Management of surgical diseases of thyroid gland indications of the United Italian Society of Endocrine Surgery (SIUEC)

A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in thyroid surgery published in 2016, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 13 members of the SIUEC highly trained and experienced in thyroid surgery. The main topics concern clinical evaluation and preoperative workup, patient preparation for surgery, surgical treatment, non-surgical options, postoperative management, prevention and management of major complications, outpatient care and follow-up.

Thyroid surgery during the COVID-19 pandemic: results from a systematic review

PURPOSE

During the COVID-19 pandemic, elective thyroid surgery is experiencing delays. The problem is that the COVID-19 pandemic is ongoing. The research purposes were to systematically collect the literature data on the characteristics of those thyroid operations performed and to assess the safety/risks associated with thyroid surgery during the COVID-19 pandemic.

METHODS

We used all the procedures consistent with the PRISMA guidelines. A comprehensive literature in MEDLINE (PubMed) and Scopus was made using ''Thyroid'' and "coronavirus" as search terms.

RESULTS

Of a total of 293 articles identified, 9 studies met the inclusion criteria. The total number of patients undergoing thyroid surgery was 2217. The indication for surgery was malignancy in 1347 cases (60.8%). Screening protocols varied depending on hospital protocol and maximum levels of personal protection equipment were adopted. The hospital length of stay was 2-3 days. Total thyroidectomy was chosen for 1557 patients (1557/1868, 83.4%), of which 596 procedures (596/1558, 38.3%) were combined with lymph node dissections. Cross-infections were registered in 14 cases (14/721, 1.9%), of which three (3/721, 0.4%) with severe pulmonary complications of COVID-19. 377 patients (377/1868, 20.2%) had complications after surgery, of which 285 (285/377, 75.6%) hypoparathyroidism and 71 (71/377, 18.8%) recurrent laryngeal nerve injury.

CONCLUSION

The risk of SARS-CoV-2 transmission after thyroid surgery is relatively low. Our study could promote the restart of planned thyroid surgery due to COVID-19. Future studies are warranted to obtain more solid data about the risk of complications after thyroid surgery during the COVID-19 era.

Hemithyroidectomy versus total thyroidectomy in the intermediate-risk differentiated thyroid cancer: the Italian Societies of Endocrine Surgeons and Surgical Oncology Multicentric Study

The surgical treatment of the intermediate-risk DTC (1-4 cm) remains still controversial. We analyzed the current practice in Italy regarding the surgical management of intermediate-risk unilateral DTC to evaluate risk factors for recurrence and to identify a group of patients to whom propose a total thyroidectomy (TT) vs. hemithyroidectomy (HT). Among 1896 patients operated for thyroid cancer between January 2017 and December 2019, we evaluated 564 (29.7%) patients with unilateral intermediate-risk DTC (1-4 cm) without contralateral nodular lesions on the preoperative exams, chronic autoimmune thyroiditis, familiarity or radiance exposure. Data were collected retrospectively from the clinical register from 16 referral centers. The patients were followed for at least 14 months (median time 29.21 months). In our cohort 499 patients (88.4%) underwent total thyroidectomy whereas 65 patients (11.6%) underwent hemithyroidectomy. 151 (26.8%) patients had a multifocal DTC of whom 57 (10.1%) were bilateral. 21/66 (32.3%) patients were reoperated within 2 months from the first intervention (completion thyroidectomy). Three patients (3/564) developed regional lymph node recurrence 2 years after surgery and required a lymph nodal neck dissection. The single factor related to the risk of reoperation was the histological diameter (HR = 1.05 (1.00-1-09), p = 0.026). Risk stratification is the key to differentiating treatment options and achieving better outcomes. According to the present study, tumor diameter is a strong predictive risk factor to proper choose initial surgical management for intermediate-risk DTC.

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.

Influence of short-term selenium supplementation on the natural course of Hashimoto's thyroiditis: clinical results of a blinded placebo-controlled randomized prospective trial

BACKGROUND

The real efficacy of selenium supplementation in Hashimoto's thyroiditis (HT) is still an unresolved issue.

OBJECTIVES

We studied the short-term effect of L-selenomethionine on the thyroid function in euthyroid patients with HT. Our primary outcome measures were TSH, thyroid hormones, thyroid peroxidase antibody (TPOAb), thyroglobulin antibody (TGAb) levels and thyroid echogenicity after 6 months of L-selenomethionine treatment. The secondary outcome measure was serum CXCL10 levels.

METHODS

In a placebo-controlled randomized prospective study, we have enrolled untreated euthyroid patients with HT. Seventy-six patients were randomly assigned to receive L-selenomethionine 166 µg/die (SE n = 38) or placebo (controls n = 38) for 6 months. TSH, free T₄ (FT₄), free T₃ (FT₃), TPOAb and CXCL10 serum levels were assayed at time 0, after 3 and 6 months. An ultrasound examination of the left and right thyroid lobe in transverse and longitudinal sections was performed. A rectangular region, the region of interest, was selected for analysis.

