Risk factors for difficult thyroidectomy and postoperative morbidity do not match: retrospective study from an endocrine surgery academic referral centre.

Hyperthyroidism, goiter and thyroiditis have been associated with complex thyroidectomy. Difficult thyroidectomies may implicate longer operating times and higher complication rates, while literature on quantification and prediction of difficulty in thyroidectomy is scant. We aim at assessing the impact of preoperative and intraoperative factors on the technical difficulty of total thyroidectomy (TT) and on the incidence of postoperative complications. We conducted a retrospective study on 197 TT from 343 thyroidectomies performed with intraoperative neuromonitoring between October 2019 and June 2022 (excluding lobectomies, nodal dissection, extra-thyroidal procedures). Operating time (surrogate of TT difficulty), postoperative hypocalcaemia, recurrent laryngeal nerve palsy and postoperative bleeding were assessed in relation to pre- and intraoperative characteristics. Vocal fold palsy(VFP) was defined as recovering < 12 months postoperatively. There were 87 thyroid cancers and 110 multinodular goiters (21 hyperfunctioning, 51 mediastinal). Median operating time was 136 min (range 51-310). Within 17.4 months overall median follow-up we recorded two transient VFPs and 12% symptomatic transient hypocalcaemia. At univariable analysis male sex (p = 0.005), BMI (p < 0.001), thyroiditis (p < 0.05), hypervascular goiter (p = 0.003) and thyroid adhesions to surrounding anatomical structures (p < 0.001) were associated with longer operating time. At multivariable analysis male male sex (p = 0.01), obesity (p = 0.001) and thyroid adhesions (p = 0.008) were factors for prolonged operating time. Above-normal anti-thyroid peroxidase antibodies correlated to transient symptomatic hypocalcemia (p < 0.001). Risk factors for complex TT were identified and did not correlate with morbidity rates. Results from this study may help optimizing operating room schedule and inform case selection criteria for training programs in thyroid surgery. Further research is required to confirm these findings.

Indocyanine Green Fluorescence Angiography Can Guide Intraoperative Localization During Parathyroid Surgery.

BACKGROUND AND AIMS: Intraoperative localization of pathologic parathyroid glands is of major importance for the hyperparathyroidism treatment. Based on the small size and the anatomic variability, the localization can be very challenging. The current practice is to compare preoperative ultrasonography with Technetium-99m sestamibi scintigraphy (MIBI) and plan the resection accordingly. In this study, we implemented indocyanine green angiography for the intraoperative localization of parathyroid glands. MATERIALS AND METHODS: This is a retrospective analysis of 37 patients with primary, secondary, or tertiary hyperparathyroidism who were operated using indocyanine green angiography for the intraoperative localization of pathological parathyroid glands. An indocyanine green solution of 2.5 mg was were intravenously administered for parathyroid gland visualization. Different fluorescence scores were correlated with changes in postoperative parathyroid hormone levels. RESULTS: Patients were divided into two groups depending on the presence of uniglandular or multiglandular disease. Sixty-four lesions were resected, and the final histopathologic analysis confirmed the parathyroid origin in 62 of them (96.8%). None of the patients with uniglandular disease developed postoperative hypoparathyroidism, whereas three patients in the multiglandular group developed temporary hypoparathyroidism symptoms. Indocyanine green imaging had higher sensitivity for the intraoperative detection of parathyroid glands compared with ultrasonography and MIBI (p < 0.001). CONCLUSION: Indocyanine green angiography indicated high sensitivity for the intraoperative identification of pathologic parathyroid glands leading to a resection rate of 95.16%. The modality was useful, especially in cases of revisional surgery or ectopic parathyroid glands. Randomized trials have already proven the value of indocyanine green imaging in predicting postoperative hypocalcemia. Our results support the regular use of this method during parathyroid surgery.

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.

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.

Comparative mapping and genomic annotation of the bovine oncosuppressor gene WWOX.

