Paola Sartori

Thyroidectomy and parathyroid hormone: tracing hypocalcemia-prone patients

BACKGROUND The aim of this prospective study was to identify patients at high risk of developing hypocalcemia after thyroidectomy on the basis of the parathyroid hormone (PTH) level on the first postoperative day. METHODS We included 160 patients undergoing total thyroidectomy in a period of 6 months by the same surgical team in this study. In all patients the PTH level was measured before surgery on the day of surgery (PTH1), and on the first postoperative day (PTH2), whereas serum calcium level was measured daily until discharge. Patients were classified as hypocalcemic if they had a serum calcium level less than the normal range on the first postoperative day, independently of symptoms of hypocalcemia. RESULTS At an average follow-up period of 5.9 months (range, 4-9 mo), 66 patients were considered hypocalcemic, 57 patients (35.6%) had a transient hypocalcemia, and 9 patients (5.6%) required calcium-vitamin D supplementation for persistent hypocalcemia. The mean PTH1 value was 54.4 +/- 17.2 pg/mL (median, 53.85 pg/mL), the mean PTH2 value was 22.8 +/- 13.3 pg/mL (median, 21 pg/mL). The mean PTH decrease in value was 51.54% +/- 27.4% (median, 51.83%; range, 4%-94%) and 43.7% of patients presented a PTH decrease of more than 50%. The presence of a postoperative hypocalcemia was statistical correlated both with the PTH2 level and with the PTH drop percent value (P < .001 and P = .002, respectively). With the use of the receiver operating characteristic curve, the maximum sum of the sensitivity and specificity for the correlation of PTH2 levels and hypocalcemia occurred at a PTH2 level of 9.6 pg/mL. CONCLUSIONS The PTH measurement on the first postoperative day may be considered a useful method to predict postthyroidectomy hypocalcemia, thus avoiding prolonged hospitalization. Moreover, PTH dosage at first postoperative day is more reliable and less expensive than intraoperative quick PTH assay.

Carcinoma of the neck showing thymic-like elements (CASTLE): report of a case and review of the literature.

Carcinoma showing thymic-like elements (CASTLE) is a rare tumor affecting thyroid and neck soft tissues, which has to be distinguished from squamous cell and anaplastic thyroid carcinoma, because it has a better prognosis. We report a new case of CASTLE which occurred in a patient submitted to total thyroidectomy with central neck dissection. The tumor stained positively for CD5, which seems to be the most useful marker in the differential diagnosis. By the analysis of the 18 cases reported in literature, total thyroidectomy with selective modified neck dissection should be the treatment of choice and radiotherapy should be considered for patients with positive nodal status.

Colorectal cancer with neuroendocrine differentiation in a child

Colorectal cancer is extremely rare in children and presents with a poor prognosis because of the delay in diagnosis and lack of histological differentiation. We report a case of a sigmoid colon carcinoma with areas of neuroendocrine cells in a 12-year-old patient without familial occurrence of colorectal cancer. Symptoms at presentation were anaemia, anorexia, abdominal pain and weight loss. The patient was treated with radical resection and adjuvant chemotherapy. One year later, a local recurrence and hepatic metastases were diagnosed and she underwent chemotherapy and surgical resection. Twenty-six months from initial diagnosis she is alive with evidence of disease. The clinical presentation, diagnosis and treatment of the previously reported cases of colorectal cancer in children are also reviewed.

Palliative management strategies of advanced gastrointestinal carcinoid neoplasms.

Background/aimsOptimal management of gastrointestinal carcinoid neoplasms that metastasize to the liver is controversial. Although operative resection seems to be the most effective approach to metastatic disease, hepatic metastases are usually multicentric and often non-resectable. We investigated the effectiveness of several forms of palliative tumor cytoreduction followed by administration of somatostatin analogues in advanced carcinoid neoplasms.MethodsWe reviewed our experience with 34 patients with gastrointestinal carcinoid neoplasms. Eighteen patients had metastases and 14 had hormonal symptoms. Twenty-two patients underwent radical surgery, ten with multiple liver metastases were treated with a combination of debulking (resection, radiofrequency ablation, chemoembolization), followed by medical treatment with long-acting octreotide and eventually by radiolabelled somatostatin analogues, and two patients with intractable disease received only biotherapies.ResultsThe six patients with metastatic disease who underwent radical curative liver resection had a median survival of 52 months, compared with a median survival of 48 months in the ten patients who underwent palliative debulking. Symptomatic improvement was observed in all the patients after debulking procedures. The two patients who underwent only medical treatment died after 9 and 18 months.ConclusionsAggressive tumor debulking should be performed in patients with liver metastases already at diagnosis even when complete resection is not feasible because the combination of cytoreductive procedures followed by biotherapies may provide good long-term survival and achieves symptom control in most patients with advanced disease.

