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OBJECTIVES: Over the last decade, surgeons have started to think of the ways in which to further reduce the trauma of surgery and improve cosmesis. Consequently, many surgeons have yielded to single incision laparoscopic surgeries (SILS) in order to maximize operative and postoperative outcomes. This study aimed to highlight the feasibility and challenges of different procedures by presenting our data about different fields of abdominal SILS practices with long term follow-up. MATERIAL AND METHODS: We retrospectively analysed an observational cohort of 155 patients who underwent surgery for different indications using the SILS technique. RESULTS: Of the 155 SILS procedures: 75 (48.4%) were cholecystectomies; 22 (14.2%) were splenectomies; 17 (11%) were hernia repairs; 11 (7.1%) were appendectomies; 8 (5.2%) were partial colon resections; 8 (5.2%) were adrenalectomies; 6 (3.8%) were distal pancreatectomy & splenectomies; 3 (1.9%) were subtotal gastrectomies; 3 (1.9%) were partial liver resections; and 2 (1.3%) were Nissen fundoplications. Ten (6.5%) early and 3 (1.9%) late postoperative complications were detected. No mortality or late morbidity (> 30 days) was detected due to SILS procedures. CONCLUSION: SILS is a feasible technique in experienced hands for specific procedures. Meticulous patient selection is also important for good cosmetic results and outcomes.

Minimal invasive procedures has become increasingly popular during the last decades. The aim of this retrospective study was to evaluate the safety and feasibility of laparoscopic splenectomy in patients with immune thrombocytopenic purpura who has very low platelet counts.Between March 28, 2005 and June 08, 2013, a total of 132 patients with the diagnosis of immune thrombocytopenic purpura were included to study. The patients who underwent laparoscopic splenectomy were alienated into two groups according to their platelet counts lower than 10000 (group 1) and higher than 10000 (group 2) RESULTS: There were 16 patients in group 1 with very low platelet counts, and 116 in group 2. One patient in group 1 had converted to laparotomy due to peroperative bleeding, and there were 5 conversion to open in group 2. There were also 2 patients in group 2 who underwent laparatomy on post operative day 1 due to delayed intra-abdominal bleeding. Moreover, one patient in each group had pancreatic fistula.Laparoscopic splenectomy is a safe technique in patients with ITP even the patients have very low platelet counts.ITP, Laparoscopy, Low platelet count, Splenectomy.Gli interventi chirurgici mininvasivi sono diventati sempre più diffusi negli ultimi decenni. Con questo studio retrospettivo si è voluto valutare la sicurezza e la fattibilità della splenectomia laparoscopica in pazienti con porpora trombocitopenica autoimmune, con una conta piastrinica molto bassa. Sono stati inclusi nello studio tra il 28 marzo 2005 e l’8 giugno 2013 un totale di 132 pazienti con la diagnosi di porpora trombocitopenica autoimmune. I pazienti sottoposti a splenectomia laparoscopica sono stati suddivisi in due gruppi in base alla conta piastrinica inferiore a 10.000 (gruppo 1) e superiore a 10000 (gruppo 2): 16 pazienti nel gruppo 1 con conta piastrinica molto bassa e 116 nel gruppo 2. In un paziente del gruppo 1 l’intervento è stato convertito a laparotomia per un sanguinamento peroperatorio, e cinque riconversione a chirurgia open sono state effettuate per 5 pazienti del gruppo 2. Due pazienti del gruppo 2 sono stati riconvertiti a chirurgia open per primo giorno postoperatorio per sanguinamento intraddominale tardivo. Inoltre un paziente in ciascun gruppo ha presentato lo sviluppo di una fistola pancreatica. In conclusioni la splenectomia laparoscopica si è dimostrata un tecnica affidabile per pazienti con trombocitopenia autoimmune anche se con conta piastrinica molto bassa.

Hypocalcemia caused by transient or definitive hypoparathyroidism is the most frequent complication after thyroidectomy. We aimed to compare the impact of incidental parathyroidectomy and serum vitamin D(3) level on postoperative hypocalcemia after total thyroidectomy (TT) or near total thyroidectomy (NTT).Two hundred consecutive patients with nontoxic multinodular goiter treated by TT and NTT were included prospectively in the present study. Group 1 (n = 49) consisted of patients with a postoperative serum calcium levelor =8 mg/dL, and group 2 (n = 151) had a postoperative serum calcium level greater than 8 mg/dL. Patients were evaluated according to age, preoperative serum 25-hydroxy vitamin D (25-OHD) levels, postoperative serum calcium levels, incidental parathyroidectomy, and the type of thyroidectomy.Patients in group 1 (n = 49) were hypocalcemic, whereas patients in group 2 (n = 151) were normocalcemic. Preoperative serum 25-OHD levels in group 1 were significantly lower than in group 2 (P.001). The incidence of hypoparathyroidism was significantly higher following TT (13.5%) than following NTT (2.5%) (P.05). The risk for postoperative hypocalcemia was increased 25-fold for patients older than 50 years, 28-fold for patients with a preoperative serum 25-OHD level less than 15 ng/mL, and 71-fold for patients who underwent TT. Incidental parathyroidectomy did not have an impact on postoperative hypocalcemia. The highest risk of postoperative hypocalcemia was found in the patients with all of the above variables.Age, preoperative low serum 25-OHD, and TT are significantly associated with postoperative hypocalcemia. Patients with advanced age and low preoperative serum 25-OHD levels should be placed on calcium or vitamin D supplementation after TT to avoid postoperative hypocalcemia and decrease hospital stay.

Ectopic secretion of growth hormone-releasing-hormone (GHRH) is a rare cause of acromegaly-representing less than 1% of patients. A 25-year-old woman was admitted to the hospital with acromegaly and a 6 x 6 cm infrahepatic mass. Sellar magnetic resonance imaging indicated diffuse pituitary enlargement consistent with hyperplasia. The infrahepatic mass was resected, and the histopathological diagnosis was a well-differentiated invasive neuroendocrine carcinoma of the duodenum with metastases to local lymph nodes. The tumor cells contained cytoplasmic immunoreactivity for GHRH. Because increased IGF-1 concentrations persisted after the operation, the patient was treated with octreotide long-acting repeatable (LAR) injections of 20 mg/month. Growth hormone and IGF-1 levels normalized. After 6 years of surveillance, a left paraaortic mass was detected by uptake of indium 111 octreotide. Surgical exploration revealed metastatic neuroendocrine carcinoma in a 2.5-cm lymph node. Postoperatively, the IGF-1 concentration was mildly elevated. Octreotide LAR therapy is being continued at 10 mg/month. This case suggests that octreotide treatment may have a beneficial effect on disease course and can be maintained for as long as 7 years in a patient with acromegaly due to a GHRH-secreting neuroendocrine carcinoma.

