Medical annual report 2015 by Murat Alsancak

Ahmet Adnan Saygun Caddesi Canan Sokak No: 5 Ulus â&#x20AC;&#x201C; Istanbul livhospital.com facebook.com/LivHospital twitter.com/LivHospital

0850 222 2 548 - 444 4 548

Liv Hospital Ulus

MEDICAL ACTIVITY REPORT 2015

INTRODUCTION Starting her life on January 7, 2013, Liv Hospital Ulus is honored to be first in issuing clinical activity report in 2015, similar to 2013 and 2014. While 374.091 patients are admitted in three years, hundreds of specific/complicated cases are treated with mortality and morbidity rates below figures reported in the literature thanks to team play. Liv Hospital is accredited in fields of Colorectal Surgery, Robotic Surgery and Obesity for the first time outside the American continent. Physician staff of Liv issued 120 papers, including 72 papers in 2014 and 48 papers in 2015 â&#x20AC;&#x201C; all published in journals indexed by SCI, and 386 international lectures, presentations and conference speeches are held, including 192 in 2014 and 194 in 2015. All these activities not only reinforced prestige of Liv Hospital Ulus in the country, they also made us have a voice at international arena. We are proud and glad that all those knowledge and achievements will be transferred to School of Medicine in 2016.

Best regards, Prof. Oktar AsoÄ&#x;lu, M.D.

Liv Hospital - Medical Director

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

PATIENTS ADMITTED

Table of Content 3 01 02 03

GENERAL INTENSIVE CARE UNIT

RADIOLOGY CLINIC

BIOCHEMISTRY LABORATORY

QUALITY MANAGEMENT STANDARDS, YEAR 2015 DATA

ANESTHESIOLOGY

GENERAL SURGERY

NEUROSURGERY

Patients admitted in 2013, 2014 and 2015

CLINICAL ACTIVITIES PATIENTS ADMITTED

UROLOGY

CARDIOVASCULAR SURGERY

PULMONARY MEDICINE

MEDICAL ONCOLOGY

RADIATION ONCOLOGY

CHECK-UP

THORACIC SURGERY

ENDOCRIONOLOGY AND METABOLIC DISEASES

PEDIATRIC SURGERY

ALGOLOGY

13 14 15

OTORHINOLARYNGOLOGY

OPHTHALMOLOGY ORTHOPEDICS AND TRAUMATOLOGY

GYNECOLOGY AND OBSTETRICS

CARDIOLOGY

GASTROENTEROHEPATOLOGY

NEUROLOGY

PSYCHIATRY AND PSYCHOLOGY

REGENERATIVE MEDICINE, STEM CELL RESEARCH AND GROWTH CENTER

NUCLEAR MEDICINE AND MOLECULAR IMAGING

PHYSICAL MEDICINE AND REHABILITATION

Number of Outpatients

120000

INTERNAL MEDICINE

DERMATOLOGY AND VENEREAL DISEASES

100000 80000 60000 40000

PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

20000 0

2013

2014

2015

Number of Inpatients 16000 14000 12000

PEDIATRICS

SCIENTIFIC ACTIVITIES

110 WORKSHOPS AND OTHER MEETINGS 124 MEDICAL MEETINGS ABROAD

286.586 37.741 12.668 49.764

• Number of Outpatients • Number of Inpatients • Number of Operations • Number of International Patients

140000

102 LIV SYMPOSIUMS

10000 8000 6000 4000 2000 0

2013

2014

2015

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

GENERAL INTENSIVE CARE UNIT

Number of Operations

General Intensive Care Patient Profile

6000 5000

Age range, 6 months to 101 years • Pediatric Patients (<16 years) 2.28% of all patients Mean age, 7.6 years Death in 1 patient (hemophagocytic syndrome)

4000 3000 2000 1000 0

2013

2014

2015

Adult Patients • Mean age - 53 years • Stay in General ICU - 2.8 days • APACHE II - 11 • Expected Mortality Risk - 19 % • Actual Mortality Risk - 6,4 %

General ICU, Geriatric Patient Profile Geriatric Patients, ≥ 65 years (29%) • 29% - Postoperative follow-up • 51% - Cardiac Emergencies • 5% - Neurological Emergencies

Number of International Patients 30000

• Mean age

- 76 years • APACHE II - 18 • Stay in General ICU - 3.9 days • Expected Mortality Risk - 34% • Actual Mortality Risk - 12%

25000 20000

Distribution of Patients in General ICU

Number of patients

15000

1200

10000

1000

5000 0

800 2013

2014

2015

600

1394 (%64)

200 0

%17 %42 %18 %23

Middle East and Africa Caucasia The Balkans Europe

2013

2014

2015

General ICU, Surgical Patient Profile

General ICU, Medical Patient Profile

%5 %21

%46

%9 %15 4

Medical Surgical

808 (%36)

400

Distribution of International Patients by Region, Year 2015

General Surgery Bariatric Surgery Neurosurgery Orthopedics Trauma Other

%13 %5 %7

%40

%31 %4

Cardiac Neurological Sepsis Intoxication CPR Other

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

General ICU, Surgical Patient Profile • Mean age - 56 years

• Pneumonia, 38%;

• Stay in General ICU - 2.7 days

Aspiration Pneumonia 36% • Abdominal 10% • Urosepsis 13% • Wound Infection 3% Oncological Patient 24%

• APACHE II - 12 • Expected Mortality Risk - 18% • Actual Mortality Risk - 2,8%

General ICU, Medical Patient Profile • Mean age - 62 years

Care Unit, 56% can be discharged. • Mean stay at intensive care unit Death 5.7 days Live 13.5 days

• APACHE II - 17 • Expected Mortality Risk - 32% • Actual Mortality Risk - 14%

General Intensive Care Patient Profile • ≥ 65 - < 85 years (82%)

• ≥ 85 Years (18%)

• 24% of all patients

• 5% of all patients

• Mean age - 73 years

• Mean age - 89 years

• Stay in General ICU - 3.8 years

• Stay in General ICU - 4.2 days

• APACHE II - 17

• APACHE II - 21

• Expected Mortality Risk - 32%

• Expected Mortality Risk - 41%

• Actual Mortality Risk 10%

• Actual Mortality Risk - 21%

• Mean age, 62 years • ≥ 65 Years

55% • APACHE II 20 • Expected Mortality Risk 42% • Actual Mortality Risk 18% • Stay in ICU - 5.4 days

Post-CPR Mortality • Of all post-CRP patients admitted to General Intensive

• Stay in General ICU - 4.3 days

Sepsis and Septic Shock

Etiology of Sepsis/Septic Shock

Distribution of Death Cases • Metastatic cancer 47%

- Acute respiratory failure 56% - Pulmonary embolism 15% • Septic shock 18% • Acute Cardiac Event 14% • Post-CPR 14% • Acute Neurological Event 7%

Liv General ICU Critical oncology patient • Mean age, 62 years • Metastatic solid tumor 44% • ICU Indication Sepsis / Septic Shock 27% • APACHE II

32 • Expected Mortality Risk - 77% • Actual Mortality Risk - 42% • Stay in ICU - 7.8 days

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

MRI, Arterial Spin Labeling Perfusion

RADIOLOGY

ASL perfusion technique is equipped in very scarce MRI devices in our country, but this modality is frequently used at our department, and cutting-edge 3 Tesla MRI device is used for this modality. It is routinely used in differentiating radionecrosis from recurrent tumor, staging tumors and evaluating patients with early stage stroke. No contrast agent is required and sometimes, more successful outcomes can be obtained in comparison with contrast-enhanced perfusion sequences.

• Diagnostic

Radiology • Interventional Radiology

Modalities

2013

2014

50000

2015

20000

45000

18000

40000

16000

35000

14000

30000

12000

20000

6000

15000

4000

10000

2000

5000

Xra y

Fl uo ro sc op y

8000

M am m og ra ph y C ol or U D ltr op as p ou ler Bo nd ne D en si to m et ry

25000

M ag ne tic Im Re ag so in na g n (M ce RI To m og Co ra m ph pu y te (C d T)

10000

Diagnostic Radiology (Example Cases)

Ax T1W, FSE, Contrast-enhanced Ax GRE-EPI, Perf., Contrast-enhanced

ASL Perfusion

CT Angiography of Coronary 2013

2014

2015

The device in Radiology Department of Liv Hospital runs imaging studies at sensitivity of 86-100% and diagnostic accuracy of 90-95%. Cutting-edge vessel analysis software is used to evaluate stenosis in coronary arteries. In addition, ventricular function and myocardium can be assessed. Current conditions of stents in coronary arteries are safely evaluated on high-resolution images. Radiation dose can be reduced up to 80 percent in comparison with other devices, if imaging study is performed using this device.

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Multiparametric MRI scan of Prostate Seventy two years old patient, who has anamnesis of Miles operation due to rectal tumor, had multiparametric prostate MRI scan to investigate underlying cause of high PSA. Multiparametric prostate MRI scan showed two lesions, which are suspicious for tumor, anterior to the gland at right and left sides. Since anal canal of the patient is occluded, anterior percutaneous approach is used to biopsy the gland, and prostate cancer is reported for the biopsy specimen. Accordingly, radical prostatectomy is carried out with robotic surgery method.

Five Ultrasound- and CT-guided biopsies taken with suprapubic approach DIAGNOSIS: PROSTATE; NEEDLE BIOPSY: PROSTATIC ADENOCARCINOMA, GLEASON SCORE: 7 (3+4) LENGTH OF TUMOR / SPECIMEN: 2mm / 66mm (3%) PERINEURAL INVASION IS PRESENT. ICD-O: M8140/3-C61

BLADDER NECK

Gleason score: 7 (3+4)

MEDICAL ACTIVITY REPORT 2015 Lower radiation dose

up to

80%

CLINICAL ACTIVITIES

Contrast-enhanced Spectral Mammography (CESM) • Contrast-enhanced

spectral mammography (CESM) device is used in our department, although it is found in limited healthcare facilities in Turkey. Combining digital mammography with contrast enhancement, CESM helps patient and physician with highly accurate results, since imaging quality of this modality is close to that of MRI.

• CESM

is an advantageous technique, since it can be scanned in shorter time relative to MRI, appointment problem is not

faced and it can be used in patients, who cannot have MRI scan due to claustrophobia, pacemaker or orthopedic prosthesis. • CESM

is successfully used in all conditions that require contrast-enhanced MRI scan of breast.

CT Arthrography of Knee The patient with a pacemaker, who is not eligible for MRI scan, had MD CT scan, after intra-articular contrast agent is administered, and next, raw images are reconstructed. A root tear is found on posterior horn of medial meniscus.

In another example image, contrast-enhanced spectral mammography showed no specific finding, although suspicious asymmetrical areas are is observed in dense breast parenchyma on mammography of the patient. Patient is recommended annual follow-up examination and discharged to home, without requirement to control mammography or MRI scan of breast.

Interventional Radiology (Example Cases)

MEDICAL ACTIVITY REPORT 2015

Irreversible Electroporation (NANOKNIFE)

CLINICAL ACTIVITIES

Radiofrequency Ablation of Lung

• This method enables ablation of tumor in patients with pancreatic cancer and involvement of mesenteric artery (inoperable). • Operating Principle: High-voltage direct current is delivered to tissue in pulses using bipolar probes and thus, irreversible

micropores are created on membranes of all cells within the ablation area. Cell death is induced. • This method can be applied in limited number of facilities in our country. • First intraoperative procedure is carried out jointly with General Surgery team.

Intra-arterial Yttrium-90 • It is the most important palliative treatment option and offers survival advantage in inoperable primary liver tumors. • It is an important therapeutic method for local management of metastatic diseases in liver, in combination with chemotherapy. • It is successfully used jointly with Nuclear Medicine Department.

