Effect of Intraoperative Neuromonitoring on Voice Quality in Total Thyroidectomy

Aim: Thyroid gland surgery has a risk of serious complications. Advancements in technology have led to improvements in complications but significant challenges to preserving voice and airway function still remain. The purpose of this study was to evaluate voice quality following total thyroidectomy under neuromonitoring and effect of intraoperative neuromonitoring (IONM) on identification of the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN). Methods: A total of 80 patients scheduled for total thyroidectomy between May 2015 and March 2016 were included in the study. All the RLNs and EBSLNs were identified. Voice assessment included preoperative and postoperative fiberoptic laryngoscopy, analysis of Jitter, Shimmer, and fundamental frequency and the Voice Handicap index-10. Results: Eighty patients were included in this study (71 females, nine males). There was no significant difference between mean initial and post-dissection electromyographic amplitudes with RLN and EBSLN stimulation. The rate of postoperative transient RLN palsy per nerve at risk was 4.375% (7/160) and null for permanent RLN palsy (0%, 0/160). Conclusion: Both subjective and objective assessments revealed preservation of voice quality in patients after total thyroidectomy under neuromonitoring. IONM may be used effectively and safely in order to identify the EBSLN during thyroid surgery

İntravasküler kateterizasyon metodlarına temel teşkil etmek üzere abdominal aorta ve dallarının çap ve kesit alanlarının çeşitli parametrelerle kıyaslanarak doppler ultrasonografi ve anatomik diseksiyon destekli analizi

