Publications by authors named "Mehmet Mihmanli"

60 Publications

The rapid effects of sleeve gastrectomy on glucose homeostasis and resolution of diabetes mellitus.

Endocrinol Diabetes Metab 2021 04 30;4(2):e00182. Epub 2020 Aug 30.

Deparment of General Surgery University of Health Sciences Sisli Hamidiye Etfal Education and Research Hospital İstanbul Turkey.

Aims: Type 2 diabetes caused by obesity is increasing globally. Bariatric surgical procedures are known to have positive effects on glucose homeostasis through neurohormonal action mechanisms. In the present study, we aimed to investigate the factors influencing glucose homeostasis independent of weight loss after the laparoscopic sleeve gastrectomy (LSG).

Methods: Patients who underwent LSG for morbid obesity in a 3-year period were evaluated. Data on demographics, clinical characteristics (duration of diabetes, resected gastric volume, antral resection margin) and laboratory parameters (preoperative and postoperative blood glucose on fasting, preoperative HbA1c levels and first-year HbA1c levels) were retrospectively reviewed. Effect of patients' body mass index (<50 kg/m, ≥50 kg/m), first-year excess weight loss (EWL%) rates, age (≥50 years, <50 years), duration of diabetes (≥5 years, <5 years) and antral resection margin (≥3 cm, <3 cm) on postoperative blood glucose profile and diabetic resolution status were investigated.

Results: Total of 61 patients constituted the study group. There were 40 female and 21 male patients with an average age of 43.8 ± 10.5 years (19-67 years). Preoperatively, mean BMI, blood glucose levels and HbA1c were 48.8 ± 8.5 kg/m, 133.6 ± 47.4 mg/dL and 7.4 ± 1.1, respectively. The mean blood glucose level at the postoperatively 5th day was 88.0 ± 16.3 mg/dL (median: 84 mg/dL) ( < .001). Fifty-nine out of 61 patients improved their glycaemic control.

Conclusions: It is noteworthy that LSG can control blood glucose levels in short term after surgery regardless of weight loss. Therefore, LSG should be preferred at earlier stages in the treatment of obesity-related T2DM in order to prevent T2DM-related complications.
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http://dx.doi.org/10.1002/edm2.182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8029577PMC
April 2021

The Effects of Diverticulum Localization and Hinchey Classification on Recurrence and Complications in Acute Colonic Diverticulitis.

Sisli Etfal Hastan Tip Bul 2020 11;54(4):451-456. Epub 2020 Dec 11.

Department of General Surgery, University of Health Sciences Turkey, Sisli Hamidiye Etfal Teaching and Research Hospital, Istanbul, Turkey.

Objectives: Diverticular disease of the colon is a pathology that arises from outward ballooning of the mucosa due to some weakness in the muscle layer. Diverticular disease may range from symptomatic uncomplicated diverticular disease to symptomatic disease with complications, such as acute diverticulitis or diverticular bleeding. Acute colonic diverticulitis occurs in about 10- 25% of patients.

Methods: In this study, 134 patients who were admitted to our emergency clinic with complaints of abdominal pain between 2016-2019 and hospitalized with the diagnosis of acute diverticulitis were included. Patients' sex, age, presence of additional disease, increase in leukocyte and C-reactive protein (CRP), localization of diverticulitis, Hinchey classification, mean length of hospital stay and treatment were evaluated. The effects of these parameters on complications and recurrence were statistically analyzed.

Results: The length of hospital stay was statistically significantly associated positively with the Hinchey classification (p<0.001). While 18 patients who were medically treated developed recurrence later, and this rate was statistically significant (p<0.001). When one of the factors, localization, which may play a role in the severity of the disease and recurrence are examined, was evaluated concerning its results in our study, we found that rectosigmoid location is an important factor for recurrence. We found that the localization in the colon and the severity of the disease were effective in the prognosis of acute diverticulitis.

Conclusion: We believe that localization and the severity of the disease should be taken into consideration when planning surgery in these patients.
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http://dx.doi.org/10.14744/SEMB.2020.03453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751249PMC
December 2020

Solitary caecal diverticulitis: Comparison of operative and non operative treatment.

J Pak Med Assoc 2020 Nov;70(11):1926-1929

SBU Sisli Hamidiye Etfal Research and Education Hospital General Surgery Clinic Sisli Istanbul, Turkey.

Objective: To evaluate the treatment options applied to solitary caecal diverticulitis patients, and to explore the possibility of non-operative treatments.

Methods: The retrospective study was conducted a tertiary referral centre, and comprised data of patients who presented with acute abdominal pain and were diagnosed either preoperatively or intraoperatively as cases of solitary caecal diverticulitis between January 2009 and December 2017. Data on demographics, physical examination findings, laboratory results, treatment modalities and outpatient clinical records was noted, and analysed analysed using SPSS 21.

Results: Of the 580 patients whose medical records were reviewed, 11(1.89%) were diagnosed as cases of solitary caecal diverticulitis. Of them, 6(54.5%) patients were treated conservatively, and 5(45.4%) surgically. The disease recurred in 1(9%) patient who was treated conservatively. Among those treated surgically, 1(20%) patient had hemicolectomy, and the rest had appendectomy and/or diverticulectomy and drainage procedures. There were no major complications during the follow- up.

Conclusions: With accurate diagnosis during preoperative period, the spread of the pathology helps to choose the best suitable surgical technique. Appendectomy should be performed to avoid future diagnostic confusion.
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http://dx.doi.org/10.5455/JPMA.12674DOI Listing
November 2020

Complex Anal Fistula: Long-Term Results of Modified Ligation of Intersphincteric Fistula Tract=LIFT.

Sisli Etfal Hastan Tip Bul 2020 24;54(3):297-301. Epub 2020 Aug 24.

Department of Surgery, Sisli Hamidiye Etfal Traning and Research Hospital, Istanbul, Turkey.

Objectives: The anal fistula is a permanent infectious tunnel formed between the anal canal and skin in the perianal region. Fistulas are treated by surgery at any stage. Many surgical methods have been reported to treat anal fistula. One of the promising surgical methods with a high success rate is ligation of the intersphincteric fistula tract, which is performed in anatomical spaces without damage to the internal and external sphincters. We evaluated the success rate of a modified ligation of the intersphincteric fistula tract procedure for complex anal fistulas in which the technical differences were minimized by the surgery being performed by the same surgical team.

Methods: In this study, Data of the 56 patients were retrospectively collected. Data regarding patient history, visual and digital anal examination, Cleveland Clinic Florida Fecal Incontinence (CCF-FI) score, anal-phase pelvic magnetic resonance imaging (MRI), rectosigmoidoscopy or colonoscopy and anal manometry were recorded. The changes in data recorded during the preoperative and postoperative periods were compared in each other.

