Pier Francesco Alesina

Total thyroidectomy for management of benign thyroid disease: review of 526 cases

Total thyroidectomy is not frequently performed in cases of benign disease because of the associated risk of postoperative hypoparathyroidism and recurrent laryngeal nerve (RLN) damage. We chose a series of patients who had undergone total thyroidectomy (TT) for benign thyroid tumors to evaluate the safety of this approach and its role in the treatment of nonmalignant lesions of the thyroid. We considered only patients with a minimum follow-up of 24 months. Records of 526 patients who underwent TT were carefully reviewed, assessing for perioperative complications and late sequelae. The mean age was 44 ± 15.7 years; 109 patients (20.7%) were male and 417 (79.3%) were female. Altogether, 65 patients (12.3%) were operated on for toxic goiter, 429 (81.6%) for bilateral nodular goiter, and 32 (6.1%) for thyroiditis. Postoperative hemorrhage requiring reoperation occurred in 8 cases (1.5%). The incidences of permanent RLN palsy (considered as a percentage of the nerves at risk) and permanent hypocalcemia were 0.4% and 3.4%, respectively. A trend toward a decrease in the complication rate was observed during the last 5 years. There were no disease recurrences during a mean follow-up of 44 months. The results of our series show that TT can be performed safely in patients, with a low incidence of lifetime disabilities. TT has the advantage of reducing/avoiding the risk of disease recurrence and reoperation and should therefore be considered a valuable option for treating benign thyroid diseases.Résumé.La thyroïdectomie total mais n’est pas réalisée fréquemment en cas de maladie bénigne en raison du risque d’hypoparathyroïde postopératoire et de lésions du nerf récurrent. Nous avons sélectionné une série de thyroïdeectomies totales (TT) pour maladie bénigne afin d’évaluer la sécurité de cette approche et son rôle dans le traitement des lésions non malignes de la thyroïde. Nous avons pris en compte seulement les patients ayant un suivi minimum de 24 mois. Les dossiers de 526 patients ayant eu une TT ont été revus pour évaluers les complications péri-opératoires et les séquelles tardives. L’âge moyen était de 44 ± 15.7 ans. Cent neuf patients (20.7%) étaient des hommes et 417 (79.3%) des femmes. Soixante=cinq patients (12.3%) ont été opérés pour goitre toxique, 429 (81.6%) pour goitre nodulaire bilatéral et 32 (6.1%) pour thyroïdite. Une hémorragie postopératoire a nécessité une ré-intervention dans 8 cas (1.5%). L’incidence de paralysie permanente du nerf récurrent (pourcentage de nerfs récurrents à risque) et d’hypocalcémie permenente ont été, respectivement, de 0.4% et de 3.4%. On a observé une tendance vers une diminution du taux de complications pendant les cinq dernières années. Aucune récidive n’a été observée avec un suivi moyen de 44 mois. Les résultats de notre série indiquent que la TT peut être réalisée avec sécurité dans cette population avec une incidence d’incapacité permenent réduite. La TT a l’avantage de réduire/éviter le risque de récidive de la maladie et de réopération et devrait être une option valable pour le traitement de maladies bénignes de la thyroïde.ResumenLa tiroidectomia total no es un procedimiento de realización frecuente en la enfermedad benigna por razón del riesgo de hipoparatiroidismo postoperatorio y de lesión del nervio laríngeo recurrente. Tomamos una serie de tiroidectomías totales (TT) practicadas por tumores benignos con el objeto de evaluar la seguridad de esta conducta y su papel en el tratamiento de lea lesiones no malignas de la tiroides. En el presente estudio sólo fueron considerados pacientes con un seguimiento mínomo de 24 meses. Se revisaron las historias de 526 pacientes que habían sido sometidos a TT para determinar las complicaciones postoperatorias y las secuelas tardías. La edad promedio fue 44 ± 15.7 años; 109 (20.7%) eran hombres y 417 (79.3%) mujeres; 65 (12.3%) fueron operados por bocio tóxico, 429 (81.6%) por bocio nodular bilateral y 32 (6.1%) por tiroiditis. Se presentó hemorragia postoperatoria que requirió reoperación en 8 casis 91.5%). La incidencia de parálisis permamente del nervio laríngeo recurrente consierada como porcentaje de los nervios en riesgo y de hipocalcemia fue 0.4% y 3.4% respectivamente. Se observó tendencia hacia la disminución de las complicaciones en el curso de los últimos 5 años. No se registró recurrencia de la enfermedad en el seguimiento de 44 meses. Los resultados del análisis de nuestra serie indican que la TT puede ser practicada con seguridad en pacientes con enfermedad benigna de la tiroides, con una baja tasa de complicaciones permenentes. La TT tiene la ventaja de reducir o abolir tanto el riesgo de recurrencia de la enfermedad como el de una reoperación, y en consecuencia, debe ser considerada Bellantone et al.: Benign Thyroid Disease and Total Thyroidectomy como una opción valiosa en el tratamiento de la enfermedad tiroidea benigna.

