Alessandro Pasculli

Can Total Thyroidectomy Be Safely Performed by Residents?: A Comparative Retrospective Multicenter Study.

AbstractThis retrospective comparative multicenter study aims to analyze the impact on patient outcomes of total thyroidectomy (TT) performed by resident surgeons (RS) with close supervision and assistance of attending surgeons (AS).All patients who underwent TT between 2009 and 2013 in 10 Units of endocrine surgery (8 in Italy, 1 in France, and 1 in UK) were evaluated. Demographic data, preoperative diagnosis, extension of goiter, type of surgical access, surgical approach, operative time, use and duration of drain, length of hospitalization, histology, and postoperative complications were recorded. Patients were divided into 3 groups: A, when treated by an AS assisted by an RS; B and C, when treated by a junior and a senior RS, respectively, assisted by an AS.The 8908 patients (mean age 51.1 ± 13.6 years), with 6602 (74.1%) females were enrolled. Group A counted 7092 (79.6%) patients, Group B 261 (2.9%) and Group C 1555 (17.5%). Operative time was significantly greater (P < 0.001) in B (101.3 ± 43.0 min) vs A (71.8 ± 27.6 min) and C (81.2 ± 29.9 min). Duration of drain was significantly lower (P < 0.001) in A (47.4 ± 13.2 h) vs C (56.4 ± 16.5 h), and in B (42.8 ± 14.9 h) vs A and C. Length of hospitalization was significantly longer (P < 0.001) in C (3.8 ± 1.8 days) vs B (2.4 ± 1.0 days) and A (2.6 ± 1.5 days). No mortality occurred. Overall postoperative morbidity was 22.3%: it was significantly higher in B vs A (29.5% vs 22.3%; odds ratio [OR] 1.46, 95% confidence interval [CI] 1.11–1.92, P = 0.006) and C (21.3%; OR 1.55, 95% CI 1.15–2.07, P = 0.003). No differences were found for recurrent laryngeal nerve palsy, hypoparathyroidism, hemorrhage, and wound infection. The adjusted ORs in multivariate analysis showed that overall morbidity remained significantly associated with Group B vs A (OR 1.48, 95% CI 1.12–1.96, P = 0.005) and vs C (OR 1.60, 95% CI 1.19–2.17, P = 0.002), while no difference was observed in Group A vs B + C.TT can be safely performed by residents correctly supervised. Innovative gradual training in dedicated high-volume hospitals should be proposed in order to allow adequate autonomy for the RS and safeguard patient outcome.

Recurrent laryngeal nerve palsy and substernal goiter. An Italian multicenter study

The aim of this retrospective multicenter study was to verify whether the substernal goiter and the type of surgical access could be risk factors for recurrent laryngeal nerve palsy during total thyroidectomy. Between 1999-2008, 14,993 patients underwent total thyroidectomy. Patients were divided into three groups: group A (control; n=14.200, 94.7%), cervical goiters treated through collar incision; group B (n=743, 5.0%) substernal goiters treated by cervical approach; group C (n=50, 0.3%) in which a manubriotomy was performed. Transient and permanent unilateral palsy occurred significantly more frequently in B+C vs. A (P≤.001) and in B vs. A (P≤.001). Transient bilateral palsy was significantly more frequent in B+C vs. A (P≤.043) and in C vs. A (P≤.016). Permanent bilateral palsy was significantly more frequent in B+C vs. A (P≤.041), and in B vs. A (P≤.037). Extension of the goiter into the mediastinum was associated to increased risk of recurrent nerve palsy during total thyroidectomy.

Gene expression profiling of normal thyroid tissue from patients with thyroid carcinoma

Gene expression profiling (GEP) of normal thyroid tissue from 43 patients with thyroid carcinoma, 6 with thyroid adenoma, 42 with multinodular goiter, and 6 with Graves-Basedow disease was carried out with the aim of achieving a better understanding of the genetic mechanisms underlying the role of normal cells surrounding the tumor in the thyroid cancer progression. Unsupervised and supervised analyses were performed to compare samples from neoplastic and non-neoplastic diseases. GEP and subsequent RT-PCR analysis identified 28 differentially expressed genes. Functional assessment revealed that they are involved in tumorigenesis and cancer progression. The distinct GEP is likely to reflect the onset and/or progression of thyroid cancer, its molecular classification, and the identification of new potential prognostic factors, thus allowing to pinpoint selective gene targets with the aim of realizing more precise preoperative diagnostic procedures and novel therapeutic approaches. STATEMENT OF SIGNIFICANCE This study is focused on the gene expression profiling analysis followed by RT-PCR of normal thyroid tissues from patients with neoplastic and non-neoplastic thyroid diseases. Twenty-eight genes were found to be differentially expressed in normal cells surrounding the tumor in the thyroid cancer. The genes dysregulated in normal tissue samples from patients with thyroid tumors may represent new molecular markers, useful for their diagnostic, prognostic and possibly therapeutic implications.

Surgical management of the pancreatic stump following pancreato-duodenectomy

Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.

Floating left innominate vein neoplastic thrombus: A rare case of mediastinal extension of follicular thyroid carcinoma

Objective We report a case of advanced follicular thyroid cancer with innominate vein involvement. To our knowledge, this seems to be the first case treated in emergency surgery, reported in literature. Method A 59-year-old woman with a five-year history of a large and mainly right-sided cervical mass presented with dyspnea, unilateral arm swelling, facial flushing, and venous congestion. An emergency computed tomography scan revealed a thyroid mass extending into the upper mediastinum with displacement and compression of the right jugular vein and carotid artery and apparent adherence to the superior vena cava and left innominate vein. Results An emergency total thyroidectomy was performed by means of a sternotomy. The lower portion of the retrosternal goiter projected directly into the left innominate vein, with tumor floating in its lumen. Removal of the neoplastic thrombus was performed, through an incision in the vein, en bloc with the thyroid mass. Both goiter and thrombus were completely replaced by follicular carcinoma. Conclusions Accurate preoperative assessment through contrast-enhanced computed tomography is strongly suggested in the presence of enlarged thyroid gland extending into the mediastinum whenever angioinvasion is suspected. This could prevent blinded maneuvers such as digital externalization of the thoracic component of the gland, which can be fatal in cases of cervico-mediastinal goiter extending into great cervical or mediastinal veins.

Irrigation during Laparoscopic Appendectomy for Complicated Appendicitis: Time to Review Current Guidelines

It could be asserted that the advent of evidencebased medicine and minimally invasive approaches are among the most remarkable revolutions that general surgeons had to face with during the second half of the 20th century. Still being one of the most common diseases leading to emergency surgery procedures, with a lifetime risk of 8.6% for males and 6.7% for females [1], acute appendicitis (AA) seems to be a paradigm of the challenging changes of current surgical practice. A recent meta-analysis [2] could not demonstrate the superiority of laparoscopic appendectomy (LA) compared with open appendectomy for what concerns the incidence of intra-abdominal abscess (IAA) (odds ratio (OR) 0.79; 95% confidence interval (CI) 0.45–1.37). One of the most reliable tools for surgeons facing with acute appendicitis is represented in the World Society of Emergency Surgery (WSES) Jerusalem guidelines [1] issued after a Consensus Conference held in 2015. Giving Level of Evidence (LoE) and Grade of Recommendation (GoR) for a wide number of questions about diagnosis and therapy of acute appendicitis, these guidelines include a section about peritoneal irrigation in complicated appendicitis treated with LA. Their statement about laparoscopic lavage affirms that it does not add any advantage if compared with suction alone (LoE 2, GoR B), the main