Results: The mean age of the patients was 41±15.5 years. The number of patients for each fistula type compromised in this study was as follows in accordance with frequency: high transsphincteric fistula, high intersphincteric fistula, and horseshoe abscess. The fistula recurred in seven patients during postoperative follow-up and the success rate of modified LIFT was calculated as 87.5%. The change in the mean±SD preoperative and postoperative CCF-FI scores and anal pressure was not statistically significant.

Conclusion: One promising advantage of the ligation of the intersphincteric fistula tract procedure is that it turns a complex fistula into a simple fistula that can be treated with minimal risk of sphincter damage.
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http://dx.doi.org/10.14744/SEMB.2020.89106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729717PMC
August 2020

Esophagoduodenoscopy or colonoscopy: which should be done first?

Turk J Surg 2020 Jun 8;36(2):172-179. Epub 2020 Jun 8.

Department of General Surgery, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.

Objectives: Esophagoduodenoscopy and colonoscopy can be done as bidirectional endoscopy in the same session. The aim of this study was to compare anesthetic requirements and hemodynamic effects in esophagoduodenoscopy or colonoscopy done first for bidirectional endoscopy.

Material And Methods: Eighty patients, aged 18-70 years with an American Society of Anesthesiologists Classification (ASA) as I-III, were included randomly into this study. The patients were allocated into two groups: Group C: first colonoscopy followed by esophagoduodenoscopy. Group E: first esophagoduodenoscopy followed by colonoscopy. All patients received standard anesthesia with 1 µg/kg fentanyl and 1 mg/kg propofol. Demographical variables, Heart rate SpO, Ramsey Sedation Score were recorded every 10 minutes. Total propofol consumption, retching during esophagoduodenoscopy and time to reach cecum were also recorded. Endoscopist and patient satisfaction were questioned.

Results: Retching during esophagoduodenoscopy was not statistically significantly different in both groups. Total procedure duration and esophagoduodenoscopy duration were statistically significant longer in Group E. Complication frequency was higher in Group E. Endoscopist and patient satisfaction were lower in Group E. There was no difference in time to reach the cecum and the recovering period. Additional propofol dose was increased in Group E.

Conclusion: Regarding shorter procedural duration, lower consumption amount of propofol and fewer complications, it could be a better choice to start bidirectional procedure with colonoscopy first.
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http://dx.doi.org/10.5578/turkjsurg.4275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7515639PMC
June 2020

Does surgical experience really matter on the treatment approach to acute cholecystitis. A randomised clinical trial.

Ann Ital Chir 2021 ;92:38-34

Aim: Experienced surgeons usually prefer early laparoscopic cholecystectomy (ELC) instead of delayed laparoscopic cholecystectomy (DLC) for the treatment of acute cholecystitis (AC). However, the question remains, if ELC is also safe for beginner surgeons. This study compares ELC versus DLC for the treatment of AC as a beginner surgeon approach.

Material And Methods: In this prospective randomized clinical trial, patients suffering AC in their first 72 hours of pain were enrolled either in Group L (n:88); patients were treated surgically with ELC immediately or Group D (n:88); patients were first treated medically and than treated surgically with DLC 4-8 weeks later. All operations and medical treatments were done by the same beginner surgeon.

Results: In Group L operation time was 60 (50-65) minutes, total hospital stay was 1.5 (1-7) days and total cost was 337.38±78.46 (287-827) USD. In Group D operation time was 50.5 (45-60) minutes, total hospital stay was 5.5(3-15) days and total cost was 499.29±199.38 (321-1506) USD. There were no significant differences regarding to the complications (p>0.05). Hospital stay and total costs were significantly higher in Group D (p<0.001).

Conclusions: This study indicates, that ELC can definitely be chosen as a treatment approach for AC even by beginner surgeons, considering that it reduces hospital stay and total cost.

Key Words: Acute Cholecystitis, Delayed laparoscopic cholecystectomy, Early laparoscopic cholecystectomy, Surgical work experience.
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January 2021

Pseudoangiomatous stromal hyperplasia causing severe breast enlargement in a 15-year-old girl: A case report.

J Pak Med Assoc 2020 Jul;70(7):1263-1265

General Surgery Clinic, University of Health Sciences, Sisli Hamidiye Etfal Education & Research Hospital, Turkey.

Pseudoangiomatous stromal hyperplasia (PASH), composed of proliferated stromal mesenchymal cells of myofibroblastic origin, is a benign lesion of the breast. A few cases associated with pseudoangiomatous stromal hyperplasia of the breast have been reported. We report this case of a 15-year-old girl with PASH accompanied by severe enlargement and painful mass in the right breast. There were no other palpable masses or lymph nodes. Biopsy of the mass showed histopathologic features characteristic of fibroadenoma. The palpable mass was around 6x5cm in diameter, while clinical manifestations aroused suspicion of malignancy mimicking sarcoma of the breast. Although, biopsy of the mass showed benign histopathologic features; surgical excision was performed because of the damage caused by enlarging breast tissue and clinical suspicion of malignancy.
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http://dx.doi.org/10.5455/JPMA.27271DOI Listing
July 2020

Male breast cancer: A 10 year retrospective case series in a tertiary care hospital.

J Pak Med Assoc 2019 Aug;69(8):1209-1212

General Surgery Clinic, University of Health Sciences, Sisli Hamidiye Etfal Education & Research Hospital, Turkey.

Male breast cancer is a rare disease and it differs from breast cancer in women by some characteristics. The incidence of the disease has increased in the last 25 years. The records of male patients who underwent surgery for breast cancer between 2007 and 2017 were retrospectively reviewed in a tertiary care hospital in Istanbul, Turkey. The patients' ages, background, family history, clinical features, histopathological features of the tumour, its stage, the treatment and the survival were investigated. SPSS 15.0 for Windows programme was used for statistical analysis.Survival analysis was performed with Kaplan-Meier method.Determinants were analysed by univariate Cox regression analysis. A total of 15 patients were evaluated in our study. Fourteen patients had invasive ductal carcinoma and one patient had intraductal papillary carcinoma. The median followup period of the patients was 36 months The axillary lymph node metastasis positivity rate (number of metastatic lymph nodes/number of lymph nodes dissected) was statistically significantly higher in patients who died than in patients who survived.In univariate Cox regression analysis, the effects of age, tumour size, estrogen, progesterone, the presence of HER2/neu receptor and axillary metastasis on survival were not determined. We believe that raising awareness on male breast cancer in the community, genetic testing and screening mammography in high-risk patients will be useful in early diagnosis of the disease and improvement of its prognosis.
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August 2019

How does the extent of antral resection affect the residual gastric volume and excessive weight loss?

Ann Ital Chir 2019 ;90:208-212

Aim: To identify the effect of the extent of antral resection on the residual gastric volume (RdGV) and excess weight loss (EWL) among patients who underwent laparoscopic sleeve gastrectomy(LSG) due to the obesity.

