Rare rectal gastrointestinal stromal tumor case: A case report and review of the literature

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal tract accounting for less than 1% of all gut tumors. GISTs occurring in the rectum are extremely rare, and these usually present at an advanced stage compared with other sites.

CASE SUMMARY

A 60-year-old male who presented with features of sensations of rectal tenesmus was referred to our department with a mass in the lower rectum that was detected during a routine checkup. Colonoscopy, transrectal ultrasound, perianal magnetic resonance imaging and ultrasonic contrast were used to diagnose the rectum GIST, and then the patient underwent complete transanal resection using the ultrasonic scalpel. The patient was discharged ten days after the operation and was defined as low risk. Therefore, he had no need to receive subsequent adjuvant therapies, and he had not suffered any anal dysfunction or had any evidence of recurrence at follow up.

CONCLUSION

Surgical resection with histologically negative margins is the standard curative treatment for rectal GISTs. Appropriate surgical techniques based on the location, size, and resectability of the tumor should attract great attention from clinicians.

LigaSure technique for splenectomy: A systematic review and meta-analysis

BACKGROUND

This study aimed to clarify the optimal management of the LigaSure technique and conventional techniques during splenectomy.

METHODS

All databases, including CBM, CNKI, WFPD, Medline, EMBASE, PubMed, and Cochrane databases up to April 2023, were searched for relevant studies comparing the LigaSure technique with conventional techniques. Six studies, extracted by 2 independent reviewers, were evaluated for blood loss, operative time, conversion, mortality, hospital stay, and transfusion.

RESULTS

The blood loss was significantly higher in the convention group than in the LigaSure group (WMD = -48.98, 95% CI: -62.41 to -35.55, P < .00001). Meanwhile, the mean operative time was significantly shorter in LigaSure group than in convention group (WMD = -10.57; 95% CI: -12.35 to -8.78), P < .00001). No significant differences were found regarding the conversion rate, hospital stay, morbidity, and transfusion.

CONCLUSIONS

The LigaSure technique has comparable effects to conventional techniques, but to some extent reduces blood loss and operative time.

ESTIMation of the ABiLity of prophylactic central compartment neck dissection to modify outcomes in low-risk differentiated thyroid cancer: a prospective randomized trial

BACKGROUND

Prophylactic central neck dissection in clinically low-risk cT1bT2N0 papillary thyroid carcinoma is controversial, due to a large number of conflicting retrospective studies, some showing an advantage in terms of locoregional recurrence, others showing no advantage. These previous studies all show high rates of excellent response. We aim to demonstrate the non-inferiority of thyroidectomy alone as compared to total thyroidectomy with prophylactic central neck dissection in conjunction with adjuvant RAI 30 mCi with rTSH stimulation in terms of excellent response at 1 year.

TRIAL DESIGN AND METHODS

Prospective randomized open multicenter phase III trial including patients with 11-40-mm papillary thyroid carcinoma (Bethesda VI) or suspicious cytology (Bethesda V) confirmed malignant on intra-operative frozen section analysis, with no suspicious lymph nodes on a specialized preoperative ultrasound examination. Patients will be randomized 1:1 into two groups: the reference group total thyroidectomy with bilateral prophylactic central neck dissection, and the comparator group total thyroidectomy alone. All patients will receive an ablative dose of 30mCi of radioactive iodine (RAI) within 4 months of surgery. The primary outcome is to compare the rate of excellent response at 1 year after surgery between the groups, as defined by an unstimulated serum thyroglobulin (Tg) level ≤ 0.2 ng/mL with no anti-Tg antibodies, an normal neck ultrasound and no ectopic uptake on the post-RAI scintiscan. Non-inferiority will be demonstrated if the rate of patients with excellent response at 1 year after randomization does not differ by more than 5%. Setting the significance level at 0.025 (one-sided) and a power of 80% requires a sample size of 598 patients (299 per group). Secondary outcomes are to compare Tg levels at 8 +/- 2 postoperative weeks, before RAI ablation, the rate of excellent response at 3 and 5 years, the rate of other responses at 1, 3, and 5 years (biochemical incomplete, indeterminate, and structurally incomplete responses), complications, quality of life, and cost-utility.

DISCUSSION (POTENTIAL IMPLICATIONS)

If non-inferiority is demonstrated with this high-level evidence, prophylactic neck dissection will have been shown to not be necessary in clinically low-risk papillary thyroid carcinoma.

TRIAL REGISTRATION

NCT03570021. June 26,2018.

Haemostatic devices in parotid surgery: a systematic review

OBJECTIVE

The Harmonic Scalpel and Ligasure (Covidien) devices are commonly used in head and neck surgery. Parotidectomy is a complex and intricate surgery that requires careful dissection of the facial nerve. This study aimed to compare surgical outcomes in parotidectomy using these haemostatic devices with traditional scalpel and cautery.

METHOD

A systematic review of the literature was performed with subsequent meta-analysis of seven studies that compared the use of haemostatic devices to traditional scalpel and cautery in parotidectomy. Outcome measures included: temporary facial paresis, operating time, intra-operative blood loss, post-operative drain output and length of hospital stay.

RESULTS

A total of 7 studies representing 675 patients were identified: 372 patients were treated with haemostatic devices, and 303 patients were treated with scalpel and cautery. Statistically significant outcomes favouring the use of haemostatic devices included operating time, intra-operative blood loss and post-operative drain output. Outcome measures that did not favour either treatment included facial nerve paresis and length of hospital stay.