RESULTS

TSH, FT4, FT3, TPOAb, thyroid echogenicity and CXCL10 were not statistically different between SE and control groups at time 0, after 3 and 6 months. In the SE group, FT₄ levels were significantly decreased (P < 0.03) after 3 months, while FT₃ increased (P < 0.04) after 3 and 6 months versus baseline values. In the control group, the FT₃ decreased after 3 and 6 months (P < 0.02) compared to baseline.

CONCLUSION

The short-term L-selenomethionine supplementation has a limited impact on the natural course in euthyroid HT. Our results tip the balance toward the ineffectiveness of short-term L-selenomethionine supplementation in HT.

The current status of lymph node dissection in the treatment of papillary thyroid cancer. A literature review

AIM

Cervical lymph node micrometastases are observed in up to 90% of papillary thyroid cancers (PTC), showing that lymph nodal involvement is very common. Nevertheless, during the last years, the role of lymph node dissection in the treatment of PTC has been controversial and, at present, the best indications to the routine or therapeutic neck dissection remain subject of research. In order to better analyze the current role of lymph node dissection in the surgical treatment of PTC, an analysis of the most recent literature data was performed.

STUDY DESIGN

By using as keywords lymph node dissection, selective, lateral or central lymph node dissection, modified radical neck dissection, prophylactic or therapeutic lymph node dissection, papillary thyroid cancer, a Pub Med data base research was carried out. The most recent guidelines of different referral endocrine societies, inhering neck dissection for PTC, were also evaluated.

RESULTS

The role of neck dissection in PTC management remains controversial regarding routine or therapeutic indications, surgical extension, and its impact on local recurrence and long term survival. Due to inhomogeneous literature data, the current status of node dissection is still subject of research.

CONCLUSIONS

There is agreement between endocrine and neck surgeons about the extension of therapeutic lymph node dissection in N+ PTC patients , and also in the prophylactic treatment of N0 "high risk" patients. Considering a recent trend toward routine central lymphadenectomy avoiding radioactive treatment, prospective randomized trials are needed to evaluate the benefits of different approaches.

Retrieval of the gastric specimen following laparoscopic sleeve gastrectomy. Experience on 275 cases

Severe obesity leads to a high incidence of complications and a decrease in life expectancy, especially among younger adults. Laparoscopic sleeve gastrectomy (LSG) first intended as the first step of biliopancreatic diversion with duodenal switch is gaining a per-se procedure role because of its effectiveness on weight loss and comorbidity resolution. Different techniques have been described for specimen extraction in LSG. In this article we report the technique adopted in 275 LSGs performed in our department. In the first 120 LSGs performed from 2007, the specimen was extracted through a mini laparotomy. In the following 155 cases the technique has been simplified: the grasped specimen has been withdrawn through the 15 mm trocar site. We registered in the fist group six cases of wound infection (5%), ten cases of hematoma (8.3%) and four cases of port site hernia (3.3%). In the second group only one case of hematoma (0.6%, p = 0.01) but no cases of wound infection (p = 0.01) or port site hernia, (p = 0.03) although we registered a specimen perforation during retrieval in 16 patients, were reported. The technique described in the 155 cases of the control group has shown to be more effective than the technique we used in the case group, allowing significantly lower operative time (112.9 ± 1.0 vs 74.9 ± 9.1 p < 0.001) and complications, and providing unchanged costs.

Long-term function of parathyroid subcutaneous autoimplantation after presumed total parathyroidectomy in the treatment of secondary hyperparathyroidism. A clinical retrospective study

INTRODUCTION

Parathyroidectomy (PTx) is recommended in patients affected by secondary hyperparathyroidism (2HPT) of chronic kidney disease-mineral bone disorders (CKD-MBD), resistant to medical treatment. Analyzing total parathyroidectomy with muscular or subcutaneous autoimplantation (TPai) outcomes in hemodialysis (HD) 2HPT patients, and monitoring intact parathyroid hormone (iPTH) levels, we evaluated long-term functional results of subcutaneous parathyroid glandular tissue autoimplantation.

METHODS

40 HD 2HPT patients, resistant to medical treatment, and awaiting for renal transplantation, underwent total parathyroidectomy with subcutaneous autoimplantation of 9-12 fragments of not nodular hyperplasia parathyroid tissue in not dominant forearm. iPTH were analyzed 24 h, and 3-6-12-24 months after surgery. The 1.08-6.99 pmol/L range was taken as reference of normal iPTH level based on which eu- (1.08-6.99), hypo- (<1.08), aparathyroidism (0) and persistence or relapse (>6.99) of disease were determined.

RESULTS

In every case PTai determined an extraordinary improvement of quality of life, associated with a notable reduction of iPTH serum level. Immediate normalization of iPTH was achieved in 50% of cases; hypoparathyroidism in 25% of cases and persistence of disease in 25% were observed. Long term follow-up showed a reduction of hypoparathyroidism and an increase of relapse rate up to 20%. Grafting resection was never performed.

