Risk stratification of 282 differentiated thyroid cancers found incidentally in 1369 total thyroidectomies according to the 2015 ATA guidelines; implications for management and treatment.

Introduction The purpose of this study was to evaluate the incidence of incidental differentiated thyroid carcinoma in thyroid operations for a benign preoperative diagnosis, to identify the risk factors involved and to risk stratify the cancer patients according to the 2015 American Thyroid Association (ATA) guidelines. Materials and methods The study was a retrospective review of all thyroidectomy operations performed in a single institution (January 2004 to January 2009). We excluded patients with a preoperative diagnosis of thyroid malignancy. Results Incidental differentiated thyroid carcinoma was diagnosed in 282/1369 patients (21%). The incidental group had a significantly higher number of males (19% vs 14%, P = 0.033) and a higher number of patients with histopathological evidence of thyroiditis (35% vs 25%, P = 0.004). There was a higher number of lymph nodes present in the incidental group but numbers did not reach statistical significance (17% vs 13%, P = 0.079). There were 270 cases in the ATA low-risk group (96%) and 12 cases in the ATA intermediate-risk group (4%). Patients with an ATA intermediate risk had a statistically higher number of capsule invasion, extrathyroidal extension and angioinvasion (P < 0.001, P < 0.001 and P < 0.001, respectively). Overall, 22% of patients with an incidental differentiated thyroid carcinoma should be considered for radioactive iodine 131I treatment. 29 of the 191 patients in American Joint Committee on Cancer stage I should be considered for radioactive iodine treatment (15%). Conclusions Males and patients with thyroiditis are at a higher risk for an incidental differentiated thyroid carcinoma. One of every five of patients diagnosed with cancer will need radioactive iodine treatment, even some patients with stage I disease.

Is preservation of the adrenal vein mandatory in laparoscopic adrenal-sparing surgery?

BACKGROUND AND OBJECTIVE: Adrenal tissue-sparing or partial adrenalectomy evolved initially for patients with bilateral synchronous adrenal surgical pathology to preserve vital adrenal volume. In the laparoscopic era, the exact criteria for performing such procedures laparoscopically have yet to be defined. Controversy exists regarding the importance of preserving the adrenal vein, main or accessory. The aim of this retrospective study was to present our short series of laparoscopic tissue-sparing adrenalectomies with vein preservation. Our main goal is not to support partial adrenalectomy as an alternative to total (this is already advocated by many surgeons) but to emphasize the vein-preserving technique. METHODS: Seven patients with peripherally located either aldosterone-producing adenomas (4 cases) or myelolipomas (4 cases) underwent laparoscopic lateral partial adrenalectomy. One patient harbored an aldosterone-producing adenoma and a myelolipoma as well. The main adrenal vein was identified and preserved in 6 patients and the accessory vein in one. RESULTS: No conversion to open adrenalectomy was necessary, and no perioperative morbidity or mortality occurred. Three adenoma patients are normotensive 44, 23, and 20 months postoperatively, while the fourth one's pressure is refractory. CONCLUSIONS: Surprisingly, total adrenalectomies preceded the partial ones, which is controversial compared with other procedures. Laparoscopic lateral partial adrenalectomy is a technically challenging tissue-sparing operation. Meticulous dissection allows preservation of the middle artery and main or accessory vein resulting in a functioning adrenal stump.

Feasibility of laparoscopic adrenalectomy for large pheochromocytomas.

BACKGROUND AND OBJECTIVES: The majority of surgeons consider large and potentially malignant pheochromocytomas an absolute contraindication for laparoscopic adrenalectomy (LA). The aim of this study was to evaluate the risks and outcomes of LA in patients with this anomaly. METHODS: Five patients (2 males, 3 females) with large (>6 cm) pheochromocytomas were selected. Preoperative investigation demonstrated no evidence of invasive carcinoma. All patients received alpha-blocker preparation for at least 20 days. Laparoscopic adrenalectomy via a lateral transperitoneal approach was performed in all cases. RESULTS: Patient's median age was 48 years, and the median tumor size was 10.8 cm. No capsular disruption and no hypertensive crises occurred during the operation. The median operating time was 148 minutes and blood loss was <150 mL. Conversion to open adrenalectomy occurred in 2 patients owing to intraoperative evidence of carcinoma. No postoperative morbidity or mortality occurred. All patients are disease free after a median follow-up of 13 months. CONCLUSIONS: In experienced hands, LA can be proposed for large and potentially malignant pheochromocytomas. Conversion to open adrenalectomy is mandatory if local invasion, capsular disruption, or technical difficulties are observed during the operation.

Small bowel intussusception due to metastatic malignant melanoma. A case report.

Small bowel metastatic deposits attributed to malignant melanoma are found in 2-5% of patients with malignant melanoma of the skin. Ileo-ileo intussusception caused by metastatic melanoma is a very rare condition. The prognosis of metastatic melanoma is poor. We report a case of a cutaneous malignant melanoma which metastasised to the small bowel causing enteroenteric intussusception. This case refers to a 66-year-old male patient who underwent surgery for suspected enteric intussusception. This diagnosis was suggested by computer tomography scan. The patient had had previous surgery for a primary malignant melanoma in the eyelid of the right eye. Segmental intestinal resection with regional lymph node dissection and ileo-ileo anastomosis was performed. Metastatic melanoma in the gastrointestinal tract should be suspected in patients with history of melanoma of the skin and acute gastrointestinal symptoms. Immediate laparotomy and excision of the affected bowel segment is the appropriate treatment.

Surgical management of large bowel obstruction due to colonic cancer.

BACKGROUND: Bowel obstruction represents a common surgical emergency. The purpose of this study is to highlight our principles while managing cases of large bowel obstruction (LBO) due to colonic carcinoma. METHODS: Twenty-one patients with LBO underwent emergency surgery. Patients with LBO caused by obstructive malignant colonic lesions underwent either with one-stage primary resection and anastomosis (14 patients, 67%) or two-stage operation (7 patients, 33%). RESULTS: There were no operation-related complications. The average length of hospitalisation was 14 days with a range from 10 to 23 days. Postoperative mortality was 14%. CONCLUSIONS: One-stage primary resection and anastomosis of the large bowel, is a feasible option in cases of emergency. LBO caused by colonic carcinoma can be performed with acceptable morbidity and mortality whenever comorbidity of the patient is not a contraindication.