Lorenzo Fregoli

Endoscopic bilateral neck exploration versus quick intraoperative parathormone assay (qPTHa) during endoscopic parathyroidectomy: A prospective randomized trial

BackgroundQuick intraoperative parathormone assay (qPTHa) during paratyroidectomy has become a standard procedure for patients with primary hyperparathyroidism (PHPT). This paper aims to compare endoscopic bilateral neck exploration (BE) versus focused parathyroidectomy plus qPTHa during minimally invasive video-assisted parathyroidectomy (QM). The endpoints of the study are the mean operative time and outcome of the surgical procedure (PTH and calcemia normalization at one and six months postoperatively).MethodsForty patients with PHPT, positive to preoperative localization studies (ultrasonography evaluation and 99Tc-MIBI scan) for a single parathyroid adenoma, were randomly allotted into two groups. In the first group (QM), 20 patients (17 women, three men, mean age 57.6 years) underwent focused endoscopic parathyroidectomy (MIVAP tecnicque) plus qPTHa . In the second group (BE) 20 patients (17 women, three men, mean age 59.6 years) underwent endoscopic parathyroidectomy plus bilateral exploration in order to check the integrity of the remaining glands.ResultsThere were no significant differences between groups at baseline. No conversion to cervicotomy was required. No postoperative complications were reported. The mean operative time was 32.0 vs 33.1 min [BE and QM group respectively, p = not significant (ns)]. A second macroscopically enlarged gland was removed in four patients in the BE group. Only one out of four glands was reported to be hyperplastic in the final histology. All patients were discharged on the first postoperative day. Calcemia levels were normalized in all patient of both groups, despite persistently high level of serum PTH in one patient in the QM group.ConclusionsBE can be performed endoscopically, avoiding both the time necessary for qPTHa and its cost, with the same effectiveness, but might in few cases lead to the unjustified removal of parathyroid glands slightly enlarged but not necessarily pathologic.

Modified lateral neck lymphadenectomy: Prospective randomized study comparing harmonic scalpel with clamp-and-tie technique

OBJECTIVE: To compare the use of harmonic scalpel (HS) with clamp-and-tie technique to evaluate their comparative merits in modified lateral lymphadenectomy (LL). STUDY DESIGN: Prospective and randomized. SUBJECTS AND METHODS: Thirty-seven patients were recruited and divided into Group A (conventional; n = 20) and Group B (HS; n = 17). Thyroid volume, neck circumference, operative time, diameter of the tumor and lymph node, drainage volume, pain, and complications were compared. Operation consisted of thyroidectomy and LL. RESULTS: Groups were homogeneous for thyroid volume, diameter of thyroid nodule and lymph node, and neck circumference. Operative time was shorter in Group B than in Group A. The fluid collection in the vacuum between 24 and 48 hours and the increase of neck circumference were lower in Group B. Pain was significantly lower in Group B after 12 hours and decrease was faster in Group B. CONCLUSION: The use of HS during LL is as safe as conventional technique and may allow shorter operative time, lower lymphatic spillage, and faster decrease of pain.

Digital gene expression profiling of a series of cytologically indeterminate thyroid nodules.

Fine‐needle aspiration cytology (FNAC) has been widely accepted as the most crucial step in the preoperative assessment of thyroid nodules. Testing for the expression of specific genes should improve the accuracy of FNAC diagnosis, especially when it is performed in samples with indeterminate cytology.

Postoperative Pain Evaluation After Robotic Transaxillary Thyroidectomy Versus Conventional Thyroidectomy: A Prospective Study.

BACKGROUND Robot-assisted transaxillary thyroidectomy (RATT) is an emerging technique with excellent cosmetic results but is supposedly more invasive and painful than conventional thyroidectomy (CT). This prospective study compared pain after RATT and CT. METHODS Inclusion criteria were a nodule <5 cm and volume <30 mL. Patients received the same analgesia. Pain was evaluated by visual analog scale (VAS) in the recovery room (VASrr), on the first postoperative day at 8:00 a.m. (VAS 8 a.m.) and 8:00 p.m. (VAS 8 p.m.), at 8:00 a.m. on the second postoperative day (VAS 8*a.m.), and after 7 days (VAS 7). Operative time and complications were evaluated. RESULTS From May 2015 to September 2015, 124 patients (all women) underwent thyroidectomy: 62 underwent RATT and 62 underwent CT. Mean age was 39.7 ± 10.2 years in the RATT group and 41.4 ± 12.5 years in the CT group. Groups were comparable for thyroid volume and nodule diameter. Operative time was longer in the RATT group than in the CT group (119.4 ± 25.5 versus 70.3 ± 11.0 minutes). Complications were three transient hypocalcemia in RATT and four in the CT group. No definitive complications occurred. VASrr was lower in the RATT group (1.79 ± 2.06 versus 2.5 ± 1.18; P < .0001). There was no difference between groups for VAS 8 a.m., VAS 8 p.m., and VAS 8*a.m., but VAS 7 was higher in the RATT group (0.85 ± 1.77 versus 0.17 ± 0.52; P < .010). DISCUSSION RATT is as safe and effective as CT. Patients undergoing RATT, surprisingly, experienced less pain in the immediate postoperative period. However, the VAS 7 score was higher in the RATT group, probably because the intact neck is favorable in the early phase of recovery, but the large dissection takes longer for healing.

