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.

Identification of potential diagnostic and prognostic biomarkers for papillary thyroid microcarcinoma (PTMC) based on TMT-labeled LC-MS/MS and machine learning

OBJECTIVES

To explore the molecular mechanisms underlying aggressive progression of papillary thyroid microcarcinoma and identify potential biomarkers.

METHODS

Samples were collected and sequenced using tandem mass tag-labeled liquid chromatography-tandem mass spectrometry. Differentially expressed proteins (DEPs) were identified and further analyzed using Mfuzz and protein-protein interaction analysis (PPI). Parallel reaction monitoring (PRM) and immunohistochemistry (IHC) were performed to validate the DEPs.

RESULTS

Five thousand, two hundred and three DEPs were identified and quantified from the tumor/normal comparison group or the N1/N0 comparison group. Mfuzz analysis showed that clusters of DEPs were enriched according to progressive status, followed by normal tissue, tumors without lymphatic metastases, and tumors with lymphatic metastases. Analysis of PPI revealed that DEPs interacted with and were enriched in the following metabolic pathways: apoptosis, tricarboxylic acid cycle, PI3K-Akt pathway, cholesterol metabolism, pyruvate metabolism, and thyroid hormone synthesis. In addition, 18 of the 20 target proteins were successfully validated with PRM and IHC in another 20 paired validation samples. Based on machine learning, the five proteins that showed the best performance in discriminating between tumor and normal nodules were PDLIM4, ANXA1, PKM, NPC2, and LMNA. FN1 performed well in discriminating between patients with lymph node metastases (N1) and N0 with an AUC of 0.690. Finally, five validated DEPs showed a potential prognostic role after examining The Cancer Genome Atlas database: FN1, IDH2, VDAC1, FABP4, and TG. Accordingly, a nomogram was constructed whose concordance index was 0.685 (confidence interval: 0.645-0.726).

CONCLUSIONS

PDLIM4, ANXA1, PKM, NPC2, LMNA, and FN1 are potential diagnostic biomarkers. The five-protein nomogram could be a prognostic biomarker.

Goiter in a fresco by i Fiammenghini, 1615 (Abbey of Santa Maria di Rovegnano, Chiaravalle, Italy)

In a large fresco, which narrates brutal episodes of torture against Cirtercian monks, in the right corner of the background an ugly aggressor with a huge goiter, symbol of evil and sin, attacks a monk with a sword.

Goiter in a Fresco by Giovanni Luigi Valesio (1611, Church of Saints Eusebio and Vittore, Peglio, Como)

In the Fresco, "Faith and Its Fight Against Heresy (1611, Church of Saints Eusebio and Vittore, Peglio, Como)" is depicted as an old woman with 'scattered and steep hairs', ugly and physically in poor condition, also due to the presence of a voluminous goiter.

Goiter in a fresco by simone peterzano, master of caravaggio (1578-1582, Garegnano Charterhouse, Milan)

Simone Peterzano mostly known as the master of Caravaggio executed frescoes in the presbytery of Garegnano Charterhouse. One fresco details a shepherd with a goiter.

Ethical and medico-legal issues of TOETVA procedure and simulation on cadavers: a scoping review

Conventional open thyroidectomy is still considered the gold standard for thyroid surgery. Transoral endoscopic thyroidectomy vestibular approach (also known as TOETVA) is often considered to be more advantageous than the other approaches, such as minimally invasive video assisted thyroidectomy, thyroidectomy via breast/axillary/retroauricular access, bilateral axillo-breast approach and axillo-bilateral breast approach. In this scoping review, we discuss the risks and the benefits of this surgical approach and its medico-legal and ethical implications, particularly focusing on the importance of practice on cadavers. Currently, there is little scientific evidence supporting TOETVA, since there are few papers on the comparison with the traditional open thyroidectomy that have been published and thus little data on the long-term outcomes of TOETVA are available. Since the better cosmetic outcome currently represents the main indication for this surgical technique, substantial medico-legal and ethical issues arise. Moreover, practice on cadavers can help surgeons to develop the technical and non-technical skills required to perform efficiently and safely this new surgical procedure.

Portomesenteric vein thrombosis following sleeve gastrectomy: Case report focusing on the role of pathogenetic factors

INTRODUCTION

Sleeve gastrectomy has currently become the most commonly performed bariatric. procedure worldwide according to the last IFSO survey, overtaking gastric bypass with. a share of more than 50% of all primary bariatric-metabolic surgery. Gastric leak, intraluminal bleeding, bleeding from the staple-line and strictures are the most common complications. Portomesenteric vein thrombosis (PMVT)after sleeve gastrectomy is. another complication that has been increasingly reported in case-series in recent.years, although it remains uncommon. In this case report is described an extended portomesenteric vein thrombosis after. sleeve gastrectomy interesting splenic vein too with a favorable course and an. uneventful follow-up. We try to search in this case for pathogenetic factors involved in. this complication.

