Unilateral phrenic nerve paralysis: a rare complication after total thyroidectomy for a large cervico-mediastinal goitre.

Unilateral phrenic nerve paralysis is a rare complication of cervico-mediastinal goitre. It occurs when adhesions grow between the intrathoracic part of the thyroid and the nerve, specially where the goitre enters the mediastinum behind the first rib. The damage may be caused by strain of the nerve due to the descent of the goitre into the chest or may be caused by the surgical manoeuvres during thyroidectomy performed by cervical approach. Two patients operated on for large cervico-mediastinal goitre are reported: a 70-year-old male with a large intrathoracic growth of the left thyroid lobe and a 54-year-old male with a large intrathoracic growth to the right lobe. A few days after total thyroidectomy they showed signs of exertional dyspnoea. The exams performed showed hemi-diaphragm relaxatio due to phrenic nerve paralysis, with resulting reduction of respiratory space. Phrenic nerve paralysis may follow total thyroidectomy for large cervico-mediastinal goitres; is not due to the operative technique, but rather to the particular anatomic conditions which may be found.

[Long-term results of primary choledochal-jejunal anastomosis]. / Esiti a distanza di anastomosi coledoco-digiunali primarie.

Long term of Roux en Y choledochojejunostomy evaluation, performed for choledocholithiasis, inflammatory or neoplastic common bile duct strictures. However the anathomopathological situations are different, when the indication is right, this kind of surgical management shows all its effectiveness also for the low mortality and the absence of long term complications.

[Aneurysm of the splenic artery. A clinical case and review of the literature]. / Gli aneurismi dell'arteria splenica. Caso clinico e revisione della letteratura.

The Authors report a case of splenic artery aneurysm (ASA) in a 64 years old woman. Most of patients affected by ASA are asymptomatic. Rupture represents a rare complication with high mortality rate. Finally the clinical, etiopathogenetic and anatomo-pathological aspects are considered.

Immunologic conditions and infectious complications in colon and rectal surgery for neoplasms.

The authors evaluated the peroperative immunologic state of patients with colorectal tumors and controlled the postoperative incidence of infections. Twenty-one patients were studied, and delayed type hypersensitivity reactivity determined by the CMI multitest (Merieux) eight days before and eight days after surgery. A lymphocytogram was performed using monoclonal antibodies. A significant percentage of patients were anergic preoperatively. Immunologic analysis revealed lymphocytosis in the first postoperative period. The largest absolute quantitative increase was shown by NK CD16+ cells. It is possible that the results, obtained by dynamic monitoring of the main parameters of cellular immunity, will offer a new way for prognostic evaluation of surgical risk.

Endocrine, hematological and immunological changes in surgical patients undergoing general anesthesia.

Some hematological endocrine, and immunological reactions in surgical patients under general anesthesia were studied. While serum cortisol, fT4, T4, rT3 levels increased, TBG, TSH, fT3 and T3 decreased. Cortisol increase and T3 and fT3 decrease were still significant three days after surgery. TSH and T3 decrease was significantly related to cortisol increase. CD4 (helper-inducer) cells dropped, rosettes, CD 5, CD 8, CD 16 (NK) and T HLA-DR (activated) number of cells did not change significantly. The decrease in CD 4 subset was significantly related to cortisol increase. Thus surgery was followed by a reduced thyroid function and decreased CD 4 subset. However this was observed also in the few patients in whom the serum cortisol level did not change. These reactions may represent immunosuppression occurring in the postoperative period.

Immunological features of endemic goiter.