Background Laparoscopic adrenalectomy has become the gold standard in most patients with adrenal tumors. It is unclear; however, at what size an adrenal neoplasm should be resected by means of an open or a laparoscopic approach. The aim of the present study was to compare the outcomes of laparoscopic adrenalectomy for large tumors with smaller tumors. Methods A prospective study of patients who underwent adrenalectomy during the period 2006–2009 was undertaken. The patients were divided into 2 groups according to the tumor size. Group 1 ( n =29) consisted of patients presenting tumors smaller than 5cm in diameter; group 2 ( n =31) consisted of patients with tumors larger than 5cm in diameter. Results Two of the 29 tumors in group 1 (6.8%) were malignant at final histology. However, 11 of the 31 tumors in group 2 (35.4%) were malignant. There were no significant differences between operating time and complications of groups 1 and 2. The intra-operative blood loss was significantly lower in group 1 than in group 2. Conclusion Laparoscopic adrenalectomy is a reasonable procedure for selected large adrenal tumors when a complete resection is technically feasible and there is no evidence of local invasion.

Background:Although electrocautery has been used widely in surgery, the fear of delayed wound healing and infection persists. We aimed to evaluate the risk factors for wound complications and the rate of wound complications, comparing the use of electrocautery or scissors in cutaneous flap creation during thyroidectomy.Design:The study group comprised 239 consecutive patients scheduled for thyroidectomy.Subjects:Patients were randomly assigned to cutaneous flap dissection by either electrocautery (group one, n = 126) or scissors (group two, n = 113). Age, gender, body mass index, American Society of Anesthesiology score, tissue weight, operating time, incision length, cutaneous tissue depth, thyroid function and surgeon experience were recorded and compared with the rate of post-operative wound complications in both groups.Results:There were no significant differences between the overall rate of post-operative wound complications, comparing groups one and two (7.9 vs 10.6 per cent, respectively; p = 0.74). Significant positive correlations were found between wound complication and age (Spearman's rank coefficient (rs) = 0.135, p = 0.036), body mass index (rs = 0.379, p = 0.0001), cutaneous tissue depth (rs = 0.677, p = 0.0001) and tissue weight (rs = 0.643, p = 0.0001). According to logistic regression analysis, a body mass index of more than 27.5 kg/m2 was associated with a 13.7-fold increased rate of post-operative wound complications.Conclusion:When creating cutaneous flaps during thyroidectomy, the use of electrocautery is as safe as the use of scissors. Such electrocautery does not increase the risk of wound complications in thyroid surgery.

Background Anastomotic leakage (AL) is a major cause of postoperative mortality and morbidity in colorectal surgery. We investigated the early prediction of peritoneal cytokine levels in developing AL after colorectal surgery. Methods Thirty-four patients with colorectal carcinoma, who underwent elective surgery, were included prospectively. Peritoneal samples were collected on the fifth postoperative day and interleukin (IL)-6, IL-10 and tumor necrosis factor-α were measured. Patients were divided into two groups: those with clinical evidence of AL (group 1) and those without any evidence of AL (group 2). Results Of the 34 patients undergoing anastomoses, clinically evident AL occurred in 4 patients (11.7%). There was a positive correlation between AL and peritoneal cytokine levels and blood loss and operation time and hospital stay. Peritoneal cytokine levels were significantly higher in group 1 as compared to group 2. The significant increase in patients with AL was observed between peritoneal cytokine levels and the postoperative days. However, a significant decrease in patients without AL was observed. Conclusion The peritoneal cytokine levels can be an additional diagnostic tool that can support the early prediction of AL in colorectal surgery.

Adrenal cysts are very rare lesions, usually asymptomatic or without characteristic symptoms. They are classified as pseudocysts, endothelial cysts, epithelial cysts or parasitic cysts. Although pseudocysts are reported to be the most common clinically recognized adrenal cysts in surgical series, endothelial cysts are more common in autopsy series. We studied 15 consecutive patients with adrenal cysts who underwent surgical resection at our institution from 1990 to 2005. Of 15 patients with adrenal cysts, 10 had pseudocysts, 3 epithelial cysts, 1 an endothelial cyst and 1 a parasitic cyst. In conclusion, a better understanding of cystic adrenal masses is necessary to recognize true adrenal cysts and differentiating them from adrenal carcinoma or adenoma by demonstrating the foci of cystic or degenerative changes.

Background Although the sensitivity of sestamibi scanning (MIBI) is high in patients with solitary parathyroid adenomas, negative sestamibi scan results are inevitable. The exact mechanism of visualization of abnormal and hyperfunctioning parathyroid tissue is not yet clear. The aims of this clinical study were (1) to evaluate positive and negative sestamibi scan results with regard to adenoma weight and oxyphil cell content and (2) to compare the effects of adenoma weight and oxyphil cell content on the results of sestamibi scanning. Patients The patients were divided in 2 groups according to their sestamibi scan results. Group 1 consisted of 27 patients with positive sestamibi scan results, and group 2 consisted of 20 patients with negative sestamibi scan results. Parathyroid adenoma weight and oxyphil cell content were determined in all patients. Results The weight and oxyphil cell content of the parathyroid adenomas in the patients of group 1 were significantly higher than those in the patients of group 2 ( P = .001). An adenoma weight >600 mg and an oxyphil cell content >20% increased the rate of obtaining a positive sestamibi scan result 10- and 4-fold, respectively. Conclusions Both adenoma weight and oxyphil cell content were found to significantly correlate with positive sestamibi scan results. In patients with high-weight adenomas, adenoma weight was the most significant factor in obtaining positive MIBI scan results, whereas in patients with low adenoma weights, high oxyphil cell content was the most significant factor in obtaining positive MIBI scan results.

Objective:Thyroid nodules are frequently present in Graves' disease. The aim of this study was to evaluate the risk of thyroid carcinoma in Graves' disease patients, with and without ultrasonographically identified nodules, who subsequently underwent surgical treatment.Design:The study group included 150 consecutive patients with diagnosed Graves' disease who subsequently underwent surgery.Subjects:The patients were divided into two groups according to whether the pre-operative ultrasound scan showed diffuse parenchyma (group one; n = 70) or nodules (group two; n = 80).Results:Of the 150 patients, 18 (12 per cent) were found to have papillary thyroid carcinoma. Papillary carcinoma was found in seven patients (10 per cent) in group one and in 11 patients (1.7 per cent) in group two. After evaluating the overall groups, the incidence of carcinoma in the parenchyma outside a nodule was 67 per cent, whereas the incidence of carcinoma in a nodule was 33 per cent.Conclusion:Carcinoma can occur in Graves' disease patients without nodules, and the absence of nodules on ultrasonographic examination does not reduce the risk of malignancy.