Streptococcus bovis endocarditis as first clinical expression of an occult colorectal neoplasm

revealed the presence of a sessile polypoid lesion in the rectal ampulla 10 cm from the anal verge, showing on biopsy a cytologic feature of severe dysplasia. Preoperative MRI suggested the extension of the lesion into the submucosal layer of the rectal wall. The patient underwent surgery consisting in a laparoscopic low anterior resection of the rectum. The course was uneventful and the patient was discharged 7 days after surgery. Specimen histologic examination reported a T1N0Mx adenocarcinoma of the rectum. At 24 months follow-up, the patient presented in good health condition with no episodes of recurrent endocarditis.

Conservative Management of a Tracheal Leakage Occurring 40 Days after Robotic Thyroidectomy

Since its introduction, robotic-assisted transaxillary thyroidectomy (RATT) has been proven to be a feasible and safe surgical technique and is gaining wide popularity. Tracheal injury is a rare complication of thyroidectomy and can be repaired immediately, if promptly recognized during the operation. Delayed tracheal leakage after thyroidectomy is described only in sporadic reports. In the largest case series of RATTs, Chung et al reported 2 patients with tracheal injury, both recognized during the operation. To the best of our knowledge, this is the first report of a delayed tracheal leakage after an apparently uneventful RATT.

Quale ruolo per la chirurgia nel carcinoma anaplastico della tiroide

Il carcinoma anaplastico della tiroide (ATC) è il tumore maligno più aggressivo e più letale della tiroide ed è uno dei tumori solidi dalla mortalità più alta nell’uomo. L’ATC ha una progressione tipicamente molto rapida, tanto che si sono osservati casi in cui il volume della massa è raddoppiato in tre giorni. La sopravvivenza mediana dei pazienti trattati varia tra i 3 e 5 mesi, anche se una terapia multimodale aggressiva può incrementare significativamente la sopravvivenza nei casi di tumori inizialmente resecabili mentre, se non si riesce a ottenere un buon controllo locale della massa primitiva, la crescita dell’ATC è inesorabile e provoca rapidamente la morte. A cominciare dai primi anni 2000 si è osservato che un trattamento multimodale combinante chirurgia, radioterapia esterna e chemioterapia può aumentare considerevolmente la sopravvivenza dei pazienti, specialmente quelli stadio IV-A e stadio IV-B. Con questi presupposti, è necessario che, una volta completato il percorso stadiativo, un team multidisciplinare che coinvolge il chirurgo, il radioterapista e l’oncoendocrinologo si riunisca al fine di delineare e pianificare accuratamente il percorso terapeutico [1]. È necessario che i componenti del team abbiano notevole esperienza nei complessi trattamenti che questa patologia richiede; è opportuno, quindi, che in mancanza di tali competenze i pazienti vengano rapidamente riferiti a centri di alta specializzazione, evitando ritardi o procedure chirurgiche inadeguate che potrebbero facilmente compromettere il risultato finale. È importante considerare che scelte chirurgiche azzardate potrebbero richiedere tempi di guarigione prolungati ritardando l’esecuzione degli ulteriori trattamenti e compromettere, quindi, la raggiungibilità dei migliori risultati. Una

Minimally Invasive Video-Assisted Parathyroidectomy; A Detailed Illustration and Highlighting an Additional Potential Advantage Over Other Targeted Parathyroid Surgeries

Targeted parathyroid surgery also referred to as minimally invasive parathyroidectomy has replaced full neck exploration as the preferred surgical approach to primary hyperparathyroidism. This is attributed to the ability to accurately localize enlarged parathyroid glands preoperatively and obtain objective evidence of adequate resection intraoperatively. The two most widely used minimally invasive parathyroid surgeries are the non-endoscopic miniincision parathyroidectomy and the minimally invasive video-assisted parathyroidectomy. The aim of this article is to provide a detailed illustration of the latter supplemented with an animated video of the procedure, and to highlight a potential advantage it offers over other targeted parathyroid procedures; the ability to perform a full neck exploration and/or a concomitant thyroid surgery without the need to convert to a standard cervicotomy.