Material And Methods: The demographical data, operative details, postoperative morbidity, mortality and the percentages of EWL in the postoperative 3, 6 and 12 months of the patients who underwent LSG between January 2014 and August 2015 were analyzed. These patients were divided into three groups regarding the antral resection margin (ARM): Group 1(n=80): ARM≤3cm; Group2 (n=35): 3
Results: A total of 145 patients were included in the study. Demographic features were similar between three groups. The mean RcGV was significantly higher in Group 1, whereas RdGV was significantly higher in Group 3. The patients in Group 1 had significantly higher EWL% than Group 3 at 12 monthspostoperatively. The mean number of stapler used for gastric resection was significantly higher in Group1. No significant complications such as hemorrhage, staple line leakage, abscess, etc.that required any interventional management were observed in all groups.

Conclusions: Enlargement of the antral resection margin (>6cm from pylorus) resulted in reduced operating cost and decelerated reach to optimal EWL% with similar postoperative outcomes.

Key Words: Antral resection margin, Excess weight loss, Laparoscopic sleeve gastrectomy, Residual gastric volume, Surgical technique.
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February 2020

Colostomy reversal after a Hartmann's procedure Effects of experience on mortality and morbidity.

Ann Ital Chir 2019 ;90:539-544

Aim: Hartmann's procedure (HP) is mostly lifesaving procedure especially for obstructive colorectal carcinomas, but remains bothersome requiring staged operation and subsequent reversal colostomy. We aimed to investigate risk factors for unfavorable surgical outcome after Hartmann's reversal.

Materials And Methods: Between September 2003 and September 2014, all patients who underwent colostomy reversal surgery after HP were enrolled into the study. Retrospective data collection included demographics (age, gender, body mass index (BMI), ASA scores) primary pathologies, interval period, surgeon who performed procedure [general surgeon (GS)/colorectal specialty (CRS)], postoperative complications and hospital stay.

Results: There were 72 patients (49M/23F) with a median age of 64 (range: 29-83) years. The median BMI was 24 (21-44). Most of the patients (82%) had ASA score 3-4. Colorectal cancer was the primary diagnosis in 79% while others included diverticular perforation, volvulus, trauma and Crohn disease. Hartmann's procedure was performed as an emergency in three-fifths of patients. Median interval period between index surgery and reversal colostomy was 7 (1-24) months. The morbidity and mortality rates for colostomy reversal surgery were 34% and 8.3%, respectively. The most common postoperative complication was surgical site infection (22%) followed by anastomotic leak 5%. Mortality and morbidity rates were significantly higher in patients with higher BMI (p=0.031), higher ASA scores (p=0.028) and patients who underwent procedure not by a CRS.

Conclusion: Reversal colostomy procedure resulted in significant morbidity and mortality, particularly in those with high BMI and ASA scores. Efforts to improve risk management and specialization in colorectal surgery may help to improve the outcome in reversal colostomy after Hartmann's procedure.

Key Words: Colorectal surgery, Experience, Hartmann's procedure, Reversal colostomy, Morbidity.
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July 2020

The Relationship of Clinicopathological Factors of the Tumor with Preoperative TSH Level in Papillary Thyroid Cancers.

Eurasian J Med 2019 Feb 3;51(1):8-11. Epub 2018 Dec 3.

Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey.

Objective: Thyroid-stimulating hormone/thyrotropin (TSH) is known to induce malignancies and tissue growth of the thyroid gland. While the relationship of higher levels of TSH with advanced stages of cancer had been published in previous studies, the relationship of the tumor with the clinicopathological factors had not been completely evaluated. The aim of the present study was to evaluate the relationship between highly risky clinicopathological factors with preoperative high levels of TSH.

Materials And Methods: The records of 89 patients (67 females and 22 males) who underwent surgery for differentiated thyroid cancer between 2011 and 2013 were reviewed. The relationship of preoperative TSH between tumor size, multicentricity, lymphovascular invasion, extrathyroidal extension, central neck metastasis, and lateral neck metastasis was evaluated.

Results: The preoperative TSH levels were high in patients with multicentricity (p=0.022), lymphovascular invasion (p=0.018), and central neck metastasis (p=0.002). The prevalence of extrathyroidal extension (p=0.41), lymphovascular invasion (p=0.020), and central metastasis (p=0.009) was significantly high in patients with a TSH level ≥2.5 mIU/L. The preoperative TSH levels were determined as an independent predictive risk factor for central neck metastases (p=0.012) and extrathyroidal extension (p=0.041) in multinomial logistical regression analysis.

Conclusion: The power of radiological imaging for the identification of central neck metastases in preoperative evaluation is limited. The preoperative high level of TSH is an independent predictive factor for central metastases and extrathyroidal extension. It can help to predict tumor staging. Furthermore, related with multicentricity and lymphovascular invasion, it can affect the high risk characteristics of the tumor except the stage. The preoperative TSH level can be considered for the probability of preoperative metastases and can contribute to plan the extent of surgery.
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http://dx.doi.org/10.5152/eurasianjmed.2018.17381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422630PMC
February 2019

Completion Thyroidectomy in Patients Diagnosed with Papillary Thyroid Cancer: Is There a Predictive Factor for Contralateral Lobe Tumor?

Sisli Etfal Hastan Tip Bul 2018 28;52(4):262-267. Epub 2018 Dec 28.

Department of General Surgery, University of Health Sciences, Istanbul Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.

Objectives: Completion thyroidectomy (CT) is defined as the removal of the residual thyroid tissue in the case of detected malignancy after lobectomy for an indeterminate or non-diagnostic biopsy. Factors such as tumor diameter, aggressive histology, extrathyroidal spread, and positive surgical margin in papillary thyroid cancer (PTC) constitute CT indications. However, the type of surgery is controversial especially in patients with a tumor diameter of 1-4 cm. Determination of predictive factors for contralateral lobe tumors (CLTs) in PTC may be helpful for rough or excessive treatment of patients with this common thyroid pathology.The aim of the present study was to determine the predictive factors and rate of detection of CLTs after CT in patients with papillary thyroid carcinoma after lobectomy.

Methods: Medical records of patients who underwent lobectomy with the final histological diagnosis of papillary thyroid carcinoma for the study period 2011 to 2016 were reviewed. Demographic data of the patients, diameter, multicentricity and subtype of tumor, extrathyroidal spread, and vascular invasion rate were obtained. Patients were divided into 2 groups as final histological examination after CT revealed benign (Group 1) and malignant (Group 2).

Results: Data of 49 patients were retrospectively analyzed during the study period. The female-to-male ratio was 33/16. The mean age of the patients was 47.59 (23-77) years. Groups 1 and 2 consisted of 30 and 19 patients, respectively. No significant difference was found between the two groups regarding demographic data and tumor characteristics.