CONCLUSION

Overall, haemostatic devices were found to reduce operating time, intra-operative blood loss and post-operative drain output.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Energy-based devices for hemostasis in thyroid surgery

The evolution of operative techniques in thyroid surgery that has taken place over the past several decades would not have been possible if not for a sui generis revolution in surgery at the turn of the 19th and 20th centuries. The three most important events of the end of the 19th century, i.e., the introduction of anesthesia, the use of artery forceps and ligation of blood vessels, as well as prophylactic management of perioperative infections decidedly affected the improvement of therapeutic results of thyroid surgery. Surgical treatment of thyroid diseases is associated with the possibility of complications developing, of which bleeding is among the most serious ones, starting from the need for an immediate reoperation and ending at a considerable damage to functionally important structures: the laryngeal nerves and parathyroid glands. The consensus reached between the development of science and progress in modern technologies has provided the basis for introducing and popularizing minimally invasive procedures, including operations using the approach through natural body openings. Such an unprecedented development of surgical techniques would not be possible without devices for closing blood vessels. Given the mechanism of hemostasis, current vascular sealing devices can generally be divided into three groups: ultrasonic, bipolar-radiofrequency and hybrid systems combining both energy modalities. While analyzing the innovative, advanced technology of all the energy-based devices, it should be stated that only if they are used in a safe manner, quality of life of patients with various thyroid conditions is improved. The employment of such devices fully confirms their usefulness; nevertheless, all the advantages should never release the surgeon from the obligation to appropriately and safely identify the surrounding structures and let him uncritically use the new device.

Safety and Cost-effectiveness of LigaSure® in Total Thyroidectomy in Comparison with Conventional Suture Tie Technique

Introduction: Total thyroidectomy has been considered to be a treatment of choice for thyroid malignancies. It has recently gained popularity as gold standard for benign thyroid disorders requiring surgical treatment. Because of higher number of complications associated with total thyroidectomy, it is still considered an adventurous endeavor. Most important improvements in thyroid surgery include laparoscopic thyroidectomy, energy based devices (EBD) like Harmonic Focus® and LigaSure® for dissection and hemostasis, intraoperative neuromonitoring, and parathyroid hormone (PTH) assay technology.

Aim of Study: Recent studies have suggested that despite lesser complication rates with LigaSure dissection method in total thyroidectomy, it is associated with prolonged operation time. Aim of our study was to compare conventional suture tie technique and LigaSure thyroidectomy, in terms of perioperative complications including bleeding, recurrent laryngeal nerve (RLN) injury, postoperative hematoma, hypocalcemia, operation time, and cost-effectiveness. 

Results: This is a retrospective descriptive study done at Shifa Internationall Hospital/Shifa College of Medicine/Shifa Tameer e’ Millat University, Islamabad, Pakistan from 1st of June 2016 to 1st of June 2018. One hundred and two (102) patients who underwent surgical treatment for benign thyroid diseases were included in the study. Study was done after approval from ethical committee of Shifa International Hospital/Shifa Tameer e’ Millat University. Group A included patients in whom LigaSure was used for hemostasis and dissection during total thyroidectomy. Group B included patients who underwent total thyroidectomy by traditional clamp, tie, and electrocautery method for hemostasis and dissection. Frequency of female patients in group A was 45 (88.2%) and in group B was 41 (80.3%). In group A frequency of male patients was 9 (17.6%) and in group B it was 7 (13.7%). Mean operative time in group A was significantly lower (92 ± 9.61 min) than group B (123 ± 7.96 min). Mean intraoperative blood loss in group A was estimated to be 51.73 ± 5.65 mL and 139.42 ± 7.31 mL in group B. Transient hypocalcemia was the most common complication in both the groups. In group A 6.8% (n=7) patients developed transient postoperative hypocalcemia. Three patients in group B (2.9%) had transient hypocalcemia.

Conclusion: LigaSure was significantly advantageous over conventional technique in reducing risk of complications and operation time as well as perioperative and postoperative blood loss. The reduction of operative times resulted in decreased operating room occupancy costs but the overall cost of surgery was significantly higher in LigaSure group.

Hemostasis with the Ultrasonic Scalpel

Background and Objectives:

The ultrasonically activated scalpel is a surgical instrument that is used in minimally invasive surgery to safely cut and seal vessels. This study reported the experimental observations of the use of a laparoscopic ultrasonic scalpel, including its safety and feasibility. in sealing vessels of different diameters in an in vivo animal model during both physiological and supraphysiological blood pressure (BP) conditions.

Methods:

One healthy female swine was used. We performed resections of the omentum, biopsies in different regions of the liver, and a hysterectomy. Vessels with diameters ranging from 2 to 10 mm were sealed with the ultrasonic scalpel under regular hemodynamic conditions and during pharmacologically induced arterial hypertension (BP challenge).

Results:

For 10 random cuts made in the omentum and during the hysterectomy, the ultrasonic scalpel was effective and fast, with no immediate or delayed bleeding. Bipolar energy, sutures, and hemoclips were not required to control bleeding. No bleeding was observed in sealed vessels up to 8 mm, even during BP challenges sustained for longer than 5 minutes. When testing vessels of 10 mm, bleeding occurred in 1 common iliac vein before 10 minutes of waiting (the point of bleeding was easily identified) and bleeding occurred in 1 of the common iliac arteries during the BP challenge.

