Ming-Lang Shih

Thyroidectomy for Hashimoto's Thyroiditis: Complications and Associated Cancers

BACKGROUND Hashimotos thyroiditis is usually treated medically; however, thyroidectomy is sometimes indicated. Thyroiditis can make thyroid dissection more difficult and possibly increase the risk of surgical complications. The aim of this study was to determine the rate of complications and associated cancer in patients with Hashimotos thyroiditis. METHODS Retrospective series of 474 patients treated surgically at the University of California, San Francisco, between January 1985 and June 2005 with final pathology demonstrating Hashimotos thyroiditis, chronic lymphocytic thyroiditis, or chronic thyroiditis. Parameters evaluated included demographics, surgical indications, and postoperative complications. RESULTS Among the 474 patients, 133 had thyroidectomy because of preoperative diagnosis of thyroid cancers (median age 39 years; 116 females and 17 males), 316 had thyroidectomy because of benign thyroid nodules or goiter (median age 47.5 years; 292 females and 24 males), and 25 had thyroidectomy to relieve local symptoms caused by thyroiditis but did not have thyroid nodules (median age 42 years; 25 females). No death or permanent surgical complications occurred. One hundred and fifty-two patients (32.1%) had transient postoperative hypocalcemia, 2 (0.4%) had transient recurrent nerve palsy, and 4 (0.8%) had a postoperative neck hematoma. Fifty-three percent had thyroid cancer at final histological examination. CONCLUSIONS Thyroidectomy can be performed in patients with Hashimotos thyroiditis with a low risk of permanent surgical complications. Cancer is common in patients who have a thyroidectomy for Hashimotos thyroiditis even when not suspected preoperatively.

Superselective transarterial chemoembolization vs hepatic resection for resectable early-stage hepatocellular carcinoma in patients with Child-Pugh class a liver function

PURPOSE In contrast to hepatic resection (HR) for resectable early-stage HCC, the efficacy of transarterial chemoembolization (TACE) is controversial. This study is designed to compare the long-term outcome of TACE using superselective technique with hepatic resection for the treating resectable early-stage HCC and Child-Pugh class A liver function. METHODS In total, 185 consecutive patients with resectable early-stage HCC and Child-Pugh class A liver function were included: 73 patients received superselective TACE (group I) and 112 patients underwent HR (group II). We evaluated the therapy-related recurrence and long-term outcome and in both groups. The risk factors of recurrence and mortality were assessed by Coxs model. RESULTS The mean survival time of group 1 patient was similar to that of group 2 patient (40.8±19.8 vs 46.7±24.6 months respectively, p=0.91). The 1-, 3-, and 5-year overall survival rates after TACE (group I)and HR (group II) were 91%, 66%, and 52% and 93%, 71%, and 57%, respectively (p=0.239). The 1-, 3-, and 5-year recurrence-free survival rates in groups 1 and 2 were 68%, 28%, and 17% and 78%, 55%, and 35%, respectively (p<0.0001). Serum albumin, tumour size, tumour number and recurrence interval were independent risk factors for mortality. Serum albumin level, tumour size, tumour number, and treatment modality of TACE or HR could predict HCC recurrence. CONCLUSION TACE is an efficient and safe treatment for resectable early-stage HCC with overall survival rates similar to that of HR. Thus, TACE is indicated in selected patients with resectable early-stage HCC.

Preliminary experience with gemcitabine and cisplatin adjuvant chemotherapy after liver transplantation for hepatocellular carcinoma

AIM Liver transplantation (LT) criteria for treatment of hepatocellular carcinoma (HCC) were refined to improved survival and disease-free rates. Adjuvant chemotherapy might eliminate disseminated tumor cells after removal of the primary liver cancer and thereby benefit LT recipients. Our purpose was to evaluate the effect of an adjuvant chemotherapy (gemcitabine and cisplatin) on outcome of patients treated with LT for HCC. METHODS Of the 99 patients who underwent liver transplantation from October 2001 through February 2006, there were 58 with HCC. Nine patients with extra-hepatic metastasis and four who died for noncancer-related reasons were excluded. Three groups (total n=45) were compared: Group A (n=15) met the Milan criteria and did not receive study chemotherapy, Group B (n=13) did not fit the Milan criteria and did not receive chemotherapy, and Group C (n=17) did not fit the Milan criteria and received gemcitabine and cisplatin. RESULTS The chemotherapy regimen was well tolerated. Leukopenia, the need for granulocyte colony-stimulating factor treatment, or both occurred in four patients. The disease-specific survival rates were better for groups A and C than for group B (p=0.02) and the disease-free survival rates were also better for groups A and C than for group B (p=0.01). CONCLUSIONS Systemic gemcitabine and cisplatin may improve disease-specific and disease-free survival in HCC patients who do not meet the Milan criteria after LT.

