Exploring the Link between BMI and Aggressive Histopathological Subtypes in Differentiated Thyroid Carcinoma-Insights from a Multicentre Retrospective Study

Obesity's role in thyroid cancer development is still debated, as well as its association with aggressive histopathological subtypes (AHSs). To clarify the link between Body Mass Index (BMI) and AHS of differentiated thyroid carcinoma (DTC), we evaluated patients who underwent thyroidectomy for DTC from 2020 to 2022 at four European referral centres for endocrine surgery. Based on BMI, patients were classified as normal-underweight, overweight, or obese. AHSs were defined according to 2022 WHO guidelines. Among 3868 patients included, 34.5% were overweight and 19.6% obese. Histological diagnoses were: 93.6% papillary (PTC), 4.8% follicular (FTC), and 1.6% Hürthle cell (HCC) thyroid carcinoma. Obese and overweight patients with PTC had a higher rate of AHSs (p = 0.03), bilateral, multifocal tumours (p = 0.014, 0.049), and larger nodal metastases (p = 0.017). In a multivariate analysis, BMI was an independent predictor of AHS of PTC, irrespective of gender (p = 0.028). In younger patients (<55 years old) with PTC > 1 cm, BMI predicted a higher ATA risk class (p = 0.036). Overweight and obese patients with FTC had larger tumours (p = 0.036). No difference was found in terms of AHS of FTC and HCC based on BMI category. Overweight and obese patients with PTC appear to be at an increased risk for AHS and aggressive clinico-pathological characteristics.

Risk factors for postoperative cervical haematoma in patients undergoing thyroidectomy: a retrospective, multicenter, international analysis (REDHOT study)

Background

Postoperative cervical haematoma represents an infrequent but potentially life-threatening complication of thyroidectomy. Since this complication is uncommon, the assessment of risk factors associated with its development is challenging. The main aim of this study was to identify the risk factors for its occurrence.

Methods

Patients undergoing thyroidectomy in seven high-volume thyroid surgery centers in Europe, between January 2020 and December 2022, were retrospectively analysed. Based on the onset of cervical haematoma, two groups were identified: Cervical Haematoma (CH) Group and No Cervical Haematoma (NoCH) Group. Univariate analysis was performed to compare these two groups. Moreover, employing multivariate analysis, all potential independent risk factors for the development of this complication were assessed.

Results

Eight thousand eight hundred and thirty-nine patients were enrolled: 8,561 were included in NoCH Group and 278 in CH Group. Surgical revision of haemostasis was performed in 70 (25.18%) patients. The overall incidence of postoperative cervical haematoma was 3.15% (0.79% for cervical haematomas requiring surgical revision of haemostasis, and 2.35% for those managed conservatively). The timing of onset of cervical haematomas requiring surgical revision of haemostasis was within six hours after the end of the operation in 52 (74.28%) patients. Readmission was necessary in 3 (1.08%) cases. At multivariate analysis, male sex (P < 0.001), older age (P < 0.001), higher BMI (P = 0.021), unilateral lateral neck dissection (P < 0.001), drain placement (P = 0.007), and shorter operative times (P < 0.001) were found to be independent risk factors for cervical haematoma.

Conclusions

Based on our findings, we believe that patients with the identified risk factors should be closely monitored in the postoperative period, particularly during the first six hours after the operation, and excluded from outpatient surgery.

Effect of Parathyroidectomy on Left Ventricular Mass Index in Patients With Primary Hyperparathyroidism

Aim Primary hyperthyroidism (PHPT) is known to affect left ventricular structure and function and may contribute to increased cardiovascular morbidity and mortality. Whether parathyroidectomy (PTX) reverses left ventricular hypertrophy/remodeling among PHPT patients remains controversial. Method In this prospective, single-center study, we enrolled patients with the diagnosis of PHPT who were scheduled for PTX. Patients underwent a complete biochemical workup and an echocardiographic examination at baseline and a six-month follow-up. The primary objective was to compare the left ventricular mass index (LVMI) at baseline and six-month follow-up. Result Eighteen patients (15 female, three male, mean age 58.7 years) were enrolled. PTH and serum calcium returned to normal immediately post-PTX and remained normal at six months. LVMI at baseline was within normal limits and reduced further at the six-month follow-up. The left ventricular ejection fraction was in the normal range before the PTX and remained unchanged during follow-up. Conclusion Curative PTX reduced LVMI further within the normal range at six months in patients with asymptomatic hyperparathyroidism, providing evidence for benefit in an important non-traditional disease manifestation.