FDG PET scans of a patient with colonic tumor and multiple hepatic metastases before and after intra-arterial yttrium 90 treatment. Complete metabolic response is observed on post-treatment images. 42 years old female patient with endometrial sarcoma and pulmonary metastases; RF ablation therapy and follow-up images.

8 years old female patient presented with complaint of difficulty walking. Definitive diagnosis is made jointly with Orthopedist in the light of imaging studies. Patient received radiofrequency ablation therapy. Patient can be discharged to home country without difficulty walking and pain

66 years old patient with hepatocellular cancer is not operable due to central tumor and multiple tumor foci. Patient is treated with chemoembolization in two sessions. Pre- and post-treatment angiography and MRI scans

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Celiac Ganglion Block

BIOCHEMISTRY LABORATORY

DISTRIBUTION OF TESTS BY YEARS

RATE OF INCREAS IN NUMBER OF TESTS RELATIVE TO PREVIOUS YEAR

2014 (%) percentage

Rate of Delay in Ordinary Test Orders

0.06

0.02

66.7

Rate of Delay in Urgent Test Orders

1.51

0.22

85.4

Pre-analytical Error Rate

1.42

1.25

12.0

Analytical Error Rate

Post-analytical Error Rate

Wrong Result Reporting

Improvement Rate 2015 (%) percentage (%) percentage

40 35 30

TIPS

25 20 15 10 5

Considering total number of tests, an increase rate of

41.7%

al To t

e on rm Ho

ol at m He

ist

Portal vein

is realized relative to Year 2014.

No re-stenosis is found on Doppler and venography of TIPS shunting of 62 years old patient (emergency surgery)

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

QUALITY MANAGEMENT STANDARDS, YEAR 2015 DATA

ANESTHESIOLOGY Mortality

2015 Surgical Procedures Surgical Site Infection Rate

0.34%

Antibiotic and Other Medication Use Rate of Prophylactic Antibiotic Starting within 1 Hour Before Surgical Incision

100%

Rate of Using Appropriate Antibiotic for Surgical Prophylaxy

99.7%

Rate of Stopping Prophylactic Antibiotic After Surgery in The Defined Timeframe

96.8%

Risk Management Rate of Pressure Ulcer Growing Inpatients

0.07%

Anesthesia Data Number of patients who are given anesthesiology service Anesthesia outside the operating room Number of outpatients Number of peripheral block Number of central block Number of obesity surgery patients Number of invasive procedures under anesthesia Morbidity rate

Mortality rate

Year 2013, 2014, 2015 14.515 4027 5153 249 950 640 2821 2013 (6) 2014 (8) 2015 (6) 2013(0) 2014 (3 CVS, 1 obesity) 2015 (0)

Morbidity: CVA (cerebrovascular accident, dural puncture, subdural hematoma, injury of tooth and tongue, anaphylaxis, position-dependent nerve injury) All patients, who developed morbidity, are discharged in healthy condition.

Utilization Management Average Lenght of Stay

2.1

Prevention and Control of Events that Jeopardize The Safety of Patients, Families and Staff

Rate of Electrical Device Burns in the OR

Rate of Operations with Missing Gauze/Surgical Tools/Compresses

Rate of Thrombophylebitis Prevelance Related to IV Cannulation

The International Patient Safety Goals Rate of Patients Incorrectly Transfered to the OR

Central blocks

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

GENERAL SURGERY

Glidescope - difďŹ cult intubation device

Ultrasound-guided peripheral block

Ultrasound-guided central catheterization. Complication rates are decreased and success rate is increased especially in children.

Liv Hospital is accredited in fields of Colorectal Surgery, Robotic Surgery and Obesity by SRC (Surgical Review Corporation) for the first time outside the American continent.

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Name of Country

Six live training surgeries, broadcasted at www.livlivesurgery.com, are watched by 2143 different IP numbers.

Number of Connections

Total

Robotic surgery is characterized by better oncologic outcomes in male patients with rectum cancer.

Total General Surgery Activities from 2013 to 2015

14350

Number of Outpatient Admissions

2517

Number of Surgeries

Comparing Short-Term Outcomes of Robotic and Laparoscopic Surgeries in Treatment of Rectal Cancer: Robotic Surgery Has Better Oncologic Outcomes MATERIALS AND METHOD: Prospective data of 92 patients, who were undergone curative resection due to primary rectal cancer from January 2013 to February 2016 and gave informed consent, are analyzed. RESULTS: Of study participants, 34 were female and 58 were male. Median age was 57 years (range: 27 to 88 years) and median body mass index (BMI) was 25 (range: 19 to 33). Forty two patients (45.6%) with locally advanced tumor were given neoadjuvant chemoradiotherapy, while 19 patients (20.6%) received short-term neoadjuvant radiotherapy. Tumor was located in distal rectum in 48 patients (52.1%), mid rectum in 19 patients (19.5%) and proximal rectum in 25 patients (27.1%). Age, gender, BMI, disease stage, neoadjuvant therapy ratio and ASA classification were similar in laparos22

copic and robotic surgery groups (p>0.05). Number of distal tumors in robotic surgery group (42.3%, n = 39) was significantly higher in comparison with laparoscopic surgery group (9.7%, n = 9; p<0.001). Abdominoperineal resection was carried out in 2 patients in each group, and sphincter-preserving surgery ratios were similar in laparoscopic surgery (91.1%) and robotic surgery (96.5%) groups (p>0.05). Transition to open surgery was required in 1 patient in each group (p>0.05). Mean duration of operation was 154.9 ±69.3 minutes in laparoscopic surgery group and minutes in robotic surgery group (p = 0.002). Mean number of lymph nodes excised and involved was 29.4 ±13.3 and 1.9±3.8, respectively, in laparoscopic surgery and 27.4±11.7 and 1.8±4.3, respectively, in robotic surgery groups (p>0.05). Distal margin was negative in all patients. Radial margin was positive in one patient (2.9%) of laparoscopic surgery group, while no radial margin positivity was observed in robotic surgery group. Mesorectal integrity was compromised in one patient (2.9%) of laparoscopic surgery group, but it was intact in all patients of robotic surgery group. Severe perioperative complication rate was 14.7% and 8.6% in laparoscopic and robotic surgery groups, respectively (p>0.05). Anastomosis leakage was identified in 4 patients (11.7%) of laparoscopic surgery group and in 2 patients (3.4%) of robotic surgery group (p>0.05). Mean stay in hospital is 5.5±2.1 and 5.6±3.2 in laparoscopic and robotic surgery groups, respectively (p>0.05).

Total Pelvic Exenteration (TPE), Intraoperative Radiotherapy (IORT) and Composite Bone Resection in 9 Patients with Locally Recurrent Rectal Cancer. METHOD: Nine patients (7 male, 2 female) were undergone TPE with diagnosis of recurrent rectal cancer from 2013 to 2016. IORT (mean 12.5 Gy) is applied to four cases, while hyperthermic intraperitoneal chemotherapy (HIPEC) is given to 2 cases. Composite bone resection is required in five cases due to negative surgical margin. S3 is resected in one case, while S5 is resected in another case and right inferior pubic ramus is resected in one case. RESULTS: Five patients developed complication (ileus in one case, wound infection in three cases and pleural effusion in one case). Hospital mortality is found in none of patients. Median follow-up period is 15 months (range: 2 to 25 months). Two patients died (one in Month 6 and one in Month 10). Seven patients are living, and two patients are given chemotherapy, one due to local recurrence (Month 25) and one due to lung metastases (Month 15). Five patients (Month 2, Month 12, Month 15, and Month 25) are still living in disease-free status. 23

MEDICAL ACTIVITY REPORT 2015 Our Cytoreductive Surgery (SRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) Outcomes in Patients with Peritoneal Carcinomatosis (PC) Secondary to Colorectal Cancer

CLINICAL ACTIVITIES

Surgical Interventions in Gastrointestinal System Tumors (2013-2015) 180 160 140 120 100 80 60 40 20 0

Open

Stomach

Laparoscopic

Colon

Robotic

Rectum

TEM

Total

MATERIALS AND METHOD: Prospective data of sequential 22 patients, who are treated with SRS and HIPEC due to PC originating from colorectal cancer (CRC) in our center from January 2013 to January 2015, are reviewed. RESULTS: Twenty patients (8 female and 14 male) are included in analysis. Etiology was colon cancer in 13 patients, rectal cancer in 4 patients and mucinous tumor of appendix vermiformis in 5 patients. Fourteen of peritoneal metastases (63.6%) were synchronous, while 8 (36.4%) were metachronous. Twelve patients (54.5%) received neoadjuvant chemotherapy. Laparoscopic SRS was performed in seven patients (31.8%, while open SRS was carried out in 15 patients (68.2%). For laparoscopic surgery group, etiology was appendix in 4 patients, colon in 2 patients and rectum in one patient. Mean duration of operation was 432Âą191 minutes. Median PCI was 7 (range: 2-27). Complete cytoreduction (CC-0) was achieved in all patients. Perioperative morbidity is observed in six patients (26%): Ileus (n= 3), pleural effusion (n=1), anastomotic leak (n=1) and pelvic abscess (n=1). All complications could be managed with conservative methods, excluding the patient who developed anastomotic leak. No toxicity or perioperative mortality secondary to intraperitoneal chemotherapy is observed. Mean hospital stay is 10.5Âą3.2 days. Recurrent disease is found in 8 patients (34.7%). Four patients died. Three patients are given chemotherapy and one patient is followed up in disease-free status in postoperative period of pelvic exenteration. Median follow-up period is 11 months (range: 1-30) and general and disease-free survival rates are 81.8% and 60.8%, respectively. 24

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Vascular Surgical Intervention

Special Case 100 90 16 years old female patient Inﬂammatory Myoﬁbroblastic Tumor

80 70 60 50 40 30

Mass lesion inﬁltrating the left lung, pericardium, left lobe of the liver, distal esophagus and proximal stomach

20 10 0

ARTERIAL INTERVENTIONS

VENOUS INTERVENTIONS

2013

BEFORE

ENDOVASCULAR

2014

VASCULAR ACCESS

OTHER

2015

SONRASI

Thoracoabdominal incision

En-Bloc Resection of Mass Lesion Distal Esophagectomy+Proximal Gastrectomy+Left Pneumonectomy+Left Hepatectomy+ Splenectomy + Pericardial Resection

Achieving revascularization with iliac stent insertion in a case with left iliac arterial occlusion

MEDICAL ACTIVITY REPORT 2015 Ă&#x2013;NCESÄ°

SONRASI

CLINICAL ACTIVITIES

Obesity Surgery

SONRASI

Surgeries Performed in Year 2013, 2014 and 2015 Surgery

Achieving revascularization with endovascular approach in a patient with peripheral arterial disease and foot wound secondary to diabetes

Number

612

Laparoscopic Gastric By-pass

1,4

Laparoscopic Mini Gastric By-pass

0,2

Revision Surgeries

2,6

Laparoscopy

0,2

640

100

Laparoscopic Sleeve Gastrectomy

Total

Early Complication Complication Wound healing process following leg vessel by-pass in patient with diabetic foot wound

BEFORE

Number

Leakage

0,3

Intraabdominal hemorrhage

0,8

Intraabdominal abscess

0,2

Fever

0,3

Intraabdominal collection

0,3

Injury of splenic artery

0,2

Total

2,0

Comparing Complication Rates of Bariatric Surgery in Liv Hospital and 10 Healthcare Centers in U.S. Liv Hospital Average of 10 Healthcare Centers in U.S. * Morbidity

4,3%

Leakage

0,3%

1-2%

Bleeding

0,8%

Intraabdominal Abscess

0,2%

Pulmonary Embolism

0,3-1,1%

Mortality

0,3%

AFTER

Healing process after laser intervention (Endovenous Thermal Ablation) to the patient with varicose veins

