Combined cardiac surgery and total thyroidectomy: our experience and review of the literature.

BACKGROUND: The prevalence of thyroid disease in patients with cardiac disease can be as high as 11.2%. Combined thyroid and cardiovascular surgery has rarely been reported. METHODS: Ten patients (6 female, 4 male, age range 51-73 years) had total thyroidectomy and cardiac surgery in the same procedure in our surgical department. Six patients had coronary artery disease; four patients had valvulopathy. The thyroid goiter was retrosternal in 6 patients. RESULTS: Mean stay in the intensive care unit was 46.4 hours; the postoperative course was complicated by transient right laryngeal nerve palsy in one case and by transient hypocalcemia in the patients in whom a parathyroid autotransplantation was performed (n = 3). There was one case of hemodynamic compromise needing vasoactive drug support; the mean hospital stay was 8.4 days. CONCLUSIONS: Our experience and our review of the literature suggest that a single-stage procedure is safe and feasible and must be preferred to different operations as it has an acceptable peri-operative and anesthesiological risk.

The impact of single parathyroid gland autotransplantation during thyroid surgery on postoperative hypoparathyroidism: a multicenter study.

BACKGROUND: We compared the surgical outcomes in patients undergoing bilateral thyroid surgery with or without parathyroid gland autotransplantation (PTAT). METHODS: One thousand three hundred nine patients underwent surgery for treatment of various thyroid diseases at three Academic Departments of General Surgery and one Endocrine-Surgical Unit throughout Italy. A nonviable gland or difficulties in dissection of the parathyroid glands were encountered in 160 (13.7%) patients. The subjects were divided into two groups: (1) patients undergoing PTAT during thyroidectomy (n = 79) versus (2) control group (n = 81), patients not undergoing PTAT. RESULTS: Clinical manifestations occurred in 5.0% of PTAT patients and in 13.6% of control patients (P = NS). Total postoperative hypocalcemia was less among PTAT than control patients (17.7% and 48.1%, respectively; P = .0001). There was no significant difference between the two groups in terms of definitive hypocalcemia (0% vs 2.5% in PTAT and control, respectively). Transient postoperative hypocalcemia was less among PTAT than controls (17.7% vs 45.7%; P = .0002). PTAT was associated with decreased occurrence of hypocalcemia in the two subgroups of patients operated for benign euthyroid disease (P < .0001), as compared with the control group. CONCLUSIONS: PTAT is an effective procedure to reduce the incidence of permanent hypoparathyroidism. Transient hypoparathyroidism appears to not be influenced by PTAT. Moreover, we observed that damage to one parathyroid gland has more side effects (ie, transient hypocalcemia) among patients who were preoperatively at low rather than at high risk of postoperative hypocalcemia.

Hypoparathyroidism after total thyroidectomy.

The aim of the study is to describe the last advances (2000-2007) in the management of hypoparathyroidism secondary to total thyroidectomies. This systematic review was conducted according to recently presented guidelines on the argument. A comprehensive literature search was performed in August 2007 consulting PubMed MEDLINE for publications, matching the terms of hypoparathyroidism/ hypocalcaemia AND parathyroid glands, total thyroidectomy, thyroid surgery, postoperative complications, and risk factors. Hypoparathyroidism remains a frequent and challenging complication following total thyroidectomy. A meticulous surgical technique with an excellent anatomical knowledge of the neck compartment are mandatory to restrain its appearance. The application of lens magnification and of parathyroid glands autotransplantation (PTAT) during thyroid surgery contribute to preventing definitive hypoparathyroidism and also to decrease the postoperative incidence of transient hypocalcaemia. Consequently, the reduction of complications rate determines the decrease of the hospitalization length, costs, and patient discomfort due to a fear of clinical manifestations, and facilitates the return to work. The microsurgical approach and the PTAT are effective and easily learnable procedures, also adaptable in less favoured areas without additional cost. We believe that these performances represent a real aid in association with an operative strategy aiming always to the preservation of parathyroid glands in situ.