The impact of age on quality of life and frailty outcomes after parathyroidectomy in patients with primary hyperparathyroidism

OBJECTIVE

Parathyroidectomy (PTx) improves quality of life (QoL) in patients with primary hyperparathyroidism (PHPT). Whether this effect is modified according to the patients' age is unknown. The aim of this study was to evaluate the impact of age on the effect of PTx on QoL and frailty in patients with PHPT, six months post-PTx.

METHODS

This was a prospective cohort study, including patients with PHPT, admitted from January 2016 to December 2019, divided into two categories: younger (≤ 65 years old) and older (> 65 years old). QoL was assessed with the Pasieka questionnaire (PAS-Q) two days pre- and six months post-operatively. Frailty was also assessed at the same time intervals, with the Frailty Index (FI).

RESULTS

One hundred and thirty-four patients (younger group: 96 patients, mean age 50.4 ± 9.8 years; older group: 38 patients, mean age 72.1 ± 4.9 years) were included. PTx resulted in a significant reduction in PAS-Q score in both groups. Notably, a greater reduction in "mood swings", "irritability", "itchy skin" and "feeling thirsty" PAS-Q domains was observed in the younger group. In contrast, a greater decrease in "bone pain", "tiredness", "weakness", "joint pain", "getting off chair" and "headaches" items was observed in the older group. Moreover, PTx led to a decrease in FI only in this group.

CONCLUSIONS

PTx leads to an improvement in QoL both in older (> 65 years) and younger (≤ 65 years) patients with PHPT, attributed to a differential effect on PAS-Q items. Frailty improves only in the older group.

Composite Paraganglioma of the Celiac Trunk: A Case Report and a Comprehensive Review of the Literature

Introduction

Composite paragangliomas consist of two components, paraganglioma and ganglioneuroma, representing a rare subgroup of paragangliomas. The purpose of the study is to describe a case of composite paraganglioma of the celiac trunk and a brief review of the existing literature.

Case Presentation

A 64-year-old female patient with a history of epigastric abdominal pain and a 51 mm-diameter tumor found in a Computerized Tomography of the abdomen was admitted to our surgical department for further evaluation and treatment. After a brief preoperative surgical assessment, the patient underwent a mini-laparotomy for the excision of this tumor. After having the results of the pathology report, a comprehensive review of the international literature was carried out by applying the appropriate search terms.

Results

As it was found intraoperatively, the tumor was located at the cephalad aspect of the common hepatic artery, over the portal vein and the inferior vena cava. A negative-margin resection was achieved and the tumor was sent for pathology analysis. The final pathology report revealed a composite paraganglioma, with α paraganglioma and a ganglioneuroma component. Seventeen cases of extra-adrenal composite paraganglioma have been reported in the international literature so far. This case was the first one found in the area of the celiac trunk.

Conclusions

Composite paragangliomas comprise rare and potentially malignant tumors with variable prognosis. Establishing their diagnosis promptly is of vital significance. Due to the first-described location of the composite paraganglioma in our case, the differential diagnosis of tumors in this area should also include composite paragangliomas.

Parathyroid adenoma in pregnancy: A case report and systematic review of the literature

OBJECTIVE

Primary hyperparathyroidism is a common disorder of the parathyroid glands. Parathyroid adenoma (PA) in pregnancy is a relatively rare disease, whose diagnosis and treatment is a challenging task. The aim of the present study is to present a new case of parathyroid adenoma during pregnancy and to give a detailed account of all reported cases of parathyroid adenoma during pregnancy in the literature.

STUDY DESIGN

A bibliographic research was performed, and characteristics of parathyroid adenomas in pregnancy such as age, gestational week at diagnosis, ionized calcium levels, genetic testing result, symptomatology, radiological method of localization, treatment method, gestational week at operation, and maternal/fetal complications were recorded.

RESULTS

A 34-year-old woman at her 25 weeks' gestation was diagnosed with parathyroid adenoma and was referred to our Surgical Department due to contraindication for conservative treatment. A parathyroidectomy was performed, and the maternal and fetal postoperative period was uneventful. Two hundred eleven cases of parathyroid adenoma in pregnancy were recorded in the literature, and statistical analysis was performed. The median gestational week at diagnosis was 21 ± 9.61 weeks. The mean level of ionized calcium was 2.69 mmol/l [SD = 0.75 (2.55-2.84 95% CI)]. Most cases were familiar (72.4%), while surgery was the preferred treatment option (67.3%). The majority of cases were asymptomatic (21.7%), and the main radiological method applied for localization was ultrasound (63.4%).

CONCLUSION

Parathyroid adenoma in pregnancy is a rare condition. The early diagnosis is of great importance as surgical treatment at the second trimester of pregnancy outweighs the maternal and fetal risks.