CASE REPORT

A 42-year old man, with a body mass index (BMI) of 45 kg/m2, with a medical history of Obstructive Sleep Apnea Sindrome (OSAS) underwent laparoscopic sleeve gastrectomy. Early postoperative course was uneventful. Six days after discharge he complained abdominal pain and was admitted at the Emergency Department. A CT scan with intravenous contrast showed an occlusion of the portal vein, of the intrahepatic major branches and an extension to the superior mesenteric vein and the splenic vein. The patient received heparin and oral anticoagulation together with intravenous hydration and proton pump inhibitors. Considering the favourable course the patient was discharged after six days with long-term oral anticoagulation therapy. Anticoagulation with acenocumarol was continued for six months after a CT scan showed resolution of the PMVT without cavernoma. He had no recurrence of symptoms.

DISCUSSION

Porto-mesenteric thrombosis after sleeve gastrectomy is a rare complication but it has been increasingly reported over the last 10 years along with the extensive use of sleeve gastrectomy. Because PMVT is closely associated with sleeve gastrectomy in comparison with other bariatric procedures, we need to investigate what pathogenetic factors are involved in sleeve gastrectomy. Thrombophylic state, prolonged duration of surgery, high levels of pneumoperitoneum, thermal injury of the gastroepiploic vessels during greater curvature dissection, high intragastric pressure, inadequate antithrombotic prophylaxis and delayed mobilization of the patient after surgery have been reported as pathogenetic factors of portmesenteric vein thrombosis. Most of the cases presented in the literature such as our clinical case resolve with medical therapy, although portal vein thrombus extends into the superior mesenteric vein and the splenic vein.

CONCLUSION

Portomesenteric venous thrombosis is a rare but serious complication of bariatric surgery, especially associated with sleeve gastrectomy. Diagnosis is based on CT examination with intravenous contrast, and initial therapy is anticoagulation. Etiologic factors reported in the literature include a long duration of surgery, a high degree of pneumoperitoneum, high intragastric pressure after sleeve gastrectomy and thermal injury to the short gastric vessels and gastroepiploic arcade. Limited operative time, controlled values of pneumoperitoneum, careful dissection with energy device of gastric greater curvature, appropriate prophylaxis with low molecular weight heparin may be useful tools to prevent and limit this complication. Nonetheless we have to search which factors may condition the evolution of an extended PMVT as that described in this case towards resolution or to a further worsening clinical state. Early diagnosis? Correct treatment? Undiscovered patientrelated factors?

Transoral endoscopic thyroidectomy by a vestibular approach: cadaver simulation experience and ethicolegal issues

This article describes the use of transoral endoscopic thyroidectomy by a vestibular approach on cadavers to improve the technical and non-technical skills of surgeons.

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.

Thyroid surgery during coronavirus-19 pandemic phases I, II and III: lessons learned in China, South Korea, Iran and Italy

OBJECTIVE

We compared demographic and clinic-pathological variables related to the number of surgeries for thyroid conditions or for cancer, morbidity, and fine needle aspiration (FNA) practices among Covid19 pandemic phases I, II, III and the same seasonal periods in 2019.

METHODS

The prospective database of the Division of Thyroid Surgery, China-Japan Union Hospital of Jilin University, Changchun, China was used for this study. Covid19 emergency levels were stratified according to the World Health Organization: phase I (January 25-February 25, 2020), phase II (February 26-March 19), phase III (March 20-April 20).

RESULTS

There were fewer outpatient FNAs and surgeries in 2020 than in 2019. There were no thyroid surgeries during phase I. There were also fewer surgeries for cancer with a significant reduction of advanced stage cancer treatments, mainly stage T1b N1a in phase II and T3bN1b in phase III. Operative times and postoperative stays were significantly shorter during the pandemic compared to our institutional baseline. In phase III, vocal cord paralysis (VCP) increased to 4.3% of our baseline numbers (P = 0.001). There were no cases of Covid19-related complications during the perioperative period. No patients required re-admission to the hospital.

CONCLUSION

The Covid19 outbreak reduced thyroid surgery patient volumes. The decrease of Covid19 emergency plans contributed to unexpected outcomes (reduction of early stage cancer treatment, decreased operative times and hospital stays, increased VCP rate).

Goiter drawing in Ulrich Boner's Der Edelstein Codices Palatini Germanici 794

We provide an example of representation of thyroid swelling in the artwork of Ulrich Boner's Der Edelstein Codices Palatini Germanici 794.

Influence of body mass index on the clinicopathological features of 13,995 papillary thyroid tumors

PURPOSE

This retrospective study aimed to assess the association between obesity, gender, and specific clinicopathological features in patients with papillary thyroid cancer (PTC) and whether diagnostic ultrasonography (US) is adversely affected by obesity in these patients.