Surgical management of the pancreatic stump following pancreato-duodenectomy.

Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.

Floating left innominate vein neoplastic thrombus: a rare case of mediastinal extension of follicular thyroid carcinoma.

OBJECTIVE: We report a case of advanced follicular thyroid cancer with innominate vein involvement. To our knowledge, this seems to be the first case treated in emergency surgery, reported in literature. METHOD: A 59-year-old woman with a five-year history of a large and mainly right-sided cervical mass presented with dyspnea, unilateral arm swelling, facial flushing, and venous congestion. An emergency computed tomography scan revealed a thyroid mass extending into the upper mediastinum with displacement and compression of the right jugular vein and carotid artery and apparent adherence to the superior vena cava and left innominate vein. RESULTS: An emergency total thyroidectomy was performed by means of a sternotomy. The lower portion of the retrosternal goiter projected directly into the left innominate vein, with tumor floating in its lumen. Removal of the neoplastic thrombus was performed, through an incision in the vein, en bloc with the thyroid mass. Both goiter and thrombus were completely replaced by follicular carcinoma. CONCLUSIONS: Accurate preoperative assessment through contrast-enhanced computed tomography is strongly suggested in the presence of enlarged thyroid gland extending into the mediastinum whenever angioinvasion is suspected. This could prevent blinded maneuvers such as digital externalization of the thoracic component of the gland, which can be fatal in cases of cervico-mediastinal goiter extending into great cervical or mediastinal veins.

Impact of pericardium bovine patch (Tutomesh(®)) on incisional hernia treatment in contaminated or potentially contaminated fields: retrospective comparative study.

PURPOSE: This retrospective comparative study analyzes the outcome of patients affected by incisional hernia in potentially contaminated or contaminated field, treated by three operative techniques. METHODS: 152 patients (62 M:90 F; mean age 65 ± 14 years) underwent incisional hernia repair (January 2002-January 2012) in complicated settings. Criteria of inclusion in the study were represented by the following causes of admission: mesh rejection/infection, obstruction without gangrene but with possible peritoneal bacterial translocation, obstruction with gangrene, enterocutaneous fistula or simultaneous presence of ileo- or colostomy. The patients were divided into three groups: A (n = 76), treated with primary closure technique; B and C (n = 38 each), with reinforcement by synthetic or pericardium bovine mesh (Tutomesh(®)), respectively. The prosthetic groups were divided into Onlay and Sublay subgroups. RESULTS: Significant decreases in C vs A were observed for wound infection (3 vs 37%) and recurrence (0 vs 14%), and in C vs B for wound infection (3 vs 53%), seroma (0 vs 34%) and recurrence (0 vs 16%). Patients with concomitant bowel resection (BR) (43%) showed (all P < 0.05) an increase of overall morbidity (55 vs 33%) and wound infection rate (42 vs 24%) compared to cases without BR. Morbidity presented no significant differences in C-Onlay or Sublay subgroups. B-Sublay subgroup has (all P < 0.05) lower overall morbidity (20 vs 75%), wound infection (10 vs 68%) and seroma (0 vs 46%) than B-Onlay. CONCLUSIONS: The pericardium bovine patch seems to be safe and effective to successfully repair ventral hernia in potentially contaminated operative fields, especially in association with bowel resection.

The uncertain primary diagnosis of inflammatory bowel diseases.