Although the sensitivity of imaging studies is high in solitary parathyroid adenomas, negative results are inevitable. The aims of this prospective clinical study are to evaluate the impact of the presence of thyroid disease on the sensitivity and positive predictive value (PPV) of ultrasonography (US), sestamibi (MIBI), and parathyroid fine needle aspiration and parathormone assay (PTH-FNA).The patients were divided into 4 groups according to preoperative imaging studies: group A (n = 62) with US, group B (n = 62) with MIBI, group C (n = 62) with US + MIBI, and group D (n = 62) with PTH-FNA. These 4 groups were subdivided according to the presence (group 1) or absence (group 2) of thyroid nodule.In the overall patients, the sensitivity and PPV of PTH-FNA to localize parathyroid adenoma was higher compared with US, MIBI, and US + MIBI (100% and 100% versus 96% and 91% versus 92% and 87% versus 95% and 94%, respectively, P.05). The sensitivity and PPV of US, MIBI, and US + MIBI in the patients without thyroid nodule was higher compared with the patients with thyroid nodule (100% and 100%, 100% and 96%, 100% and 100% versus 93% and 84%, 85% and 80%, 96% and 86%, respectively, P.05). The sensitivity and PPV of the PTH-FNA was 100% in the patients with and without a thyroid nodule.PTH-FNA can be performed safely for the confirmation of parathyroid adenoma localized by preoperative imaging studies. In patients with a concomitant thyroid nodule, PTH-FNA was more accurate to detect the parathyroid adenoma than the other imaging studies.

Background The aim of our study was to evaluate the oxidant/antioxidant status of thyroid tissue in Graves' disease (GD) patients and to compare the results of GD thyroid tissue with plasma of patients and healthy controls. Methods We studied 25 consecutive patients with GD hyperthyroidism who underwent surgical treatment. The patients were divided into groups according to the duration of antithyroid drug treatment, the type of antithyroid drugs used, the presence of ophthalmopathy, and recurrence after a complete course of antithyroid drugs. Thiobarbituric acid-reacting substances (TBARS), glutathione peroxidase (GPx) activity, superoxide dismutase (SOD) activity, and total thiol (t-SH) content of tissue and plasma samples were determined. Results TBARS concentrations were found to be significantly increased in GD patients' plasma compared with controls' plasma (0.1 ±0.02 nmol/mg protein vs. 0.062 ± 0.01 nmol/mg protein). Significantly decreased t-SH concentrations were measured in GD patients' plasma compared with controls (8.26 ± 1.9 nmol/mg protein vs. 13.03 ± 3.3 nmol/mg protein). Tissue TBARS, t-SH, GPx, and SOD measurements in GD patients indicated significantly increased concentrations compared with the plasma levels of patients. Patients with shorter treatment duration before the operation had significantly increased plasma and tissue TBARS and decreased plasma and tissue t-SH concentrations. Patients on propylthiouracil treatment had significantly lower plasma and tissue concentrations of TBARS than patients on methimazole. Patients with recurrence had significantly higher plasma and tissue TBARS and lower plasma and tissue t-SH concentrations than patients treated for the first time. Conclusions In euthyroid GD patients on antithyroid drugs, increased oxidative stress and a compensatory increase in the antioxidant defense system are more prominent in thyroid tissue than in plasma. Patients who relapsed had markers indicating increased oxidative stress. Thus, ongoing autoimmunity may contribute to increased oxidative stress in GD patients, even in the euthyroid state.

Thyroidectomies of hyperthyroidic patients are known to be more blood-spattered than the operations performed for euthyroid nodular diseases and require careful hemostasis. Our purpose was to evaluate the efficacy of the use of LigaSure in patients with hyperthyroidism.Between January 2004 and October 2005, 100 patients underwent total or near-total thyroidectomy. Bipolar vessel ligation system (LigaSure) was the choice of modality for hemostasis in half of these patients, and the conventional suture ligation technique was used for the rest. The following data were evaluated non-randomized and prospectively in this study: patients demographics, thyroid pathology, operative duration, presence of complications, and the duration of the hospital stay. Comparisons of the data were evaluated by the Wilcoxon and chi-square tests.Among the patients of the LigaSure group, 14 patients were detected to have hyperthyroidism (seven patients with Graves' disease and another seven patients with multinodular toxic goiter), while 36 patients were found to be euthyroidic. The durations of the operation time and of the hospital stay of the patients in the LigaSure group were significantly lower than the conventional thyroidectomy group (p0.05). The complication rates of the LigaSure and conventional thyroidectomy groups were 4 and 6%, respectively (p0.05).The use of LigaSure as an operative technique in the treatment of Graves' disease and toxic goiter is a safe and effective modality that provides a shorter hospital stay and a shorter operation time as well.

Objectives: Primary hyperparathyroidism (pHPT) is a common endocrine disease. The aim of this study was to assess the effect of the presence of thyroid nodules, adenoma weight, and ectopic localization on the sensitivity of different imaging studies in patients with hyperparathyroidism. Study Design: A series of 125 patients with pHPT who underwent low-frequency ultrasonography, high-frequency ultrasonography, Thallium-Technetium scintigraphy, sestamibi scintigraphy, and combined technique was reviewed retrospectively. Patients were divided in two groups depending on the presence or absence of thyroid nodules. Results: The overall sensitivity of low-frequency ultrasonography, high-frequency ultrasonography, Thallium-Technetium scintigraphy, sestamibi scintigraphy, and combined technique was 69%, 89%, 71%, 86%, and 98%, respectively. The sensitivity of these imaging studies was 94%, 100%, 94%, 96%, and 100%, respectively, in our patients with no thyroid nodules but decreased to 54%, 84%, 54%, 81%, and 79%, respectively, in the presence of thyroid nodules. The parathyroid adenoma weight in true-positive imaging studies was significantly higher than those in false-positive and false-negative imaging studies. The numbers of ectopic parathyroid adenomas were found to be higher in the group of parathyroid adenomas undetected with ultrasonography when compared with ultrasonographically detected adenomas. Conclusion: In patients with parathyroid adenoma, the sensitivity of imaging studies correlates with the presence of thyroid nodules, adenoma weight, and ectopic localization.

To discuss the presentation, diagnosis, treatment, histopathological findings, and complications of patients who underwent thyroidectomy for substernal goiter in our surgical clinic.We retrospectively analyzed 170 patients with substernal goiters among 2650 patients undergoing surgical treatment for various thyroid diseases between 1990 and 2003. We evaluated the clinical data, preoperative diagnostic findings, surgical treatments, histopathological results, and postoperative complications.The most common symptoms were a cervical mass (88%) and dyspnea (35%), but 26% of the patients were asymptomatic. Chest radiography provided the first evidence of a substernal goiter in 77% of the patients. We performed total or near total thyroidectomy and operated through a cervical incision in all but 12 of the patients. There was no operative mortality but 12 (7%) patients suffered temporary hypoparathyroidism and 4 suffered transient vocal cord paralysis (2%). Malignancy was diagnosed by histopathological examination in 22 (13%) patients.We think that the diagnosis of a substernal goiter is an indication for thyroidectomy, which is associated with very low postoperative morbidity.