MATERIALS AND METHODS

This study retrospectively analyzed 13,995 adult patients with PTC from a single medical center in China. Data stratification was performed to assess the association of obesity with US features and aggressive clinicopathological features in different models according to the World Health Organization Body Mass Index (WHO-BMI) and Chinese BMI classification (CN-BMI). The odds ratio (OR) of malignant US features and aggressive clinicopathological features was calculated from binary logistic regression models.

RESULTS

The BMI, obesity ratio, malignant US features, and aggressive pathological characteristics of males were significantly higher than those of females. After adjusting for confounding factors, the association of obesity with malignant US features and aggressive pathological characteristics was found to be sex-dependent. Next, obesity (WHO-BMI) was found to have an "interfering effect" on the US assessment of PTC (OR = 0.754, 95% CI 0.609-0.932, P = 0.009) in women. Among both sexes, obesity (WHO-BMI) increased the risk of tumor size (OR_male = 1.539 and OR_female = 1.521) and multifocality (OR_male = 1.659 and OR_female = 1.449). However, obesity did not increase the risk of capsular invasion or tumor staging in males. The above results are consistent with the CN-BMI. In addition, age was found to have an "interfering effect" on the US evaluation of malignant nodules in both sexes.

CONCLUSION

The results of our study confirm that higher BMI is significantly associated with aggressive clinicopathological features of PTC. Gender differences were present with obesity ratios and aggressive clinicopathological features being significantly higher in men.

Will the shepherd be able to play the alpine horn with that huge goiter (XVI century)?

PURPOSE

There are many of the representations in iconography of individuals with goiters reported in the literature.

METHODS

The article describe a unique representation of goiter, as observed by the authors in a sculpture in Italy.

RESULTS

In a Nativity, in the upper part of the altar of the Church of the Annunciata, Boccioleto (Val Sermenza, Piedmont, Italy), a horn player with a huge goiter, gladdens the Holy Family. Wooden work by Francesco Antonio d'Alberto, 1694.

CONCLUSION

This is an appropriate example of the iconography of "real goiter," since in this case the sculptor had the aim of showing person with goiter.

Lymph node characteristics of 6279 N1 differentiated thyroid cancer patients

PURPOSE

This study examined the clinicopathological characteristics of 6279 N1 differentiated thyroid cancer (DTC) patients who underwent operations in our center.

METHODS

This was a retrospective longitudinal analysis. We categorized the DTC on the basis of various lymph node (LN) characteristics. Logistic regression models and multiple linear regression models were used for the correlation analysis.

RESULTS

A total of 3693 (58.8%) N1a patients and 2586 (41.1%) N1b patients were included. Patients with N1b disease had larger metastatic foci (0.5 vs. 0.15 cm), a greater number of metastatic LNs (5 vs. 2), a greater number of dissected LNs (25 vs. 7), and a smaller lymph node ratio (NR, number of positive LNs / number of sampled LNs) (23.1% vs. 28.6%) than patients in stage N1a. Comparing the clinicopathological features, we found that male, increased tumor size, multifocality, and thyroiditis increased the risk of stage N1b disease (P<0.05). Sex, multifocality, capsular infiltration, and tumor size were associated with the size of the metastatic LNs (P<0.05). Sex, capsular infiltration, and nodular goiter were associated with the NR (P<0.05). Male sex, tumor located in inferior lobe, maximal tumor diameter (MTD) <1cm, and nodular goiter were independent predictors for skip metastases (P<0.05). MTD <1cm, central neck metastasis and advanced age were independent predictors for bilateral lateral neck metastasis (BLNM) (P<0.05).

CONCLUSION

The LN characteristics of stage N1a and N1b disease were associated with significantly different features, such as sex, tumor size, multifocality, capsular infiltration, and nodular goiter.

Classifying pain in transoral endoscopic thyroidectomy

PURPOSES

Knowledge of visual analog scale (VAS) pain assessment for transoral endoscopic thyroidectomy vestibular approach (TOETVA) is limited. The purpose of this analysis was to classify the postoperative discomfort scores in patients undergoing TOETVA compared to open thyroidectomy.

METHODS

Observational clinical study of patients who underwent thyroidectomy by VAS pain assessment from September 2016 to March 2017. Patients were stratified into two groups: patients eligible for TOETVA (Group TOETVA) and non-candidates for endoscopic intervention (open thyroidectomy approach-OTA). VAS was recorded in the recovery room, at 24 h, + 2, + 5, + 15, + 30, + 90 days, and 6 months after surgery. Pain assessment was stratified in VAS-lower lip, VAS-chin, VAS-jaw, VAS-anterior neck, VAS-cervical/back, VAS-swallowing, VAS-brushing, VAS-speaking, and VAS-shaving. Secondary outcome assessed were analgesic rescue dose, morbidity, operative notes, hospital stay, and histopathology.