Small Bowel Perforation Caused by Pancreaticojejunal Anastomotic Stent Migration after Pancreaticoduodenectomy for Periampullary Carcinoma

CONTEXT Pancreaticoduodenectomy is the gold standard for patients with resectable periampullary carcinoma. The protection of the anastomosis by positioning of an intraluminal stent is a technique used to lower the frequency of anastomotic fistulas. However the use of anastomotic stents is still debated and stent related complications are reported. CASE REPORT A fifty-three-year old male underwent pancreaticoduodenectomy (PD) for a T2N0 periampullary carcinoma with a pancreaticojejunal (duct to mucosa) anastomosis protected by a free floating 6 Fr Nelaton stent in the Wirsung duct. Twenty-three months after surgery the patient accessed Emergency Department for severe abdominal pain associated to temperature, high white blood cell count and an significant increase in C reactive protein. Method Abdominal CT scan shown the presence of a tubular stent in the mesogastrium/lower right quadrant. No evident free intra-abdominal air was detected. The patient was submitted to explorative laparotomy. After debridement for localized peritonitis the Nelaton trans anastomotic stent was found in the abdomen. There was no evidence of bowel perforation, but intestinal loops covered with fibrin and suspect for impending perforation were resected. CONCLUSION There is a lack of evidence about the true rate of post-operative complications related to pancreatic stenting. We believe that in patients presenting with abdominal pain or peritonitis that previously underwent PD with stent-guided pancreaticojejunal anastomosis, the hypothesis of stent migration should at least be taken into consideration.

Reply to G. Dionigi’s letter: energy based devices and recurrent laryngeal nerve injury: the need for safer instruments

1. Professor Dionigi’s comments are undoubtfully remarkable; as he pointed out, both Harmonic Scalpel (HCS) and Ligasure® (electrothermal bipolar vessel-sealing systems) are gaining popularity since they significantly reduce operating time in open as well as in videoassisted thyroid surgery [1–3]. 2. Up to now, studies about heat dispersion of energybased devices in thyroid surgery are lacking, and those which use a nerve model do not clarify the safety distance to prevent nerve injury [4, 5]. 3. Proper training of the surgical team before these devices are used is essential because it is of paramount importance to maintain an adequate safety distance not only from recurrent laryngeal nerve (RLN) but also from other vital structures as the trachea. However, as reported by Bergenfelz [6], even with a distance exceeding the one recommended by the maker, the rate of transient RLN palsies was higher in patients submitted to surgery with HCS. 4. In literature, there are no data about the new Harmonic Focus® device, which has a smaller tip than the traditional HCS scissor and an aluminum coating which, as reported in product leaflet, should further reduce heat dispersion. Moreover, results of the Ethicon® (Ethicon Endo Surgery INC, Cincinnati, OH, USA) study about safety margins close to the nerves are not available yet. 5. Chan [7] in 2006 reported intraoperative neurophysiological monitoring (IONM) as not effective in preventing RLN injury, and Delbridge [8], the following year, added it is unuseful in resident training and considered it as a “technological toy” which can be harmful if viewed as a substitute of training by an experienced thyroid surgeon. Moreover, it is very expensive and not cost effective. 6. The German study, the largest ever published about IONM, demonstrated that visual identification of the RLN is the gold standard for nerve protection in all types of thyroid surgery [9]; IONM may be useful only in special cases. The same group in 2008 reviewed world literature on this topic, trying to detect some evidence-based guidelines; they concluded the additional use of IONM did not result in significantly decreased rates of postoperative RLN palsies when compared to visual dissection [10]. 7. Probably, at least as long as new and hopefully safer devices are developed, near by the nerve, the safest hemostatic method is still represented by tiny stitches or vascular clips which, as pointed out by Prof. Dionigi, can even be removed.