Some immune aspects of simple endemic goiter have been studied through a comparison of IgG, IgA, IgM, kappa and lambda chains, and C3 and C4 in the peripheral blood of 59 patients operated on for goiter and the peripheral blood of 49 normal controls. The median IgM was lower in the goiter blood. The incidence of thyroglobulin (Tg) and microsomal (Mi) antibodies (Abs) was 20.3% in goiter blood and that of nonthyroid autoAbs was 37%. Active and total rosetted blood lymphocytes were counted and OKT3, OKT4, OKT8, Leu 1, Leu3a, Leu2b, T DR+, and NK cell populations were classified. Helper T cells were occasionally decreased when goiter was associated with lymphocytic thyroiditis. The NK percentage was sometimes higher in goiter blood, whereas the T DR+ percentage was not significantly different in the two groups. Lymphocyte infiltration (LI) was noted in 32% of goiters (about 5% with a diffuse and nodular pattern). A prevalence of helper/inducer cells was observed among the infiltrating T cells. HLA-DR antigen (Ag) positive epithelial cells were seen, not only in LI areas. Granular deposits of IgG, IgA, IgM, and C3 on the follicular basal membrane were stained in 6.7% of goiters Patterns histologically and immunologically similar to those in Hashimoto's thyroiditis may therefore be observed in long-standing simple endemic goiter, suggesting that an autoimmune mechanism may be involved in its pathogenesis.

Cortisol in human tissues at different stages of life.

Aim of the work was to measure the cortisol level in human tissues at different stages of life, by means of radioimmunoassay and by chromatography. Viable samples of 13 different tissues were obtained during surgical intervention from 30 to 70 years old patients of either sex. Mean tissue cortisol concentration was 78 +/- 35 ng/g, ranging from 20 +/- 10 ng/g in the thyroid to 124 +/- 76 ng/g in the kidney. Similar values were measured in the corresponding tissues from not decayed corpses, so that paired values could be mediated. However the pancreas, and corrupted autopsy tissues, gave nil or exceedingly high cortisol concentration values; in some cases, opposite extreme values were measured in different organs of the same body. Cortisol concentration was also measured in 11 sound different tissues of spontaneously aborted or stillbirth fetuses, between 16 and 36 weeks of gestation. Mean value was 63 +/- 27 ng/g, ranging from 30 +/- 25 ng/g in the liver to 104 +/- 52 ng/g in the lungs. Also in fetuses nil or exceedingly high cortisol values occurred in altered tissues. One hundred and fourteen samples of limbs and carcasses of 7 to 12 gestational weeks embryos, obtained from voluntary abortions, were also examined: 20% gave nil result, in the remaining mean cortisol concentration was 32 ng/g. In 33 samples of embryos' mixed viscera, RIA and chromatography gave unreliable exceedingly high values. The nil and the exceedingly high values measured in the altered autoptic tissue specimens were inconsistent with the cortisol blood level measured in the patients, as were those measured in embryonic tissues with the acknowledged blood and adrenals cortisol levels at that stage of life. Thus cortisol may be measured by RIA and by chromatography in sound tissues, while the values obtained in the pancreas, in corrupted tissues, and in embryonal viscera do not represent the hormonal milieu, but are likely artifacts due to impeachment of the diagnostic system.

Thyroid cancer histotype changes as observed in a major general hospital in a 21-year period.

The existing registries of thyroid carcinoma are seldom comparable as far as epidemiological data, diagnostic criteria and histopatological description are concerned. Epidemiological studies report a progressive increase in the incidence of thyroid carcinoma in the last twenty years and in both sexes this increase of incidence has been referred to papillary histotype. Data collected from surgical series show a rate of thyroid carcinomas from 7 to 20% of total thyroid surgeries. The present study was designed in order to obtain a retrospective review of the distribution of thyroid carcinoma's different histotypes in the last 21 years in a major General Hospital. Detailed analysis of patients with histologically confirmed thyroid carcinoma admitted between 1974 and 1994 to the Surgery Department of Mauriziano Hospital of Torino, Italy showed an overall 11.8% prevalence of thyroid cancer out of the total thyroid surgeries. The rate of papillary carcinoma was the highest (54.3%) followed by follicular carcinoma (27.6%), anaplastic carcinoma (11.1%), medullary carcinoma (4.6%) and others (2.4%). The papillary-to-follicular ratio varied from 0.60 in 1974-76 to 6.88 in 1992-94. Female to male ratio of all thyroid carcinoma histotypes was 2.0 or more; papillary and follicular histotypes had the highest ratio. The variations of the histotype rate observed may be consequence of the silent increase of daily iodine intake throughout the subsequent years, while improved diagnostic tools available and increased experience of the medical staff have probably increased the number on thyroid ablations performed. Our data confirm the changing epidemiology of thyroid carcinoma, reported by international literature.