Conclusion:

Our findings corroborate that the ultrasonic scalpel can safely seal arteries up to 8 mm in diameter to prevent or control bleeding during laparoscopic procedures, even when BP exceeds normal levels.

Comparing the safety of harmonic ACE and ACE+ around the recurrent laryngeal nerve in swine models

Purpose

Among the various energy-based devices, ultrasonic shears are popular in thyroid surgeries. In this study, we tested the safety of Harmonic ACE and Harmonic ACE+ around the recurrent laryngeal nerve (RLN) in experimental swine models.

Methods

Harmonic ACE and Harmonic ACE+ were each tested in 4 piglets. Harmonic ACE and Harmonic ACE+ were activated at a 0- to 5-mm distance from the RLN. The function of the RLN was assessed using continuous electrophysiological monitoring.

Results

For Harmonic ACE, there was no adverse EMG event found when activated at 4- and 5-mm distances from the RLN. At a 2- to 3-mm distance, there were 4 adverse EMG events observed. In these 4 cases, adjacent tissue shrinkage occurred after 6 to 15 seconds of activation, and the RLN touched the Harmonic ACE. At a 1-mm distance, there were 2 adverse EMG events found after 25 seconds of activation. For Harmonic ACE+, there was no adverse EMG event observed when activated at 1- and 3-mm distances from the RLN. At a 0-mm distance, 2 adverse EMG events occurred after 6 to 10 seconds of activation.

Conclusion

The safe distance of Harmonic ACE and ACE+ was 4 and 1 mm, respectively, in the swine models. Harmonic ACE+ is safer than Harmonic ACE because it did not cause any tissue shrinkage. Surgeons need to understand the characteristics of devices for safe operation.

Update on sutureless thyroidectomy

INTRODUCTION

The Harmonic scalpel ("Focus" and the new version "Focus+") is one of the first devices for surgical simultaneous cutting and tissue coagulation which allows to obtain dissection and hemostasis by direct application of ultrasound and allows minimally invasive surgical procedures with minimal lateral thermal spread and, thus, minimal adjacent tissue destruction. The aim of the study is to complete the previous study that we made in 2014, based on the TT performed between January 2008 and December 2013, with new data about TT performed in our Surgical Division between January 2014 and December 2016 and compare the outcome using the Ultrasonic scalpel versus the device Ligasure in term of safety, operative time, overall drainage volume, complications, hospital stay.

PATIENTS AND METHODS

250 patients were randomized into two groups: Group A where Ultracision were used and Group B where the Ligasure device was used.

RESULTS

The results of the group A and of the Group B 2014-2016 have been compared with the results of the previous study and we found that they are similar, but asymptomatic hypocalcaemia increased in the patients of the new study.

CONCLUSIONS

We found that the use of Ultrasonic scalpel and Ligasure is effective both in the hemostasis of all vessels and in dissection of tissues and confirm the results of our first study without significant difference in the rate of post-operative morbidity with these two different energy based devices used.

Comparison of surgical outcomes and complications between the Harmonic FOCUS and conventional surgery for open thyroidectomy

The aim of the present study was to evaluate the potential advantages of the ultrasonic scalpel compared with the conventional technique in thyroid surgery. Patients with resectable thyroid cancer and Basedow's disease were assigned to ultrasonic scalpel or conventional technique (knot-tying and electrocoagulation). The present study used the Harmonic FOCUS^® (HF) as an ultrasonic scalpel. Between February 2013 and May 2016, 45 patients were enrolled into the study. Duration of the surgery was significantly decreased in the HF group compared with the conventional surgery (CS) group (median 142 vs. 151 min; P=0.0406). Intraoperative blood loss and total volume of drainage fluid were significantly decreased in the HF group compared with the CS group (median 40 vs. 125 ml; P=0.0054, and median 120 vs. 175.5 ml; P=0.0490). Duration of drain placement and length of hospitalization stay were similar in the two groups. Furthermore, the overall incidence of postoperative complications did not differ between the two groups. Overall, the present study suggests that open thyroidectomy using the HF is safe and effective and not associated with any increase in complications.

Effect of fibrin vs cellulose based haemostatic agents with traditional haemostatic procedures in thyroid surgery

Objective:

To compare the efficacy of fibrin-based hemostat and cellulose-based hemostat with traditional procedures in patients undergoing thyroid surgery.

Methods:

Between January 2012 and December 2016, 255 patients were scheduled to undergo total thyroidectomy at Surgical Clinic Nis. The patients were randomized to: Group-I use of classic surgical procedures to achieve hemostasis, Group-II use Surgicel and Group-III use Beriplas

Results:

A statistically significant reduction of surgical time was found for Group-I compared with Group-II and III (p≤0.01 for both groups). Statistically significant reduction of intraoperative blood loss was found for Group-I compared with Group-II from 102.3mL vs. 86.1mL (p≤0.01) as well as compared to Group-III (mean 77.4mL, p≤0.01). Removal of the wound drain occurred sooner in the Group-II and III compared with Group-I (mean 37.1h vs. 40.1h, p≤0.05; mean 31.2h vs. 40.1h, p≤0.01). There were no significant differences in terms of postoperative morbidity among the groups.