The effect of intraoperative autofluorescence monitoring on unintentional parathyroid gland excision rates and postoperative PTH concentrations-a single-blind randomized-controlled trial

PURPOSE

Intraoperative imaging of parathyroid glands (PGs) has been developed in order to reduce the risk of unintentional parathyroidectomy during total thyroidectomy. This novel modality is based on their intrinsic characteristic of autofluorescence (AF) after near-infrared light exposure. The aim of this study was to assess the effect of this method on the risk of unintentional PG excision (total or partial) during total thyroidectomy.

METHODS

This was a single-blind, randomized-controlled trial including adult patients who underwent scheduled total thyroidectomy between December 2019 and March 2020. These patients were randomly allocated to two groups: one in which near-infrared autofluorescence imaging (NIRAF) was applied (NIR group) and one without NIRAF (NONIR group). Hormonal and biochemical assessment was performed pre- and 24-h postoperatively. AF findings and the number of PGs autotransplanted were recorded.

RESULTS

One-hundred and eighty patients were eligible. Unintentional (total or partial) PG excision rates during total thyroidectomy in the NONIR (n = 90) and NIR (n = 90) groups were 28.9% [95% confidence interval (CI) 19.8-39.4%] and 14.4% (95% CI 7.7-22.1%), respectively (p = 0.02). Furthermore, NIR reduced the risk of parathyroid tissue presence in the specimen sent for pathology (relative risk 0.51, 95% CI 0.28-0.92; p = 0.02). However, the number of PGs identified by NIR could not predict the risk of postoperative hypoparthyroidism.

CONCLUSIONS

NIRAF imaging during total thyroidectomy led to a significant reduction in PG excision rates. However, this modality did not result in the reduction of postoperative hypoparathyroidism or hypocalcemia risk.

Do surgeons really know how to perform neuromonitoring in thyroid surgery? An awareness study

Background

The aim of this questionnaire-based observational study is to examine the awareness of endocrine surgeons regarding the use of intraoperative neuromonitoring (IONM) techniques in thyroid surgeries.

Methods

A survey project based on a structured questionnaire was conducted during the 14^th Spring Meeting of the Greek Society of Endocrine Surgeons (GSES). The questionnaire consisted of 14 items and was handed to all participants-by the key speaker-during the neuromonitoring session.

Results

In the 14^th spring meeting of GSES there were 205 delegates present. Among them there were 35 residents and 6 medical students. The surgeons being potential responders were 119. In the session of IONM, there were 83 eligible surgeons present and the questionnaire was answered voluntarily by 59 of them (71.08%). The responders' group consisted of 26 members of the GSES and 33 non-members.

Conclusions

Most of the participants believed that there are many benefits in the use of IONM such as anatomically identifying the branches of the laryngeal nerve, monitoring their functionality or offering to patients' greater confidence to the surgery. Attention should be paid not to abandon the conventional techniques for identifying the laryngeal nerve, as IONM may not always be available. Evidence is needed to establish the proper indications for its application.

Do Near-Infrared Intra-Operative Findings Obtained Using Indocyanine Green Correlate with Post-Thyroidectomy Parathyroid Function? the Icgpredict Study

OBJECTIVE

Postoperative hypoparathyroidism (hypoPT) still remains a significant complication after thyroidectomy. Intra-operative imaging modalities, such as near-infrared fluorescence using indocyanine green (ICG), may assist in identifying and preserving the parathyroid glands (PGs). The purpose of this study was to test the association between the intra-operative ICG staining scoring system and 24-hour postoperative parathyroid hormone (PTH) levels, as well as its capability for intra-operative PG identification.

METHODS

This was a prospective study, recruiting patients scheduled for total thyroidectomy by the same surgical team, from December 2018 to April 2019. Intra-operative angiography was performed after infusion of ICG solution (5 mg). Two minutes later, images were acquired using the near-infrared system.

RESULTS

Sixty patients fulfilled the eligibility criteria. The percentage of temporary postoperative hypoPT (defined as PTH <14 pg/mL) was 11.66%. No association between intra-operative ICG staining score (expressed as the number of PGs scoring <2 per patient) and 24-hour postoperative PTH (r = 0.011; P = .933) or serum calcium concentrations (r = 0.127; P = .335) was observed. There was also no correlation between the location of PGs scoring ≤2 and postoperative PTH (P = .257) or serum calcium levels (P = .950). Moreover, with regard to secondary endpoint, ICG correctly identified PGs in 98.3% of cases. ICG score was not affected by age, gender, duration of operation, or thyroid gland pathology. No allergic reactions attributed to ICG administration were observed.

CONCLUSION

The intra-operative ICG staining scoring system did not predict 24-hour postoperative PTH and serum calcium levels. However, this modality may assist in intra-operative PG identification during a total thyroidectomy.

