The frequency of malignancy and the relationship between malignancy and ultrasonographic features of thyroid nodules with indeterminate cytology.

Various approaches are available for the management of nodules that are evaluated to be indeterminate according to the results of thyroid fine needle aspiration biopsy. The present study aimed to determine the rate of malignancy and the ultrasonographic features that could be used as predictor of malignant pathologies at the nodules with indeterminate cytology. A total of 201 patients who underwent total thyroidectomy and whose fine needle aspiration biopsy results were evaluated to be Hurthle cell lesion (n = 99), follicular neoplasm (n = 61) and [corrected] suspicious for malignancy (n = 41) were enrolled in this study. Of these patients, 178 were females (88.6 %) and 23 were males (11.4 %). The rates of malignancy were found to be 33.3 % in the Hurthle cell lesion group, 23.0 % in the follicular neoplasm group and 53.7 % in the suspicious for malignancy group (p = 0.006). The comparison of the ultrasonographic characteristics of the malignant and benign nodules revealed hypoechogenicity and microcalcification to be more common in malignant nodules (34.3 vs. 16.9 %, p = 0.005; 27.1 vs. 13.1 %, p = 0.014; respectively). While 92.3 % of the malignant nodules were ≥1 cm, 82.9 % of the benign nodules were ≥1 cm (p = 0.042). We believe that as the patients at Hurthle cell lesion group have higher risk of malignancy than the patients with Follicular Neoplasia so total thyroidectomy will be suitable for these patients. [corrected]. In addition, microcalcification and hypoechoic nodules at patients with indeterminate cytology can be related with increased risk of malignancy. [corrected].

Risk factors for surgical site infection after gastrectomy with D2 lymphadenectomy.

Surgical site infection (SSI) is a potentially morbid and costly complication of surgery. We conducted this study to establish the preoperative and operative factors predisposing to SSI after gastric resection and D2 lymphadenectomy. Data on all patients undergoing gastrectomy and D2 lymphadenectomy within a 2-year period, at a tertiary reference hospital in Turkey, were collected retrospectively. The outcome of interest was a diagnosis of incisional SSI as defined by the Centers for Disease Control and Prevention. Multivariate analysis by stepwise logistic regression was then performed on those variables associated with incisional SSI. We identified 72 patients with SSI after gastrectomy and D2 lymphadenectomy. The median age of the patients was 61 years (range 31-81 years) and 43 were men. Incisional SSI was diagnosed in 15 (20.8%) patients. Of all the preoperative and operative variables measured, an increased patient body mass index was an independent predictor of incisional SSI. An increased incidence of SSI was found in overweight patients, but these infections were transient and not life threatening.

Activities of adenosine deaminase and 5'-nucleotidase in cancereous and non-cancereous human gastric tissues.

INTRODUCTION: Gastric cancer is still one of the most common fatal types of cancer in the world. The abnormalities in purine metabolism are a characteristic feature of many human tumors. Little is known about the correlation between the activities of key enzymes of purine nucleotide pathway and some clinical indicators of gastric cancer invasiveness and aggressiveness. METHOD: Seventeen (11 men, 6 women) patients with gastric cancer were admitted to the hospital. The activities of Adenosine deaminase (ADA) and 5'-nucleotidase (5'NT) in their cancerous and non-cancerous tissues were measured. RESULTS: 5'NT activities were significantly higher in cancerous tissues than in non-cancerous tissues. CONCLUSION: 5'NT activities increased in gastric cancer tissues but had no association with clinicopathologic findings (Tab. 2, Ref. 9). Full Text (Free, PDF) www.bmj.sk.

Peritoneal hydatidosis with ileus.

BACKGROUND: The parasitic infection hydatidosis or echinococcosis, is a parasitic infection caused most frequently by flatworm Echinococcus granulosus. Hydatidosis is endemic in Turkey where animal husbandry is common. Eventhough, Hydatid disease can develop anywhere in the human body it is most frequently occurs in the liver and then the lungs. Rupture of hydatid cysts into the peritoneal cavity, although rare, still presents a challenge for the surgeon. CASE: A 20-year-old man presented with ileus after 24 hours of mild abdominal distention, pain and nausea. On examination his abdomen was tender, with guarding and rebound tenderness and had a 3 cm long subcostal incision scar. All laboratory investigations were in the normal range. Exploratory laparotomy revealed multiple peritoneal cyst hydatid lesions with the largest measuring 10 cm in size and one also located in the right lobe of the liver. CONCLUSIONS: Rupture of hydatid cysts into the peritoneal cavity, although rare, still presents a challenge for the surgeon. This pathology should be included in the differential diagnosis of acute abdomen in endemic areas, especially in patients with a history of cyst hydatid (Fig. 1, Ref. 12). Full Text (Free, PDF) www.bmj.sk.

