Umberto Caliceti

Transient hypoparathyroidism following thyroidectomy : A prospective study and multivariate analysis of 604 consecutive patients

Objectives The purpose of this study was to identify the risk factors for postoperative transient hypoparathyroidism in a group of patients undergoing thyroid surgery. Study Design A prospective study was conducted on 604 patients undergoing thyroid surgery. Subjects and Methods Gender, final diagnosis, extent of resection, biology of pathology, intrathoracic involvement, surgery for recurrent multinodular goiter, and presence and number of parathyroid glands in a surgical specimen were analyzed as risk factors for postoperative transient hypoparathyroidism. The chi-square test and a logistic regression analysis were applied. RESULTS: On logistic regression analysis, only the extent of surgery constituted an independent variable for transient hypoparathyroidism (P = 0.001). Conclusion The extent of surgery to central and/or lateral neck lymph nodes is responsible for a high rate of transient hypoparathyroidism owing to a high probability of unplanned parathyroidectomy or parathyroid gland devascularization.

Supracricoid partial laryngectomies after radiation failure: A multi‐institutional series

Radiation therapy (RT) is one of the gold standard treatments for early laryngeal cancer, and total laryngectomy is still the most applied surgical procedure after failure. Selected recurrences can be managed by supracricoid partial laryngectomies (SCPLs).

The value of neurostimulation and intraoperative nerve monitoring of inferior laryngeal nerve in thyroid surgery

Objective: To determine the accuracy of neurostimulation with laryngeal palpation (NSLP) and intraoperative neuromonitoring (IONM) to predict the postoperative function of recurrent laryngeal nerve (RLN) in thyroid surgery. Study Design: Historical cohort study. Subjects and Methods: A retrospective case control study with 993 patients. The control group (799 patients with 1450 nerves at risk) included patients who underwent NSLP and the case group (194 patients with 354 nerves at risk) consisted of those who underwent NSLP in association with IONM. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV), and accuracy were calculated for NSLP and IONM, with nerve palsy as the target outcome. Results: A significant difference in nerve injury between the case and the control group (P = 0.31) was not observed. The presence or absence of laryngeal twitch (LT) (P < 0.0001) and the acoustic response to electrical stimulation (P = 0.003) were significantly associated with nerve function at the end of the surgery. Conclusion: Our results indicate that NSLP is a safe and reliable intraoperative method of RLN monitoring. Moreover our data confirm that IONM is not a helpful tool to reduce the rate of palsy in thyroid surgery.

Minimally invasive nonendoscopic thyroidectomy.

OBJECTIVES: Minimal-access thyroid surgery, using various techniques, is increasingly being reported. The present study reviews our experience with thyroid surgery using a minimally invasive approach (MIT). STUDY DESIGN: Between October 2002 and December 2004, a prospective nonrandomized study of patients undergoing thyroid surgery was performed to evaluate the variables that might condition the indications to minimally invasive nonendoscopic approach. RESULTS: 296 patients underwent thyroid surgery; 46 of these were eligible for MIT through a 2.5- to 3-cm incision. There was one case of transient inferior laryngeal nerve palsy and no postoperative definitive hypoparathyroidism. MIT was converted to conventional thyroidectomy only in two cases. Cosmetic results were considered excellent by all patients. CONCLUSIONS: Minimal-access thyroid surgery is a safe and feasible alternative to conventional thyroid surgery in selected cases. The advantage that this technique offers, in addition to low morbidity, is an improved cosmetic result.

Laryngeal neuromonitoring and neurostimulation versus neurostimulation alone in thyroid surgery: A randomized clinical trial

The aim of this study was to assess a prospective, randomized clinical trial (RCT) comparing neurostimulation with laryngeal palpation (NSLP) of recurrent laringeal nerve (RLN) alone with NSLP associated with laryngeal neuromonitoring (LNM) to evaluate the ability of LNM in reducing the rates of RLN palsy.

Accuracy of PTH assay and corrected calcium in early prediction of hypoparathyroidism after thyroid surgery

Objective To evaluate the accuracy of the intraoperative parathyroid hormone (ioPTH) and 6-hour PTH (6hPTH) assay in predicting transient hypoparathyroidism after thyroidectomy. Study Design A nonrandomized prospective study was conducted on patients undergoing thyroid surgery. Subjects and Methods Of 138 patients undergoing thyroid surgery, intraoperative PTH was measured 10 minutes after gland removal. Serum calcium, magnesium, inorganic phosphorus, albumin, and PTH levels were assayed 6 and 16 hours after surgery and daily until patient discharge. Results The development of postoperative hypocalcemia was associated with low ioPTH (P < 0.0001) and 6hPTH (P < 0.0001) values, and the decline of PTH from baseline (P < 0.0001). The cutoff for percentage decline of ioPTH and 6hPTH (55.7% and 379%, respectively) was more accurate than an absolute value. Accuracy, and positive and negative predictive values were 88 percent, 63 percent, and 100 percent for ioPTH and 75 percent, 46 percent, and 100 percent for 6hPTH, respectively. Conclusion With the use of ioPTH decline in association with 16-hour corrected calcium, it is possible to distinguish early normocalcemic patients from hypocalcemic ones in most cases.