RESULTS

41 TOETVA and 45 OTA constituted the analysis. There were differences between the TOETVA and OTA for age, gland volume, mean nodule diameter, coexistence thyroiditis, bilateral procedures, and use of drain. Operative time was longer in TOETVA. Results indicated that TOETVA was associated with reduced neck, cervical back, and swallowing VAS scores in the 24 h after surgery. Conversely, jaw and brushing teeth resulted in higher VAS score in TOETVA group. OTA patients never experienced lower lip or chin pain. The use of rescue analgesics did not differ between the two groups.

CONCLUSIONS

VAS was used to measure treatment outcome in TOETVA. VAS scores achieved overall a minimal clinical importance difference from the two procedures. There appears to be both a short- and long-term different range of interpretations of pain between TOETVA and OTA.

Observational study: the use of the Ventralight Echo PS (positioning system) prosthesis in the treatment of incisional hernia

The treatment of incisional hernias, especially those that are multiple or recurring, has always represented important challenges for surgeons. An incisional hernia is a mechanical damage of the abdominal wall that can result in respiratory problems and alterations of splanchnic circulation, especially when in large size hernias. The increasing availability of prostheses with greater resistance Romato infections and tension, lightness, biocompatibility, and reduced visceral adhesions has improved outcomes and minimized relapses. It is still important, however, to carefully choose the type of prosthesis and surgical technique, whether laparotomic or laparoscopic, correlated to the positioning site of the prosthesis. In this observational study we report the results and outcomes of 50 patients surgically treated for incisional hernia in our hospital. The surgical technique used to repair the hernias was laparoscopic with the use of the Ventralight Echo PS. This prosthesis is equipped with a comfortable and innovative pneumatic system that facilitates its positioning during surgery. In our experience, it has brought undeniable advantages for the treatment of incisional hernias and for all patients with parietal defects who could benefit from laparoscopic treatment.

Experimental study of needle recording electrodes placed on the thyroid cartilage for neuromonitoring during thyroid surgery

BACKGROUND

Needle electrodes placed on the thyroid cartilage (TC) are an alternative to endotracheal tube (ET) electrodes for assessing recurrent laryngeal nerve (RLN) function during thyroid surgery. Needle electrodes placed on the TC were evaluated in an experimental porcine model.

METHODS

Continuous intraoperative neuromonitoring was used to record the electromyogram. Each TC side was delineated into nine areas to determine the optimal placement of the electrode, and needle electrode area, depth and orientation for optimal electromyographic (EMG) amplitudes were evaluated. RLN root locations were stimulated at four locations: vagus nerve distal to the neuromonitoring electrode, and most proximal, middle and laryngeal entry points of the nerve. A nerve retraction injury model was adapted to compare RLN monitoring by TC versus ET electrodes.

RESULTS

An optimal site for placement of needle electrodes was identified, and electromyograms obtained from the various needle insertion depths and orientations were similar. Latencies recorded from the TC and ET electrodes were similar. The amplitude profile of TC electrodes responded earlier to RLN injury than that of ET electrodes. Amplitude and drop to loss of signal were also registered earlier.

CONCLUSION

EMG amplitudes obtained using TC electrodes were higher, and identified RLN injury earlier than ET electrodes. Surgical relevance Needle electrodes placed on the thyroid cartilage (TC) are an alternative to endotracheal tube (ET) electrodes for assessing the function of the recurrent laryngeal nerve (RLN) in thyroid surgery. This study used an experimental porcine model to evaluate the use of needle electrodes inserted in the TC, compared with ET electrodes, for producing an electromyographic (EMG) profile of the RLN. Nine areas of the TC, with various needle insertion depths and orientations, were compared. Perichondral insertion into the avascular area of the TC was found to be safe. The EMG amplitude and latency features recorded via the TC and ET electrodes were compared, using both intermittent and continuous monitoring. Changes in EMG amplitudes in response to nerve traction injury were registered earlier with TC electrodes than with ET electrodes, and the amplitudes were higher and more stable. Latencies obtained via the TC and ET electrodes were similar. These results indicate that the development of a non-invasive monitoring electrode with improved function, easy placement and low cost is possible.

