Antibiotic prophylaxis in thyroid surgery: a preliminary multicentric italian experience

Post-operatory wound infections are a very uncommon finding after thyroidectomy. For these reasons international guidelines do not routinely recommend systemic antibiotic prophylaxis

Parathyroid Retrospective Analysis of Neoplasms Incidence (pTRANI Study): An Italian Multicenter Study on Parathyroid Carcinoma and Atypical Parathyroid Tumour

Background: Parathyroid cancer (PC) is a rare sporadic or hereditary malignancy whose histologic features were redefined with the 2022 WHO classification. A total of 24 Italian institutions designed this multicenter study to specify PC incidence, describe its clinical, functional, and imaging characteristics and improve its differentiation from the atypical parathyroid tumour (APT). Methods: All relevant information was collected about PC and APT patients treated between 2009 and 2021. Results: Among 8361 parathyroidectomies, 351 patients (mean age 59.0 ± 14.5; F = 210, 59.8%) were divided into the APT (n = 226, 2.8%) and PC group (n = 125, 1.5%). PC showed significantly higher rates (p < 0.05) of bone involvement, abdominal, and neurological symptoms than APT (48.8% vs. 35.0%, 17.6% vs. 7.1%, 13.6% vs. 5.3%, respectively). Ultrasound (US) diameter >3 cm (30.9% vs. 19.3%, p = 0.049) was significantly more common in the PC. A significantly higher frequency of local recurrences was observed in the PC (8.0% vs. 2.7%, p = 0.022). Mortality due to consequences of cancer or uncontrolled hyperparathyroidism was 3.3%. Conclusions: Symptomatic hyperparathyroidism, high PTH and albumin-corrected serum calcium values, and a US diameter >3 cm may be considered features differentiating PC from APT. 2022 WHO criteria did not impact the diagnosis

Interposition of the gallbladder in the common hepatic duct: a rare dangerous anomaly. Case report

Introduction. Anomalies of the gallbladder position in the biliary tract are rare, but they could be very dangerous during cholecystectomy. Case report. A 48-year-old man presented with a 2-week history of intermittent epigastric pain, scleral jaundice and elevation of liver function tests. After a magnetic resonance cholangiogram and an endoscopic retrograde cholangiogram with sphincterotomy, he was submitted to laparoscopic cholecystectomy, the conversion to laparotomy was decided for the suspect of gallbladder interposition. The anatomical anomaly was confirmed and a Roux-en-Y hepaticojejunostomy was executed, with end-to-side anastomosis between the confluence of the hepatic ducts and the fourth loop of jejunum, on a biliary stent. This catheter was removed in the tenth postoperative day; after cholangiography and CT abdominal scan the patient was discharged, without complications. Conclusion. The gallbladder interposition is a rare malformation which seems to arise from an embryonic anomaly occurring between the 4th and the 5th week and whose potential causes have not been detected. A similar outcome could be also determined by a Mirizzi syndrome, but in our case it is excluded because intra-operatively there was no inflammatory reaction that could justify the presence of a fistula between the gallbladder and the common hepatic duct. Once the gallbladder interposition is found, the surgical treatment consists in removing the gallbladder itself and the corresponding part of the common hepatic duct. The reconstruction is carried out by a Roux-en-Y hepaticojejunostomy with anastomosis at the hepatic hilum, positioning a biliary stent

I tumori desmoidi intra-addominali: una patologia rara, ma importante

I tumori desmoidi sono rare neoplasie benigne, con elevata tendenza alla recidiva locale, classificabili in forme extra- e intra-addominali (fibromatosi mesenteriche). Complessivamente sono stati trattati nel nostro Dipartimento, tra il 1997 ed il 2006, 8 pazienti con tumori desmoidi, di cui sei (3 uomini e 3 donne) affetti da localizzazioni extraddominali e quindi sottoposti ad exeresi radicale. In due casi il tumore desmoide era intra-addominale: un uomo di 55 anni, ricoverato per addome acuto, e sottoposto in urgenza ad asportazione di una formazione ascessualizzata inglobante un’ansa digiunale incarcerata, a circa un metro dal Treitz; nel secondo caso, un uomo di 52 anni è stato sottoposto, in elezione, ad asportazione di una neoformazione capsulata del piccolo omento responsabile di una sintomatologia dolorosa addominale gravativa. In entrambi i casi la diagnosi istologica è stata di fibromatosi mesenterica. Il trattamento chirurgico dei tumori desmoidi deve tendere alla exeresi radicale per evitare le recidive (25-65%); proprio queste hanno stimolato la ricerca di altri tipi di trattamento, poiché il reintervento, di per sé, può essere un fattore favorente la recidiva. Sono stati indagati: la radioterapia, con buoni risultati nel 79-96% dei casi; l’utilizzo della terapia ormonale antiestrogena, con successo nel 51%; il tamoxifene ad alte dosi, che sembra ottenere stabilizzazione nelle forme non resecabili; l’uso di FANS, in associazione a tamoxifene e chemioterapia. Risultati conclusivi sull’efficacia di questi trattamenti non sono disponibili per la rarità dei tumori desmoidi anche nei maggiori Centri

Unilateral phrenic nerve paralysis: a rare complication after total thyroidectomy for a large cervico-mediastinal goitre