Receiver operating characteristic analysis of leukocyte counts in operations for suspected appendicitis.

STUDY OBJECTIVE: There has been no clear-cut value of the white blood cell (WBC) count in differential diagnosis of acute appendicitis in emergency medicine. Therefore, the aim of this study was to assess the preoperative WBC counts in 3 groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendectomy: uninflamed appendix, uncomplicated acute appendicitis, or complicated acute appendicitis. METHODS: The medical records of 540 patients who underwent appendectomy for suspected acute appendicitis during a 17-month period were retrospectively reviewed. Data for 3 groups of patients were analyzed to calculate the sensitivity and specificity of the WBC count in the diagnosis of acute appendicitis, and we calculated likelihood ratios for 2 cut-points with either high sensitivity or high specificity. Receiver operating characteristic curves were used to evaluate the WBC count in relation to the true diagnosis and severity of acute appendicitis. RESULTS: We were able to identify patients with appendicitis on a statistically significant level using receiver operating characteristic curves of WBC counts (area under the curve = 0.756, P < .001), but the WBC count had no diagnostic value in differentiating between uncomplicated and complicated groups (area under the curve = 0.55, P = .086). Likelihood ratio ranged from 1.79 (95% confidence interval, 1.17-2.3) for WBC count of more than 10,500 cells/mm(3) to 3.20 (95% confidence interval, 2.72-3.24) for WBC count of more than 14,300 cells/mm(3). CONCLUSION: White blood cell count is helpful in the diagnosis and exclusion of appendicitis. However, there is no value to differentiate advanced appendicitis.

Effects of aqueous green tea extract on activities of DNA turn-over enzymes in cancerous and non-cancerous human gastric and colon tissues.

AIM: The purpose of this study was to investigate possible effects of green tea extract on the activities of DNA turn-over enzymes, namely adenosine deaminase (ADA) and xanthine oxidase (XO) in gastric and colon tissues from patients with stomach and colon cancer. MATERIALS AND METHODS: Six cancerous and 6 non-cancerous adjacent human gastric tissues, and 7 cancerous and 7 non-cancerous adjacent colon tissues obtained surgically were treated with aqueous green tea extract at 3 different concentrations for 1 hour, and then ADA and XO activities were measured. RESULTS: In all of the tissues, XO activities were found to elevate after treatment with green tea extract. Additionally, ADA activity was found to be inhibited in the cancerous gastric tissues by the green tea extract. Elevated XO and reduced ADA activities due to treatment with green tea extract may lower salvage pathway activity and lead to inhibition in carcinogenesis. CONCLUSION: Our data suggest that green tea may support the medical treatment of stomach and colon cancer.

Can biliary-cyst communication be predicted before surgery for hepatic hydatid disease: does size matter?

BACKGROUND: The aim of this study was to determine if there is any predictive factor indicating the risk of bile leakage before surgery for hepatic hydatid disease in clinically asymptomatic patients. METHODS: The data of 116 patients who underwent surgery for hepatic hydatid disease were reviewed retrospectively. There were 43 men (37%) and 73 women (63%) with a mean age of 45 +/- 15 years. Because of high preoperative serum bilirubin and liver function test levels, 12 patients were excluded from the study. These patients underwent preoperative endoscopic retrograde cholangiopancreatography. In addition, 2 medically treated patients were excluded from the study. The following variables were analyzed as potential predictors of biliary-cyst communication: age, sex, physical examination findings, leukocyte count, liver function test results, and ultrasonographic cyst features (type, diameter, number, and localization). RESULTS: Bile leakage was detected in 24 out of 102 patients. There were no differences in age, sex, cyst type, alkaline phosphatase level, gamma-glutamyl transpeptidase level, alanine aminotransferase level, aspartate aminotransferase level, bilirubin level, and number of cysts and cyst locations between the patients with and without bile leakage. The mean cyst size in patients with biliary leakage was 10.2 cm as compared with 6.1 cm in patients with no biliary leakage (P < .05). When the cut-off value of cyst diameter was accepted as 7.5 cm, the specificity and sensitivity for biliary-cyst communication were 73% and 79%, respectively. CONCLUSIONS: These data suggest that cyst diameter is an independent factor that is associated with a high risk of biliary-cyst communication in clinically asymptomatic patients. Preoperative endoscopic retrograde cholangiopancreatography should be performed in these asymptomatic patients to reduce the incidence of postoperative complications.