Inferior vena cava duplication

Dear Editor, Duplication is an uncommon anomaly of the inferior vena cava and it may occur in up to 3 % of general population. Although it remains asymptomatic, inferior vena cava duplication may play a role as a confounding factor in imaging diagnostic tests and also may represent a hazard for bleeding during retroperitoneal surgery. A 72-year-old woman was referred to the department for a pelvic mass involving the wall of the intraperitoneal rectum. Two years before she had undergone open surgery consisting of hysterectomy and bilateral annessectomy for ovarian cancer. Surgery was followed by chemotherapy courses. In the follow-up, a CT scan of the abdomen revealed, in adjunct to the pelvic lesion, a rounded enhanced structure 11 mm in diameter located near the left side of the infrarenal aorta that was reported as an enlarged lymph node (Fig. 1). Clinical features strongly suggested a pelvic recurrence from ovarian cancer involving the rectum with aortic lymph-nodes metastasis and surgery was planned. At laparotomy, the diagnosis of pelvic recurrence of ovarian cancer extended into the rectal wall was confirmed. After mobilization of the descending colon and the sigmoid, it was discovered that the left common iliac vein did not merge with the right common iliac vein to form the inferior vena cava (IVC) (Fig. 2). The left common iliac vein proceeded cephalad representing a left IVC, to flow into the left renal vein (RV). During its course, the left IVC drained the left gonadic vein. The venous trunk formed by the left IVC and the left RV passed anteriorly to the aorta, and drained into the right IVC to form a single suprarenal IVC (Fig. 3). No enlarged node was found around the aorta. The IVC anomaly did not prevent performing the planned procedure of anterior resection of the rectum that was safely accomplished. Surprisingly, the IVC anomaly had not been mentioned in the report of the hystero-annessectomy operation. The IVC is formed between weeks 6 and 10 of gestation. It has been estimated that duplication occurs in 0.2–3.0 % of the general population [1]. The infrarenal portion of the IVC is formed from two embryonic veins, the supracardinal veins. The right supracardinal vein persists and develops as IVC while the left supracardinal vein regresses. Persistence of both supracardinal veins results in duplication of IVC [2]. Failure to form an adequate anastomosis between the embryonic supracardinal veins has been suggested as an alternative theory to explain the IVC anomaly [3]. Typically, the IVC presents bilaterally and the left renal vein ends into the left IVC, which crosses anterior to the aorta to join the right IVC. Depending on the size of the duplicated IVC and the preaortic trunk, a morphologic classification of this anomaly has been proposed [4]. Type I duplication refers to bilateral and symmetrical IVC having the same caliber of the preaortic trunk; in type II, both the right and left IVC are symmetric but their caliber is smaller compared to the caliber of the preaortic trunk, and in type III duplication the caliber of the left IVC is smaller in comparison to the caliber of the right IVC and the preaortic trunk. In the presented case, the caliber measured by CT scan was 11 mm for the left IVC and 19 mm for the right & Massimo Chiarugi massimo.chiarugi@med.unipi.it

La tiroidectomia robotica trans-ascellare: pro e contro

SommarioNegli ultimi due decenni sono state ideate, in alternativa alla tiroidectomia convenzionale, numerose tecniche endoscopiche e/o mininvasive che hanno portato a una riduzione del dolore e a un migliore risultato cosmetico. La Minimally Invasive Video-Assisted Thyroidectomy (MIVAT), ideata a Pisa dal Prof. Miccoli, permette di asportare la tiroide con noduli fino a 3,5 cm con eccellente risultato estetico e migliore decorso postoperatorio, e rappresenta la tecnica mininvasiva più diffusa al mondo per l’asportazione della tiroide. Da pochi anni in Corea è stata ideata una nuova tecnica chirurgica endoscopica condotta attraverso un’incisione ascellare con l’ausilio del sistema robotico Da Vinci: la Tiroidectomia Transascellare Robot-assistita. Questa tecnica chirurgica consente di asportare la tiroide con noduli fino a 5–6 cm senza cicatrici a livello del collo, con eccellenti risultati cosmetici. In due anni nel nostro centro sono stati effettuati oltre 200 interventi di tiroidectomia robotica con risultati estremamente soddisfacenti.