Surrenectomia bilaterale sincrona: quale è l'approccio migliore?

Lo scopo di questo studio è stato quello di comparare prospetticamente i risultati di due approcci, laparoscopico con paziente in flank position e retroperitoneale, alla surrenectomia bilaterale sincrona prendendo in considerazione i tempi operatori, le complicanze intra e post-operatorie, i tempi di recupero post-operatorio e la durata della degenza ospedaliera. Lo studio ha coinvolto due centri, il Dipartimento di Chirurgia dell'Università di Pisa, U.O. di Endocrinochirurgia per l'approccio laparoscopico in flank position, e il Dipartimento di Chirurgia dell'Università di Halle in Germania per l'approccio retroperitoneale. Tra il 1994 ed il 2008 34 pazienti consecutivi su un totale di 638 operati per patologia surrenalica nello stesso periodo sono stati sottoposti a surrenectomia bilaterale sincrona nei due centri di riferimento terziario per la chirurgia endocrina e mini-invasiva coinvolti nello studio. 20 pazienti sono stati sottoposti a surrenectomia bilaterale laparoscopica transperitoneale a Pisa (Gruppo A) e 14 pazienti a surrenectomia bilaterale retroperitoneale ad Halle (Gruppo B). Nel gruppo A le indicazioni all'intervento erano: Sindrome di Cushing in 4 casi e Morbo di Cushing in 9 casi. 3 pazienti presentavano una Sindrome di Cushing da secrezione di ACTH ectopica e 4 pazienti erano affetti da feocromocitoma bilaterale. Nel gruppo B le indicazioni all'intervento erano: Morbo di Cushing in 3 pazienti, Sindrome di Cushing in un paziente, feocromocitoma in 7 pazienti di cui 6 affetti da MEN 2, Sindrome di Conn in un paziente, iperplasia surrenalica congenita in un paziente e produzione di ACTH ectopico in un paziente Il gruppo A era costituito da 7 maschi e 13 femmine, il gruppo B da 6 maschi e 8 femmine. L'età media del gruppo A era 48,1 anni, quella del gruppo B 38,9 anni (p=0.06). Il BMI non era statisticamente differente tra i due gruppi (29,4 nel gruppo A contro 26,3 nel gruppo B p=0,08). Il diametro medio delle masse surrenaliche asportate era significativamente maggiore nel gruppo A rispetto al gruppo B (lato destro: 61,1mm contro 42,8mm con p=0,002; lato sinistro 64,1mm contro 37,4mm con p=0,003). Non sono state evidenziate differenze statisticamente significative tra i due gruppi in termini di tempi operatori globali, comprendendo quindi anche i tempi di intubazione, estubazione e cambiamento di posizione del paziente per l'approccio transperitoneale, e di tempi operatori propriamente detti, ossia dall'incisione alla sutura della cute. Non sono state registrate complicanze post-operatorie di rilievo nei due gruppi. In conclusione non è possibile determinare quale tra questi due approcci, transperitoneale e retroperitoneale, sia il migliore per la surrenectomia bilaterale sincrona. Entrambi si sono dimostrati fattibili, sicuri ed efficaci nel trattamento delle masse surrenaliche con un outcome per il paziente pressochè identico. Per questo motivo la scelta tra le due tecniche spetta al chirurgo, sulla base delle sue capacità e preferenze e delle caratteristiche del paziente. Ovviamente la cosa migliore e più auspicabile sarebbe che ci fosse la possibilità in ogni centro di poter eseguire entrambi gli approcci sulla base delle caratteristiche della patologia e del paziente, laparoscopica transperitoneale per masse superiori ai 60mm o in caso di concomitante patologia addominale, retroperitoneale per pazienti già sottoposti ad interventi addominali, con obesità di grado severo o con masse molto piccole così da ridurre al minimo l'invasività della procedura

Minimally invasive video-assisted thyroidectomy (MIVAT)

Minimally invasive video-assisted thyroidectomy (MIVAT) was first described in 1999 and it has become a widespread technique performed worldwide. Although initially limited to benign thyroid nodules, MIVAT was progressively adopted for all types of thyroid diseases, while remaining within the selection criteria. It is reported that, in selected cases, MIVAT is comparable to standard open thyroidectomy (SOT) in terms of oncologic radicality, time, costs and complications rate, with the advantage of a better cosmetic result and a lower post-operative pain

