Turkish Journal of Surgery - 2002; 18(1)

THE ROLE OF PREOPERATIVE TREATMENT IN RECTAL CANCER

CENG�Z GEM�C� — 2002-03-01

There is progressive increase in organ preserving treatments by virtue of radiotherapy and or chemotherapy. These treatment approaches have taken their place as standart treatment for suitable cancer patients (Breast cancer, Head and Neck cancers e.t.c.). Sphincter-sparing surgery after preoperative radio � chemotherapy is another treatment modality that takes its place as organ preserving approach for suitable rectal cancer patients.

RELATIONSHIP OF ANGIOGENESIS AND AXILLARY LYMPH NODE METASTASIS IN BREAST CANCER

G�NAY G�RLEY�K, D�LEK K��KERCAN, �ZLEM A�IKALIN, �NDER PEKER, ABDULLAH SA�LAM — 2002-03-01

The aim of the present study is to evaluated the relationship of tumor angiogenesis with axillary lymph node metastasis in patients with breast carcinoma. Solid tumors need neovascularisation for growing and metastatic activity. High angiogenesis of primary tumor may be a high risk index. Axillary lymph node metastasis, number of metastatic lymph node, extracapsular invasion of metastatic lymph node was determined in 44 patients operated on for invasive ductal carcinoma. Angiogenesis value of primary tumor was also determined with immunohistochemical method. Results were compared in order to establish the relationship. Mean angiogenesis value of primary tumors significantly increased with axillary node metastasis (p=0.00536). An increase of angiogenesis was found according to tumor size in patients without axillary nodal metastasis (p=0.068). Angiogenesis value of tumors with vascular invasion increased (p=0.07) when compared with tumors without invasion. We found significant increase of angiogenesis with high number of metastatic lymph nodes (p=0.044) and existence of extracapsular invasion (p=0.0058). Tumor growing and metastatic ability is dependent to angiogenetic potential in breast carcinoma. Angiogenesis of the primary tumor increases while metastatic stage advancing. Angiogenesis may be a risk marker when determined routinely with good standardization.

THE ACCURACY OF SENTINEL LYMPH NODE BIOPSY IN INVASIVE BREAST CARCINOMA

ABUT KEBUD�, ADNAN ��G�R, MURAT ATAY, G�RKAN YETK�N, DEHAN YAZICI, AYG�N YILDIZ — 2002-03-01

Aim: This study aims to investigate the correlation of sentinel lymph node (SLN) and axillary lymph node (ALN) metastasis in patients with invasive breast cancer. Background: Recently, breast cancer can be detected in early-stages by mass screening. In early stage breast cancer patients, the rate of negative axillary lymph node are high. Axillary lymph node dissection(ALND) may result in significant morbidity. Thus, sentinel lymph node dissection(SLND) which has minimal morbidity in contrast to ALND is being used by many investigators. Methods: 53 patients with invasive breast cancer first underwent SLND followed by the appropriate surgical procedure. All patients had early-stage breast cancer. In this series ,the radioactive agent (technesium) was used to investigate the sentinel lymph node/nodes. Demogrophic data of the patients and histopathological evaluation of the primary tumor, ALN and SLN was assessed. Results: According to the diameter of the primary tumor 37 (69.8%) patients were evaluated as T1, 14 (26.4%) as T2 and 2 (3.8%) as T3.SLN's were detected in 50 of 53 (94.33%) cases. For T1 tumors 9 patients were SLN(+), 7 of these were ALN (+); for T2 tumors 12 patients were SLN (+),only 3 of these were ALN(+). For T3 tumors 2 patients were both SLN and ALN (+). In 12 (22.6%) patients were both SLN and ALN(+). In 27 (50.9%) patients both SLN and ALN were((). In 11 (20.7%) patients SLN was(+), whereas ALN was ((). The 3 patients in whom SLN's couldn't be demonstrated, ALN was negative. Conclusion: Currently SLND can be easily performed in invasive breast cancer patients by experienced hands. SLN's have high accuracy in demonstrating the lymphatic spread and the status of axiilary nodes in breast cancer. Increasing data suggests that SLND may replace ALND which has high morbidity in early-stage breast cancer.

