The role of LigaSure™ and Harmonic Scalpel in the preservation of recurrent laryngeal nerve during thyroidectomy

INTRODUCTION

Transient or permanent damage to the recurrent laryngeal nerve (RLN) during thyroidectomy is of paramount importance for patient quality of life. The aim of this study is to systematically review the literature concerning the role of the most popular energy-based vessel-sealing devices (LigaSure™ (LS) and Harmonic Scalpel (HS)) in preservation of the RLN during thyroidectomy. The safety and inferiority or superiority of LS and HS compared with conventional haemostatic techniques are highlighted.

METHODS

A systematic search of the literature was performed. Clinical trials, prospective and retrospective studies that significantly compared the use of LS and HS with conventional haemostasis regarding the postoperative incidence of RLN palsy were included.

FINDINGS

The search resulted in 43 studies, including 17,953 patients treated using energy-based devices or conventional haemostatic methods. Concerning the incidence of RLN palsy, 40 studies showed no significant difference between the energy-based device and conventional groups, whereas two studies demonstrated a significant superiority in performance for LS and HS compared with conventional haemostasis. Only one study exhibited significant inferiority of LS and HS compared with conventional methods. No statistical relationship was observed between energy-based devices and conventional techniques regarding permanent damage to the RLN.

CONCLUSION

The performance of both LS and HS shows no inferiority compared with conventional haemostatic techniques, regarding damage to the laryngeal nerve. Further well-designed studies are needed to investigate their potential benefit in preservation of the RLN.

Histone Deacetylase Inhibitors and Papillary Thyroid Cancer

BACKGROUND/AIM

Papillary Thyroid Cancer (PTC) is the most common type of endocrine malignancy. Although PTC has an excellent prognosis, the recurrent or metastatic disease could affect patients' survival. Recent studies show that Histone Deacetylase Inhibitors (HDACIs) might be promising anticancer agents against PTC. The aim of this review is to evaluate the role of HDACIs as an additional modality in PTC treatment and to depict the latest trends of current research on this field.

MATERIALS AND METHODS

This literature review was performed using the MEDLINE database. The search strategy included terms: "thyroid cancer", "papillary", "HDAC", "histone", and "deacetylase".

RESULTS

Agents, such as Suberoyl Anilide Hydroxamic Acid, Trichostatin A, Valproic Acid, Sodium butyrate, Panobinostat, Belinostat, Romidepsin, CUDC907 and N-Hydroxy-7-(2-naphthylthio)-Hepanomide have shown promising anti-cancer effects on PTC cell lines but fail to trigger a major response in clinical trials.

CONCLUSION

HDACIs have no significant effect as monotherapy against PTC, but further research needs to be conducted in order to investigate their potential effect when used as an additional modality.

Cardiac allograft vasculopathy after heart transplantation: Pathophysiology, detection approaches, prevention, and treatment management

Cardiac allograft vasculopathy (CAV) continues to be a significant risk factor for the recipient's long-term survival following heart transplantation. Our knowledge of its etiology is constantly changing as new imaging techniques provide direct insight into the disease's natural history. CAV identification continues to be difficult since symptoms may be varied or nonexistent. Due to the irreversible nature of the disease, early diagnosis is critical to halting development. Prognostic tools and biomarkers have proliferated as a result of advancements in diagnostic techniques. Simultaneously, pharmaceutical advancements have aided in the amelioration of the disease's progressive progression.

The Use of Robotics in Surgery of Benign Liver Diseases: A Systematic Review

BACKGROUND

Surgical treatment of benign liver diseases (BLD) remains a field of conflict, due to increased risk and high complication rate. However, the introduction of minimally invasive surgery has led to increased number of patients with BLD being treated surgically, with similar outcomes and fewer complications. Current data support the application of laparoscopic surgery (LS) and robotic surgery (RS) in surgical treatment of liver malignancies, but there are insufficient data concerning the application of robotic surgery in BLD. In the present systematic review, we aimed to evaluate the application of RS in BLD surgery.

METHODS

After a thorough search of Medline, Scopus, and Cochrane Library, 12 studies were considered eligible with a total number of 115 patients with BLD.

