THYROID SURGERY, NEW TECNIQUES: ROBOT ASSISTED TRANSAXILLARY THYROIDECTOMY (RATT) vs MINIMALLY INVASIVE VIDEOASSISTED THYROIDECTOMY ( MIVAT)

Background. No studies have compared Robot assisted transaxillary thyroidectomy (RATT) and Minimally Invasive Videoassisted Thyroidectomy (MIVAT) regarding cosmetic outcome and satisfaction Methods Patients matching the inclusion criteria (benign nodule less than 6 cm and thyroid volume less than 30 mL) were randomly allotted to undergo MIVAT (group A) or RATT (group B). Cosmetic result, overall satisfaction, operative time and complications were evaluated. Results 62 patients underwent hemithyroidectomy (30 in group A and 32 in group B). All patients were females except one male in each group. Mean age was 36.9 years (group A) and 33.8 years (group B). Nodule diameter was larger in group B (33.9 mm) than in group A (15.2 mm). Surgical time was comparable: 46.5 minutes in group A and 54.9 minutes in group B. Total time (intubation-extubation) was shorter in group A (71.6 minutes) than in group B (122.6 minutes). Complications were one transient laryngeal nerve injury in both groups and one subcutaneous hematoma in group B. Postoperative stay was longer in group B (1.92 days) than in group A (1.15 days). On the PASQ questionnaire, “scar appearance” and “satisfaction with appearance” scores resulted better in group A than in group B. In the SF-36 questionnaire, domains of “social activity” and “general health” were better in group B than in group A, while “bodily pain” resulted higher in group B than in group A. Conclusions RATT seems not to overcome MIVAT when comparing two groups of patients undergoing thyroidectomy for benign disease, although nodule diameter was significantly larger in the RATT group

Day case parathyroidectomy: is this the right way for the patients?

Minimally-invasive video-assisted parathyroidectomy (MIVAP) can be considered as the primary treatment of choice for single parathyroid adenoma. Often, this technique is performed in a day surgery setting and is associated with regional anaesthesia (RA). Many studies have already reported the feasibility and safety of MIVAP in day surgery. Here our focus has been on the patient's personal experience with these procedures through an assessment of their recovery at home

Use of the new Lake Louise Criteria improves CMR detection of atypical forms of acute myocarditis

The purpose of our study was to compare diagnostic performance of old and new Lake Louise Criteria (oLLC and nLLC) among different clinical presentations: infarct-like (IL), cardiomyopathic (CM) and arrhythmic (AR). 102 patients with clinical suspicion of acute myocarditis underwent cardiac magnetic resonance (CMR) on a 1.5 T scanner. Protocol included cine-SSFP, T2-weighted STIR, T2 mapping, early and late gadolinium enhancement and T1 mapping acquired before and after gadolinium administration. The degree of agreement has been calculated with Cohen's K test. 42 patients also underwent endomyocardial biopsy (EMB). IL onset was present in 54/102 patients, CM in 28/102 and AR in 20/102. nLLC were positive in 58.3% of the patients, while oLLC in 37.9%, k = 0.57 (IC: 0.428-0.713). The degree of agreement between nLLC and oLLC was 0.49 (IC: 0.111-0.876) for AR onset (nLLC positive in 35% vs oLLC in 15%), 0.25 (IC: 0.035-0.459) for CM pattern (nLLC positive in 60.7% vs oLLC 17.9%) and 0.73 (IC: 0.543-0.912) for IL presentation (nLLC positive in 66.7% vs oLLC in 57.4%). Diagnostic accuracy was 75% for both nLLC and oLLC among IL onset, and 41.6% for oLLC vs 66.7% for nLLC, as regards CM clinical presentation. nLLC have improved diagnostic performance of CMR for the diagnosis of acute myocarditis, in particular for atypical clinical presentation

Track Recurrence after Robotic Transaxillary Thyroidectomy: A Case Report Highlighting the Importance of Controlled Surgical Indications and Addressing Unprecedented Complications

Background: Robot-assisted transaxillary thyroid surgery (RATS), widely accepted and used in Asian countries, can be an appealing treatment option both for patients with major concerns regarding a cervical scar and for their surgeons. Patients benefit from scarless neck surgery, while their surgeons benefit from improved dexterity and ergonomics compared with remote-access endoscopic thyroid surgery. However, validating any novel surgical procedure for thyroid pathology should be based on evidence regarding its feasibility, radicality, and safety compared to the time-honored, safe and effective, conventional open thyroidectomy. It should also be evaluated for potential risks that are not present with conventional approaches. Patient findings: This study reports a patient with surgical track and cervical nodal recurrence, and distant metastasis following a two-stage robot-assisted surgery, and radioactive iodine ablation therapy for a papillary thyroid carcinoma that was initially regarded a single indeterminate nodule. Summary: This case emphasizes the importance of thoroughly evaluating the oncological safety of RATS, and points out the possibility of "malignant seeding along the surgical access" being an untraditional potential complication associated with the procedure. Conclusions: While tailoring the surgical strategy to the patients' concerns and desires is important, adhering to fundamental onco-surgical principles is a priority. Furthermore, unconventional complications associated with novel surgical procedures should be properly evaluated and addressed

A nonfunctioning parathyroid carcinoma misdiagnosed as a follicular thyroid nodule.