Conclusions:

Fibrin based haemostat seems to be an effective hemostatic agent for patients undergoing thyroid surgery. We suggest that, where appropriate, this fibrin-based haemostat should be used as a first line hemostatic agent in thyroidectomy in combination with conventional surgical means of hemostasis.

Is Outpatient Thyroid Surgery for Everyone?

Thyroidectomy is a common surgical procedure. Traditionally, surgeons have performed thyroidectomy on an inpatient basis. However, consistent with current trends in surgery, some practices are transitioning thyroidectomy to an outpatient setting. Although concerns for hypocalcemia and postoperative bleeding exist regardless of surgeon experience, multiple studies demonstrate that outpatient thyroidectomy is safe in the hands of high-volume surgeons. Indeed, experienced thyroid surgeons who perform thyroidectomy in an outpatient setting experience excellent patient outcomes and reduced costs. However, outpatient thyroidectomy may not be suitable for all surgeons, hospitals, or patients. When evaluating whether to implement an outpatient thyroid program, a practice should consider a number of important factors including the team performing the procedure, the hospital, and the patient. With the appropriate staff education and experience, hospital setting, and patient selection, practices in a multitude of settings can successfully develop a safe, cost-effective outpatient thyroid program.

The Learning Curve of Transareola Single-site Laparoendoscopic Thyroidectomy: CUSUM Analysis of a Single Surgeon's Experience

Transareola single-site laparoendoscopic thyroidectomy (TASSET) is a rapidly advancing minimally invasive procedure. The purpose of this study was to evaluate the learning curve for TASSET.

Safety of energy based devices for hemostasis in thyroid surgery

Energy based devices (EBD) have been developed, implemented and increasingly applied in thyroid surgery because they can provide a combined dissection and haemostatic effect. In particular, advantages of EBD have been described in terms of efficacious haemostasis, reduction of procedure-associated time, reduced incision length, less operative blood loss and transfusion need, decreased postoperative drain, pain and hospital stay. In addition, EBD are essential for endoscopic procedures. On the contrary, a potential drawback is the increased health care costs. This paper reviews relevant medical literature published on the safety of new devices for achieving hemostasis and dissection around the recurrent laryngeal nerve (RLN).

Comparative analysis between a bipolar vessel sealing and cutting device and the tie and suture technique in thyroidectomy: A randomized clinical trial

BACKGROUND

Advanced bipolar and ultrasonic devices have shown significant reduction in the surgical time of thyroid operations. This randomized, controlled trial assessed if operative time and other relevant outcomes are different for thyroidectomies performed either with a second-generation advanced bipolar device or traditional tie and suture technique.

METHODS

Forty-one patients were randomized into 2 groups (advanced bipolar device and traditional tie and suture). Secondary end points included estimated blood loss, postoperative hemorrhage or hematoma requiring operative reintervention, recurrent laryngeal nerve injury, hypoparathyroidism, pain intensity, number of ligatures, analgesia usage, and loss of signal during recurrent laryngeal nerve monitoring.

RESULTS

Preoperative characteristics were similar between both groups. Mean operative time in the advanced bipolar device group was reduced by 32.5 minutes compared with the traditional tie and suture group (P = .006). Intraoperative blood loss was similar in both groups. Four patients presented postoperative vocal cord dysmotility, 3 in the traditional tie and suture group and 1 in the advanced bipolar device group (P = ns). Two of these 4 patients also had a >50% amplitude decrease during continuous intraoperative neuromonitoring, 1 in each group. Pain intensity, 12 hours after operation, was significantly greater in the traditional tie and suture group (P = .015), even though pain medication requirements during the initial 24 hours after operation were similar between groups (P = .97). There were no cases of postoperative hemorrhage or hematoma requiring reintervention. Postoperative, symptomatic hypocalcemia occurred in 6 patients, 4 in the traditional tie and suture, and 2 in the advanced bipolar device group. One of them developed permanent hypocalcemia.

CONCLUSION

The use of an advanced bipolar device in thyroid operation reduces operative time by >30 minutes, with a similar postoperative outcome profile when compared with the traditional tie and suture technique.

Safety of LigaSure in recurrent laryngeal nerve dissection-porcine model using continuous monitoring

OBJECTIVES/HYPOTHESIS

This study investigated recurrent laryngeal nerve (RLN) real-time electromyography (EMG) data to define optimal safety parameters of the LigaSure Small Jaw (LSJ) instrument during thyroidectomy.

STUDY DESIGN

Prospective animal model.

METHODS

Dynamic EMG tracings were recorded from 32 RLNs (16 piglets) during various applications of LSJ around using continuous electrophysiologic monitoring. At varying distances from the RLN, the LSJ was activated (activation study). The LSJ was also applied to the RLN at timed intervals after activation and after a cooling maneuver through placement on the sternocleidomastoid muscle (cooling study).

RESULTS

In the activation study, there was no adverse EMG event at 2 to 5 mm distance (16 RLNs, 96 tests). In the cooling study, there was no adverse EMG event after 2-second cooling time (16 RLNs, 96 tests) or after the LSJ cooling maneuver on the surrounding muscle before reaching the RLNs (8 RLNs, 24 tests).

CONCLUSION

Based on EMG functional assessment, the safe distance for LSJ activation was 2 mm. Further LSJ-RLN contact was safe if the LSJ was cooled for more than 2 seconds or cooled by touch muscle maneuver. The LSJ should be used with these distance and time parameters in mind to avoid RLN injury.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 127:1724-1729, 2017.