DISCUSSION

In brief, RS appears to be a safe and feasible option for BLD surgery. When compared to open surgery, RS is associated with lower blood loss, shorter length of stay, and fewer complication rate. Regarding LS, the peri- and postoperative outcomes were similar, but RS can overcome the technical limitations of LS. However, the cost of RS remains a major drawback in its widespread application.

CONCLUSIONS

Considering our findings, RS can be a safe and feasible option for BLD surgery, but further studies are needed to justify the introduction of RS in liver surgery and to define the type of patients that will benefit the most from it.

Left Coronary Artery Circumflex Branch Arising From Main Stem of Pulmonary Artery: An Uncommon Anatomical Variation

The left circumflex coronary artery anatomy is considered highly variable. Herein, we present a case of a 9-year-old male child with a remarkable medical history of a spontaneously closed interventricular septal defect, without residual regurgitation, who was referred for cardiological evaluation in view of orthopedic surgery. During the preoperative examination, echocardiography was performed, which showed multiple flows in the interventricular septum as well as a diastolic flow at the level of the pulmonary valve. Due to these findings, it was decided to perform a cardiac catheterization. On cardiac catheterization, it was diagnosed an anatomical variation of the circumflex branch of the left coronary artery arising from the main stem of the pulmonary artery. Significant stenosis was remarkable, as well as collateral circulation of both the circumflex and the left anterior descending artery with the right coronary artery. The child finally at the age of 11 underwent cardiothoracic surgery. To conclude, during asymptomatic cardiological evaluation, we should always think about the possibility of anatomic variations of the coronary arteries. Missing these types of anomalies may predispose to inadvertent life-threatening complications or sudden death.

Effect of energy-based devices on post-operative parathyroid function and blood calcium levels after total thyroidectomy

Introduction: Energy-based devices are widely used in thyroid surgery in order to achieve optimal hemostasis, while their role in the incidence of hypocalcemia and hypoparathyroidism comprises a topic evaluated in numerous studies.Areas covered: The aim of this systematic review is to investigate the potential benefit of Ultrasonic Shears and Electrothermal Bipolar (Radiofrequency) System in thyroid surgery regarding the incidence of post-operative hypocalcemia and hypoparathyroidism. A systematic review of the literature in PubMed/Medline and Scopus databases was conducted. Forty-nine studies met the inclusion criteria and were analyzed. A statistically decreased rate of transient hypocalcemia and hypoparathyroidism was reported in 15 studies and 4 studies, respectively, when using energy-based devices. However, 18 and 13 surveys examined transient hypocalcemia and hypoparathyroidism, respectively, and demonstrated no statistical difference between energy-based devices and conventional hemostasis. No difference was observed between the groups concerning permanent hypocalcemia. Out of 13 studies, only 2 showed a significant reduction in the occurrence of permanent hypoparathyroidism in the energy-based device group.Expert opinion: Energy-based devices reduced the rate of transient hypocalcemia and hypoparathyroidism after thyroid surgeries in 42.8% and 23.5% of the included studies, respectively. Further studies are needed to evaluate their impact on permanent post-operative hypocalcemia and hypoparathyroidism.

Esophageal defect repair by artificial scaffolds: a systematic review of experimental studies and proportional meta-analysis

BACKGROUND

The traditional technique of gastrointestinal reconstruction of the esophagus after esophagectomy presents plenty of complications. Hence, tissue engineering has been introduced as an effective artificial alternative with potentially fewer complications. Three types of esophageal scaffolds have been used in experimental studies so far. The aim of our meta-analysis is to present the postoperative outcomes after esophageal replacement with artificial scaffolds and the investigation of possible factors that affect these outcomes.

METHODS

The present proportional meta-analysis was designed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and A MeaSurement Tool to Assess systematic Reviews guidelines. We searched Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL, and Google Scholar databases from inception until February 2020.

RESULTS

Overall, 32 studies were included that recruited 587 animals. The pooled morbidity after esophageal scaffold implantation was 53.4% (95% CI = 36.6-70.0%). The pooled survival interval was 111.1 days (95% CI = 65.5-156.8 days). Graft stenosis (46%), postoperative dysphagia (15%), and anastomotic leak (12%) were the most common complications after esophageal scaffold implantation. Animals that underwent an implantation of an artificial scaffold in the thoracic part of their esophagus presented higher survival rates than animals that underwent scaffold implantation in the cervical or abdominal part of their esophagus (P < 0.001 and P = 0.011, respectively).

