Giancarlo Candela

Bilateral benign multinodular goiter: What is the adequate surgical therapy? A review of literature

BACKGROUND Benign multinodular goiter (BMNG) is the most common endocrine disease requiring surgery. During the last few years a more aggressive approach has become the trend for bilateral BMNG treatment. METHOD Randomized clinical trials of any size that compared bilateral subtotal resection, Dunhill procedure and total thyroidectomy for benign multinodular goiter, published between January 2000 and the end of March 2015, were reviewed. DISCUSSION Total thyroidectomy can be considered the most reliable approach in preventing recurrence. The Dunhill procedure is related to a higher rate of recurrence, but rarely recurrences after Dunhill procedure lead to reoperation. Total thyroidectomy avoid completion thyroidectomy for incidental carcinoma and its related risks. Recurrent laryngeal nerve (RLN) palsy becomes less common as surgical experience increases. Transient and permanent hypoparathyroidism is strictly related to the extent of neck dissection. In the risk-cost analysis we must consider the type of patient candidated to surgery and the impact of the surgical protocol we apply. When thyroid surgery is taken in consideration, specific complication rates of different procedures in each hospital must be analyzed accordingly to patient-specific risk factors and local expertise. CONCLUSION The Dunhill procedure seems to be a good compromise between radicality and prevention of complications, avoiding reoperation for recurrence or completion thyroidectomy for incidental thyroid carcinoma. More follow-up studies and prospective studies are necessary to better evaluate, definitively, whether to prefer total thyroidectomy or Dunhill procedure in case of benign goiter surgery.

Leiomyosarcoma of the thyroid gland: A case report and literature review

Primary smooth muscle tumors of the thyroid gland are extremely rare neoplasms. Due to their rarity, clinical case studies concerning management are lacking. According to a literature review, only 19 cases of primary thyroid leiomyosarcomas (TLs) have been reported. In the majority of patients, the prognosis is poor since adjuvant radiochemotherapy is ineffective on local recurrence and on long-term survival. In this study, we report the case of a 77-year-old male affected by a rapidly enlarging mass of the anterior neck, associated with bilateral lung metastases, and increasing dysphagia and dyspnea during the previous 6 months. A Tir4 neoplasm fine needle cytological diagnosis of the right thyroid lobe was reached and the patient underwent total thyroidectomy (TT). Definitive histological examination identified a TL. The patient succumbed 40 days later due to respiratory distress. A literature review was performed and TL differential diagnoses, management, including alternative treatment strategies, and adjuvant therapy were analyzed. TL is an aggressive rare mesenchymal malignant tumor. Although an improved multimodal approach is often necessary, TT and neck dissection represent the treatment of choice and are often the only possible therapy. Adjuvant radiochemotherapy appears to be ineffective and a high mortality rate is observed. TL remains a fatal tumor, and innovative and more effective therapeutic strategies to improve management and outcomes are required.

Iatrogenic Bile Duct Injuries Following Laparoscopic Cholecystectomy: Myth or Reality? A Recent Literature Review from 2006 to 2011

At the end of 1980’s, the introduction of mininvasive surgery in clinical practice represented a significant achievement of science and technology research, and laparoscopic cholecystectomy (LC) is nowadays considered a gold standard in the treatment of symptomatic cholelithiasis, according to well known and acknowledged advantages. Although experience is essential to avoiding rates of morbidity in any surgical procedure, in LC the effect of the learning curve does not seem to be the most important factor in minimizing the possibility of iatrogenic bile duct injuries (IBDI) because most of them are related to anatomic misdiagnoses and lapses from basic principles of biliary surgery. IBDI are still a severe complication of biliary surgery, characterized by high morbidity and in some cases significant mortality, often due to the onset of septic complications. They cause a costs rise, related to diagnostic and therapeutic procedures, and they are often associated with distressing litigations, frustrating for surgeons. Factors that may be related to IBDI include certain pitfalls believed to be inherent in the laparoscopic approach: the two-dimensional view and the absence of tactile sensation. However, an analysis of literature until 2005 shows that the “mini-invasive” approach is related to a higher incidence of iatrogenic bile duct injuries (IBDI), both of the main and accessory bile ducts. In 2002 Nuzzo (Nuzzo, 2002), by the means of an Italian survey, proved a three times higher incidence of IBDI than in open cholecystectomy (OC), showing about 300 bile duct injuries out of every 100000 cholecystectomies per year in Italy, pointing out in that country a considerable mortality, in most of cases related to sepsis, with a significant rise of morbidity and healthcare costs ensuing from hospital stay, instrumental investigations, and medium and long-term clinical follow-up. Moreover, IBDI are reported to have late severe aftermath, causing the surgeon frustration and expensive litigation. After accomplishing a learning curve for mini-invasive approach, led by an experienced surgeon, the most significant etiopathogenetic factors of IBDI are the misidentification of the main biliary tree (BT) and wrong manoeuvres to manage bleedings. Treatment of IBDI requires a multidisciplinary approach – namely endoscopy, interventional radiology and surgery – in referral centres,