Intraoperative radio-guided localization of parathyroid adenomas using 3D freehand SPECT technology.

Parathyroidectomy for primary hyperparathyroidism (PHPT) could have poor outcomes, even with accurate preoperative localization of the adenomas, because their intraoperative localization can be challenging. Freehand single photon emission computed tomography (fhSPECT) is a new technique for radio-guided intraoperative navigation. Its use during parathyroidectomy could be useful and such data are limited. We herein present our experience on the feasibility of fhSPECT for intraoperative detection of abnormal parathyroid glands. We retrospectively reviewed the clinical data of 55 patients (30-77 years old) with PHPT due to parathyroid adenomas, that were subjected to parathyroidectomy from 12/2017 to 7/2022. In average, 111 ± 74 MBq of Tc-99 m Sestamibi were injected intravenously, approximately 2 h before the operation and fhSPECT was used to generate 3D images during parathyroidectomy. Measurements of PTH and calcium levels were performed preoperatively, postoperatively and 4-6 months after the procedure. FhSPECT successfully identified the parathyroid adenoma in all the patients. It took 3 min (median time) for fhSPECT to detect at least one radioactive spot in all patients. The mean duration of the operation was 66.6 ± 7.3 min. Forty-nine patients out of 55 had solitary and 6/55 had multiple adenomas, whereas 6/55 had ectopic abnormal parathyroid glands. None of the patients had persistent hyperparathyroidism during follow-up. To the best of our knowledge, this is the largest series of patients with PHPT that underwent fhSPECT assisted parathyroidectomy. Our data suggest that this navigation system is helpful in identifying parathyroid adenomas intraoperatively.

Comparison of early and late complications after various bariatric procedures: incidence and treatment during 15 years at a single institution.

BACKGROUND: Bariatric procedures are effective in the life-long treatment of clinically severe obesity, but they are technically demanding and have known complications. The present study presents mortality and morbidity with different procedures from the prospective 15-year bariatric database of the University Hospital of Patras in Greece. METHODS: From June 1994 through December 2008, 1,162 morbidly obese patients underwent various bariatric procedures at our institution (35 vertical banded gastroplasties, 151 laparoscopic sleeve gastrectomies, 90 open and 137 laparoscopic Roux-en-Y gastric bypasses, 699 biliopancreatic diversions with long limbs, and 50 reoperations). Postoperative metabolic deficiencies and causes of early and late morbidity for various bariatric procedures were compared by using the z-test for the comparison of proportions. Logistic regression analysis was used to model the occurrence of early and late death and complications. RESULTS: Total mortality was 1.81% (early 0.6%, intermediate 0.26%, late 0.95%). No significant predictors for early death were found, but age (odds ratio (OR), 1.077; 95% confidence interval (CI), 1.024-1.133; P = 0.004) and BMI (OR, 1.156; 95% CI, 1.023-1.306; P = 0.02) were predictors for late death. Early and late morbidity were 8% and 27.71%, respectively. The total leakage incidence was 1.98% and was significantly higher (P < 0.05) after reoperation. Fifteen of the 23 leaks were successfully treated conservatively. Most late complications were incisional hernias (18.85%)--almost all after open procedures. Hypoalbuminemia incidence was significantly higher after biliopancreatic diversion with long limbs (3.58%) and reoperation (8%). CONCLUSIONS: Bariatric procedures, even in specialized centers, may have serious complications because of their technical complexity in a high-risk population. Almost all can be managed successfully.

Thyroid angiosarcoma (TAS) - A rare diagnosis not to be missed.

Raising awareness about primary TAS, a rare and aggressive mesenchymal tumor, is important so that early diagnosis and undelayed radical surgery along with complementary radiation are possible. Extending the existing knowledge on the course and final outcome of the disease may help identify the best treatment approach to improve survival.

Primary Burkitt lymphoma of the thyroid gland in a 28-year-old female.

Not required for Clinical Vignette.

Thyroid abscess as a complication of percutaneous ethanol ablation of cystic thyroid nodules.

