Efficacy of opioid-free anesthesia in modified radical mastectomy: a cross-sectional observational study.

Introduction: Perioperative management of female patients undergoing breast surgeries differs from other patients due to chronic pain and postoperative nausea and vomiting. The anesthesia could consist of opioid-free general anesthesia (OFA) or non-opioid-free general anesthesia (NOFA). OFA relies on multimodal analgesia preoperatively and postoperatively. However, it is not yet established whether OFA could replace NOFA as a standard regimen for the management of breast surgeries. The aim of this study is to evaluate the efficacy of OFA for breast surgeries in female patients. Materials and methods: Patients undergoing modified radical mastectomy were retrospectively recruited. Two groups were defined: group 1, consisting of treated patients using OFA and group 2, consisting of treated patients using NOFA. Mean time to extubate and mean dose of morphine after recovery were computed. Postoperative morphine and antiemetic use were assessed for up to 24 h. A comparison of the computed data was conducted between both groups. Results: A total of 116 patients were included with a mean age of 53±13 years. Group 1 consisted of 56 (mean age was 54±14 years). Group 2 consisted of 60 patients (mean age was 51±12 years). Demographic parameters and time to extubate did not yield significant differences. We noticed morphine sparing at T0 and T12 with statistically significant differences P=0.043 and P=0.006, respectively. Conclusion: OFA could be considered in modified radical mastectomy management in female patients; nerve block seemed to act as morphine sparing in operative and postoperative settings by providing significantly less time to extubate with less postoperative morphine requirement.

Redo thyroid surgery without drains.

PURPOSE: Redo thyroid surgery is associated with higher risk of hematoma than the initial thyroid surgery. We report a single surgeon's experience of performing redo thyroid surgery without drains. METHODS: This retrospective single-institutional study evaluates the safety and efficiency of redo thyroid surgery without drains by comparing three groups of patients: those who underwent primary bilateral thyroidectomy (Group 1), those who underwent completion thyroidectomy (Group 2); and those who underwent thyroidectomy for recurrent thyroid diseases (Group 3). RESULTS: The demographic characteristics did not differ among the groups. Substernal extension and hyperthyroidism were more frequent in group 1, whereas the weight of the resected thyroid gland was lower in groups 2 and 3. Hematoma occurred in 5%, 4%, and 4% of patients in Groups 1, 2, and 3, respectively. Postoperative transient hypocalcemia occurred in 19%, 16%, and 21% of patients in Groups 1, 2, and 3 respectively. The postoperative incidence of transient recurrent laryngeal nerve (RLN) paralysis in Groups 1, 2, and 3, was 6%, 7%, and 8%, respectively. The incidence of permanent unilateral RLN paralysis in Groups 2 and 3 was 1%. The postoperative length of stay was 1 day in 92% of the patients from all groups. CONCLUSIONS: Avoiding the routine use of drains in redo thyroid surgery is safe and effective, it does not increase overall surgical morbidity, and it reduces the overall length of stay in hospital.

Correlations of neck ultrasound and pathology in cervical lymph node of papillary thyroid carcinoma.

Background: High-resolution sonography is becoming a method of choice for the detection and diagnosis of cervical lymph node metastasis in patients with papillary thyroid carcinoma (PTC). The purpose of this study is to assess the diagnostic accuracy of neck ultrasound (US) in the detection of lymph node metastases from PTC.Methods: Data for all patients with papillary thyroid cancers and preoperative neck US were reviewed retrospectively. The diagnostic accuracy of US was determined according to whether histologically confirmed cancer was present in surgical cervical lymph node specimens.Results: A total of 206 patients (149 central and 57 central and lateral lymph nodes dissection) were included. Their mean age was 56 years (14-88 years). Central and lateral lymph nodes were involved in 68% (n = 141 patients; 141/206) and 60% (n = 34 patients; 34/57) of cases, respectively. The sensitivity, specificity, positive predictive value and negative predictive value of US in predicting papillary thyroid carcinoma (PTC) metastasis in the central neck were 69%, 71%, 84% and 51% respectively, and in the lateral neck were 85%, 65%, 78% and 75% respectively.Conclusions: Preoperative neck US is a valuable tool in the detection of cervical lymph node metastases from papillary thyroid cancer and can provide reliable information to assist in surgical management.

