Hypocalcemia following total thyroidectomy: early factors predicting long-term outcome

Hypocalcemia following total thyroidectomy (TT) must be considered permanent in patients requiring calcium replacement therapy after one year. The aim of this study was to identify early risk factors predicting long-term outcome of postoperative hypocalcemia. Among 453 patients who underwent TT from January 1998 to May 2003, a cross-sectional study between 44 patients with transient hypocalcemia (9,7%) and 3 patients with permanent hypocalcemia (0,7%) was carried out. Both low serum calcium level (< 8 mg/dl) and high serum phosphorus level (>4,5 mg/dl), measured on postoperative day 7, were predictive for outcome. Central neck lymph node dissection, performed for thyroid carcinoma, also correlated with outcome. Serum phosphorus level >4,5 mg/dl on postoperative day 7 resulted the only independent factor predicting permanent hypoparathyroidism. Therefore indication for central dissection would be very strict. When serum phosphorus level is unfavorable a correct replacement therapy is mandatory to prevent the consequences of permanent hypocalcemia

Clinical Study Gastric Cancer in the Young: Is It a Different Clinical Entity? A Retrospective Cohort Study

Background. The rate of gastric cancer in young patients has increased over the past few decades. The aim of this study was to search for independent risk factors related to patients of younger age. Methods. From January 1996 to December 2012, a series of 179 consecutive patients were admitted to our surgical department because of a gastric cancer. We carried out a retrospective cohort study in 20 patients younger than 50 and in 112 patients aged 50 and older treated by curative gastrectomy. The comparison involved the evaluation of patient and tumor characteristics. Results. Younger patients had significantly less comorbidities and a more favorable American Society of Anesthesiology score; they had significantly less preoperative weight loss and a significantly longer duration of symptoms; Helicobacter pylori infection and diffuse histological type were significantly associated with younger age. There was no statistically significant difference regarding overall and cancer-related 5-year survival; advanced cancer stage and diffuse histological type were the independent negative prognostic factors influencing cancer-related survival. Conclusions. We do not have sufficient evidence to consider gastric cancer in younger patients as a different clinical entity. Further studies are needed to understand carcinogenesis in younger patients and to improve gastric cancer classification

Gastric Cancer in the Young: Is It a Different Clinical Entity? A Retrospective Cohort Study

Background. The rate of gastric cancer in young patients has increased over the past few decades. The aim of this study was to search for independent risk factors related to patients of younger age. Methods. From January 1996 to December 2012, a series of 179 consecutive patients were admitted to our surgical department because of a gastric cancer. We carried out a retrospective cohort study in 20 patients younger than 50 and in 112 patients aged 50 and older treated by curative gastrectomy. The comparison involved the evaluation of patient and tumor characteristics. Results. Younger patients had significantly less comorbidities and a more favorable American Society of Anesthesiology score; they had significantly less preoperative weight loss and a significantly longer duration of symptoms; Helicobacter pylori infection and diffuse histological type were significantly associated with younger age. There was no statistically significant difference regarding overall and cancer-related 5-year survival; advanced cancer stage and diffuse histological type were the independent negative prognostic factors influencing cancer-related survival. Conclusions. We do not have sufficient evidence to consider gastric cancer in younger patients as a different clinical entity. Further studies are needed to understand carcinogenesis in younger patients and to improve gastric cancer classification

Surgical treatment of perforated diverticular disease: evaluation of factors predicting prognosis in the elderly

Diverticulitis free perforation carries a high mortality rate in the elderly, and this motivates the search for specific prognostic factors. The aim of this study was to assess prognostic factors in patients over 70 years of age that were operated on for generalized peritonitis caused by perforated colonic diverticulitis. A retrospective study in 22 patients was performed: demographic data, American Society of Anaesthesiology grading, site and diameter, degree of perforation according to Hinchey's classification, duration of symptoms, Manheim Peritonitis Index (MPI) score, and surgical treatment were evaluated. Patients over 70 years of age were grouped in deceased and not deceased. In this subgroup, postoperative mortality rate was 40%, and diameter of perforation, duration of symptoms, and MPI score seemed significantly related to postoperative death. In the elderly, prognosis is strongly related to duration of symptoms, and treatment delay is caused by late hospitalization because of a low sensibility to the disease symptoms in old people

Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy

Background: The role of intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) during thyroid surgery is still debatable. The aim of this meta-analysis was to evaluate the potential improvement of IONM versus RLN visualization alone (VA) in reducing the incidence of vocal cord palsy. Methods: A literature search for studies comparing IONM versus VA during thyroidectomy was performed. Studies were reviewed for primary outcome measures: overall, transient, and permanent RLN palsy per nerve and per patients at risk; and for secondary outcome measures: operative time; overall, transient and permanent RLN palsy per nerve at low and high risk; and the results regarding assistance in RLN identification before visualization. Results: Twenty studies comparing thyroidectomy with and without IONM were reviewed: three prospective, randomized trials, seven prospective trials, and ten retrospective, observational studies. Overall, 23,512 patients were included, with thyroidectomy performed using IONM compared with thyroidectomy by VA. The total number of nerves at risk was 35,513, with 24,038 nerves (67.7%) in the IONM group, compared with 11,475 nerves (32.3%) in the VA group. The rates of overall RLN palsy per nerve at risk were 3.47% in the IONM group and 3.67% in the VA group. The rates of transient RLN palsy per nerve at risk were 2.62% in the IONM group and 2.72% in the VA group. The rates of permanent RLN palsy per nerve at risk were 0.79% in the IONM group and 0.92% and in the VA group. None of these differences were statistically significant, and no other differences were found. Conclusions: The current review with meta-analysis showed no statistically significant difference in the incidence of RLN palsy when using IONM versus VA during thyroidectomy. However, these results must be approached with caution, as they weremainly based on data coming from nonerandomized observational studies. Further studies including high-quality multicenter, prospective, randomized trials based on strict criteria of standardization and subsequent clustered meta-analysis are required to verify the outcomes of interest

Carotid body tumour. Case report and literature review

The tumour of the carotid body is rare. About 1000 cases had been reported in the literature. It may occur sporadically in 90% of cases and it affects both sexes in the same proportion and in the middle age. This tumour may be misdiagnosed if it is not suspected. Ultrasono-graphy and color-Doppler scan show a hypervascular tumour between the internal and external carotid arteries. CT-scan defines the tumour s extent on the surrounding structures. Angiography is the gold standard for diagnosis, showing a hypervascular mass displacing the bifurcation of the carotid arteries. Sometimes radiotherapy and embolization are indicated but the surgical excision of carotid body tumours is the therapy of choice. The surgical approach through incision like carotid artery operation is performed. If the subadventitial plane between tumour and arterial wall is not identified, resection of carotid artery and insertion of a shunt is required. Although the diagnosis and the surgical technique advances, the incidence of postoperative nerve injury is high in the different series. The clinical suspect and the early diagnosis are very important because low morbidity rate occurs with resection of a small chemodectoma. The surgical excision can be followed by postoperative respiratory depression or dyspnea both with regional and general anesthesia. The authors report a case of a medium size tumour operated on and developing a mild transient weakness of cranial nerve VII. Recent trends in evaluation and therapy are analysed and the literature is reviewed

Current indications for laparoscopic adrenalectomy in the era of minimally invasive surgery

The aim of this study was to clarify the current indications for laparoscopic adrenalectomy, reviewing both our own experience and the literature data. Since January 2000, 22 patients have undergone adrenalectomy in our department: 17 (77.3%) with the laparoscopic approach and 5 (22.7%) with the traditional one. The indications for laparoscopy were: 6 Cushing's adenomas, 4 aldosterone-producing adenomas, 4 non-functional adenomas, 2 pituitary-dependent bilateral adrenocortical hyperplasias and 1 metachronous adrenal metastasis. The conversion rate to laparotomy was 11.7%. The indications for the open approach were: tumours greater than 7 cm and previous abdominal surgery. The mean size of laparoscopic specimens was smaller than those removed by the open procedure (3.9 cm versus 6.7 cm). The mean postoperative hospital stay in the laparoscopic group was 4.9 days as compared to 10.2 days in the open group. Morbidity was encountered in 2/17 laparoscopically treated patients (11.7%) and in 2/5 patients in the open group. In our early experience, laparoscopic adrenalectomy has been the procedure of choice for removing unilateral or bilateral tumours measuring less than 7 cm in diameter. Nevertheless, apart from diameter cut-off, on the basis of evidence from the literature, an invasive carcinoma is currently considered the only absolute contraindication to laparoscopy

Can intraoperative cholangiography be avoided during laparoscopic cholecystectomy?

Controversy exists as to whether intraoperative cholangiography should be performed routinely or selectively during laparoscopic cholecystectomy. The aim of the present study was to assess in which circumstances intraoperative cholangiography can be avoided during laparoscopic cholecystectomy. From January 1999 to June 2002, 168 patients undergoing laparoscopic cholecystectomy for cholelithiasis without intraoperative cholangiography were prospectively evaluated at our Department. Inclusion criteria were established according to a preoperative diagnostic protocol, considering only those patients with normal liver function tests and ultrasound common bile duct diameters &amp;lt; or = 5 mm or &amp;gt; 5 mm, but with normal magnetic resonance cholangiopancreatography findings. Laparoscopic cholecystectomy was carried out without intraoperative cholangiography and postoperative results and follow-up data were recorded and analysed. No major biliary injuries were encountered and no patients had residual bile duct stones after at least a one-year postoperative follow-up. A complete preoperative diagnostic work-up proved to be of fundamental importance for decreasing the incidence of residual bile duct stones. When protocol criteria are satisfied, intraoperative cholangiography may be safely omitted during laparoscopic cholecystectomy and meticulous laparoscopic technique is the main way to reduce the incidence of iatrogenic biliary lesions to a minimum