Conclusion: Despite the fact that we have not been detecting any predictive factor in predicting the presence of tumor on the contralateral lobe in our study, the detection of a tumor on the contralateral lobe is frequent.
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http://dx.doi.org/10.14744/SEMB.2018.83713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7406558PMC
December 2018

Comparative analysis of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass procedures for the treatment of morbid obesity.

Ann Ital Chir 2018 ;89:406-412

Background: Roux-en-Y gastric bypass (RYGB) has been considered as the most efficient method in bariatric surgery. Indeed, Laparoscopic Sleeve Gastrectomy (LSG) which is easier to do, has been increasingly used in the recent years. The aim of the present study was to compare short-and mid-term outcomes of RYGB and LSG.

Methods: Medical records of 62 patients who underwent either RYGB (GroupR) or LSG (GroupL) in our General Surgery Department between 2010 and 2013 were retrospectively reviewed. Demographics, comorbidities, preoperative laboratory values, length of hospital stay and postoperative complications were recorded. During follow-up in the postoperative period, body-mass-index (BMI), excess weight loss (EWL), triglyceride levels (TG), and low-density lipoprotein (LDL) levels were recorded at the 1st, 3rd, 6th, and 12th months.

Results: Mean length of hospital stay was significantly higher in GroupR (p = 0.001), which was also correlated with BMI. EWL at 1st, 3rd, 6th, and 12th months was significantly higher in GroupR. Hair loss was significantly higher in GroupR (p < 0.05). The rates of diabetes mellitus and hypertension in the preoperative period and at 6th and 12th months did not significantly differ between the groups. Preoperative TG and LDL values were significantly higher in GroupR (p < 0.05).

Conclus Ons: This study indicated, that RYGB is statistically more effective than LSG, but LSG has clinically almost the same effect as RYGB, and also hospital stay, postoperative complications as hair loss are decreased in LSG.

Key Words: Laparoscopic Sleeve Gastrectomy, Morbid Obesity, Roux-en-Y Gastric Bypass.
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June 2019

Emergency computed tomography for the diagnosis of acute appendicitis: How effectively we use it?

Ulus Travma Acil Cerrahi Derg 2018 Jul;24(4):311-315

Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul-Turkey.

Background: Technological developments support using ultrasonography (US) in all patients, if available, and advanced diagnostic methods such as abdominal computed tomography (CT) in case of clinical suspicion during diagnostic process of acute appendicitis. We aimed to investigate whether CT was appropriately and efficiently used in the diagnosis of acute appendicitis.

Methods: Between May 2013 and February 2016, 811 patients who underwent appendectomy were retrospectively reviewed from an IRB-approved database, and those who underwent a preoperative CT were enrolled into the study. Results of Alvarado scores and US were recorded in addition to which clinic requested the CT (general surgery or emergency department).

Results: The frequency of CT use in the diagnostic process was 25% (n=208/811). Ultrasound was negative for appendicitis in 53% of these patients. The mean Alvarado score was 5±1.5 (range: 3-8). General surgeons requested 57% of CTs. Alvarado scores were significantly higher in patients whose CT was requested by general surgery than in those whose CT was requested by the emergency clinic (5.6 vs. 4.7, p=0.013). Regarding histopathological results, age and Alvarado scores were significantly lower (p=0.015 and 0.037, respectively), whereas the frequency of negative CT was significantly higher (p=0.042) in those with negative appendectomy (n=29, 14%).

Conclusion: Most patients who underwent CT in the diagnostic process had an Alvarado score between 5 and 8 and negative ultrasound for appendicitis preoperatively. These findings may provide efficient use of CT in the diagnosis of appendicitis with an acceptable rate of 25% compared with the findings in current literature. However, further research is needed to ensure more efficient use of CT because negative appendectomy has been a concern in our series despite promising results of this study.
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http://dx.doi.org/10.5505/tjtes.2017.36390DOI Listing
July 2018

Approach to the diagnosis and treatment of mesenteric panniculitis from the surgical point of view.

Turk J Surg 2018 1;34(2):121-124. Epub 2018 Jul 1.

Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey.

Objective: To evaluate the diagnostic and treatment approaches for patients diagnosed with mesenteric panniculitis.

Material And Methods: We retrospectively reviewed all patients diagnosed with mesenteric panniculitis between January 2010 and March 2016. We recorded the demographic features, clinical symptoms, laboratory values, radiological methods, treatment approach, and outcomes of the patients.

Results: We evaluated 22 patients (17 male and five female) with a mean age of 45.8±15.7 years. The most frequent complaint was abdominal pain. The patients' histories included colon cancer (n=1), prostatic cancer (n=2), renal cell cancer (n=1), diabetes mellitus (n=4), and chronic obstructive pulmonary disease (n=1). Laboratory values revealed elevated C-reactive protein levels in 14 patients (43%). Computed tomography was performed in all the patients. Only 10 patients were followed up in the surgical ward, the remaining 12 underwent outpatient treatment. No complication associated with hospitalization or during outpatient follow-up period was observed.

Conclusion: Mesenteric panniculitis can be successfully treated conservatively without surgical intervention. Clinical doubt is of great importance for diagnosis, and plausible underlying malignancy should be kept in mind.
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http://dx.doi.org/10.5152/turkjsurg.2018.3881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6048643PMC
July 2018

A comparative study of two techniques in the treatment of condyloma acuminata.

Ann Ital Chir 2018 ;89:455-460

Objectives: Condyloma acuminata (CA) is mainly caused by human papillomavirus (HPV) types 6 and 11. Clinicians use many different methods to treat analcondyloma acuminate ( CA). In this study, we aimed to compare electrocautery ablation (ECA) and argon plasma coagulation (APC) techniques in terms of postoperative bleeding, pain, scar development, loss of sexual sensation, and recurrence rates.

Methods: A retrospective analysis of collected data was performed for 49consecutive patients with CA, who underwent surgery between July 2011 and July 2014. Patients were grouped and evaluated according to surgical technique, including an ECA group and an APC group. Postoperative bleeding was determined by the number of dressings used in the first postoperative week. Scar severity in the perianal region following ablation therapy was evaluated by scar diameter. A visual analog scale (VAS) was used to measure pain and loss of sexual sensation. All patients were followed for 9 months.

Results: There were statistically significant differences between the ECA and APC groups in terms of postoperative bleeding, pain, scar development, and loss of sexual sensation. No difference in recurrence rate was observed.

Conclusions: APC is a safe and effective alternative for the surgical treatment of patients with CA. Although it appears to be more comfortable than ECA techniques, more randomized controlled trials are necessary to reinforce this claim.

Key Words: Argon plasma coagulation, Condyloma acuminata, Electrocautery ablation, Human Papilloma Virus, Surgical treatment.
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June 2019

The Impact of Micropapillary Component Ratio on the Prognosis of Patients With Invasive Micropapillary Breast Carcinoma.

J Invest Surg 2020 Jan 29;33(1):31-39. Epub 2018 May 29.