Total or Subtotal Colectomy with Primary Anastomosis for Occlusive Left Colon Cancer: A Safe, Acceptable and Applicable Procedure.

INTRODUCTION: Occlusive left colon cancer is a major emergency setting in colon cancer with high morbidity and mortality rates. Different surgical treatment exist since there is no clear guidelines for the best treatment. We have conducted this retrospective study in order to evaluate the safety, morbidity, and bowel movement status of the operated patients. METHODS: One-hundred and one left occlusive colon cancer patients were operated of total or subtotal colon resection with primary anastomosis from March 2000 till March 2017 in Hotel Dieu de France hospital. We analyzed the sex ratio, age, caecum condition, tumor localization, number of synchronous adenoma and adenocarcinoma, Dukes stage, major complications and the number of stools per day at 3 and 12 months after surgery. RESULTS: Mean hospital stay was 7.8 days. Thirteen complications were observed in 11 (10.9%) patients, in which one (1%) patient had splenectomy for severe hemorrhage. Six synchronous adenocarcinoma and 40 adenoma with dysplasia were diagnosed on pathology specimens proximal to occlusion site. Caecum laceration was found in 33 (32.6%) of cases. No patient had anastomotic leak. After 12 months of surgery, the average bowel movement was 2 stools per day. CONCLUSION: Our study showed that treating occlusive left colon cancer with total or subtotal colectomy with primary anastomosis is a safe procedure, with a good bowel movement status and presents the advantage to resect an important number of synchronous tumors and adenomas proximal to the occlusion site.

Omental ischemia.

Omental ischemia is a rare cause of acute abdomen. Clinical diagnosis is usually difficult because clinical signs and symptoms are similar to other common causes of abdominal pain. The most common differential diagnosis is acute appendicitis. Diagnosis is mainly based on ultrasound, and especially computed tomography scan analysis. There is, at present, no standard treatment modality for omental ischemia. When diagnosed by radiological imaging, omental ischemia can be managed conservatively. We hereby review incidence, etiology, pathology, clinical presentation, differential diagnosis, biological anomalies, radiological features, and treatment options of omental ischemia.

Splenic artery aneurysm presenting as a submucosal gastric lesion: A case report.

We are reporting the rare case of splenic artery aneurysm of 4 cm of diameter presenting as a sub mucosal lesion on gastro-duodenal endoscopy. This aneurysm was treated by endovascular coil embolization and stent graft implantation. The procedure was uneventful. On day 1, the patient presented an acute severe epigastric pain and cardiovascular arrest. Abdominal computed tomography scan showed an active leak of the intravenous contrast dye in the peritoneum from the splenic aneurysm. We performed an emergent resection of the aneurysm, and peritoneal lavage. Postoperatively, hemorrhagic choc was refractory to large volumes replacement, and intravenous vaso-active drugs. On day 2, he presented massive hematochezia. We performed a total colectomy with splenectomy and cholecystectomy for ischemic colitis, with spleen and gallbladder infarction. Despite vaso-active drugs and aggressive treatment with Factor VIIa, the patient died after uncontrolled disseminated intravascular coagulation.

Vanek's tumor of the small bowel in adults.

Inflammatory fibroid polyps (IFPs), or Vanek's tumor, are one of the least common benign small bowel tumors. IFP affects both sexes and all age groups, with a peak of incidence in the fifth and seventh decades. They can be found throughout the gastrointestinal tract but most commonly in the gastric antrum or ileum. The underlying cause of IFPs is still unknown. Genetic study of IFP showed mutations in platelet derived growth factor alpha in some cases. At the time of diagnosis most IFPs have a diameter of 3 to 4 cm. The lesions have always been recorded as solitary polyps. Symptoms depend on the location and the size of the lesion, including abdominal pain, vomiting, altered small bowel movements, gastrointestinal bleeding and loss of weight. IFPs arising below the Treitz ligament can present with an acute abdomen, usually due to intussusceptions. Abdominal computed tomography is currently considered the most sensitive radiological method to show the polyp or to confirm intussusceptions. Most inflammatory fibroid polyps can be removed by endoscopy. Surgery is rarely needed. Exploratory laparoscopy or laparotomy is frequently recommended as the best treatment for intussusceptions caused by IFP. The operation should be performed as early as possible in order to prevent the intussusceptions from leading to ischemia, necrosis and subsequent perforation of the invaginated bowel segment. This report aims at reviewing the diagnosis, etiology, genetics, clinical presentation, endoscopy, radiology, and best treatment of IFP.

