Antonina Catalfamo

Limits of continuous neural monitoring in thyroid surgery

We read with interest the paper by Chávez et al. “Continuous intraoperative neural monitoring in thyroid surgery: a Mexican experience”, published on December issue of Updates in Surgery [1]. The manuscript is greatly knowledgeable, and rise significant results on continuous intraoperative neural monitoring (CIONM) in thyroid surgery [1]. Even though in contrast with our title statement, Chávez et al.’s report and other recent studies have shown that CIONM is associated with significant less permanent recurrent laryngeal nerve (RLN) injuries compared to intermitted neural monitoring (IONM) [1–5]. CIONM represents a gradually surgical progress, achieving and advancing to the objective of less RLN injuries [1–5]. Nevertheless, CIONM has some limits, both technological and interpretative. Simplification New surgical techniques and technology have simplified surgery and have enhanced the safety of procedures. The surgical placement step of CIONM probe should be simplified as it is time consuming and is considered to be more difficult than in other intermitted monitored and non-monitored procedures [6–8]. A new approach to the vagal nerve has been proposed to achieve procedure simplification [9]. The first tests with prototypes of transcutaneous or percutaneous CIONM models demonstrated a significant feasibility [9]. These technique appear to be equal compared to standard CIONM. Such new alternatives for CIONM, may improve safety and simplification [9]. However, new CIONM probes have been addressed, there still are technical opportunities to simplify the CIONM procedure. Learning curve Learning curve issues and implementation errors have contributed to recent discussion about CIONM safety [7, 8]. Certainly, notwithstanding the wellknown benefits of CIONM, proper training remains the gold standard for the safe CIONM procedure. Currently, there is no data available on the CIONM learning curve, both inherent to the technical component (i.e., using and setting up the CIONM equipment correctly) and the interpretive component (is the person performing the continuous monitoring able to distinguish between a true response versus an artifactual one?). Alarms threshold In the literature, there is some variation in the criteria used for “alerts” [1–5]. An “alert” must be raised because the following combined criteria (a) more than 50% amplitude loss, (b) more than 10% latency increase, (c) number of combined recordings, (d) synchronously and logically associated with high-risk surgical maneuver, (e) systemic, anesthetic, technical factors ruled out [1–5]. The stringency of the criteria for raising an “alert” is an important factor that is responsible for the different false-positive and false-negative rates. The uniformity in the criteria for “alerts” is essential. If a low threshold is used for raising an alert, then there is increased chance of false positives, with surgical procedures being unnecessarily altered or abandoned by these false positives. On the contrary, if a high threshold is used for raising an alert, then the chance of false negatives with resultant postoperative neurological deficits is a problem. Therefore, further research is definitely needed from the clinical sector to more fully define parameters for determining the significance of response decrement. RLN palsy still occurs with CIONM More importantly, the surgeon must know that even with the CIONM the RLN paralysis can occur. The CIONM allows to recognize and * Gianlorenzo Dionigi gdionigi@unime.it

Staged Thyroidectomy: A Single Institution Perspective: Staged Thyroidectomy

The increasing use of intraoperative neuromonitoring (IONM) in thyroid surgery has revealed the need to develop new strategies for cases in which a loss of signal (LOS) occurs on the first side of a planned total thyroidectomy.

La chirurgia tiroidea transorale

SommarioLa classica incisione del collo a livello mediano ha rappresentato l’approccio predominante per rimuovere la patologia della tiroide, sia benigna che maligna, e delle ghiandole paratiroidi, ma può provocare cicatrici cervicali antiestetiche. Un certo numero di approcci di accesso remoto alla tiroide e alle ghiandole paratiroidi sono stati descritti nel recente passato. Questi possono essere tecnicamente impegnativi, specialmente nei pazienti in sovrappeso, e richiedono grandi incisioni al di fuori del collo. Qui descriviamo l’approccio vestibolare transorale per la tiroidectomia, riportando la nostra esperienza iniziale che prevede indicazioni precise e l’utilizzo di tecniche endoscopiche. La chirurgia del collo con approccio vestibolare transorale offre l’assenza di un’incisione del collo in alternativa ad altri approcci di accesso remoto alla ghiandola tiroidea maggiormente invasivi. È una tecnica promettente per i pazienti programmati per una tiroidectomia che desiderano ottimizzare l’estetica.

Metachronous bilateral ectopic breast carcinoma: a case report

An incomplete regression of the mammary line during embryogenesis occurs in 0.2-6% of the population, which may result in the presence of ectopic breast tissue (EBT). The development of a carcinoma in the EBT is a rare event. The authors present a case report of a 76-year-old female patient, with a lobular carcinoma in an abdominal wall EBT submitted to surgery and adjuvant chemotherapy.

Medullary thyroid cancer: strategy, pitfalls and technical aspects with emphasis on remedial surgery

Medullary thyroid cancer (MTC) is a rare neuroendocrine tumor that has specific diagnostic and therapeutic requireents. Currently, imaging tools show great limits to localize all residual MTC foci. Non-invasive imaging is helpful but far from perfect for guiding the re-exploration for loco regional residual MTC. The therapeutic approach is different between sporadic and hereditary MTC. In order to obtain the biochemical and anatomical control the first surgical resection is critical. Calcitonin (Ctn) rate used for MTC recurrence detection as serum marker is definite. Yet it poses a unique challenge notwithstanding its ability in detecting microscopic subclinical disease; it is not clear if patients with evident biological signs of residual MTC should be closely observed when MTC is finally found out through different investigations that localize it, or if a different aggressive approach is necessary including central neck dissection, whether or not associated with ipsilateral or bilateral lateral neck dissection. In all phases of the disease, the co-treatment by physicians with experience in MTC therapy should be sought.

Pre- and post-operative patient care for transoral thyroidectomy

Endoscopic thyroidectomy (ET) allows surgeons to remove a thyroid tumor from a remote site, while providing excellent results from a cosmetic viewpoint. Minimally invasive surgery is widely employed for the treatment of thyroid diseases. Several minimal access approaches to the thyroid gland have been described. The commonly performed surgeries have been endoscopic lobectomies. We have performed ET trans orally by the inferior vestibular approach. Our preliminary results indicate that ET performed via transoral is a technically feasible and safe procedure with excellent cosmetic results for patients with benign thyroid tumors. In this report, we have summarized a focused on the pre- and post-operative patient care of this procedure.

Endoscopic thyroidectomy: why we need a transoral approach

Transoral thyroidectomy (TT) is a feasible novel surgical procedure that does not need visible incisions, a truly scar-free surgery. Inclusion criteria are (a) patients who have a ultrasonographically (US) estimated thyroid diameter not larger than 10 cm, (b) US estimated gland volume ≤45 mL, (c) nodule size ≤50 mm, (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (e) follicular neoplasm, (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through three-port technique placed at thexa0 oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sterncleidomuscles. TT is done fully endoscopically using conventional endoscopic instruments. TT represents probably the best scarless approach to the thyroid due to the short distance between the thyroid and the incisions, respecting the surgical planes.