Firm mass in thyroid of an elderly patient: not always cancer

Summary In elderly patients presenting with a solid thyroid mass, the differential diagnosis between benign and malignant lesion is not always straightforward. We present the case of an 85-year-old woman with fever and an enlarged, firm and painful thyroid mass. Blood exams documented a mild thyrotoxicosis with a moderate inflammatory status. Thyroid scintiscan showed an absent uptake of 131I. Ultrasound and CT scan documented a 3 cm hypoechoic nodule with infiltration of the sternocleidomastoid muscle, very suspicious for neoplastic nature. Fine-needle aspiration and tru-cut biopsy were performed. During biopsy, the lesion was partially drained and a brownish fluid was extracted. The culture resulted positive for Klebsiella pneumoniae whereas the pathological analysis of the specimen was not conclusive due to the presence of an intense inflammatory response. A targeted oral antibiotic therapy was then initiated, obtaining only a partial response thus, in order to achieve a definite diagnosis, a minimally invasive hemithyroidectomy was performed. The pathological analysis documented acute suppurative thyroiditis and the clinical conditions of the patient significantly improved after surgical removal of thyroid abscess. In elderly patients with a solid thyroid mass, although neoplastic origin is quite frequent, acute suppurative thyroiditis should be considered as a differential diagnosis. Learning points: A solid and rapidly growing thyroid mass in elderly patients can hide a multifaceted variety of diseases, both benign and malign. A multidisciplinary team (endocrinologist, surgeon, radiologist and pathologist) could be necessary in order to perform a correct differential diagnosis and therapeutic approach. Surgery can be decisive not only to clarify a clinically uncertain diagnosis, but also to rapidly improve the clinical conditions of the patient

Video-assisted thyroidectomy: indications and results

Background and aims: Minimally invasive video-assisted thyroidectomy (MIVAT) was set up and introduced in our department in 1998. Its results, after an acceptable relapse, can now be evaluated, also speculating on new possible indications. Patients and methods: The procedure is based on a unique incision in the central neck, 2 cm above the sternal notch, using small conventional retractors and needlescopic (2 mm) reusable instruments. Haemostasis is achieved by a harmonic scalpel. Patients, 833, underwent MIVAT since June 1998. There were 715 females and 118 males (ratio 4:1). Lobectomy was carried out in 323 (38.7%) patients, total thyroidectomy in 510 (61.2%) patients. Results: Mean operative time of lobectomy was 36.2 min (range: 20-120); for total thyroidectomy, 46.1 min (30-130). Conversion to standard cervicotomy was required in 16 cases (1.9%); Operative complications were represented by transient monolateral recurrent nerve palsy in eight cases (0.9%), definitive monolateral recurrent nerve palsy in seven cases (0.8%). Twenty patients exhibited a hypoparathyroidism, which corresponds to 3.9% of total thyroidectomies performed, but only two showed permanent hypoparathyroidism (0.3%). Conclusion: MIVAT can be considered a safe operation offering significant cosmetic advantages with possible new promising indications such as prophylactic thyroidectomy in rearranged during transfection (RET) gene mutation carriers. It is still limited to a minority of patients, in particular, in endemic goitre countries. © Springer-Verlag 2006. Author keyword

Sentinel node mapping in thyroid cancer: an overview

: In this paper we describe the current status of sentinel node mapping (SNM) in thyroid tumors and its potential perspectives. SNM in thyroid cancer has been tested since the end of the twentieth century, mainly in papillary thyroid cancer (PTC) and in medullary thyroid cancer (MTC). In PTC, it has been employed to find occult lymph node metastases in the central compartment of the neck as an alternative or indication for prophylactic dissection, by several methods. All of them have proven effective in spotting sentinel nodes, but the results have been somewhat diminished by uncertainty about the clinical significance of occult metastases in differentiated thyroid cancer. SNM in MTC has also been used to find occult lymph node metastases in the lateral compartments of the neck, also with excellent results hindered by a similar doubt about the real clinical significance of MTC micrometastases. Well designed, adequately sized randomized controlled trials are lacking, so SNM in thyroid tumors remains an interesting yet experimental methodology. New technology is emerging that could facilitate such studies, which could add solid information about the clinical significance of occult neck metastases in thyroid cancer

Minimally invasive video-assisted thyroidectomy: reflections after more than 2400 cases performed.

