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.

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.

Detection of coronary artery disease by digital stress echocardiography: comparison of exercise, transesophageal atrial pacing and dipyridamole echocardiography.

OBJECTIVES: This study assessed and compared the diagnostic potential of exercise, transesophageal atrial pacing and dipyridamole stress echocardiography in a clinical setting. BACKGROUND: Although they have been widely studied, no data exist with regard to comparisons of these procedures in a head-to-head study in different clinical settings. METHODS: One hundred four consecutive patients with suspected coronary artery disease undergoing coronary angiography and with no previous myocardial infarction or rest left ventricular wall motion abnormalities underwent digital posttreadmill, transesophageal atrial pacing and dipyridamole echocardiography. RESULTS: Feasibility of digital exercise echocardiography was 84%; 8 of 88 remaining patients had a nondiagnostic exercise echocardiographic test (inadequate exercise or imaging). In 80 patients with feasible and diagnostic digital exercise echocardiography, sensitivity, specificity and accuracy were, respectively, 89%, 91% and 90%. Eighty of the 104 patients underwent transesophageal atrial pacing and dipyridamole echocardiography. Feasibility of the alternative stress procedures was 77% for transesophageal atrial pacing and 96% for dipyridamole. In 60 patients successfully undergoing both alternative stress procedures, sensitivity and specificity were 83% and 76% for atrial pacing and 43% and 92% for dipyridamole echocardiography, respectively. In the group of 24 patients with nondiagnostic exercise echocardiography and consequent indication to alternative stress procedures, accuracy of transesophageal atrial pacing was higher than that of dipyridamole echocardiography (73% vs. 45%, p = 0.06). CONCLUSIONS: Because of its higher diagnostic potential and additional functional information, exercise is the stress of choice when stress echocardiography is used to detect the presence of coronary artery disease. Alternative stresses can be used in patients with nondiagnostic exercise echocardiography. Transesophageal and dipyridamole echocardiography differ in feasibility and diagnostic reliability (higher sensitivity of transesophageal atrial pacing, higher specificity of dipyridamole). These characteristics must be considered when selecting procedures to be used as alternatives to exercise.

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.

Management of narrower anastomotic colonic strictures. Case report and proposal technique.

Management of narrower (<5-mm) colonic anastomotic stricture mainly is performed endoscopically by repeated balloon dilation often ineffectively. The use of metal self-expanding stents in the malignant and benign stricture of the large bowel has been suggested only recently, and is still being debated. In this report we propose a single-stage procedure that we developed to manage narrower anastomotic colonic stricture. A 60-year-old man 2 years previously had undergone surgery for perforated sigmoid diverticulitis by means of Hartmann's procedure. He was submitted to two mechanical recanalization attempts, both of which failed with dehiscence of anastomoses. He reached us with a significant stricture of the colorectal anastomoses (smaller than 5 mm in diameter) and a diversion ileostomy. After two endoscopic balloon dilations, we observed the relapse of the anastomotic stricture, so we decided to draw up another strategy. We performed a dilation with a TTS balloon, leaving a metallic self-expanding covered stent in situ for 3 months. The aim was to achieve the definitive healing of the anastomotic scar tissue at the desired diameter. We removed the stent during the ileostomy closure. At the time of this writing, 18 months of follow-up evaluation, the patient defecates without any problem

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.

A catastrophic complication of systemic lupus erythematosus: massive mesenteric infarction.

The AA reports a case of a 64-year-old female patient affected for 3 years by systemic lupus erythematosus who developed a massive perforating mesenteric infarction. An immediate surgical treatment with resection of the small bowel and right colon followed by a side-to-side primary anastomosis between the remaining jejunum and transverse colon were performed. The patient died 15 days after surgery due to recurrence of a mesenteric and pulmonary thromboembolia.

Determination of Optimum Irrigation Regime and Water Use Efficiency of Sugar Beet Grown in Pathogen-Infested Soil.

A field experiment was conducted to quantify the effects of different irrigation frequencies on sugar beet yield in pathogen-infested soils. Four irrigation regimes (every 2, 3, 4, and 5 weeks) and four inoculation treatments (beet necrotic yellow vein virus [BNYVV], beet soilborne mosaic virus [BSBMV], BNYVV+BSBMV, and a noninoculated control) were arranged in a split-plot design and replicated four times. Irrigation frequency and virus infection affected disease severity and yield. Sugar beets irrigated every 4 weeks had the lowest disease severity, and yield was not significantly different from the every 2 weeks frequency. Sucrose content was higher for beets in the 4-week irrigation treatment compared with the 2- and 3-week frequencies. Beets inoculated with BNYVV had higher disease severity and lower root yield than beets inoculated with BSBMV and BNYVV+BSBMV. A greenhouse experiment was conducted to evaluate the effect of water level on disease severity and water use in sugar beet. Four treatments (BNYVV, BSBMV, BNYVV+BSBMV, and a noninoculated control) and three water levels (pot capacity [PC], 75% PC, and 50% PC) were arranged in a split-plot design and replicated five times. Pots of each treatment were weighed every other day to determine evapotranspiration. Evaporation was determined from unplanted pots, and plant transpiration was calculated by the difference. Beets irrigated at 75% pot capacity showed minimal disease incidence and a root weight comparable to the fully irrigated healthy control. Plants in the BNYVV treatment had a significantly higher disease severity than beets infected by BSBMV or BNYVV+BSBMV. Root weights and plant water use were significantly affected by virus infection. Beets in the BNYVV+BSBMV treatment had a significantly higher root dry weight and water use than beets in the BNYVV treatment, suggesting that BSBMV reduced the impact of disease caused by BNYVV.

