EXTRAUMBILICAL SINGLE-INCISION LAPAROSCOPIC CHOLECYSTECTOMY WITH STANDARD LAPAROSCOPIC INSTRUMENTS

Background and Aim: Single-incision laparoscopic surgery is a rapidly progressing field as it combines some advantages such as cosmesis and less incisional pain. However, it also has some disadvantages such as limitation of movement and clashing of the hand instruments, which increase the complexity and technical challenges of the operation. In this study, we describe a pilot trial of single-incision laparoscopic cholecystectomy through a paramedian access site. Material and Methods: A total of 25 patients underwent single-incision laparoscopic cholecystectomy with this method. Acute cases with empyema and patients with history of previous abdominal surgery were excluded. Single-incision is established on the right upper quadrant, right latero-superior of the umbilicus, so that trocar sites and projection of the gallbladder on the abdominal wall are on the same vertical line. Standard laparoscopic instruments were placed into the abdominal cavity providing triangulation. Once the laparoscope, grasper, and dissector are in place, the overall procedures are similar to the standard laparoscopic cholecystectomy. Results: Single-incision laparoscopic cholecystectomy through an extraumbilical access site was successfully completed in all 25 patients without conversion to open surgery. Additional skin incisions and trocar access were required only in two patients. The mean operative time was 39.3 min (range: 20-75 min). The mean body mass index was 27.2. Postoperative course was uneventful in all patients. The mean postoperative hospital stay was shorter than 24 h, and all patients were discharged at first day postoperatively. No postoperative complications including seroma, wound infection, and trocar-site hernia were observed at 6-month follow-up. Conclusion: We described a new access site for single-incision laparoscopic cholecystectomy using standard laparoscopic instruments. We believe that this type of access site overcomes the technical difficulties of performing single-incision laparoscopic cholecystectomy, and it is a promising alternative method for the treatment of patients with symptomatic gallstone disease as a minimal invasive abdominal surgery

Clinical and functional results of radiofrequency ablation and microwave ablation in patients with benign thyroid nodules

Objectives: To determine how well ultrasound-guidance percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) performed for benign symptomatic thyroid nodules in terms of clinical and functional outcomes. Methods: Patients who had a thyroid nodule-linked symptoms acting as dysphagia, cosmetic issues, pain, a foreign body sense, hyperthyroidism secondary to autonomous nodules, or concern of malignancy were involved in the study. The primary was the comparison in symptom scores obtained at 1, 3, and 6 months after RFA and MWA. The volume alterations in nodules and alterations in thyroid gland functions were secondary objectives. Results: This prospective study carried out from November 2014 and January 2017 at the General Surgery Department, Marmara University, Faculty of Medicine, Istanbul, Turkey included a total of 100 nodules (50% MWA, 50% RFA). There were statistically significance in pain scores, dysphagia scores, and foreign body sensation scores at 1, 3, and 6 months after therapy in both ablation groups (p=0.0006, p=00004, p=0.0005). At the same time, there were statistically significant reductions in size and volume of the nodules for RFA and MWA (p=0.0004, p=0.0003). There was no significant difference between the RFA and MWA groups' cosmetic scoring and volume changes (p=0.68, =0.43). Conclusion: Alternative therapies for benign symptomatic thyroid nodules include RFA and MWA. The findings of this research revealed that both approaches are safe and effective

Gallstones and Concomitant Gastric Helicobacter pylori Infection

Background. The association of gallstones with Helicobacter pylori has been investigated but not clearly demonstrated. In this study, the presence of H. pylori in the gallbladder mucosa of patients with symptomatic gallstones was investigated. Method. Ninety-four consecutive patients with symptomatic gallstone disease were enrolled for the study. Gastroscopy and gastric H. pylori urease test were done before cholecystectomy to all patients who accepted. After cholecystectomy, the gallbladder tissue was investigated in terms of H. pylori by urease test, Giemsa, and immunohistochemical stain. Results. Overall 35 patients (37%) gallbladder mucosa tested positive for H. pylori with any of the three tests. Correlation of the three tests Giemsa, IHC, and rapid urease test was significant (r(s): 0590, P > 0.001). Rapid urease test was positive in the gastricmucosa in 47 (58.7%) patients, and it was positive in the gallbladder mucosa in 21 patients (22%). In 15 patients both gastric and gallbladder tested positive with the urease test. There was significant correlation of rapid urease test in both of gallbladder and gastric mucosa (P = 0.0001). Conclusion. Study demonstrates the presence of H. pylori in the gallbladders of 37% of patients with symptomatic gallstones