We present the case of a 49-year-old male with the diagnosis of pancreatic insulinoma who underwent laparoscopic enucleation. The surgical procedure was completed successfully. The patient suffered from postoperative low-volume pancreatic fistula, which was self-limited. This was the first laparoscopic enucleation of an insulinoma in Turkey. The laparoscopic enucleation procedure is an appropriate method for superficially located pancreatic corpus and tail insulinomas.

Four patients with Graves' disease in whom antithyroid drugs could not be used were treated by plasmapheresis preoperatively. On admission all patients had severe hyperthyroidism. All patients were treated by beta blockers, cholestyramine and inorganic iodine before plasmapheresis. Plasmapheresis course consisted of three sessions. Removed plasma was replaced by a synthetic colloid solution and human albumin other than fresh-frozen plasma. Plasmapheresis led to decreases in serum T3 concentrations >78-40% and free T4 concentrations >69%. Near-total thyroidectomy could be performed in all patients. Although screening coagulation tests were within normal limits, patients 1 and 4 experienced more blood loss than usual during the operative procedure. Plasmapheresis could be used as an alternative therapeutic option in the preoperative management of severe hyperthyroid patients with contraindications to antithyroid drugs. However, this is an invasive procedure and patients should be followed carefully for prolonged clinic/subclinic coagulopathy due to plasma exchange.

To examine whether CO2 pneumoperitoneum and positive end expiratory pressure (PEEP) in mechanical ventilation affect the systemic spread of intraabdominal infection.Sprague-Dawley male rats weighing 200-300 g were allocated to three groups of 12 animals in each. All rats received mechanical ventilation under general anesthesia. An intraabdominal infection model was established by injecting with 1 ml of Escherichia coli (10(9) CFU/mL) intraperitoneally. Half of the animals in each group were exposed to PEEP (10 cmH2O). CO2 pneumoperitoneum at 13 mmHg was applied to the rats in group 1. Group 2 rats underwent laparotomy. Group 3 served as controls. In addition, TNF-alpha serum levels were measured at baseline and 3 h. A peritoneal specimen for histopathological examination were obtained after the rats were killed at the end of 3 h. For the assessment of data, descriptive statistical methods (mean, standard deviation) as well as Friedman test for repeated measurements in multiple groups, Kruskal-Wallis test for intergroup comparisons, Dunn's multiple comparison test for subgroup comparisons, Mann-Whitney U test for comparisons between paired groups, chi-square and Fisher's exact test for comparison of qualitative data, and McNemar's test for assessment of changes in group variables over time were used. The results were considered statistically significant if probability (p) values were0.05.Grades of peritonitis in group 1 and 2 were seen to differ nonsignificantly. In group 1, baseline blood cultures were not included in the assessment between the subgroups that received PEEP or not, as there was no growth in any of the subgroups. No significant difference was detected between growth in blood cultures at 1, 2, and 3 h ( p0.05). Application of PEEP in subgroups did not alter the blood culture results ( p0.05). Significant differences were seen between the initial and final TNF-alpha values of groups (KW: 18.94, p0.0001). The values in control group were observed to be significantly lower than those in groups 1 and 2 ( p0.01, p0.001). Bacteremia and systemic spread of the intraabdominal infection did appear to be different according to the PEEP application. After the assessments of ventilation parameters in our study, significant reductions in pH and HCO3 levels were detected in group 1 as a result of pneumoperitoneum, which was consistent with the literature. There is a significant difference between pH values at baseline and at the end of 1 h because of pneumoperitoneum (Fr: 10.01, p0.05). PEEP application in subgroups did not create significant differences in terms of respiratory parameters ( p0.01).No difference was found between the applications of CO2 pneumoperitoneum and laparotomy with regard to bacteremia and infection-induced peritonitis. It was determined that pneumoperitoneum along with PEEP application had neither a positive nor a negative impact on intraabdominal infection.

Background: Gastric and mucosal changes were studied when different synthetic materials were used for gastric banding. Methods: 60 Wistar-Albino rats (weight 200-250 g, age 12 weeks) were classiffied into 5 groups. Gastric banding was carried out with different materials: group 1 - polytetrafluoroethylene (PTFE), group 2 - polythylene (PE), group 3 - polypropylene (PP), group 4 - silicone; and group 5 - controls. Histopathological examination of proximal and distal gastric mucosa and esophagus were evaluated for foreign body reaction, lymphocytic infiltration, neutrophil infiltration, gastric wall invasion, and gastroesophageal reflux. Results: PE and PP caused a much more severe foreign body reaction that PTFE and silicone. Lymphocytic infiltration (chronic inflammation) was not significantly different between PP, PE, and PTFE, and was present in 80% of rats with these materials (P >0.05); in the silicone group, lymphocytic reaction was minimal. There was no neutrophilic infiltration in the silicone group (P =0.001), but this sign of acute inflammation was present in the other groups. However, the neutrophilic inflitration showed no difference between PE, PTFE and PP. PP, PE and PTFE migrated into the gastric wall at similar rates (no significant difference, P >0.05); in the silicone group, however, intragastric migration was not observed. With regard to gastroesophageal reflux, no significant difference was found between all the groups (P>0.05). In all groups, no histopathologic change was observed in the gastric mucosa proximal and distal to the bands. Conclusion: Silicone was the ideal material for banding, because it had good tissue adaptation and caused no inflammatory response.

Purpose The purpose of this study was to determine the value of the intraoperative gamma probe and the efficacy of dual-phase Tc-99m sestamibi imaging in patients with primary hyperparathyroidism. Methods Twenty-one patients with primary hyperparathyroidism were examined prospectively. Results of same-day dual-phase Tc-99m sestamibi scintigraphy and intraoperative gamma probe evaluations were compared with the intraoperative findings and histopathologic diagnoses. A 15-mm handheld gamma probe was used to measure gamma activity in the neck and upper mediastinum. Nuclear mapping by gamma probe showed a single quadrant of neck that emitted gamma radiation significantly greater than the other three quadrants, which correlated with the sestamibi scan. Results Dual-phase Tc-99m sestamibi scintigraphy determined and localized parathyroid lesions in 20 patients (sensitivity, 94%). Of the 20 parathyroid lesions removed, 15 were located in normal positions, whereas five were explored in ectopic sites (one within the thyroid, one in the anterior mediastinum, one in a retrotracheal position, one in the carotid sheath, and one in the retroesophageal region). Although the index of thyroid nodules varied from 15.8% to 22.9%, the index for parathyroid lesions was 77.3% to 112.8%. Conclusions These results confirm that parathyroid lesions, especially at ectopic sites, can be treated successfully in shorter operative times with minimal complications with the help of the intraoperative gamma probe.