BACKGROUND: The purpose of this study is to re-evaluate our series of patients affected by a colonic non-neoplastic disease, in order to measure the percentage in whom we were unable to make a correct diagnosis after the first clinical and histological approach and to single-out the reasons for our inability to reach the correct diagnosis. METHODS: During the period 1985-1999 we observed 1228 patients affected by chronic inflammatory colonic diseases. RESULTS: In 859 patients (69.9%) an ulcerative colitis was diagnosed for the first time, and 248 patients (20.1%) were affected by Crohn's colitis. One hundred and twenty-one patients (9.8%) were defined as being affected by an undetermined colitis. Forty-three patients of these had a definite diagnosis, afterwards: 27 patients were affected by ulcerative colitis and 16 by Crohn's colitis. Differential diagnosis between inflammatory large bowel diseases (ILBD) and other forms of colitis was set out as follows: 62 cases out of 1228 were consequent on a bacterial infection or parasitosis; in 28 patients a colitis pseudomembranosus was diagnosed. Eighteen cases of ischemic colitis are reported and 14 patients were affected by NSAID-related colitis. In another 6 patients we diagnosed a postradiation colitis. In 22 cases mimicking a Crohn's colitis we ascertained 9 patients affected by intestinal lymphoma, 11 mycobacterium tuberculosis related intestinal infections and 2 cytomegalovirus related colitis. CONCLUSIONS: Despite progress in scientific acquisitions and in diagnostic methods, correct initial diagnosis of ILBD is still difficult, even though it will be defined with time.

One-day vs standard thyroidectomy. A perspective study of feasibility.

BACKGROUND: The aim of this randomized controlled trial is to evaluate the feasibility of one-day thyroidectomy, comparing the results of this method vs standard thyroidectomy. METHODS: From June 2000 to June 2001, 110 patients underwent total thyroidectomy under general anesthesia for thyroid disease. The patients were randomized into 2 groups: in group A (40 patients) we used the one-day thyroidectomy; in group B (70 patients) we employed standard thyroidectomy. In both groups postoperative mobilization was immediate and the mean postoperative hospitalization stay was 21 hours (range: 18-24) in group A and 60 hours (range: 21-120) in group B. The mean follow-up was 10 months (range: 6-18 months). RESULTS: The patients of group A showed hypoparathyroidism with temporary hypocalcaemia in 3 cases (7.5%) vs 5 (7.1%) of group B; this finding was not statistically significant. No cases of definitive hypoparathyroidism, nor lesions of RLN, of the external branches of the superior laryngeal nerve, nor postoperative hemorrhage were observed in either group. CONCLUSIONS: The one-day thyroidectomy was found to be a safe, feasible and cost effective procedure, it is convenient for both the patient and the surgeon, and offers the same immediate and long-term results as the standard thyroidectomy in selected patients.

Rectal perforations. Personal experience and literature review.

BACKGROUND: Rectal perforation presents high morbidity and mortality and its treatment is still not standardized, it is still rather based on the surgeon's personal experience. This retrospective trial, with a literature review, aims to define these types of lesions, and tries to identify the diagnostic and therapeutic options able to reduce related morbidity and mortality. METHODS: On 1175 operations conducted for colo-rectal emergency, over a ten-year period at our institution, fourteen consecutive patients (1.2%) were seen and treated for rectal perforation. In 43% of cases the treatment consisted in Hartmann's procedure, in the 28.5% ones in rectal wound repair with diverting colostomy and in 28.5% left in diverting colostomy alone. RESULTS: There were no postoperative complications in 86% of patients, and no deaths from sepsis. In 28.5% of cases intestinal continuity was restored at our institution. CONCLUSIONS: Our results demonstrate that a standardized protocol which is based on patients' conditions, type and degree of rectal injury and of peritonitis, must be followed in order to determine the type of surgical option and consequently to reduce the morbidity and mortality related to rectal perforation.

Trabucco versus Rutkow versus Lichtenstein techniques in the treatment of groin hernia. A controlled randomized clinical trial.

BACKGROUND: The aim of this prospective study is to compare the results of the 3 most common tension-free techniques usually performed (Trabucco vs Rutkow vs Lichtenstein). METHODS: From January 1993 to December 1995 we selected 150 patients to undergo elective surgery for primary monolateral inguinal hernia. The patients were randomized into 3 groups: in group A (53 patients) we used the original plug and patch technique proposed by Rutkow and Robbins; in group B (47 patients) we introduced a modification to the technique originally described by Trabucco, anchoring the plug to the internal ring, fixing the patch on the pubic tubercle and on the tails of the mesh; in group C (50 patients) the Lichtenstein technique was employed. The study was performed using a randomized single blind controlled trial (RCT). The statistical analysis of our data was performed by c2 test and confirmed by the Fisher exact test. The mean follow-up was 73 months (range:58-94). RESULTS: We had no statistically significant differences in the results of the 3 groups. Otherwise the patients of group C showed a significantly higher incidence of suprapubic or more rare inguino-scrotal haematoma (p<0.0033 C vs B; p <0.0038 C vs A). The mean recovery time was between 12 and 14 days in the 3 groups, with no significant statistical differences. CONCLUSIONS: The only difference observed is a higher incidence of postoperative haematoma in group C.