CONCLUSION

Tissue engineering seems to offer an effective alternative for the repair of esophageal defects in animal models. Nevertheless, issues like graft stenosis and lack of motility of the esophageal scaffolds need to be addressed in future experimental studies before scaffolds can be tested in human trials.

A Brief Review of Brain's Blood Flow-Metabolism Coupling and Pressure Autoregulation

BACKGROUND

 The human brain, depending on aerobic glycolysis to cover its metabolic needs and having no energy reserves whatsoever, relies on a constant and closely regulated blood supply to maintain its structural and functional integrity. Cerebral autoregulation, that is, the brain's intrinsic ability to regulate its own blood flow independently from the systemic blood pressure and cardiac output, is an important physiological mechanism that offers protection from hypoperfusion injury.

DISCUSSION

 Two major independent mechanisms are known to be involved in cerebral autoregulation: (1) flow-metabolism coupling and (2) myogenic responses of cerebral blood vessels to changes in transmural/arterial pressure. A third, less prominent component of cerebral autoregulation comes in the form of neurogenic influences on cerebral vasculature.

CONCLUSION

 Although fragmentation of cerebral autoregulation in separate and distinct from each other mechanisms is somewhat arbitrary, such a scheme is useful for reasons of simplification and to better understand their overall effect. Comprehension of cerebral autoregulation is imperative for clinicians in order for them to mitigate consequences of its impairment in the context of traumatic brain injury, subarachnoid hemorrhage, stroke, or other pathological conditions.

Laparoscopic and Robotic Management of Ureteral Stricture in Adults

BACKGROUND/AIM

The aim of this review was to provide an update on the status of minimal invasive treatment of ureteral stricture either with a laparoscopic or robotic surgery.

MATERIALS AND METHODS

Eligible studies, published until November 2019 were retrieved through Medline, Cochrane and Pubmed databases. Predetermined inclusion and exclusion criteria were used as selection method for data synthesis and acquisition. The study was performed in accordance with the PRISMA statement.

RESULTS

A total of 19 retrospective studies met the inclusion criteria. All of them demonstrated the safety, feasibility and success of both laparoscopic and robotic ureteral reconstruction. Individual case series or cumulative comparison analysis of the available studies showed at least equivalent success rates and a trend favoring laparoscopic and robotic groups in terms of estimated blood loss and length of hospital stay to the detriment of longer operative times and possibly higher cost.

CONCLUSION

Current evidence suggests the effectiveness, safety and increasing incorporation of minimally invasive techniques for complex stricture repair and reconstruction.

The Effect of Pituitary Gland Disorders on Glucose Metabolism: From Pathophysiology to Management

This review aims to explore, present, and discuss disorders of glucose metabolism implicated in pituitary gland diseases, the appropriate interventions, as well as the therapeutic challenges that may arise. Pituitary pathologies may dysregulate glucose homeostasis, as both the excess and deficiency of various pituitary hormones can affect glucose metabolism. Increased circulating levels of growth hormone, glucocorticoids or prolactin have been shown to mainly provoke hyperglycemic states, while hypopituitarism can be associated with both hyperglycemia and hypoglycemia. Addressing the primary cause of these disorders with the use of surgery, medical treatment or radiotherapy forms the cornerstone of current management strategies. Physicians should bear in mind that some such medications have an unfavorable effect on glucose metabolism too. When unsuccessful, or until the appropriate treatment of the underlying pituitary problem, the addition of established antidiabetic therapies might prove useful. Further studies aiming to discover more accurate and effective drug preparations in combination with optimal lifestyle management models will contribute to achieving a more successful glycemic control in these patients.

Percutaneous laser ablation of cervical metastatic lymph nodes in papillary thyroid carcinoma: clinical efficacy and anatomical considerations

Background: Papillary thyroid carcinoma is the most common type of thyroid cancer; despite its generally indolent course, patients often develop local post-operative recurrences. Re-operation, however, holds a high complication rate, while at the same time, not all patients benefit from radioiodine ablation. This systematic review investigates the application of laser ablation therapy (LAT) for cervical lymph node metastases as an additional treatment modality.Methods: This systematic review was conducted in accordance with the PRISMA Statement. Medline electronic database and Cochrane Library were searched for eligible articles.Results: Five studies were included in the systematic review. All studies included patients with metastatic lymph nodes from papillary thyroid carcinoma, that were unsuitable for further radioiodine or surgical treatment. Patients were treated with two different LAT devices. Regardless of the utilized assessment modalities, all researchers reported significant outcomes on local disease control. No permanent complications were observed.Conclusions: LAT is relatively safe and effective for the treatment of cervical metastatic lymph nodes in patients with papillary thyroid carcinoma.

