Marco Puccini

Extent of Surgery in Thyroglossal Duct Carcinoma: Reflections on a Series of Eighteen Cases

The occurrence of carcinoma of the thyroglossal duct remnant (TDRCa) is reported to be less than 1%. We retrospectively analyzed 18 cases (14 females, 4 males; mean age, 38.17 years) of TDRCa who underwent surgery in our department, to evaluate the correct workup for diagnosis and treatment. Nine patients underwent a total thyroidectomy and a Sistrunk procedure (SP) whereas 8 underwent a completion total thyroidectomy after a postoperative diagnosis of TDRCa. One patient was diagnosed with TDRCa several years after total thyroidectomy for goiter. Postoperatively all patients were given radioiodide and levothyroxine therapy. Mean follow-up was 85 months. No patient died of tumor-related disease. Thyroglossal duct neoplasms were represented by papillary carcinoma in 16 cases; thyroid histology demonstrated papillary carcinoma in 6 cases (33.3%). Three patients demonstrated single regional node metastasis and only one of them demonstrated the presence of malignant thyroid disease. When clinical diagnosis of thyroglossal duct cyst is made, the workup should be completed by ultrasound (US) scan and fine-needle aspiration cytology (FNAC) in order to plan the correct surgery for a possible TDRCa. Total thyroidectomy should always be considered with SP to permit the correct treatment and follow-up in those patients. Long-term survival of patients with cTDRCa is excellent.

One-day thyroid surgery:retrospective analysis of safety and patient satisfaction on a consecutive series of 1,571 cases over a three-year period

Short-stay thyroid surgery (<24 h hospital stay) is becoming increasingly popular but some potentially lethal complications are considered strong arguments against shortening hospitalization after thyroidectomy. The authors reviewed the data of 1,571 patients undergoing one-day thyroid surgery over a 3-year period to determine safety and patient satisfaction. There were 1,244 females and 327 males. Mean age was 43 years. Patient satisfaction was evaluated by a questionnaire given on discharge, while post-discharge surgical recovery was analyzed by the PSR scale. Total thyroidectomy was performed in 1,119 patients (71%), hemithyroidectomy in 450 (29%), isthmusectomy in 2. Morbidity occurred in 152 patients (9.6%). Surgical complications were transient hypocalcemia in 112 cases and permanent hypoparathyroidism in 3; monolateral transient nerve palsy occurred in 10 cases, bilateral in 3; definitive monolateral recurrent palsy in 4 cases. Bleeding requiring re-intervention occurred in 10 cases, wound complications in 5 cases, and intraoperative tracheal lesion in 1 patient. Among complicated patients, 129 (84.8%) were treated after discharge as outpatients. Conversion to inpatient treatment occurred in 28 patients (1.7%) (25 for surgical reasons). Four patients (0.2%) required hospital readmission. Patients were very satisfied in 84.2%, satisfied in 9.5%, poorly satisfied in 4.3%, completely unsatisfied in 2%. Postoperative recovery mean score by PSR scale resulted in 85.14% (0–100%). Our results confirm that the one-day surgery model is safe, effective, and highly agreeable in patients undergoing surgery for thyroid disease.

Adrenalectomy for solid tumor metastases: Results of a multicenter European study

BACKGROUND We assessed the results of adrenalectomy for solid tumor metastases in 317 patients recruited from 30 European centers. METHODS Patients with histologically proven adrenal metastatic disease and undergoing complete removal(s) of the affected gland(s) were eligible. RESULTS Non-small cell lung cancer (NSCLC) was the most frequent tumor type followed by colorectal and renal cell carcinoma. Adrenal metastases were synchronous (≤6 months) in 73 (23%) patients and isolated in 213 (67%). The median disease-free interval was 18.5 months. Laparoscopic resection was used in 46% of patients. Surgery was limited to the adrenal gland in 73% of patients and R0 resection was achieved in 86% of cases. The median overall survival was 29 months (95% confidence interval, 24.69-33.30). The survival rates at 1, 2, 3, and 5 years were 80%, 61%, 42%, and 35%, respectively. Patients with renal cancer showed a median survival of 84 months, patients with NSCLC 26 months, and patients with colorectal cancer 29 months (P = .017). Differences in survival between metachronous and synchronous lesions were also significant (30 vs. 23 months; P = .038). CONCLUSION Surgical removal of adrenal metastasis is associated with long-term survival in selected patients.