The aim of the present study was to assess the usefulness of thyroid nuclear medicine studies, fine needle aspiration biopsy (FNAB) and color doppler sonography in the evaluation of thyroid nodules. Our study group consists of 81 patients with a solitary hypoactive thyroid nodule or with multinodular goiter having dominant nodule. Perinodular and intranodular blood flow, diameter of inferior thyroid artery and its flow velocity were the parameters measured by color doppler sonography. Also estimation of arterio-venous (A-V) shunt formation was another important parameter indicating the angioneogenesis. Results were not significant to distinguish the malignant and benign thyroid nodules (p > 0.05); 66% (n: 14) of 21 patients who had A-V shunt, had the final diagnosis of thyroid carcinoma. These data revealed sensitivity, specificity, negative and positive predictive values of color doppler sonography in carcinoma diagnosis among the patients with solitary hypoactive nodules or multinodular goiters having dominant nodule, as corresponding: 66%, 100%, 83% and 100%. In conclusion, arterio-venous shunt detected with color doppler sonography was the only parameter having high predictive value for malignancy. Recent studies on this topic imply that color doppler sonography will take place in algorithm of thyroid nodule evaluation.

We report a case of adrenal schwannoma, which is an extremely rare neoplasm. The patient was a 49-year-old woman, with abdominal discomfort for three months, who had been referred to our unit after detection of a right adrenal mass on abdominal magnetic resonance imaging. Although the mass was embedded in the liver, laparoscopic adrenalectomy was successfully accomplished. The definitive diagnosis was made only after immunohistochemical studies, which revealed a benign schwannoma. Complete laparoscopic excision is the treatment of choice whenever feasible. Turk Jem 2010; 14: 20-2

Multiple peripheral pulmonary carcinoid tumors or their smaller counterparts (tumorlets of carcinoid type) are the most unusual form of carcinoids as a cause of ectopic corticotropin syndrome. Only three case reports were found in the literature. We describe a 35 year-old female patient with ectopic corticotropin secretion due to multiple peripheral pulmonary carcinoid tumors and tumorlets. A high-dose dexamethasone suppression test result led to the diagnosis of Cushing's disease in our case. But no tumor was identified on sella imaging and bilateral inferior petrosal sinus sampling was non-diagnostic. Computed tomography of the lungs revealed multiple acinar-nodular parenchymal infiltrations confined to the left lung. Corticotropin-dependent hypercortisolism persisted after bilateral adrenalectomy. A second operation was necessary to remove the hyperplastic adrenal remnants. Meanwhile, computed tomography findings of the thorax were unchanged. We decided to explore these nodules by open lung biopsy. During the procedure multiple nodules ranging 12 to 3 mm in diameter scattered throughout the left lung were observed and left pneumonectomy was performed. Histopathological diagnosis was multiple peripheral carcinoid tumors and tumorlets of carcinoid type showing positive immunostaining with corticotropin. This observation emphasizes a rare form of carcinoids as a cause of ectopic corticotropin secretion and its unusual response to high dose dexamethasone suppression test.

The BioEnterics Intragrastric Balloon (BIB) together with restricted diet has been used for the treatment of obesity and morbid obesity.A prospective study was conducted on 100 patients who had undergone the BIB procedure between February 2005 and February 2007.Mean age, mean weight, and mean BMI of the patients were 35.35 +/- 9.25 years, 113.23 +/- 24.76 kg (range 73-200 kg), and 39.28 +/- 6.98 kg/m(2) (range 30-69.2 kg/m(2)), respectively. Six months after the BIB procedure, mean weight and mean BMI were reduced to 100.46 +/- 26.05 kg (range 58-178 kg) and 34.70 +/- 11 kg/m(2) (range 21.83-61.59 kg/m(2)), respectively. There was a statistically significant reduction in weight and BMI at 6 months after the BIB procedure (p0.01). Excess weight loss (EWL) at 6 months ranged between 0 and 28 kg, with a mean value of 12.68 +/- 7.70 kg. The subjects had 0 to 99.2% %EWL (mean 28.63 +/- 19.29). Reduction in BMI at 6 months ranged between 0 and 12.3 kg/m(2), with a mean value of 4.51 +/- 2.85 kg/m(2), and percent excess body mass index loss (%EBMIL) was 38.20 +/- 28.78% (range 0-158%). At 6 months, there was a significant reduction in body weight and BMI (p0.01) in both groups. The reduction in BMI of the morbidly obese group was significantly greater than that of the obese group (p = 0.035), and both the %EWL and %EBMIL of the morbidly obese patients were significantly lower than those of the obese patients at 6 months (p = 0.001).BIB application is a reasonable weight loss method with few complications.

Hydatid cyst may be found in almost any part of the body, but most often in the liver and the lungs. Other organs affected occasionally include the brain, muscle, kidney, heart, pancreas, adrenal, and thyroid gland. Hydatidosis located in the thyroid is an infrequent finding, even in endemic regions. In the present study, 2 cases of hydatid cyst of the thyroid gland are reported. Preoperative investigations, including thyroid scanning, thyroid ultrasonography, and aspiration of the nodule, could not help in establishing the diagnosis. The histopathologic examination revealed hydatid cyst. During the differential diagnosis of the cystic thyroid lesions, hydatid disease of the thyroid gland should be considered in endemic areas. Surgical intervention is mandatory. Chemotherapy is necessary to avoid recurrence.

Background: Adjustable gastric banding (AGB) is a minimally-invasive approach which allows adjustment of gastric restriction. Methods: The AGB was evaluated retrospectively in a consecutive series at 3 centers. From October 1998 to October 2001, 70 patients (49 women), mean age 34.3 years (18-59) with morbid obesity (preoperative mean BMI 45.2 kg/m2) underwent AGB The open approach was employed in the first 35 patients. Laparoscopic placement was used in the second 35 patients. Complete follow-up has been obtained in all patients. Results: Mean postoperative follow-up has been 18 months (12-39). Mean operative time was 120 minutes in the open approach and 150 minutes in the laparoscopic AGB. Mean hospital stay was 5 days after the open approach and 1.7 days after the laparoscopic surgery. The excess weight loss after 18 months was 59%. Incidence of early postoperative complications was 27.1%, including nausea and vomiting in 8 patients (5 in open approach, 3 in laparoscopic placement), wound infection in 10 patients (all 10 in open approach), and Wernicke's encephalopathy in 1 patient (open approach). Incidence of late complications was 28.5%, and included band migration in 2 patients (both by laparoscopic placement), pouch dilatation in 10 patients (6 in open approach, 4 in laparoscopic placement), incisional hernias in 4 patients (all by open approach), and port infections in 4 patients (all 4 in open approach). Conclusion: AGB has been effective in achieving good weight loss to 3 years follow-up. The ability to adjust the degree of gastric restriction has enabled progressive weight loss.

