G. Cocchiara

Terminal ligature of inferior thyroid artery branches during total thyroidectomy for multinodular goiter is associated with higher postoperative calcium and PTH levels

PURPOSE To evaluate the impact of truncal versus terminal branch ligature of the inferior thyroid artery (ITA) on postoperative calcium and PTH plasma levels in patients undergoing total thyroidectomy for multinodular goiter. METHODS A prospective randomized study was performed comparing a group of patients that underwent either truncal ligature of the ITA (group 1) or terminal ligature of ITA branches (group 2). RESULTS A series of 126 consecutive patients with non-toxic euthyroid multinodular goiter underwent total thyroidectomy. Truncal ligature of the ITA was performed in 63 patients (group 1) and terminal branch ITA ligature in 63 patients (group 2). Postoperative ionized serum calcium (mmol/L) at 24 hours was significantly lower in group 1 than in group 2 patients (1.22 ± 0.06 vs. 1.25 ± 0.05, P<0.05) and at 48 hours (1.20 ± 0.05 vs. 1.23 ± 0.05, P<0.05). Mean postoperative PTH levels (pg/mL) at 4 hours after thyroidectomy were significantly lower in group 1 than in group 2 patients (22.32 ± 11.64 vs. 25.82 ± 12.87, P=0.044). Mean hospital stay (hours) was higher in group 1 than in group 2 patients (87.47 ± 41.04 vs. 70.34 ± 24.82, P<0.05). CONCLUSION This study shows that terminal ligature of ITA branches during total thyroidectomy for multinodular goiter is associated with higher mean postoperative calcium and PTH levels, and shorter hospital stay. However, no significant difference in terms of permanent hypoparathyroidism was observed between the two groups.

Sphincter-like motion following mechanical dilation of the internal inguinal ring during indirect inguinal hernia procedure.

IntroductionEven today, there is still great speculation as to the underlying pathogenesis of inguinal hernia. As a result, it could be extrapolated that the vast majority of repairs are based upon conjecture. Most current repairs are founded upon the principle of “closing the defect” in the anatomy, either by suturing closed under tension, covering with a mesh or obliterating the defect with a plug. Many variants of each method are refined to achieve better clinical outcomes. Yet few, if any, strive to understand a fundamental question: “What has gone wrong with the normal physiological and anatomical mechanisms that prevent abdominal structures protruding through the abdominal wall?” We consider, in the normal subject, the muscular structures that converge and wrap around the inguinal canal as a highly dynamic structure, which forms a reactive barrier to the augmentation of intra-abdominal pressures. In effect, the structures work together like a “striated sphincter complex.” Through years of surgical experience, we have seen the formation of adhesions and fibrosis in these delicate and key structures, and hypothesised that they may impair its shuttering action, thus, creating a patency of this jammed inguinal ring leading to hernia. Based upon these observations, we have created a hernia repair variant that tries to “unblock” the muscles prior to repair, thus, hopefully restoring a degree of physiologic function.MethodsA retrospective study describes the results of 47 patients operated for indirect inguinal hernia with a standardised procedure consisting of meticulous adhesiolysis of the hernia area and mechanical dilation (divulsion) of the inguinal orifice in order to break stiff fibres within the muscle, allowing viable muscle fibres to contract freely once more. After dilation, a proprietary lamellar-shaped implant was delivered into the canal. Its form and function are designed to eliminate impingement of the cord structures and give a gentle outwards force to induce a reactive contraction of the sphincter-like muscle complex during healing. This gentle contraction offers the possibility to eliminate fixation of the implant.ResultsThe removal of scar tissue, dilation and the introduction of the implant into the internal inguinal ring induced a forceful “gripping” contraction by the sphincter complex in all patients. Even without fixation, it became almost impossible to pull the implant out of the canal. After obliterating the orifice with the lamellar implant, it was clear that there was no dilative compression upon the cord structures.ConclusionThe results of this combined procedure, scar removal, dilation and implant delivery, led to thoughtful suggestions regarding the anatomy and the physiology of the inguinal canal. The procedural adhesiolysis during indirect inguinal hernia repair has always shown the well described concentric muscular arrangement formed by the internal oblique and transversus muscles. This circular-shaped muscular structure is often recognised as a static barrier that, due to weakness and/or together with other causes, fails in its role and allows indirect inguinal hernia protrusion. According to the results of our observations, we consider this concentric muscular complex as a dynamic formation: we will use the term “striated sphincter complex.” Its steady tightening motion after divulsion and the insertion of a lamellar implant is always accompanied by a strong gripping action, which is not seen prior to divulsion. This indicates that it could correspond to a sphincter: the “inguinal sphincter.” The impairment of this sphincter could be the cause of the inguinal canal’s patency and the development of hernia.