Comprehensive Re-Sequencing of Adrenal Aldosterone Producing Lesions Reveal Three Somatic Mutations near the KCNJ5 Potassium Channel Selectivity Filter

Background Aldosterone producing lesions are a common cause of hypertension, but genetic alterations for tumorigenesis have been unclear. Recently, either of two recurrent somatic missense mutations (G151R or L168R) was found in the potassium channel KCNJ5 gene in aldosterone producing adenomas. These mutations alter the channel selectivity filter and result in Na+ conductance and cell depolarization, stimulating aldosterone production and cell proliferation. Because a similar mutation occurs in a Mendelian form of primary aldosteronism, these mutations appear to be sufficient for cell proliferation and aldosterone production. The prevalence and spectrum of KCNJ5 mutations in different entities of adrenocortical lesions remain to be defined. Materials and Methods The coding region and flanking intronic segments of KCNJ5 were subjected to Sanger DNA sequencing in 351 aldosterone producing lesions, from patients with primary aldosteronism and 130 other adrenocortical lesions. The specimens had been collected from 10 different worldwide referral centers. Results G151R or L168R somatic mutations were identified in 47% of aldosterone producing adenomas, each with similar frequency. A previously unreported somatic mutation near the selectivity filter, E145Q, was observed twice. Somatic G151R or L168R mutations were also found in 40% of aldosterone producing adenomas associated with marked hyperplasia, but not in specimens with merely unilateral hyperplasia. Mutations were absent in 130 non-aldosterone secreting lesions. KCNJ5 mutations were overrepresented in aldosterone producing adenomas from female compared to male patients (63 vs. 24%). Males with KCNJ5 mutations were significantly younger than those without (45 vs. 54, respectively; p<0.005) and their APAs with KCNJ5 mutations were larger than those without (27.1 mm vs. 17.1 mm; p<0.005). Discussion Either of two somatic KCNJ5 mutations are highly prevalent and specific for aldosterone producing lesions. These findings provide new insight into the pathogenesis of primary aldosteronism.

Central Neck Lymph Node Removal During Minimally Invasive Video-Assisted Thyroidectomy for Thyroid Carcinoma: A Feasible and Safe Procedure

BACKGROUND AND PURPOSE In 1998, we developed a technique for video-assisted thyroidectomy (VAT) which we proposed using also in patients with small low-risk papillary thyroid carcinomas (PTC). In some cases, enlarged lymph nodes are incidentally found at surgery for PTC. These nodes should be removed because of the risk of metastases. In this paper, we report on the patients in whom we removed enlarged central neck lymph nodes during VAT for PTC and discuss the feasibility and safety of video-assisted central neck lymph node dissection (VALD). PATIENTS AND METHODS The procedure is performed by a totally gasless video-assisted technique through a single 1.5-to 2.0-cm skin incision above the sternal notch. Dissection is performed under endoscopic vision using a technique very similar to that of conventional surgery. Only enlarged lymph nodes were removed and sent for frozen section examination (FS). No other dissection was performed in case of negative FS. Five patients underwent VALD during VAT for PTC. RESULTS The mean number of lymph nodes removed was 2.4. No metastases were found at FS or final histology examination. Postoperative complications included two transient postoperative hypocalcemias. No evidence of residual or recurrent disease was observed at postoperative follow-up. The cosmetic result was excellent. CONCLUSION Our experience demonstrates that removal of central compartment lymph nodes is feasible and safe. Perhaps also complete central neck lymph node dissection can be performed. Some doubts persist about the oncologic validity of this approach. For definitive conclusions, larger series and comparative studies are necessary.

Video-assisted thyroidectomy for papillary thyroid carcinoma

Background: In patients with small papillary thyroid carcinomas (PTC), we evaluated the operative feasibility and safety of video-assisted thyroidectomy (VAT) and the completeness of the surgical resection. Methods: Video-assisted thyroidectomy was attempted in 24 patients with thyroid malignancy. Total thyroid resection for PTC was achieved completely by VAT in 20 of them, who were included in this study. Results: In this study, 12 total thyroidectomies and 8 lobectomies followed by completion thyroidectomies were performed. Eight patients also underwent central neck lymph node dissection. Mean postoperative serum thyroglobulin was 0.2 ng/ml for patients receiving LT4 suppressive treatment and 4.2 ng/ml for patients after LT4 withdrawal. Postoperative ultrasonography showed no residual thyroid tissue. The mean radioiodine uptake at postoperative scintiscan was 2.2%. Conclusions: In the case of PTC, VAT is feasible and safe. The completeness of the surgical resection seems comparable with that reported for conventional surgery. Nevertheless, larger series and longer follow-up evaluation are necessary for definitive conclusions to be drawn about its oncologic validity.