External validation of prognostic models among cancer patients undergoing emergency colorectal surgery.

BACKGROUND: The aim of this study was to evaluate the predictive accuracy of different scoring systems on patients undergoing emergency colorectal surgery. METHODS: The Acute Physiology and Chronic Health Evaluation II or III, the Simplified Acute Physiology Score II, the Mortality Probability Model II, and the Colo-rectal POSSUM scoring systems were applied to 102 patients who underwent colorectal resection for cancer. Validation of scoring systems was tested by assessing calibration and discrimination. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic curve analysis. RESULTS: Overall, 17 deaths occurred. The Simplified Acute Physiology Score II showed good calibration (x(2) = 1.079, P = .982) and discrimination (areas under the receiver-operating characteristic curve .83). CONCLUSIONS: These data suggest that the SAPS II scoring system was accurate in predicting outcome for patients undergoing emergency colorectal surgery.

Comparison and validation of scoring systems in a cohort of patients treated for perforated peptic ulcer.

BACKGROUND AND AIMS: The aim of this study is to evaluate the predictive accuracy of different scoring systems on surgery for perforated peptic ulcer referred to an academic department of general surgery in a tertiary reference center. PATIENTS AND METHODS: Seventy-five consecutive patients (Male/female ratio = 64:11; mean age, 44 years; range, 16-85) with perforated peptic ulcer disease were investigated. Disease severity scores and mortality predictions were calculated using the collected data during admission. Discrimination and calibration characteristics of each system, namely, the acute physiology and chronic health evaluation II and III, the simplified acute physiology score II, and the mortality probability models (MPM) II, were determined by using the area under receiver operating characteristics curve and the Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS: Among the 75 patients included, there were eight (10.6%) mortalities. All systems had a reliable power of discrimination and calibration. Among the systems tested, MPM II was the best performing as far as discrimination and calibration characteristics were considered. The parameters of MPM II system that were related to systemic perfusion of the patient were significantly positive in patients who died compared to those who survived. CONCLUSIONS: MPM II that predicted mortality at admission is better than the other systems in predicting mortality. Results also indicate the importance of maintenance of systemic perfusion of the patient at the early phases of peptic ulcer perforation.

Comparison and validation of scoring systems in a cohort of patients treated for biliary acute pancreatitis.

OBJECTIVES: There are a few prospective studies assessing the severity of acute pancreatitis with exclusive criteria for biliary etiology. The aim of this study was to assess the reliability of prediction of the severity and mortality of acute biliary pancreatitis by using the Ranson, Acute Physiology And Chronic Health Evaluation II and III, Simplified Acute Physiology Score II, and Mortality Probability Model (MPM) II systems. METHODS: Fifty-eight patients with acute biliary pancreatitis were studied prospectively. Disease severity scores and mortality predictions were calculated using the collected data in the first 24 hours of admission and for Ranson score in the first 48 hours. Discrimination and calibration characteristics of each system were determined by using area under receiver operating characteristics curve and Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS: Among 58 patients included, there were 4 mortalities (6.8%). Fifteen patients (25.8%) had severe disease, and 5 patients (8.6%) had systemic and local complications. All systems had reliable power of discrimination and calibration. Among systems tested MPM II was the best performing as far as discrimination, and calibration characteristics are considered. The items of MPM II that were positive in patients with severe pancreatitis were those related to systemic perfusion. CONCLUSIONS: Mortality Probability Model II predicted mortality at admission is better than the other systems in predicting the severity of pancreatitis. Results also indicate the important role of systemic perfusion at the early phases of acute pancreatitis in the progression of disease.

Evaluation of P-POSSUM and CR-POSSUM scores in patients with colorectal cancer undergoing resection.

INTRODUCTION: The aim of this study was to evaluate the predictive accuracy of P-POSSUM and CR-POSSUM models on patients undergoing colorectal resection. METHODS: P-POSSUM and CR-POSSUM predictor equations for mortality were applied retrospectively to 321 patients who had undergone colorectal resection for cancer. P-POSSUM and CR-POSSUM scores were validated by assessing their calibration and discrimination. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Evaluation of the discriminative capability of both models was performed using receiver-operating characteristic (ROC) curve analysis. RESULTS: Overall, 22 deaths were observed. CR-POSSUM predicted 25 deaths (chi2 = 12.20, P = 0.13), and P-POSSUM predicted 29 deaths (chi2 =18.85, P = 0.002). ROC curves analysis revealed that CR-POSSUM has reasonable discriminatory power for mortality. CONCLUSIONS: These data suggest that CR-POSSUM may provide a better estimate of the risk of mortality for patients who undergoing colorectal resection.