Microsurgical treatment of varicocele in outpatients using the subinguinal approach.

BACKGROUND: The aim of this study is to analyze the results of a group of patients who underwent subinguinal microsurgical varicocelectomy using local anaesthesia in one-day-surgery. METHODS: From 1997 to 1998 150 patients were selected from the whole group of patients who underwent surgical treatment for varicocele. The varicocele was always on the left side and the mean age was 27.1 years (range: 16-43). The diagnosis was based on clinical features (testicular pain or scrotal sensation), physical examination and Doppler ultrasound. Where there was infertility with abnormal semen analysis and/or patient's intolerance to the symptoms, surgery was suggested. The patients underwent varicocelectomy by sub-inguinal approach using local anaesthesia. The microsurgical technique of dissection was performed. RESULTS: All operations were performed on an outpatient basis (post-operative stay: 3-7 hours) and the operating time was 20 to 45 minutes. Follow-up was performed by physical examination, doppler ultrasound and semen analysis. Immediate and long-term complications were: 7 (4.7%) transient pain, 3 (2.0%) ecchymosis, 1 (0.7%) transient hydroceles and 1 (0.7%) permanent hydroceles, 2 (1.3%) palpable recurrence, 2(1.3%) doppler recurrence and 1 (0.7%) long-term recurrence, 0 testicular atrophy. 120/150 (80%) patients showed an improvement of semen analysis and 19/41 (46.3%) patients with infertility achieved a pregnancy with the partner. CONCLUSIONS: Microsurgical treatment of varicocele in outpatients by subinguinal approach is a safe and reliable procedure. It is performed in local anaesthesia, preserves the lymphatics, spermatic artery and vas and in our experience showed an improvement of semen analysis and pregnancy rates with minimal morbidity.

[The dehiscence of colorectal anastomoses: the risk factors]. / Le deiscenze nelle anastomosi colo-rettali: fattori di rischio.

OBJECTIVE: To evaluate the results of emergency and elective colorectal resective surgery; to identify general and local factors that influence the anastomotic leak rate. MATERIAL AND METHOD: 200 selected consecutive patients (115 males and 85 females, medium age 50.6 years, range 16-87) underwent resective colorectal surgery between 1990 to 1997. 154 (77.0%) were operated in elective surgery and 46 (23.0%) in urgency, for carcinoma, diverticular disease, mesenteric infarction, chronic intestinal disease, dolicosigma, anastomotic leakage, familiar polyposis or lesions by firearm. The operations consisted in 58 right colectomy, 28 left colectomy, 6 resection of the transverse and 29 of the sigmoid colon, 40 anterior resection, 12 total colectomy, 19 closing of colostomy, 6 by-passes. Anastomoses were performed in 88 cases by manual and in 110 by mechanical sutures. RESULTS: We observed 12 (6%) anastomotic leakages. Mortality rate was 1.0%. 13%.0 of these patients were underwent before to emergency and 3.9% to elective surgery; 5.7% by manual and 6.4% by mechanical suture. Diagnosis of leakage was made by clinical features, blood vessel examinations and abdominal TC scan. DISCUSSION: The risk factors of anastomotic leakage are general or local. Chronic obstructive pulmonary disease, perioperative transfusion, level of serum albumin, use of corticosteroid in the first group and sepsis, bowel obstruction, anastomotic level and tension and poor blood supply in the second, appear the most important causative factors in the development of anastomotic leaks. CONCLUSION: The incidence of dehiscence in colo-rectal surgery was seen significatively lower when anastomoses were performed in ideal circumstances than in the presence of one or more unfavorable factors. Healing remains a process depending more on the patient than on any aspect of the surgical technique.