The impact of type and number of bowel resections on anastomotic leakage risk in advanced ovarian cancer surgery

OBJECTIVE To identify risk factors for anastomotic leakage (AL) in patients undergoing primary advanced ovarian cancer surgery and to evaluate the prognostic implication of AL on overall survival in these patients. METHODS We analyzed our institutional database for primary EOC and included all consecutive patients treated by debulking surgery including any type of full circumferential bowel resection beyond appendectomy between 1999 and 2015. We performed logistic regression models to identify risk factors for AL and log-rank tests and Cox proportional hazards models to evaluate the association between AL and survival. RESULTS AL occurred in 36/800 (4.5%; 95% confidence interval [3%-6%]) of all patients with advanced ovarian cancer and 36/518 (6.9% [5%-9%]) patients undergoing bowel resection during debulking surgery. One hundred fifty-six (30.1%) patients had multiple bowel resections. In these patients, AL rate per patient was only slightly higher (9.0% [5%-13%]) than in patients with rectosigmoid resection only (6.9% [4%-10%]), despite the higher number of anastomosis. No independent predictive factors for AL were identified. AL was independently associated with shortened overall survival (HR 1.9 [1.2-3.4], p=0.01). CONCLUSION In the present study, no predictive pre- and/or intraoperative risk factors for AL were identified. AL rate was mainly influenced by rectosigmoid resection and only marginally increased by additional bowel resections.

Video-Assisted Thyroidectomy

OBJECTIVE In 1998, we developed a technique for video-assisted thyroidectomy (VAT). In this paper, we report on the entire series of patients who underwent VAT and discuss the results obtained. METHODS Seventy-three patients were selected for VAT. Eligibility criteria were: thyroid nodules </=35 mm in maximum diameter; estimated thyroid volume within normal range or slightly enlarged; small, low-risk papillary carcinomas; no previous neck surgery or irradiation and no thyroiditis. The VAT procedure was totally gasless. It was performed under endoscopic vision through a single 1.5 to 2.0-cm skin incision, using a technique very similar to conventional surgery. RESULTS Eighty-one VATs were attempted on 73 patients. Forty-five lobectomies, 24 total thyroidectomies and eight completion thyroidectomies were successfully performed. Mean operative time was 82 minutes for lobectomy, 100 minutes for total thyroidectomy and 77 minutes for completion thyroidectomy. The conversion rate was 4.9%. Postoperative complications included two transient recurrent nerve palsies, five transient symptomatic postoperative hypocalcaemias and one wound infection. The cosmetic result was considered excellent by most of the patients. CONCLUSION VAT is a feasible and and safe procedure that allows for excellent cosmetic results. In selected cases, it can be a valid option for the surgical treatment of thyroid diseases.

Continuous intraoperative neuromonitoring in minimally invasive video assisted thyroid surgery: first experience

Background: Visual identification of the recurrent laryngeal nerve (RLN) is mandatory in thyroid surgery independent of the approach. Intermittent intraoperative neuromonitoring (ioNM) is broadly in open and minimally invasive thyroid surgery. However, the use of continuous intraoperative neuromonitoring (C-ioNM) has yet not been described for minimally invasive video-assisted thyroidectomy (MIVAT). The correct placement of the vagal electrode and the problem of its dislocation represent the limiting factor due to the narrow space. We describe the technique for correct electrode positioning and report on our first experiences with the C-ioNM in MIVAT. Methods: C-ioNM was used in 9 patients eligible for MIVAT. To avoid dislocation of the electrode due to traction or interference with the electrode-wires during dissection both the wires and the electrode were pulled through an additional skin incision. MIVAT was then performed using a 5 mm 30° optical device and special instruments according to the original description from Miccoli. Video assisted hemithyroidectomy was performed in 3 patients, while 6 patients underwent total thyroidectomy. Results: Video-assisted application of the vagal electrode and positioning of the wires via an additional access was feasible in all patients without complications. In 6 cases, the electrode-wires were pulled through an additional skin incision on the dominating side lateral to the sternocleidomastoid muscle. In two patients the wires were pulled through an additional incision in the midline below the surgical approach. In one patient the wires were diverted directly through the primary incision. A significant intermittent decrease of the electromyographic (EMG) amplitude was observed in one patient. However, postoperative RLN palsy rate was zero. Conclusions: C-ioNM in MIVAT is feasible. An additional skin incision is helpful to avoid electrode dislocation. Traction of the thyroid lobe during thyroid lobe mobilization does not seem to affect RLN function. However, more data has to be collected to definitely estimate the significance of C-ioNM in MIVAT.