Risk of Complications with Energy-Based Surgical Devices in Thyroid Surgery: A National Multicenter Register Study

BACKGROUND

Energy-based surgical devices (EBD) combining cutting and coagulation are increasingly used in thyroid surgery. However, there is a lack of information about potential benefits and risk of complications outside controlled trials. The aims of this national multicenter register study were to describe the use of EDB, their potential effect on complication rates, and on operation time.

MATERIALS AND METHODS

The Scandinavian Quality Register for Thyroid and Parathyroid surgery includes 35 surgical units in Sweden and covered 88% of the thyroid procedures performed during 2008–2009. The use of the EBD was specifically registered for 12 months, and 1297 patients were included. Surgically related complications and operation time were evaluated. The clamp-and-tie group (C-A-T) constituted the control group for comparison with procedures where EBD was used.

RESULTS

The thyroid procedures performed included C-A-T (16.6%), bipolar electrosurgery (ES: 56.5%), electronic vessel sealing (EVS: 12.2%), and ultrasonic dissection (UD: 14.5%). Mean operative time was longer with EVS (p < 0.001) and shorter with UD (p < 0.05) than in the other groups. The bipolar ES group and the EVS group had higher incidence of calcium treatment at discharge and after 6 weeks than the UD group. No significant difference in nerve injury was found between the groups. There was a significant more frequent use of topical hemostatic agents in the EBD group compared to C-A-T.

CONCLUSION

In this national multicenter study, the use of UD shortened and EVS increased operating time. There was a higher risk of calcium treatment at discharge and after 6 weeks after use of EVS and bipolar ES than after UD use. There was a significant more frequent use of topical hemostatic agents in the EBD groups compared to C-A-T.

Ultrasonic, bipolar, and integrated energy devices: comparing heat spread in collateral tissues

BACKGROUND

Integrated devices incorporating ultrasonic and bipolar technology have been used in laparoscopic surgery, however, are not yet incorporated into open operations. Here, we compare thermal spread and recurrent laryngeal nerve (RLN) functional data of the integrated THUNDERBEAT Open Fine Jaw device, the bipolar Ligasure Small Jaw, and the ultrasonic Harmonic Focus for open thyroidectomy.

MATERIALS AND METHODS

The three energy devices were compared in a live porcine model using three tissue types including liver, muscle, and thyroid. The devices were fired three times on each energy setting, and the thermal spread was measured by thermocouples that were inserted in surrounding tissues at 1-mm intervals. To determine RLN injury, devices were fired at successive 1-mm increments from the RLN until the monitor signal was lost.

RESULTS

When comparing heat generated across these devices at 1 mm, the peak temperature (Celsius) reached in liver tissue was observed with the ultrasonic device (115.4 ± 86.7), in muscle tissue with the integrated device (104.2 ± 82.1), and in thyroid with the bipolar device (81.4 ± 41.3). Temperatures generated at individual settings on each device were similar (P = 0.11-0.81). RLN injury occurred after firing on manually approximated tissue 1-mm away from the RLN for all devices; however, there was no signal loss at ≥2 mm.

CONCLUSIONS

Heat transfer was similar among all devices with the exception of the ultrasonic device when used in the liver, which showed higher temperatures. Liver tissue showed the most consistent results. RLN injury did not occur if the devices were fired on manually approximated tissue ≥2 mm from the nerve.

Is sutureless thyroid surgery safe in the hands of surgical trainees. A single centre retrospective study

Background

The safety and efficacy of sutureless thyroid surgery have been confirmed in many series. Equally, surgical expertise has been shown to influence postoperative outcome. This study aimed at investigating the safety of sutureless thyroid surgery in the hands of surgical trainees and to find out if this technique could be safely integrated into endocrine surgical training programs.

Methods

A single center retrospective comparison of the outcome of surgeries performed by experienced surgical attendings and trainees was performed. The LigaSure Precise was used in all cases.

Results

Two hundred and eight patients were included. The trainee group comprised of 61 cases managed by surgical trainees. Surgery was performed by surgical attendings in 147 cases (consultant group). The incidences of transient and permanent hypocalcaemia were 20.7 and 0.9 % respectively, the corresponding values for recurrent nerve injury were 6.3 and 0.9 %. Postoperative bleeding occurred in 3.4 %. There was no difference amongst both groups with regard to postoperative outcome (p > 0.05).

Conclusions

While sutureless thyroid surgery was safely performed by surgical trainees without relevant increase in perioperative complications in our department, further larger scale studies would be needed to confirm this would be the case more widely.

Total thyroidectomy: Conventional Suture Ligation technique versus sutureless techniques using Harmonic Scalpel or Maxium

Objectives

Harmonic Scalpel (HS) and Maxium (MAX) are surgical shears that enable simultaneous vessel sealing and tissue coagulation. This study compares the outcome of Total Thyroidectomy (TT) using Conventional Suture Ligation (CSL) technique versus (vs) two sutureless techniques; H S and MAX techniques in terms of safety, operative time, blood drainage volume, hospital stay and surgical complications.

Study design

This is a prospective observational cohort study.

Setting

This study was performed in AL-Karama Teaching Hospital/College of Medicine/University of Wasit/Iraq.