Comparing LigasureTM Exact dissector with other energy devices in total thyroidectomy: a pilot study

Background

Hemostasis is fundamental in thyroid surgery. The aim of this randomized active comparator-controlled study was to compare the effectiveness of Ligasure^TM Exact to previously existing sealing devices in patients undergoing thyroidectomy.

Methods

A total of 180 patients were randomly allocated into 4 groups according to the hemostatic device used: Focus Harmonic Scalpel^® (FHS), Ligasure^TM Small Jaw (LSJ), Thunderbeat^® (TB), and Ligasure^TM Exact (LE). We recorded epidemiologic and biochemical data, operative difficulty, postoperative vocal alteration and pain, complications, operating time, grams of gland excised per minute, and hospitalization.

Results

Differences (P<0.001) were observed concerning duration of surgery, operative difficulty and quantity of gland removed per minute. Concerning duration of surgery it is shorter for LE followed by TB and then by both FHS and LSJ. Concerning the quantity of thyroid removed per minute LE leads, followed by FHS and TB. The least amount of gland removed per minute is by LSJ. Finally, operative difficulty was less for LE, while it was equal for all other three devices.

Conclusions

Energy devices are now frequently used in thyroidectomy. Comparing these devices seems to qualify them as equal concerning post-operative complications, hemostasis, and acute inflammatory reaction. However, Ligasure^TM Exact Dissector seems to have better results concerning duration of surgery, quantity of thyroid tissue removed per minute and intraoperative difficulty.

Should total thyroidectomies be performed by high-volume endocrine surgeons? A cost-effectiveness analysis

PURPOSE

The increased experience of a thyroid surgeon reduces the risk of postoperative complications. However, whether it is also cost-effective is currently unknown. The aim of the present study was to compare cost-effectiveness of high-volume (HVS) with low-volume surgeons (LVS) when performing a total thyroidectomy.

METHODS

This was a retrospective study, comparing the mean cost of a total thyroidectomy per patient, between HVS and LVS. This included the cost of surgical procedure and pre- and post-operative inpatient hospitalization. A threshold of 25 thyroidectomies/year was used to discriminate between HVS and LVS.

RESULTS

Four-hundred and forty-one patients were classified into HVS and 342 into the LVS group. With regard to surgical complications, higher rates of temporary hypoparathyroidism and endangered airway were observed in the LVS than in the HVS group. The estimated total cost per patient was higher in the LVS compared with the HVS group [€1721 ± 396 ($1910 ± 439) versus €979 ± 68 ($1086 ± 487); p < 0.0001]. This cost remained higher when sub-analysis was performed for each surgical stage, involving either surgical procedure or pre- and post-operative inpatient hospitalization. Differences between LVS and HVS mainly involved the cost in surgical procedure (23% attributed to occupation of the operating room) and postoperative inpatient hospitalization (45% of the total thyroidectomy cost).

CONCLUSION

Total thyroidectomy performed by a HVS seems to be cost-effective compared with the one conducted by LVS. This is mostly attributed to the lower rates of surgical complications, such as postoperative hypoparathyroidism and airway obstruction.

Parathyroid cysts: A review of 359 patients reported in the international literature

BACKGROUND

Parathyroid cysts are lesions that represent 1-5% of neck masses. They are subdivided into two categories: functioning and non-functioning.The aim of the present review is to give a detailed account of all reported cases of parathyroid cysts in the literature and to analyze statistically the available data.

METHODS

A bibliographic research was performed from 1905 until 2016. A database with the patients' characteristics was made and analyzed statistically.

RESULTS

A total of 218 articles were found, reporting 359 cases of cysts. Mean age of patients was 49.24 y/o and the male/female ratio was 1:1.85. The most common locations were left thyroid lobe (113/358 patients, 31.6%), and superior mediastinum (69/358 patients, 19.3%), while the most common symptoms were neck mass (148/355 patients, 41.7%), compressive symptoms (73/355 patients, 206%) and hyperparathyroidism (62/355 patients, 17.5%). Non-functioning cysts were more frequent (220/357 patients, 61.6%). Regarding dimensions, mean diameter was 4.88 cm. Ultrasound and FNA are used for their diagnosis, while cystic fluid analysis may help the differential diagnosis. Recurrences were mentioned in 27/97 patients (27.8%) with available data. No deaths due to parathyroid cysts were mentioned in the literature.

CONCLUSION

Parathyroid cysts should be taken into consideration in case of parathyroid dysfunction or asymptomatic neck mass. The surgeon's careful manipulations on the cyst are crucial for a definitive treatment.