DISCUSSION

Subcutaneous autotrasplantation is a very simple and fast surgical technique. Nevertheless, similar success and recurrence rates were reported following muscular or subcutaneous grafting, as confirmed in our experience.

CONCLUSIONS

Subcutaneous grafting was effective as muscular implantation, with comparable functional results, but avoiding its potential complications.

Short-term outcomes after rehabilitation treatment in patients selected by a novel rehabilitation score system (Brusciano score) with or without previous stapled transanal rectal resection (STARR) for rectal outlet obstruction

PURPOSE

The purpose of this study was to examine short-term outcomes of rehabilitation treatment in patients with or without previous stapled transanal resection (STARR) for rectal outlet obstruction by using a novel rehabilitation score system (Brusciano score).

METHODS

This is a retrospective cohort study conducted at a single tertiary referral institution including all patients with chronic functional constipation admitted to the outpatient unit from 2004 to 2009.

RESULTS

Among 330 consecutive patients, 247 (74.8 %) (204 females and 43 males) showing a significantly higher rehabilitation score (mean of 15.7 ± 1.8; range, 7-25) than healthy controls (mean, 3.2 ± 1.2; range 2-6) (p < .0001) were selected for rehabilitation. Of the 247 patients evaluated, group A (no previous surgery) consisted of 170 patients (53 males; mean age, 44.8 ± 12.9 years; range, 19-80) of which 38 presented mixed constipation, whereas group B (previous surgery) consisted of 77 patients (18 males; mean age, 47.0 ± 11.2 years; range, 22-81). The Brusciano score, Agachan-Wexner score and quality of life improved in both groups of patients after treatment. Better improvements of Brusciano and Agachan-Wexner scores were observed in patients with previous STARR (group B).

CONCLUSIONS

The rehabilitation score system employed in this study seems to be a useful tool in selecting and assessing the outcome of patients who might benefit from rehabilitation treatment. Constipation and quality of life were significantly improved by the rehabilitation treatment. Further studies are needed to clarify either the impact of rehabilitation treatment on long-term outcome of patients treated for rectal outlet obstruction or its role in those who develop problems over time.

Total thyroidectomy without prophylactic central neck dissection combined with routine oral calcium and vitamin D supplements: is it a good option to achieve a low recurrence rate avoiding hypocalcemia? A retrospective study

AIM

Routine central neck dissection for differentiated thyroid cancer (DTC) to prevent a future recurrence is still a matter of discussion, due to the increased risk of injury to parathyroid glands, without a clear demonstrable benefits in terms of long-term survival. Aim of this study was to investigate if, treating patients with total thyroidectomy (TT) without prophylactic central lymphadenectomy can minimize the risk of hypocalcemia by routine administration of oral calcium and vitamin D supplements, providing at the same time a low recurrence rate.

METHODS

In the set of a retrospective study, 221 patients affected by DTC were enrolled. All of them underwent to TT without prophylactic central lymphadenectomy. In the early postoperative period, oral calcium 2g/d taken twice (1 g every 12 hours) and vitamin D 1 g/d taken twice (0.5 g every 12 hours) were administered; changes in serum calcium and hypocalcemia-related symptoms were recorded. Follow-up was based on neck ultrasound and monitoring of serum Tg and Tg-antibodies levels every 6 months during suppressive l-tiroxine treatment.

RESULTS

Symptomatic hypocalcemia developed only in 6.3% of patients, whereas laboratory hypocalcemia developed in 10%. Hypocalcemic symptoms were minimal in 4 patients. Intravenous calcium was administered to 6 patients with severe hypocalcemic symptoms. Permanent hypocalcemia developed in two patients.

CONCLUSION

Until a conclusive evidence of the actual benefit of prophylactic central lymphadenectomy in the treatment of DTC, it may be avoided. The oral calcium and vitamin D supplements can take a role in the prevention of postoperative hypocalcemia and for increasing the likelihood of a safe and early discharge from the hospital.

Long-term outcomes following "presumed" total parathyroidectomy for secondary hyperparathyroidism of chronic kidney disease

AIM

The most efficacious surgical treatment for renal hyperparathyroidism is still subject of research. Considering its low incidence rate of long-term relapse, "presumed" total parathyroidectomy without autotrasplantation (TP) may be indicated for secondary hyperparathyroidism (2HPT) in patients with chronic kidney disease (CKD), not eligible for kidney transplantation. The aim of this study was to analyse the TP long-term results in 2HPT haemodialysis (HD) patients.

METHOD

Between January 2004 and October 2009, 25 2HPT HD patients, not eligible for kidney transplantation, underwent TP of at least four parathyroid glands. Clinical status and intact parathyroid hormone (iPTH) serum levels were assessed intraoperatively and during a 36-month follow-up.

RESULTS

TP improved the typical clinical symptoms and a significant reduction of iPTH serum levels was achieved in each patient. Aparathyroidism was never observed; in case of severe postoperative hypocalcemia, hypocalcemic seizures were never reported and the long-term recurrence rate was 8%. Only one patient received a kidney transplantation. Postoperative cardiovascular events (hypertension, peripheral artery disease, arrhythmia, coronary or cerebrovascular disease) were observed in 32% of cases and mortality rate was 16%.