Patients and methods

This study was performed from June 2012 to 2015. A total of 80 patients, 60 patients were females and 20 patients were males (average/mean of age was 39/38 years). They underwent TT after been randomized into the following three groups: CSL group when Suture Ligation Technique was used, HS group when Harmonic Scalpel was used and MAX group when bipolar electrosurgery Maxium was used.

Results

The postoperative evaluation of operative time, blood drainage volume and surgical complications revealed no statistically significant differences between HS group & MAX group, but there were statistically significant differences between CSL group vs. HS and MAX groups. Operative time statistics showed significant differences between CSL vs. HS and MAX groups, 113 ± 10.9 minutes (min), 93 ± 13 min and 92 ± 10.6 min respectively, p-value < 0.001 and 95% confidence interval [CI] (92.3712, 101.6288). The postoperative blood drainage volumes were significantly different between the three groups: CSL group = 150 ± 12.7 ml, HS group = 89 ± 16.21 ml and MAX group = 118 ± 9.6 ml, P-value = 0.046 and 95% [CI] (89.9932, 99.6068).

Conclusions

HS and MAX are safe, effective, and time-saving techniques. They are also associated with low blood loss and low complication rates. HS and MAX are good alternative techniques to CSL for thyroid surgery.

•

HS and MAX are safe useful and fast alternatives to conventional techniques in total thyroidectomy.

•

These two devices facilitate surgical procedures and cancel any need for clips and suture ligations.

•

They significantly reduce operative time without increases in the amount of blood losses and hospital stay.

•

Probably the only disadvantage of these two devices is the cost of the single-use devices.

Effectiveness of an advanced hemostatic pad combined with harmonic scalpel in thyroid surgery. A prospective study

INTRODUCTION

Hemostasis during thyroidectomy is essential; however the most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with the combination of harmonic scalpel (HS) and an advanced hemostatic pad (Hemopatch).

METHODS

Patient undergone TT were divided into two groups: HS + hemopatch and HS + traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates.

RESULTS

Between September 2014 and March 2015, 60 patients were enrolled (30 to Hs + Hemopatch, 30 to Hs and standard hemostasis); 71.4% female; mean age 48.5 years. The 24-h drain output was lower in the HS + hemopatch group compared with standard TT. HS and hemopatch also had a shorter mean surgery time (p < 0.0001) vs standard TT.

CONCLUSION

combination of hemopatch plus HS is effective and safe for TT with a complementary hemostatic approach.

Risk factors for post-thyroidectomy haematoma

Background:

There has been increasing emphasis on performing ‘same-day’ or ‘out-patient’ thyroidectomy to reduce associated costs. However, acceptance has been limited by the risk of potentially life-threatening post-operative bleeding. This study aimed to review current rates of post-operative bleeding in a metropolitan teaching hospital and identify risk factors.

Method:

Medical records of patients undergoing thyroidectomy between January 2007 and March 2012 were reviewed retrospectively. Pre-operative, operative and pathological data, and post-operative complication data, were examined.

Results:

The study comprised 205 thyroidectomy cases. Mean age was 51.6 years (standard deviation = 14.74), with 80 per cent females. Unilateral thyroidectomy was performed in 81 cases (39.5 per cent) and total thyroidectomy was performed in 74 cases (36.1 per cent; 5.3 per cent with concomitant lymph node dissection). Nine patients (4.4 per cent) suffered post-operative bleeding, of which six required re-operation. Analysis showed that post-operative systolic blood pressure of 180 mmHg or greater was associated with post-operative bleeding (p = 0.003, chi-square test).

Conclusion:

Rates of significant post-operative bleeding are consistent with recent literature. Post-operative hypertension, diabetes and high post-operative drain output were identified as independent risk factors on multivariate analysis; when identified, these may be caveats to same-day discharge of thyroidectomy patients.

A Gelatin-Thrombin Matrix Topical Hemostatic Agent (Floseal) in Combination With Harmonic Scalpel Is Effective in Patients Undergoing Total Thyroidectomy: A Prospective, Multicenter, Single-Blind, Randomized Controlled Trial

BACKGROUND

Hemostasis during thyroidectomy is essential; however, the safest, most efficient, and most cost-effective way to achieve this is unclear. This randomized, multicenter, single-blind, prospective study evaluated the efficacy and safety of using different hemostatic approaches in patients undergoing total thyroidectomy.

METHODS

Patients aged ≥18 to 70 years were randomized to Floseal + a harmonic scalpel (HS), Floseal alone, HS alone, or standard total thyroidectomy. Primary endpoint was 24-hour drain output. Secondary endpoints included surgery duration and complications.

RESULTS

Two hundred and six patients were randomized to Floseal + HS (n = 52), Floseal alone (n = 54), HS alone (n = 50), and standard total thyroidectomy (n = 50). The 24-hour drain output was lower in the Floseal + HS group compared with standard thyroidectomy. Floseal + HS also had a shorter surgery time (P < .0001) versus the other 3 treatments.

CONCLUSION

Floseal + HS can be effective at reducing postsurgical drain output and provides a complementary hemostatic approach in patients undergoing total thyroidectomy.

The Harmonic Scalpel versus Conventional Hemostasis for Neck Dissection: A Meta-Analysis of the Randomized Controlled Trials

Objective

Neck dissection is the most definitive and effective treatment for head and neck cancer. This systematic review aims to compare the efficacy and surgical outcomes of neck dissection between the harmonic scalpel and conventional surgical techniques and conduct a quantitative meta-analysis of the randomized trials.