Parathyroid carcinoma (PC) is a rare endocrine malignancy. The tumor is mostly functioning, causing severe primary hyperparathyroidism, with high serum calcium and parathyroid hormone (PTH) levels. Nonfunctioning PC is extremely rare. We report a 50-year-old male patient who was referred to our Department for a right thyroid nodule, incidentally detected on carotid Doppler ultrasound scan, with a fine-needle aspiration cytology showing a follicular lesion. At the time of our evaluation, neck ultrasound showed a 1.3 cm right hypoechoic thyroid nodule with irregular margins and the absence of enlarged bilateral cervical lymph nodes. Thyroid function tests were normal. Serum calcium was normal and plasma PTH slightly above the upper limit of the normal range. The patients underwent right lobectomy. The intraoperative frozen-section pathological examination raised the suspicion of a PC. Definitive histology showed a markedly irregular infiltrative growth of the tumor with invasion of the thyroid tissue and cervical soft tissues. Immunostaining for thyroglobulin was negative, whereas staining for chromogranin A and PTH showed a strong reactivity. Based on the microscopic findings and the immunohistochemical profile, the tumor was diagnosed as a PC. Postoperative serum calcium and phosphate levels were in the normal range. One month after surgery, serum calcium and PTH were normal. Neck ultrasound and total body computed tomography scan were negative for local and metastatic disease. Eight months later, serum calcium was normal and plasma PTH level remained around the upper limit of normal range. Neck ultrasound did not show any pathological lesions. This is the first case of a nonfunctioning sporadic PC misdiagnosed prior of surgery as a follicular thyroid nodule. The parathyroid nature of the neck lesion could not be suspected before surgery. Fine-needle aspiration cytology (FNAC) may fail to distinguish a parathyroid tumor from a benign thyroid nodule because at FNAC, parathyroid and thyroid lesions have some morphological similarities. Histological criteria are not always sufficient for the differential diagnosis, which can definitely be established using immunohistochemistry

Delayed-Enhanced Cardiac MRI for Differentiation of Fabry's Disease from Symmetric Hypertrophic Cardiomyopathy

OBJECTIVE. Fabry's disease may be difficult to differentiate from symmetric hypertrophic cardiomyopathy. Our aim was to compare the myocardial location and distribution patterns of delayed enhancement between patients with Fabry's disease who are affected by symmetric myocardial hypertrophy and patients with symmetric hypertrophic cardiomyopathy in order to identify a specific sign to best differentiate the two diseases. CONCLUSION. Patients with Fabry's disease-related hypertrophy showed left ventricular (LV) delayed enhancement with a typical and consistently found pattern characterized by the involvement of the inferolateral basal or mid basal segments and a mesocardial distribution that spared the subendocardium. This pattern seems to be specific to Fabry's disease; in fact, patients with symmetric hypertrophic cardiomyopathy had variable locations and distributions of delayed enhancement. These observations may contribute to identifying Fabry's disease as a specific cause of symmetric hypertrophy

Prevention and management of bleeding in thyroid surgery

Post-thyroidectomy neck hematoma represents a major concern for surgeons because it can result in severe and even life-threatening complications. In fact, postoperative hemorrhage may result in airway compression and respiratory distress, and therefore, effective hemostasis is an important goal in thyroid surgery. Postoperative hematoma occurs at a rate of approximately 0.1% to 1.1%. Almost all cases occur in the first 6 h after surgery and can be the result of several surgeon or patient factors. For many years the clamp-and-tie technique has been the most common way to divide the main vascular pedicles of the thyroid gland. Alternatively, bipolar electrocautery has been used for only very small vessels. Other hemostatic systems have been introduced and proved to be potentially very useful in neck surgery and, in particular, for thyroid surgery. This new class of instruments is generally known as "energy devices" because they use different forms of energy, such as advanced bipolar (LigaSureTMSmall Jaw Medtronic, Covidien product, Mineapolis, MN, USA) and ultrasound (Harmonic Focus; Ethicon, Johnson and Johnson, Cincinnati, OH, USA), and hybrid devices that join these two technologies (Thunderbeat by Olympus, Japan). Although they all generate a significant elevation of temperature in the tissues, as in any form of energy, the temperatures reached by these instruments are never as high as the standard monopolar electrocautery. For small bleeding very close to critical structures, where energy devices are too dangerous to be used and clamp and tie is not possible, several studies have assessed the use of adjunctive hemostatic agents. In conclusion, all energy devices have been shown to significantly decrease operative times without increasing costs or complications. Adjunctive hemostatic agents have shown equivalent differences when added to standard methods from a clinically significant perspective