Turkish Journal of Surgery - 2002; 18(4)

GENERAL APPROACH TO LIVER TRANSPLANTATION SURGERY

MEHMET �A�LIK�LEK��, DAN�EL AZOULAY, OL�V�ER SCATTON, HAKAN CAMBAZ, S�HA AYDIN — 2002-11-01

Liver transplantation was first performed by Thomas Starzl in 1963. During in a period of 38years, asa result of improvements in transplantation surgery, transplantation types, immunosupresive therapy, organ preserving,.intensive care and reanimation liver transplantation is being successfully performed in different centers. Posttransplantation success rate is increased after the usage of cyclosporine in 1980s. Liver transplantation is regarded as an effective treatment in chronic liver diseases. In this article surgical techniques of liver transplantation and their outcomes are discussed with a review of the literature.

TWO ROLES FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN BILIARY INJURY AND BENIGN STRICTURES: DEFINITIVE TREATMENT AND BRIDGING TO SURGERY. PERSONAL EXPERIENCE IN 111 CASES

YAMAN TEKANT — 2002-11-01

Aim: To define the role of endoscopic retrograde cholangioponcreatography (ERCP) in the treatment of biliary injury and benign strictures. Background: Biliary injury continues to be one of the most challenging complications to treat for the general surgeon. Its management, in most patients, reguires a multidisciplinary approach. In this context, the therapeutic role of ERCP needs to be better defined. Methods: A retrospective analysis on patients subjected to ERCP in a hepatopancreatobiliary reference center with the diagnosis of biliary injury or benign stricture. Files of 111 patients were reviewed and the operations as the cause of biliary injury, symptoms and duration, endoscopic findings and therapy, complications, results and follow-up records were evaluated. Results: Canulation of the bile duct was successful in 108 patients (97%). Simple bile leak was detected in 33 patients (30%), major biliary injury in 42 (38%), billary stricture in 25 (22%) and narrowing of the choledochoduodenostomy in three. In five patients, no leak could be demonstrated despite the existence of an external biliary fistula. Endoscopic sphincterotomy (ES) was performed in all patients with a simple bile leak, a 10 Fr stent was added in five and the fistula closed in all except one. A 10Fr stent could be inserted to bridge the defect in eight patients with major injury, closing their external fistulas and preparing them for surgical repair. Of the 25 patients with a bile duct stricture, three were not fit for surgery; two were stented and one received baloon dilatation endoscopically. One patient was operated upon due to bleeding from the sphicterotomy site despite efforts at endoscopic hemostasis (0.9%). There was no procedure related mortality. Conclusion: ERCP/ES was found to be effective in the definitive treatment of simple bile leaks. In major injury without complete transsection, ERCP may bridge the patient to surgical repair without further intervention, by stent closure of the fistula.

SURGICAL MANAGEMENT OF DIFFERENTIATED THYROID CARCINOMA

2002-11-01

Controversy exists about optimal surgical treatment of differentiated thyroid carcinoma. The main point of the argument centers on the type or the extent of thyroidectomy. The purpose of this clinical retrospective study is to review the outcomes of surgical procedures carried out on patients with differentiated carcinoma of the thyroid. We conducted a retrospective analysis of 68 patients with differentiated thyroid carcinoma who underwent surgery between 1990 and 2000. Patients (11 men and 57 women)ranged in age from 17 to 83 years (mean 44 years). When decision making regarding the extent of thyroidectomy and servical node dissection, we took into consideration gross findings at operation and prognostic factors such as patients age, tumor size, presence of local invasion, presence of nodal involvement and distant metastases. The most common presenting symptom was cervical mass (87%). Fine needle aspiration biopsy (FNAB) was employed in 57 patients and was diagnostic for malignancy in 41 patients (72%). Histologic examination revealed 61 cases of papiller carcinoma and 7 cases of follicular carcinoma. At the time of diagnosis, 19 patients had cervical enlarged lymph nodes and 25 patients had local invasion. Surgical approaches consisted of total thyroidectomy in 49 patients (72%), lobectomy and subtotal lobectomy in 17 (25%), lobectomy and near-total lobectomy in 2 (3%). Modified neck dissection was added to eleven patients who underwent total thyroidectomy. There was no operative death but cancer related mortality rate was 10.3%. Temporary and permanent hypoparathyroidizm rate were 22% and 4%. Rates of temporary and permanent recurrent laryngeal nerve palsy were 4% and 1% respectively. We concluded that the selection of treatment for differentiated thyroid carcinoma should be considered on the basis of risk factors. Lobectomy plus subtotal lobectomy, near total thyroidectomy and total thyroidectomy with or without cervical node dissection are all safe procedures to be performed with minimal morbidity.

THE DIAGNOSTIC VALUE AND NATURAL HISTORY OF C-REACTIVE PROTEIN IN PATIENTS OPERATED ON FOR PRESUMED DIAGNOSIS OF ACUTE APPENDICITIS

2002-11-01

To evaluate the predictive value of C-reactive protein (CRP) in patients operated on for presumed diagnosis of acute appendicitis, CRP levels at preoperative period and 24, 48 and 72 hours postoperatively were detected quantitatively in 143 consecutive patients who underwent appendectomy between September 1999 and July 2001. The surgeon was blinded of their results. The sensitivity and specifity of CRP as well as its optimal cut-off value for both were investigated comparing with leukocyte levels. The difference between groups and their postoperative CRP kinetics were evaluated. Histo-pathological findings confirmed an inflamed appendicitis in 95 patients, pertorated appendicitis in 22 patients, lymphoid hyperplasia or normal appendix in remaining 26 patients, 10 of which had other surgical pathologies. In all patients with perforated appendicitis, serum CRP levels were elevated while 9 patients with inflamed appendicitis have a normal CRP levels. The number of patients with normal CRP levels were significantly fewer than those with normal WBC in nonappendicitis groups (8/26 vs 15/26; p<0.05). The sensitivity, specifity, positive, and negative predictive value of preoperative CRP levels were respectively 92.3%, 69.2%, 93.1, %, 66.7% with an accuracy of 88. 1 %. The cut-off value of CRP for optimal sensitivity and specifity was found to be 20.2 mg/L by a 'Receiver Operating Characteristics' curve. While other surgical pathology and nonspecific abdominal pain groups showed similar patterns(p=0.097), postoperative CRP kinetics were different between appendicitis groups and the other groups(p<0.01). Serum CRP levels greater than 20 mg/L may support the surgeon's clinical diagnosis while the normal CRP levels may be used for further observation of the patient when the diagnosis is obscure. Postoperative CRP kinetics in acute appendicitis differ from other medical or surgical diseases causing right iliac fossa pain.