Methods

Randomized controlled trials (RCTs) were identified from the major electronic databases (MEDLINE, EMBASE and Cochrane Library) using the keywords ‘‘harmonic scalpel’’ and ‘‘neck dissection,’’ and a quantitative meta-analysis was conducted. The operative time and intraoperative bleeding were the primary outcome measures, and other parameters assessed included the drainage fluid volume and length of hospital stay.

Results

Seven trials that met the inclusion criteria included 406 neck dissection cases (201 in the harmonic scalpel group). Compared with conventional surgical techniques, the HS group had an operative time that was significantly reduced by 29.3 minutes [mean difference: -29.29; 95% CI = (-44.26, -14.32); P=0.0001], a reduction in intraoperative bleeding by 141.1 milliliters [mean difference: -141.13; 95% CI = (-314.99, 32.73); P=0.11], and a reduction in drainage fluid volume by 64.9 milliliters [mean difference: -64.86; 95% CI = (-110.40, -19.32); P=0.005] , but it is not significant after removal of studies driving heterogeneity. There was no significant difference in the length of the hospital stay [mean difference: -0.21; 95% CI = (-0.48, 0.07); P=0.14].

Conclusion

This systematic review showed that using the harmonic scalpel for neck dissection significantly reduces the operative time and drainage fluid volume and that it is not associated with an increased length of hospital stay or perioperative complications. Therefore, the harmonic scalpel method is safe and effective for neck dissection. However, the statistical heterogeneity was high. Further studies are required to substantiate our findings.

Effectiveness of preventative and other surgical measures on hypocalcemia following bilateral thyroid surgery: a systematic review and meta-analysis

BACKGROUND

A variety of measures have been proposed to reduce the incidence of post-thyroidectomy hypocalcemia. The aim of this study was to perform a systematic review and meta-analysis of preventive and other surgical measures on post-thyroidectomy hypocalcemia as reported in the literature.

METHODS

Comprehensive searches of the PubMed, EMBASE, and Cochrane databases were performed, and the quality of included papers was assessed using the Cochrane risk of bias tool or a modified Newcastle-Ottawa Scale (NOS). The results of all included studies were summarized, and meta-analyses were performed where appropriate.

RESULTS

Thirty-nine randomized controlled trials (RCTs) and 37 observational studies were included. Measures studied included hemostatic techniques, extent of thyroidectomy and central neck dissection, surgical approach, calcium/vitamin D/thiazide diuretic supplements, parathyroid gland autotransplantation (PGAT) and intraoperative parathyroid gland (PG) identification, truncal ligation of inferior thyroid artery (ITA), preoperative magnesium infusion, and use of magnification loupes and Surgicel. Measures associated with significantly lower rates of transient hypocalcemia in meta-analysis were postoperative calcium and vitamin D supplementation compared to either calcium supplements alone (odds ratio (OR) 0.66; p=0.04) or no supplements (OR 0.34; p=0.007), and bilateral subtotal thyroidectomy (BST) compared to Hartley Dunhill (HD) procedure (OR 0.35; p=0.01). Meta-analyses did not demonstrate any measure to be significantly associated with a reduction in permanent hypocalcemia.

CONCLUSION

This review identified postoperative calcium and vitamin D supplementation and bilateral subtotal thyroidectomy (over HD) as being effective in prevention of transient hypocalcemia. However, the majority of RCTs were of low quality, primarily due to a lack of blinding. The wide variability in study design, definitions of hypocalcemia, and methods of assessment prevented meaningful summation of results for permanent hypocalcemia.

The safety of the Harmonic® FOCUS in open thyroidectomy: a prospective, randomized study comparing the Harmonic® FOCUS and traditional suture ligation (knot and tie) technique

Since Kocher and Billroth refined an acceptable technique, the thyroidectomy has become one of the most frequent procedures in endocrine surgery and bilateral total thyroidectomy is performed in the majority of thyroid diseases. This work evaluated the use of the Harmonic(®) FOCUS and traditional suture ligation (knot and tie) technique in a prospective, randomized study of open thyroidectomy. Eighty two patients were randomized and divided into two similarly sized groups: the Harmonic(®) FOCUS group (F group) and traditional group (T group). The use of the harmonic FOCUS shows some statistically significant advantages limited to a few intraoperative parameters: surgical time and volume of blood loss. The surgical time was significantly shorter in F group than in the T group (105 ± 27 min vs 143 ± 32 respectively; p < 0.05). Intraoperative volume blood loss was significantly more in the T group than in the F group (36 ± 23 ml vs. 24 ± 18; p < 0.05). The postoperative parameters (volume of drainage fluid, serum calcium at 12 and 48 h, hypocalcemia, wound complication, RLN palsy, postoperative pain and length of hospital stay) showed no statistical difference. The Harmonic Focus may provide a cost-effective option only in high volume centers where reducing operative time may balance the number of daily procedures.

Sutureless thyroidectomy

OBJECTIVE

The ultrasonic scalpel is a surgical shear that uses high-frequency mechanical energy to enable simultaneous vessel sealing and tissue coagulation at the same time. We conducted a prospective study to compare the outcome of total thyroidectomy using the ultrasonic scalpel versus the device Ligasure in terms of safety, operative time, overall drainage volume, complications, hospital stay.

