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Background: Although total thyroidectomy is the procedure of choice in patients with thyroid carcinoma, this surgical approach has emerged as a surgical option to treat patients with benign multinodular goiter (BMNG), especially in endemically iodine-deficient regions. The aim of this study was to review our experience with patients with BMNG in an endemically iodine-deficient region treated by either subtotal or total/near-total thyroidectomy, and to document whether total or near-total thyroidectomy decreased the rate of completion thyroidectomy for incidentally diagnosed thyroid carcinoma in comparison to the patients with BMNG treated initially by subtotal thyroidectomy., Methods: Two thousand five hundred ninety-two patients with BMNG were included. There were 1695 bilateral subtotal thyroidectomies (group 1) and 1211 total or near-total thyroidectomies (group 2) for BMNG during this period. All patients were euthyroid and had no history of hyperthyroidism, radiation exposure, or familial thyroid carcinoma. Any patient with preoperative or perioperative suspicion of malignancy or hyperthyroidism was excluded., Results: Bilateral subtotal thyroidectomy was performed in 1695 patients (58.3%) in group 1 and total or near-total thyroidectomy in 1211 patients (41.7%), in group 2, respectively. The incidence of incidental thyroid carcinoma was found to be 7.2% (n = 210/2906). Although the rate of permanent hypoparathyroidim and transient or permanent unilateral recurrent laryngeal nerve (RLN) palsy were not significantly different between the two groups, transient hypoparathyroidism was significantly higher in group 2 than in group 1 (8.4% vs. 1.42%; p < 0.001, odds ratio [OR] = 52.98). The incidence of thyroid carcinoma was significantly higher in group 2 (10.7%, n = 129/1211) than in group 1 (4.68%, n = 81/1695) (p < 0.001; OR = 39.1).Thirty-eight patients in group 1 (2.24%) underwent completion thyroidectomy, whereas completion thyroidectomy has been not indicated in group 2 (p = 0.007). Two of 38 patients (5.26%) had thyroid papillary microcarcinoma on their remnant thyroid tissue. The rate of recurrent goiter was 7.1% in group 1. The average time to recurrence in group 1 was 14.9 +/- 8.7 years. Six of 121 patients with recurrent disease (4.95%) has been operated on., Conclusions: Subtotal thyroidectomy resulted in a significantly higher rate of completion thyroidectomy for incidentally diagnosed thyroid carcinoma compared with total or near-total thyroidectomy in patients with BMNG. The extent of surgical resection had no significant effect on the rate of permanent complications. We recommend total or near-total thyroidectomy in BMNG to prevent recurrence and to eliminate the necessity for early completion thyroidectomy in case of a final diagnosis of thyroid carcinoma.

Background: The impact of age, gender, and coexisting cold nodules on the frequency of thyroid carcinoma in hyperthyroid patients in an endemic iodine-deficient region was investigated., Methods: The medical records of 817 patients who underwent operations for Graves' disease (GD) (n= 342), toxic multinodular goiter (TMG) (n = 299), and toxic adenoma (TA) (n = 176) between January 1988 and April 2006 were reviewed., Results: Cold nodules were found in 293 (36%) of the patients, and 524 (64%) patients had no cold nodules. The incidence of thyroid carcinoma was 6.5% (53/817).The frequency of carcinoma was 3.8% in GD, 6.4% in TMG, and 12% in TA. The frequency of carcinoma in older patients (>/=50 years) was significantly higher than in younger patients (10.2% vs 4.3%, P = .001). The presence of cold nodules significantly increased the frequency of carcinoma (13% vs 2.9%, P = .001). A tumor was discovered within a cold nodule in 45% of the patients with thyroid carcinoma., Conclusion: Cold nodules are frequent in hyperthyroid patients in endemic iodine-deficient regions. Older patients (>/=50 years) and cold nodules are significant risk factors for malignancy in patients with hyperthyroidism. Surgical treatment may be suitable for those particular patients if malignancy can not be excluded.

