Ercument Gurluler

Background/Objectives: Parathyroid imaging is used for preoperative localization rather than biochemical diagnosis. Conventional planar and SPECT-based scintigraphy may yield equivocal reports when thyroid activity obscures lesion localization. This study evaluated whether combining software-assisted subtraction imaging with ultrasound-correlated interpretation improves reporting certainty and reduces ambiguity. Methods: This prospective reporting study included 96 consecutive patients referred for parathyroid scintigraphy because of biochemical or clinical suspicion of primary hyperparathyroidism. Each anonymized imaging dataset was evaluated by two independent consensus reader pairs using different interpretation strategies. The control arm (CTRL) used conventional dual-time-point Tc-99m sestamibi planar and SPECT images with Tc-99m pertechnetate thyroid images. The intervention arm (INT) additionally used software-assisted subtraction images and ultrasound-correlated interpretation. Endpoints included suspected parathyroid adenoma (PTA)-positive reporting, certainty, clinically actionable localization, high-confidence localization, and non-actionable reporting. Surgical/pathological reference localization was available in 22 operated patients. Results: INT increased PTA-positive reporting compared with CTRL [82/96 (85.4%) vs. 53/96 (55.2%), p < 0.001]. Median certainty increased from 1 (IQR, 0–2) to 3 (IQR, 1–3) (p < 0.001). Clinically actionable localization increased from 32/96 (33.3%) to 68/96 (70.8%) (p < 0.001), and high-confidence localization increased from 17/96 (17.7%) to 55/96 (57.3%) (p < 0.001). Non-actionable reporting decreased from 64/96 (66.7%) to 28/96 (29.2%). In the operated subgroup, correct localization was higher with INT [20/22 (90.9%) vs. 12/22 (54.5%), p = 0.008]. Conclusions: Software-assisted subtraction imaging, when combined with ultrasound-correlated interpretation, improved the clinical usability of conventional parathyroid scintigraphy by increasing reporting certainty, reducing ambiguity, and improving actionable localization. Reference-based findings were supportive, and ongoing follow-up is expected to provide surgical/pathological confirmation for robust diagnostic accuracy analyses.

Kidney transplantation is considered the best therapeutic option for end-stage renal disease. This study aimed to evaluate post-transplant graft function and survival outcomes in recipients of standard versus marginal cadaveric donor kidneys. A total of 30 cadaveric kidney transplantations performed with standard donor kidneys were retrospectively evaluated. Data on donor and recipient characteristics, kidney donor risk index (KDRI) and kidney donor profile index (KDPI) values, serum creatinine levels (up to 5th post-transplant year), delayed graft function, acute rejection status, graft and recipient survival rates were recorded. SCD and ECD groups were similar in terms of acute rejection (5.3% vs. 0.0%, p=1.000) and delayed graft function (42.1 vs. 54.5%, p=0.510) rates. Graft survival was significantly higher in the SCD group vs. ECD group (100.0% vs. 72.7%, p=0.041), while two the groups were similar in terms of recipient survival rates (94.7% vs. 90.9%, p=1.000). Graft loss occurred within the first three years in the ECD group. Higher serum creatinine levels were noted in the ECD vs. SCD group for the 1st month, 6th month and 1st year (p=0.042, p=0.015 and p=0.022, respectively) but not in the 3rd and 5th post-transplant years. Donor age (r=0.606 and r=0.602, respectively), KDRI (r=0.737 and r=0.759, respectively) and KDPI (r=0.590 and r=0.593, respectively) were significantly correlated with death-censored and total graft loss (p<0.001 for each). Our findings, although associated with relatively poorer transplantation outcomes, highlight that, marginal cadaveric donor kidneys expand the donor pool for kidney transplantation, are superior alternative to dialysis.