Serum endostatin levels in gastric cancer patients: correlation with clinicopathological parameters.

BACKGROUND/AIMS: The aim of this study was to evaluate the predictive role of the circulating levels of endostatin in gastric cancer patients. METHODOLOGY: This study is a retrospective case-control study. We measured serum endostatin levels of 30 patients aged between 34-83 years with gastric cancer and 30 patients without malignant pathology operated for benign pathologies with age ranging from 18 to 69. RESULTS: Serum levels of endostatin were correlated with the Lauren classification. Significantly higher serum endostatin levels were obtained in Lauren intestinal type tumors than Lauren diffuse type tumors. CONCLUSIONS: These data suggest that serum endostatin levels do not correlate with clinicopathological parameters, except tumor histopathology (according to Lauren classification), in gastric cancer patients.

Value of preoperative serum CA 19-9 levels in predicting resectability for pancreatic cancer.

BACKGROUND: Pancreatic cancer carries a poor prognosis; at operation approximately 25% of patients will be found to have unresectable tumours even though CT has demonstrated that they are resectable. At our tertiary care centre, we wished to find out if there is an optimum cut-off value for the CA 19-9 level preoperatively that will indicate that the pancreatic cancer is unresectable despite radiologic imaging that suggests otherwise according to receiver operating characteristic (ROC) curve analysis. METHODS: Preoperative demographic data, clinical features and serum CA 19-9 levels were reviewed for 51 patients with pancreatic cancer who underwent laparotomy between 1998 and 2003. Preoperatively, resectability was determined from a complete history, physical examination and radiologic imaging. An ROC curve was constructed for the CA 19-9 levels. The sensitivity, specificity, positive and negative predictive values of CA 19-9 were calculated with several cut-off points. RESULTS: There were 18 (36%) resectable and 33 (64%) unresectable pancreatic cancers. The mean CA 19-9 level was 68.8 U/mL in the resectable group and 622 U/mL in unresectable group. When a CA 19-9 level of 256.4 U/mL was used as a cutoff point, the specificity and sensitivity was 92.3% and 82.4% respectively. CONCLUSION: Preoperative CA 19-9 levels may be a useful marker for determining preoperatively which patients have unresectable disease despite the demonstration on CT of resectable disease.

Increased expression of cyclooxygenase-2 (COX-2) in radiation-induced small bowel injury in rats.

BACKGROUND: Radiation therapy is a widely used adjuvant therapy for various abdominal and pelvic cancers. On the other hand, it is not a benign treatment modality, as most radiation patients suffer from some kind of radiation enteritis. Currently available treatments are only palliative and no ideal compound has as yet been discovered. The aim of this study was to evaluate cyclooxygenase-2 (COX-2) expression, and to investigate the possible protective effect of the selective COX-2 inhibitor, Rofecoxib, in acute and late stages of radiation-induced intestinal injury in rats. MATERIALS AND METHODS: Forty-eight male Sprague-Dawley rats were randomly divided into eight groups. After abdominal irradiation of all of the animals except the six in the control group, the expression of the enzyme cyclooxygenase-2 (COX-2) was evaluated in different cell types present in the intestinal wall 2 h post exposure (study day 0) and again on study days 4, 14, and 60. The effects of Rofecoxib on histological damage, intestinal myeloperoxidase (MPO) activity, and malondialdehyde (MDA) levels were also measured. RESULTS: Expression of COX-2 in vascular endothelial cells was found to be significantly increased on post exposure days 4 and 14 (2.4 and 2.9 stained vessels/high power field [hpf] respectively compared to 1.3 vessels/hpf for controls) (P = 0.002). Expression of COX-2 in fibroblasts increased immediately after irradiation (29 cells/hpf 2 h after irradiation compared to 12 cells/hpf for non-irradiated control animals) and remained high during the entire study period (P < 0.001), whereas there was a peak COX-2 expression (54.9 cells/hpf) on day 14 that was similar to what was observed in endothelial cells. Irradiation of rats significantly increased intestinal epithelial damage, MPO activity, and MDA levels in comparison to the control group in a time-dependent fashion. Treatment with rofecoxib significantly decreased these elevations except on day 4 of the study. CONCLUSION: The current study suggests that the COX-2 pathway is involved in radiation induced intestinal injury and that targeting COX-2 may be useful in limiting radiation enteritis.