Comparison of Pheochromocytoma-Specific Morbidity and Mortality Among Adults With Bilateral Pheochromocytomas Undergoing Total Adrenalectomy vs Cortical-Sparing Adrenalectomy

IMPORTANCE Large studies investigating long-term outcomes of patients with bilateral pheochromocytomas treated with either total or cortical-sparing adrenalectomies are needed to inform clinical management. OBJECTIVE To determine the association of total vs cortical-sparing adrenalectomy with pheochromocytoma-specific mortality, the burden of primary adrenal insufficiency after bilateral adrenalectomy, and the risk of pheochromocytoma recurrence. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from a multicenter consortium-based registry for 625 patients treated for bilateral pheochromocytomas between 1950 and 2018. Data were analyzed from September 1, 2018, to June 1, 2019. EXPOSURES Total or cortical-sparing adrenalectomy. MAIN OUTCOMES AND MEASURES Primary adrenal insufficiency, recurrent pheochromocytoma, and mortality. RESULTS Of 625 patients (300 [48%] female) with a median (interquartile range [IQR]) age of 30 (22-40) years at diagnosis, 401 (64%) were diagnosed with synchronous bilateral pheochromocytomas and 224 (36%) were diagnosed with metachronous pheochromocytomas (median [IQR] interval to second adrenalectomy, 6 [1-13] years). In 505 of 526 tested patients (96%), germline mutationswere detected in the genes RET (282 patients [54%]), VHL (184 patients [35%]), and other genes (39 patients [7%]). Of 849 adrenalectomies performed in 625 patients, 324 (52%) were planned as cortical sparing and were successful in 248 of 324 patients (76.5%). Primary adrenal insufficiency occurred in all patients treated with total adrenalectomy but only in 23.5% of patients treated with attempted cortical-sparing adrenalectomy. A third of patients with adrenal insufficiency developed complications, such as adrenal crisis or iatrogenic Cushing syndrome. Of 377 patients who became steroid dependent, 67 (18%) developed at least 1 adrenal crisis and 50 (13%) developed iatrogenic Cushing syndrome during median (IQR) follow-up of 8 (3-25) years. Two patients developed recurrent pheochromocytoma in the adrenal bed despite total adrenalectomy. In contrast, 33 patients (13%) treated with successful cortical-sparing adrenalectomy developed another pheochromocytoma within the remnant adrenal after a median (IQR) of 8 (4-13) years, all of which were successfully treated with another surgery. Cortical-sparing surgery was not associated with survival. Overall survivalwas associated with comorbidities unrelated to pheochromocytoma: of 63 patients who died, only 3 (5%) died of metastatic pheochromocytoma. CONCLUSIONS AND RELEVANCE Patients undergoing cortical-sparing adrenalectomy did not demonstrate decreased survival, despite development of recurrent pheochromocytoma in 13%. Cortical-sparing adrenalectomy should be considered in all patients with hereditary pheochromocytoma

Five-Year Disease-Free Follow-Up of a Borderline Breast Phyllodes Tumor in a 15-year-old Patient

Phyllodes tumors are large breast tumors representing only 1% of breast neoplasms and are rarely seen in young women. Histologically, phyllodes tumors are classified as benign, borderline, or malignant based on the characteristics of the stroma. Although wide local excision is recommended for the treatment modality, the reoccurrence rate after surgical excision varies between 36% and 65%, with recurrence more likely in those with the tumor at the margins of excision. Our aim was to report - a case in a 15-year-old girl with a 115-mm borderline phyllodes tumor in her left breast mimicking a juvenile fibroadenoma. We presented a 5-year disease-free follow-up after wide local excision with negative margins

Surgeon Behavior and Knowledge on Hand Scrub and Skin Antisepsis in the Operating Room