METHODS

Between January 2008 and December 2013,400 patients (260 women, 140 men; mean age 46 years) undergoing thyroidectomy were randomized into two groups: group A, where Ultracision were used, and group B, where the Ligasure device was used.

RESULTS

There was no significant differences between the two groups in terms of age, gender, indication for thyroidectomy, thyroid gland weight and diameter, histopathologic diagnosis, preoperative and postoperative serum calcium levels, postoperative complications and reoperative thyroid surgery, time of operation and amount of drainage.

CONCLUSIONS

The ultrasonic scalpel and the Ligasure ares safe, effective, useful, and time-saving alternative to the traditional suture ligation technique for thyroid surgery. They simplified total thyroidectomy, eliminating the need for clamp-and-tie maneuvers while achieving efficient hemostasis.

Use of the harmonic blade scalpel as a novel technique for thoracoscopic resection of pediatric paraspinal masses in children

INTRODUCTION

Data support use of video-assisted thoracoscopic surgery (VATS) for safe and effective resection of paraspinal masses in children. Our aim was to describe outcomes following this operation using a novel technique and to compare its use with that of other established techniques.

SUBJECTS AND METHODS

We performed a retrospective chart review of all children (<18 years old) undergoing thoracoscopic resection of paraspinal masses in 2000-2011. Demographics, operative details, and clinical outcomes were summarized and compared between those undergoing resection using a Harmonic (Ethicon Endo-Surgery, Blue Ash, OH) blade scalpel (HBS) and those who did not.

RESULTS

Sixteen cases were identified (median age, 57.5 months; range, 2-204 months). Six cases (37%) underwent VATS with use of the HBS, and 10 (63%) did not. Demographic and clinical factors were well matched. Median tumor diameter was larger in the HBS group (49.2 cm(3) versus 18.7 cm(3); P=.07). Operative time was similar between groups (121 versus 138 minutes; P=.25), as was the estimated blood loss (10 mL versus 30 mL; P=.91) and chest tube duration (2.1 versus 1.8 days; P=.78). Three cases of Horner's syndrome developed in the standard resection group, and one complication occurred in the HBS group.

CONCLUSIONS

The Harmonic blade scalpel can be used as a simple alternative to standard dissection techniques for thoracoscopic resection of paraspinal masses in children.

A Prospective, Randomized Study between the Small Jaw® and the Harmonic Focus® in Open Thyroidectomy

OBJECTIVES

LigaSure Small Jaw(®) (LSJ) was recently developed and applied to thyroid surgery along with Harmonic Focus(®) (HF). We compared the 2 devices in open total thyroidectomy for papillary thyroid carcinoma (PTC).

STUDY DESIGN

A prospective, randomized study.

SETTING

Tertiary care center.

METHODS

This prospective, randomized study included 126 patients enrolled between December 2011 and June 2012. The numbers of patients in the LSJ group and the HF group were 64 and 62, respectively. Operative times, drain output, parathyroid status, complications, laboratory data, hospital stay, and analgesia requirements were analyzed.

RESULTS

Operation time, parathyroid status, postoperative complications including hypocalcemia, oral calcium supplement, calcium, parathyroid hormone, usage count of painkiller, and hospital stay were not different among the 2 groups. Ionized calcium on postoperative days 1, 2, and 10 was higher in the LSJ group (P = .04, P = .04, P = .01), and drain output was lower in the LSJ group (106.8 vs 123.6 mL, P = .01).

CONCLUSIONS

Open thyroidectomy for PTC using the HF or the LSJ was safe and effective and was not associated with any increase in complications. Surgical outcomes and operative morbidity were equivalent between the 2 groups.

Radiofrequency-induced small bowel thermofusion: an ex vivo study of intestinal seal adequacy using mechanical and imaging modalities

BACKGROUND

Bipolar radiofrequency (RF) induced tissue fusion is believed to have the potential to seal and anastomose intestinal tissue thereby providing an alternative to current techniques which are associated with technical and functional complications. This study examines the mechanical and cellular effects of RF energy and varying compressive pressures when applied to create ex vivo intestinal seals.

METHODS

A total of 299 mucosa-to-mucosa fusions were formed on ex vivo porcine small bowel segments using a prototype bipolar RF device powered by a closed-loop, feedback-controlled RF generator. Compressive pressures were increased at 0.05 MPa intervals from 0.00 to 0.49 MPa and RF energy was applied for a set time period to achieve bowel tissue fusion. Seal strength was subsequently assessed using burst pressure and tensile strength testing, whilst morphological changes were determined through light microscopy. To further identify the subcellular tissue changes that occur as a result of RF energy application, the collagen matrix in the fused area of a single bowel segment sealed at an optimal pressure was examined using transmission electron microscopy (TEM).

RESULTS

An optimal applied compressive pressure range was observed between 0.10 and 0.25 MPa. Light microscopy demonstrated a step change between fused and unfused tissues but was ineffective in distinguishing between pressure levels once tissues were sealed. Non uniform collagen damage was observed in the sealed tissue area using TEM, with some areas showing complete collagen denaturation and others showing none, despite the seal being complete. This finding has not been described previously in RF-fused tissue and may have implications for in vivo healing.

CONCLUSIONS

This study shows that both bipolar RF energy and optimal compressive pressures are needed to create strong intestinal seals. This finding suggests that RF fusion technology can be effectively applied for bowel sealing and may lead to the development of novel anastomosis tools.