PARATHYROID FUNCTION AFTER TOTAL THYROIDECTOMY: A RANDOMIZED CLINICAL TRIAL CONCERNING THE INFLUENCE OF THE SURGICAL TECHNIQUE

OBJECTIVE

Thyroidectomy impairs parathyroid function, even if it does not necessarily lead to postoperative clinical hypocalcemia. This study was prospective and evaluated the parathyroid hormone (PTH) function in nonclinically symptomatic patients after total thyroidectomy performed by two different techniques.

METHODS

Prospective randomized clinical trial including 269 patients undergoing classic or harmonic scalpel total thyroidectomy. Pre-operatively and at 48 hours, biochemical analysis was performed. Simultaneously, a sodium bicarbonate test (SBT) was performed.

RESULTS

Calcium and PTH were altered for both groups ( P<.001). During SBT at 3 minutes after infusion, PTH rose and reached its maximum for both groups ( P<.001) and then decreased at 5 minutes ( P<.001 and P = .004) and at 10 minutes ( P = .006 and P = .043) before returning to baseline levels. At 5 and 10 minutes of the SBT, some differences were observed between the groups. The difference in clinically obvious parathyroid dysfunction between groups was not significant, but there was a difference in the peak PTH levels after bicarbonate stimulation. Similarly, total secretion during the test, as well as total secretion for the first 10 minutes, was practically the same for the two groups. Additionally, partial subclinical postoperative hypoparathyroidism was clearly more common in the harmonic scalpel thyroidectomy group ( P<.001).

CONCLUSION

SBT demonstrated more impairment in the harmonic scalpel group, as parathyroid function was altered after thyroidectomy.

ABBREVIATIONS

HSTT = harmonic scalpel total thyroidectomy PTH = parathyroid hormone SBIT = sodium bicarbonate infusion test.

Laparoscopic spleen-preserving distal pancreatectomy in a solitary true pancreatic cyst

BACKGROUND

Solitary true pancreatic cysts (STPCs), or epithelial cysts, are benign lesions that are extremely rare in adult patients. Advances in radiographic techniques have improved the ability to identify pancreatic cystic lesions. We report a case of a large and symptomatic STPC in a 47-year-old female patient who was treated successfully with spleen-preserving laparoscopic distal pancreatectomy. We also review the clinical and pathologic features of all reported STPCs within the past 25 years.

DATABASE

To compose the review, we did a search of the international literature for STPCs that had occurred in adults. Fourteen related articles were found describing cases of STPCs. Clinical and pathologic information was collected for all of the reported pancreatic cysts, and a database was formed. STPCs are detected more frequently in women than in men. The mean age of occurrence is 43.2 years, and the mean cyst size is 5.6 cm. Fifty percent of true cysts are located in the head of the pancreas. Size and site are responsible for the symptoms caused, although 22.8% were asymptomatic. Diagnosis was made postoperatively in all cases by histopathologic studies. No case of malignancy was reported in any STPC.

CONCLUSIONS

STPCs are rare and benign lesions commonly discovered incidentally during abdominal imaging. Surgical treatment is considered the appropriate therapy for large and symptomatic STPCs. The definitive diagnosis is established by histopathologic and immunohistochemical studies.

Smoking Cessation: Services and Applications for Mobile Devices

The aim of this review is to present mobile health applications which help individuals to change their smoking habit. An online search on scientific databases and mobile application stores was conducted to collect information about m-Health and the smoking cessation. 12 papers found discussing about mobile applications and solutions for quit smoking referred to 4 different technological approaches. Based on the research results, mobile devices and their applications constitute an excellent mean that can help smokers by providing counseling and give them the necessary motivation to smoking cessation.

mHealth in Chronic Pain Assessment: Present and Future

Chronic Pain (CP) is a condition which is difficult to assess. Existing methods are based on self-management treatments and leaving the big part of the assessment on the patient. According on this method, mHealth applications offer tools to CP patients to self-manage their condition and improve it. All the applications are limited by the type of data they collect and the data based on self-reporting. In the future the applications for CP management will not be based only on this type of data. Multiple types of data will be gathered and analyzed, as well as the specialists will be able to have a better prospective for the patients' pain levels.

Wireless Monitoring for Patients with Cardiovascular Diseases and Parkinson's Disease

The use of applications for mobile devices and wireless sensors is common for the sector of telemedicine. Recently various studies and systems were developed in order to help patients suffering from severe diseases such as cardiovascular diseases and Parkinson's disease. They present a challenge for the sector because such systems demand the flow of accurate data in real time and the use of specialized sensors. In this review will be presented some very interesting applications developed for patients with cardiovascular diseases and Parkinson's disease.