Department of General Surgery, Istanbul Sisli Hamidiye Etfal Medical Practice and Research Center, University of Health Sciences, İstanbul, Turkey.

: Invasive micropapillary carcinoma (IMPC) of the breast is a rare and aggressive variant of invasive ductal carcinoma characterized by high-grade lymphovascular invasion and high rates of nodal metastasis. The prognostic significance of the micropapillary component (MC) ratio that constitutes this aggressive variation is controversial. In this study, we aimed to investigate the effect of the MC ratio on the prognosis of these patients. : The data of 47 patients with IMPC were retrospectively reviewed. Patients were divided into two groups: MC ratio of 10-75% (Group 1) and greater than 75% (Group 2). The demographic characteristics of the patients, histopathologic features of the tumors, and survival rates were compared. : We detected no significant difference in demographic characteristics between groups 1 and 2 ( = 0.21). No significant difference was detected in terms of tumor diameter, lymph node metastasis, lymphovascular invasion, histologic grade, multicentricity, local recurrence, distant metastasis, and overall survival. : In the micropapillary subgroup of invasive ductal carcinoma, although positive receptor characteristics are directly proportional to the increase in MC ratio, recurrence and survival rates are not affected by micropapillary component level.
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http://dx.doi.org/10.1080/08941939.2018.1474302DOI Listing
January 2020

Is Interval Cholecystectomy Necessary After Percutaneous Cholecystostomy in High-Risk Acute Cholecystitis Patients?

Sisli Etfal Hastan Tip Bul 2018 26;52(1):13-18. Epub 2018 Mar 26.

Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, İstanbul, Turkey.

Objectives: Percutaneous cholecystostomy (PC) for acute cholecystitis (AC) is frequently performed in high-risk surgical patients as an alternative treatment modality. However, debate remains over whether or not an interval cholecystectomy for these patients should be performed. The aim of this study was to investigate the outcomes of PC in high-risk surgical patients with AC.

Methods: Between September 2013 and June 2016, 27 of 952 patients with AC were treated with PC. The data collection included demographic variables, including comorbidities, the timing of the PC, the length of the hospital stay, the follow-up period, the complications related to PC, and readmission to hospital.

Results: There were 16 female and 11 male patients, with a mean age of 73±12.4 years (range: 49-97 years). Comorbid diseases included ischemic heart disease (n=6), diabetes mellitus (n=5), chronic obstructive pulmonary disease (n=6), and others (n=10). The mean timing of PC was 2.2±1.4 days (range: 1-3 days). The mean length of hospital stay was 9.6±2.1 days (range: 7-14 days), and the catheter was removed after the first month. The mean follow-up period after the PC catheter removal was 19.6±8.6 months (range: 10-38 months). Only 6 patients (22.2 %) were readmitted to the hospital. Cholecystectomy was performed in 4 cases, and 2 responded to medical treatment.

Conclusion: Despite ongoing controversy about the management of AC in high-risk surgical patients, PC is an adequate and safely applicable procedure in this group of patients. However, an interval cholecystectomy should be considered in persistent cases, which account for a small percentage. Longer-term follow-up studies with a larger sample size are needed to support our results.
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http://dx.doi.org/10.14744/SEMB.2018.30092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315074PMC
March 2018

Complication Risk in Secondary Thyroid Surgery.

Sisli Etfal Hastan Tip Bul 2018 20;52(1):19-25. Epub 2018 Mar 20.

Health Sciences University, İstanbul Şişli Hamidiye Etfal Health Practice and Research Center, İstanbul, Turkey.

Objectives: Secondary thyroid surgery is rare, compared with primary thyroid surgery. However, secondary surgery has a greater risk of complications due to the formation of scar tissue as well as increased fragility of the tissues following the previous surgery. Several surgical techniques and strategies have been recommended to decrease the complication rate associated with secondary surgery. The aim of this study was to evaluate the complication rate in patients who underwent secondary thyroid surgery using a lateral approach and intraoperative nerve monitoring (IONM).

Methods: The data of 44 patients who underwent secondary surgical intervention after thyroid surgery performed for benign or malignant thyroid disease (Group 1), and of 44 patients who underwent primary surgery (Group 2) were compared. Lobectomy patients with a histopathological result of malignant disease, whom were applied completion thyroidectomy were excluded from the study. Secondary surgery was performed using a lateral approach. Access was achieved between the anterior edge of the sternocleidomastoid muscle and the strap muscles. In primary surgery, the thyroid lodge was entered through the midline. Standard IONM was applied in all cases. Hypocalcemia was defined as a serum calcium level of ≤8 mg/dL within the first postoperative 48 hours, regardless of clinical symptoms. Transient and permanent recurrent laryngeal nerve paralysis was evaluated based on the number of nerves at risk. The lobectomy was considered to be high-risk with the presence of recurrence, Graves' disease, substernal goiter, and application of central dissection.

Results: The mean age of Group 1 and 2 was 49.9±14.1 years and 45±12.6 years , respectively (range: 22-90 years; p=0.69). Female patients constituted 90.9% (n=40) of the population in Group 1 and 75% (n=33) of the patient population in Group 2 (p=0.87). In Group 1, 11 (25%) patients, and 7 (15.9%) patients in Group 2 underwent surgical intervention due to the presence of a malignant disease (p=0.29). Bilateral intervention was applied in 26 (59.1%) patients in Group 1 and 28 (63.6%) patients in Group 2. The rate of transient and permanent hypocalcemia in Groups 1 and 2 was 34.1% (n=15) vs 22.5%, and 2.5% (n=1) vs 0%, respectively, without any significant intergroup difference (p=0.237, p=1). In Group 1, 71 lobes were operated on, and there were 72 in Group 2. All of the interventions in Group 1 (100%), and 31.9% (n=23) of those in Group 2 were high-risk, and there was a significant intergroup difference (p<0.0001). The rate of transient and permanent vocal cord paralysis were 4.2% (n=3) vs 2.8% (n=2) and 6.9 % (n=5) vs 0% in Groups 1 and 2, respectively (p=0.719; p=0.245).

Conclusion: When performed with a meticulous and attentive technique, secondary surgical intervention can be applied without increasing the incidence of permanent complications. Though there is substantial risk associated with all of these procedures, the rate of vocal cord paralysis was similar to that seen after primary intervention, and was thought to be related to surgical experience and technique, as well as the use of IONM.
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http://dx.doi.org/10.14744/SEMB.2017.87609DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315072PMC
March 2018

Effects of Laparoscopic Sleeve Gastrectomy on Parathyroid Hormone, Vitamin D, Calcium, Phosphorus, and Albumin Levels.

Obes Surg 2017 12;27(12):3149-3155

Endocrinology Clinic, Sisli Hamidiye Etfal Education and Research Hospital, Halaskargazi Cad. Etfal Sok., 34733, Sisli, Istanbul, Turkey.