Objective: We investigated the biochemical and histopathological effects of vitamin C, low-molecular-weight heparin (LMWH), and hypertonic solution on acute necrotizing pancreatitis and on lungs as a terminal organ., Materials and Methods: We included 48 Sprague-Dawley rats in the study, which were divided into six groups, each with eight rats. The rats in group 1 were sacrificed immediately, in order to determine normal reference values for biochemical and histopathological data. Twenty-four hours after giving intraperitoneal L-arginine to the remaining five groups, development of pancreatitis was shown through assessment of amylase and CRP values. Rats in group 2 were sacrificed at the 24th hour and assigned to the control group for biochemical or the histopathological data groups, in which pancreatitis was induced. The rats in the remaining four groups were given intravenous (IV) isotonic NaCl (group 3), IV vitamin C (group 4), subcutaneous LMWH (group 5), IV hypertonic NaCl (group 6) between 24-48 hours. Each group was assessed with respect to amylase, Serum glutamic oxaloacetic transaminase (SGOT), Lactate dehydrogenase (LDH), C-reactive protein (CRP), bicarbonate, base excess (BE), Ca++, ascorbic acid, and leukocyte at hour 72. Additionally, pancreatic and lung tissue was histopathologically evaluated., Results: In the treatment groups, amylase and leukocyte levels at the 72nd hour were found to be significantly lower than at the 24th hour (p<0.05). The most significant decrease in amylase and leukocyte levels was found in group 6, and damage to the pancreas was found to be lowest in groups 4 and 6., Conclusion: We observed that in rats, hypertonic NaCl solution and vitamin C reduced the amount of necrosis in the pancreas.

Background: To investigate whether radioguided surgery (RGS) has any beneficial effects on the complication rates and the completeness of completion thyroidectomy (CT) in a center experienced in endocrine surgery., Methods: Thirty-three patients scheduled for CT for thyroid carcinoma were randomly selected for 2 types of intervention. CT was performed by RGS following administration of 5 mCi technetium-99m in 15 patients (group 1) and with conventional surgical exploration without RGS in 18 patients (group 2). The duration of the CT, thyroid function tests, iodine-131 uptake at 24 hours at the third postoperative week, and complication rates were compared between groups 1 and 2., Results: In groups 1 and 2, the duration of CT (63.3 +/- 7.5 vs 65 +/- 10.8 minutes, P = .7), postoperative serum thyrotropin-stimulating hormone (TSH) levels (43.9 +/- 17.5 mIU/L vs 36.8 +/- 8.6 mIU/L, P = .2), postoperative (131)I uptake at 24 hours (6.86 +/- 1.7 vs 7.0 +/- 1.3, P = .8), and complication rates (13.3% vs 5.6%, P = .6) showed no significant differences., Conclusion: RGS during CT offers no benefit over conventional surgical exploration with respect to operation time, complication rates, or completeness of surgery in a center experienced in endocrine surgery. However, it might be helpful for general surgeons who are less familiar with re-operative thyroid surgery.

Objective: When considering abdominal region injuries, the colon is one of the most frequently wounded organs. Due to the septic contents of the colon, failure to treat or improper treatment of colon injuries increases the risk of major complications and may result in death. The aim of our study is a retrospective evaluation of colon injury cases over a 5-year period., Materials and Methods: Forty-nine patients with a diagnosis of colon injury were included in the study. The cause of colon injury, injured area, Flint colon injury score, additional organs injured, type of surgical procedure performed, postoperative complications and mortality were evaluated., Results: The most frequent cause of colon injury was cutters (57.2%), followed by firearms (36.7%). The left colon was the most common site of injury (40.8%), followed by the transverse (28.6%) and right colon (20.4%). Primary treatment or resection and primary anastomosis were performed on 38 patients (77.6%), while primary treatment and proximal decompression colostomy were performed on 11 patients (22.4%). Eighteen of the patients (36.7%) experienced major postoperative complications, and 6 patients (12.2%) died., Conclusion: The morbidity and mortality of colonic injuries can be reduced by rapid patient transportation, good operational experience, use of wide spectrum antibiotics and postoperative care in an intensive care unit.

