Cannizzaro Ma

The use of FOCUS Harmonic scalpel compared to conventional haemostasis (knot and tie ligation) for thyroid surgery: a prospective randomized study

Haemostasis is crucial in thyroid surgery to avoid intraoperative and postoperative complications. In the present study, we evaluated the efficiency and the safety of Harmonic scalpel when compared to conventional suture ligation in open total thyroidectomy. We enrolled 265 patients who underwent total thyroidectomy for multinodular disease since October 2011 up to October 2013. They were randomized into two groups: 141 in group HS (Harmonic Scalpel), 124 in group CT (Conventional tecnique). We recorded the following data: operative time, post-operative blood loss, length of hospital stay and complications. The patients were monitored for 48 hours after surgery. Several differences were observed between the two groups (HS vs CT): the use of Harmonic scalpel was associated to a significant reduction of surgical operative time (110 min in CT vs 79.36 min in HS, p = 0.00001) and also associated to a lower blood loss (97.38 ml in CT vs 68.72 ml in HS, p = 0.00001). The length of stay was significantly shorter in the HS group (2.75 days in CT vs 1.93 days in HS) Complication rate was similar in the two groups. According to our experience, the Harmonic scalpel represents a safe alternative to conventional haemostasis in thyroid surgery, allowing for a significant reduction of operative time, blood loss and hospitalization. The rate of complication demonstrated no significant difference among the two groups.

Cervico-mediastinal goiter: is telescopic exploration of the mediastinum (video mediastinoscopy) useful?

Surgeons are aware that most mediastinal goiters can be excised through a Kocher transverse collar incision, but in rare circumstances a partial-complete median sternotomy or a thoracotomy are mandatory. During an operation to remove a large cervico-mediastinal goiter (CMG) a profound, not massive, bleeding in the anterior mediastinum developed. Bleeding was unsuccessfully treated with packing. Instead, to perform an urgent sternotomy we used telescopic imaging to identify the source of hemorrhage, and a metallic clip was used to stop the bleeding. Since then we have prospectively used the telescope in the case of large CMG causing compression of an adjacent structure. This report is a preliminary communication demonstrating the technique. Telescopic exploration of the mediastinum was performed in seven patients. The goiters were located in the middle mediastinum in five patients and in the anterior and middle mediastinum in one, respectively. The use of a telescope can help the surgeon during the removal of a large mediastinal goiter. It facilitates a) the visualization of the intrathoracic tributaries reducing the risk of hemorrhage, b) the research of ectopic thyroid gland, and finally c) minimizes the risk of complications of a median sternotomy.

Persistent hyperparathyroidism owing to a giant parathyroid adenoma in posterior mediastinum.

A 65-YEAR-OLD WOMAN presented to our observation with persistent hypercalcemic syndrome 4 months after a total thyroidectomy for a goiter associated with hypercalcemic syndrome. At that time, operative bilateral cervical exploration revealed 4 normal parathyroid glands. Postoperatively, the hypercalcemic syndrome did not disappear, and calcium and parathyroid hormone levels remained elevated. Chest tomography showed the presence of a ‘‘missed’’ 7-cm mass in the posterior mediastinum, which was confirmed on sestamibi scintigraphy. Remedial right videoassisted minithoracotomy was performed, and the mass removed. It descended to the level of azygous vein and was adherent to the esophagus and the trachea (Figure). Histology confirmed the presence of a large parathyroid adenoma weighing 95g. The calcium and parathyroid hormone levels returned to normal after surgery. The patient is symptom free 5 years postoperatively.

Klebsiella Pneumoniae pulmonary infection with thyroid abscess: Report of a case

Thyroid abscess is a rare clinical entity, usually associated with a pyriform sinus fistula. A prompt diagnosis is important because it may progress rapidly into a life-threatening condition. We report a very unusual case of thyroid abscess associated with a lung infection, both caused by Klebsiella pneumoniae. The patient was treated successfully with a culture-appropriate antibiotic and an uneventful thyroid lobectomy. A delay in diagnosis of morbidities associated with a thyroid abscess may result in rapid exacerbation of this condition; therefore, prompt and appropriate treatment is mandatory for a successful outcome.