Hürthle cell carcinoma of the thyroid with contralateral malignant pleural effusion.

Background: Thyroid cancers with pulmonary metastases have been well documented. However, malignant pleural effusion has rarely been reported. Case Report: We present a 77-year-old patient who had Hürthle cell carcinoma of the thyroid with contralateral malignant pleural effusion. The diagnosis was based on consistency in the histopathological and immunohistochemical features of pleural fluid cytology and the final pathology of the thyroid tumor. Results: The patient was treated with total thyroidectomy and postoperative radioactive-iodine ablation. Unfortunately, he died for recurrent pleural effusion and pulmonary complication 6 months later. Conclusion: Identifying the origin of malignant pleural effusion is important to provide treatment guidance. In this report, we review the literature on diagnosis and treatment of thyroid cancer with malignant pleural effusion.

Hyalinizing trabecular tumor of thyroid: Does frozen section prevent unnecessarily aggressive operation? Six new cases and a literature review

Background: Fine‐needle aspiration cytology (FNAC) is very accurate in detecting papillary thyroid carcinomas (PTCs). According to the Bethesda system for reporting thyroid cytopathology, the risk for malignancy is 97–99% when FNAC is used to diagnose PTC; the malignancy risk is 60–75% when FNAC results in suspected PTCs. The presence of hyalinizing trabecular tumor (HTT) of the thyroid can cause misdiagnosis because its cytological features mimic PTCs. However, the use of frozen section analysis can assist in the recognition of unique architecture features of HTT, and thus may help prevent the undertaking of an unnecessarily aggressive operation. Methods: We retrospectively reviewed all patients diagnosed with HTT by permanent histopathology from February 2009 to October 2013. After acquired agreement of the patients, we analyzed all data and reviewed another nine cases of HTT reported in the English‐language medical literature to examine the efficacy of frozen section. Results: There were six patients included in our research (5 women and 1 man), with an average age of 48.8 years. Using frozen section, four patients were diagnosed with HTT and two patients were misinterpreted as PTC. Consequently, four patients had lobectomy and two patients had total thyroidectomy, with no surgical complications. Of the nine cases of HTT reviewed from the English literature, the use of frozen section showed three HTT cases, three PTC cases, two medullary thyroid carcinoma cases, and one deferral case. Overall, the use of frozen section as a diagnostic method prevented additional surgical resection in eight patients (53%). Conclusion: Frozen section can sometimes but not always be used to diagnose HTT. When HTT is diagnosed by its trabecular pattern through the use of frozen section, it may prevent total thyroidectomy.

Anterior approach for a symptomatic giant hepatic haemangioma (>30 centimetre).

Haemangiomas are the most common benign liver tumour. They occur in all age groups but predominantly in women. Most haemangiomas are small and do not cause symptoms. They often do not need to be removed or treated. However, they may be large and produce a mass effect. Those with a diameter of more than 4 cm are called giant haemangiomas.1 Some of these patients with giant haemangiomas present with hepatomegaly, cardiac failure from arteriovenous shunting within the liver and coagulopathy. Secondary portal hypertension, spontaneous rupture and traumatic rupture were unusual. Although, they had been reported before.2–4Therapeutic options include steroids, hepatic artery ligation, hepatic artery embolization, radiation therapy, a-interferon, surgical resection and liver transplantation. Indications for surgical resection are usually determined by the presence of symptoms, a high risk of rupture and possible malignancy. Herein, we described a middle-age woman with a giant haemangioma (>30 cm) of the right hepatic lobe. It nearly occupied the whole right liver and increased the incidence of rupture. It is very difficult to resect the whole tumour using the conventional approach. Alternatively, the anterior approach could be adopted for this patient. We had also successfully carried out the surgery of the extended right lobectomy for the symptomatic giant haemangioma using the anterior approach. The procedure and advantage of this technique are discussed.