CONCLUSIONS

Considering its low long-term relapse rate and the absence of postoperative aparathyroidism, TP may still be considered the treatment of choice in patients with aggressive forms of 2HPT or of advanced dialytic vintage, with no access to renal transplantation. In case of postoperative hypoparathyroidism, hypocalcaemia can be effectively managed by medical treatment.

Role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy

AIM

to evaluate the role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy.

PATIENTS AND METHODS

50 consecutive patients, undergoing total thyroidectomy, were enrolled. Oral calcium and vitamin D were administered in the pre and post-operative time. The data concerning symptomatic and laboratoristic hypocalcemia were collected.

RESULTS

Incidence of symptomatic hypocalcemia was very low (6%); incidence of laboratoristic hypocalcemia was 10%. No permanent hypocalcemia developed.

CONCLUSIONS

Implementing oral calcium and vitamin D both before and after total thyroidectomy can reduce the incidence of hypocalcemia related to surgery.

Surgical treatment of papillary thyroid carcinoma without lymph nodal involvement

BACKGROUND

In the treatment of differentiated thyroid cancer (DTC), in absence of enlarged lymph nodes, the role of routine central lymph node dissection (RCLD) remains controversial. The aim of this study is to analyze data resulting from total thyroidectomy (TT) not combined with RCLD in the treatment of DTC.

METHODS

We retrospectively evaluated the clinical records of 80 patients treated between January 1996 and December 2003 with TT without RCLND, in absence of suspected enlarged lymph nodes at preoperative ultrasonography and intraoperatively during neck exploration. In this series, 75 patients (93.7%) underwent radioiodine (RAI) ablation, followed by Thyroid Stimulating Hormone (TSH) suppression therapy. In case of locoregional lymph nodal recurrence, a central (VI) and ipsilateral (III-IV) selective lymph node dissection was performed.

RESULTS

Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and unilateral temporary vocal fold paralysis were respectively 2.55% and 2.55%. Locoregional recurrence, with positive cervical lymph nodes, after a 10.3 ± 4.7 years mean follow-up was observed in 3 patients (3.75%). They were submitted to a central (VI) and ipsilateral (III-IV) selective neck dissection without significant complications.

CONCLUSIONS

In our series, TT not combined with RCLD was associated to a low locoregional recurrence rate, even if the lack of a control group treated with RCLD does not allow any generalized assumption. RCLD may be indicated in high risk patients, in whom lymph nodal recurrence is more frequent. More prospective randomized studies are needed to better define the role of RCLD and postoperative radioiodine ablation.

[Bilio-intestinal bypass in the treatment of metabolic syndrome in obese patient]

INTRODUCTION

obesity (O) is a chronic patologic condition, evolutive and relapsing, with multifactorial etiopathogenesis, consisting in an alteration of the body's composition characterized by a relative and absolute excess of fat, that gets worse the life quality and causes complications that can lead to death.

PATIENTS AND METHODS

experience concerns twenty-five diabetic obese patients underwent bilio-intestinal by-pass between January 2006-December 2007. All these patients, before the surgical operation, underwent a rigorous clinical and laboratory examination. Besides, a precise rate control of laboratory, overlap with those performed in the pre-operative period of operation, was required for each patient: the first after one month, the second after six months and the third after twelve months.

RESULTS

the average weight loss was about 40 kg and, more important, these data show that the BMI is reduced, until to become stable, after 12 months from surgical operation, about values 34-31 Kg/m², obtaining, in this way, an improvement of values in the development metabolic syndrome and, above all, heart rate and ventricular repolarization.

CONCLUSIONS

the data obtained by our study support the hypothesis to suggest the operations of bariatric malassorbing surgery, in particular bilio-intestinal by-pass, as prophylactic methods for dismetabolics diseases, with reduction of cardiovascular risk in obese patient.

[Retroperitoneal dedifferentiated liposarcoma (DDLS) with hyperglycemic activity: case report and literature review]

The authors describe a Retroperitoneal De Differentiated LipoSarcomas (DDLs), that for its clinical behavior shows peculiar characteristics and original aspects: typical is the recurrence due to local invasiveness, but absolutely original seems to be the surviving time, maybe correlated to its histological evolution (dedifferentiation from leiomyosarcoma to liposarcoma) and an interesting correlation from the tumor recurrence and the glycemic curve first and after the surgical treatments. A 66-year-old woman, presenting typically with very big abdominal masses, treated three times in almost three years, every time with aggressive surgical treatments. Histological response was leiomyo-sarcoma in the first two operations and liposarcoma in the last treatment and in every preoperative phase the patient, normally prediabetic, started to have problem of glycemia balancing, needing an insulin support until the postoperative phases when its glycemia was coming back in normal value without insulin needs, of course until a new tumor recurrence. This last aspect, not depending on pancreas involvement or hormonal activity (immune-histo-chemistry was never conforming a neuro-endocrine activity), seems probably due directly to a mass and metabolic effect of the tumor. Beginning from the description of this case and its interesting biology and reviewing most of the literature on the argument, authors hope to give our support to still debated and partially unknown aspects of these kinds of tumors.