How to avoid and to manage post-operative complications in thyroid surgery

Complications of thyroidectomy are hypoparathyroidism, recurrent laryngeal nerve palsy, and hemorrhage. These complications have a low incidence. Hypoparathyroidism is the most frequent complication of total thyroidectomy. Its incidence varies between 0.5 and 65%. This complication is also visible after reoperation for recurrent disease and in patients previously treated with radioiodine. Damage to the recurrent laryngeal nerve can be temporary or permanent, unilateral or bilateral. The bilateral lesion, associated with severe episodes of breathlessness, is a rare complication (0.4%). Intraoperative control of nerves is crucial to prevent damage. The hematoma creates an obstacle to venous and lymphatic flow and consequently breathing difficulties. The preventive hemostasis during surgery is important. Therapeutic treatment is described.

The thyroid disease in the elderly: Our experience

INTRODUCTION The number of elderly people in Italy is growing, so it is important to study the presentation of diseases in these subjects. MATERIALS AND METHODS We selected 1362 patients who underwent thyroidectomy for different thyroid diseases from January 2008 to December 2014. The patients weredivided into two groups, according to the age. The patients aged 65 years and over were included in the group A, and the patients under the age of 65 years were included in the group B. DISCUSSION Thyroid diseases in the elderly often present with atypical symptoms which are very similar to symptoms of the aging process. In elderly hypothyroidism occurs frequently sub-clinically and hyperthyroidism is often presented with cardiovascular symptoms. In our study we evaluated the differences in incidence of thyroid diseases in the elderly and in the younger groups of patients. CONCLUSION The data analyzed in this study showed that in the elderly we have a reduced secretion and metabolization of thyroid hormones. The symptomatology in the elderly is nonspecific and can create a delay in the correct diagnosis.

Comparison between Focus Harmonic scalpel and other hemostatic techniques in open thyroidectomy: A systematic review and meta-analysis.

The purpose of this review was to compare the efficacy and surgical outcomes of total thyroidectomy between the Focus Harmonic scalpel (Ethicon, Cincinnati, OH) and other hemostatic procedures.

A rare case of primary thyroid amyloidosis

Highlights • The patient complained of dysphagia and respiratory difficulty.• He had not shown any signs of systemic amyloidosis.• The patient underwent total thyroidectomy.• Based on morphological and histochemical features, the diagnosis of “amyloid goiter” was rendered.

Hypocalcemia after thyroidectomy: iPTH levels and iPTH decline are predictive? Retrospective cohort study

Background Hypocalcemia is the most common complication of thyroid surgery. The aim of this study was to determine the early predictive factors of postoperative hypocalcemia and to analyze their efficiency. Methods We performed a retrospective study of 345 consecutive patients who underwent total thyroidectomy at the Endocrine Surgery Department (Policlinico G. Rodolico Hospital of Catania) between January 2011 and November 2013. We measured serum intact parathormone (iPTH) levels preoperatively and 4 h after surgery. The threshold values of hypocalcemia for iPTH levels and iPTH relative decline were obtained by receiver operating curves (ROC) analysis. Results The incidence of hypocalcemia was 32.2% (111 of 345 patients). Our statistical analysis revealed that hypocalcemia rate was strongly correlated with the lower iPTH values and greater iPTH decline (P < 0.001). The threshold enabling prediction of hypocalcemia were 12,5 pg/mL for iPTH and 55,7% for relative iPTH decline. Patients with iPTH <12,5 pg/mL developed hypocalcemia in 58.6% of cases while those with iPTH ≥12,5 pg/dl in 18.8%. Among 175 patients with iPTH relative decline greater than 55,7% hypocalcemia was diagnosed in 91 cases (52%), while other 170 patients with iPTH relative decline less than 55,7% developed hypocalcemia only in 20 cases (11,7%). Conclusions The decreased iPTH levels and increased iPTH relative decline resulted to be an accurate predictive factors of postoperative hypocalcemia. The early administration of Calcium and vitamin D in the high-risk patients should be put on in order to prevent the symptoms of hypocalcemia and to reduce the costs and duration of hospitalization.

Foot soft tissue myopericytoma: Case-report and review

Highlights • Myopericytoma is a rare tumor of deep soft tissues.• Small tumefying at the level of the plantar region, between the 2nd and 3rd toe of the right foot.• Neoformation of 0.6 cm in diameter, well circumscribed, capsulated and with free resection margins.• The immunohistochemical profile was consistent for positive alpha-actin and negative desmine.