Persistent renal hyperparathyroidism caused by intrathyroidal parathyroid glands

Renal hyperparathyroidism usually occurs in chronic renal failure patients on regular dialysis. However, renal hyperparathyroidism resulting from intrathyroidal parathyroid glands is an uncommon condition. We herein present the case of a 35-year-old woman who has been on hemodialysis for 20 years. She had renal hyperparathyroidism with generalized weakness and bone pain for 2 years. The patient initially underwent parathyroidectomy at a local institution, during which two large parathyroid glands were resected from the right side (no parathyroid glands were found on the left side); however, the surgical procedure was unsuccessful, and the patient had persistent renal hyperparathyroidism after the operation. She was then transferred to our hospital and ectopic intrathyroidal parathyroid glands were localized by neck ultrasonography and technetium-99m sestamibi scans with single-photon emission computed tomography imaging preoperatively. A left thyroid lobectomy was performed and two intrathyroidal parathyroid glands were found. The patient recovered uneventfully and her symptoms resolved. Therefore, clinicians should be aware of the possibility of renal hyperparathyroidism resulting from intrathyroidal parathyroid glands in cases where the renal hyperparathyroidism persists after parathyroidectomy.

A paraduodenal hernia (Treitz's hernia) causing acute bowel obstruction

Paraduodenal hernias, also called Treitz’s hernia, are unusual causes of intestinal obstruction and account for 0.9% of all intestinal obstructions (1). Paraduodenal hernias constitute half of all internal abdominal hernias and occur when the small bowel herniates into the paraduodenal fossa with manifestation of intestinal obstruction (2). Specific clinical signs are often absent, leading to the frequent delay of correct diagnosis, with bowel necrosis resulting in up to 20% of patients (3). Herein, we present our case to increase the awareness of Treitz’s hernia and suggest the early CT scan intervention may be helpful to make the preoperative diagnosis of paraduodenal hernia.

Application of marionette technique for 3-port laparoscopic liver resection.

Background: Laparoscopic liver resection has become a feasible and safe procedure for liver tumor, but it requires experienced surgeons in the case of hepatobiliary and laparoscopic surgeries. More minimally invasive laparoscopic techniques of liver surgery are developed. We here report our experience of using a marionette technique for 3-port laparoscopic liver resection. Methods: Between June 2009 and December 2010, 7 patients underwent 3-port laparoscopic liver resection with the use of marionette technique. Five patients had hepatocellular carcinoma. Two patients with prior abdominal operations for colon cancer had colorectal liver metastasis. The procedure of marionette technique was performed as below: after insertion of the 3 trocars, a 2-0 nylon straight needle line was inserted through the abdominal wall, and using the needle holder, it was allowed to traverse the liver edge twice. Then, the straight needle line was forced out of the abdominal wall and clamped using mosquito for traction. Another straight needle line was similarly created at the opposite side of the liver edge. Results: None of the patients had to be converted to open surgery. The mean operative time was 96.7±63.2 minutes (range, 45 to 195 min), and the mean volume of blood loss was 45.6±27.9 mL (range, 30 to 100 mL). The mean pain score recorded on the visual analog scale was 2.7±0.8. The mean hospital stay was 5.6±1.7 days (range, 4 to 9 d). Currently, all the 7 patients are alive, and the tumors have not recurred (Supplementary Digital Content video 1 http://links.lww.com/SLE/A67). Conclusions: Our experience demonstrated that the simple marionette technique procedure could help surgeons ease laparoscopic liver resection and achieve better postoperative results.

Experience with Reversed L-Shaped Incision for Right Hemicolectomy Combined with Liver Resection

BackgroundVarious types of incisions have been applied in simultaneous resections of colorectal cancer and synchronous liver metastases. We describe our experience with the reversed L-shaped incision for simultaneous right hemicolectomy and liver resection.MethodsWe applied the reversed L-shaped incision in nine patients who underwent simultaneous right hemicolectomy and right liver resection or left hepatectomy. A reversed L-shaped incision of the abdomen was consisted of midline and transverse incisions with the junction of the umbilicus. The operative field was kept open using Kent retractors. First, right colon mobilization was performed easily and right hemicolectomy was performed. Subsequently, liver mobilization with identification of hepatic vessels was achieved and right liver resection or left hepatectomy was performed.ResultsThe reversed L-shaped incision successfully provided a good and rapid exposure in nine patients. There were no complications, such as wound infection, lung atelectasis/pneumonia, or incisional hernia, in patients with the reversed L-shaped incision.ConclusionsOur preliminary experience demonstrated that the reversed L-shaped incision might be a good choice in a subset of patients with simultaneous right hemicolectomy and right liver resection or left hepatectomy. However, a large, prospective, controlled study comparing different incision types in the same procedure with variables, such as operating time, postoperative pain scores, patient’s satisfaction, and postoperative complication, is needed to support the benefit of the reversed L-shaped incision.