Thyroidectomy with ultrasonic dissector: a multicentric experience

INTRODUCTION

We have conducted a clinical controlled trial (CCT) on patients who had undergone thyroidectomy for goitre or thyroid carcinoma. The endpoint of this study was to evaluate the benefits of ultrasonic dissector vs conventional technique (vessel ligation and tight) in patients undergoing thyroid surgery.

PATIENT AND METHODS

Between January 2007 and December 2009 a CCT was conducted on 2.736 consecutive patients admitted to our clinical wards, who had undergone thyroidectomy for goitre or thyroid carcinoma. They were divided in two group: 1.021 patients (203 male and 818 female) underwent thyroidectomy with ultrasonic dissector (UAS) and 1.715 patients (369 male and 1.346 female) underwent throidectomy with conventional technique (vessel ligation and tight) (CT).

RESULTS

The operative time (UAS 80 minutes mean, 50 to 120 min., vs CT 120 minutes, 70 to 180 minutes) was much lower in the thryoidectomy with UAS group. The incidence of transient laryngeal nerve palsy (UAS 17/1.021 patients. 1.6% vs CT 16/1.715 patients, 0.9%) was higher in the thyroidectomy with UAS group; the incidence of permanent laryngeal nerve palsy was similar in two groups(UAS group; there are no relevant difference in the incidence of permanent hypocalcemia (UAS 26/1.021 patients, 2.5% vs 35/1.715 patients, 2%) which was similar in two groups. Also the average post-operative hospitalization was similar in two groups (2 days).

CONCLUSIONS

Actually, the only significant advantage shown from this CCT is represented in terms of cost-effectiveness (reduction of the usage of operating room and hospitalization) for patients treated with UAS, subsequent to the significant reduction of operative duration. Although the analysis showed that the patients who were treated with ultrasonic dissection don't present more favourable results in incidence of post-operative transient complication:transient laryngeal nerve palsy (1.6% in UAS vs 0.9% in CT) and transient hypocalcaemia (9.5% in UAS vs 7.7% in CT). There is no significant difference in the incidence of permanent laryngeal nerve palsy (0.9% in UAS vs in 1% CT). The experience of surgeon is the only important factor which can influence the appearance of these complications; the usage of Ultrasonic dissector can only help surgical action but can't repair the experience of the operator.

Radical axillary dissection in sentinel lymph node biopsy era: it's still a considerable technique in breast cancer management?

The new staging technique of sentinel node biopsy facilitates the identification of pathological node negative patients in whom axillary dissection may be avoided; however, patients with a positive sentinel node biopsy would require a thorough examination of their nodal status. Axillary dissection provides good local control, accurate staging and prognostic information for decisions about adjuvant therapy. We describe a technique of radical axillary clearance that includes levels I, II and III; this isn't associated with additional morbidity to patients and involves minimal extension of operative time.

Ultrasound scissors versus electrocautery in axillary dissection: our experience

The ultrasound scissors are recently emerging as an alternative surgical tool for dissection and haemostasis and have been extensively used in the field of minimally invasive surgery. We studied the utility and advantages of this instrument compared with electrocautery to perform axillary dissection. The operative and morbidity details of thirty-five breast cancer patients who underwent axillary dissection using the ultrasound scissors were compared with 35 matched controls operated with electrocautery by the same surgical team. There was no significant difference in the operating time between the ultrasound scissors and electrocautery group (36 and 30 mins, p>0.05). The blood loss (60 +/- 35 ml and 294 +/- 155 ml, p<0.001) and drainage volume (200 +/- 130 ml and 450 +/- 230 ml, p<0.001) were significantly lower in the ultrasound scissors group. There was a significant reduction of draining days in ultrasound scissors group (mean one and four days, respectively p<0.05). There was significant difference in the seroma rate between the two groups (10% and 30%, respectively). Axillary dissection using harmonic scalpel is feasible and the learning curve is short. Ultrasound scissor significantly reduces the blood loss and duration of drainage as compared to electrocautery.

