Turkish Journal of Surgery - 2006; 22(2)

Surgical approach to gallbladder cancer

2006-06-01

Purpose: In this study; the patients in stages 2-3, whom extended cholecystectomy were performed were compared to the patients in same stages whom palliative procedures were done, in terms of survival. Background: Although gallbladder cancer is not seen as frequent as the other gastrointestinal cancers, it is not a rare entity. Usually it is diagnosed in late stage; but in early stage, there is no consensus about its surgical treatment strategies. Material and Method: 34 patients had undergone surgical procedures for gallbladder adenocarcinoma between June 1993 and April 2004. 4 (12%), 2 (6%), 8 (24%), 13 (38%) and 7 (20%) patients were in stages 1, 2, 3A, 3B and 4, respectively. Results: In stage 1, cholecystectomy and extended cholecystectomy were performed in 3 and 1 patients, respectively. Extended cholecystectomy was done in both of the patients in stage 2 and 9 of the 21 patients in stage 3. Palliative procedures were performed in all 7 cases in stage 4. Postoperative complications were seen in 7 patients. 2 patients died in early postoperative period due to multi-organ failure. 23 (67%) patients died with local recurrence (n:18) or with distant metastasis (n:5) during their follow-up period. Among 23 patients in stages 2-3, 11 (48%) patients had undergone curative-intended surgery. The 6 (55%) cases out of 11 were still alive and median survival time of these patients was found to be 30.9�9.5 months. All the 12 patients in the similar stages, whom palliative procedures were performed, died during follow-up period and the median survival time was 6.1�1.2 months. Both groups were statistically different in terms of survival (p= 0.012). Conclusion: Extended cholecystectomy effected survival in the patients in stages 2 and 3. In the patients in stage 1, we were not able to reach a conclusion due to shortage of patients in this stage.

Laparoscopic Heller myotomy in surgical treatment of achalasia

Onur Hoca, Adnan Bulut, Zafer Erg�l — 2006-06-01

Purpose: The aim of this study was to evaluate the general properties, surgical techniques and complications of laparoscopic Heller myotomy in surgical treatment of achalasia including our clinical experience. Patients and Methods: Eight patients who underwent laparoscopic Heller myotomy in Ministry of Health Ankara D��kap� Y�ld�r�m Beyaz�t Training and Research Hospital 3rd General Surgery Clinic between May 1999 and December 2004 were examined retrospectively. Results: Six female and two male patients were included in this study. The mean age was 42.33 (range 19-57). All patients had dysphagia and all had increased lower osephageal resting pressure. Six patients were treated by laparoscopic Heller myotomy, other two patients were treated by laparoscopic Heller myotomy adding Toupet anti reflux procedure. There was no conversion to open surgery. Mucosal perforation occurred in one patient and it was treated by laparoscopic suturing techniques. The mean operation time was 95 minutes (range 56-160). Oral liquid food intake was allowed on the second day of the operation. The mean duration of hospital stay was 3.2 days (range 2-5). Conclusion: Laparoscopic surgery and laparoscopic Heller myotomy is a more preferable and effective procedure in surgical treatment of achalasia because of reduced duration of hospital stay, increased patient comfort during the surgical procedure, improved cosmetic results and gives patient early return to normal activity and social life .

Early postoperative results of gastric bypass surgery for the treatment of morbid obesity

2006-06-01

Purpose: The aim of this study was to evaluate the clinical outcomes of patients who had undergone gastric bypass surgery for morbid obesity. Material and Methods: Seven morbidly obese patients who had undergone Roux-en-Y gastric bypass surgery, at 3rd. General Surgery Department of Sisli Etfal Training and Research Hospital, between March 2005 and January 2006 have been evaluated prospectively. The patients' weight, body mass index (BMI) and excess weight loss % (EWL%) have been reported at postoperative 1st, 3rd and 6th months. Results: The mean body weight of the patients was 122.14kg (104-148), and BMI 47.29kg/m² (40.05-65.25), preoperatively. At 6th months, the mean body weight was 91.42 kg, BMI 35.6kg/ m² and EWL was 48.79%. Conclusion: Gastric bypass surgery is an effective treatment for morbid obesity which results in weight loss and improvement of coexisting disorders related to morbid obesity.

The role and complications of completion thyroidectomy in the management of well differentiated thyroid cancer

2006-06-01

Purpose: The optimal management of completion thyroidectomy after the unexpected diagnosis of misdiagnosed thyroid cancer by means of morbidity and indication. Materials and methods: 30 patients with unexpected diagnosis of thyroid cancer who received completion thyroidectomy were retrospectively reviewed from 2002 to 2005. Rate of residual misdiagnosed cancer and postoperative early and late complications were evaluated. Results: We reviewed the records of 30 patients who underwent completion thyroidectomy because of unexpected diagnosis of well differentiated thyroid cancer. 23 of the patients were women and 7 men with a median age of 49.5 (19 – 75). Residual malignancy was found in 9 patients (30%) after completion thyroidectomy and four patients had lymph node metastases. In seven patients (23.3%) the malignancy was localized in the contralateral lobe. The postoperative morbidity in completion thyroidectomy consisted of transient hypoparathyroidism in five patients (16.6%) (Ca<8mg/dl) and in one patient permanent hypoparathyroidism (longer than 6 months). There was no recurrent laryngeal nerve palsy. Conclusion: For misdiagnosed well differentiated thyroid cancers completion thyroidectomy can be done safely with acceptable morbidity.