Minimally Invasive Video-Assisted Thyroidectomy

The minimally invasive video-assisted approach was first described in 1996 for parathyroid (Miccoli et al. 1997) and few years later for thyroid surgery (Bellantone et al. 1999; Miccoli et al. 1999). In the same period following the enthusiastic results of laparoscopic abdominal surgery, a purely endoscopic parathyroidectomy and thyroidectomy with multiple trocars placement and CO2 insufflation were also performed (Gagner 1996; Huscher et al. 1997). The innovation of the video-assisted technique consisted of a gasless procedure performed through a single 1.5–2 cm central access and use of an endoscope for magnification. Because of its similarity to conventional surgery, this method gained quickly a quite large acceptance (Miccoli et al. 2002). Moreover, the attraction of the mini-incision has been supposed in earlier studies to be coupled with an advantage in terms of postoperative pain and cosmetic result in favour of MIVAT when compared to conventional thyroidectomy (Miccoli et al. 2001; Bellantone et al. 2002). Our experience with MIVAT is based on more than 1,500 procedures performed over more than 10 years experience in a tertiary referral centre for endocrine surgery.

Energy Devices in Minimally Invasive Thyroidectomy

An accurate haemostasis is essential during any surgical procedure. This problem is well known for thyroid surgery since over one century when Billroth, considered one of the best surgeons in Europe, reported a mortality of 40% on a series of 20 patients in 1869. Few decades later, in the hands of Theodor Kocher, thyroidectomy developed into a safe operation with a mortality rate of 0.5% by 1898 (Richard 1990). The key for these extraordinary results was the technique he introduced which first ligated the major arteries and veins followed by identifying and isolating the recurrent laryngeal nerve (Kocher 1883). Since that time, suture ligation has continued to be the gold standard of obtaining haemostasis. The introduction of the minimally invasive thyroid surgery poses the problem to break this 100-year-old rule. The impossibility to ligate is obvious for the purely endoscopic operations such as the endoscopic neck, thoracic and axillary approach (Henry and Segab 2006; Strik et al. 2007; Kang et al. 2009), but also the video-assisted operation due to the limited working space permits conventional ligatures only after the extraction of the thyroid lobe through the skin incision (Miccoli et al. 2006). Many instruments are now available for this use and have been demonstrated to be at least as safe as the knot-and-tie technique.

Effect of Morbid Obesity and Tumor Diameter on Feasibility of Posterior Retroperitoneoscopic Adrenalectomy for Cushing’s Syndrome: Reply

We thank Agarwal and coauthor for their comments about our article [1]. Concerning the question about the number of morbidly obese patients, we found that from 170 patients affected by manifest (mCS) or subclinical Cushing’s syndrome (sCS), 51 patients (30%) had a body mass index (BMI) [ 30 (range, 31–62). The majority were affected by mCS (32 cases, 63%). In particular, 26 patients (51%) had a BMI [ 35. As demonstrated, the posterior retroperitoneoscopic approach is feasible and safe even in these patients as only one conversion to open surgery occurred in this series. Technically essential is an increased CO2-pressure (up to 30 mmHg) that allows an adequate creation of the retroperitoneal space. Concerning suspected adrenal malignancies, we do not follow the concept that the laparoscopic transabdominal approach should be preferred over the retroperitoneoscopic access. In contrast, we see a potential advantage of the retroperitoneoscopic route as peritoneal spillage of tumor cells can be avoided. Fourteen tumors (14/170, 8.2%) were at preoperative imaging C 6 (range, 6–10) cm. If predictable, we do not approach adrenocortical cancer minimally invasive. Beside tumor size and imaging features, type of hormone secretion has to be taken into account. Based on these parameters, we were extremely successful; we removed only one adrenocortical cancer in the series of 170 Cushing patients. As demonstrated earlier, large tumor size itself does not represent a contraindication for retroperitoneoscopic adrenalectomy [2, 3]. Today, we do not see the critical size for malignancy in adrenocortical tumors C 6 cm but in those C 8 cm. From this estimation excluded are bilateral macronodular hyperplasias that are almost always benign.