Biliary tract injuries during laparoscopic cholecystectomy: three case reports and literature review

INTRODUCTION

Biliary tract injuries (BTI) represent the most serious and potentially life-threatening complication of cholecystectomy. During open cholecystectomies (OC), the prevalence of bile duct injuries has been estimated at only 0.1-0.2%. We report 3 cases of BTI during laparoscopic cholecystectomy (LC). CASE 1: Ascalesi Hospital, Naples 2003-2007, 875 LC (BTI 0,11%). During the dissection of triangle of Calot a partial resection of biliary common duct was made. Immediately the lesion was evident and sheltered in laparoscopy, suturing with a spin reabsorbable, without biliar drainage. The post-operative outcome was good, without alteration of the some parameters, and the patient was discharged after three days. At the last follow-up (January 2006) the cholangiography didn't show stricture or leakage. CASE 2: General and Laparoscopic Surgical Unit San Giovanni di Dio Hospital Frattamaggiore 2004-2007, 720 LC (BTI 0,13%). Patient affected by cholecystitis with gallstones. The patient did not present jaundice, but abdominal pain, leucocitosis, fever and US evidence of parietal gallbladder inflammation. LC was performed after 36 h; during operation, common biliar duct was misidentified for subverted anatomy caused by inflammation. The common bile duct was clipped, and the patient presented jaundice after three days after operation. The colangiography was performed showing the stop. Therefore a reoperation was needed and laparotomic Roux-en-Y hepaticojejunostomy was performed. CASE 3: Dpt of Emergency Surgery, Second University of Naples 2000-2007, LC 520 (BTI 0,19%). Patient affected by more than 20 years symptomatic cholelithiasis, with only obesity risk factor; she underwent laparoscopic cholecystectomy and sudden bleeding of the cystic artery, poor vision and probably the long history of symptoms, producing a flogistic alteration of the anatomy, caused a misidentification of the cystic duct and the common bile duct with complete or lateral clipping of the common hepatic duct. The error was unrecognized intra-operatively but after progressive jaundice the postoperative colangiography showed a nearly complete stop by two clips. Roux-en-Y hepaticojejunostomy with intraoperative cholangiographic control was performed.

DISCUSSION

The most common cause of BTI is the failure to recognize the anatomy of the triangle of Calot. This is attributed to factors inherent to the laparoscopic approach, to inadequate training of the surgeon and to local anatomical risk factors. The laparoscopic "learning curve" of the surgeon is the most important factor of bile ducts injury. But also local anatomical risk factors are important such as acute cholecystitis, severe chronic scarring of the gallbladder and bleeding or excessive fat in the hepatic hilum. These local risk factors seem to be present in 15% to 35% of BTI. Abnormal biliary anatomy, such as a short cystic duct or a cystic duct entering into the right hepatic duct also may increase the incidence of BTI. Schematic representation of the common mechanisms of BTI during LC are: misidentification of the cystic duct and the common biliary duct, lateral clipping of the common biliary duct, traumatic avulsion the cystic duct junction, diatermic injury of common biliary duct during dissection of the Calot triangle or during the cholecystectomy, injury of anomalous right hepatic duct.

CONCLUSION

Conversion to laparotomy, in difficult cases involving inflammatory changes, aberrant anatomy or excessive bleeding, is not to be considered as a failure but rather as good surgical decision in order to ensure the patient's safety.

New trends on fibrin glue in seroma after axillary lymphadenectomy for breast cancer

BACKGROUND

Axillary lymphadenectomy remains an integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods to reduce seroma magnitude and duration, fibrin glue has been proposed in several studies with controversial results.

PATIENTS AND METHODS

Ninety patients underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 45 patients; the other 45 patients were treated conventionally.

RESULTS

Suction drainage was removed between post-operative (p.o.) days 3 and 4. Seroma magnitude and duration were significantly reduced (p 0.004 and 0.02, respectively), and there were fewer evacuative punctures, in patients receiving fibrin glue compared with the conventional treatment group.

CONCLUSIONS

Use of fibrin glue does not always prevent seroma formation, but does reduce seroma magnitude, duration and evacuative punctures.

Metachronous Paget's disease of the breast: case report

Paget breast disease is a kind of intraductal carcinoma that through an intracanalicular diffusion invades the basal epidermal layer, reaching the areola and nipple, producing a typical erythematous desquamative eczematous-like lesion. This neoplasia can remain undetected for a long time and inadequately treated as a dermatological affection. Synchronous or metachronous lesions are very uncommon. Surgical choice is conditioned by the presence of a tumor below the epidermal lesion, by its dimensions, and by the possible lymph node involvement. Surgical therapy can be radical or conservative. From our experience we think that lesion biopsy is always necessary to formulate a correct diagnosis and to schedule an appropriate therapeutic approach. In our case, a biopsy was performed first, then on the basis of the frozen section analysis a radical mastectomy with axillary third level lymph nodes dissection, because of the large dimensions of the lesion and the previous history of a methachronous lesion.

Ductal carcinoma in situ of the breast: our experience

AIM

The ductal carcinoma in situ (DCIS) is a more and more frequent neoplasia, representing over 25% of diagnosed breast cancer in recent surveys.It is particularly interesting as concerns several aspects of which the most important are issues linked to clinical diagnosis and the difficulties of histopathological classification, with evident and important therapeutic implications.

PATIENTS AND METHODS

The authors report their experience about 161 ductal carcinoma in situ of the breast. Guidelines for surgical treatment are: radiological or clinical diagnosis, tumor's extension, histological classification, grading and margin status. At the present the authors prefer breast conserving surgery with tumor margin's study. They report their experience in the last seven years about sentinel lymph node biopsy.