İntravasküler kateterizasyon metodlarına temel teşkil etmek üzere abdominal aorta ve dallarının çap ve kesit alanlarının çeşitli parametrelerle kıyaslanarak Doppler ultrasonografi ve anatomik diseksiyon destekli analizi ÖZET İntravasküler kateterizasyon metodlarına temel teşkil etmek üzere aorta abdominalis ve dallarının internal çap, kesit alanlarının çeşitli parametrelerle kıyaslanarak; erişkinde Doppler ultrasonografide in vivo ölçümü ve yenidoğan kadavralarında anatomik diseksiyonla in vitro erken ateroskleroz oluşumunun oil-red-O boyasıyla histolojik olarak gösterilmesi, internal çap ve kesit alanlarının morfometrik yöntemlerle ölçülmesi amaçlandı. Marmara Üniversitesi Tıp Fakültesi Anatomi A.D. Laboratuvarı’nda 22 yenidoğan kadavrası (15 erkek, 7 kız) diseke edildi.Morfometrik ölçümler ve varyasyonlar kaydedildikten sonra; truncus coeliacus’un (TC) ve bu dala ait 3 ana dalın proksimal bölgelerinden (a.gastrica sinistra, a.hepatica communis (AHC), a.lienalis), ayrıca a.mesenterica superior (AMS), a.mesenterica inferior’un (AMİ), aortanın da 5 seviyeden; A1: TC’nin hemen üzeri, A2: TC ile AMS arası, A3: AMS'nin hemen altı, A4: AMİ'nin hemen üzeri, A5: AMİ'nin hemen altı olmak üzere, kesitleri alındı. Kriyomikrotom (frozen seksiyon) ile 10 mikrometrelik kesitler alınıp yağ boyası oil-red-O ile boyandı. Kesitler, oküler mikrometre ile ışık mikroskobunda ölçüldü. Şişli Etfal Eğitim ve Araştırma Hastanesi Radyoloji Departmanı Doppler Ultrasonografi (USG) Ünitesi'ne ardışık randomize başvuran 24 erişkin gönüllü (20 kadın, 4 erkek) üzerinde aynı radyoloji uzmanı tarafından yapılan aynı damarların ölçümleri değerlendirildi. İstatistiksel analizler, GraphPad Prisma V.3 paket programı ile yapılmıştır. İkili grupların karşılaştırmasında Mann-Whitney-U, nitel verilerin karşılaştırmalarında ki-kare testi kullanılmıştır. Yenidoğanın büyüklüğü ile tüm aorta internal çaplarında, AMS ve AMİ’de istatistiksel anlam farkı mevcut olup aorta internal çapı, USG sonuçlarında da olduğu gibi distale doğru daralmaktaydı. Kadavra ve USG sonuçlarında cinsiyet, istatistiksel anlamlı sonuç vermese de, USG’de vücut kitle indeksi ve yaşın internal çaplarla istatistiksel anlamlı sonuç verdiği görülmüştür. Ateroskleroz, 9 kadavrada (9/22,%41) mevcuttu. A.lienalis, lipid tespit edilen kadavralarda, küçük damarlar içinde en fazla oranda tutulmuştu (3/9). İncelenen damarlarda, kadavraların %46’sında varyasyon mevcuttu. AHC, lipid birikimiyle varyasyonun istatistiksel anlam farkının gösterildiği tek damardı. Sonuç olarak, ateroskleroz yenidoğan döneminde başlamaktadır. İntravasküler girişimler için uygun kateter seçimi; uygun ve güvenilir parametreler rehberliğinde, varyasyon zenginliği de göz önünde tutularak, güvenle yapılabilir.Anahtar kelimeler: aort, ateroskleroz, endotelyum, kateter, mezenterik iskemi The analysis of the diameters and the cross-sectional areas of the abdominal aorta and its branches by comparing with various parameters supported via Doppler ultrasonography and anatomical disection to constitute a base for intravascular catheterization methodsSUMMARY (Abstract) The analysis of the internal diameters and the cross-sectional areas of aorta abdominalis and its branches by comparing with various parameters supported via Doppler ultrasonography in living adults in vivo and anatomical disection in newborn cadavers in vitro, to constitute a base for intravascular catheterization methods and the histological demonstration of early atherosclerosis by oil-red-O lipid staining of those vessels with concomitant morphometric measurements was aimed. Twenty-two newborn cadavers (15 males, 7 females) were disected in the laboratory of the Anatomy department of the medical faculty of Marmara University. The proximal cross-sections of truncus coeliacus (TC) with its 3 main branches (a. gastrica sinistra, a. hepatica communis (AHC), a.lienalis), and a.mesenterica superior (AMS) in addition to a.mesenterica inferior (AMI), besides 5 aorta levels, namely A1: just superior to TC, A2: between TC and AMS, A3: just inferior to AMS, A4: just superior to AMI and A5: just inferior to AMI were taken following the enlistment of the morphometric measurements and variations. Ten micrometer thick sections were obtained with frozen section using cryomicrotome which were stained by oil-red-O lipid dye afterwards. The cross-sections were measured with ocular micrometer with light microscope. The measurements of the analogous vessels of 24 adults (20 females, 4 males) volunteers, who applied randomly and consecutively to the Duplex Doppler ultrasonography unit of the Radiology Department of Şişli Etfal Teaching and Research Hospital, obtained always by the same radiologist, were evaluated. The statistical analysis were made by GraphPad Prisma V.3 package program. Mann-Whitney-U and chi-square tests were used in the comparisons of the doubled groups and qualitative data, respectively. There was statistical significance in the comparison of the tallness of the neonate and all internal diameters of the aorta, AMS, AMI and; aortic internal diameter was narrowing caudally, supported by the similar results gained by ultrasonography. There was statistical significance in the ultrasonographic results between the internal diameters when compared both with body mass index and age, although not supported by gender both in cadavers and ultrasonographic results. Atherosclerosis was present in 9 cadavers (9/22,41%). A.lienalis was the most commonly encountered small vessel among the cadavers with lipid deposition (3/9). Variation, in regard to the documented vessels only, was present in 46% (10/22) of the cadavers. AHC was the only vessel where statistical significance was demonstrated in regard to variation versus lipid deposition. As a conclusion, atherosclerosis begins in the neonatal period. The choice of the appropriate catheter for intravascular interventions can be safely undertaken by the guidance of appropriate and reliable parameters with richness of variations kept in view. Key words: aorta, atherosclerosis, catheter, endothelium, mesenteric ischemi