Background: Laparoscopic sleeve gastrectomy (LSG) reduces obesity-related co-morbidities, such as diabetes, hypertension, and hyperlipidemia. Endocrinological abnormalities may occur as undesired side effects. Most centers routinely prescribe folic acid, cyanocobalamin (vitB12), and protein replacement in the postoperative period, but 25-OH-vitamin-D3 (vitD) and intact parathyroid hormone (iPTH) levels are not routinely followed up. The aim of this study was to identify the effects of LSG on iPTH, vitD, calcium (Ca), phosphorus (P), alkaline phosphatase (ALP), and albumin levels.

Methods: Data of morbidly obese patients who underwent LSG between January and December 2014 were studied in this prospectively designed study. Serum levels of iPTH, vitD, Ca, P, folic acid, vitB12, ALP, and albumin were measured preoperatively and postoperatively at the 3rd, 6th, and 12th months.

Results: In total, 119 patients were analyzed. All patients had normal iPTH, vitD, Ca, P, folic acid, vitB12, ALP, and albumin values preoperatively, and 31.6% had received vitD supplementation during their nutritionist observation time before surgery. At the 3rd, 6th, and 12th postoperative months, 21 (17.6%), 17 (17.3%), and 1 (0.8%) patients, respectively, had increased iPTH and ALP and decreased vitD levels. A total of 39 (32.7%) patients needed high-dose vitD treatment during a 1 year follow-up. Approximately 37.5% of the patients who received vitD supplementation preoperatively needed vitD supplementation postoperatively. Hospital records of 101 of 119 patients who underwent LSG could be screened to determine their vitD supplementation requirements previously ordered by their nutritionist for a 1-year period before LSG. Thirty-two (31.6%) of the 101 patients had received vitD supplementation during the 1-year period preoperatively.

Conclusions: Although serum levels of iPTH, vitD, Ca, P, vitB12, ALP, and albumin may be normal preoperatively, severe vitD insufficiency requiring high-dose vitD replacement may develop in morbidly obese patients postoperatively. Instead of iPTH and vitD, which are expensive to measure, ALP serum level, which is correlated with iPTH levels, can be a good indicator to monitor calcium metabolism.
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http://dx.doi.org/10.1007/s11695-017-2747-xDOI Listing
December 2017

How to avoid negative appendectomies: Can US achieve this?

Ulus Travma Acil Cerrahi Derg 2017 Mar;23(2):134-138

Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul-Turkey.

Background: Clinical diagnosis of acute appendicitis is based primarily on symptoms and physical findings. However, diagnosis of appendicitis is not always straightforward. The aim of this study was to demonstrate the diagnostic effectiveness of ultrasonography (US) in these cases in combination with white blood cell count (WBC) and C-reactive protein (CRP) level.

Methods: Retrospective analysis of data collected on 470 consecutive patients who underwent appendectomy at the same institution between January 2014 and January 2016 was conducted. Data included demographic features, preoperative WBC and CRP levels, and US measurement of diameter of appendix. Patients were divided into 3 groups: lymphoid hyperplasia (LH), non-complicated acute appendicitis (NCAA), and complicated acute appendicitis (CAA), according to postoperative histopathological examination results.

Results: There were 331 male and 139 female patients with mean age of 32.29±11.44 years included in the study. Mean WBC level was 12.31103/µL (±4.47 103/µL), 13.3 103/µL (±3.87 103/µL) and 14.08 103/µL (±4.11 103/µL) in LH, NCAA, and CAA groups, respectively (p=0.016). Mean CRP level was 14.2±19 mg/L, 36.9±59 mg/L, and 40.8±66 mg/L in LH, NCAA, and CAA groups, respectively (p=0.008). Mean outer diameter of the vermiform appendix on US was 4.8 mm (±3.9 mm), 6.9 mm (±4.08 mm) and 7.6 mm (±3.92 mm) in LH, NCAA, and CAA groups, respectively (p<0.01). When all variables were compared with each other, there were statistically significant differences in US findings according to group.

Conclusion: WBC count and CRP level were higher in patients with acute appendicitis, but these findings alone were insufficient for definitive diagnosis. US findings were effectual both in diagnosis and demonstration of severe inflammation. US should be combined with laboratory tests and used as standard initial imaging in diagnostic pathway of patients with clinically suspected appendicitis. The authors of this study believe that this diagnostic pathway will reduce negative appendectomy rate.
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http://dx.doi.org/10.5505/tjtes.2016.79328DOI Listing
March 2017

Approach to inguinal hernia in high-risk geriatric patients: Should it be elective or emergent?

Ulus Travma Acil Cerrahi Derg 2017 Mar;23(2):122-127

Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul-Turkey.

Background: Elderly patients are more prone to have inguinal hernia due to weakened abdominal musculature. However, surgical repair of inguinal hernia (SRIH) may not be performed or may be delayed due to greater risk in presence of comorbidities. Present study is investigation of outcome of elective and emergency SRIH in geriatric patients.

Methods: Records of total of 384 high-risk (American Society of Anesthesiology classification III-IV) patients aged >65 years who underwent SRIH between January 2010 and December 2014 were reviewed. Patients were divided into 2 groups according to procedure type: elective (Group EL) or emergency (Group EM). Demographic features and surgical and postoperative period data of 2 groups were recorded and compared.

Results: Demographic data were similar, but number of ASA IV patients was greater in Group EM. Frequency of intestinal resection was significantly greater in emergency surgery group (1% vs 21%; p<0.01). Length of hospital stay (1.3 days vs 7.9 days; p<0.01) and intensive care unit stay (0.17 days vs 4.04 days; p<0.01) were also greater in Group EM. Morbidity (1% vs 24%; p<0.01) and mortality (0.3% vs 11%; p<0.01) were also significantly higher in Group EM compared to elective SRIH group.

Conclusion: Emergency inguinal hernia surgery is associated with significantly higher morbidity and mortality compared with elective SRIH in high-risk geriatric patients. Elective hernia repair in these patients should be considered to reduce risk of need for intestinal resection as well as length of hospital stay.
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http://dx.doi.org/10.5505/tjtes.2016.36932DOI Listing
March 2017

Case of an intrahepatic sewing needle and review of the literature.

Ulus Travma Acil Cerrahi Derg 2017 Jan;23(1):77-80

Department of General Surgery, Şişli Etfal Training and Research Hospital, İstanbul-Turkey.

An intrahepatic foreign body (FB) is rarely observed. In most cases, object passes from the gastrointestinal tract to the liver via migration. Uncomplicated intrahepatic FB can be followed without surgical intervention; however, complicated intrahepatic FB requires laparoscopy or laparotomy. Presently described is laparoscopic operation on 22-year-old female patient who had incidental sewing needle in the right liver lobe. As there were initially no complications, follow-up monitoring was recommended. However, the patient subsequently complained of stomach pain and developed fever. Laparoscopic exploration located sewing needle in the right liver lobe lateral to the gall bladder with end of needle protruding from the liver. Needle was removed with laparoscopic grasper. Review of the literature regarding 23 other intrahepatic sewing needle cases is also presented.
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http://dx.doi.org/10.5505/tjtes.2016.48995DOI Listing
January 2017

The breast lesion excision system (BLES) A preliminary experience.