RESULTS

The most frequent histotype resulted comedocarcinoma (61,8%) followed by non comedo (38,2%). Local recurrence after DCIS therapy is 6,1%.

CONCLUSIONS

80-90% of the patients currently treated for DCIS present non-palpable breast lesions at diagnosis. Breast conserving surgery is the first choice and radiotherapy and endocrine therapy are indicated for selected patients.

[Conservative anal fistula treatment with collagenic plug and human fibrin sealant. Preliminary results]

The authors, on the basis of a long clinical experience with human fibrin glue in general surgery, compared two different extracellular matrix (collagen), Surgisis and TissueDura, with human fibrin glue, applied during the operation, and sometimes in postoperative, to obtain the healing of perianal fistulas. The collagenic extracellular matrix provides, according to the rationale suggested, an optimal three-dimensional structure for the fibroblastic implant and neoangiogenesis, hence for the fistula "fibrotizzation" and closure. The encouraging results for transphincteric fistulas and a simple and easy technique push to researchers on samples statistically significant.

[Non recurrent inferior laryngeal nerve: our surgical experience]

AIM

Iatrogenic damage to the recurrent laringeal nerve is the most feared complication in thyroid surgery and the main cause for vocal cord palsy. Prevention of such a lesion is based upon the thorough search for the nerve along its anatomic pathway. In the present study the Authors discuss an important anatomic variation: non-recurrent inferior laryngeal nerve, emphasizing the aspects of surgical anatomy, on the basis of their own experience in neck surgery.

MATERIALS AND METHODS

The study takes into conideration 301 surgical interventions on the thyroid gland, in 268 women and 33 men; consisting in 256 total thyroidectomies and 45 loboisthmectomies, as follows: 186 for nodular goiter, 48 for follicular nodule, 34 for papillifer carcinoma, 33 for toxic goiter. The identification and exposure of inferior laryngeal nerve was performed according to the principles and technique by Lahey.

RESULTS

The overall prevalence of non recurrent inferior laryngeal nerve was equal to 0.33% (1/301 operations). The anomaly is prevailing on the right side, being due by an anomalous reabsorption of the IV ventral arch. This is the cause of the formation of a subclavian artery that is responsible for dysphagia lusoria.

CONCLUSIONS

The rationale for the preservation of recurrent nerve is its systematic identification and exposure along all its course from its laryngeal entry. Diagnosis of non recurrent inferior laryngeal nerve is exclusively intra-operative. The anomaly is clinically asymptomatic and its suspicion can be posed in case of vascular anomalies or dysphagia. In such a circumstance the golden diagnostic tool is the angio Tc-RMN, while both the EGDS and baritate esophagous can be of some diagnostic help.

Plurifocal breast cancer and double lymphatic spread

BACKGROUND

Sentinel node (SN) has been proved to be a reliable technique in predicting the lymph nodes state of the axilla in breast cancer. For the majority of the authors the intradermal and peritumoral injection is the best way.

PATIENTS AND METHODS

Our experience, from 1997, includes 587 cases of SN in women with resectable breast cancer less than 3 cm of diameter. We performed the lymphoscintigraphy after a peritumoral injection of radioactive tracer and, if the lesion was superficial, we associated an intradermal injection on the skin above the lesion itself. Two patients had multifocal right breast cancer. We did two separate injections around each tumor.

RESULTS

The radioactive tracer spread towards the internal mammary chain and homolateral axillary nodes.

CONCLUSIONS

We consider the peritumoral injection as essential in tumors located deeply in the breast (under ultrasound guide if not palpable) together with intradermal injection in superficial ones. Using this technique the possibility of a mis-identification of the SN is reduced.

Fibrin glue to reduce seroma after axillary lymphadenectomy for breast cancer

Axillary lymphadenectomy remains an integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among the methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial

RESULTS

Sixty patients underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray was applied to the axillary fossa in 30 patients; the other 30 patients were treated conventionally. Suction drainage was removed between postoperative days III and IV. Seroma magnitude and duration were significantly reduced (P=0.004 and 0.02, respectively), and there were fewer evacuative punctures, in patients receiving fibrin glue compared with the conventional treatment group. The authors conclude that the use of fibrin glue does not always prevent seroma formation, but does reduce seroma magnitude, duration and necessary evacuative punctures.

Sentinel lymph node biopsy in the treatment of breast cancer. Experience in 527 cases

AIM

Knowledge of axillary lymph node status is a key aid to staging and prognosis and it represents a guideline for adjuvant therapy in breast cancer. Despite the morbidity it causes, complete axillary dissection was long the mainstay of treatment. Sentinel lymph node biopsy has proved so reliable in the evaluation of node involvement that axillary node dissection is now generally performed when sentinel node biopsy tests negative.

METHODS

In this 3-phase study, 50 patients were enrolled to evaluate the learning curve of sentinel node biopsy (phase 1, September 1997-January 1998); 256 patients (age range 27-81 years) with infiltrative breast cancer (T <3 cm, clinical N0) underwent level 1 lymph node dissection when the sentinel node tested negative at histopathology (phase 2, February 1998-March 2001); 221 patients with T <3 cm underwent dissection of the sentinel node when it tested negative for metastasis (phase 3, April 2001-March 2005).