BACKGROUND: Surgical site infections adversely affect patients' well-being. In this study, hand-washing details and adherence to surgical site antisepsis applications among surgical staff were observed and recorded. Then, a questionnaire was given to test surgeons' theoretical knowledge on operating room principles. METHODS: Staffs from 5 surgical units were selected (surgeons and nurses from general surgery, urology, plastic surgery, thoracic surgery, and gynecology and obstetrics) and observed. They were questioned on the choice and properties of antiseptics, proper duration of hand washing and use of brushes, and essentials of patient skin antisepsis. RESULTS: A total of 107 observations (53 residents, 27 nurses, 6 attending staff; and 21 academic staff) were done. Overall mean (+/- standard deviation) hand-washing time was 69.1 (49.8) seconds (range: 43.8-98; p: 0.001). Overall, 79 (73.8%) never used a brush, 18 (16.8%) used the brush for the nails only, and 10 (9.4) used the brush for hands and arms as well as the nails. Mean (+/- standard deviation) time from the application of skin antiseptic to surgical incision time was 6.7 (3.5) minutes (p: 0.088). According to the questionnaire, surgeons believed that proper hand-washing time should be 4.2 +/- 2.8 minutes (p = 0.13). Brush usage was questioned and 50 (70.4%) favored brush usage whereas 21 (29.6%) were against it. The question for mechanism of action of povidone iodine is answered as 'bactericidal' by only 69%. CONCLUSION: The study shows that both adherence to local hand-hygiene protocols and surgical staffs' basic knowledge about surgical antisepsis are low. (C) 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved

Multiparametric breast MRI with 3T: Effectivity of combination of contrast enhanced MRI, DWI and 1H single voxel spectroscopy in differentiation of Breast tumors

Objectives: To evaluate the diagnostic accuracy of dynamic contrast enhanced breast MRI (DCE-MRI) combined with diffusion weighted imaging (DWI) and 1H single-voxel magnetic resonance spectroscopy (1HMRS) in differentiating malignant from benign breast lesions. Methods: One hundred twenty-nine patients with 138 lesions were included in the study. Multiparametric MRI of the breast was performed with a 3T unit. A DWI is followed by DCE-MRI and 1HMRS. All lesions were biopsied within one week after MRI. Histopathologic findings were accepted as the standard of reference. Probability of malignancy was assessed according to BI-RADS for DCE-MRI. ADC values were measured for DWI and choline peaks were assessed using a semi-quantitative method in 1HMRS. Two blinded radiologists evaluated findings in consensus. Diagnostic performance of DCE-MRI, DWI and 1HMRS alone or in combination for multiparametric imaging were statistically evaluated. Results: Histopathology revealed malignancy in 54.4% of lesions (75/138). DCE-MRI showed the highest AUC (0.978), sensitivity (97.33%) and specificity (88.89%) compared to DWI and 1HMRS. Sensitivity was 100% when a positive result from any one of three techniques was accepted as malignancy, albeit with a trade-off for 65.1% specificity. Highest specificity (98.4%) was attained when all three techniques were required to be positive, though with a lower sensitivity (82.7%) as trade-off. Logistic regression analysis confirmed significant association with DCE-MRI (p < 0.001) and 1H MRS (p = 0.009) but not with DWI (p = 0.127). There was one case of fat necrosis which was false positive in all three techniques. Conclusions: Multiparametric imaging with combination of DCE-MRI, DWI and 1HMRS does not improve, and may even reduce the diagnostic accuracy of breast MRI. Although, the specificity may be improved with a trade-off for lower sensitivity, we have not set a convenient algorithm for the combined use of these techniques. (C) 2016 Elsevier Ireland Ltd. All rights reserved

Role of Melatonin and Luzindole in Rat Mammary Cancer

Background: Recent studies have analyzed the efficacy of various agents in experimental chemoprevention trials. In our study, the effects of melatonin (Mel) and its antagonist Luzindole (Luz) on Heme oxygenase-1 (HO-1) in a NMU (N-methyl-N-nitrosourea)-induced rat mammary carcinoma model are investigated. We aim to demonstrate the relationship between Mel and HO-1. Methods: Spraque-Dawley rats were treated with NMU at age 55 days to induce mammary carcinoma. Forty-eight rats were divided into four groups consisting of: (a) physiological saline group (PSG); (b) control group, NMU is given; (c) Mel group (500 mu g daily); (d) Mel antagonist Luz group (0.25 mg/kg/day i.p.). The animals were sacrificed; their serum and tissues were sampled for histopathologic evaluation, markers of endocrine derangement (serum prolactin, estradiol, and progesterone levels), apoptotic changes, DNA fragmentation, markers of oxidative stress and HO-1 immune expression were measured. Results: Most tumors developed in the Luz group (42%), followed by the control group (33%), and the Mel group (17%). The tumor latency was longer in Mel-treated group (control and Luz at week 17, Mel at week 21). The maximum tumor volume was also smaller in Mel group when compared to control and Luz groups (p < .05). In Mel group estradiol, progesterone, and prolactin levels were decreased compared to control group (p < .001; p < .01; and p < .01) and levels of apoptotic activity and DNA fragmentation ratio increased. Conclusions: The increment of HO-1 expression with Mel is described; possible underlying mechanisms of these effects await further investigations