Hideko Kurihara

Are There Significant Benefits of Minimally Invasive Endoscopic Thyroidectomy

Minimally invasive surgery using endoscopic vision is widely employed for the treatment of thyroid diseases. We have performed endoscopic thyroidectomy by the axillary approach (axillary approach) and video-assisted thyroidectomy via a 3 cm cervical incision (video-assisted approach). In this study, we evaluated the efficacy of these two procedures. Each procedure was performed in 20 consecutive consenting patients. The degree of invasiveness after surgery was compared using postoperative results. The amount of pain and satisfaction with surgery was evaluated by grade (1–5) using a patient questionnaire. All thyroidectomies were completed successfully. No recurrent laryngeal nerve palsies occurred. Operating time for the video-assisted approach was significantly shorter than that for the axillary approach (p < 0.01). The amount of pain for the axillary approach on 1, 3, and 5 days after operation, respectively, was graded 3.2 ± 0.7, 2.1 ± 0.6, and 1.6 ± 0.7 compared to 2.7 ± 1.1, 1.7 ± 0.7, and 1.1 ± 0.2 for the video-assisted approach. The postoperative course was significantly less painful in patients undergoing the video-assisted approach on postoperative days 3 and 5 (p < 0.01). The degrees of satisfaction for the axillary approach and the video-assisted procedure were 1.2 ± 0.4 and 2.4 ± 1.0, respectively (p < 0.01). The video-assisted approach is less “invasive” than the axillary approach, but the axillary approach may be indicated for patients who are anxious about the visible cosmetic results.

Section 3. Adrenal: Laparoscopic partial adrenalectomy

Since corticosteroids are indispensable hormones, partial or cortical-sparing adrenalectomies may be adopted for the surgical treatment of adrenal diseases. In this article, we describe the technique and results of these procedures. Laparoscopic partial or cortical-sparing adrenalectomy has been performed in 10 patients. Seven cases had an aldosterone-producing adenoma (APA) and three had a pheochromocytoma. Three cases with an APA and a case with a pheochromocytoma had tumors located far from the adrenal central vein, and the vein could be preserved. Four cases with an APA and two with a pheochromocytoma had tumors located close to the adrenal central vein, and it was necessary to section the central vein to resect them. All endoscopic procedures were performed successfully. There were no postoperative complications. At follow-up, adrenal 131I-adosterol scintigrams showed the preservation of remnant adrenal function in all patients. Laparoscopic partial or cortical-sparing adrenal surgery was safely performed, and adrenal function was preserved irrespective of whether the adrenal central vein could be preserved or not. We consider this to be a useful operative technique for selected cases.

Section 1. Parathyroid: Direct mini-incision parathyroidectomy

Abstract We describe our technique for performing a mini-incision parathyroidectomy in patients with hyperparathyroidism. Since our procedure differs from conventional parathyroidectomy in requiring a 2- or 3-cm skin incision and no raising of skin flap, this technique resulted in a good cosmetic status and less invasiveness. Hypesthesia or paresthesia in the neck and discomfort while swallowing related to a large skin incision and raising of skin flap are minimized. Although the cosmetic results of endoscopic techniques are better than those of our procedures, endoscopic instruments remain traumatic, can easily inflict iatrogenic lesions to parathyroid adenomas and enhance the risk of tumor cell exfoliation, especially if the parathyroid adenoma is manipulated by the instruments. Our surgical procedure can be less technically demanding and time-consuming. Although the number of patients whom we have treated in this manner is still small, we believe that our new procedure constitutes a useful surgical treatment for hyperparathyroidism.

Section 2. Thyroid: Direct mini-incision thyroidectomy

We recently developed a new surgical technique for carrying out thyroidectomy, to minimize surgical invasiveness and improve the cosmetic result. Our procedure differs from conventional thyroidectomy in requiring a 3-cm skin incision and no raising of the skin flap. Since this technique decreased tissue trauma by obviating unnecessary neck exploration, hypesthesia or paresthesia in the neck and discomfort while swallowing, related to a large skin incision and raising of the skin flap, are minimized. Since thyroidectomy is performed after delivering the thyroid gland through the small skin incision, sufficient exposure for dissection of the pretracheal and paratracheal space can be obtained. Therefore, injuring the recurrent laryngeal nerve and the parathyroid gland can be avoided. Although the number of patients that we have treated in this manner is still small, we believe that our new procedure constitutes a useful surgical treatment for patients with thyroid disease.

Vascular reconstruction for thyroid carcinoma with carotid artery involvement

Well-differentiated thyroid carcinoma accounts for more than 80% of all thyroid malignancies. These tumors have a distinct propensity for multifocal involvement and regional lymph node metastasis but are usually associated with an excellent overall prognosis. Nevertheless, 10–15% of these tumors can display aggressive behavior, hallmarked by local invasion, distant metastasis, treatment resistance and increased mortality. The most important prognostic factor from a surgical standpoint is extra thyroidal extension. The common structures involved in the central compartment are strap muscles, recurrent laryngeal nerve, trachea, laryngeal framework, esophagus and pharyngeal constrictors. Structures in the lateral neck compartment that can be involved include the carotid artery, internal jugular vein, vagus nerve, spinal accessory nerve and phrenic nerve. Among them, tumors are considered inoperable if they involve the carotid artery. En bloc resection of these tumors with the carotid artery may be undertaken, but there is a risk of postoperative cerebral ischemia. However, recent progress in vascular techniques has rendered carotid reconstruction possible. In this paper, we report two types of surgical techniques that allow carotid resection and reconstruction with locally advanced thyroid papillary carcinomas to be safely and easily performed.

Esophageal skip metastasis from an adenocarcinoma of the gastric cardia

Although diffuse‐type gastric carcinomas sometimes spread within the esophageal mucosa, a distant skip metastasis from a gastric carcinoma to the esophagus wall has rarely been reported. We herein report the case of a patient found to have a carcinoma of the gastric cardia with a skip metastasis to the esophagus, approximately 10 cm distant from the esophagogastric junction. A 53‐year‐old man was admitted to our department suffering from a sudden hematemesis. An upper gastrointestinal endoscopic study revealed an infiltrative ulcerating tumor of the gastric cardia and a small, reddish, elevated submucosal tumor on the middle third of the esophagus, apart from the tumor on the cardia. A histological study of the biopsy specimens from both tumors showed poorly differentiated adenocarcinomas. The patient underwent total thoracic esophagectomy and proximal gastrectomy combined with a splenectomy through a cervicoabdominal approach. The resected specimen contained a tumor of the cardia, 7.4 × 5.1 cm in area, that had infiltrated the submucosal layers of the lower esophagus up to 2.0 cm from the esophagogastric junction. The skip metastases were located 0.5, 4 and 7.2 cm from the oral side of the main tumor.