Conn Syndrome: 14 Years' Experience from Two European Centres

OBJECTIVE To evaluate the long term results of adrenalectomy for primary hyperaldosteronism. DESIGN Multicentre retrospective cohort study. SETTING Two university hospitals, UK and Italy. SUBJECTS 55 patients who presented with a mean (SD) preoperative blood pressure of 181/110 (21/10) mmHg and a mean (SD) potassium of 2.8 (0.4) mmol/L (range 1.6-4) during the period October 1978 to October 1992. INTERVENTIONS Unilateral adrenalectomy, usually by the extraperitoneal approach. Adrenalectomy was total in all but nine cases. MAIN OUTCOME MEASURES Accuracy of preoperative investigations for the diagnosis and localisation of the lesions, histology, morbidity and mortality, long term outcome (mean follow up 8.8 years). RESULTS Computed tomography gave a diagnostic accuracy for unilateral lesions of 88%, the postural stimulation test 80%, norcholesterol scintigraphy 84%, and ultrasonography 57%. Histological examination showed carcinoma (n = 1), diffuse hyperplasia (n = 2), nodular hyperplasia (n = 11) including 5 with macronodular hyperplasia, double adenoma (n = 1) and single adenoma (n = 40). No patient died, and 10 developed minor complications. At the latest follow-up 44/52 patients with benign unilateral lesions (85%) have been cured by adrenalectomy. CONCLUSIONS Our results confirm the safety of the extraperitoneal approach, and suggest that the improvement in the accuracy of preoperative investigations has allowed a careful selection of patients with the consequent amelioration of the long term outcome of surgery for Conns syndrome. As laparoscopic adrenalectomy is currently advocated as the operation of choice for surgically-remediable mineralocorticoid excess, its long term results will have to be comparable with these standards.

Minor-but-complex liver resection: An alternative to major resections for colorectal liver metastases involving the hepato-caval confluence

Abstract Major hepatectomy (MH) is often considered the only possible approach for colorectal liver metastasis (CRLM) at the hepato-caval confluence (CC), but it is associated with high morbidity and mortality. With the aim to reduce MH, we developed the “minor-but-complex” (MbC) technique, which consists in the resection of less than 3 adjacent liver segments with exposure of the CC and preservation of hepatic outflow until spontaneous maturation of peripheral intrahepatic shunts between main hepatic veins. We have evaluated applicability and outcome of MbC resections for the treatment of CRLM involving the CC. In this retrospective cohort study, all consecutive liver resections (LR) performed for CRLM located in segments 1, 7, 8, or 4a were classified as MINOR – removal of <3 adjacent segments; MbC – removal of <3 adjacent segments with CC exposure; and MH – removal of ≥3 adjacent segments. The rate of avoided MH was obtained by the difference between the rate of potentially MH (PMH) plus potentially inoperable cases and the rate of the MH performed. Taking into account that postoperative mortality is mainly related to the amount of resected liver, MbC was compared with minor resections for safety, complexity, and outcome. Of the 59 LR analyzed, 29 (49.1%) were deemed PMH and 4 (6.8%) potentially inoperable. Eventually, MH was performed only in 8 (13.5%) with a decrease rate of 42.4%. Minor LR was performed in 23 (39.0%) and MbC LR in 28 (47.5%) patients. Among MbC cases, 32.1% had previous liver treatments, 39.3% required vascular reconstruction (no reconstructed vessel thrombosis occurred before maturation of peripheral intrahepatic shunts between main hepatic veins), and 7.1% had grade IIIb–IV complications, their median hospital stay was 9 days and 90-day mortality was 0%. After a median follow-up of 22.2 months, oncological results were comparable with those of minor resections. MbC hepatectomy lowers the need for MH and allows for the resection of potentially inoperable patients without negative impact on safety and survival.