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Endocrine Surgery

DEPARTMENT OF NEUROSURGERY

Distribution of Operations by Years

120

22.27%

100 80

Number of surgical interventions in Year 2015:

46.44%

40 20 2013

2014

Number of Operations

2013

2014

Distribution of Patients Who Developed Morbidity 5.88%

cases

31.27%

2015

1. Surgical Interventions

Morbidity

247 13117

Number of special surgical interventions:

5.88%

29.41%

5.88%

2015

Breast Surgery

17.64% 29.41%

4.61% 6.92%

12.19%

10.76%

5.48% Increase in Neurological Deficits

15.38%

26.15% 36.15%

Wound Problem

12.19%

70.12%

Infection

Neurology Tumor Council • Neurosurgeons • Neurologists • Endocrinologists • Medical Oncologists

CSF fistula Epidural Hematoma

• Radiation Oncologists

Pulmonary Embolism

• Neuroradiologists

Hypocortisolemia

• Physiatrists

Modified Radical Mastectomy

MRM (Modified Radical Mastectomy)

Simple Mastectomy

Mastectomy

Segmented Mastectomy +/- Axillary

Breast Conserving Surgery (BCS)

1000

800

Sentinel Node Dissection /Axillary

(Segmented Mastectomy +/- Axillary Sentinel

600

Dissection

Node Dissection /Axillary Dissection)

Excision of Cyst / Tumor

Benign Breast

Distribution of Surgeries By Disease Groups

1200

400

200

Cyst Puncture / Abscess Drainage

Revision Procedures

2015

Follow-up Examination Surgery

dr o

ph a

Tr au m

0 an Neu d ro sp -o in nc al ol Ne co og ur rd y ov tu bra as m in cu or lar s AV a M ne u sa r Pi nd ysm tu ita AV s ry Fs gl an d su rg er m Sp y i i n Sp im nal in all su al y i rg su nv er rg as y, er ive y, in co st m ru p m lic en at Pe tati ed on rip he ra ln er ve Fu br nc ain tio st nal im d ul ee at p io n

2014

Physical Examination

2013

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

2. New Operating Theater Technologies

3. Cases

• Surgeries are started to be performed, in this year, using cutting edge technology Zeiss Pentero 900 operating microscope with 3D recording and imaging system, that enables fluorescent guided tumor surgery, perioperative ICG angiography and navigation. • This system is first used at this hospital in Turkey and tumors are stained with sodium fluorescein and intraoperatively visualized with a special filter system. • Again, Hitachi Aloka Neuroultrasound system, which can be integrated to Medtronic Stealth Station 7 neuronavigation system, is started to be used for intraoperative imaging in this year.

40 year-old male patient. Right pontocerebellar angle tumor. Microscopic total tumor resection is performed with fluorescein guided navigation and neuromonitoring.

26-year old female patient. Right perisylvian low-grade glial tumor is totally resected with fluorescein guidance and neuronavigation.

Our operating theater equipped with cutting edge technology during a cranial surgery.

56 years old patient with pituitary macroadenoma is operated with trans-sphenoidal microscopic / endoscopic approach. Pre- and post-operative MRI scans verified total resection of the mass lesion. Image obtained with Zeiss Pentero 900 microscope with Yellow-560 ﬁlter in a Na-ﬂuorescein guided intracranial tumor surgery.

Use of neuronavigation in pituitary gland surgery.

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

UROLOGY CLINIC

Patient and Surgery Data Distribution of Number of Patients By Years

Total number of outpatients between 2013 and 2015:

11.841 increase in comparison with Year 2014.

40%

Number of Patients

7000 5250 3500 1750 0

2013

2014

2015

Outpatient Procedures Approximately 1500 procedures in total are performed at outpatient settings in Year 2015; such as uroflowmetry, PVR measurement, EDSWT, urethral catheterization, ICI, and intracavitary therapy.

increase in number of operations in comparison with Year 2014.

82%

Distribution of Number of Patients By Years Number of Operations

700 525 350 175 0

2013

2014

2015

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Clinical and Surgical Outcomes

Microscopic TESE:

Shock Wave Method in Erectile Dysfunction is started to be used by Urology Team of Liv Hospital for the very first time in this country.

71%

recovery rate

with shockwave treatment

85%

recovery rate

in minimal-moderate cases

53%

recovery rate in severe cases

Microscopic TESE: microsurgical sperm retrival in male reproductive disorders

Sperm is retrieved with microsurgical TESE in

68%

of patients, who have no history of prior surgery.

Flexible Ureterorenoscopy (Retrograde Intrarenal Surgery): We can treat calculus of kidney by inserting flexible ureterorenoscope, which has steerable tip, into external urethral meatus.

Microsurgical Varicocelectomy: In microsurgical varicocelectomy, no post-operative pain is experienced thanks to subinguinal incision measuring 1.5 to 2 cm in length. Average surgical duration is 40 minutes, and average hospitalization period is 6 hours. We observed recurrence (30-40%), hydrocele (20-30%) and testicular atrophy (5-10%), which are all observed when conventional methods are used, in none of our cases in 3 years.

Steno-free status with flexible ureterorenoscope in first session:

92% 100% Second session:

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Robotic Pyeloplasty: Pyeloplasty is preferred for strictures located at junction of kidney and ureter. This procedure can be performed with open, laparoscopic or robotic methods. We use robotic pyeloplasty method in this group of patients due to ease of placing suture, imaging quality and delicacy of surgical instruments. Mean hospitalization is 2 days, mean surgical duration is 60 minutes and surgical success rate is 100% with this method.

Mini Percutaneous Nephrolithotomy (MiniPerc): Sometimes, stones measuring 1 cm in size at localization of inferior or middle pole cannot be reached with flexible ureterorenoscope due to abnormal renal anatomy. In this group of patients, a small incision (0.5 cm) is made on back of the patient and stone is removed. In those cases, rate of stone-free status is 100%, mean hospitalization is 2 days and mean surgical duration is 40 minutes.

Robotic Radical Prostatectomy: Robotic radical prostatectomy is commonly used worldwide in patients, who are diagnosed with prostate cancer, for radical prostate surgeries. Prostate gland is located at deepest level of pelvic cavity and the gland is surrounded by a large neurovascular plexus. We obtain successful outcomes thanks to imaging quality and delicate moves of devices. Robotic prostate surgeries are performed using DaVinci robot since the foundation of this hospital.

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Unusual Case-1: Balloon Dilatation Method in Suturation of Lower End of the Ureter The patient, who underwent vaginal hysterectomy abroad, presented to our clinic with complaints of right lumbar pain and hydroneph-

DEPARTMENT OF CARDIOVASCULAR SURGERY

rosis. Possibly, suturation of lower end of right ureter was present. Guide wire was placed with ureteroscopic approach, and dilatation was achieved with balloon dilatation without need to open method, and Double J catheter could be placed. Last imaging study was retrograde ureterography, which was scanned 6 weeks after operation, while Double J stent was removed.

Groups of Patients Treated

36% 54% 10%

Geriatric Patient Congenital Heart Conditions

An image of robotic mitral valve surgery

Other

Coronary By-pass Surgery

Unusual Case-2: Laser Prostatectomy in 100-Year Old Patient Our 100-year old international patient, who was bound to live with catheter as patient was considered as â&#x20AC;&#x153;inoperableâ&#x20AC;?, could be

We pay great attention to define surgery strategies for in coronary by-pass to protect the patient for the longest possible time. Therefore, we commonly use breast artery that is considered as gold standard. At least one chest artery is used in 98% of our patients. On the other hand, bilateral breast arteries are used in 30% of patients, and when total number of breast arteries is considered, it is found that breast artery is preferred in 60% of patients.

returned back to normal catheter-free life again 1 year after two-stage laser prostatectomy was performed with closed method on hyperplasic prostate gland (prostatic size was 7 folds larger than normal gland). Major advantages of laser surgery include bleeding-free surgery and low complication rates in senior patients. Spontaneous voiding could be achieved in this patient, who traveled back to home country with no urinary catheter. Cryoablation procedure is performed to correct rhythm disorders during robotic mitral valve surgery.

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Minimally Invasive Heart Surgery

Correct Assessment in Valve Surgeries Valve surgeries are performed alone or in combination with coronary by-pass surgeries. Native valve tissue is conserved in repair procedures in 30% of our patients. Approximately 50% of prosthetic valves we use are biological valves those do not require use of blood thinner. Robotic surgery methods are successfully used in isolated repairs of mitral valve.

We successfully perform by-pass surgeries in our clinic. Breast artery (internal mammary artery) is prepared and blood supply is bypassed between ribs through an approximately 3-4 cm incision with robotic method. Hybrid approaches are preferred in selected patients.

Little Hearts Congenital heart conditions are successfully treated in our clinic. While anesthesia induction and heart surgery is not possible for children <10 kg in many clinics, these operations can be successfully performed in Cardiovascular Surgery Clinic of Liv Hospital.

3-cm incision in a patient who underwent robotic mitral valve repair.

High-Risk Patients Expected mortality rate according to international risk scoring systems:

Heart surgery of a 27-week preterm baby (body weight = 600 g)

9.6% 4.7%

We discharged our neonate patient, who underwent surgery while body weight was 1200 g, after body weight is increased up to 2000 g.

The score we achieved:

A 2-year old patient, who underwent complete surgical correction of Tetralogy of Fallot

Surgeon on console in a robotic surgery

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

THORACIC SURGERY

Surgical intervention

19.44%

Morbidity

PEDIATRIC SURGERY

Lung Resection / Cancer, Metastasis, Benign Tumor Lobectomy,

37.5%

Segmentectomy, Pneumonectomy, Wedge Resection

• Genitourinary

system • Oncological Surgery

• Thoracic

Surgery • Neonatal Congenital Disorders • Reconstructive Surgery

Videothoracoscopic Surgeries Mediastinoscopy/mediastinotomy

14.90%

Minimally Invasive repair of “pectus excavatum”

Mortality

• Gastrointestinal

27.77%

Invasive thymoma

2013

Thoracic Wall Tumor Tube Thoracostomy, Biopsy, Foreign body, Bronchoscopy etc.

4.16% 1.38% 1.38% 8.33%

Distribution of Patients By Years

2014

48.62% 36.47%

2015

Case Presentation

Mediastinal bronchogenic cyst

Mediastinal tumor Recurrent neuroblastoma. Intraabdominal metastatic tumors

Thoracotomy

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

OTORHINOLARYNGOLOGY and HEAD&NECK SURGERY

In our Otorhinolaryngology Clinic, special cases, who can be treated in only several leading healthcare facilities worldwide, are treated along with basic surgical interventions for otorhinolaryngologic diseases. Specialized surgeries are carried out, such as endoscopic anterior skull base surgery with navigation guidance, free flap reconstructions with microvascular anastomosis and tracheal end-to-end anastomosis in tracheal stenosis along with cochlear implantation for patients with total sensorineural hearing loss.