Transoral thyroidectomy: advantages and limitations

In this opinion paper of the Journal of Endocrinological Investigation, leading experts in the field report on their current clinical experience with a novel approach for thyroid gland surgery, namely, "transoral thyroidectomy" (TOT). This feasible and novel surgical procedure does not require visible incisions and is, therefore, a truly scarless surgery. Patients meeting the following criteria can be considered as candidates for TOT: (a) an ultrasonographically (US) estimated thyroid diameter ≤10 cm; (b) US-estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) presence of a benign tumor such as a thyroid cyst or a single- or multi-nodular goiter; (e) Bethesda 3 and/or 4 category and (f) papillary microcarcinoma without the evidence of metastasis. The procedure is conducted via a three-port technique at the oral vestibule using a 10-mm port for the 30° endoscope and two additional 5-mm ports for the dissecting and coagulating instruments. TOT is performed using conventional endoscopic instruments and is probably the best scarless approach to the thyroid because of the short distance between the thyroid and the incisions placed intra-orally that do not result in any cutaneous scar and upon following the surgical planes. Experts in TOT organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologist to develop the standards for practicing this emerging technique.

Endpoints for screening thyroid cancer in the Republic of Korea: thyroid specialists' perspectives

Cancer screening is aimed primarily at reducing deaths from the specific cancer. Thyroid-specific cancer mortality may be the most ambitious endpoint for obtaining estimates of screening effect. Numerous observations have accumulated over the years, indicating that thyroid cancer mortality endpoint has been difficult to study and is confounded by population heterogeneity, provision of randomization, and requirement of large cohorts with sufficiently long follow-up due to the excellent prognosis of the cancer. Accordingly, it may be important to reconsider how to best measure thyroid cancer screening efficacy. Recommendations against thyroid cancer screening should be based upon trials designed to evaluate its effectiveness not only in significant reduction in cancer mortality, but also of other distinct endpoints. It is desirable to evaluate derivative endpoints that can reliably predict reductions in mortality. The term "derivative" means a variable that is related to the true endpoint and is likely to be observable before the primary endpoint. Derivative endpoints may include thyroid cancer incidence, the proportion of early-stage tumors detected, more treatable stage, the identification of small tumors (to maintain in observation), decrease in the number of people who develop metastatic disease, the increased chance of lesser extent surgery, and the application of minimally invasive approaches, as well as no need for lifelong thyroid replacement therapy, a consistent follow-up, low-dose or no RAI administration and risk factor assessments where case findings should be continuous. The Korean guidelines for thyroid cancer national-level screening were published by a relevant group of multidisciplinary thyroid experts. It was concluded that the evidence is insufficient to balance the benefits and harms of thyroid cancer screening. However, the paper seems to raise the necessary investments in future research and demand a complete analysis for derivative endpoints, and offer screening participants with complete information necessary to make decisions that will provide them with the most value when a small thyroid cancer is screen-identified.

Breast cancer and thyroid diseases: analysis of 867 consecutive cases

INTRODUCTION

The aim of this study was to evaluate the association of breast cancer with thyroid diseases. Many authors have already studied the possible relationship between these two diseases, but the results are nowadays conflicting.

MATERIALS AND METHODS

Our study examining 867 patients with breast cancer (862 women and 5 men, average age = 61 years old) of whom 141 also had thyroid disease evaluated the recurrence of thyroid diseases and their association with different types of breast cancer. Statistical analyses were performed using SPSS software for Windows; we used nonparametric tests (Chi-square and Mann-Whitney), and the level of significance was set at p < 0.05.

RESULTS

We found a significant association between breast cancer diagnosed after menopause and thyroid disease (p < 0.003). Moreover, we analyzed the role of thyroid autoimmunity identifying an association between chronic autoimmune thyroiditis and breast cancer diagnosed before menopause (p < 0.05). Regarding receptor profile of breast carcinoma, we have found an increased expression of estrogen receptors in patients with autoimmune thyroiditis compared to patients with any other thyroid diseases (p < 0.03). Contrariwise, we do not have found any difference between the group with every thyroid disease and the group without thyroid disease (p < 1.00). We did not find other statistically significant associations with breast cancer's parameters like family history, tumor size, lymph node metastasis, distant metastasis, cancer clinical and pathological stage, differentiation grade and expression of Ki67, p53 and Her2 in the two main groups with or without thyroid disease. Likewise, we did not found other statistically significant association between hypothyroidism or hyperthyroidism and breast cancer.

Extended lymphadenectomy in elderly and/or highly co-morbid gastric cancer patients: A retrospective multicenter study

BACKGROUND

Gastrectomy with extended lymphadenectomy is considered the gold standard treatment for advanced gastric cancer, with no age- or comorbidity-related limitations. We evaluated the safety and efficacy of curative gastrectomy with extended nodal dissection, verifying survival in elderly and highly co-morbid patients.

METHODS

In a retrospective multicenter study, we examined 1322 non-metastatic gastric-cancer patients that underwent curative gastrectomy with D2 versus D1 lymphadenectomy from January 2000 to December 2009. Postoperative complications, overall survival (OS), and disease-specific survival (DSS) according to age and the Charlson Comorbidity Score were analyzed in relation to the extent of lymphadenectomy.