Objectives: To investigate the interplay and clinicopathological correlates of tumor size, cancer foci (multifocality/bilaterality), and aggressive variants in patients with operated differentiated thyroid cancer (DTC). Methods: A total of 596 patients with operated DTC (median age: 47.0 (range: 18.0-87.0 years, 77.5% were females) were included in this retrospective cohort study. Data on patient demographics, cancer foci, concomitant Hashimoto's thyroiditis, surgery type, DTC subtype (papillary thyroid cancer [PTC], follicular thyroid cancer [FTC]) and variants, tumor size, lymph node metastasis, tumor invasion were recorded. Results: PTC aggressive variant (21.9%, P=0.045), extrathyroidal invasion (24.6%, P=0.012), tall cell PTC variant (60.3%, P=0.043), and widely invasive FTC variants (60.0% P=0.002) rates were significantly higher in the bilateral multifocal tumors than in the unifocal and unilateral multifocal tumors. The rates of Hashimoto's thyroiditis (59.8%, P<0.001) and PTC subtype (99.6%, P<0.001) were significantly higher, while the rates of lymph node metastasis (5.8%, P<0.001), capsule invasion (11.6%, P<0.001), vascular invasion (0.4%, P<0.001) and extrathyroidal invasion (4.5%, P<0.001) were significantly lower in 10 mm tumors. Presence vs. absence of PTC aggressive variant was associated with significantly higher greatest tumor size (12 mm, P=0.013) and higher rates of multifocal tumor (50.5%, P=0.013) and extrathyroidal invasion (33.0%, P<0.001). Conclusions: Our findings revealed the presence of bilaterality/multifocality and aggressive variants in a considerable proportion of patients with operated DTC, and a multifaceted interplay between bilaterality/multifocality, tumor size, and PTC aggressive variants, in addition to their individual effects on increased risk of tumor invasion, particularly the extrathyroidal invasion.

This study aimed to investigate the prevalence and clinicopathological correlates of intestinal endometriosis, amongst other extra-pelvic endometriosis foci, presenting as bowel obstruction in general surgery practice. A total of 23 female patients (mean ± SD age: 34.9 ± 6.5 years) who underwent abdominal surgery for acute bowel obstruction and received histopathological diagnosis of endometriosis were included in this retrospective case-series study. Data on patient characteristics, obstetric history, preoperative laboratory and imaging findings, preoperative provisional diagnosis, type of surgical intervention and the pathological diagnosis, and postoperative outcomes were recorded. Definitive diagnoses on histopathological work-up involved intestinal endometriosis (52.2%), scar endometriosis (26.0%), ovarian endometriosis (13.0%) and inguinal endometriosis (8.7%). Postoperative complication, reoperation and recurrence rates were 8.7%, 8.7%, and 13.0%, respectively. Intestinal endometriosis, when compared to other extra-pelvic endometriosis foci (scar and inguinal), was associated with significantly higher preoperative platelet counts (332.0(284.0-528.0)vs. 239.0(223.0-370.0) 103/µL, p = 0.010), lower albumin levels (4.0(2.7–4.7) vs. 4.5(4.2–4.9) g/dL, p = 0.029), higher rates of preoperative CT utilization (91.7% vs. 0.0%, p < 0.001) and emergent surgery (83.3% vs. 0.0%, p = 0.001) and longer LOS (median 4.5 (1.0–26.0) vs. 1.0(1.0–1.0) days, p = 0.001) along with a non-significant tendency for higher postoperative complication (16.7% vs. 0.0%) and ICU stay (25.0% vs. 0.0%) rates. Our findings revealed intestinal endometriosis, predominantly in the terminal ileum/appendix, was the most common extra-pelvic cause of acute bowel obstruction. The scar endometriosis, inguinal endometriosis and ovarian endometriosis appeared to be other potential but less prevalent aetiologies in this setting.