6000 5000 4000 3000 2000 1000 0

2013

Physical Examinatio

2014

2015

Follow-up Examination

Surgery

3.44%

Ear Surgery

31.03% 48.3%

17.24%

12.82%

Nasal Surgery

20.51%

66.66%

6.66% 2.22% 24.44%

4.44%

Head & Neck Cancer Surgery

1.11%

13.33%

Endolaryngeal laser surgery Parotid gland cancer Oral cavity cancers Paranasal sinus cancer Partial larynx surgery with open technique Total laryngectomy Thyroid cancer

7.77%

29.73%

5.40% 2.7%

Head & Neck surgery

6.76%

8.1%

1.35% 1.35%

1.35%

12.16% 21.62%

Septoplasty + Radiofrequency reduction of hypertrophic nasal turbinate Functional Endoscopic Sinus Surgery Rhinoplasty

15%

Oropharyngeal Surgery

9.46%

Tympano-mastoidectomy Stapedectomy Cochlear Implantation Resection of glomus tympanicum

Tonsillectomy + Adenoidectomy Uvulopalatopharyngoplasty 85%

Heminglossectomy+ neck dissection + free flap Intraoral tumor resection + pedicle flap Partial glossectomy + Neck dissection Laryngectomy + Neck dissection Neck dissection Hemifacial resection + Free flap Parotidectomy Thyroidectomy Resection of Pterygopalatin fossa tumor Excision of glomus caroticum Endolaryngeal laser surgery

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Partial Surgeries

Tongue Cancer

Thanks to the partial larynx cancer surgery, patients can continue an ordinary life as they can speak normally and are fed by mouth without tracheostomy.

Tongue cancer is among intraoral cancers and the only treatment option is surgery. Thanks to the free tissue flaps with microvascular anastomosis after surgical resection of tongue cancer, speaking ability is completely normal and patient can be fed by mouth and resume ordinary life activities.

Supraglottic larynx cancer

Free tissue reconstruction with microvascular anastomosis Supracricoid larynx cancer

Case Presentation 64 years old male patient; tongue cancer has been reconstructed with radial forearm free flap and patient continues ordinary daily life. Early stage larynx cancers and vocal cord tumors are treated with laser surgery (intraoral approach) and patients are discharged to home in same day at cancer-free status.

Endolaryngeal Laser Surgery Transoral Endoscopic Partial Cordectomy

Free tissue reconstruction with microvascular anastomosis

MEDICAL ACTIVITY REPORT 2015 32 years old female patient, tongue cancer. Patient is able to continue daily life without any disorder in speaking thanks to the free flap reconstruction with microvascular anastomosis following surgical resection.

CLINICAL ACTIVITIES

Tongue Base Cancer that involves Larynx 32 years old female patient, tongue cancer. Patient is able to continue daily life without any disorder in speaking thanks to the free flap reconstruction with microvascular anastomosis following surgical resection.

Free tissue reconstruction with microvascular anastomosis

Posterior Pharyngeal Wall Cancer

Free tissue reconstruction with microvascular anastomosis

MEDICAL ACTIVITY REPORT 2015

Intraoperative Radiotherapy Intraoperative radiotherapy, representing the highest technology, is first performed to treat advanced stage head & neck cancers at Otorhinolaryngology Clinic of Liv Hospital Ulus in Turkey.

CLINICAL ACTIVITIES

Paraganglioma Surgery Glomus caroticum surgery is the most difficult, risky and stressful operation among head & neck surgeries. This operation is successfully performed in our clinic.

Paraganglioma Cerrahisi

Cochlear Implantation

Intraoperative Radiotherapy

Thanks to the cochlear implantation surgery which is a miracle in medicine, people who cannot speak and are detached from society due to being deaf and dumb can now ensure their speaking and intelligence development like other normally-hearing individuals and they can serve the society instead of being a burden.

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

New Approaches in Treatment of Keratoconus; Recently, topo-guided laser is started to be used for visual rehabilitation following crosslinking therapy that became popular nowadays in treatment of keratoconus. With topo guided laser therapy, the difference between intact corneal surface and irregularities secondary to corneal disease or trauma is calculated by computer and only these parts are corrected. After corneal surface is smoothened, visual accuracy is increased (R 2). We successfully perform these therapies in our clinic since 2013.

OPHTALMOLOGY CLINIC

4000

450

3500

400

3000

350

2500

300

2000

250

1500

200

1000

150

500

100

2014

2015

Physical Follow-up Examination Examination

50 0

Phacoemulsification Retinal Surgery

2013

2014

Laser

Other

2015

TWe use novel technology from diagnosis to treatment; the devices we use at outpatient clinic and during surgical interventions are products of the latest technology. Here are some examples of our surgical interventions in which complication rates are decreased as advantages of technical equipment and surgical knowledge are combined. Femtosecond Cataract Surgery, Multifocal and Toric Intraocular Lens Implantation; Femtosecond cataract surgery is a technique that is developed recently and increases visual outcomes especially in premium-group lenses (multifocal and multifocal toric*). With this technique, some parts of surgery are performed with femtosecond laser and therefore, placement of lens and the targeted correction become more accurate (R 1). Lenses implanted after cataract surgery eliminate myopia, hyperopia and astigmatism. Verion device ensures perfect positioning of toric lenses. *Multifocal lenses provide clear near, distant and middle vision without using eyeglasses.

R.2. Preoperative and postoperative aberration values of transepithelial topolink PRK+CXL, topography and difference maps are seen.

R I. Determining lens position with Verion device

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Femtosecond Laser Lamellar Keratoplasty; Lamellar and full-thickness keratoplasties (penetrating keratoplasty) are performed in our clinic. We carried out Femtosecond laser lamellar keratoplasty this year for the first time. We planned this surgery one year ago, but we could perform it with one-year delay due to cornea supply. Advantage of this technique is the ability to perform transplantation without using suture, resulting with elimination of astigmatism secondary to suture. It is performed for the first time in our country. Pre- and post-operative OCT and anterior segment images of our patient (R3)

In our unit, we also have another fundus camera which we use for color fundus photography and angiography.

R 6. B-Ultrasound image of a patient who we have operated for proliferative vitreoretinopathy.

R 5. Ultrasonic biomicroscopy of anterior segment, biometry; A-scan and B-scan of posterior segment with high-resolution is possible with Ellex Eyecube ultrasonography device that we currently use in our outpatient clinic.

The novel YAG laser device in our clinic enables capsulotomy and iridotomy, while selective laser trabeculoplasty is used to control intraocular pressure. (R 7)

R 7 Yag laser and SLT device

R 3 femtosecond laser lamellar keratoplasty. Pre- and post-operative

Some of specialized surgeries that we performed PPV+keratoplasty; highest technology, surgical material and equipment are used in all ophthalmic surgeries. When considered with corporate reliability, our department makes a difference. On the contrary to conventional Argon Laser devices, pattern laser photocoagulator substantially shorten laser shot time and treatment is completed in shorter time, since pattern scans are used. Pain-free treatment is possible with this device, which is available only in several ophthalmology clinics in our country (R 8)

Retinal Applications and Equipment In diagnosis, it is possible to obtain high-resolution real time video angiography images and OCT images â&#x20AC;&#x201C; nearly equal to pathology sections in image quality - with Heidelberg OCT-FFA-ICG combined device (R 4). Normal OCT

Traumatic macular hole.

Postoperative

R 8 Pattern laser photocoagulator

R 4 Pre- and post-operative image of a patient with traumatic macular hole

MEDICAL ACTIVITY REPORT 2015 Leica F40 surgery microscope that is used in operating rooms is a very advanced model that provides 3D real image also for assistant. It is also equipped with a video recording system that helps recording during surgery (R 9)

CLINICAL ACTIVITIES

Monoblock wide-angle RUV 800 system visualizes retina in posterior segment surgeries and the system provides non-contact high-resolution images (R 10)

ORTHOPEDICS AND TRAUMATOLOGY Number of Outpatients

Number of Operations

Number of Consultations

11.623 2.224 241 Orthopedics and Traumatology 2015 Patient Data %13,5

%2,69

%20,09 %41

R 10 Wide-angle RUV 800 system

R 9 Operating microscope

Spinal Surgery Arthroplasty Sports Surgery Orthopedic Trauma Surgery Hand Surgery Pediatric Orthopedics

%18,03 %13,5

We are one of the AoSpine Europe Education Centers in Turkey. International Fellow program is started.

MakoPlasty

Retinal detachment surgery with air tamponade

Spinal Surgery

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Special Case

Spinal robot is used only in our facility in Turkey. Thanks to this technology, error margin is zeroed for spinal implants.

20 years old patient, Advanced scoliosis

AOSpine Spine Centers Spine Center of Liv Hospital has been selected as the only AOSpine European Education Center in our country since 2016 for 3 years and has started the first international fellow education in this end.

12 years old patient, Advanced scoliosis surgery

Alphatec Spine Education Center Spine Center of Liv Hospital has been selected as Middle East Spine Education Center by Alphatec Spine. Accordingly, spine surgeons in middle east region started visiting our center for education.

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

GYNECOLOGY AND OBSTETRICS

Total number of patients 8000 7000 6000 5000 4000 3000 2000 1000 0 2013

2014

2015

Obstetrics (Delivery) 800 700 600 500 400 300 8 MAKOplasties (Robotic Unicondylar Knee Prosthesis) in 2015

200 100 0

Normal delivery

Caesarean section

2013

Level II Ultrasound Scan

2014

Number of Double Tests

NST (Number of Patients)

2015

Comparative, Data for Year 2013, 2014 and 2015 1200 1000 800 600 400 200 0

Major Surgery

Minor Surgery

Delivery

2013

2015

2014

IVF Cycle

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

• Single-Port Robotic Surgery Operation

Hysterectomy surgeries have been performed in three appropriate indications in our clinic in this year. • Thanks to this method that is superior regarding cosmetic outcomes, wound is hidden by umbilicus and patient will have no barely visible incision scar. Diaphragmatic peel in ovarian tumor; tumor inﬁltration

Gynecologic and cancer surgeries are successfully carried out with endoscopic method in obese patients.

Paraaortic lymphadenectomy in ovarian tumor

Giant ovarian lesion

Single Port

Gynecologic and cancer surgeries are successfully carried out with endoscopic method in obese

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Cardiac Imaging

CARDIOLOGY CLINIC

• Invasive Cardiology • Cardiac Imaging • Cardiac Electrophysiology

Cardiac Catheterization and Coronary Angiography Laboratory from 2013 to 2015:

Door-to-balloon time for all patients Mortality rate of elective and emergency cases in hospital Bioresorbable vascular scaffolds (bioabsorbable stents) Drug eluting metallic stents Plain metallic stents Balloon and stent procedures are performed for patients, who are admitted to the emergency service due to heart attack, within less than 60 minutes.

60 min. 0% 30% 61% 9%

The patient, who presented with heart attack, is immediately started on two blood thinner agents.

100% 60 minutes

Bioabsorbable or metallic drug eluting stent is implanted to 9 out of every ten patients.

Success rate is 100% in emergency-planned cases.

Bio ab

le rbab so

ng uti el

2800 Cases

Advanced echocardiography applications • 4D echocardiography • 2D and 4D transesophageal echocardiography (TEE) • Subclinic cardiac dysfunction analysis (Speckle tracking) • Subclinic atherosclerosis imaging (Measurement of carotid intimal-medial thickness) • Stress echocardiography • Carotid Doppler ultrasound • Optimizing dyssynchrony evaluation for Cardiac resynchronization therapy (CRT) • Intraoperative TEE are performed.

100%

90%

Totally, 6656 cardiac imaging studies are performed from 07.01.2013 to 31.12.2015 in our imaging laboratory and distributions of imaging studies are as follows.