Sigmoid Diverticulitis: Our Experiences with 13 Patients

Objective: We aimed to present our treatment approach and results of the treatment in patients with the diagnosis of sigmoid diverticulitis. Material and Methods: In this study, we evaluated patients who presented to the emergency unit between March 2009 and February 2010 and have been diagnosed with sigmoid diverticulitis. The data were prospectively collected and retrospectively analyzed. Our patients were classified and staged according to Hinchey’s classification system. The results of the treatment, complication rates, and duration of hospitalization were presented in the light of the literature. Results: Thirteen patients (9 males, 4 females) with a mean age of 52 years and median age of 58 (35-58 years) were diagnosed with sigmoid diverticulitis. Five patients underwent laparotomy (Hinchey III-IV), while Hartmann’s procedure was carried out in 4 patients and resection and primer anastomosis was performed in 1 patient. Eight patients who were classified as Hinchey I-II (diverticulitis-abscess) were followed up with medical treatment. The mean duration of hospitalization was 8.6 (4-21 days) and 17.4 (10-27 days) days in Hinchey I-II and III-IV groups, respectively. All patients in the laparotomy group developed at least one complication. Conclusion: Hinchey stage III-IV sigmoid diverticulitis requires laparotomy. Complication rates are higher and duration of hospitalization is longer in patients with Hinchey stage III-IV when compared to those with Hinchey I-II. We conclude that Hinchey stage I-II diverticulitis can be successfully managed with medical treatment. (The Me di cal Bul le tin of Ha se ki 2012; 50: 21-4

Retrospective Evaluation of Patients Aged 45 Years or Younger Diagnosed with Colorectal Cancer

Aim: The incidence of colorectal carcinoma is less common under 45 years of age when compared to older patients. In the last decades, the prognosis, pathological, genetic and physiological behavior of the tumor in young patients gained the attention of the researchers. It is a reality that nowadays, colorectal cancers are more commonly encountered in younger population. Methods: We retrospectively analyzed colorectal cancer patients who had been under 45 years of age and operated on in our surgery clinic in a period of 6 years. Forty-one young patients out of a total of 331 patients with colorectal carcinoma were evaluated. Gender, age, tumor markers, anemia, pathology reports, in addition to Dukes classification and histological subtype (mucinous or non-mucinous) were recorded. Results: 25 patients were male (61%) and 16 were female (39%).The most common complaint was restlessness and the most common type was non-mucinous adenocarcinoma. The most common locations were rectum and sigmoid colon, in 23 (56%) and 11 (27%) patients, respectively. While 1 patient (2%) was in stage A, almost half of the patients (49%) were in stage D. Conclusion: Colorectal carcinoma in young individuals is usually encountered in males and is often in advanced stage at time of diagnosis, in addition to more aggressive behavior when compared to elderly patients. (The Me di cal Bul le tin of Ha se ki 2011; 49: 110-3