Perineal pilonidal sinus. Case report.

Pilonidal sinus is a very common disease and its most frequent location is in the presacral area. Other locations are extremely rare. We describe the case of a 28-year-old white man, a baker by profession, with a swelling around the right side of the anus, pain with burning, itching and seropurulent secretion which had been present for 7 months. A physical examination demonstrated the presence of multiple cutaneous fistulas. A fistulography and the endoscopy demonstrated the absence of fistulas-in-ano. Moreover, MRI confirmed the diagnosis of a perianal mass not communicating with the anal canal. Surgical exploration revealed the presence of hair and an excision of the mass with fistulas was performed. Healing was rapid and uncomplicated. Perineal pilonidal sinus with foreign body inflammatory reaction was the histological diagnosis.

[Correlation between chronic obstructive bronchial disease and colonic anastomosis dehiscence in the elderly]. / Correlazioni tra broncopatia cronica ostruttiva e deiscenza dell'anastomosi colica in età geriatrica.

BACKGROUND: Anastomotic leakage remains a major complication after large bowel surgery. Chronic obstructive pulmonary disease is frequent disease in the elderly. AIMS: The authors want to analyze the correlation between systemic tissue hypoxia, resulting from chronic obstructive pulmonary disease and anastomotic leakage in large bowel surgery in a group of patients over 65 years. PATIENTS AND METHODS: In the period 1979-2001 at our surgical Department, 590 patients underwent colorectal surgery; 211 elderly patients (> 65 years) with large bowel anastomosis were selected. In 29/211 (13.7%) chronic obstructive pulmonary disease was diagnosed. The group of patients affected by chronic obstructive pulmonary disease was defined as group A; the other, as group B. The incidence of anastomotic leakage in patients with and without chronic obstructive pulmonary disease was evaluated. RESULTS: The overall incidence of anastomotic leakage was 5.6% (12/211); a difference in the incidence of anastomotic leakage was found in the group A vs. B: 7/29 (24.1 %) in the group A were affected by dehiscence vs. 5/182 (2.7%) of group B. This difference was statistically significant (p = 0.001). CONCLUSIONS: Chronic obstructive pulmonary disease can be a factor increasing the risk of anastomotic leakage. The elderly patient is often affected by chronic obstructive pulmonary disease and consequently show an higher risk of colonic anastomotic failure than younger patients.

[Urgent ulcerative colitis: our experience]. / Rettocolite ulcerosa in urgenza ed emergenza: nostra esperienza.

The authors refer their experience in Urgent Ulcerative Colitis. They define the various clinical maniferstations and then specify the necessary elements for a corrent nosological arrangement. About diagnosis, their confirm the inconvenience of clinical examination like as colonscopy or an opaque clysma, giving their choice to other parameters, like as clinical, hematic (PCR), microscopic and cultural of the faeces, radiological (direct abdomen radiography; abdomino-pelvic echography; abdomino-pelvic TC, better if spiral), endoscopic (rectoscopy with minimal insufflation). They explain their guideline about medical therapy, the strategy adopted in relation to its duration, the protocol of evaluation during the administration period and the predictive sighs of its possible failure. After having precised the surgical indications, they stop a little about the timing of a surgical interventation, underlining its primary importance. In the range of a surgical strategy. They give their choice to the total colectomy with associated ioleostomy for its less incidence of complications and mortality versus proctocolectomy, reserving this last one to that cases with irreprensible rectal hemorragy, with preservation of the anal canal for a possible delayed ileo-anal anastomosis. They also think, at last, that after an Urgent Total Colectomy, the immediate ileo-rectum anastomosis could have an high risk of dehiscence of the anastomosis itself and so it must be reserved only to that selected cases which offer local and general guarantees of solidity of the anastomosis and it must be preferably done joinly whit a loop ileostomy at the bottom of the anastomosis itself.