Background: Papillary thyroid carcinomas are associated with metastases and decreased survival in a small group of patients. Aim: The aim of this study is to determine the factors associated with recurrences/metastases in papillary thyroid carcinoma patients. Subjects and methods: One hundred and thirty- one patients with papillary thyroid carcinoma were evaluated retrospectively. The diagnosis was papillary microcarcinoma (PMC) in 48 patients. All patients had undergone near-total/total thyroidectomy. Radioactive iodine was given to 103 patients. Age at diagnosis, gender, previous history of thyroid disease, tumor stage, histopathological characteristics of tumor and initial treatment strategies were evaluated. Results: Recurrences/metastases developed in 17 patients during follow-up. Recurrences developed at a significantly higher percentage in patients with a tumor stage >T1 and patients with lymph node metastasis at presentation. No significant difference was observed in recurrence ratio between patients with PMC and patients with a tumor diameter ≥ 1cm. In the Coxregression analysis only the advanced tumor stage (>T1) and presence of lymph node metastases were found to be significant predictors for recurrence (univariate analysis, odds ratio =4.02 and 3.15, respectively). However, multivariate analysis did not reveal any significant independent predictors. According to the Kaplan-Meier survival analysis, lymph node metastases at presentation were associated with a decrease in recurrence-free survival at statistical significance (p=0.05). No mortality was observed during follow-up. Conclusion: Papillary thyroid carcinoma leads to recurrences/metastases in a small group of patients. Initial characteristics of the patients — i.e. presence of lymph node metastases — may predict recurrences/metastases in these patients.

A 74-year-old male patient presented with anal and sacral pain 18 months after abdomino-perineal resection for rectal cancer. Computerized tomography (CT) of the pelvis demonstrated a well defined mass anterior to the lower sacrum, posteriorly infiltrating and destroying the fourth and fifth sacral nerves and invading the right gluteal fossa. A 7.5 x 15 x 2 cm encapsulated mass was demonstrated during the operation using a posterior approach and the lower sacral segments together with the tumour were removed by amputation at S3 level. Histopathology revealed chordoma. This case is unique because of the rarity of chordoma in association with rectal tumour at the sacrococcygeal region.

Although it is recommended to perform completion thyroidectomy as soon as possible after the initial operation, there are no consensus guidelines about the appropriate time interval for the reoperation. The aim of the present study was to compare the postoperative complications, the amount of residual tissue, and postoperative thyroid-stimulating hormone (TSH) and thyroglobulin (Tg) levels following completion thyroidectomy that was performed at different time intervals.Sixty patients who had already undergone bilateral subtotal thyroidectomy for benign colloidal goitre and who were then diagnosed as having thyroid carcinomas at histopathologic examination were included in the study. Twenty-nine patients had completion thyroidectomy within 90 days of the initial operation (group 1). Thirty-one patients had completion thyroidectomy 90 days after the initial operation (group 2).Tertiary clinic.The incidence of transient recurrent laryngeal nerve palsy did not show any significant difference between the groups. The incidence of transient hypoparathyroidism was significantly high in group 1 (p.001). The number of parathyroid glands identified during completion thyroidectomy in group 1 was lower than in group 2. In addition, it has been shown that more tissue can be excised in group 2 patients in comparison with group 1 patients, as demonstrated by comparing the reduction in the thyroid volume and the levels of TSH and Tg between the two groups.If it is not possible to perform completion thyroidectomy within the first week of the initial operation, completion thyroidectomy 90 days after the initial operation is beneficial to reduce the incidence of complications and makes more thyroid tissue excision possible.

Hypothesis Age, postoperative serum parathormone (PTH) level, and preoperative serum 25-hydroxyvitamin D 3 (25-OHD) level predict postoperative hypocalcemia after total thyroidectomy. Design Prospective clinical trial. Setting Tertiary referral center. Patients One hundred thirty patients with nontoxic multinodular goiter. Patients were divided into 2 groups according to the postoperative serum calcium level. Group 1 (n = 32) consisted of patients with a postoperative serum calcium level of 8 mg/dL or less, and group 2 (n = 98) consisted of patients with a postoperative serum calcium level higher than 8 mg/dL. Interventions The preoperative serum 25-OHD level and preoperative and postoperative serum calcium and PTH levels were determined. Main Outcome Measures The number of patients developing hypocalcemia and prediction of postoperative hypocalcemia by the serum 25-OHD and PTH levels. Results Hypocalcemia developed in 32 patients (24.6%) (group 1). The preoperative serum 25-OHD level and postoperative serum calcium and PTH levels in group 1 were significantly lower than in group 2 ( P = .001). With logistic regression analysis, factors that were predictive of postoperative hypocalcemia included a preoperative serum 25-OHD level less than 15 ng/mL ( P P = .01; odds ratio, 16.4), and being older than 50 years ( P = .01; odds ratio, 4.6). Conclusions Age, a low preoperative serum 25-OHD level, and a low postoperative serum PTH level are significantly associated with postoperative hypocalcemia. The low preoperative serum 25-OHD level was more significant than the low postoperative serum PTH level in the prediction of postoperative hypocalcemia.

Purpose:We aimed to evaluate the accuracy of ultrasonography, radioactive iodine uptake and serum thyroid-stimulating hormone level in predicting the volume of remnant thyroid gland.Methods:Sixty-six thyroidectomy patients were divided into two groups according to their functional status, i.e. those operated upon for nontoxic multinodular goitre (group one) and those operated upon for hyperthyroidism (group two). Ultrasonography, radioactive iodine uptake and thyroid-stimulating hormone assay were performed in all patients during the first post-operative month. The two groups were subdivided according to the amount of remnant thyroid volume detected on ultrasonography: 5 ml.Results:The remnant thyroid volume was positively correlated with the radioactive iodine uptake (rs = 0.684, p = 0.0001). The increase in remnant thyroid tissue radioactive iodine uptake was significantly greater in the patients operated upon for hyperthyroidism compared with those operated upon for nontoxic multinodular goitre (p = 0.0001). There was a negative correlation between remnant thyroid volume and post-operative serum thyroid-stimulating hormone level (rs = −0.865, p = 0.0001) and between remnant thyroid tissue radioactive iodine uptake and post-operative serum thyroid-stimulating hormone level (rs = −0.682, p = 0.0001).Conclusion:Ultrasonography is a more accurate measure of remnant thyroid volume than radioactive iodine uptake in patients operated upon for hyperthyroidism, compared with those operated upon for nontoxic multinodular goitre.