Sigmoid diverticulitis: Our experiences with 13 patients

Amaç: Sigmoid divertikülit tanısı konan hastalara tedavi yaklaşımlarımızı ve sonuçlarını sunmayı amaçladık. Yöntem ve Gereç: Mart 2009-Şubat 2010 tarihleri arasında acil polikliniğe müracaat eden, klinik ve radyolojik olarak sigmoid divertikülit tanısı konan hastalar değerlendirmeye alındı. Veriler prospektif olarak toplanıp retrospektif olarak değerlendirildi. Hastalarımızı Hinchey sınıflamasına göre evrelendirerek tedavileri, komplikasyon oranlarını ve hastanede yatış sürelerini literatür eşliğinde sunduk. Bulgular: On üç hastaya sigmoid divertikülit tanısı kondu. Bu hastaların dokuzu erkek, dördü kadın olup median yaş 58 (35-88), ortalama yaş ise 52 idi. Eşlik eden hastalık olarak; bir hastada diyabet, bir hastada da kronik akciğer hastalığı mevcuttu. Peritonit ve perforasyon saptanan beş hasta (Hinchey evre III-IV) ameliyat edildi. Dört hastaya Hartman prosedürü uygulanırken, bir hastaya rezeksiyon ve primer anastomoz uygulandı. Sekiz hasta ise Hinchey sınıflamasına göre evre I-II (divertikülit, apse) olarak değerlendirildi ve medikal tedavi ile takip edildi. Ortalama yatış süresi Hinchey evre I-II gurubunda 8,6 (4-21), Hinchey evre III-IV gurubunda ise 17,4 (10-27) gün olarak hesaplandı. Medikal tedavi ile takip edilen hastalarda komplikasyon gelişmezken, ameliyat edilen hastaların hepsinde en az bir komplikasyon gelişti. Sonuç: Hinchey sınıflamasına göre evre III-IV hastalara cerrahi işlem gereklidir. Bu hastaların ameliyat sonrası komplikasyon oranları evre I-II’ye göre fazla ve yatış süreleri uzun olmuştur. Evre I-II olan hastaların medikal tedavi ile başarılı bir şekilde tedavi edilebileceğini düşünmekteyiz. (Ha se ki T›p Bül te ni 2012; 50: 21-4)Objective: We aimed to present our treatment approach and results of the treatment in patients with the diagnosis of sigmoid diverticulitis. Material and Methods: In this study, we evaluated patients who presented to the emergency unit between March 2009 and February 2010 and have been diagnosed with sigmoid diverticulitis. The data were prospectively collected and retrospectively analyzed. Our patients were classified and staged according to Hinchey's classification system. The results of the treatment, complication rates, and duration of hospitalization were presented in the light of the literature. Results: Thirteen patients (9 males, 4 females) with a mean age of 52 years and median age of 58 (35-58 years) were diagnosed with sigmoid diverticulitis. Five patients underwent laparotomy (Hinchey III-IV), while Hartmann's procedure was carried out in 4 patients and resection and primer anastomosis was performed in 1 patient. Eight patients who were classified as Hinchey I-II (diverticulitis-abscess) were followed up with medical treatment. The mean duration of hospitalization was 8.6 (4-21 days) and 17.4 (10-27 days) days in Hinchey I-II and III-IV groups, respectively. All patients in the laparotomy group developed at least one complication. Conclusion: Hinchey stage III-IV sigmoid diverticulitis requires laparotomy. Complication rates are higher and duration of hospitalization is longer in patients with Hinchey stage III-IV when compared to those with Hinchey I-II. We conclude that Hinchey stage I-II diverticulitis can be successfully managed with medical treatment. (The Me di cal Bul le tin of Ha se ki 2012; 50: 21-4

A study to use hematological and biochemical parameters as a key in the diagnosis of acute mesenteric ischemia

Aim: Acute mesenteric ischemia is still fatal in 59-92% of cases. Delay in diagnosis of acute mesenteric ischemia can cause dramatic increase in morbidity and mortality rates.  However several diagnostic and disease related factors have been widely studied. Controversy still remains. In this study, we evaluated hematological and biochemical parameters in patients with acute mesenteric ischemia.Methods: 46 patients (study group) who underwent emergent surgery for acute mesenteric ischemia and 46 patients (control group) operated for acute abdomen with another etiology other than acute mesenteric ischemia and internalized to intensive care unit were included in this study. Medical records and clinical data of acute mesenteric ischemia patients between January 2008 and December 2014 were evaluated with regard to 8 parameters; age, amylase, white blood cell count, mean platelet volume, creatine kinase, lactate dehydrogenase, lactate and D-dimer. These parameters were selected for their increased levels in acute mesenteric ischemia patients according to many published medical studies. Control group was formed randomly from patients followed in intensive care unit for their co-morbidities after acute abdomen operation in the same period. Gender was included in the table but was not taken into account as a parameter for the study. Results: Mean values of age, white blood cell count, creatine kinase, lactate dehydrogenase, lactate and D-dimer were significantly higher in acute mesenteric ischemia group than the control group. Mean platelet volume was significantly lower in acute mesenteric ischemia group. The p values were for age (p=0.009), for amylase (0.475), for white blood cell (p=0.001) for mean platelet volume (0=0.001), for creatinine kinase (p=0.017), for lactate dehydrogenase (p=0.001), for lactate (p=0.001), for D-dimer (p=0.001) respectively. Conclusion: White blood cell count, creatine kinase, lactate dehydrogenase, lactate and D-dimer levels increase; mean platelet volume decrease in acute mesenteric ischemia patients significantly