THE USE OF MAGNETIC RESONANCE CHOLANGIOGRAPHY IN THE DIAGNOSIS OF OBSTRUCTIVE BILIARY DISEASES

2002-03-01

Aims: The aim of this prospective study was to assess the diagnostic accuracy of MRCP and to determine whether MRCP may help to prevent unnecessary interventional procedures. Background: In the evaluation of patients with suspected biliary obstruction ultrasonography and computed tomography are sometimes not enough to determine the obstruction level and etiology. Endoscopic retrograde cholangiopancreaticography and percutaneous transhepatic cholangiography mostly provides the diagnosis of biliary obstructive lesion but they are invasive and mostly depend on the experience of the surgeon. The value of magnetic resonance cholangiopancreatography (MRCP) is under debate. Methods: Between April 1997 and December 2000, magnetic resonance cholangiography was performed on 78 patients suspected to have biliary obstruction after clinical examination and laboratory findings. In all the patients the magnetic resonance cholangiography results have been compared with the direct cholangiography (ERCP,PTC), surgical exploration or clinical follow-up results. Results: In 53 of 78 patients biliary obstruction was diagnosed with direct cholangiogrphy and operative findings. In the remaining 25 patients no pathology was found to cause biliary obstruction. Magnetic resonance cholangiography gave correct results in 50 of 53 patients with biliary obstruction (sensitivity 94.34%) and in 23 of 25 patients without biliary obstruction (spesificity 92%). Conclusion: In biliary obstructive diseases, for the correct diagnosis of obstruction level and etiology, magnetic resonance cholangiography gave approximotely the same results with the results obtained by direct cholangiography. Magnetic resonance cholangiography is useful in the selection of patients that will benefit from therapeutic cholangiography. Magnetic resonance cholangiography also helps to reduce the unnecessary invasive methods.

RESULTS OF ADJUSTABLE SILICON GASTRIC BANDING IN TREATMENT OF MORBID OBESITY

HAL�L CO�KUN, ALP BOZBORA, YE��M ERB�L, SEL�UK �ZARMA�AN, YUSUF ORHAN — 2002-03-01

In this study we tried to show how efficient adjustable silicon gastric banding is effective in morbid obese patients. This study included 25 patients who had adjustable silicon gastric banding operation for morbid obesity in General Surgery Department of Istanbul University during January 1997-1999. All the patients have been investigated and treated by Endocrinology and Metabolism Department and have been showed as a candidate for surgery by the American Society of Bariatric Surgery criterias. The most useful parameter in definition success is the meaningful change in body mass index of the patients' postoperative controls. Mean BMI of the patients which was 48.2 preoperatively, had decreased to 43.6 in the 3rd month; 39.4 in the 6th month; and 35.64 in the 12th month. After surgical treatment diseases (DM, hypertension, sleep apne syndrome, chronic obstructive lung diseases) which accompanies obesity are recovering. In the early period after the treatment we saw nausea and vomiting in 5 patients, wound infection in 5 patients, gastric fistul in 2 patients and Wernicke's encephalopathy in one patient. In the late period we saw gastric band migration in 2 patients, one rezervoir infection and incisional hernia in one patient. Adjustable silicon gastric banding is easy to tolerate and a good choice for morbid obese patients which has the minimal metabolic complications.

COMPARISION OF POLYETHYLENE GLYCOL AND SODIUM PHOSPHATE IN BOWEL PREPARATION FOR ELECTIVE COLORECTAL CANCER SURGERY

2002-03-01

The aim of the study was to compare polyethylene glycol (PEG) and Na phosphate (SF) oral electrolyte solutions which were used in mechanical bowel cleansing for patients with colorectal cancer in terms of patient tolarence, side effects and efficacy using macroscopic, biochemical and histopathologic parameters. In this double blind randomized prospective clinical study which was conducted between March 1999 and September 2000, 40 patients were randomized into two groups, 4.5 L PEG solution (Transipeg 90 cachets) was used for mechanical bowel cleansing in the first group (20 patients), and 90 mL SF in the second group (20 patients). Patient tolarence pertaining to the use of the bowel cleansing solutions was sought by detailed questions. Blood samples were taken from all patients prior to and following mechanical cleansing to assess biochemical alterations. Bowel cleansing was evaluated intraoperatively by detecting whether or not the bowel contained gas, liquid, soft stool with particles or hard stool. In the bowel mucosa specimen obtained through biopsy, cript lengths, cell content of sialomusin and sulphomusin, Proliferating Cell N�clear Antigen (PCNA) score, and morphological alterations were assessed by the pathologist. Postoperative morbidity and mortalities were recorded. There was no statistically significant difference between two groups regarding blood pH, PaO2, PaCO2, HCO3, O2 saturation, Na, K, Cl, Ca, ALT, AST, BUN, Htc, creatinin, glucose, AST and ALT prior to and following mechanical cleansing (p>0.05). There was no statistically significant difference between the two groups in terms of cripta length measurements, goblet cell counts, and morphologic changes. There was statistically significant difference in PCNA scores which is a determinant of mitotic activity in favor of the PEG group (p< 0.01). The efficacy of PEG and SF in bowel cleansing was 95% and 90%, respectively (p>0.05). Six patients (30%) in the PEG group showed full compliance, 9 patients (45%) was able to tolerate the procedure fairly easily despite some complaints, and 5 patients (25%) tolerated with difficulty. In the SF group, 17 patients (85%) showed full compliance, 3 patients (15%) was able to tolerate the procedure fairly easily despite some complaints, and there was no patients who tolerated with difficulty. This difference was statistically significant (p<0.001). There was no difference between two groups regarding morbidity, and no mortality was detected. We believe that, SF which is not different from PEG in terms of efficacy and side effects can be prefered in mechanical bowel cleansing instead of PEG which needs to be ingested in greater amounts.