Trans-thoracic Echocardiography • 2D and 4D echocardiography • 2D echocardiography • 2D and 4D Speckle Tracking • CRT optimization • Stress echocardiography

Dru g

Transesophageal Echocardiography Bifurcation Interventions Pre

Post

DK Cruch Stent Technique

• 2D and 4D TEE • 2D and 4D intraoperative TEE • Complication • Procedure duration is

Doppler Ultrasound Scan of Carotid + Vertebral Arteries

92.3% 31% 44% 18% 5% 2%

2.72% 84.5% 16.5% 0% 25 min in average

4.7%

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Cardiac Electrophysiology

Pacemaker implantations account for one third of outpatient clinic services rendered from 2013 and 2015

GASTROENTEROHEPATOLOGY 7%

16%

18%

59%

SVT AT-Flatter AF VT

AT-Flatter: Atrial tachycardia and ﬂatter; AF: Atrial ﬁbrillation; VT: Ventricular tachycardia; SVT: Supraventricular tachycardia

Outpatient Clinic Services Education campus for doctors from

84 countries

Number of Patients

450 400 350 300 250

with cooperation of Liv Hospital and FUJİ FİLM

200 150 100 50

In all Catheter Ablation Procedures • Success rate 93% • Serious complication rate 0,9% • Minor complication rate 1,8%

January February March

ICD implantation Cardiac resynchronization therapy (three-cable pacemaker) Two-cable pacemaker implantation Battery replacement Single-cable pacemaker implantation Removal of electrode and placement of new electrode Revision of battery pouch

June

July

August SeptemberOctober NovemberDecember

Endoscopic Procedures Upper gastrointestinal system endoscopy Lower gastrointestinal system endoscopy Enteroscopy Endosonography

Patient rates 28.28% 21.71% 23.73% 18.68% 4.04% 2.52% 1.01%

The most important complication of pacemaker implantation is infection. Infections that develop within postoperative Year 1 is related with the operation. Infection rate increased compared to the past. The reason is arising out of more complicated operations, since more complex pacemakers with more cables are started to be used, more run-down batteries are replaced and more worn pacemaker cables are renewed. Mean infection risk in first one year is reported as 1.5%. However, risk of infection increases 5-7 times in three-cable pacemakers and 3-4 times in battery changes. As it can be seen on the table above, a critical number of three-cable pacemakers is implanted and battery changes are made in our hospital. Nevertheless, no pacemaker device infection is seen in our three-year follow-up. Success rate of three-cable pacemaker implantation with transvenous approach is 90% in cardiac resynchronization therapy. Most important cause of failure is inability to place the third cable, which is positioned in left ventricle, due to anatomic difficulties. Three-cable pacemaker implantations are 100% successful in our hospital. 68

May

Distribution of Outpatients by Month

List of Pacemaker Procedures that Have Been Performed in Our Hospital So Far are given in Table 1. Procedure Type

April

Video Capsule Endoscopy Images

Balloon Enterescopy Angiodysplasia

Type I Ectasic Lesions, Jejunum

59.07% 38.78% 0.84% 0.54%

Stent Placement in Esophageal Tumor

Barett-Esophagitis, Radiofrequency Ablation Therapy

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Fibroscan

PULMONARY DISEASES DEPARTMENT

Fibroscan is mostly used for patients with steatohepatitis and chronic C hepatitis, and advanced stage fibrosis or cirrhosis is found in 25-30% of patients. The fact that diagnosis is made with a noninvasive method in this group of patients rather than liver biopsy makes an important difference and increased patient satisfaction.

EBUS accounts for

46.32% 10.43%

Interventional Radiology Procedures

increase in number of patients in comparison with Year 2014.

Chemoembolization (TAKE) is performed in 40.54% of 37 patients, who are followed by Interventional Radiology and Hepatobiliary Surgery Clinics within principle of multidisciplinary approach, while radiofrequency ablation (RFA) is performed in 54.05% of patients and transjugular intra-hepatic portosystemic shunt (UPS) therapy is given to 5.40% of patients.

of FOB applications

“Smoking Cessation Outpatient Clinic” has been admitting patients since April, 2015 and “Breath Therapy Outpatient Clinic” has been serving patients since October, 2015.

350 300 250 200 66 years old patient with hepatocellular carcinoma was not eligible for surgery since the tumor was at central localization and multiple foci were observed. Thus, patient was treated with 2 sessions of chemoembolization. Angiography and MRI images before and after procedure

150 100 50 0

January February

March

April

May

2013

June

2014

July

August September October November December

2015

89 years old patient with hepatocellular carcinoma, who is not eligible for surgery. MRI scans before RF ablation and CT scans after treatment

Portal vein

TIPS STENT

Opening right common branch, which is fully occluded by tumor, with Argon Plasma Coagulation (APC)

No re-stenosis is found on Doppler and venography of TIPS shunting of 62 years old patient (emergency surgery)

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

ENDOCRIONOLOGY AND METABOLIC DISEASES

Pulmonology Department - Quality Indicators • Pulmonary thromboembolism prophylaxis rate in >60 years old patients who are hospitalized: %90 • Pulmonary rehabilitation is started for 70 % of COPD patients within the first 48 hours after hospitalization

• Rate of re-admission within 30 days in patients who are hospitalized with severe COPD: 8%. The same rate for patients with

January 2013 - December 2015 350 300 250 200 150 100 50 0 Placement of Pleurocan

January February

March

April

May

2013

June

2014

July

August September October November December

2015

EBUS

Patient Training Meetings: Diabetes Breakfasts Endobronchial valve placement in emphysema

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Treatment of Pain due to Fibromyalgia

ALGOLOGY CLINIC

Thoracic Paravertebral Radiofrequency Thermocoagulation Complication 0% Activity Success 80%

Treatment Fields: • Neck and arm pains secondary to cervical hernia, and lumbar and leg pain secondary to lumbar hernia, • Neck and back pains secondary to fibromyalgia, • Migraine and tension type headaches, • Pains secondary to Shingles, • Cancer pains, • Pains secondary to spinal cord damage,

• Phantom pain secondary to amputation of arm and leg, • Peripheral neuropathy pain secondary to conditions such as diabetes mellitus, • Pains secondary to peripheral vascular diseases arising out of circulatory failure are treated.

• Pains secondary to compression of nerve root due to postoperative fibroses in lumbar and cervical regions,

18.79%

Treatment of Pain due to Osteoarthrisis of Knee Intraarticular Pulsed Radiofrequency Thermocoagulation for Knee Joint Complication 0% Activity Success 75%

22.60%

New Patient Follow-up patient.

3.26%

Consultation Order Non-Cancer Pain Cancer Pain 19.67%

19.33%

Intervention

16.35%

Rotator Kuff Sendromuna Bağlı Omuz Ağrı Tedavisi

Distribution Rates Of Patients Placed on Treatment of Low Back Pain and Leg Pain Secondary To Lumbar Hernia Radiofrequency Thermocoagulation of Lumbar Dorsal Root Ganglion Radiofrequency Thermocoagulation of Lumbar Facet Median Nerve Lumbar Transforaminal Steroid Injection Complication Activity Success

Treatment of Shoulder Pain due to Rotator Cuff Syndrome Complication 0% Activity Success 75%

42.8% 54.2% 2.85% 0% 75%

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

NEUROLOGY CLINIC AND ELECTRONEURODIAGNOSTIC LABORATORY

• In

our Neurology Outpatient Clinic, medical care services are rendered for cerebrovascular diseases, multiple sclerosis, movement disorders, neuromuscular diseases, epilepsy, dementia, neuro-oncology, neuro-infection, and Pediatric Neurology services are rendered for children. • In our Electroneurodiagnostic Laboratory, all tests comply with international standards and relevant medical conditions are diagnosed.

EMG Laboratory Procedures

PSYCHIATRY AND PSYCHOLOGY Distribution of Patients By Years

Distribution of Patients in 2015

8.07%

23.34% 68.58%

2015 2014 2013

Total number of interviews at outpatient clinic

35.92% 62.56%

Total number of interviews at inpatient clinic

Psycho-Oncology

1.68% 1.12% 0.56% 0.28% 3.37% 5.61%

EMG SEP VEP %87.32

RR interval Tremor recording Single Fiber EMG EMG-guided Botox Injection

Bariatric surgery awareness meeting is performed regularly for preoperative sleeve gastrectomy patients.

• In our Neurology Clinic, neuromonitoring service is rendered for all indicated operations (all brain surgeries, all brain stem/

posterior fossa / angle surgeries, all spinal cord surgeries, all plexus and peripheral nerve operations). • In our Migraine Outpatient Clinic, the target is to follow up patient with “no medicine” by cooperating with Nutrition Outpatient Clinic in order to plan patient-specific diet, and successful outcomes are obtained. • In our inpatients, ‘zero bed sore’ is targeted with the help of qualified nursing care and successful results are obtained. • Patients with chronic conditions such as CVD and Parkinson’s Disease are placed on rehabilitation, in cooperation with Physical Medicine and Rehabilitation Clinic, in order to enable patients resume daily life activities within possible shortest time and successful outcomes are obtained.

Group therapy for support program “Journey with Cancer”

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

REGENERATIVE MEDICINE - STEM CELL GROWTH CENTER

SVF Procedure 6 5 4

LivMedCell is the pioneer in the field of “cellular therapy” in our country by closely monitoring recent developments worldwide. LivMedCell produces cellular products in its laboratory where best manufacturing principles are met, as approved by Ministry of Health. LivMedCell has served many clinics with cellular products produced in GMP laboratory in 2015. Moreover, it has presented scientific gains in many local and international congresses and it continues contributing to global science with published studies.

3 2 1 0

October December January

February

March

April

Liv Hospital

May

June

July

August September Octobar November December

Other Institutions

Number of stromal vascular fraction procedures carried out by Liv Hospital LiveMedcell

Fibroblast Product Release

Flow Cytometry Procedure

16 14

10 8

6 4

October December January

February

March

April

May

Liv Hospital

June

July

August September October November December

Other Institutions

October December January

February

March

April

Liv Hospital

Liv Hospital LivMedcell Annual Fibroblast Product Release

May

June

July

August September Octobar November December

Other Institutions Liv Hospital LivMedcell annual ﬂow cytometry analysis report

Mesenchymal Stem Cell Product Release 25 20 15 Duchenne Muscular Dystrophy (DMD) Project

10 5 0

October December January

February

March

April

Liv Hospital

May

June

July

August September October November December

Other Institutions

Liv Hospital LivMedcell Annual Mesenchymal Stem Cell Product Release

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

What We Did Besides Routine Procedures In 2015

NUCLEAR MEDICINE AND MOLECULAR IMAGING

In Diagnostic Division of Nuclear Medicine Department • Gama Meter

• Two Lead Armored Therapy Rooms

• PEM

• Hot Lab (the division where

• Gama Probe

• Gamma Camera

Radioactive Substances are Prepared) • Stress Test Unit exists

• Gama Meter

• Gama Probe

Post-treatment period

Pre-treatment Period

In Therapeutic Division of Nuclear Medicine Department;

• PET /CT

• C14 Device

Post-treatment period

• Hot

Lab (the division where Radioactive Substances are Prepared)

Procedures Carried Out in Nuclear Medicine Department

Therapy Procedures with Local and Systemic Radionuclides

• In Nuclear Medicine Department, both diagnostic

• Radioimmunotherapy (Yttrium-90 (Y90 )�

imaging and radionuclide therapy procedures are performed. • Radioactive Iodine therapy

• Radioembolization (Y90 Micro-sphere Therapy) • Radionuclide Therapy of Metastatic Bone Pains

We Appended Our Signature Under Diagnoses of Very Rare Diseases

• Radionuclide Synovectomy

Distinctive Features of Nuclear Medicine and Molecular Imaging Department Comparing to Other Clinics at Same Field • The best evaluation, reporting and therapy for each

• Personalized evaluation and up-to-date diagnostic and

patient based on analytical approach at international level • Perfectionism • Experienced practitioner and technical crew with certifications at international standards

therapeutic approaches at academic level

1800 1600 1400 1200

Data Of Nuclear Medicine And Molecular Imaging Department

1000

Outpatient

ERDHEIM CHESTER DISEASE The number of patients who are diagnosed with this disease since 1930 is less than 500, as reported in the literature.