Iatrogenic hypoparathyroidism after surgery for retrosternal goitre. A single centre retrospective analysis

AIM The aim of this study is to assess, retrospectively, the incidence of secondary hypoparathyroidism after total thyroidectomy in patients with retrosternal goitre. MATERIAL AND METHODS From January 2009 to September 2015, 622 patients who undergone total thyroidectomy for goitre, were retrospectively observed. The patients were divided into two group: Group A, including 58 patients with retrosternal goitre and Group B, including 562 patients with in situ goitre. Those patients with diseases of the parathyroid glands, assumption of drugs modifying calcium metabolism and who received blood transfusions before or after surgery, were excluded from the study. In both groups, a total thyroidectomy was performed under general anaesthesia. The upper and lower parathyroid glands in both groups were observed in situ as well. All surgical specimens underwent histological examination. RESULTS Transient hypocalcaemia was observed in a higher percentage in group A (15% vs 7%, P <0.05). The mean hospital stay was greater in group A (P <0.05). There were no statistically differences between the two groups in terms of permanent hypocalcaemia and post-operative blood ionized calcium (72hours and 1 month). CONCLUSIONS Many efforts should be made to respect parathyroids during total thyroidectomy in retrosternal goitre; greater attention should be given to inferior parathyroid glands that should be displayed, respecting the vasculature and performing a terminal lower thyroid artery ligation in order to reduce the risk of transient hypocalcaemia and - as a consequence - the average hospital stay.

Mediastinal syndrome from plasmablastic lymphoma in human immunodeficiency virus and human herpes virus 8 negative patient with polycythemia vera: a case report

BackgroundPlasmoblastic lymphoma is a rare and aggressive subtype of diffuse large B cell lymphoma, which occurs usually in the jaw of immunocompromised subjects.Case presentationWe describe the occurrence of plasmoblastic lymphoma in the mediastinum and chest wall skin of an human immunodeficiency virus-negative 63-year-old Caucasian man who had had polycytemia vera 7 years before. At admission, the patient showed a superior vena cava syndrome, with persistent dyspnoea, cough, and distension of the jugular veins. Imaging findings showed a 9.7 × 8 × 5.7 cm mediastinal mass. A chest wall neoformation biopsy and ultrasound-guided fine-needle aspiration biopsy of the mediastinal mass allowed diagnosis of plasmoblastic lymphoma and establishment of an immediate chemotherapeutic regimen, with rapid remission of compression symptoms.ConclusionsPlasmoblastic lymphoma is a very uncommon, difficult to diagnose, and aggressive disease. The presented case represents the first rare mediastinal plasmoblastic lymphoma in a human immunodeficiency virus-/human herpesvirus-8-negative patient. Pathologists should be aware that this tumor does appear in sites other than the oral cavity. Fine-needle aspiration biopsy is a low-cost, repeatable, easy-to-perform technique, with a high diagnostic accuracy and with very low complication and mortality rates. Fine-needle aspiration biopsy could represent the right alternative to surgery in those patients affected by plasmoblastic lymphoma, being rapid and minimally invasive. It allowed establishment of prompt medical treatment with subsequent considerable reduction of the neoplastic tissue and resolution of the mediastinal syndrome.

Informed consent in high-risk renal transplant recipients.

Before performing a clinical, diagnostic, and/or therapeutic action, the doctor is required to provide the patient with a bulk of information defined as informed consent. This expression was used for the first time in 1957 during a court case in California and the two words--informed and consent--are used together to underline the fact that the patient cannot give his or her true consent without first receiving correct information concerning the medical act in question. With regard to the medicolegal aspects governing organ transplants, despite the bulk of detailed work performed by health service workers involved in this surgical field with the aim of preparing adequate informed consent models, this has not yet been accompanied by the necessary legislative development. The informed consent model to be presented to the kidney transplant candidate should include a detailed description of the recipients comorbidity and should aim at reducing the number of medicolegal actions, which have become more and more frequent in the last few years due to the ever increasing number of patients considered as suitable for transplantation. Informed consent, therefore, should not be a mere bureaucratic formality to be obtained casually, but should be carefully stipulated together with the patient by the transplant surgeon. It is, in fact, an indispensable condition for transforming a potentially illegal action, that is, the violation of an individuals psychophysical integrity, into a legal one.