RESULTS

The sentinel node was preoperatively detected in 98.6% of cases after peritumoral and intradermic injection of the radionuclide tracer and intraoperatively in 99% (90% with radio-guided surgery, 10% with vital staining). The sentinel node was positive in 15% of patients with T1 and metastatic in 65%.

CONCLUSIONS

Our results are in line with the published data; therefore, the study will go forward to examine the role of the micrometastasis in the sentinel node and of in-transit tumoral cells.

One-day thyroid surgery: retrospective analysis of safety and patient satisfaction on a consecutive series of 1,571 cases over a three-year period

Short-stay thyroid surgery (<24 h hospital stay) is becoming increasingly popular but some potentially lethal complications are considered strong arguments against shortening hospitalization after thyroidectomy. The authors reviewed the data of 1,571 patients undergoing one-day thyroid surgery over a 3-year period to determine safety and patient satisfaction. There were 1,244 females and 327 males. Mean age was 43 years. Patient satisfaction was evaluated by a questionnaire given on discharge, while post-discharge surgical recovery was analyzed by the PSR scale. Total thyroidectomy was performed in 1,119 patients (71%), hemithyroidectomy in 450 (29%), isthmusectomy in 2. Morbidity occurred in 152 patients (9.6%). Surgical complications were transient hypocalcemia in 112 cases and permanent hypoparathyroidism in 3; monolateral transient nerve palsy occurred in 10 cases, bilateral in 3; definitive monolateral recurrent palsy in 4 cases. Bleeding requiring re-intervention occurred in 10 cases, wound complications in 5 cases, and intraoperative tracheal lesion in 1 patient. Among complicated patients, 129 (84.8%) were treated after discharge as outpatients. Conversion to inpatient treatment occurred in 28 patients (1.7%) (25 for surgical reasons). Four patients (0.2%) required hospital readmission. Patients were very satisfied in 84.2%, satisfied in 9.5%, poorly satisfied in 4.3%, completely unsatisfied in 2%. Postoperative recovery mean score by PSR scale resulted in 85.14% (0-100%). Our results confirm that the one-day surgery model is safe, effective, and highly agreeable in patients undergoing surgery for thyroid disease.

[Ductal carcinoma in situ of the breast]

The Authors report their experience about 127 ductal carcinoma in situ (DCIS) of the breast. Guidelines for surgical treatment are: radiological or clinical diagnosis, tumor's extension, histological classification, grading and margin status. At the present the Authors prefer breast conserving surgery with tumor margin's study. They report their experience in the last seven years about sentinel node biopsy. Radiotherapy and endocrine therapy are indicated for selected patients; local recurrence after DCIS therapy is 8,1% on a 6,1 years follow-up.

Case report: laparoscopic cholecystectomy in situs viscerum inversus

Situs viscerum inversus is a rare condition, in which the organs are transposed from their normal location in the opposite side of the body. The inversion of L-R asymmetry may be complete (SVI totalis) or partial (SVI partialis), whereby transposition is confined to either the abdominal or thoracic viscera. The authors report a case of videolaparocholecystectomy for cholelithiasis successfully performed on a 41-year-old Caucasian woman with situs viscerum inversus totalis. The patient was discharged on the 2nd postoperative day. The symptomatology disappeared right after the intervention, and still now, after a follow-up of six months, is absent. The procedure was safely performed on the patient with no particular difficulties, except for the reverse position of the angle between the operating and exposing trocars, which led to a difficult approach to the Calot triangle when using the right hand of the surgeon.

[The integrated radiosurgical treatment of rectal cancer]

The value of radio-surgical protocols in the treatment of advanced rectal cancer has been studied retrospectively. 21 patients operated between 1986 and 1990 fulfilling some criteria were considered for this study. They were 9 men and 12 women with rectal cancer Duke's stage B2-C; 16 were treated with preoperative radiotherapy (30-35 Gy), 5 were treated with postoperative radiotherapy (40-60 Gy). The operative procedures were 12 anterior resections and 9 Miles operations. The 5 years results were: a) cancer free survival 52%; 2 patients alive with relapse; 2 patients with non cancer related death (DIC, radiation enteritis); d) cancer related deaths 28%; e) local recurrence was observed (3 pts) only in association with metastatic disease; f) no isolated local recurrence was observed. Preoperative radiotherapy with 30-35 Gy is judged the preferred protocol for decreasing the rate of isolated local recurrence and for increasing the survival rate. Omental flap transposition plays an important role in the radio-surgical treatment of advanced rectal cancer.

[Giant benign and malignant pathology of the ovary]

After a discussion of ovarian tumour classification, two cases of giant neoplasm, one benign the other malignant are reported. Ultrasonography and CA125 research represent two irreplaceable investigations, for preoperative balance and for therapeutic strategy.