Inpatient

800 600 400 200 0

2013

2014

2015 81

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

PHYSICAL MEDICINE AND REHABILITATION

Physical Medicine and Rehabilitation is a field of science that deals with diagnosis and treatment of many diseases including joint, muscle and tendon diseases, spine problems, osteoporosis, rehabilitation after orthopedic surgeries, rehabilitation of neurological diseases such as stroke, Parkinson, multiple sclerosis and rehabilitation after fractures.

Distribution of Patients By Years

PEDIATRICS

Our Pediatrics Clinic Our clinic provides trustable and qualified diagnostic and therapeutic services successfully by using most current therapy approaches with team of specialists in branches like pediatric hematology, pediatric endocrinology, pediatric allergic diseases and pulmonary diseases, pediatric nephrology and pediatric cardiology.

1200

Neonatal Intensive Care Unit Equipped with Novel Technology

1000

600

In Neonatal Intensive Care Unit, a separate room is reserved for each incubator for the first time in Turkey. Infection rate in the unit is only 2% since each patient is given medical care in a separate room. This number is 15-20% in average around the world.

400

Infection Rate

800

200 0

2013

2014

2015

International infection rate

15-20%

Distribution of Physical Medicine and Rehabilitation Patients in 2015

Total Number of Births and NICU admissions 50 45 40 35 30 25 20

3.26%

15 10

16.25%

5 0

30.96%

January

February

March

April

May

June

Total Number Of Births

July

August September October November December

Number of NICU patients

20.13%

29.3%

Spinal problems Rehabilitation after orthopedic surgery Joint and tendon diseases Neurological rehabilitation Other 82

Rehabilitation after orthopedic surgery

MEDICAL ACTIVITY REPORT 2015 Rate of discharge for babies who tolerate breastfeeding

CLINICAL ACTIVITIES

97%

MEDICAL ONCOLOGY Mortality and Morbidity Secondary to Chemotherapy

Data for Year 2015

3500 3000 2500

Immunotherapies that have promising outcomes in various cancers (i.e., malignant melanoma and lung cancer) such as ipilulumab, pembrolizumab and nivolumab are available in the clinic, along with conventional chemotherapies. Our patients are given novel therapies approved by FDA such as pertuzumab that blocks Her2 pathway in metastatic breast cancer when combined with trastuzumab and ramucirumab which is a new therapy option for patients with stomach cancer. 7000

2000

6000

1500

5000 4000

1000

Outpatient Inpatient

3000 2000

500

1000 Pe dia tri cN eu Pe ro dia log tri y cE nd oc rin olo Pe gy dia tri Im c Al m ler un gy Pe olo & dia gy tri cC Pe a rd dia iol tri og cG y as tro en ter olo Pe dia gy tri cH em ato log Pe dia y tri cP sy ch iat Ch ry ild De ve lop m en Ge t ne ra lP ed iat ric s

Number of Outpatients

Number of Consultations

Number of Invasive Procedures

2013

2014

2015

134 Tumor Council meetings are held

Thanks to immunotherapy, a new approach of medical treatment in cancer, immune system of body can be improved and growth and spread of cancer cells can be prevented.

MEDICAL ACTIVITY REPORT 2015

RADIATION ONCOLOGY

Distribution of Patients Treated with TrueBeam STX

13%

CLINICAL ACTIVITIES

CHECK-UP CLINIC

Distribution by Type of Therapy

Our check up controls has increased by

350%

1% 35%

65%

86% IMRT CRS Conformal

in 3 years

Curative therapy/CRS Palliative therapy

Number of Outpatients Number of Patients Who Received Radiotherapy

Number of Patients in 2015 Number of patients who are presented to this department within a year is as follows: Although we had 1.733 controls in 2013, this figure is increased by 350% in 3 years. If we consider help of physicians from other departments during busy months, we can see that this rate is even higher.

700 600 500 400 300 200

TrueBeam STX

With IORT, an intraoperative single shot radiotherapy, high-risk tumor bed is irradiated from inside while healthy organs and tissues are conserved.

Stereotactic Radiotherapy

100 0

January

February

March

April

May

2013

June

2014

July

August September October November December

2015

Our center is a special pioneering facility in Turkey that can plan therapy with 3 Tesla MRI device at planning position with thermoplastic head masks in treatment of primary tumors and metastases of central nervous system.

Thermoplastic head mask

3-Tesla MRI at therapy planning position with mask

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Check-Up Programs • Liv Health@liv Base Package

• Liv Online Male

• Liv Standard Female

• Liv Virtual Journey in Colon – Bowel Health

• Liv Standard Male

• Live Whole Body Screening Check-Up

• Young Liv Female – up to 39 years

• Liv Coronary Angiography + Ct of Thorax Check-Up

• Young Liv Male – up to 39 years

• Liv I Do Sports

• Liv Young Plus Female – 40 to 49 years (including Mammography)

• Liv Let’s Do Sports, Children

• Liv Young Plus Female – 40 to 49 years (excluding Mammography)

• Liv Is My Caretaker Also Healthy?

• Liv Young Plus Male – 40 to 49 years

• Liv Kids 1

• Liv Active Female – 50 to 65 years (including Mammography)

• Liv Kids 2

• Liv Active Female – 50 to 65 years (excluding Mammography)

• Liv Child Check-Up Package

• Liv Active Male – 50 to 65 years

• Liv School Kid Package

• Liv Active Plus Female – 50 to 65 years (including Mammography)

• Liv Pediatric Genitourinary System Screening

• Liv Active Plus Female – 50 to 65 years (excluding Mammography)

• Liv Men’s Health Package (Wide)

• Liv Active Plus Male – 50 to 65 years

• Liv Standard Urology Package

• Executive Liv Female (including Mammography)

• Liv Prostate Package

• Executive Liv Female (excluding Mammography)

• Liv “Determine Your Heart Age”

• Liv Executive Male

• Liv Spring Check-Up

• Live Shape Advanced Cardiac Diagnosis Program

• Liv Health@liv Mobile Base Package

• Live Shape Plus Advanced Cardiac Diagnosis Program

• Liv Standard Mobile Women

• Liv Online Female

• Liv Standard Mobile Men

INTERNAL MEDICINE

We admitted thousands of both inpatients and outpatients, who have medical conditions ranging from minor diseases to most complex disorders, worldwide to the Department of Internal Medicine of Liv Hospital within past 3 years. For example, we treated lots of patients from many countries such as Germany, France, U.K. United States of America, Romania, Albania, Turkmenistan, Kazakhstan, Azerbaijan, Georgia, Saudi Arabia, Libya, Syria and Iraq. Usually, patients with more than one medical condition or complex-chronic diseases present to our hospital. Number of patients with chronic diseases increases as the society is getting older. These patients are very susceptible and it is not usually possible to predict which condition will emerge. You may face a problem, while you are making efforts to treat another one, easily resulting with a vicious cycle. A holistic approach is required for patients with chronic diseases. We have lots of colleagues who are specialized and experienced in fields of Gastroenterology, Endocrinology, Nephrology, Cardiology, Pulmonary Medicine, Oncology, Hematology, Rheumatology and Infectious Diseases. Multiple departments work in coordination for patients with systemic disorder.

Internal Medicine, Inpatient

Internal Medicine Examination 3500

300

3000

250

2500

200

2000

150

1500

100

1000

500

2013

2014

2013

2014

2015

Internal Medicine, Consultations 300

Complicated Cases

250

• 40/M: Renal Cell Carcinoma, Diffuse Metastases, Calcium 19.9

200

• 87/M: Fever, weight loss and sweating: Patient was diagnosed with Vasculitis

150

• 69/M: Glanzmann Thrombasthenia

100 50 0

2013

2014

2015

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Nephrology

Complicated Cases

1800

• 85/M, Acute cholecystitis and acute renal damage:

1600

Creatinine increased to 5.6. Percutaneous cholecystostomy • 54/M, Hemodialysis Patient: Patient is followed up with diagnoses of Aneurysm of Aorta and Septic Arthritis. • 25/M: Nephrotic syndrome, Aphthous ileitis and CMV infection. • 48/F: Chronic Renal Disease, Chronic Liver Disease (HBS +), Pancytopenia, Hepatosplenomegaly (for 3 years), Pericardial Effusion, Tamponade Risk, Malnutrition (35.5 kg)

1400 1200

Physical Examination

1000

Inpatient

800 600 400 200 0

2013

2014

2015

DERMATOLOGY AND VENEREAL DISEASES

Hospital Activities in Year 2015 10.51% 2.33%

Number of Outpatients Number of Follow-up Patients Number of Inpatient Consultations Number of Invasive Procedures

28.97% 58.18%

Invasive Procedures

Hematology

17.94%

0.32%

800 700 600 500

Physical Examination

0.86% 1.18% 1.40%

400

Inpatient

3.67% 1.08% 0.54% 2.59% 2.37%

300 200

9.51%

100 0

41.40%

8.86%

Electrocauterization Cryotherapy Skin Biopsy Fungus Screen Intra-lesional Injection Skin Prick Test Laser (Scar, Rejuvenation Therapy)

Botulinum Toxin Therapies Filler Application PRP Application Chemical Peeling Needle Radiofrequency Intralipotherapy Mesotherapy

8.21%

2013

2014

2015

Rheumatology 300 250 200

Physical Examination

150

Consultation

100 50 0

Skin rejuvenation with fractional laser

2014

Treatment of Acne scar with Dermapen

Medical Rhinoplasty

2015

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY

Difficult Cases

Mortality

0% Hospital Data For Year 2015 18.60%

Number of Outpatients Surgical Interventions at Outpatient Settings Post-Abdominoplasty Complication in U.K.

81.40%

Surgery Data for Year 2015 24.25% Repair of Diastasis Recti + Abdominoplasty

Reconstructive Surgery Aesthetic Surgery

Tubular breasts

75.75%

MEDICAL ACTIVITY REPORT 2015

CLINICAL ACTIVITIES

Surgeries Performed Jointly with Other Departments

Congenital Breast Anomaly Preoperative

Postoperative

Breast Reconstruction - Jointly with General Surgery

Preoperative

Postoperative

Body Lifting after Obesity Surgery â&#x20AC;&#x201C; Jointly with General Surgery

MEDICAL ACTIVITY REPORT 2015

Stem Cell Applications

CLINICAL ACTIVITIES

Replantation + ADRC

MEDICAL ACTIVITY REPORT 2015

SCIENTIFIC ACTIVITIES

5- Akyüz F, Uyanıkoğlu A, Ermiş F, Arıcı S, Akyuz U, Baran B, Pınarbaşı B, Gül N ‘’Gastroesophageal reflux in asymptomatic obese subjects: An esophageal impedance-pH study.’’ World J Gastroenterology March 2015, Vol 21, Issue 9.

SCIENTIFIC ACTIVITIES

6- Karakoç ZÇ, Taşçıoğlu D, Koruk ST, Şimşek B. Acute Cytomegalovirus Disease in Healthy Adult. Klimik Journal (November 2015 – accepted)

Scientific Council Meetings Scientific meetings are held regularly at pre-determined days of the week in our hospital.

Year 2015 Activity Type

Number of Meetings

Number of Patients

36 12 46 46 134

58 18 -51 764

Difficult Cases Meeting Morbidity/Mortality Doctor Conferences Heart Council Tumor Council

Local and International Letters and Verbal Presentations with contribution of Liv, Conference and Panel Talks,

386

events.

