Intraoperative neuromonitoring in thyroidectomy: The learning curve

AIM: To evaluate the learning curve in the use of intraoperative neuromonitoring of recurrent laryngeal nerve and vagus in thyroid surgery. MATERIALS OF THE STUDY: We analyzed 140 pts treated consecutively for thyroid disease. All the patients were neuromonitored with Intraoperative neuromonitoring of recurrent laryngeal nerve and vagus. We divided these patients in 7 groups to collect the adverse events during our learning curve. RESULTS: We monitored consecutively 271 nerves. The incidence of transient paralysis was 0.73%.No significant differences were recorded in the groups about the calceium values,the mean operative time. Sensitivity was 100%, specificity 99%, Predictive positive value was 33%, negative predictive value was 100%. DISCUSSION: The recurrent laryngeal nerve injury is the most frequent adverse event in thyroid surgery. The causes of the lesion are different. The introduction of non-invasive monitoring devices that define the standard of IONM in thyroidectomy is increasing in the last period. In our study we performed the neuromonitoring in four times finding several benefits: avoid damage from excessive traction of the thyroid; early identification of RLN extra-laryngeal branches; identification and preservation of the parathyroid glands. CONCLUSION: The use of neuromonitoring in course of thyroidectomy helps the surgeon to early localization, identification, visualization and dissection of the RLN. It is important highlight that for the surgeon, especially the less experienced, the opportunity to immediately verify the absence of nerve structures and the presence of lesions is very important especially in education and research. We confirm that real learning curve requires at least 60 consecutive cases as reported by others in literature

Laparoscopic Resection of Synchronous Liver Metastasis Involving the Left Hepatic Vein and the Common Trunk Bifurcation: A Strategy of Parenchyma-Sparing Resection with Left Sectionectomy and 4a Subsegmentectomy by Arantius Approach

When colorectal cancer presents with liver metastasis, hepatic resection remains the most important factor in prolonging survival, and new paradigms have been proposed to augment resectability. An adequate liver remnant and vascularisation are the only limits in complex liver resection, and parenchyma-sparing surgery is a strategy for minimising the complications, preserving liver function, and allowing patients to undergo further liver resection. The laparoscopic approach represents a new challenge, especially when lesions are located in the superior or posterior part of the liver. We discuss the case of an 81-year-old patient with a single synchronous liver metastasis involving the left hepatic vein and leaning into the middle hepatic vein at the common trunk, where we performed a simultaneous laparoscopic colonic resection with a left sectionectomy extended to segment 4a. The strategic approach to the Arantius ligament by joining the left and middle hepatic vein allowed us to avoid a major liver hepatectomy, preserve the liver parenchyma, reduce complications, enhance patient recovery, and perform the entire procedure by laparoscopy. Our example suggests that the Arantius approach to the left hepatic vein and the common trunk could be a feasible approach to consider in laparoscopic surgery for lesions located in their proximity

The prognostic role of tumor size in patients with gastric cancer

The identification of prognostic factors in gastric cancer is important for predicting patients' survival and determining therapeutic strategies

A prospective cohort analysis of the prevalence and predictive factors of delayed discharge after laparoscopic cholecystectomy in Italy: the DeDiLaCo Study

Background: The concept of early discharge ≤24 hours after Laparoscopic Cholecystectomy (LC) is still doubted in Italy. This prospective multicentre study aims to analyze the prevalence of patients undergoing elective LC who experienced a delayed discharge >24 hours in an extensive Italian national database and identify potential limiting factors of early discharge after LC. Methods: This is a prospective observational multicentre study performed from January 1, 2021 to December 31, 2021 by 90 Italian surgical units. Results: A total of 4664 patients were included in the study. Clinical reasons were found only for 850 patients (37.7%) discharged >24 hours after LC. After excluding patients with nonclinical reasons for delayed discharge >24 hours, 2 groups based on the length of hospitalization were created: the Early group (≤24 h; 2414 patients, 73.9%) and the Delayed group (>24 h; 850 patients, 26.1%). At the multivariate analysis, ASA III class ( P <0.0001), Charlson's Comorbidity Index (P=0.001), history of choledocholithiasis (P=0.03), presence of peritoneal adhesions (P<0.0001), operative time >60 min (P<0.0001), drain placement (P<0.0001), pain ( P =0.001), postoperative vomiting (P=0.001) and complications (P<0.0001) were independent predictors of delayed discharge >24 hours. Conclusions: The majority of delayed discharges >24 hours after LC in our study were unrelated to the surgery itself. ASA class >II, advanced comorbidity, the presence of peritoneal adhesions, prolonged operative time, and placement of abdominal drainage were intraoperative variables independently associated with failure of early discharge