BACKGROUND: The minimally invasive video-assisted approach was developed for primary hyperparathyroidism in 1997 and the year after for thyroid disease. Since then, the technique has been adopted worldwide, and indications moved from the initial benign disease to low-risk and intermediate-risk carcinoma, demonstrating a level of oncologic radicality comparable to the conventional open approach when inclusion criteria are strictly respected. METHODS: Between 1998 and 2014, 2412 minimally invasive video-assisted thyroidectomies (MIVAT) were performed in our department. The indication for surgery in 825 patients (34.3 %) was a malignant tumor, in particular, a papillary carcinoma in 800 patients. Among them, 528 patients operated on between 2000 and 2009 had a mean complete follow-up of 7.5 (standard deviation, 2.3) years. RESULTS: A total thyroidectomy was performed in 1788 patients (74.1 %) and a hemithyroidectomy in 564 (23.4 %). Also performed was central compartment lymphadenectomy in 31 patients (1.3 %) and parathyroidectomy for the presence of a solitary parathyroid adenoma in 29 (1.2 %). Mean duration of the procedure was 41 (standard deviation, 14) minutes. After a mean follow-up of 7. 5 years, 528 patients who underwent MIVAT for low-risk or intermediate-risk papillary carcinoma presented a cure rate of 85 % (undetectable thyroglobulin), comparable with the 80 % rate reported in patients who had undergone open thyroidectomy during the same period. CONCLUSIONS: After a long experience and a considerable number of procedures performed in a single center, MIVAT is confirmed as a safe operation, with a complication rate comparable with open thyroidectomy. MIVAT offers a cure rate for the treatment of low-risk and intermediate-risk malignancies that is comparable with an open procedure when inclusion criteria are strictly respected

No Outcome Differences between a Laparoscopic and Retroperitoneoscopic Approach in Synchronous Bilateral Adrenal Surgery

BACKGROUND: Two main approaches have been described for endoscopic adrenalectomy: the transperitoneal approach with the patient in the lateral decubitus position (LA) and the retroperitoneal approach with the patient in the prone position (ERA). The goal of the present study was to compare the results of LA and ERA for endoscopic bilateral synchronous adrenalectomy. PATIENTS AND METHODS: Between 1994 and 2008, 34 patients underwent bilateral synchronous adrenalectomy in two referral centers: 20 patients underwent LA in Pisa (group A), and 14 patients underwent ERA in Halle (group B). Sex, age, preoperative diagnosis, body mass index, preoperative medical treatments, diameter of glands, blood loss, operative time, complications, conversion, intensive care unit stay, day of first oral intake, length of postoperative recovery, histology report, and outcome were analyzed. RESULTS: There were 7 men and 13 women in group A and 6 men and 8 women in group B. Mean age was 48.1 years in group A and 38.9 years in group B. Body mass index was similar in the two groups. Diameters of the glands were larger in group A than in group B, at 61.1 versus 42.8 mm for the right side and 64.1 versus 37.4 mm for the left side. Mean hospital stay was longer in group B (8.2 versus 5.25 days; P = 0.002), whereas the intensive care unit stay was longer in group A (1.44 versus 1 day). CONCLUSIONS: It is not possible to determine which of the two approaches is better; both are feasible, safe, and effective and patient outcomes are almost the same

Prepuce-sparing corporoplasty as a safe alternative for patients with acquired penile curvature.

Objectives: penile curvature is a rare condition, classified as congenital or acquired (Peyronie's disease) (PD). Surgical correction is the standard treatment. It's common practice to associate circumcision with penile de-gloving to prevent complications. In this paper we evaluate the feasibility of penile surgery avoiding circumcision. Materials and methods: patients presenting with penile curvature were treated using a modified Nesbit procedure. Patients were divided into group A if they opted for a prepuce-sparing surgery and the others into group B. Patients were evaluated pre and postoperatively and postoperative complications were assessed. The 5-item International Index of Erectile Function (IIEF-5) was administered before and 6 months after surgery and we compared the difference of mean value using T-Test. Results: Group A and B were made of 53 and 16 patients respectively. Median age was 59 years [interquartile range (IQR) 12] in A and 62 (IQR 9) in B (p = 0.2). Median curvature was 40° (IQR 40°) in A and 40 ° (IQR 30°) in B (p = 0.62). Mean difference between pre- and post-operative IEFF was 1.9 ± 2 in A and 2.6 ± 2.1 in B (p = 0.36). Conclusions: According to our experience, surgical correction of penile curvature without performing circumcision could be a safe and feasible strategy. We recommend performing circumcision only in patients who present with pre-operative phimosis