Objectives: To evaluate diagnostic performance of ultrasound (US) and 99mTc-sestamibi scintigraphy (MIBI) in preoperative depiction and localization of parathyroid adenoma in patients with primary hyperparathyroidism (PHPT) Methods: A total of 645 patients (mean age: 52.3 [range; 18-81] years, 72.9% were females) who underwent parathyroidectomy for PHPT due to histopathologically-confirmed adenoma were included in this retrospective cohort study. The accuracy of preoperative US and MIBI in the depiction and localization of parathyroid adenomas was evaluated with respect to intraoperative localization. Results: Preoperative MIBI was more accurate than preoperative US in identifying upper right (6.2% vs. 2.6%) and upper left (7.5% vs. 3.8%) orthotopic adenomas, and ectopic adenomas (1.5% vs. 0.7%). Failure to identify an adenoma was less commonly noted on preoperative MIBI than on preoperative US (26.9% vs. 32.8%). The US mainly failed to diagnose the adenomas located in the upper left (27.4%), lower left (25.9%) and upper right (19.3%) orthotopic sites, while MIBI mainly missed those located in the lower left (36.2%), lower right (24.7%) and upper left (20.1%) orthotopic sites. True-positive depiction rates on the preoperative US (60.4% for ≤250 mg, 80.3% for ≥901 mg) and MIBI (56.7% for ≤250 mg, 86.7% for ≥901 mg) were increased as the parathyroid weight increased. Conclusions: Our findings indicate inconclusive results in the identification of parathyroid adenoma in nearly one-third of cases with both US and MIBI and the side-specific and site-specific variations in their performance. Hence, the combined use of these imaging modalities may be of great clinical value in the precise preoperative depiction and localization of parathyroid adenomas.

This study aimed to determine the anatomical position of recurrent laryngeal nerve (RLN) relative to inferior thyroid artery (ITA) in a consecutive total thyroidectomy series. A total of 421 patients (mean (min–max) age: 45.6 (18–78) years, 76.2% were women) who had total thyroidectomy accompanied with intraoperative exposure of the bilateral RLNs were included in this prospective single-surgeon thyroidectomy series study. Patient demographics and thyroidectomy indications (benign and malignant) were recorded in each patient. The relation of RLN to ITA was assessed bilaterally using the 3-subtype system (anterior to the ITA, posterior to the ITA, and between the branches of the ITA). Most of the thyroidectomy indications (69.1%) were related to malignant disease including papillary carcinoma in 54.9% of cases. The posterior RLN-ITA pattern was the most commonly noted pattern, regardless of the side (74.1% on the left and 68.4% on the right), followed by the anterior RLN-ITA pattern (17.3% on the left and 21.1% on the right) and the between pattern (8.6% on the left and 10.4% on the right). In conclusion, this prospective single-surgeon thyroidectomy series study regarding the position of RLN relative to ITA indicate the predominance of posterior RLN-ITA pattern, similarly, on both the right and the left sides. Accordingly, our findings do not support the higher prevalence of “anterior” or “between” RLN-ITA patterns on the right side, opposing the consideration of right RLN to be at a higher risk of iatrogenic injury.

The aim of the study was to investigate the utilization and outcomes of Hartmann's procedure in the emergency left colon surgery with respect to other stoma interventions. A total of 70 consecutive patients (mean±SD age: 71.1±15.5 years, 51.4% were males) who underwent emergency surgery for the left colon were included in this retrospective cohort study. Data on patient demographics, primary diagnosis, emergency surgery indication, operative risk, stoma type (Hartmann's procedure, primary anastomosis with diverting loop ileostomy, double-barreled ostomy), surgeon sub-specialty, postoperative complications, and stoma reversal time and rates were recorded. Hartmann's procedure (72.9%) was the most commonly utilized stoma type, followed by primary anastomosis with diverting loop ileostomy (14.3%) and double-barreled ostomy (10.0%), while primary anastomosis was performed only in 2.8% of patients. The stoma reversal rate was 25.0%, and the median time to stoma reversal was 10 months (range, 3 to 48 months). Hartmann's procedure was less commonly performed by colorectal surgeons than by general surgeons (35.3% vs. 68.4%, p=0.013) and was associated with a lower chance of stoma reversal compared to other stoma types, including primary anastomosis with diverting loop ileostomy and double-barreled ostomy (15.7% vs. 52.9%, p=0.006). In conclusion, our findings revealed that Hartmann's procedure, although performed less commonly by colorectal surgeons than by general surgeons, was still the most prevalent procedure applied for the surgical management of left colon emergencies, particularly in the setting of tumor-induced obstruction or perforation, despite the potential risk of severe postoperative complications and lower stoma reversal rates with this procedure.