Treatment options of inflammatory appendiceal masses in adults.

At present, the treatment of choice for uncomplicated acute appendicitis in adults continues to be surgical. The inflammation in acute appendicitis may sometimes be enclosed by the patient's own defense mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. The management of these patients is controversial. Immediate appendectomy may be technically demanding. The exploration often ends up in an ileocecal resection or a right-sided hemicolectomy. Recently, the conditions for conservative management of these patients have changed due to the development of computed tomography and ultrasound, which has improved the diagnosis of enclosed inflammation and made drainage of intra-abdominal abscesses easier. New efficient antibiotics have also given new opportunities for nonsurgical treatment of complicated appendicitis. The traditional management of these patients is nonsurgical treatment followed by interval appendectomy to prevent recurrence. The need for interval appendectomy after successful nonsurgical treatment has recently been questioned because the risk of recurrence is relatively small. After successful nonsurgical treatment of an appendiceal mass, the true diagnosis is uncertain in some cases and an underlying diagnosis of cancer or Crohn's disease may be delayed. This report aims at reviewing the treatment options of patients with enclosed appendiceal inflammation, with emphasis on the success rate of nonsurgical treatment, the need for drainage of abscesses, the risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Idiopathic sclerosing encapsulating peritonitis: abdominal cocoon.

Abdominal cocoon, the idiopathic form of sclerosing encapsulating peritonitis, is a rare condition of unknown etiology that results in an intestinal obstruction due to total or partial encapsulation of the small bowel by a fibrocollagenous membrane. Preoperative diagnosis requires a high index of clinical suspicion. The early clinical features are nonspecific, are often not recognized and it is difficult to make a definite pre-operative diagnosis. Clinical suspicion may be generated by the recurrent episodes of small intestinal obstruction combined with relevant imaging findings and lack of other plausible etiologies. The radiological diagnosis of abdominal cocoon may now be confidently made on computed tomography scan. Surgery is important in the management of this disease. Careful dissection and excision of the thick sac with the release of the small intestine leads to complete recovery in the vast majority of cases.

Safety of thyroidectomy and cervical neck dissection without drains.

BACKGROUND: Many studies have reported that drainage after thyroidectomy does not decrease the rate of local postoperative complications. We sought to review the safety of thyroidectomy combined with cervical neck dissection (CND) without drainage. METHODS: The medical records of consecutive patients who underwent thyroidectomy without drainage were retrospectively reviewed. Two groups were defined depending on whether CND was or was not performed. The main outcome was identification of patients with cervical bleeding, hematoma or seroma. RESULTS: We included 1127 patients (139 who had CND and 988 who did not). Of these, 207 patients (18%) had transient postoperative hypocalcemia, 9 (0.8%) had permanent postoperative hypoparathyroidism, 56 (5%) had transient postoperative hoarseness and 7 (0.6%) had permanent vocal cord paralysis. A total of 44 patients (4%) experienced postoperative hematoma and/or seroma: 8 patients (6%) who had CND and 36 (4%) who did not. There was no major bleeding in the 2 groups; all patients had minor bleeding or seroma not requiring surgical intervention. The postoperative stay in hospital for both groups was 1 day in 92% of patients. Wound infection occurred in 0.8% of all patients: 1 (0.7%) who had CND and 8 (0.8%) who did not. There was no significant difference between the groups in overall perioperative complications or in time of hospital discharge. CONCLUSION: Thyroidectomy without drains is safe and effective, even in combination with CND.

Association of parathyroid pathology with well-differentiated thyroid carcinoma.