Background: We compared the diagnostic values of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and ultrasonography (USG)-guided fine-needle aspiration biopsy (FNAB) in the detection of thyroid carcinoma associated with multinodular goiter., Methods: USG-guided FNAB and DCE-MRI were performed consecutively on 26 patients who had multinodular goiter with dominant nodules and clinical suspicion of malignancy. DCE-MRI findings, cytodiagnosis, and final histopathologic results were correlated. We compared the sensitivity, specificity, diagnostic accuracy, and positive (PPV) and negative predictive values (NPV) of DCE-MRI and USG-guided FNAB., Results: Of 57 nodules in 26 patients, 16, 37, and 4 nodules showed delayed, plateau, and rapid washout patterns, respectively. Thyroid carcinoma was found in 8 patients (31%). Delayed washout pattern in a nodule was correlated with the histologic diagnosis of thyroid carcinoma (P < .001). None of the nodules with thyroid carcinoma had a plateau or rapid washout pattern. The sensitivity and NPV of DCE-MRI to diagnose thyroid carcinoma were greater when compared with those in USG-guided FNAB (100 vs 71.4%, and 100 vs 91.7%, respectively; P < .001)., Conclusion: When other diagnostic methods are inconclusive, DCE-MRI is superior to USG-guided FNAB to exclude thyroid carcinoma in patients with multinodular goiter.

Objective: To assess the diagnostic value of dynamic contrast medium-enhanced magnetic resonance imaging (DCE-MRI) in detection of thyroid carcinoma compared with fine-needle aspiration biopsy and frozen section analysis in multinodular goiter., Design: Prospective clinical study., Setting: University hospital., Patients: Thirty consecutive patients with nodular goiter without any clinical risk and symptoms associated with thyroid carcinoma were studied. Twenty-five patients had euthyroid multinodular goiter, and 5 had toxic nodular goiter. Scintigraphy, ultrasonography, and DCE-MRI were performed preoperatively in all patients, as well as fine-needle aspiration biopsy and frozen section analysis in 17 patients with dominant cold nodules., Main Outcome Measures: Contrast enhancement patterns on DCE-MRIs and histopathologic results of thyroidectomy specimens were correlated. The sensitivity, specificity, diagnostic accuracy, and positive and negative predictive values of DCE-MRI and the results of fine-needle aspiration biopsy and preoperative frozen section analysis to detect thyroid carcinoma were compared., Results: Thyroid carcinoma was found in 11 patients (36.7%), but was clinically significant in only 4 (13.3%). Delayed washout pattern of contrast enhancement significantly correlated with a histologic diagnosis of thyroid carcinoma (P < .001). The conditional probability of thyroid cancer in a patient with multinodular goiter with a delayed washout pattern was 0.78. The sensitivity and diagnostic accuracy of DCE-MRI to detect thyroid carcinoma was higher compared with fine-needle aspiration biopsy and frozen section analysis (100% vs 50% and 85.7%, and 90% vs 70.6% and 87.5%, respectively). The negative predictive value of DCE- MRI was 100%, ruling out thyroid carcinoma in all patients with benign goiter., Conclusion: Dynamic contrast-enhanced magnetic resonance imaging is useful to detect or exclude thyroid carcinoma with high diagnostic accuracy in patients with multinodular goiter when results of other diagnostic methods are inconclusive.

Aim: To assess the efficacy and safety of ultrasound guided percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in a well-defined high risk patients under general anesthesia., Methods: The data of 27 consecutive patients who underwent percutaneous transhepatic cholecystostomy for the management of acute cholecystitis from January 1999 to June 2003 was retrospectively evaluated. All of the patients had both clinical and sonographic signs of acute cholecystitis and had comorbid diseases., Results: Ultrasound revealed gallbladder stones in 25 patients and acalculous cholecystitis in two patients. Cholecystostomy catheters were removed 14-32 d (mean 23 d) after the procedure in cases where complete regression of all symptoms was achieved. There were statistically significant reductions in leukocytosis, (13.7 x 10(3)+/-1.3 x 10(3) microg/L vs 13 x 10(3)+/-1 x 10(3) microg/L, P < 0.05 for 24 h after PC; 13.7 x 10(3)+/-1.3 x 10(3) microg/L vs 8.3 x 10(3)+/-1.2 x 10(3) microg/L, P < 0.0001 for 72 h after PC), C -reactive protein (51.2+/-18.5 mg/L vs 27.3+/-10.4 mg/L, P < 0.05 for 24 h after PC; 51.2+/-18.5 mg/L vs 5.4+/-1.5 mg/L, P < 0.0001 for 72 h after PC), and fever (38+/-0.35 centigrade vs 37.3+/-0.32 centigrade, P < 0.05 for 24 h after PC; 38+/-0.35 centigrade vs 36.9+/-0.15 centigrade, P < 0.0001 for 72 h after PC). Sphincterotomy and stone extraction was performed successfully with endoscopic retrograde cholangio-pancreatography (ERCP) in three patients. After cholecystostomy, 5 (18%) patients underwent delayed cholecystectomy without any complications. Three out of 22 patients were admitted with recurrent acute cholecystitis during the follow-up and recovered with medical treatment. Catheter dislodgement occurred in three patients spontaneously, and two of them were managed by reinsertion of the catheter., Conclusion: As an alternative to surgery, percutaneous cholecystostomy seems to be a safe method in critically ill patients with acute cholecystitis and can be performed with low mortality and morbidity. Delayed cholecystectomy and ERCP, if needed, can be performed after the acute period has been resolved by percutaneous cholecystostomy.