Managing the Quality of Life in Patients with Multiple Sclerosis: A Literature Review

The present research attempts to approach a complex concept. The quality of life of multiple sclerosis patients. A literature review was conducted. Based on the finding, it seems that the quality of life for multiple sclerosis patients is influenced by many factors such as self-confidence, which is a direct result of self-ability and mobility, the stage of disease, the social relations as experienced by the patients and the risk of sudden substantial of health deterioration. In addition, telemedicine applications may help either the patients or the health professionals to manage better the provided quality of life to multiple sclerosis patients.

Virtual Reality in the Rehabilitation of Patients with Neurological Disorders

Neurological disorders affect the lifestyle and the living conditions of a patient. Virtual Reality is a technology that may be used to simulate various types of tasks in a computerized environment guiding the patient and help on rehabilitation. This review try to answer how Virtual Reality technologies can effect on the patients rehabilitation's results. Treatments which involves Virtual Reality applications offer new ways to make the patients more committed to their program and keeps them motivated. Another characteristic of a Virtual Reality treatment is that both patients and therapists can observe the mistakes made during a physiotherapy session. The insert of VR sessions in traditional rehabilitation therapy of patients with neurological disorders have produced positive results.

Classic clamp-and-tie total thyroidectomy for large goiters in the modern era: To drain or not to drain

AIM: To evaluate the role of drains in clamp-and-tie total thyroidectomy (cTT) for large goiters.

METHODS: A hundred patients were randomized into group D (drains maintained for 24 h) and ND (no drains). We recorded epidemiological characteristics, thyroid pathology, hemostatic material, intraoperative events, operative time and difficulty, blood loss, biochemical and hematological data, postoperative vocal alteration and pain, discomfort, complications, blood in drains, and hospitalization.

RESULTS: The groups had comparable preoperative characteristics, pathology, intraoperative and postoperative data. Hemostatic material was used in all patients of group ND. Forty patients in group D and 9 in ND felt discomfort (P < 0.001).

CONCLUSION: Drains in cTT for large goiters give no advantage or disadvantage to the surgeon. The only “major disadvantage” is the discomfort for the patient. Inversely, drains probably influence surgeons’ serenity, especially when cTT is performed in nonspecialized departments.

A prospective multi-institutional study assessing clinical outcome with the NiTi compression anastomosis ring (Biodynamix ColonRingTM) in elective colorectal anastomoses

BACKGROUND/AIMS

This 3-institution study assessed the short-term clinical outcome and safety profile of the NiTi Biodynamix ColonRingTM compression anastomosis in elective colorectal resection.

METHODOLOGY

A prospective, open-label, non-randomized trial was conducted at 3 separate institutions between October 2008 to October 2009 in patients undergoing elective colorectal resection with the Biodynamix ColonRingTM compression anastomosis ring, assessing technical factors in its operative use, immediate and short-term clinical outcome parameters (length of hospital stay, time to first passage of flatus and stool and to oral intake) and peri-operative complications including anastomotic failure or stenosis and wound infection.

RESULTS

Forty patients (22 females, mean age 65.9 years; range 36-83 years were included in the analysis with 14 cases being performed laparoscopically. The median duration of surgery was 120 minutes (range 60-456 minutes) with a mean anastomotic time of 14.8 minutes (range 1.75-50 minutes). The mean height of anastomosis from the anal verge was 18.2cm. The median time to passage of first flatus and first stool was 2.4 and 3.5 days, respectively with a mean hospital stay of 7.3 days. There was one postoperative death (unrelated to an anastomotic complication) with 2 anastomotic leaks (5%), 2 wound infections (5%) and no cases of early anastomotic stricture.

CONCLUSIONS

The compression anastomosis ColonRingTM handles easily with an acceptable clinical outcome following both laparoscopic and open use. The incidence of anastomotic and wound complications is comparable to conventional stapled technology.

Small bowel perforation due to CMV enteritis infection in an HIV-positive patient

BACKGROUND

Cytomegalovirus infection of the gastrointestinal tract is common and is more often seen in patients with acquired immunodeficiency syndrome (AIDS). Although small bowel infection is less common than infection of other parts of the gastrointestinal system, it may lead to perforation, an acute complication, with dreadful results.

CASE PRESENTATION

This article reports a case of Cytomegalovirus ileitis with multiple small bowel perforations in a young man with human immunodeficiency virus (HIV) infection. The patient developed abdominal pain with diarrhea and fever, and eventually acute abdomen with pneumoperitoneum. The patient had poor prognosis and deceased despite the prompt surgical intervention and the antiviral therapy he received. At pathology a remarkable finding was the presence of viral inclusions in smooth muscle fibers. The destruction of muscle cells was the main cause of perforation.

CONCLUSION

Morbidity and mortality associated with perforation from CMV enteritis in AIDS patients are high and the life expectancy is short. Cytomegalovirus disease is multifocal; therefore, excision of one portion of the gastrointestinal tract may be followed by a complication elsewhere. Our case elucidate that muscle cell destruction by the virus is a significant cause leading to perforation.