Objectives: To evaluate the incidence and risk factors of recurrent laryngeal nerve palsy and hypoparathyroidism following thyroidectomy. Design: Retrospective case–control study. Setting: Tertiary clinic. Participants: From September 1990 to September 2005, 3250 consecutive patients who had a thyroidectomy for treatment of various thyroid diseases. Main outcome measures: The rates of nerve palsy and hypoparathyroidism were evaluated based on thyroid pathology, the choice of operative procedure, whether the nerve was identified, and the experience of the surgeon. Results: Overall, the rate of nerve palsy was 1.8% and that of hypoparathyroidism was 6.6%. On univariate analysis the rates of complications were siginificantly higher in the patients who had an extended thyroidectomy, identification of the recurrent laryngeal nerve during surgery, repeat surgery and patients older than 50 years of age. Complications were no commoner in operations performed by trainees under supervision than experienced surgeons. On multivariate analysis extended thyroidectomy had a 12 fold (95% CI 1.7, 92) increased risk of nerve palsy. Repeat surgery had a 3 fold (95% CI 2.1, 4.7) increased risk of postoperative hypoparathyroidism. Conclusion: Extentended thyroidectomy and repeat surgery had a significant effect on the incidence of recurrent laryngeal nerve palsy and postoperative hyperparathyroidism respectively following thyroid surgery.

Granuloma inguinale is an indolent, progressive, ulcerative and granulomatous skin disease caused by Calymmatobacterium granulomatosis. It is generally treated with antibiotics. However, long-standing and complicated disease requires surgical treatment. Two patients with extensive and multiple perianal fistulas and abscesses unresponsive to medical treatment were managed with radical surgical resection. The first patient healed by primary intention, but a diverting colostomy was made for the second patient and the tissue defect was closed with a rotation flap. Follow-up at 4 years revealed the disappearance of the symptoms and the absence of recurrence in both patients.

Purpose. The key to successful parathyroid surgery is accurate preoperative tumor localization. This study investigates the use of ultrasound (US)-guided parathyroid fine needle aspiration (FNA) as a confirmatory diagnostic method in patients with hyperparathyroidism undergoing minimally invasive parathyroidectomy. Methods. Patients were selected for minimally invasive parathyroidectomy based on the finding of a single parathyroid adenoma identified with US and/or sestamibi scans and confirmation of the suspected parathyroid lesion via FNA and parathyroid hormone (PTH) assay. The value of aspirate obtained from the thyroid gland intraoperatively served as the negative control. Results. A total of 56 tissue FNAs were performed in 27 patients. US detected masses suggestive of parathyroid lesion in all 27 patients, and 31 US-guided FNAs were performed. No complications related to the procedure were noted. Intraoperatively, FNA was performed in the thyroids of 25 patients undergoing minimally invasive parathyroidectomy. Aspirates from lesions subsequently confirmed as having developed from the parathyroid gland had a mean PTH level of 4,677 ± 123 pg/ml (range, 3,600–5,000 pg/ml), which was significantly higher than thyroid aspirates, which yielded a mean PTH level of 48 ± 7 pg/ml (range, 5–57 pg/ml). The sensitivity of US and sestamibi scans in the detection of abnormal parathyroid glands was 88% and 77%, respectively. The sensitivity of US-guided FNA in confirming the parathyroid origin of a lesion was 100%. Conclusion. US-guided FNA for PTH assay can be performed safely for the confirmation of lesions identified with preoperative US for the selection of patients eligible for minimally invasive parathyroidectomy. © 2006 Wiley Periodicals, Inc. J Clin Ultrasound, 2006

The widespread use of ultrasound, computerized tomography, and magnetic resonance imaging has led to an increase in the number of incidental adrenal masses identified. Asymptomatic incidentally discovered adrenal masses may indicate that subclinical Cushing syndrome (SCS) is not uncommon. We aimed to evaluate the cardiovascular risk of patients with SCS before and after surgery.An autonomous cortisol-producing tumor was detected in 11 of 94 patients with adrenal incidentaloma between 1995 and 2005. Twenty-eight patients suffering from classical Cushing syndrome (CS) associated with unilateral adrenocortical adenoma, who were treated at our department in the same period, served as a control group. Cardiovascular risk factors such as blood pressure, body mass index, and lipid profile were evaluated before and 1 year after surgery.The frequency of hypertension (61% versus 63%), obesity (46% versus 55%), diabetes mellitus (50% versus 36%), hypercholesterolemia (39% versus 36%), and low HDL cholesterol (28% versus 36%) were not significantly different between CS and SCS patients, respectively. Adverse cardiovascular risk profile improved 1 year after adrenalectomy in both groups, although the changes were not significant with respect to body mass index, frequency of diabetes, and hyperlipidemia in SCS patients. But frequency of systolic/diastolic hypertension decreased significantly in this group.These findings indicate that the increased incidence of cardiovascular risk factors commonly observed in classical CS, is also present in SCS. Unilateral adrenalectomy does not always lead to significant improvements in cardiovascular risk profile in SCS.

Bladder pheochromocytomas are extremely rare and constitute less than 5% of bladder tumors. The initial symptoms of the patient are mostly nonspecific caused by hypertension. The postmicturition hypertensive crisis is the typical warning sign of this disease. In this article, we present a 29-year-old female having hypertensive attacks following micturition. Radiological imaging techniques revealed a 3 x 3 x 4-cm bladder tumor that was hormonally active. This is the first case reported of bladder pheochromocytoma that was laparoscopically treated without using the adjunct transurethral resection. The postoperative follow-up of the patient confirms the success of the surgical procedure.

Hydatid cysts may be found in almost any part of the body, but most often they are found in the liver and lungs. Other organs that are occasionally affected include the brain, muscle, kidney, heart, pancreas, and adrenal and thyroid glands. We report a case of hydatid cyst of the adrenal gland.

In recent years, total or near-total thyroidectomy has emerged as a surgical option to treat patients with multinodular goiter, especially in endemic iodine-deficient regions. The aim of this study was to compare the complication rates of total and near-total thyroidectomy in multinodular goiter and the incidence of thyroid cancer requiring radioactive iodine ablation and completion thyroidectomy between groups.Patients with euthyroid multinodular goiter without any preoperative suspicion of malignancy, history of familial thyroid cancer, or previous exposure to radiation were randomized (according to a random table) to total thyroidectomy (group 1, n = 104) and near-total thyroidectomy leaving less than 2 g (group 2, n = 112).There were no persistent complications. The incidence of transient hypoparathyroidism in group 1 (26%) was significantly higher than in group 2 (9.8%) (p0.001). The rate of asymptomatic hypocalcemia in group 2 (7.4%) was lower than in group 1 (27%) (p0.001). The incidence of papillary cancer was 9.6% in group 1 and 12.5% in group 2 (p0.05). None of the patients underwent completion thyroidectomy before ablative therapy. Ten patients were found to have the histological criteria for radioactive iodine ablation. Of these 10 patients, four were in group 1 and six were in group 2 (p0.05).In conclusion, we recommend near-total thyroidectomy in multinodular goiter instead of total or subtotal thyroidectomy. While near-total thyroidectomy and total thyroidectomy obviate the need for completion thyroidectomy in incidentally found thyroid cancer, and while there is no difference in the rate of recurrent laryngeal nerve palsy between the two methods, near-total thyroidectomy causes a significantly lower rate of hypoparathyroidism compared to total thyroidectomy.