Ulcerative colitis is a multifactorial inflammatory disease of the colon and rectum with an unknown etiology. The present study was undertaken to investigate the effect of glutamine administration on oxidative damage and apoptosis in 2,4,6-trinitrobenzene sulfonic acid (TNBS)-induced colitis. Rats received 1 g/kg/day glutamine for intragastric gavage for 7 days before TNBS solution administration and 3 days following TNBS solution administration until sacrifice. Then colonic and pancreatic malondialdehyde (MDA) and glutathione (GSH) levels, and colonic caspase-3 activities of the sacrified rats were measured. TNBS-induced colitis caused significantly increased in the caspase-3 activity and colonic and pancreatic MDA levels and decreased colonic and pancreatic GSH levels compared to those in the sham group. Glutamine treatment was associated with decreased MDA levels and caspase-3 activity and increased GSH levels in the colinic and pancreatic tissue. Histopathological examination revealed that the colonic mucosal structure was preserved and pancreatic inflammation decreased in the glutamine-treated group. In conclusion, glutamine appears to have protective effects against TNBS-induced colonic and pancreatic damage. These results imply a reduction in mucosal damage due to anti-inflammatory and antiapoptotic effects of glutamine.

Idiopathic thrombocytopenic purpura (ITP) is an isolated thrombocyte disease that has no correlation with other causes of clinical thrombocytopenia in adults. About 70% of patients with ITP were successfully treated by medical care and splenectomy, but nearly 30% of ITP patients do not respond to these treatments. The aim of this study is to evaluate the predictive factors that affect the success of treatment in 26 patients with ITP. Thirteen patients with ITP responded to splenectomy (responsive group), whereas 13 other patients were resistant to medical treatment and splenectomy (resistant group). The control group consisted of 13 patients who had undergone posttraumatic splenectomy. Age, sex, spleen weight, the number of follicles per mm(2), and the length of time between diagnosis and splenectomy were retrospectively analyzed. No significant difference was found between the groups with respect to these variables. Mean maximum follicle diameter (MMaFD), mean minimum follicle diameter (MMiFD), and the number and distribution of CD56 (+) cells were evaluated for each spleen specimen. There was no statistical difference in the distribution of CD56 (+) cells between the ITP patients and the control group, but the number of CD56 (+) cells was significantly higher in the control group than in patients with ITP. While MMiFD showed no statistical difference between the groups of ITP patients, a MMaFD of 350 microm and above was significantly more likely in the resistant group than in the other groups. In conclusion, this study has shown that the MMaFD is a significant predictor of the response to splenectomy.

Inflammatory pseudotumor of the bladder is a rare benign lesion of unknown etiology. We present a new case of pseudotumor of the urachus in a 16-year-old boy with no significant urologic history. This benign condition mimics invasive malignant tumors of the urinary bladder, and aggressive surgery is the basic treatment modality.