OBJECTIVE: The objective was to evaluate the association of well-differentiated thyroid carcinoma and parathyroid pathology. METHODS: The medical records of 14 patients with concomitant pathologies were retrospectively reviewed. RESULTS: Parathyroidectomies (1.3%) and thyroidectomies (3.5%) performed for well-differentiated thyroid carcinoma resulted in the diagnosis of concomitant pathologies. Five patients had a primary hyperparathyroidism (PHPT) and nine were operated for thyroidectomy with intraoperative finding of an enlarged parathyroid gland. Patients (64%) were normocalcemic preoperatively. Thirteen had papillary carcinoma. Fifty percent of patients had multiple foci of papillary microcarcinoma. Twenty-nine percent of patients had parathyroid hyperplasia. All patients with preoperative hypercalcemia normalized their serum calcium. During follow-up, thyroglobuline, calcium serum values and cervical ultrasound showed no evidence of recurrence of the diseases. CONCLUSIONS: These observations stress the importance of pre and intraoperative evaluation to detect overt thyroid and parathyroid pathology before performing a parathyroidectomy for hyperparathyroidism or a thyroidectomy for a well-differentiated thyroid carcinoma.

Digestive manifestations of parathyroid disorders.

The parathyroid glands are the main regulator of plasma calcium and have a direct influence on the digestive tract. Parathyroid disturbances often result in unknown long-standing symptoms. The main manifestation of hypoparathyroidism is steatorrhea due to a deficit in exocrine pancreas secretion. The association with celiac sprue may contribute to malabsorption. Hyperparathyroidism causes smooth-muscle atony, with upper and lower gastrointestinal symptoms such as nausea, heartburn and constipation. Hyperparathyroidism and peptic ulcer were strongly linked before the advent of proton pump inhibitors. Nowadays, this association remains likely only in the particular context of multiple endocrine neoplasia type 1/Zollinger-Ellison syndrome. In contrast to chronic pancreatitis, acute pancreatitis due to primary hyperparathyroidism is one of the most studied topics. The causative effect of high calcium level is confirmed and the distinction from secondary hyperparathyroidism is mandatory. The digestive manifestations of parathyroid malfunction are often overlooked and serum calcium level must be included in the routine workup for abdominal symptoms.

Surgical treatment of papillary thyroid carcinoma.

Papillary carcinoma accounts for 85% of differentiated thyroid cancers. We witness a yearly increased incidence and this is may be, in part, due to the increasing use of neck ultrasonography. Certain histologic subtypes of papillary carcinoma have a worse prognosis related to vascular invasion, invasion into extrathyroidal tissues, extensive tumor necrosis and/or mitoses. Adequate surgery is the most important treatment variable influencing prognosis, while radioactive iodine treatment, TSH suppression, and external beam irradiation each play adjunctive roles in at least some patients. Numerous schemes have been developed in an effort to achieve more accurate risk factor stratification. Each of the schemes allows accurate identification of the majority (70-85%) of patients at low risk of mortality (T1-3, M0 patients), allowing the follow-up and management of these patients to be less intensive than the higher-risk minority (T4 and M1 patients), who may benefit from a more aggressive management strategy. Overall 5- and 20-year survival in the low-risk group was 100% and 99% respectively. However, the survival in the high-risk group dropped to almost 72% and 57% respectively.

Cervical neck dissection without drains in well-differentiated thyroid carcinoma.

This study aims to review the safety of thyroidectomy combined with cervical neck dissection without drainage in well-differentiated thyroid carcinoma (WDTC). The medical records of consecutive patients who underwent thyroidectomy without drainage for WDTC were retrospectively reviewed. Group 1 included 123 patients who underwent thyroidectomy with central neck dissection and Group 2 included 46 patients who underwent thyroidectomy with central and lateral neck dissection. One hundred twenty-seven patients underwent thyroidectomy without neck dissection and were included in Group 3. Overall, 16 patients (5%) developed postoperative hematoma and/or seroma, seven patients (6%) in the Group 1, three patients (7%) in the Group 2, and six patients (5%) in Group 3. All patients had minor bleeding or seroma not requiring surgical intervention. Overall, 68 patients (23%) had transient postoperative hypocalcaemia, and four patients(1%) had permanent hypoparathyroidism. Seventeen patients (6%) had transient postoperative hoarseness and three had permanent vocal cord paralysis (0.6%). The postoperative stay for all groups was 1 day in 91 per cent of the cases. Patients from Groups 1 and 2 had no increased perioperative local complications or length of stay as compared with Group 3. Cervical neck dissection and thyroidectomy without drains is safe and effective in the treatment of WDTC.