Relationship Among Seed Size, Planting Date, and Common Root Rot in Hard Red Winter Wheat.

A dryland field study was conducted to determine the effect of seed size and planting date of hard red winter wheat on the severity of common root rot caused by Bipolaris sorokiniana (Sacc.) Shoemaker. Seed of cvs. Hawk, TAM 200, TAM 107, Scout 66, and Siouxland 89 were separated into three size categories of small, mixed, and large and were planted in the first weeks of September and October 1994 and 1995. Disease ratings for incidence and severity of subcrown internode infections were made in March and at harvest. At harvest, grain yields were collected. In both years of the study, there was no interaction between seed size and cultivars for any of the measured variables. Overall, seed size had no effect on disease severity or grain yield for either year. However, when sorted by planting date, plants from small seed yielded less than plants from other seed. October plantings showed lower disease indices than September plantings at the March evaluation. At the harvest disease evaluation, there were no differences in disease severity between planting dates for the first year but, in the second year of the study, plants from the October planting had lower disease than those from the September planting. There was no significant correlation among seed size, final yield, and disease index. The results of this study suggest that the expense of planting higher-quality certified seed cannot be justified for producing hard red winter wheat in dryland conditions in the Texas Panhandle, considering the current price of wheat and the average dryland yield.

Lack of Relationship Between Susceptibility to Common Root Rot and Drought Tolerance Among Several Closely Related Wheat Lines.

Common root rot caused by Bipolaris sorokiniana is a disease of wheat associated with plant stress. Three cultivars (Siouxland, TAM 200, and TAM 107) and several hard red winter wheat lines closely related to TAM 107, but known to differ with respect to drought tolerance, were included in a 2-year dryland field study to evaluate whether observed variation in drought tolerance was associated with susceptibility to B. sorokiniana. Untreated seed of each entry or seed treated with imazalil was planted in soil naturally infested with B. sorokiniana. Plants were evaluated at jointing and at harvest. Disease incidence and severity, number of plants, number of heads, and grain weight per meter were evaluated. Grain weight and number of heads of individual plants were recorded in order to correlate disease rating of each plant with yield components. Plot yield and test weight also were measured. There were significant entry by seed treatment interactions for number of heads per plant, grain weight per plant, and grain weight per meter. A year by treatment interaction was found for the jointing disease index, and plants grown from seed treated with imazalil had a significantly lower disease index than those grown from nontreated seed. Observed drought tolerance among the three varieties and eight closely related plant introductions was not associated with disease susceptibility to common root rot.

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 risk factors and prevention of recurrences in rectal surgery]. / Fattori di rischio e prevenzione delle recidive nella chirurgia del retto.

The authors report their own experience of 34 patients operated on for rectal cancer. In 8 cases abdomino perineal resection and in 26 anterior resection with anastomoses (6 in second time) were performed. Operatory mortality was nil and with an average follow up of 34 months 5 local recurrences were observed 16%. Among the risk factors examined the most important seems to be the stage of the disease; imperative it is therefore a correct surgical approach which warranted a significant reduction of local recurrences. This surgical approach includes a safety distal clearance from the tumour (at least 2.5 cm.), radical lymphadenectomy and complete removal of the mesorectum.

[The role of palliation in peri-ampullar tumors in the elderly]. / Il ruolo della palliazione nei tumori periampollari in età geriatrica.

Authors wonder about the actual part of the palliative practices in periampullar cancers of the geriatric age, and the choice criteria of the different surgical options that are practicable. They reaffirm that the common radical operation is the pancreaticoduodenectomy, even if, as it is verifiable in the relevant literature and in our series of cases, it is practicable only a few times. The necessity of amending the toxic-septic condition of the neoplastic cholestasis, which certainly is more unfavourable during the geriatric age, gives to the palliative procedures a better role, because few patients could be treated with a curative intention. Authors report their experience and their results about the icterus regression, mortality, morbidity and the average survival rate. About the surgical palliative options of the bilio-digestive shunts, they give the same importance to the gallbladder jejunostomy and to the common bile duct jejunostomy, granting to the first their preference in the geriatric age for the simplest and rapid execution. They point out the necessity of the gastrojejunostomy in all the present or incipient jejuno's obstruction, because of the surgical action importance, and to avoid another operation. They give, even in the geriatric age, their preference to the surgical palliative treatments, proposing to reserve the endoscopic and radiologic practices to the patient undergoing an operation for the precarious general state, for the high operating risk and the modest residual life. In fact, the non surgical treatments are suitable to amend the neoplastic cholestasis, but they aren't equivalent to the surgical palliative, that is more effective for the greater survivals, a better life's quality, a smaller mortality and morbidity.

[Bassini's technique versus Trabucco's technique in the treatment of inguinal hernia: randomized comparative study]. / La tecnica di Bassini vs. la tecnica di Trabucco nel trattamento dell'ernia inguinale: studio comparativo randomizzato.

The authors have carried out a perspective randomized trial between two homogeneous groups, each one of 30 pts., consisting of 50 males and 10 females with an average age of 42 (18-65) affected by an uncomplicated inguinal hernia. Group A underwent a Bassini repair technique and group B underwent a Trabucco's operation. The early results in terms of clinical conditions and days of post-operative course and period of return to work were analysed with Shapiro-Wilk and t tests. The group B patients had a significant reduction of the post-operative period (2.3 days vs 3.46), a significant reduction of post-operative pain (present in all group A patients vs 6.6%) with rapid return to normal functions and to work. All these conditions reduce the costs of the operation for society and the health service. There were no statistically significant differences in terms of morbidity and long-term follow-up (about 9 months).

[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.

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.