The Case of Bezoar in a Patient Presenting with Vomiting

Bezoars are solid mass of a indigestible material accumulating in the gastrointestinal tract. Although rarely, bezoars may cause gastrointestinal obstruction. We aimed to present the case of a patient presenting with the complaint of vomiting in whom a diagnosis could not be established for a long period of time

Effect of Intraoperative Neuromonitoring on Voice Quality in Total Thyroidectomy

Aim: Thyroid gland surgery has a risk of serious complications. Advancements in technology have led to improvements in complications but significant challenges to preserving voice and airway function still remain. The purpose of this study was to evaluate voice quality following total thyroidectomy under neuromonitoring and effect of intraoperative neuromonitoring (IONM) on identification of the recurrent laryngeal nerve (RLN) and external branch of the superior laryngeal nerve (EBSLN). Methods: A total of 80 patients scheduled for total thyroidectomy between May 2015 and March 2016 were included in the study. All the RLNs and EBSLNs were identified. Voice assessment included preoperative and postoperative fiberoptic laryngoscopy, analysis of Jitter, Shimmer, and fundamental frequency and the Voice Handicap index-10. Results: Eighty patients were included in this study (71 females, nine males). There was no significant difference between mean initial and post-dissection electromyographic amplitudes with RLN and EBSLN stimulation. The rate of postoperative transient RLN palsy per nerve at risk was 4.375% (7/160) and null for permanent RLN palsy (0%, 0/160). Conclusion: Both subjective and objective assessments revealed preservation of voice quality in patients after total thyroidectomy under neuromonitoring. IONM may be used effectively and safely in order to identify the EBSLN during thyroid surgery.Amaç: Tiroid ameliyatının olası ciddi komplikasyonları vardır. Teknolojideki ilerlemeler komplikasyonların azalmasına neden olmuştur ama hava yolu ve sesle ilgili önemli sorunlar halen devam etmektedir. Bu çalışmanın amacı, intraoperatif sinir monitörizasyonunun (İONM) rekürren larengeal sinirin (RLN) ve superior larengeal sinirin eksternal dalının (EBSLN) tanınmasıyla total tiroidektomiyi takiben ses kalitesinin değerlendirilmesidir. Yöntemler: Mayıs 2015 ve Mart 2016 tarihleri arasında total tiroidektomi ameliyatı planlanan 80 hasta çalışmaya dahil edildi. Olgulardaki tüm RLN ve EBSLN traseleri başarı ile belirlendi. Ses kalite değerlendirmeleri ameliyat öncesi ve sonrası dönemde; fiberoptik laringoskopi, Jitter, Shimmer analizleri, temel fundamental frekans ve Ses Handikap indeksi-10 ile değerlendirildi. Bulgular: Seksen hasta (71 kadın/dokuz erkek) çalışmaya dahil edildi. Diseksiyon başlangıç ve sonrasında hem RLN hem de EBSLN için ortalama elektromiyografi amplitüdünde anlamlı ölçüde fark yoktu. Ameliyat sonrası geçici RLN felci oranı (7/160) %4,375 iken, kalıcı RLN felcine (%0, 0/160) rastlanmadı. Sonuç: Hem öznel hem de nesnel değerlendirmede total tiroidektomi esnasında sinir monitörizasyonu kullanıldığında, hastalarda ses kalitesinin korunduğu tespit edildi. İONM, tiroid ameliyatı sırasında EBSLN tespitinde etkili ve güvenli bir şekilde kullanılabilir