Ann Ital Chir 2016 ;87:583-588

Objective: BLES (Intact Breast lesion Excision System) is a new defined system which can remove the lesion completely. We aimed to evaluate and compare the results of BLES used for breast lesions requiring histological verification with other percutaneous biopsy methods in the literature.

Methods: Patients with breast lesions smaller than 20mm and for whom biopsy was indicated were involved in the study. 18(1 male, 17 female, mean age: 41. 83, age range: 26-72) patients were included the study. BLES is applied with a single insertion. Radiofrequency is used to excise the breast tissue after the insertion. Around the lesion, tissue capture basket is moved back and forth. Once captured, the basket and the probe is removed from the incision area.

Results: All of the lesions were excised en-bloc. The only complication occured was subdermal hematoma in one case (5.5%) which resolved spontenously. Pathological analysis of the specimens revealed 9 fibroadenoma, 3 fibroadenomatosis hyperplasia, 3 complicated and calcified cysts, 1 ductal epithelial hyperplasia, 1 carcinoma in situ with intraductal papillary carcinoma focus and 1 ductal carcinoma in situ with 2 mm invasive carcinoma focus. The last two cases underwent resectıon and sentınal lymph node procedure.

Conclusion: BLES is a is non-invasive method which has no need for additional initiatives in benign cases, provide sufficient samples for pathological diagnosis and remove the lesion in one piece. BLES method can be applied in selected cases.

Key Words: Breast Lesion Excision System, Breast, Biopsy, Radiofrequency, Lesion.
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October 2017

Contribution of intraoperative neural monitoring to preservation of the external branch of the superior laryngeal nerve: a randomized prospective clinical trial.

Langenbecks Arch Surg 2017 Sep 29;402(6):965-976. Epub 2016 Dec 29.

General Surgery, Bahcesehir University Medical Faculty, Istanbul, Turkey.

Purpose: The purpose of this study was to evaluate the effect of intraoperative neuromonitoring (IONM) on the injury rate of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy.

Methods: A total of 133 consenting patients (98 female, 35 male; mean age, 45.6 ± 11.7 years) undergoing thyroidectomy were randomly assigned to 2 groups. In group 1 (n = 65 patients, 105 nerves), superior thyroid pole dissection was performed with no attempt to identify the EBSLN; in group 2 (n = 68 patients, 106 nerves), IONM was used to identify the EBSLN during surgery. EBSLN function was evaluated by intraoperative electromyography of the cricothyroid muscle. The EBSLN Voice Impairment Index-5 (VII-5) was conducted preoperatively and at 1, 3, and 6 months postoperatively. The primary outcome was the prevalence of EBSLN injury. The secondary outcomes were the identification rate of the EBSLN using IONM and changes in postoperative voice performance.

Results: EBSLN injury was detected in eight (12.3%) patients and nine (8.6%) nerves in group 1 and in one (1.5%) patient and one (0.9%) nerve in group 2 (patients, p = 0.015; nerves, p = 0.010). IONM contributed significantly to visual (p < 0.001) and functional (p < 0.001) nerve identification in group 2. The VII-5 indicated more voice changes in group 1 than 2 at 1, 3, and 6 months postoperatively (p = 0.012, p = 0.015, and p = 0.02, respectively).

Conclusion: IONM contributes to visual and functional identification of the EBSLN and decreases the rate of EBSLN injury during superior pole dissection. Routine use of IONM to identify the EBSLN will minimize the risk of injury during thyroidectomy.
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http://dx.doi.org/10.1007/s00423-016-1544-7DOI Listing
September 2017

Early prediction of post-thyroidectomy hypocalcemia by early parathyroid hormone measurement.

Ann Ital Chir 2016 ;87:417-421

Aim: Hypoparathyroidism is the most common complication of total thyroidectomy (TT). Postthyroidectomy hypocalcemia occurs 24 to 48 hours after the operation. It prolongs the length of hospital stay, even though transient in most cases. The aim of this study was to predetermine the patients who may develop postthyroidectomy hypocalcemia by using early postoperative serum intact parathormone (iPTH) and calcium (Ca2+) measurements, and to investigate the effects of early initiated oral calcium and vitamin D treatments on the development of transient hypocalcemia.

Material And Methods: Patients who underwent TT after initiation of the early iPTH measurement protocol in January 2013 were included into the study group (Group 1, n=202). The control group (Group 2) was composed of 72 patients who underwent TT before the protocol. Prior to the initiation of the protocol, Ca2+ was measured instead of iPTH. In the study group, the serum Ca2+ and iPTH levels were measured before surgery, and 1 and 24-hours after. A calcium level below 8 mg/dL was accepted as biochemical hypocalcaemia, and a iPTH level under 15pg/mL was accepted as hypoparathyroidism. In the study group, patients with below normal iPTH levels were treated with prophylactic oral calcium and vitamin D.

Results: In Group 1, 15.8% (n=32) of the patients had hypoparathyroidism on the 1h and 24 h iPTH measurements. There was no statistically difference with regard to PTH levels measured in the postoperative 1st hour and at the 24th hour (p= 0.078). Biochemical hypocalcaemia developed in 16 (7.9%) and 13 (18%) patients in Groups 1 and 2, respectively, 24 hours after thyroidectomy (p<0.05). Mean length of hospital stay was 2.17 and 3.26 days in the study and control groups (p<0.001).

Conclusions: We believe that the measurement of iPTH levels one hour after thyroidectomy, when compared to levels at 24 hours after procedure, is a safe, reliable, and adequate method for the effective management of plausible postthyroidectomic hypocalcemia. It yields significantly shorter hospital stay periods.

Key Words: Calcium, Hypoparathyroidism, Postoperative complication, Total thyroidectomy.
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September 2017

The role of red cell distribution width in the prognosis of patients with gastric cancer.

Cancer Biomark 2017 ;18(1):19-25

Background: Although the red cell distribution width (RDW) has been reported as a reliable predictor of prognosis in several types of cancer, to our knowledge the prognostic value of RDW in gastric carcinoma has not been studied, so far.

Objective: We aimed to investigate the role of red cell distribution width (RDW) in predicting prognosis in gastric cancer patients.

Methods: All gastric cancer patients who underwent curative surgery (n= 172, 110M/62F) over a five-year study period were evaluated. Data on demographics, preoperative RDW levels, tumor characteristics (early stage: I and II, advanced stage: IIIA-B-C), disease-free (DFS) and overall survival (OS) were retrospectively reviewed. Patients were classified as high RDW group (RDW ≥ 16, n= 62) or low RDW group (RDW < 16, n= 110).