RESULTS

Postoperative morbidity was 30.4%. Complications were more frequent in highly co-morbid elderly patients, and, although general morbidity rates after D2 and D1 lymphadenectomy were similar (29.9% and 33.2%, respectively), they increased following D2 in highly co-morbid elderly patients (39.6%). D2-lymphadenectomy significantly improved 5-year OS and DSS (48.0% vs. 37.6% in D1, p < 0.001 and 72.6% vs. 58.1% in D1, p < 0.001, respectively) in all patients. In elderly patients, this benefit was present only in 5-year DSS. D2 nodal dissection induced better 5-year OS and DSS rates in elderly patients with positive nodes (29.7% vs. 21.2% in D1, p = 0.008 and 47.5% vs. 30.6% in D1, p = 0.001, respectively), although it was present only in DSS when highly co-morbid elderly patients were considered.

CONCLUSION

Extended lymphadenectomy confirmed better survival rates in gastric cancer patients. Due to high postoperative complication rate and no significant improvement of the OS, D1 lymphadenectomy should be considered in elderly and/or highly co-morbid gastric cancer patients.

Harlequin syndrome after thyroidectomy for compressive retrosternal goiter. Case report and review of the literature

A 74-year-old woman with known euthyroid multinodular retrosternal goiter necessitated an urgent intubation at home, due to acute respiratory distress evoked by tracheal compression. Extubation after a few days failed, and she underwent an urgent total thyroidectomy. During postoperative extubation the patient developed suddenly unilateral facial flushing and sweating at the left side, without ptosis of the left levator palpebrae superioris. These symptoms persisted during the next 24 hours. The skin at the right side of the face remained uninvolved. In the early postoperative period this appearance recurred at moments of emotions, exercise or heat. Beside this, the patient had a normal recovery. Six weeks later this reaction couldn't be provoked anymore. 'Harlequin' syndrome (unilateral facial flushing and sweating) is caused by a lesion of the controlateral sympathetic chain at the levels T2 and T3. It is unknown if the sweating and vasodilation at the "healthy" side is normal or if it is a reaction of hyperactivity.

Recurrent laryngeal nerve injury in video-assisted thyroidectomy: lessons learned from neuromonitoring

INTRODUCTION

The objective of the study was to assess the mechanism of recurrent laryngeal nerve (RLN) injury during video-assisted thyroidectomy (VAT).

METHODS

The study examined 201 nerves at risk (NAR). VAT with laryngeal neuromonitoring (LNM) was outlined according to this scheme: (a) preparation of the operative space; (b) vagal nerve stimulation (V1); (c) ligature of the superior thyroid vessels; (d) visualization, stimulation (R1), and dissection of the RLN; (e) extraction of the lobe; (f) resection of the thyroid lobe; (g) final hemostasis; (h) verification of the electrical integrity of the RLN (V2, R2). The site, cause, and circumstance of nerve injury were elucidated with the application of LNM. Laryngeal nerve injuries were classified into type 1 injury (segmental) and 2 (diffuse).

RESULTS

Fourteen nerves (6.9 %) experienced loss of R2 and V2 signals. 80 percent of lesions occurred in the distal 1 cm of the course of the RLN. The incidence of type 1 and 2 injuries was 71 and 29 % respectively. The mechanisms of injury were traction (70 %) and thermal (30 %). Traction lesions were created during the extraction of the lobe from the mini-incision [point (e)]. Thermal injury occurred during energy-based device use in (f) and (g) circumstances.

CONCLUSIONS

RLN palsy still occurs with routine endoscopic identification of the nerve, even combined with LNM. LNM has the advantage of elucidating the mechanism of RLN injury. Traction and thermal RLN injuries are the most frequent lesions in VAT.

Report of four simultaneous pancreas-kidney transplants in HIV-positive recipients with favorable outcomes

The advent of combined antiretroviral therapy (cART) dramatically changed the view of human immunodeficiency virus (HIV) infection as an exclusion criterion for solid organ transplantation, resulting in worldwide reports of successful transplants in HIV-infected individuals. However, there are few reports on simultaneous pancreas-kidney transplant in HIV-positive recipients detailing poor outcomes. A series of four pancreas-kidney transplant performed on HIV-infected individuals between 2006 and 2009 is presented. All recipients reached stably undetectable HIV-RNA after transplantation. All patients experienced early posttransplant infections (median day 30, range 9-128) with urinary tract infections and bacteremia being most commonly observed. In all cases, surgical complications led to laparotomic revisions (median day 18, range 1-44); two patients underwent cholecystectomy. One steroid-responsive acute renal rejection (day 79) and one pancreatic graft failure (month 64) occurred. Frequent dose adjustments were required due to interference between cART and immunosuppressants. At a median follow-up of 45 months (range, 26-67) we observed 100% patient survival with CD4 cell count >300 cells/mm(3) for all patients. Although limited by its small number, this case series represents the largest reported to date with encouraging long-term outcomes in HIV-positive pancreas-kidney transplant recipients.