Recurrent laryngeal nerve palsy and substernal goiter. An Italian multicenter study.

The aim of this retrospective multicenter study was to verify whether the substernal goiter and the type of surgical access could be risk factors for recurrent laryngeal nerve palsy during total thyroidectomy. Between 1999-2008, 14,993 patients underwent total thyroidectomy. Patients were divided into three groups: group A (control; n=14.200, 94.7%), cervical goiters treated through collar incision; group B (n=743, 5.0%) substernal goiters treated by cervical approach; group C (n=50, 0.3%) in which a manubriotomy was performed. Transient and permanent unilateral palsy occurred significantly more frequently in B+C vs. A (P≤.001) and in B vs. A (P≤.001). Transient bilateral palsy was significantly more frequent in B+C vs. A (P≤.043) and in C vs. A (P≤.016). Permanent bilateral palsy was significantly more frequent in B+C vs. A (P≤.041), and in B vs. A (P≤.037). Extension of the goiter into the mediastinum was associated to increased risk of recurrent nerve palsy during total thyroidectomy.

The indocyanine green method is equivalent to the 99mTc-labeled radiotracer method for identifying the sentinel node in breast cancer: a concordance and validation study.

AIMS: The aim of this study was to assess concordance between the indocyanine green (ICG) method and (99m)Tc-radiotracer method to identify the sentinel node (SN) in breast cancer. Evidence supports the feasibility and efficacy of the ICG to identify the SN, however this method has not been prospectively compared with the gold-standard radiotracer method in terms of SN detection rate. METHODS: Between June 2011 and January 2013, 134 women with clinically node-negative early breast cancer received subdermal/peritumoral injection of (99m)Tc-labeled tracer for lymphoscintigraphy, followed by intraoperative injection of ICG for fluorescence detection of SNs using an exciting light source combined with a camera. In all patients, SNs were first identified by the fluorescence method (ICG-positive) and removed. A gamma ray-detecting probe was then used to determine whether ICG-positive SNs were hot ((99m)Tc-positive) and to identify and remove any (99m)Tc-positive (ICG-negative) SNs remaining in the axilla. The study was powered to perform an equivalence analysis. RESULTS: The 134 patients provided 246 SNs, detected by one or both methods. 1, 2 and 3 SNs, respectively, were detected, removed and examined in 70 (52.2%), 39 (29.1%) and 17 (12.7%) patients; 4-10 SNs were detected and examined in the remaining 8 patients. The two methods were concordant for 230/246 (93.5%) SNs and discordant for 16 (6.5%) SNs. The ICG method detected 99.6% of all SNs. CONCLUSIONS: Fluorescent lymphangiography with ICG allows easy identification of axillary SNs, at a frequency not inferior to that of radiotracer, and can be used alone to reliably identify SNs.

Treatment of chronic pilonidal sinus with local anaesthesia: a randomized trial of closed compared with open technique.

OBJECTIVE: To compare open with closed treatment of chronic pilonidal sinus. PATIENTS AND METHODS: From 1993 to 1996, 100 patients were submitted to excision of chronic pilonidal sinus, with local anaesthesia and were randomized in two groups: group A in which open treatment and group B in which direct suture were performed. The follow-up, ranging from 37 to 89 months, was performed by outpatient visits or by phone. RESULTS: Short-term results showed 6 (12.0%) post-operative complications in group A vs 10 (20.0%) in group B. Long-term results showed 9 (18.0%) complications in group A vs 7 (14.0%) in group B. Mean wound healing was 58 days (range: 29-93) in group A vs 12 (range: 9-61) in group B. The return to normal activity was 25.7 (range: 11-77) vs 10.4 (range: 5-32). Wound healing and the return to normal activity were the only statistically significant differences. CONCLUSIONS: Regarding morbidity neither technique has particular advantages over the other. The closed technique produced quicker wound healing and a quicker return to normal activity.