The value of vacuum-assisted closure in septic patients treated with laparostomy

The ideal method of temporary abdominal closure (TAC) should allow rapid closure, easy maintenance, and wound repair with minimal tissue damage. The aim of this retrospective study is to compare open abdomen outcomes between patients managed with vacuum-assisted closure (VAC), and patients managed with other methods of TAC, when septic abdomen is present. Two groups of patients with septic open abdomen: 27 treated with VAC versus 31 treated with other techniques of TAC. We studied open abdomen duration, number of dressing changes, re-exploration rate, successful abdominal closure rate, overall mortality, and development of enteroatmospheric fistulas. The VAC device demonstrated its superiority concerning open abdomen duration (P < 0.001), number of dressing changes (P < 0.001), re-exploration rate (P < 0.002), successful abdominal closure rate (P < 0.0001), and development of enteroatmospheric fistulas (P < 0.00001). Compared with other methods of TAC, our experience with the VAC device demonstrated its advantages concerning clinical feasibility. The high rates of direct fascia closure with an acceptable rate of ventral hernias are further benefits of this technique.

The Value of Vacuum-Assisted Closure in Septic Patients Treated with Laparostomy

The ideal method of temporary abdominal closure (TAC) should allow rapid closure, easy maintenance, and wound repair with minimal tissue damage. The aim of this retrospective study is to compare open abdomen outcomes between patients managed with vacuum-assisted closure (VAC), and patients managed with other methods of TAC, when septic abdomen is present. Two groups of patients with septic open abdomen: 27 treated with VAC versus 31 treated with other techniques of TAC. We studied open abdomen duration, number of dressing changes, re-exploration rate, successful abdominal closure rate, overall mortality, and development of enteroatmospheric fistulas. The VAC device demonstrated its superiority concerning open abdomen duration ( P < 0.001), number of dressing changes ( P < 0.001), re-exploration rate ( P < 0.002), successful abdominal closure rate ( P < 0.0001), and development of enteroatmospheric fistulas ( P < 0.00001). Compared with other methods of TAC, our experience with the VAC device demonstrated its advantages concerning clinical feasibility. The high rates of direct fascia closure with an acceptable rate of ventral hernias are further benefits of this technique.

Rupture of right hepatic duct into hydatid cyst

Echinococcal disease can develop anywhere in the human body. The liver represents its most frequent location. Hepatic hydatid cysts may rupture into the biliary tract, thorax, peritoneum, viscera, digestive tract or skin. We report a rare case with rupture of the right hepatic duct into a hydatid cyst in a woman with known hydatid disease and choledocholithiasis. The increased intra-luminal pressure in the biliary tree caused the rupture into the adjacent hydatid cyst. The creation of the fistula between the right hepatic duct and the hydatid cyst decompressed the biliary tree, decreased the bilirubin levels and offered a temporary resolution of the obstructive jaundice. Rupture of a hydatid cyst into the biliary tree usually leads to biliary colic, cholangitis and jaundice. However, in case of obstructive jaundice due to choledocholithiasis, it is possible that the cyst may rupture by other way around while offering the patient a temporary relief from his symptoms.

Typical image of splenic hydatidosis

This is a typical case of a splenic hydatid cysts. We present the clinical features, the diagnostic work-up and the management of the disease.

Abdominal compartment syndrome - Intra-abdominal hypertension: Defining, diagnosing, and managing

Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) are increasingly recognized as potential complications in intensive care unit (ICU) patients. ACS and IAH affect all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. ACS/IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of ACS/IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. We start this article with a brief historic review on ACS/IAH. Then, we present the definitions concerning parameters necessary in understanding ACS/IAH. Finally, pathophysiology aspects of both phenomena are presented, prior to exploring the various facets of ACS/IAH management.

Cervical thymic cysts in adults

BACKGROUND

Three types of cervical thymic anomalies have been described: ectopia, thymic cyst, and thymoma. Thymic cysts are very rare causes of benign neck masses in adults and are usually not diagnosed before surgery. Their prevalence is less than 1% of all cervical masses, and they are usually noted in childhood. We systematically reviewed the literature concerning cervical thymic cysts (CTCs) in adults.

SUMMARY

We identified 36 adult patients with a CTC. Our analysis included age, gender, cyst size, location, type, symptoms, time from cyst appearance, treatment, pathology, and follow-up. The male/female ratio was 4/5, the mean age was 36 years. Most of the cysts were asymptomatic masses diagnosed by pathology. In only one case did the differential diagnosis include a thymic cyst. Surgery should be considered the treatment of choice, but the size and location of the lesion and its relationship to nearby vital structures should be defined as clearly as possible preoperatively. Excision can be made via a transverse cervical incision. It may be a demanding procedure because of the close anatomical relationship of the CTCs with the carotid sheath and major nerves of the neck (recurrent laryngeal nerve, glossopharyngeal nerve, hypoglossic nerve, and phrenic nerve), particularly if there is adherence of the CTC with those structures.