Implementation of systematic neuromonitoring training for thyroid surgery

Neural monitoring is increasingly applied to thyroid surgery and yet few surgeons have received formal training in intraoperative neuromonitoring (IONM). Standardized application of neural monitoring is an expected outcome of formal training programs in IONM. This study was designed to document a systematic training course that focuses on standardized state-of-art IONM knowledge. Seventeen 1-day courses were organized by the Department of Surgical Sciences, University of Insubria Medical School (Varese-Como, Italy), between 2009-2010. The course included didactic and practical training sessions. Some specific steps and checklist identified for courses included: knowledge of IONM technology and troubleshooting algorithms; IONM anesthetic perspectives, standards of IONM equipment set up and technique. A total of 75 trainees completed a questionnaire after completion of the respective courses. Questions probed demographic data, operative IONM experience and evaluation of course content. Data gathered showed that 97% of participants had no prior experience with the standardized approach of IONM technique (i.e. stimulation of the vagal nerve). The most useful parts of the course were judged to be (a) algorithms for perioperative IONM problem solving (30%), (b) live surgery with hands-on training (25%), (c) standardization of IONM technique (25%), and (d) IONM equipment set-up (20%). Poor reimbursement for hospital thyroid procedures is the main reason of limitation of IONM technology. The course offered participants novel knowledge and training and gave participants a systematic and standard approach to IONM technique.

Preoperative methods to improve erythropoiesis

Preoperative anemia creates a challenge for surgical treatment and patient outcomes after major surgery. Prior to a surgical intervention, it is optimal to increase erythropoiesis to improve oxygen transport through the bloodstream for patients at high risk of anemia and to avoid the complications of allogeneic blood transfusion. In this way, patients could receive predeposited autologous blood or, during the surgical procedures, undergo acute normovolemic hemodilution. This approach is allowed by the use of recombinant human erythropoietin in association with erythropoiesis-inducing factors such as iron and folic acid. In this article, we discuss the recent clinical evidences.

Microwave ablation therapy for treating primary and secondary lung tumours: technical note

PURPOSE

The purpose of our study was to retrospectively evaluate the feasibility, safety and effectiveness of microwave ablation (MWA) in nine patients with unresectable lung tumour.

MATERIALS AND METHODS

Ten lesions were treated in ten ablation sessions in nine patients. The treatments were performed with a microwave generator with 45 W and 915 MHz connected to a 14.5-gauge antenna for 10 min. Antenna placement was performed with computed tomography (CT) fluoroscopy guidance or XperGuide. All patients underwent CT follow-up at 1, 3 and 6 months from the procedure.

RESULTS

Technical success was obtained in all cases; mortality at 30 days was 0%.

CONCLUSIONS

This study shows that in selected patients, MWA is a valid alternative to other ablative techniques. Further studies are required to demonstrate the short- and long-term effects of this technique and to make a comparison with other available ablation systems, especially with radiofrequency.

Laparoscopic cholecystectomy as day-surgery procedure: current indications and patients' selection

AIM OF THE STUDY

To review the current indications, to establish predictive factors of success and the safety of LC as a day-surgery procedure.

METHODS

Randomized clinical trials were searched on PubMed between January 2000 and June 2008 using "laparoscopic cholecystectomy", "day-surgery" as keywords.

RESULTS

A total of 20 trials was identified and analyzed. The indications for LC in day-surgery unit were symptomatic and chronic cholelitiasis without evidence of common bile duct stones; acute cholecystitis and pancreatitis cases were excluded. The trials considered as inclusion criteria: ASA score, BMI, social aspect and the preoperative workout included: abdominal US, liver function tests and routine preoperative tests, while the results considered the reasons for hospital stays and for readmission and measured patient satisfaction; some trials included analyze of costs of LC as day-surgery procedure the role of the surgeon's experience.

DISCUSSION

The present study confirms that day-surgery LC is safe and feasibility in selected patients; serious complications are rare and most frequently prolonged hospital stay and the readmission are connected with minor and more easily controlled complications or social reasons. Outpatient surgery requires careful planning and preparation in order to reach acceptable patients' satisfaction: preoperative workout is extremely imports allowing to reduce errors selection. Considering surgical training, it has been demonstrated that in the centres in which the trainees are involved in day-surgery LC there not significant difference in terms of number of complications, patient outcomes, prolonged stay and readmission. The adequate control of pain, nausea or vomiting is essential component in day-case LC service and it is possible at home after LC.

CONCLUSION

Day-case laparoscopic cholecystectomy is feasible with an acceptable discharge rate and level of patient satisfaction. The success depends on appropriate patient selection and on well-trained staff and skilful operative technique together with safe anaesthesia.