Intraoperative parathyroid hormone testing in primary hyperparathyroidism surgery: time for giving up?

PurposeIntraoperative PTH testing (IOPTH) in treatment of primary hyperparathyroidism (PH) is debated. Some authors advise against IOPTH in patients with concordant preoperative imaging undergoing focused parathyroidectomy. This study aims to compare focused parathyroidectomy success rates with and without IOPTH in patients with concordant preoperative imaging.MethodsRetrospective cohort study involving 599 consecutive patients underwent surgery for PH from 2012 to 2017. Patients with discordant preoperative imaging were excluded. 426 patients underwent focused parathyroidectomy (214 patients without IOPTH and 212 with IOPTH) and were considered for the statistical analysis. In case of insufficient IOPTH decay (less than 50%), a bilateral exploration was carried out.ResultsThe IOPTH group and the non-IOPTH group were similar for demographics and preoperative PTH and calcaemia. 413 patients were cured and disease persistence rates between groups were not significantly different (p > 0.05).ConclusionsAlthough further testing and randomized-controlled trials are required to validate our findings, our data show that IOPTH does not seem to improve the outcome in patients with concordant preoperative imaging undergoing focused parathyroidectomy.

Laparoscopic Surgery for Solid Pseudopapillary Pancreatic Tumor in a Pediatric Patient

Context Solid pseudopapillary pancreatic tumor is a rare pancreatic malignancy affecting mainly young females and quite often pediatric population. In literature there is no consensus about its management especially regarding surgical approach. We report our experience in treating one case occurred in a pediatric patient. Case report A 14-year-old female was admitted at Pediatric Department complaining of abdominal pain in lower quadrants associated to repeated vomiting. Biochemistry was normal except for leucocytosis. Abdominal ultrasound scan shown a 7 cm isoechoic epigastric lesion lateral but contiguous to the stomach and gallstones. The patient was submitted to a nuclear magnetic resonance which shown a 76 mm round lesion involving the pancreatic tail with sharp margins, without contrast enhancement and with fibrolipidic content. She underwent laparoscopic spleen preserving distal pancreatectomy and synchronous cholecystectomy. Postoperative course was uneventful and she was discharged after ten days. At histology the neoplasm proved to be a solid pseudopapillary pancreatic tumor mainly composed by round or polygonal cells with pseudopapillary areas. It stained positively for cytokeratin, vimentin, CD10 and had progesterone receptors. There was no vascular invasion. The patient is currently disease free after 12 months. Conclusions Since these tumors occur mainly in young females, laparoscopic resection, especially for lesions of the distal pancreas, is a valid treatment option provided safe margins can be achieved. In facts this neoplasm has been recently upgraded from borderline pancreatic lesions to malignancies.

Laparoscopic Surgery for Endocrine Pancreatic Tumors: Experience of a Referral Center

Context Laparoscopic pancreatic surgery is not common practice in Italy and is carried out in few centers. The reasons for this are manifold, such as the current selection of patients and both skills in laparoscopic and pancreatic surgery, are necessary to perform this operation safely. Objective We report the experience of a referral center for laparoscopic surgery comparing outcomes of laparoscopic and open procedures for endocrine pancreatic neoplasms. Materials Thirty patients (10 males and 20 females aged 57±14 years) were submitted to surgery for neuroendocrine pancreatic tumors from 2001 to 2010. Apart of 7 patients undergone duodenopancreatectomy, 13 patients received laparoscopic surgery and 10 open surgery. Results Mean overall operating time and postoperative hospital staying were 268±97 minutes and 26±28 days, respectively. Mortality was nil; overall morbidity was 56.5%. When comparing laparoscopy and open procedures operating time, postoperative hospital staying and even morbidity rate were similar (P>0.05). Conclusions Laparoscopic pancreatic surgery for endocrine tumors is safe and boasts a complication rate similar to that of open surgery. However, since it is a demanding procedure, it should be performed only in selected centers with a consolidated experience in laparoscopic and pancreatic surgery.