To determine the prevalence of vitamin D deficiency and the effects of vitamin D status on parathyroid adenoma weight, clinical and biochemical indices in patients with primary hyperparathyroidism (pHPT) were studied.Eighty patients with pHPT who underwent surgical treatment and in whom the presence of parathyroid adenoma were confirmed histopathologically were studied retrospectively from recorded data files. Patients were divided into three groups: patients with 25-hydroxyvitamin D (25-OHD) concentrations15 ng/ml (group 1, n = 44), patients with 25-OHD concentrations15-25 ng/ml (group 2, n = 9), and patients with 25-OHD concentrations26 ng/ml (group 3, n = 27). Serum calcium, phosphate, alkaline phosphatase, creatinine, and albumin levels and urinary calcium excretion were determined by auto-analyzer. Plasma 25-OHD and parathyroid hormone (PTH) levels were determined by immunoradiometric assay using commercially available kits.No statistically significant differences were observed with respect to serum calcium, phosphorus, albumin, and creatinine concentrations between these groups. Serum PTH, alkaline phosphatase concentrations, urinary calcium excretion, parathyroid adenoma weight, and postoperative sixth month PTH concentrations were significantly higher in group 1 patients than in group 2 and group 3 patients. Significant correlations were observed between parathyroid adenoma weight and serum 25-OHD concentrations (r = -0.348, P = 0.020); parathyroid adenoma weight and urinary calcium excretion (r = 0.348, P = 0.021). Multiple regression analysis revealed that parathyroid adenoma weight, serum 25-OHD, and preoperative PTH concentrations correlated independently and significantly with postoperative sixth month PTH concentrations.Vitamin D deficiency leads to more severe bone disease, increased parathyroid tumor growth, and delayed postoperative recovery of parathyroid function in patients with primary hyperparathyroidism.

Although metastases to the thyroid gland are common in autopsy studies, clinically significant metastases are rare. A 58-year-old Turkish patient, presenting with thyroid metastasis 2 years after undergoing left nephrectomy for renal cell carcinoma, is reported in this case report. Thyroid metastasis can be the initial presentation of renal cell carcinoma, or it may occur a long time after nephrectomy, which can lead to misdiagnosis of primary thyroid neoplasm. Radiographic features are not useful in making discrimination between the two, however a fine needle aspiration biopsy can be useful. The role of surgical therapy is controversial.

Reoperative thyroid surgery may be required in patients who undergo any procedure less than total or near total thyroidectomy. The aim of this study was to investigate advantages of gamma-probe guided revision thyroidectomy (GGRT) over conventional revision thyroidectomy (CRT) in patients with differentiated thyroid carcinoma (DTC). GGRT was assessed according to the TSH values, complication rates and the incidence of carcinoma in residual thyroid tissue. In this randomised prospective clinical trial, 25 patients with differentiated thyroid carcinoma who had previously undergone surgery for benign multinodular goiter were included in the study. GGRT was performed in 11 (44%) patients (Group 1) and CRT in 14 (65%) (Group 2). The intraoperative mean ratio of thyroid activity to background activity (T/B) was detected as 5.1 +/- 1.4 and the mean ratio of thyroid bed activity to background activity after excision (Tbed/B) was 1.3 +/- 0.3, (p0.01). Although the incidence of carcinoma in residual thyroid tissue was higher in group 1 (4/11) in comparison to group 2 (1/14), it was not statistically significant. The elevation of the TSH concentration at the first post-operative month was significantly higher in group 1 in comparison with group 2 (18 +/- 25 5 +/- 3 mlU/l), (p0.02). These results indicate that intraoperative gamma probe application may be beneficial to detect and remove residual thyroid tissue in revision thyroidectomy.

We investigated the incidence of primary thyroid lymphoma in thyroid malignancies.A total of 304 patients whose diagnoses were made as thyroid malignancies between January 1990 and December 2000 were retrospectively evaluated. Of these, primary thyroid lymphoma was documented in four female patients (1.3%; mean age 56.2 years; range 40 to 65 years). Findings from history, physical examination, blood biochemistry, thyroid hormone levels (T3, T4, TSH, thyroglobulin), thyroid scintigraphy, fine-needle aspiration biopsy, and cervical computed tomography (CT) were evaluated. Histopathologic results were evaluated according to the Revised European-American Lymphoma (REAL) classification.The most common complaints on admission were a rapidly growing cervical mass, hoarseness, and dyspnea. In all the cases, thyroid hormone levels were normal, but thyroglobulin levels were 5 to 10 times as high as normal. Preoperative fine-needle aspiration was not helpful in two cases, whereas cervical CT was diagnostic. Pathologic diagnosis was diffuse large B cell lymphoma in all the cases. Postoperatively, three cases underwent chemotherapy and one case chemotherapy combined with radiotherapy. All the patients were operated on before 1997; one patient died, the remaining three patients have been under follow-up with no recurrences.In our cases, treatment of localized thyroid lymphoma by surgery combined with chemotherapy or/and radiotherapy was effective.

A 23-year-old female patient presented with hirsutism and fatigue nine months after delivery. Endocrine assessment showed high testesterone, DHEA-S and androstenedione levels. Abdominal computed tomography and ultrasonography revealed the presence of a large tumor in the right renal region. Right adrenalectomy was performed resulting in a diagnosis of a functional adrenal tumor. Pathological examination showed a steroidogenically active tumor. Adjuvant chemothe-raphy was administered postoperatively. At three months following surgery all endocrinological tests normalized, but liver metastases were detected by abdominal CT. Eight months after the operation the patient died of hepatic and renal failure. Androgen-secreting adrenal tumors are seen very rarely, yet the prognosis is poor due to their agressive nature.

Clinically significant metastases to the thyroid gland are very rare; however, they can present as the initial malignancy. The authors report a 53-year-old man who underwent surgery for malignant melanoma 5 years earlier, and recently presented with a thyroid nodule that turned out to be a metastasis of the primary malignancy. Fine-needle aspiration showed malignant cells, but was unable to indicate that their origin was malignant melanoma. Total thyroidectomy was the therapy chosen for the patient.

Background:Wernicke'sencephalopathy is an uncommon complication seen after morbid obesity surgery. Neurological and cardiac symptoms can occur. Early and adequate replacement of thiamin is crucial. Methods: A patient, who was operated by adjustable silicone gastric banding had severe vomiting 1 week after the operation. Physical examination showed no abnormalities except neurological signs consisting of ataxia, disorientation and diplopia. All radiological and biochemical parameters were in the normal range. Result: After replacement of vitamin B1 (thiamin) intravenously 20 mg twice daily, all the neurological signs regressed day by day. Oral thiamin pills have been continued. Conclusion: Wernicke's encephalopathy which occurs as a result of thiamin deficiency is a rare complication that has serious morbidity with rapidly progressing neurologic symptoms, and must be treated immediately. Surgeons who treat morbidly obese patients must follow the metabolic and nutritional status of the patient.