ANTEROLATERAL THIGH FREE FLAP FOR TRACHEAL RECONSTRUCTION AFTER PARASTOMAL RECURRENCE

Stomal recurrence after total laryngectomy is 1 of the most serious issues in head and neck surgery, both because of the complexity of its management and because of its morbidity. Prior to the introduction of free‐tissue transfer, mediastinal tracheostomy has been the standard reconstructive procedure with high rate of complications. The ideal reconstructive solution to these problems must provide well‐vascularized soft tissues that can cover the defect after resection and also allow suturing of the tracheal remnant to skin edges without tension.

Branchial cyst of the parapharyngeal space: report of a case and surgical approach considerations

IntroductionNeoplasms arising within the parapharyngeal space are rare and represent approximately 0.5% of all head and neck tumors. The majority of these lesions consist of minor salivary gland tumors, tumors of the deep lobe of the parotid gland, and tumors of neurogenic origin (paragangliomi and schwannomi), while branchial cysts are extremely rare. Despite advances in radiographic images, surgical excision remains the definitive technique for the diagnosis of parapharyngeal space tumors.Results and discussionThe authors report a case of branchial cyst of the parapharyngeal space excised through a combined transcervical–transmandibular approach and discuss the several surgical techniques proposed to approach this type of tumors.

Detection of HPV16 African variants and quantitative analysis of viral DNA methylation in oropharyngeal squamous cell carcinomas

BACKGROUND HPV16 is the most prevalent genotype in oropharyngeal squamous cell carcinomas (OPSCCs), but there are few information about intratype variants prevalence and their clinical relevance in these tumors. Moreover, since HPV DNA detection alone is not sufficient to determine a favorable prognosis for OPSCCs, additional diagnostic/prognostic biomarkers are necessary. OBJECTIVES To assess the prevalence of HPV intratype variants and evaluate the role of HPV16 DNA methylation as prognostic marker in OPSCCs. STUDY DESIGN We analyzed 81 biopsies of OPSCCs for HPV detection and genotyping with a pyrosequencing-based HPV DNA-test. We also quantified viral DNA methylation frequency in the LCR by pyrosequencing in patients with transcriptionally-active HPV16-infection, analyzing it in function of available clinical/virological data. RESULTS The overall HPV prevalence was 74.1% and HPV16 was confirmed the most prevalent genotype (51/60, 85.0%). Interestingly, we detected, for the first time, HPV16 African variants in 10/51 cases (19.6%), pointing out their clinical relevance also out of the anogenital district. Regarding viral DNA methylation, the E2BS1 showed a significantly higher mean methylation frequency compared to E2BS3/4, as previously observed in high-grade precancerous lesions of the uterine cervix. On the other hand, patient with a mean methylation frequency in the early promoter >10% showed only a tendency to have a worse prognosis. CONCLUSIONS Our results highlight both the involvement of HPV16 African variants in OPSCCs development and the necessity of further studies to deepen the role of viral methylation in these tumors, in order to better define similarities/differences compared to cervical cancer.

The Value of RLN Neurostimulation in Thyroid Surgery

Objective: Neurostimulation with laryngeal palpation (NSLP) is an intermittent monitoring technique that facilitates nerve identification and permits an assessment of the recurrent laryngeal nerve (RLN) function during thyroid surgery. In this study we report our experience with NSLP, evaluating the predictive value of this technique for postoperative RLN deficit. Method: We analyzed retrospectively a consecutive series of 1584 patients undergoing thyroid surgery from 2002 to 2011 at Sant’Orsola - Malpighi Hospital of Bologna. Sensitivity, specificity, PPV, and NPV were calculated for NSLP, considering an absent laryngeal twitch (LT) at the end of the surgical procedure as predictive for RLN palsy. Results: The incidence of nerve palsy, calculated on a total of 2917 nerves at risk, was 2.1% (64 cases). Sensitivity, specificity, and positive and negative predictive values resulted respectively: 53%, 96.5%, 34.9%, and 98.4%. Conclusion: Our results indicate that NSLP is still a useful and economic tool for RLN monitoring during thyroid surgery. Moreover the high specificity and NPV of NSLP confirm that this technique provides important prognostic information regarding vocal cord function at the end of dissection of the first lobe during total thyroidectomy.