Not required for Clinical Vignette.

Patient outcomes following surgical management of thyroid nodules classified as Bethesda category III (AUS/FLUS).

INTRODUCTION: The Bethesda classification system for reporting thyroid cytopathology is the standard for interpreting fine needle aspirate (FNA). Because of its heterogeneity and inconsistent reporting, atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS), known as Bethesda category III, is the most controversial category. Thyroid nodules that fall within Bethesda categories III-IV have an overall risk of malignancy of between 15 and 40%. The aim of this study was to determine the malignancy rate in Bethesda III nodules. MATERIAL AND METHODS: A retrospective study was performed for 1166 patients who underwent thyroid surgery for multinodular goitre (MNG) or solitary nodular goitre (SNG) in our institution between June 2010 and May 2020. Data retrieved included demographic characteristics of the patients, FNB cytology, thyroid function test results, type of thyroidectomy, and final histology results. RESULTS: During the study period, 29.5% (344/1166) of patients with an FNA categorized as AUS/FLUS underwent thyroid surgery. Of these 344 patients, 190 were diagnosed with MNG and 154 with SNG. Incidental malignancy was found in 35 of 190 cases of MNG (18.42%) and 31 of 154 cases of SNG (20.13%). The most common malignant tumour type in either category was the follicular variant of papillary thyroid carcinoma. CONCLUSIONS: The current study demonstrates that patients with a FNA categorized as AUS/FLUS may have a higher risk of malignancy than traditionally believed. Reconsideration may be necessary to guidelines that recommend observation or repeat FNA in this category of patients.

A shift to more targeted thyroidectomies increased the detection of thyroid cancer and in particular low-risk papillary tumors in Southwestern Greece the decade 2007 to 2016.

OBJECTIVES: Data regarding thyroid cancer (TC) epidemiology in Greece in the last decade are scarce, so we investigated the trends in TC detection during 2007 to 2016. METHODS: We retrospectively studied 2040 pathology reports of total thyroidectomies performed at our institution from 2007 to 2016. RESULTS: A number of 478 cases of TC were identified in the studied decade. The overall incidence of TC among thyroidectomies rose over the years. The proportion of papillary T1 tumors among thyroidectomies increased in the second period of our study (2012-2016), while that of papillary T2 to T4 tumors and other TC subtypes remained unchanged. Papillary T1 tumors represented 63.6% of all TC cases and 75.3% of them were low-risk microcarcinomas (papillary thyroid microcarcinoma). The strategy of fine needle aspiration (FNA) prior to surgery in the management of thyroid nodules was adopted by more clinical endocrinologists in the area of Southwestern (SW) Greece in the second period of our study (2012-2016:29.7% vs 2007-2011:18.4%, P < .001). Consequently, the indication for thyroidectomy was set by FNA more frequently in 2012 to 2016 than in 2007 to 2011 (42.5% vs 26.4% of cases, P < .001). CONCLUSIONS: The wider use of FNA in the triage of thyroid nodules led to increased rates of TC in thyroidectomies performed in SW Greece during the decade 2007 to 2016; low-risk, small papillary tumors represented the majority of TC cases.

Laparoscopic versus open appendectomy: which way to go?

AIM: To compare the outcome of laparoscopic versus open appendectomy. METHODS: Prospectively collected data from 293 consecutive patients with acute appendicitis were studied. These comprised of 165 patients who underwent conventional appendectomy and 128 patients treated laparoscopically. The two groups were compared with respect to operative time, length of hospital stay, postoperative pain, complication rate and cost. RESULTS: There were no statistical differences regarding patient characteristics between the two groups. Conversion to laparotomy was necessary in 2 patients (1.5%). Laparoscopic appendectomy was associated with a shorter hospital stay (2.2 d vs 3.1 d, P = 0.04), and lower incidence of wound infection (5.3% vs 12.8%, P = 0.03). However, in patients with complicated disease, intra-abdominal abscess formation was more common after laparoscopic appendectomy (5.3% vs 2.1%, P = 0.002). The operative time and analgesia requirements were similar in the two groups. The cost of treatment was higher by 370 EUR in the laparoscopic group. CONCLUSION: Laparoscopic appendectomy is as safe and efficient as open appendectomy, provided surgical experience and equipment are available.