Hypothesis: We hypothesized that surgical treatment would improve respiratory muscle strength in symptomatic hyperparathyroidism (HPT)., Design: Prospective clinical trial., Setting: A tertiary referral center., Patients: Fifteen consecutive patients with symptomatic HPT and 10 with euthyroid multinodular goiter (control group) without a history of obstructive or restrictive lung disease., Interventions: Forced vital capacity and forced expiratory volume in 1 second were measured before and 6 months after surgery to estimate respiratory muscle involvement. These measurements were compared with the reference values estimated individually in each patient. Mann-Whitney and Wilcoxon signed rank tests were used for statistical analysis, and P<.05 was considered statistically significant., Main Outcome Measures: Respiratory dysfunction in patients with symptomatic HPT, pulmonary function after parathyroidectomy, and the correlation between the preoperative serum parathyroid hormone and total serum calcium values and the impairment in pulmonary function., Results: Preoperative forced vital capacity and forced expiratory volume in 1 second measurements were below the reference values in 11 (73%) and 9 (60%) patients, respectively. All the patients were normocalcemic, and forced vital capacity and forced expiratory volume in 1 second measurements significantly improved at postoperative month 6 (P = .001). No significant difference was detected in the control group. Improvement in pulmonary function correlated with preoperative serum calcium and parathyroid hormone values in patients with HPT (P<.05 and P<.001, respectively)., Conclusions: Symptomatic HPT impairs inspiratory and expiratory components of respiratory function, and normalization of serum calcium levels after surgical treatment is associated with a significant improvement in lung function.

Purpose: By reviewing our experience, we evaluated the presentation, management, and long-term outcome of patients with subclavian and axillary artery injuries resulting from trauma., Methods: We retrospectively reviewed the data of 38 patients who received treatment for subclavian or axillary artery injuries in the Emergency and Trauma Department of Medical Faculty of Istanbul, Istanbul University between January 1989 and July 2002., Results: Arterial injuries were repaired with an end-to-end anastomosis in 10 (26.3%) patients, primary repair in 6 (15.7%), autologous vein graft interposition in 16 (42%), ligation in 5 (13.1%), and a proximal subclavian-brachial artery bypass in 1 (2.6%). One (2.6%) of the arterial reconstructions failed in the perioperative period. Fourteen (36%) patients presented with a neurological deficit, which recovered after the intervention in 2 (5.2%) patients. A wound infection developed in 8 (21%) patients and 2 (5.2%) patients died of concomitant injuries. Thirteen (36.1%) of the remaining 36 patients were followed up for a mean period of 7 months., Conclusion: Successful management of subclavian and axillary artery injuries requires prompt diagnosis because the occult nature of these injuries necessitates a high index of suspicion. Although revascularization procedures are often successful, it is the associated neurological, orthopedic, and soft tissue injuries that affect the functional outcome of the limb.

Background: Ruptured abdominal aortic aneurysm (RAAA) is a highly mortal entity. In recent years, the role of seasonality has been proposed in the incidence of RAAA. In this study, we sought possible correlations between monthly atmospheric pressures and the number of patients admitted with RAAA., Methods: Twenty-four patients who were admitted to our Trauma and Emergency Surgery Department with a diagnosis of RAAA from January 1995 to May 2003 were retrospectively evaluated. Data were collected from patient records, admission charts, hospital death certificate registry, and operating-room records. Only patients whose diagnosis of RAAA was confirmed during surgery were included. Atmospheric pressure records of Istanbul for individual months covering the study period were obtained from the Meteorology Office. The incidences of RAAA and the mean monthly atmospheric pressures were compared., Results: Most of the patients were admitted in winter months. Admissions culminated in January with six patients, at which time the mean atmospheric pressure was 765.5 mmHg. There were no admissions in May, during which the mean atmospheric pressure was 760.8 mmHg. The distribution of monthly admissions for RAAA was not statistically significant (p>0.05). The mean atmospheric pressures tended to run a higher course before the months in which increased admissions were seen., Conclusion: Our findings do not corroborate the presence of a relationship between the incidence of RAAA and the atmospheric pressure.

Neuroblastomas comprise a major part of adrenal tumors in children. However, they are seldom reported in adults. In this report we present the case of a 30-year-old woman who was operated on for an incidentaloma. Following an adrenalectomy, she was put on a chemoradiotherapy regimen. A histopathologic assessment of the specimen revealed Homer-Wright rosettes against a background of fibrillary matrix, which indicated a diagnosis of a neuroblastoma. In spite of a low incidence in adulthood, it should be emphasized that all adrenal tumors without any particular characteristics may be a neuroblastoma, which tends to show a very poor prognosis. Hence, such patients should undergo postoperative chemoradiotherapy, which may improve both the remission rates and survival.