Randomized, prospective comparison of postoperative pain in low- versus high-pressure pneumoperitoneum.

BACKGROUND: Reduced postoperative pain after laparoscopic cholecystectomy (LC) compared to open cholecystectomy (OC) may be able to be further optimized. To reduce pain, focus should be directed on the effects of individual components of pain. METHODS: A double-blind, randomized, controlled trial was carried out in a tertiary care hospital. Fifty-three elective patients with symptomatic gallstones were enrolled into the study. Patients were randomized to low- or high-pressure pneumoperitoneum groups. In all patients, gas pressure was set to 15 mmHg during placement of ports. Later on, in the low-pressure group, the rest of the procedure was performed at 10 mmHg pressure. At 6 and 24 h postoperatively, a short-form McGill Questionnaire (MPQ) was obtained from all patients. Patients were then asked to complete a 10-cm visual analogue scale (VAS) for abdominal pain. RESULTS: Pain scores were generally low for both groups. Statistical comparisons of mean cumulative McGill score and VAS abdominal pain scores in both groups did not reach statistical significance at 6 and 24 h after operation. CONCLUSION: There was no correlation between high- and low-pressure laparoscopy and postoperative pain after LC. Peritoneal stretching may be more responsible for shoulder pain but has less effect on intensity of abdominal pain or incisional pain. On the basis of these negative findings, routine use of low-pressure pneumoperitoneum for alleviation of postoperative pain following LC is not recommended.

Does technique alter quality of life after pilonidal sinus surgery?

BACKGROUND: Pilonidal sinus is a common disease in young adults that carries high postoperative morbidity and patient discomfort. Controversy still exists about the best surgical technique for the treatment of the disease in terms of recurrence rate and patient discomfort. METHODS: From January 2000 to November 2003, 100 consecutive age- and sex-matched patients with chronic pilonidal sinus disease were randomized to receive surgical treatment in the forms of either excision and primary closure or rhomboid excision and Limberg flap. Time to return to work and to complete healing were recorded. To evaluate quality of life and patient comfort, all patients were asked to complete a questionnaire including short form 36, Visual Analogue Scale, time to sitting on toilet without pain, and time to walking without pain 3 months after surgery. RESULTS: Each group was composed of 50 patients. Mean follow-up was 19 months. There was a significant difference between the groups in terms of length of hospital stay (P=.005), time to complete healing (P<.001), time off work (P<.001), and wound infection rate (P=.03). Statistically significant differences were noted between the groups in items of general health perception (71.1+/-11.7 vs 78.2+/-14.1; P=.008), social functioning (87.3+/-32.8 vs 110.4+/-33.8; P=.001), and pain (54.5+/-14.0 vs 67.5+/-18.4; P<.001). Times to sitting on toilet and walking without pain showed significant differences between the groups (P=.006 and P<.001, respectively). The mean postoperative Visual Analogue Scale scores were 6.5+or= 1.7 and 7.4+/- 1.4, respectively (P<.001). CONCLUSIONS: Shorter hospital stay, earlier healing, shorter time off work, lower ratio of complications, lower pain perception, and improved general health perception are the main advantages of te Limberg flap technique in pilonidal sinus surgery. All together, these parameters add to patient comfort and satisfaction after surgical treatment.

Pelvic perfusion for locally recurrent unresectable rectal tumors.

BACKGROUND/AIMS: Pelvic perfusion evolved as a palliative and curative treatment modality for advanced pelvic tumors and literature data support its use in different steps of the disease. METHODOLOGY: 15 patients with recurrent rectal tumor, without any systemic metastases were included in the study. Mean age was 49.7 years, 12 males, 3 females. Mean survival was 18 months. RESULTS: 15 unresectable rectal cancer patients were included in this study. Three (20%) complete response, 6 (40%) partial response, 2 stable disease (13.3%) and 4 (26.7%) progression were seen after pelvic perfusion. Mean survival is 26.54 months after perfusion (median=10). In multivariate analysis response rate to isolated perfusion and tumor size are significant factors effecting survival (p<0.05). The patients who did not receive chemotherapy after detection of pelvic recurrence did better (p=0.0086). Response to isolated pelvic perfusion (IPP) is an important factor for survival of locally advanced rectal tumors in log-rank test (p=0.0001). CONCLUSIONS: Isolated pelvic perfusion is a good alternative for non-resectable pelvic malignancies and should be considered as an important part of the multidisciplinary approach for these tumors.