The Potential Role of Carbon Nanoparticles in Lymph Node Tracing, Recurrent Laryngeal Nerve Identification and Parathyroid Preservation During Thyroid Surgery: A Systematic Review

BACKGROUND/OBJECTIVE

Carbon nanoparticles (CNs) are a novel injected suspension used during thyroidectomy in order to black stain the thyroid gland and the lymph nodes while maintaining the anatomic color of the parathyroid glands and the laryngeal nerves. The aim of this systematic review is to investigate the benefits of carbon nanoparticles in thyroid surgical procedures and examine their role in lymph node tracing, parathyroid preservation, and recurrent laryngeal nerve protection.

METHODS

A systematic review of the literature in the PubMed/Medline database was performed. Articles reporting randomized clinical trials, prospective, and retrospective studies that compared the use of carbon nanoparticles in one group of patients with a control-blank group were included. The article was reported in accordance with PRISMA guidelines (CRD42021243015).

RESULTS

The search strategy retrieved 22 studies of the literature. Fourteen studies calculated a greater number of lymph nodes detected/dissected in the central neck zone to the patients using CN solution and 1 article noted a higher rate of lymph nodes resected in the lateral neck zone in the same group of patients. A significant increase in the number of metastatic lymph nodes retrieved in the CN group was found in 7 studies. Twenty-one studies suggested that the use of CNs for the protection of the parathyroid glands was beneficial. Transient hypoparathyroidism and transient hypocalcemia were presented with a significantly lower incidence in the CN group in 13 and in 8 studies, respectively.

CONCLUSION

Carbon nanoparticles may improve both central and lateral neck dissection and enhance parathyroid gland identification and preservation.

Captopril versus atenolol to prevent expansion rate of thoracic aortic aneurysms: rationale and design

Thoracic aortic aneurysms are correlated with significant mortality and morbidity. No therapy, however, is effective at limiting aneurysm expansion and preventing rupture. Angiotensin-converting enzyme inhibitors can reduce the wall shear stress and inflammation, both of which play vital roles in the expansion of the aneurysm. A total of 636 patients will be randomized into one of three parallel arms, receiving captopril, atenolol or placebo. The primary end point will be the rate of change in the absolute diameter of the aortic root and ascending aorta on MRI of the aorta after 36 months. The trial will investigate the efficacy of angiotensin-converting enzyme inhibitors versus beta-blocker therapy in reducing the growth rate of thoracic aortic aneurysms and rupture. Trial registration number: NCT04224675.

Single-session high-intensity focused ultrasound (HIFU) ablation for benign thyroid nodules: a systematic review

BACKGROUND

Thyroid nodules are common; the majority of them are benign and asymptomatic. Thyroidectomy might be an option; however, the frequency of post-operative complications mandates the development of alternative approaches, such as high-intensity focused ultrasound ablation (HIFU). HIFU induces thermal destruction without penetrating the skin. The present systematic review aims to synthesize all available data, evaluating studies with single-session HIFU therapy and investigating its efficacy.

MATERIALS AND METHODS

This systematic review was conducted in accordance with the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and MetaAnalyses). Eligible articles were identified by a search of Medline bibliographic database (PubMed) and Cochrane Library. Out of 39 results, 11 articles were considered to meet the inclusion criteria.

RESULTS

All eligible studies included patients with solid or predominantly solid benign thyroid nodules. All patients were treated with the same HIFU device. The success rate of the method was defined in the majority, with the volume reduction rate (VRR) over 50% from baseline. The mean or median VRR ranged from 48.7 to 70.41%, depending on the last follow-up date. No major complications were observed.

CONCLUSION

Single-session HIFU is safe and effective for the treatment of benign thyroid nodules.