Stapled haemorrhoidopexy versus Milligan-Morgan haemorrhoidectomy in teatment of haemorrhoidal disease

Adnan Bulut, Sahil Evcimen, �. Oskay Kaya, Onur Hoca — 2006-06-01

Purpose: The aim of this study was to compare, postoperative complications and effects on healing duration of stapled haemorrhoidopexy versus Milligan-Morgan haemorrhoidectomy. Materials and Method: This trial was a prospective randomized study. 30 patients, in two groups, were included in this study who underwent stapled haemorrhoidopexy (16 patients) and Milligan-Morgan haemorrhoidectomy (14 patients). Results: There were 9 male and 7 female patients in stapled haemorrhoidopexy group and the mean age was 44.6 (range 25-64). The Milligan-Morgan haemorrhoidectomy group had 9 male and 5 female patients and the mean age was 40.07 (range 22-61). Patients in both groups have 3rd and 4th degree haemorrhoidal disease. Preoperative faecal continence scoring was assessed and rectoscopy was performed in all patients. Postoperatively pain scores measured by visual analoge scale (=VAS) at 1st, 3rd and 7th days and urinary retention, bleeding, postoperative continence and pain scoring was assessed. In stapled haemorrhoidopexy group; postoperative pain scores at all times were lower ( day 1; 2,56 vs 4,5 day 3; 2,56 vs 4,92 day 7; 1,75 vs 2,71). Bleeding was higher at 1st-3rd days in Milligan-Morgan group (6 vs 11). There were no statistical differences for other complications. Conclusion: Stapled haemorrhoidopexy is a safe and effective method that is associated with reduced postoperative pain and bleeding.

A giant intrathyroidal parathyroid adenoma posing diagnostic dilemma

Alper Akcan, H�lya Akg�n, H�z�r Aky�ld�z, Y�cel Ar�ta� — 2006-06-01

The success of surgery depends on accurate localization of abnormal parathyroids. The accuracies of numerous methods of imaging such as ultrasonography, radionuclide imaging, magnetic resonance imaging and computed tomography have been reported extensively. Ultrasonography and sestamibi scanning are currently the most widely used methods. We report a case of a giant parathyroid adenoma, representing to our knowledge the largest parathyroid mass documented in the literature. Despite its clinical and laboratory findings suggestive of primary hyperparathyroidism, preoperative imaging studies of this giant adenoma were not presumptive of a definitive diagnosis.

A nonpalpable breast carcinoma case that can not be detected by radiological examinations

Hakan Uncu, Fikri K��kel — 2006-06-01

Mammography is used as a standard screening procedure for the detection of breast carcinoma in asymptomatic women . Ultrasonography (USG) and magnetic resonance (MR) are performed as alternative imaging modalities, if breast cancer may be missed at mammography. Herein a case is reported without any pathological finding on physical examination, mammography, USG and MR studies. Since there was only a family history fine-needle aspiration biopsy (FNAB) was performed and malignant epithelial cells were seen, breast carcinoma was diagnosed by this way. After infiltrative ductal carcinoma on the ground of ductal carcinoma in-situ (DCIS) was determined in the histopatologic examination of surgical biopsy specimens, modified radical mastectomy was performed. FNAB of nonpalpable breast lesions of some patients with risk and without any radiological finding must be performed or not. This question must be discussed.

Total, near-total and subtotal thyroidectomy – Which procedure in which case?

�zer Makay, G�khan ��z, Mahir Aky�ld�z, Enis Yetkin — 2006-06-01

The optimal extent of thyroidectomy for different thyroid diseases with surgical indications is controversial. Since the risk of reccurence for benign and malignant disease is a major consequence, more aggressive surgical management is believed to be warranted. Although there seems to be a strong selection bias in favor of the use of near-total and total thyroidectomy, more conservative approaches like subtotal or partial thyroidectomy have also been suggested for both benign / malignant conditions. ‘Which procedure, in which case’ has been a matter of debate. This debate is likely to continue. Advantages, disadvantages and the benefit-risk ratio have to be outweighed carefully. Herein, our objective was to find out the current place of the changing concepts of the extent of thyroidectomy in patients undergoing thyroid surgery.

Rudolf Nissen: His activities at the Cerrahpasa Surgical Clinic and his contributions to Turkish Surgery

Ertu�rul G�ksoy — 2006-06-01

The 1933 University Reform was one of the advancements that the Republic showed with the targets set by Atat�rk. In 1933, the will of building a new Turkey and the negative condition of the times resulted in positive outcomes. Rudolf Nissen was one of the young not able to stay in Germany because of the negative working conditions brought about by the Nazis. He was one of the scientists that had foreseen the negative working conditions before they were implemented and had left. He, together with pathologist Schwartz, was one of the first to sign an agreement with the Turkish Government. Nissen was born in 1896, and in 1921 he became an assistant to the world famous surgeon Prof.Dr.Sauerbruch in Munich; he later became head assistant and professor. In 1931, he successfully completed the pneumonectomy and his fame spread throughout the world. In 1933, he was appointed to the Directorship of Istanbul University Medical Faculty's Cerrahpa�a 1 st Surgery Clinic at the age of 37 as a Ordinarius Professor. He made many productive Works as the head of the Surgical Clinic, and with the new operating techniques and the surgeons he trained made great contributions to Turkish surgery. Based on his efforts a new surgery building was planned and built. He wrote 4 Turkish and German surgical books and 62 Turkish scientific publications. He became a legend with his surgical operations, especially lung operations; for example, the operation he performed in 1936 was the basis for the Nissen fundoplication. One of the great surgeons of the 20th century, Nissen went to the United States in 1939 and stayed there between 1940-1952, working around Boston and New York. He became the head of the Basel Surgery Clinic in Switzerland in 1952. He retired in Basel in 1967 and passed away in 1981. Nissen was the first from those who had left Germany to publish his memoirs. His fame continues in our country and he is remembered with admiration.