Video-assisted thyroidectomy performed in a one-day surgery setting

BACKGROUND AND AIM

Evidence base data have demonstrated that video-assisted thyroidectomy (VAT) has good results regarding safety, morbidity, patient cure rate, pain and cosmesis. Aim of this study was to evaluate the performance of VAT in an ambulatory setting (i.e. one-day surgery, <24-h stay).

MATERIALS AND METHODS

Between September 2007 and July 2008, 43 patients underwent VAT in a one-day surgery division. Patient selection criteria for VAT were: thyroid nodules <30 mm, gland volume <20 ml, no history of thyroiditis or neck surgery or irradiation, "low risk" papillary carcinoma and absence of enlarged lymph nodes. One-day surgery patient selection criteria were medical and social logistic (Materazzi G, et al. Eur Surg Res 2007;39:182-8). Intraoperative neuromonitoring (IONM) was used for RLN identification. Intact parathyroid hormone (iPTH) levels were determined early postoperatively at +6-h. Postoperative complications, conversion rate were analyzed.

RESULTS

No cases required conversion to open surgery or ordinary recovery (i.e. >24h). Incidence of temporary hypoparathyroidism was 11.6% (5/43) with no case of symptomatic hypocalcemia. Incidence of temporary RLN injury was 2.3% (1 patient) with no case of permanent or bilateral RLN injury. All patients were satisfied with the type of recovery.

CONCLUSIONS

This preliminary report is an example of the safe incorporation between new technologies (IONM, early iPTH measurement) with improvement of the quality and safety of VAT performed in a one-day surgery setting.

Image-guided percutaneous treatment of abdominal-pelvic abscesses: a 5-year experience

PURPOSE

This study was undertaken to evaluate the efficacy of image-guided percutaneous drainage in treating abdominal and pelvic abscesses.

MATERIALS AND METHODS

From August 2001 to August 2006, 95 patients (49 men and 46 women; mean age 61 years, range 25-92) with 107 abscesses underwent image-guided percutaneous drainage. Thirty-one abscesses were retroperitoneal (9 peripancreatic, 17 perirenal, 5 pararenal), 37 intraperitoneal (2 in communication with the small bowel), 8 intrahepatic (2 in communication with the extrahepatic biliary system and 2 with the intrahepatic biliary system), 4 perisplenic and 27 pelvic (4 in communication with the large bowel). Seventy-one of 107 procedures were performed with ultrasonographic (US) guidance and 36/107 with computed tomography (CT) guidance. All procedures were carried out with 8-to 14-Fr pigtail drainage catheters.

RESULTS

Immediate technical success was achieved in 107/107 fluid collections. No major complications occurred. In 98/107 abscesses, we obtained progressive shrinkage of the collection (>50%) with consequent clinical success. In 9/107 cases, percutaneous drainage was unable to resolve the fluid collection. There were 12 cases of catheter displacement and six of obstruction.

CONCLUSIONS

Percutaneous drainage is feasible and effective in treating abdominal and pelvic abscesses. It may be considered both as a preparatory step for surgery and a valuable alternative to open surgery. Failure of the procedure does not, however, preclude a subsequent surgical operation.

Combined treatment of ablative therapy with percutaneous radiofrequency and cementoplasty of a symptomatic metastatic lesion of the acetabulum

We report the case of a symptomatic metastatic lesion of the acetabulum from colon adenocarcinoma in an 82-year-old woman patient treated by a combined approach of thermal ablation with percutaneous radiofrequency and cementoplasty. We obtained an immediate technical success with a good control of pain without any complications at a 6-month clinical follow-up.

Post-radiofrequency ablation syndrome after percutaneous radiofrequency of abdominal tumours: one centre experience and review of published works

The aim of this study was to evaluate prospectively post-radiofrequency ablation (RFA) syndrome and to determine its effect on the quality of life in the 15 days after percutaneous RFA treatment. We carried out an internal review board-approved prospective study of the delayed symptoms that occurred after 71 consecutive RFA sessions in 53 patients (12 women and 41 men; age range 45-83 years; mean age 71.6 years) with 45 primary liver tumours, 34 liver metastases, 3 renal cell carcinoma (RCC), 2 residual lesions from RCC after nephrectomy and 1 pancreatic metastases from RCC. Postablation symptoms occurred in 17 of 53 (32%) patients. Six of 17 patients developed low-grade fever (from 37.5 to 38.5 degrees C). Other symptoms included delayed pain (9/17), nausea (7/17), vomiting (3/17), malaise (3/17) and myalgia (1). Postablation syndrome is a common phenomenon after RFA of solid abdominal tumours. Not only in our study but also in the previous ones the occurrence is observed in approximately one-third patients. Patients should be informed that these symptoms are self-limiting after RFA and most patients should be able to resume near-complete preprocedural levels of activity within 10 days after the procedure.