Results: Overall mortality and postoperative 60-day mortality in both groups were 55% and 14%, respectively. A borderline significant association between RDW (0.063) and mortality was noted. Preoperative RDW levels were significantly higher in patients with short-term mortality (17.9 ± 4.3 vs. 16 ± 3.2, p= 0.015). In high RDW group, the incidence of advanced gastric cancer was significantly higher (75 vs. 51%, p= 0.002), whereas DFS (0.035) and OS (p= 0.04) were lower.

Conclusion: The frequency of advanced cancer was high in patients with high RDWvalues. High RDW values were strongly associated with short-term mortality although only a borderline relationship with overall survival was observed.
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http://dx.doi.org/10.3233/CBM-160668DOI Listing
March 2017

Delaying surgery after neoadjuvant chemoradiotherapy improves prognosis of rectal cancer.

World J Gastrointest Oncol 2016 Sep;8(9):695-706

Mehmet Mihmanlı, Esin Kabul Gürbulak, İsmail Ethem Akgün, Mustafa Fevzi Celayir, Pınar Yazıcı, Ayhan Öz, Sinan Ömeroğlu, Department of General Surgery, Şişli Etfal Training and Research Hospital, Şişli 34371, Istanbul, Turkey.

Aim: To investigate the prognostic effect of a delayed interval between neoadjuvant chemoradiotherapy (CRT) and surgery in locally advanced rectal cancer.

Methods: We evaluated 87 patients with locally advanced mid- or distal rectal cancer undergoing total mesorectal excision following an interval period after neoadjuvant CRT at Şişli Hamidiye Etfal Training and Research Hospital, Istanbul between January 2009 and January 2014. Patients were divided into two groups according to the interval before surgery: < 8 wk (group I) and ≥ 8 wk (group II). Data related to patients, cancer characteristics and pathological examination were collected and analyzed.

Results: When the distribution of timing between group I (n = 45) and group II (n = 42) was viewed, comparison of interval periods (median ± SD) of groups showed a significant difference of as 5 ± 1.28 wk in group I and 10.1 ± 2.2 wk in group II (P < 0.001). The median follow-up period for all patients was 34.5 (9.9-81) mo. group II had significantly higher rates of pathological complete response (pCR) than group I had (19% vs 8.9%, P = 0.002). Rate of tumor regression grade (TRG) poor response was 44.4% in group I and 9.5% in group II (P < 0.002). A poor pathological response was associated with worse disease-free survival (P = 0.009). The interval time did not show any association with local recurrence (P = 0.79).

Conclusion: Delaying the neoadjuvant CRT-surgery interval may provide nodal down-staging, improve pCR rate, and decrease the rate of TRG poor response.
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http://dx.doi.org/10.4251/wjgo.v8.i9.695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027025PMC
September 2016

Malignancy risk of oncocytic changes in thyroid nodules: who should we offer surgery to?

Acta Chir Belg 2016 Feb;116(1):30-5

a Department of General Surgery , Sisli Etfal Training and Research Hospital , Istanbul , Turkey ;

Background Oncocytic (Hürthle) cell in fine-needle aspiration biopsy (FNAB) remains challenging for surgeons. Surgical treatment is recommended for oncocytic change in FNAB, since it can sometimes be a struggle to determine the nature of thyroid nodules. We aimed to investigate the clinical significance of oncocytic changes in FNAB in terms of management of patients. Methods The FNAB samples of 172 patients with thyroid nodules were reviewed. Of these, 39 patients with cytologic findings of oncocytic changes on FNAB [POC: predominance of oncocytic cells; SFON-H: suspicious for follicular or oncocytic neoplasm (Hürthle cell type), SM-O: suspicious for malignancy-papillary or follicular carcinoma; oncocytic variant)] were included. Results FNAB demonstrated POC in 14 (35.8%), SFON-H in 15 (38.4%), and SM-O in 10 (25.6%) patients. The overall malignancy rate was 35.8% (n = 14). Clinical and laboratory data were not found to be associated with thyroid cancer while nodule size was significantly higher in patients with thyroid malignancy (15.2 versus 23.3 mm, p = 0.032). Regarding FNAB results including oncocytic changes, the rate of malignancy was significantly different and almost three-fold higher in nodules classified as SFON-H and SM-O [48% versus 14.2% with POC, p = 0.044]. Besides, there was a positive correlation between SFON-H and SM-O cytology and malignancy (p = 0.036, r = 0.337). Conclusions It is hard to discern the significance of oncocytic changes in FNAB report and to determine an optimal approach as a surgeon. We recommend surgery for the patients with an FNAB showing SFON-H and SM-O whereas POC should be better to be followed-up.
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http://dx.doi.org/10.1080/00015458.2015.1136484DOI Listing
February 2016

Which is the best predictor of thyroid cancer: thyrotropin, thyroglobulin or their ratio?

Hormones (Athens) 2016 Apr;15(2):256-263

General Surgery Clinic, Istanbul, Turkey.

Objective: Since documented incidence of thyroid cancer has been rising over time, in part due to incidental small papillary cancer, several studies have been carried out to investigate the role of possible serum markers of thyroid cancer prior to surgery.

Design: Prospective cohort study.

Aim: To investigate the role of thyroglobulin (Tg), thyrotropin (TSH) and the TSH:Tg, Tg:TSH ratio in the preoperative diagnosis of thyroid cancer.

Patients And Methods: Between January 2014 and January 2015, 202 of 242 consecutive patients scheduled for surgical treatment for thyroid disorders at Şişli Etfal Training and Research Hospital, General Surgery Clinic were included in the study. Prospective data collection included demographics, thyroid function tests, Tg levels, fine needle aspiration biopsy (FNAB) results (208 FNABs in 187 patients), surgical procedures and final histopathological examinations.

Results: There were 134 patients with benign thyroid diseases and 68 patients with thyroid gland malignancy. Preoperative Tg level was significantly lower in the malignant group (64 ng/mL vs. 20ng/mL, p<0.001, respectively), whereas there was no difference in TSH between groups. TSH:Tg levels were found to be significantly higher in patients with malignant thyroid diseases (0.24±1 vs. 0.87±3.4, p=0.024). Although univariate analysis showed that the TSH:Tg ratio was a predictor for thyroid malignancy (OR 0.001; 95% CI, 0.01-0.125; p=0.007) in conjunction with FNAB, multivariate analysis failed to demonstrate any statistical significance for any factor except FNAB.

Conclusion: Preoperative assessment of serum Tg and TSH levels appear not to be helpful in identifying patients with thyroid cancer. However, a higher preoperative serum TSH:Tg ratio may hint at an increased risk for thyroid carcinoma. Further studies are needed to elucidate the potential role of preoperative laboratory values of thyroid function.
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http://dx.doi.org/10.14310/horm.2002.1677DOI Listing
April 2016