72 scientific papers in 2014 and 47 scientific papers in 2015,

120

SCI papers in total

7- Bayiz H, Özkaya S, Dirican A, Ece F The rapid effects of budesonide plus formoterol in patients with obstructive airway diseases. Des Devel Ther. 2015 Sep 21;9:5287-90. 8- Gonen I Factors influencing parental consent in a hypothetical pediatric vaccine trial in a developing country setting: A questionnaire study. Account Res. 2015;22(1):1-13. 9- Okan G, Yıldız Z, Gökdemir G, Yorulmaz E, Vural P, Doğru-Abbasoğlu S, Uysal M G-231A and G+70C polymorphisms of endothelin receptor type-A gene could affect the psoriasis area severity index score and endothelin 1 levels Indian J Dermatol. 2015 Mar-Apr;60(2):211. 10- Say EM, Okan G, Gökdemir G Treatment outcomes of long-pulsed Nd: YAG laser for two different subtypes of J Clin Aesthet Dermatol. 2015 Sep;8(9):16-20. 11- Güngör Ş, Gökdemir G, Çiçek YG, Topal İO, Canat D The effect of 25 (OH)D on endothelial and immunological markers in Behçet’s disease. J Dermatolog Treat. 2015 Oct 8:1-6. 12- Yalçın M, Kenar H, Dayı B, Şişman R, Karaöz E. The Effect of Light Curing Units on Proliferation and Senescence of Human Dental Pulp Mesenchymal Stem Cells. International Journal of Dental Sciences and Research (Accepted). 13- Aras Y, Sabancı PA, Kabataş S, Duruksu G, Subaşı C, Karaöz E.The Effects of Adipose Tissue-Derived Mesenchymal Stem Cell Transplantation During The Hyperacute and Acute Phases Following Spinal Cord Injury. Turkish Neurosurgery, (Accepted). 14- Dolanbay EG, Yardimoglu M, Yalçınkaya E, Yazır Y, Aksoy A, Karaöz E, Çalışkan E Expression of trophinin and dipeptidyl peptidase IV in endometrial co-culture in the presence of embryo: A comparative immunocytochemical study. Molecular Medicine Reports, (Accepted). 15- Cinik R, Yüksel N, Pirhan D, Aslan M, Subaşı C, Karaöz E The Effect of Everolimus on Scar Formation in Glaucoma Filtering Surgery in a Rabbit Model. Current Eye Research (Accepted). 16- Asutay F, Polat S, Gül M, Subaşı C, Kahraman SA, Karaöz E The effects of dental pulp stem cells on bone regeneration in rat calvarial defect model: Microcomputed tomography and histomorphometric analysis. Archives of Oral Biology, 60:1729-1735, 2015.

Local and International Letters and Verbal Presentations with contribution of Liv, Conference and Panel Talks

17- Gov E, Kenar H, Unal ZS, Arga KY, Karaöz E Cardiomyogenic differentiation potential of human lipoaspirate derived stem cells on hyaluronic acid/gelatin plasma gels. Turkish Journal of Biology, May, 2015.

Our surgeons participated to and submitted letters in 188 Local and International Congresses, Symposiums and Courses as visiting lecturer or trainer.

18- Yılmaz I, Sarıboyacı AE, Subaşı C, Karaoz E Differentiation Potential of Mouse Embryonic Stem Cells into Insulin Producing Cells in Pancreatic Islet Microenvironment. Exp. Clin Endocrinol Diabetes. 2015 Nov 20. [Epub ahead of print] PubMed PMID: 26588493.

Scientific Publications with Contribution of Liv

1- “Diabetes Mellitus From the Past to the Future” Editors: Prof. Şazi İmamoğlu, M.D., Prof. İlhan Satman, M.D., Prof. Sema Akalın, M.D., Assoc. Prof. Serpil Salman, M.D., Prof. Candeğer Yılmaz, M.D., December 2015-Ankara 2- Salman S, Adaş M “Management of Diabetes in Special Cases”, in the book “Diabetes Mellitus from the Past to the Future”, pages 527-536, 2015 3- Salman S, February 2015: Turkey Diabetes Foundation “Guide for Diagnosis and Treatment of Diabetes” 4- Salman S, May 2015: Turkish Association of Endocrinology and Metabolism - Guideline For Diagnosis, Treatment and Follow-up of Diabetes Mellitus and its Complications – 2015 (Updated 7th Edition) 98

19- Kasap M, Yeğenağa I, Akpınar G, Tuncay M, Aksoy A, Karaöz E Comparative Proteome Analysis of hAT-MSCs Isolated from Chronic Renal Failure Patients with Differences in Their Bone Turnover Status. PLoS One. 2015 Nov 17;10(11) 20- Öksüz S, Alagöz MŞ, Karagöz H, Küçükodac Z, Karaöz E, Duruksu G, Aksu G.Comparison of Treatments With Local Mesenchymal Stem Cells and Mesenchymal Stem Cells with Increased Vascular Endothelial Growth Factor Expression on Irradiation Injury of Expanded Skin. Ann Plast Surg. 2015 Aug;75(2):219-30. 21- Sağlam Ö, Ünal ZS, Subaşı C, Ulukaya E, Karaöz E IL-6 originated from breast cancer tissue-derived mesenchymal stromal cells may contribute to carcinogenesis. Tumor Biol. 2015 Jul;36(7):5667-77. 99

MEDICAL ACTIVITY REPORT 2015

SCIENTIFIC ACTIVITIES

22- Emre E, Yüksel N, Duruksu G, Pirhan D, Subaşı C, Erman G, Karaöz E. Neuroprotective effects of intravitreally transplanted adipose tissue and bone marrow-derived mesenchymal stem cells in an experimental ocular hypertension model. Cytotherapy. 2015 May;17(5):543-59.

36- Bilateral Diaphragm Paralysis Due To Phrenic Nerve Palsy After Two-Level Cervical Corpectomy. The Spine Journal.

23- Ozbek E, Adas G, Otunctemur A, Duruksu G, Koc B, Polat EC, Kemik Sarvan A,Okcu A, Kamali G, Subaşı C, Karaöz E Role of Mesenchymal Stem Cells Transfected With Vascular Endothelial Growth Factor in Maintaining Renal Structure and Function in Rats with Unilateral Ureteral Obstruction. Exp Clin Transplant. 2015 Jun;13(3):262-72. doi: 10.6002/ect.2014.0080. Epub 2014 Dec 22. PubMed PMID:25542189.

37- Management of Postoperative Discitis. Asian Spine Journal. (accepted, ahead of printing)

24- Hakki SS, Kayis SA, Hakki EE, Bozkurt SB, Duruksu G, Unal ZS, Turaç G, Karaoz E. Comparison of mesenchymal stem cells isolated from pulp and periodontal ligament. J Periodontol. 2015 Feb;86(2):283-91. doi:10.1902/jop.2014.140257.Epub 2014 Oct 17. PubMed PMID: 25325708. 25- Hakkı SS, Bozkurt BS, Hakkı EE, Kayış SA, Turac G, Duruksu G, Karaoz E. Isolation of palatal adipose tissue-mesenchymal stem cells (PAT-MSCs). Journal of Clinical Periodontology, Volume 42, Issue Supplement S17, Pages 259, June 2015, Abstracts of EuroPerio8, London, UK, 3-6 June 2015. 26- Kizilel S, Bal T, Karaoz E. Mesenchymal Stem Cells (MSCs) Improve Beta Cell Function within Biomimetic PEG Hydrogels. 2015 4th TERMIS World Congress, September 8–11, 2015 Boston, Massachusetts. TISSUE ENGINEERING: Part A Volume 21, Supplement 1, 2015. DOI: 10.1089/ten.tea.2015.5000.abstracts. 27- Öksüz S, Alagöz MŞ, Karagöz H, Küçükodac Z, Karaöz E, Duruksu G, Aksu G, Urhan M Comparison of Treatments with Local Mesenchymal Stem Cells and Mesenchymal Stem Cells with Increased Vascular Endothelial Growth Factor Expression on Irradiation Injury of Expanded Skin. Plast Reconstr Surg. 2015 Oct;136(4 Suppl):35-6.

Gökçen HB, Erdoğan S, Kara K, Ersözlü S, Öztürk C. Gökçen HB, Erdoğan S, Kara K, Ersözlü S, Öztürk C. 38- Author of Chapter in book “Thoracic Surgery” Assist. Prof. Ümit Aydoğmuş, M.D., Prof. Gökhan Yuncu, M.D. Chronic Mediastinitis. In Mustafa Yüksel, Akın Eraslan Balcı (Editors). Thoracic Surgery “Red Book” Second Edition Istanbul. Nobel Tıp Kitabevi 2015; 705. 39- Aydoğmuş Ü, Türk F, Yuncu G Surgical repair with palatal mucosal graft in subglottic stenosis caused by Wegener’s granulomatosis. How to do it? Turkish Journal of Thoracic and Cardiovascular Surgery 2015;23(3):595-600. 40- Antar V, Baran O, Kasımcan MO, Katar S, Kotil K. A Late Infection After Occipitocervical Instrumentation – A Case Report. Journal of Clinical and Analytical Medicine. DOI: 10.4328/JCAM.3239, 2015. 41- Kasımcan MO, Kaptan H, Aktas S, Bakar B, Karabaglı H Protective Effects of Methotrexate and Tenoxicam in Peridural Fibrosis in Rat Laminectomy Model. Journal of Neurological Sciences [Turkish] 32:(3)#45; 528-538, 2015. 42- The effect of neoadjuvant therapy on the size, number, and distribution of mesorectal lymph nodes. Yegen G, Keskin M, Büyük M, Kunduz E, Balık E, Sağlam EK, Kapran Y, Asoğlu O, Güllüoğlu M Ann Diagn Pathol. 2016 Feb;20:29-35. doi: 10.1016/j.anndiagpath.2015.10.008. Epub 2015 Oct 29.

28- Aydın M, N Cayonu, M Kadıhasanoğlu, L Irkilata, M K Atilla, M Kendirci. “Comparison of sexual functions in pregnant and non-pregnant women” Urol J; 14: 12(5), 2339-44, 2015.

43- Robotic versus laparoscopic surgery for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of short-term outcomes.

29- Penbegul, N, M Atar, M Kendirci, Y Bozkurt, N.K. Hatipoğlu, A Verit, A Kadıoğlu. “Pioneering robotic procedures: Automations for medical liquids in 12th Asia Minor.” De Historia Urologiae Europaeae Vol. 22, pp93-107 (2015).

Serin KR, Gultekin FA, Batman B, Ay S, Kapran Y, Saglam S, Asoglu O

30- Book Chapter: H Şirin ve M Kendirci, “Benign Prostate Hyperplasia/Symptoms of Lower Urinary System and Sexual Dysfunction”, Turkish Association of Urology, 2015 (Submission).

J Robot Surg. 2015 Sep;9(3):187-94. doi: 10.1007/s11701-015-0514-3. Epub 2015 May 19. 44- Fulminant Case of Leptomeningeal Carcinomatosis Secondary to Esophageal Adenocarcinoma. Fresko BT, Selam MT, Tuzlali H, Batman B, Asoğlu O

31- KavadarliI(1), Kaya V(1). Minimum stromal thickness for corneal collagen crosslinking J Cataract Refract Surg 2015 Jan;41(1):250-1. doi: 10.1016/j.jcrs.2014.11.003 (let to Ed).

J Gastrointest Cancer. 2016 Mar;47(1):111-3. doi: 10.1007/s12029-015-9731-2.

32- ASA III osteoporotic fracture in 62 patients treated with vertebroplasty under local anesthesia. Eur J OrthopSurgTraumatol DOI 10.1007/s00590-015-1700-8

Kaytan Sağlam E, Yücel S, Balık E, Sağlam S, Asoğlu O, Yamaner S, Buğra D, Oral EN, Kizir A, Kapran Y, Sakar B, Akyüz A, Güllüoğlu M

Emre TY1, Gökcen HB2, Atbaşı Z3, Kavadar G4, Enercan M5, Ozturk C6.

J Cancer Res Clin Oncol. 2015 Feb;141(2):361-7. doi: 10.1007/s00432-014-1816-y. Epub 2014 Sep 5.