Minimally Invasive Video-Assisted Thyroidectomy versus Conventional Thyroidectomy in Pediatric Patients

Background Minimally invasive video-assisted thyroidectomy (MIVAT) proved to be safe and effective in the treatment of both benign and malignant disease. The aim of the present study is to compare MIVAT approach with conventional approach for total thyroidectomy in a group of 99 pediatric patients operated in the Department of General Surgery of the University of Pisa between March 2007 and July 2012. Patients A total of 99 pediatric patients under the age of 18 years with thyroid disease referred to our Department to undergo total thyroidectomy. Patients were divided into two groups according to the surgical technique performed: 34/99 (34.3%) patients (MIVAT group [MG]) and 65/99 (65.7%) patients, (conventional group [CG]) who underwent total thyroidectomy, respectively, with MIVAT approach and conventional approach. Results In MG mean operative time for total thyroidectomy was 40 ± 6.57 minutes (range 30-60 min); postoperative hospital stay was 1 day for 18 patients (53%), 2 days for 12 patients (35.25%), 3 days for 4 patients (11.8%); transient hypoparathyroidism (hypoPTH) was observed in 12 cases (35.3%) and permanent hypoPTH in 2 cases (5.9%); transient postoperative unilateral vocal cord palsy was observed in 2 patients (5.9%). In CG mean operative time for total thyroidectomy was 49.3 ± 12.9 minutes (range 30-80 min); postoperative hospital stay was 1 day for 16 patients (24.6%), 2 days for 40 patients (61.5%), 3 days for 8 patients (12.3%), and 4 days for 1 patient (1.6%); transient hypoPTH was observed in 23 cases (35.4%) and permanent hypoPTH in 4 cases (6.1%), who needed therapy with calcitriol and calcium carbonate; transient postoperative unilateral vocal cord palsy was observed in 4 patients (6.1%). There were no cases of permanent vocal cord paralysis in both groups. The correlation between two groups of patients showed that mean operative time was significantly lower in MG (p = 0.0007). Conclusion Pediatric patients of MG showed a significantly lower operative time and postoperative hospital stay with respect to pediatric patients of CG if compared with conventional technique. This result with the evidence of similar degree of completeness and rate of postoperative complications make MIVAT a valid option for the treatment of pediatric patients when performed by a well-trained staff in a third referral center. © Georg Thieme Verlag KG

Underestimated risk of cancer in solitary thyroid nodules â\u89¥3Â cm reported as benign

Background: The study aims to assess the risk of cancer in solitary thyroid nodules â\u89¥30 mm in size reported as Bethesda II, and its implications. Method: The clinical records of 202 patients, who underwent thyroid lobectomy for solitary nodules measuring â\u89¥30 mm, reported as Bethesda II on preoperative FNAC between Jan 2015 and Apr 2016 were reviewed. Data collected included nodule size and consistency, and final histopathology results. The risk of cancer and the recommended management according to ATA guidelines were the outcomes of interest. Comparisons were then made between two size categories: (30â\u80\u9340 mm; n = 72; C1) and (>40 mm; n = 130; C2), and two nodule consistencies. Results: Mean nodule size was 43.2 mm (range 30â\u80\u9392). Ninety-five percent were solid and 5% were predominantly cystic. The risk of cancer was 22.8% (46/202) with no size threshold, or graded increase in risk observed. Based on biologic behavior, 50% of cancers were considered clinically significant. Accordingly, the risk of cancer for which surgery is recommended was 11.4% (23/202). The risk of cancer requiring total thyroidectomy was 9.4% and was influenced by nodule size (19 vs. 60% in C1 and C2, respectively; p = 0.01). Predominantly cystic nodules had a greater risk of malignancy compared to predominantly solid nodules even after adjusting for size (40 vs. 9.9%; p = 0.01 and 40 vs. 12.5%; p = 0.02, respectively). Conclusion: The risk of malignancy in Bethesda II solitary nodules â\u89¥30 mm is considerable implying a need for changing the way these are approached and refining cytopathology reporting