Robotic-assisted parathyroidectomy and short-term outcomes: a systematic review of the literature

Minimal invasive techniques in endocrine surgery were lately adopted by surgical teams due to significant complications related to inadequate operative space and high risk of injuring crucial surrounding structures, such as vessels and nerves. Over the last years, technological improvements introduced robotic systems and approaches in endocrine surgery. Several case reports and series have described the safety and efficacy of these procedures such as robotic thyroidectomy and robotic parathyroidectomy. In the current review, we included 15 studies which described robotic-assisted parathyroidectomy for cervical parathyroid adenoma, in patients diagnosed with primary hyperparathyroidism or secondary hyperparathyroidism. No significant negative short-term outcomes were observed, in terms of postoperative complications, such as temporary or permanent injury of RLN, postoperative hypoparathyroidism and blood loss. The cosmetic result was, definitely, superior in comparison to conventional open parathyroidectomy. Despite the fact that RAP is an effective and curative method for patients with PHPT or secondary hyperparathyroidism, there are no available randomized clinical trials to establish this modern procedure as a gold-standard treatment strategy for these patients.

Intravenous lipid emulsion as an antidote in clinical toxicology: a systematic review

OBJECTIVE

Intravenous lipid emulsions (ILE) were developed many decades ago to supply nutritional requirements to patients unable to obtain adequate enteral nutrition. The utility of ILE was extended to therapeutics, facilitating the delivery of drugs. More recently, the potential for ILE to act as an antidote for inversion of drug toxicity has been recognized. This review aims to summarize the literature on ILE therapy as an antidote. Suggested mechanisms of action, safety profile, and recommendations on the administration of ILE in cases of drug intoxication are highlighted.

MATERIALS AND METHODS

A complete literature survey was performed using the PubMed database search to collect available information regarding mechanisms of ILE action as an antidote, ILE administration for drug toxicity, and presentation of adverse events.

RESULTS

A total of 102 studies met the selection criteria for inclusion in the review. Mainly used for local anesthetics toxicity, ILE therapy has been expanded in clinical toxicology involving overdose treatment of drugs other than local anesthetics. Partitioning in a lipid phase of fat droplets is a mechanism named the lipid sink phenomenon that has primarily been described to explain this action of ILE and remains the most widely accepted. At the same time, recent research has also revealed several molecular mechanisms that may contribute to ILE efficacy.

CONCLUSIONS

ILE therapy comprises a recognized approach in clinical toxicology. Due to the lack of randomized clinical trials, recommendations on administration are based on animal studies and published cases. Thus, the constantly increased knowledge about ILE therapy supports the need for a detailed appraisal.

COVID-19 related stress exacerbates common physical and mental pathologies and affects treatment (Review)

COVID-19 pandemic has caused a global public health emergency resulting in unprecedented individual and societal fear and anxiety. The stress surrounding this biothreat appears to have clinical implications in all aspects of medicine, both in mental and physical health spheres. The impact of COVID-19 related anxiety in Cardiology, Paediatrics, Oncology, Dermatology, Neurology and Mental Health and how it affects treatments is discussed. Moreover, the need for introducing novel communication and therapeutic approaches is highlighted in the new landscape of the COVID-19 era.

Cardiac allograft vasculopathy after heart transplantation: current prevention and treatment strategies

OBJECTIVE

Cardiac allograft vasculopathy (CAV) is a leading cause of mortality in heart transplantation patients. Despite optimal immunosuppression therapy, the rate of CAV post-transplantation remains high. In this review, we gathered all recent studies as well as experimental evidence focusing on the prevention and treatment strategies regarding CAV after heart transplantation.

MATERIALS AND METHODS

A complete literature survey was performed using the PubMed database search to gather available information regarding prevention and treatment strategies of CAV after heart transplantation.

RESULTS

Several non-immune and immune factors have been linked to CAV such as ischemic reperfusion injury, metabolic disorders, cytomegalovirus infection, coronary endothelial dysfunction, injury and inflammation respectively. Serial coronary angiography combined with intravascular ultrasound is currently the method of choice for detecting early disease. Biomarkers and noninvasive imaging can also assist in the early identification of CAV. Treatment strategies such as mammalian target of rapamycin inhibitors proceed to grow, but prevention remains the objective.

CONCLUSIONS

Early detection is the key to therapy management. It enables early identification and diagnosis of patients with CAV, who would gain the most from prompt treatment. Further investigation is needed to elucidate the multifactorial pathophysiological process of CAV, develop detection methods and find treatments that prevent or slow disease progression.