Neck lesions mimicking thyroid pathology

IntroductionNodular lesions within the neck may origin from several structures. A misdiagnosed origin may expose the surgeon to inappropriate procedures. These lesions are paradoxically frequent in high specialised centre for endocrine surgery.Patients and methodsIn the year 2006, three patients were first admitted to our department with a diagnosis of thyroid nodule (1) or lymphatic metastases of thyroid carcinoma (2). The first patient had ultrasound (US) and Tc-99-m scan orienting for thyroid nodule. The two other patients, presented with lateral neck lesion in ipsilateral sincronous and previous diagnosis of papillary thyroid carcinoma, respectively, with US and computed tomography scan confirmed lesion but with a FNA cytology negative for tumoural cells.ResultsAll three patients underwent surgical exploration. In the first two cases, a whitish tender nodule (4 and 4.5cm), cleavable from surrounding structures, was removed with final histology of Schwannoma and Paraganglioma, respectively. Both patients experienced Bernard Horner Syndrome. In the last patients, a firm grey nodule of 5cm strictly adherent to muscular planes was removed with diagnosis of Castleman’s Disease.ConclusionsNodular neck lesions mimicking a thyroid pathology (thyroid nodules or metastatic lymph nodes) are rare but can represent a tough challenge for surgeons who might fall into incorrect surgical approaches, resulting in high morbidity. Pre-operative work-up would help the surgeon to obtain the correct diagnosis, thus, to follow the better surgical approach. Nevertheless, a careful approach would be used for that neurogenic tumour amenable of resection without jeopardising nervous structures.

Unexpected histological findings of lesions diagnosed in the adrenal region in a series of 420 patients submitted to adrenal surgery. Review of our experience

Introduction: The incidence of adrenal incidentalomas is reported to be up to 30% in the current literature; nevertheless, in some patients undergoing surgery, a final diagnosis of non-adrenal origin of the mass is performed. In this paper we present our experience of 13 patients with unexpected histological findings of lesions diagnosed in the adrenal region. Patients and methods: From June 1986 to December 2004, 420 patients underwent adrenalectomy in our Department. Since the introduction of videolaparoscopic technique in 1993, 228 adrenalectomies have been performed videolaparoscopically. Pre-operative diagnosis was: incidentaloma (34.0% of patients), Conn’s adenoma (29.0%), Cushing’s adenoma (13.9%), pheochromocytoma (8.8%), suspicious metastasis (7.3%), Cushing’s disease (6.0%), other (1.0%). Results: Final histology revealed an unexpected diagnosis of non-adrenal origin of the mass in 13 patients (3.1%). Histology demonstrated a benign neurogenic tumor in 10 patients. In the other 3 patients diagnosis was respectively of lymphnode, hemangioma and a gastric metastasis of melanoma. Five patients out of 7 had a successful laparoscopic resection of the lesion. Mean operative time in this group was higher compared to laparoscopic resection for adrenal lesion (95.3 min vs 73.2 min). Conclusion: A small percentage of our patients (3.1%) demonstrated unexpected findings of the lesion pre-operatively misinterpreted as an adrenal mass. Despite a complete pre-operative assessment, adrenal lesions might reveal a different origin, increasing the surgical challenge as well as the morbidity for the patient.

Effects of Fibrin Sealant in Thyroid Surgery

During the last 6 months of 1991 we operated on 250 patients for thyroid diseases; among them, 116 were studied to evaluate the effects of a fibrin sealant (Tissucol, Immuno) in thyroid surgery. We analyzed our data with regard to the technique performed (total lobectomy, subtotal thyroidectomy, or total thyroidectomy), without considering basic illness. Patients treated with fibrin glue (n=51) formed group 1. Untreated patients (n=65) formed group 2.