Unilateral phrenic nerve paralysis is a rare complication of cervico-mediastinal goitre. It occurs when adhesions grow between the intrathoracic part of the thyroid and the nerve, specially where the goitre enters the mediastinum behind the first rib. The damage may be caused by strain of the nerve due to the descent of the goitre into the chest or may be caused by the surgical manoeuvres during thyroidectomy performed by cervical approach. Two patients operated on for large cervico-mediastinal goitre are reported: a 70-year-old male with a large intrathoracic growth of the left thyroid lobe and a 54-year-old male with a large intrathoracic growth to the right lobe. A few days after total thyroidectomy they showed signs of exertional dyspnoea. The exams performed showed hemi-diaphragm relaxatio due to phrenic nerve paralysis, with resulting reduction of respiratory space. Phrenic nerve paralysis may follow total thyroidectomy for large cervico-mediastinal goitres; is not due to the operative technique, but rather to the particular anatomic conditions which may be found

Thyroidectomy with ultrasonic dissector: a multicentric experience

Obiettivo. Abbiamo condotto uno studio clinico controllato (Clinical Control Trial - CCT) su 2.736 pazienti (pz) sottoposti a tiroidectomia per gozzo o carcinoma della tiroide. Obiettivo dello studio era valutare i benefici del dissettore ad ultrasuoni rispetto alla sola tecnica chirurgica convenzionale (legatura e sezione del vaso). Pazienti e metodi. Tra gennaio 2007 e dicembre 2009 2.736 pz sono stati arruolati in questo CCT e suddivisi in due gruppi: 1.021 pz (203 M e 818 F) sottoposti a tiroidectomia con dissettore ad ultrasuoni (UAS) e 1.715 (369 M e 1,346 F) sottoposti a tiroidectomia con tecnica convenzionale (CT). Risultati. La durata dell’intervento chirurgico (UAS 80 min in media, da 50 a 120 min, vs CT 120 min, da 70 a 180 min) è minore nel gruppo sottoposto a tiroidectomia con UAS. L'incidenza di paralisi transitoria del nervo laringeo ricorrente (UAS 17/1.021, 1,6%, vs CT 16/1.715 , 0.9%) è risultata maggiore nel gruppo sottoposto a tiroidectomia con UAS; l'incidenza di paralisi permanente del nervo laringeo ricorrente è stata simile nei due gruppi (UAS 9/1.021, 0,9%, vs CT 18/1.715, 1%). L'ipocalcemia transitoria (UAS 98/1.021, 9,5%, vs CT 132/1.715, 7,7%) è risultata maggiore nel gruppo sottoposto a tiroidectomia con UAS; non vi sono differenze significative per l’ipocalcemia permanente (UAS 26/1.021, 2,5%, vs 35/1.715, 2%). La degenza media post-operatoria è stata simile (2 giorni). Conclusioni. Questo CCT ha dimostrato un significativo vantaggio in termini di diminuzione dei costi per i pazienti trattati con UAS; ciò è conseguente alla riduzione dei tempi dell’intervento chirurgico. L’UAS non ha presentato vantaggi in termini di complicanze post-operatorie transitorie: ipocalcemia (UAS 9,5% vs CT 7,7%) e paralisi del nervo laringeo ricorrente (UAS 1,6% vs CT 0.9%). Non ci sono neppure differenze nell’incidenza di paralisi permanente del nervo laringeo ricorrente (UAS 0,9% vs CT 1%) e di ipocalcemia permanente (UAS 2,5% vs CT 2%). L'esperienza del chirurgo è l'unico fattore significativo nella comparsa di complicanze. L'utilizzo del dissettore ad ultrasuoni può agevolare l'atto chirurgico, ma non si può sostituire all'esperienza dell'operatore. È necessario eseguire nuovi e più ampi RCT con il nuovo dissettore ad ultrasuoni Focus

Recurrent laryngeal nerve damage and phonetic modifications after total thyroidectomy: Surgical malpractice only or predictable sequence?

Modifications of phonation occurring after total thyroidectomy (TT) are usually attributed to surgical malpractice, but other causes of voice impairment even in nonoperated subjects should also be taken into account. This study analyzes 208 patients who underwent TT from January 1, 1999 through December 31, 2001. Follow-up ended on December 31, 2003. Only cases in which the surgeon ruled out the possibility of operative damage to the laryngeal nerves were included. All patients underwent pre- and postoperative clinical and instrumental nose and throat examination (NTE). Preoperatively, 86 patients (41%) showed hoarseness or dysphagia: 4 (2%) monoplegia and 12 (6%) hypomobility of the vocal cords due to impaired function of the recurrent laryngeal nerve (RLN); 6 (3%) cord hypotonia due to impairment of the superior laryngeal nerve (SLN); 34 (16%) dysphagia: and 30 (14%) hoarseness due to other causes. At follow-up 1 month after surgery, 71 patients (34%) had an onset of previously absent signs and symptoms: 8 (4%) had palsy of one vocal cord (2% permanent); 6 (3%) had cord hypomobility (all temporary); 12 (6%) had cord hypotonia due to disease of the SLN, 4 of which (2%) were permanent; 44 patients (21%) had symptoms due to scarring and adhesions between the laryngotracheal axis and the prethyroid muscles and between these and the skin. One patient (0.5%) had a nodular cord lesion that occurred after 3 months. Overall, more than one-third of the patients had preoperative voice modifications or swallowing impairment, around one-third had these problems after TT, and less than one-third were free of pre- and postoperative complications. The surgeon's care to avoid damage to the anatomica integrity of the of laryngeal nerves does not exclude functional problems of the nerves and of laryngeal dynamics. In fact, such problems could be referred to outcomes linked to the operation itself (hematoma, edema, scarring adhesion) or to events that only temporarily follow surgery but must be considered as an unavoidable sequel (e.g., neuritis, viral neuritis, myopathy). The patient should undergo a careful clinical and instrumental NTE to detect conditions prior to surgery, and the information provided by the surgeons should be thorough to allow the patient to be aware of all possible sequels and consequences