospectively. Age, gender, clinical findings, diagnostic methods, intraoperative findings, type of surgery, histopathological findings and survival of the patients were evaluated. RESULTS: Fifteen of the cases were male (75%) and five were female (25%), with a median age of 55 years (35-80). The most frequent symptoms were abdominal pain and acute gastrointestinal bleeding. Tumors were gastric (40%), small intestinal (45%), colonic (10%) or rectal (5%). The median tumor size was 9.1 centimeters. Pathological evaluation showed that number of mitoses per 50 high-power field (hpf) was more than five in nine of 10 cases and CD-117 was positive in four of four cases. The mean follow-up period was 21 (1-72) months, and median survival was 21 (1-72) months. CONCLUSIONS: The prognosis of GIST is frequently related to the tumor size and rate of mitosis. Despite the recent demonstration of C-kit protooncogene and introduction of imatinib mesilate as a new chance in treatment, radical surgery remains to be the most effective treatment of GISTs.