HIGH INCIDENCE OF THYROTOXICOSIS IN MIDDLE AND ADVANCED AGED PATIENTS WHO UNDERWENT THYROID SURGERY IN AN ENDEMIC GOITRE AREA OF IODINE DEFICIENCY

2002-03-01

The aim of this study is to evaluate the results of endemic goiter surgery performed in our hospital which is located in an area of endemic iodine deficiency. The pathogenesis of endemic goiter is different, and functional status of the thyroid differs with progression of the disease. Results of patients undergoing thyroid surgery in a region of iodine deficiency may provide important contribution to epidemiological studies. Demographic features of patients, status of thyroid function, indications for surgery, and findings of operation and pathological examination were analysed in 149 consecutive endemic goiter cases underwent thyroid surgery. Results obtained from patients with thyrotoxicosis were compared with those from patients with nontoxic goiter. Female/ male ratio was 6/1 and mean age 46.5 in the series. More than half of the patients were between 41-60. Eighty patients (53.8%) had thyrotoxicosis. Mean age of thyrotoxic cases was 50 years, which was significantly higher than that of nontoxic cases (p=0.0005). Fifty-four percent of thyrotoxic cases were over 50 years of age, while 77 % of nontoxic cases were below 50 (p=0.0001). Multinodular goiter has constituted indication for surgery in 92.5% with toxic and 88.4% with nontoxic cases. Surgical methods varied from unilateral total lobectomy to bilateral total thyroidectomy. No operative mortality was noted. We conclude that goiter prevalence, incidence of nodular goiter increase in middle aged patients in endemic iodine deficiency regions. Autonomy of solitary and multiple nodules was resulted with thyrotoxicosis in middle and advanced ages for whom nodlar formation was the main indication for surgery. High incidence of hyperthyroidism is a prominent finding in middle and advanced aged patients underwent thyroid surgery in endemic iodine deficiency regions.

THE EFFECT OF THYROXINE SUPPRESSIVE THERAPY IN ENDEMIC BENIGN NODULAR GOITER: SHOULD THYROXINE BE USED ROUTINELY?

TAHS�N �OLAK, AZ�Z YAZAR, MUSA D�RL�K , CENG�Z PATA, ARZU KANIK, AHMET DA� — 2002-03-01

We retrospectively evaluated the effect of thyrotropin suppressive therapy with thyroxine on the volume of benign-solitary single nodule and dominant nodule of multinodular goiter in a relatively low iodine intake area. In this study 119 euthyroid patients with a benign,predominantly solid, single nodule (n=18) or multinodular goiter (n=101), who received 100 microg of thyroxine daily, were evaluated. Patients were admitted to the study after evaluation of thyroid biochemical parameters (FT3, FT4, TSH), ultrasound examination, and fine needle aspiration biopsy. First and last evaluations were compared. At the end of the study, mean follow-up was 12.83 � 6.16 (3-25). Five of 18 (27.7 %) patients with single solid nodule had 50 % or more regression of the nodular volume (responders). Seventeen of 101 (16.8 %) patients had 50% or more regression of the dominant nodule volumes. On the other hand, treatment was not evaluated as successful in 11 of 18 (61%) patients in group 1 and 69 of 101 (68.3%) patients in group 2. We concluded that thyroxine suppressive therapy might be partially effective in arresting the growth or reducing the volume of small endemic euthyroid goiter, thus requiring a more careful evaluation in routine usefulness.