CONCLUSIONS

CTCs are uncommon lesions causing neck swelling and are often misdiagnosed preoperatively. Surgical excision and histological examination of the specimen usually makes the diagnosis. The existence of normal thymus gland in the mediastinum should be confirmed intraoperatively, but this is not critical in adult patients. A CTC should be included in the differential diagnosis of cervical cystic masses.

Vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: a clinical trial

BACKGROUND

Multiple techniques have been introduced to obtain fascial closure for the open abdomen to minimize morbidity and cost of care. We hypothesized that a modification of the vacuum-assisted closure (VAC) technique that provides constant fascial tension and prevents abdominis rectis retraction would facilitate primary fascial closure and reduce morbidity.

METHODS

In all, 53 patients with severe abdominal sepsis were allocated randomly into 2 groups, and 30 patients were analyzed. In the VAC group, we included patients managed only with the VAC device, whereas the retentions sutured sequential fascial closure (RSSFC) group included patients to whom RSSFC was performed.

RESULTS

The abdomen was left open for 12 days (P = .0001) with 4.4 ± 1.35 changes per patient for the VAC group (P = .001) and 8 days with 2.87 ± 0.74 dressing changes per patient for the RSSFC group, respectively. Abdominal closure was possible in only 6 patients in the VAC group, whereas for the RSSFC group, abdominal closure was achieved in 14 patients (P = .005). Planned hernia was exclusively decided in patients in the VAC group (P = .001). The hospital stay was 17.53 ± 4.59 days for the VAC group and 11.93 ± 2.05 days for the RSSFC group (P = .0001). The median initial intra-abdominal pressure (IAP) was 12 mm Hg for the VAC group and 16 mm Hg for the RSSFC group (P < .0001).

CONCLUSION

We demonstrated the superiority of RSSFC compared with the single use of the VAC device. In our opinion, sequential fascial closure can immediately begin when abdominal sepsis is controlled.

Management of an extrasphincteric fistula in an HIV-positive patient by using fibrin glue: a case report with tips and tricks

Background

Individuals with impaired immunity are at higher risk of perianal diseases. Concerning complex anal fistulas impaired healing and complication rates are also higher. Definitive treatment of a fistula aims controlling the purulent discharge and prevents its recurrence. It depends mainly on the trajectory of the fistula and the underlying disease.

We present a case of a HIV-positive patient with a complex extrasphincteric anal fistula who was treated successfully with fibrin glue application. We further, discuss tips and tricks when applying fibrin glue as plugging material in complex anal fistulas.

Case presentation

A sixty-one-year-old HIV-positive male referred to us for warts and extrasphincteric fistula. Because of the patients' immunological status, we opted against surgery and recommended fibrin glue plugging. The patient was discharged the same day. A follow-up examination was performed 5 days after the initial fibrin glue application showing that the fistula canal was obstructed. Three months and a year post-intervention the fistula tract remains closed.

Conclusion

The best treatment for a disease gives at least the same result with the other treatments with minimised risk for the life of the patient and minimal application effort. Conservative closure of fistula with fibrin plugging is simple, safe and with less morbidity than surgery. Our patient was successfully treated without endangering his life despite his precarious medical state. Not everybody believes in the effectiveness of fibrin glue application, however we consider this solution in cases of complex fistulas at least as primary procedure in special populations such as the immunosupressed.

Severe eosinophilic cholangitis with parenchymal destruction of the left hepatic lobe due to hydatid disease

Hydatid cysts of the liver are known to occasionally rupture into the bile ducts and cause cholangitis. The histological features of this complication have not been adequately described in the literature. Herein is reported a case of severe eosinophilic cholangitis of the left hepatic lobe, occurring in a 24-year-old man with a large (16 cm) hydatid cyst, which obstructed and eroded the left hepatic duct. The patient presented with upper abdominal discomfort and low-grade fever of 3 weeks' duration. Sections of the left lobectomy specimen showed marked inflammatory infiltrates in the portal tracts, predominantly composed of eosinophils, extensively involving bile ducts of all sizes. Occasional small bile ducts were replaced by epithelioid cell granulomas surrounding eosinophilic microabscesses. The inflammatory infiltrates extended into the lobules, resulting in marked hepatocyte loss. This case demonstrates that echinococcosis may cause severe eosinophilic cholangitis with extensive parenchymal destruction, apparently resulting from a hypersensitivity reaction to parasitic antigens.