Complications and risk factors related to the extent of surgery in thyroidectomy. Results from 2,043 procedures.

OBJECTIVE: To evaluate the rate of complications and the risk factors in relation to the extent of surgery in patients undergoing thyroidectomy in a tertiary university center. DESIGN: Data were collected retrospectively from 2,043 consecutive patients who underwent thyroid surgery for various thyroid diseases at the University Hospital of Patras, Greece, between January 1996 and December 2007. Recurrent laryngeal nerve palsy (RLNP) and hypoparathyroidism were set as the primary end points, while hematoma and wound infection were set as the secondary endpoints. RESULTS: Total, near-total and subtotal thyroidectomy was performed in 1,149,777 and 117 patients, respectively. Transient RLNP occurred in 34 (1.6%) and permanent in 19 (0.9%) patients. Multivariate logistic regression analysis showed that extended resection (OR-odds ratio-1.6), Graves' disease (OR 2.7), thyroiditis (OR 2.1), recurrent goiter (OR 2.3) and thyroid malignancy (OR 1.7) were all independent risk factors for transient RLNP, whereas Graves' disease (OR 2.2) and recurrent goiter (OR 1.7) emerged as independent risk factors for permanent RLNP. The rates of transient and permanent hypoparathyroidism were 27.8% and 4.8%, respectively. Multivariate analysis for transient hypoparathyroidism revealed that the extent of surgical resection (OR 2.2), Graves' disease (OR 2.1), recurrent goiter (OR 1.7), female gender (OR 1.5) and specimen weight (OR 1.6) were independent predictors. However, the extent of surgical resection (OR 2.7), Graves' disease (OR 1.8), recurrent goiter (OR 1.5) and malignant disease (OR 1.5) were independent risk factors for permanent hypoparathyroidism. Postoperative wound infection and hematoma occurred in 6 (0.3%) and 27 (1.3%) patients, respectively. No correlation was observed between wound infection or postoperative hemorrhage and the extent of surgery. CONCLUSIONS: Despite the higher morbidity, total thyroidectomy is emerging as an attractive surgical option even for benign thyroid disease due to the risk of subclinical (occult) malignancy, the possibility of goiter relapse as well as of the increased risk of complications following reoperation.

A less invasive management of post-thyroidectomy descending necrotizing mediastinitis is feasible: a case report and literature review.

BACKGROUND: Descending necrotizing mediastinitis (DNM) is a life-threatening complication secondary to oropharyngeal abscesses, esophageal perforation, or neck infections spreading into the mediastium, but very uncommon after thyroidectomy. Early diagnosis and close clinical and laboratory monitoring are crucial for patient survival. CT scanning of the cervical and thoracic area is a useful tool for diagnosis and follow-up. Different surgical approaches in the management of DNM have been proposed, the most widely accepted being a combined cervicotomy with lateral thoracotomy procedure. CASE REPORT: A rare case of DNM with group A ss-hemolytic streptococci, in a 47-year-old patient developing after thyroidectomy for multinodular goiter is presented. A more conservative approach through a cervical incision was followed and thoracic drains for pleural effusion evacuation were inserted. After re-operation, repeated CT scanning for disease progression and prompt surgical wound cleaning were performed. Antibiotic therapy was continued up to one month after release. The patient's recovery was uneventful and continues well. CONCLUSIONS: To the best of the authors' knowledge this is the second case of post-thyroidectomy DNM reported. According to present data it is recommend that a less invasive approach could be satisfactory when prompt diagnosis is established and the thoracic drainage is effective. This case suggests that repeated postoperative CT scanning and close clinical and laboratory monitoring could make an additional thoracotomy a second-line procedure. Moreover, due to the fact that only two cases of post-thyroidectomy DNM are reported worldwide, therapy of this condition remains an open question.