33- Selective Thoracic Fusion Provides Similar Health-Related Quality of Life but Can Cause More Lumbar Disc and Facet Joint Degeneration: A Comparison of Adolescent Idiopathic Scoliosis Patients With Normal Population 10 Years After Surgery. Spine Deformity 3 (2015) 469e475.

46- The role of the laparoscopy on circumferential resection margin positivity in patients with rectal cancer: long-term outcomes at a single high-volume institution.

Meriç Enercan, MD, Sinan Kahraman, MD, Mutlu Cobanoğlu, MD, Bahadır Hüseyin Gökçen, MD, Selhan N Karadereler, MD, Ayhan Mutlu, MD, Levent Onur Ulusoy, MD, Çağatay Öztürk, MD.

Surg Laparosc Endosc Percutan Tech. 2015 Apr;25(2):129-37. doi: 10.1097/SLE.0000000000000060.

34- Lumbar Degenerative Disc Disease and Non-Fusion Techniques and Treatment TOTBİD Journal 2015; 14:305–308doi: 10.14292/totbid.dergisi.2015.48 Gökçen HB, Erdoğan S, Öztürk C 35- Neurologic Deficit Secondary to Cement Leakage During Percutaneus Vertebroplasty In Multiple Myeloma

45- Adjuvant chemoradiotherapy after D2 resection in gastric cancer: a single-center observational study.

Dural AC, Keskin M, Balık E, Akıcı M, Kunduz E, Yamaner S, Asoğlu O, Güllüoğlu M, Buğra D 47- Özkurt E, Tükenmez M, Çelet B, Öner G, Güven E, Müslümanoğlu M, İğci A, Özmen V, Fayda M, Cabioğlu N Radiotherapy Does Not Increase Implant/Expander Loss in Breast Cancer Patients Who Underwent Immediate Breast Reconstruction. Annals of Surgical Oncology, Supplement Volume 22(2);May, 2015. 48- Oscar M. Ramirez, Ümran İleri. Tridimensional Brow, Glabella, and Temple Enhancement with Microf Fat Injection During Endoscopic Forehead Rejuvenation, Oculaplasty, 2015

Patient. The Journal Of Turkish Spinal Surgery. Volume: 26 • Number: 4 • October 2015 pp. 303-306 Murat M, Sinan E, Bahadır G, Selahattin Ö, Çağatay Ö 100

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MEDICAL ACTIVITY REPORT 2015

LIV SYMPOSIUMS

INTRA-OPERATIVE RADIOTHERAPY (IORT) PUBLIC DAY 05.06.2015

102

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MEDICAL ACTIVITY REPORT 2015

LIV SYMPOSIUMS

LATEST TECHNOLOGY IN CANCER SURGERY: INTRA-OPERATIVE RADIOTHERAPY 06.06.2015

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MEDICAL ACTIVITY REPORT 2015

LIV SYMPOSIUMS

IMAGING IN ENDOCRINOLOGY: ENDOCRINOLOGY, SURGERY, RADIOLOGY AND NUCLEAR MEDICINE MEETING 19.12.2015

106

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MEDICAL ACTIVITY REPORT 2015

LIV SYMPOSIUMS

II. ADVANCED CARDIOVASCULAR SOLUTIONS SYMPOSIUM 26.12.2015 SEMPOZYUM GÜNLERi DAYS XII. LIV SYMPOSIUM

Advanced Cardiovascular Solutions

II. ADVANCED CARDIOVASCULAR SOLUTIONS

S Y M P O S I U M 2015

FOR HEALTHCARE PROFESSIONALS

December 26, 2015 Saturday

Bilgi University Central Istanbul Campus Make online registration at acslive.org for participation.

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MEDICAL ACTIVITY REPORT 2015

WORKSHOPS AND OTHER MEETINGS

GAS, CONSTIPATION AND INCONTINENCE – ASSOCITATION OF GASTROINTESTINAL ENDOSCOPY TGD – NEUROGASTROENTEROLOGY MOTILITY STUDY GROUP – TRAINING PROGRAM 07.02.2015

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livhospital.com facebook.com/Livhospital | twitter.com/Livhospital

444 4 548 - 0850 222 2 548

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MEDICAL ACTIVITY REPORT 2015

WORKSHOPS AND OTHER MEETINGS

MARMARA SPINE GROUP – MONTHLY MEETINGS

DIFFERENT APPROACHES TO RECTAL CANCER 18.03.2015

24.02.2015

MARMARA OMURGA GRUBU AYLIK TOPLANTILARI 18:30-19:00 19:00-19:20

19:20-19:40

19:40-21:40

Yiyecek ve içecek ikramı Metastatik omurga tümörlerinde radyoterapi ve intraoperatif radyoterapi Dr. Tayfun Hancılar Metastatik omurga tümörlerinde doğru tanı ve tedavi yaklaşımı Dr. Mehmet Aydoğan Tartışma ve vaka sunumları Dr. Yunus Emre AKMAN Dr. Sinan KAHRAMAN Dr. İsmail OLTULU Dr. Yunus ATICI Moderatör: Dr. Murat BEZER

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İletişim: maydogan50@hotmail.com / +90 507 651 36 04

Ahmet Adnan Saygun Cad. Canan Sok. No:5 Ulus - Beşiktaş - İstanbul facebook.com/Livhospital | twitter.com/Livhospital

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livhospital.com.tr

0850 222 2 548

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MEDICAL ACTIVITY REPORT 2015

IS HEART OF FETUS NORMAL? OR ABNORMAL? 29.03.2015

WORKSHOPS AND OTHER MEETINGS

TURKISH ASSOCIATION OF PSYCHIATRY / COGNITIVE – BEHAVIORAL THERAPY TRAINING 28.03.2015 - 29.03.2015

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MEDICAL ACTIVITY REPORT 2015

TURKISH ASSOCIATION OF LUNG CANCER, MARMARA REGION MEETING 08.04.2015

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WORKSHOPS AND OTHER MEETINGS

ENDOSCOPIC THERAPHY OF BARRETT'S EUSOPHAGUS WITH RADIOFREQUENCY 05.10.2015 - 06.10.2015

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MEDICAL ACTIVITY REPORT 2015

WORKSHOPS AND OTHER MEETINGS

SEXUAL HEALTH SYMPOSIUM 09.06.2015

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MEDICAL ACTIVITY REPORT 2015

OBESITY GROUP MEETINGS 17.10.2015

WORKSHOPS AND OTHER MEETINGS

ASSOCATION OF LUNG CANCERS, WINTER SYMPOSIUM 25.11.2015

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MEDICAL ACTIVITY REPORT 2015

WORKSHOPS AND OTHER MEETINGS

SIGNIFICANCE OF ABLATION THERAPY IN GASTROENTEROLOGY: BARRX 25.12.2015 Scientific meetings titled “Significance of Ablation Therapy in Gastroenterology; BarrX (Live Endoscopy)” and “Gas, Constipation and Incontinence” are held jointly by Association of Gastrointestinal Endoscopy and Liv Hospital, and approximately 80 to 100 participants are hosted in each meeting. Second one of these meetings is broadcasted in real time over Internet, such that all gastroenterologists of the country could watch, and accordingly, this organization is among initials of Gastroenterology society.

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MEDICAL ACTIVITY REPORT 2015

2nd BALKANS SYMPOSIUM KOSOVO 20.02.2015 Diagnosis and Treatment of Lung Cancer Surgical Treatment of Lung Cancer Prof. Ferah Ece, M.D. Prof. Gökhan Yüncü, M.D.

MEDICAL MEETINGS ABROAD

SCHOOL OF MEDICINE, PHRISHTINA UNIVERSITY, “NOVELTIES IN DIAGNOSIS AND TREATMENT OF LUNG CANCER” CONFERENCE KOSOVO 20.02.2015 “Novelties in Diagnosis and Treatment of Lung Cancer” Prof. Ferah Ece, M.D.

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MEDICAL ACTIVITY REPORT 2015

BASIC CELL CULTURE TECHNIQUES TRAINING – KAZAKHSTAN – NATIONAL MEDICAL RESEARCH CENTER ASTANA - KAZAKHSTAN 04.03.2015

MEDICAL MEETINGS ABROAD

3rd BALKANS SYMPOSIUM MACEDONIA 05.03.2015 Novelties in Field of Surgery Prof. Oktar Asoğlu, M.D.

Current Studies and Applications in Stem Cell Prof. Erdal Karaöz, M.D.

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MEDICAL ACTIVITY REPORT 2015

4th BALKANS SYMPOSIUM BOSNA 28.04.2015 Minimally Invasive and Robotic Surgery: Advantages of Bioabsorbable Stents in This Era

MEDICAL MEETINGS ABROAD

3rd INTERNATIONAL ONCOLOGY CONGRESS UZBEKISTAN 11.05.2015 - 16.05.2015 Robotic Surgery in Colorectal Cancer Prof. Oktar Asoğlu, M.D.

Prof. Ahmet Özkara, M.D. Assoc. Prof. Alp Burak Çatakoğlu, M.D.

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MEDICAL ACTIVITY REPORT 2015

STEM CELL AND PLASTIC SURGERY CONGRESS UZBEKISTAN 11.05.2015 Developments in Plastic Surgery Assoc. Prof. Ümran İleri, M.D.

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MEDICAL MEETINGS ABROAD

INTRA-OPERATIVE RADIOTHERAPY (IORT) CONFERENCE BULGARIA 25.05.2015 Robotic Surgery Procedures in Gynecological Cancers Assoc. Prof. Cem İyibozkurt, M.D.

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MEDICAL ACTIVITY REPORT 2015

5th BALKANS SYMPOSIUM MACEDONIA 19.06.2015 Current Treatment Options in Spinal Disorders Robotic Unicompartmental Knee Arthroplasty

MEDICAL MEETINGS ABROAD

TABRİZ UNIVERSITY, WORKSHOP IRAN 22.08.2015 - 23.08.2015 Laparoscopic Colorectal Surgery Prof. Oktar Asoğlu, M.D.

Assoc. Prof. Çağatay Öztürk, M.D. Assoc. Prof. Uğur Haklar, M.D.

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MEDICAL ACTIVITY REPORT 2015

ONCOLOGY SEMINAR UZBEKISTAN 03.09.2015 Bone Marrow Transplantation Prof Oral Nevruz, M.D. Ali Enver Kurt, M.D.

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MEDICAL MEETINGS ABROAD

INTRA-OPERATIVE RADIOTHERAPY (IORT) ROMANIA 19.09.2015 Differences Between Radiotherapy and IORT Prof. Oktar Asoğlu, M.D.

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MEDICAL ACTIVITY REPORT 2015

STEM CELL SEMINAR NETHERLANDS 04.10.2015 Clinical Use of Stem Cells Prof. Erdal Karaöz, M.D.

MEDICAL MEETINGS ABROAD

NEUROSURGERY CENTER AND TAŞKENT ONCOLOGY CENTER CONFERENCES UZBEKISTAN 09.10.2015 - 10.10.2015 Use of Fluorescein Guidance in Brain Tumors Prof Talat Kırış, M.D.

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MEDICAL ACTIVITY REPORT 2015

MIDDLE ASIA INTERNATIONAL ANTI-CANCER LEADERS FORUM UZBEKISTAN 14.10.2015 Treatment Options in Colorectal Cancer Prof. Oktar Asoğlu, M.D.

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MEDICAL MEETINGS ABROAD

LIV HOSPITAL ONCOLOGY CONFERENCE ROMANIA 09.11.2015 - 10.10.2015 TrueBeam STX Stereotactic Radiotherapy Prof. Merdan Fayda, M.D. Assoc. Prof. Handan Tokmak, M.D.

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