WWOX (WW domain-containing oxidoreductase) is the gene mapping at FRA16D HSA16q23.1, the second most active common fragile site in the human genome. In this study we characterized at a detailed molecular level WWOX in the bovine genome. First, we sequenced cDNA from various tissues and obtained evidence in support of a 9-exon structure for the gene, similar to the human gene. Then, we recovered BACs using exon tags and annotated the gene to a >1-Mb genomic region of BTA18 using the Btau 4.0 genome assembly as a reference, thus resolving an issue related to exon 9, which is not included in the genomic annotation of the gene in the Entrez database. Finally, BACs spanning WWOX were used as FISH probes to obtain comparative mapping of the gene in Bos taurus, Bubalus bubalis, Ovis aries and Capra hircus to BTA18q12.1, BBU18q13, OAR14q12.1 and CHI18q12.1, respectively. Our data show that the chromosomal location of WWOX is conserved between man and 4 major domesticated species. Moreover, the annotation of the bovine gene also suggests a highly conserved genomic arrangement, including number and size of introns.

The river buffalo (Bubalus bubalis, 2n = 50) cytogenetic map: assignment of 64 loci by fluorescence in situ hybridization and R-banding.

Sixty-four genomic BAC-clones mapping five type I (ADCYAP1, HRH1, IL3, RBP3B and SRY) and 59 type II loci, previously FISH-mapped to goat (63 loci) and cattle (SRY) chromosomes, were fluorescence in situ mapped to river buffalo R-banded chromosomes, noticeably extending the physical map of this species. All mapped loci from 26 bovine syntenic groups were located on homeologous chromosomes and chromosome regions of river buffalo and goat (cattle) chromosomes, confirming the high degree of chromosome homeologies among bovids. Furthermore, an improved cytogenetic map of the river buffalo with 293 loci from all 31 bovine syntenic groups is reported.

[Breast cancer in pregnancy]. / Il carcinoma della mammella in gravidanza.

Breast cancer in pregnancy is a very rare condition. At present this doesn't seem a condition with a particularly grim prognosis. It's often only an underestimate of the mammalian masses in pregnancy which produces a delay in the diagnosis and the consequent grim prognosis. The authors recommend on the basis of their experience a careful control of mammalian masses in pregnancy and an opportune diagnosis that allows to operate as soon as possible. It's likewise underlined that interruption of the pregnancy don't seem to improve the prognosis.

Proopiomelanocortin-related peptides and methionine enkephalin in human follicular fluid: changes during the menstrual cycle.

Several studies indicate the presence of different pituitary hormones or neuropeptides in ovarian follicular fluid from various species. Recently our group showed that the ovarian follicular fluid of health women contains two of the endogenous opioid peptides, beta-endorphin and methionine enkephalin, in concentrations that are tenfold to twentyfold higher than in circulating plasma. The presence of immunoreactive beta-lipotropin was also shown. The aim of the present study was to evaluate whether adrenocorticotropic hormone, which in pituitary cells is synthesized from proopiomelanocortin such as beta-endorphin and beta-lipotropin, is also present in follicular fluid and the possible changes of proopiomelanocortin-related peptides during the menstrual cycle. Concentrations of beta-endorphin, methionine enkephalin, adrenocorticotropic hormone, and beta-lipotropin were measured in 60 healthy menstruating women at different periods of the menstrual cycle (20 during the follicular, 22 in the preovulatory days, and 18 during the luteal phase). Thirteen women participated in an in vitro fertilization program and thus received clomiphene citrate (100 mg/day from the fifth to the ninth day) plus 5000 IU human chorionic gonadotropin before starting the program. All samples were collected at laparoscopy under general anesthesia. In another eight patients fluid was collected from follicular cysts. Peptides were extracted on octadodecasilyl silica columns with 80% methanol in 0.5 mol/L acetic acid. The identity of follicular fluid beta-endorphin, methionine enkephalin, adrenocorticotropic hormone, and beta-lipotropin and standard peptides was demonstrated with high-pressure liquid chromatography. Peptide concentrations were measured in extracts by radioimmunoassays either directly by (methionine enkephalin and adrenocorticotropic hormone) or after (beta-endorphin and beta-lipotropin) gel filtration on Sephadex G-75. The concentrations of methionine enkephalin, adrenocorticotropic hormone, and beta-lipotropin were similar in the different periods of the cycle. Conversely, beta-endorphin concentrations were significantly higher in preovulatory days than in the other periods; no differences were evident between spontaneous and stimulated cycles. These results indicate that proopiomelanocortin-related peptides are present in the follicular fluid and that beta-endorphin concentrations change during the menstrual cycle, with the highest values occurring in the preovulatory follicle.

Plasma beta-endorphin levels in anovulatory states: changes after treatments for the induction of ovulation.

The goal of this study was to evaluate the effects of menstrual cyclicity on plasma beta-endorphin (beta-EP) levels. For this purpose, beta-EP and cortisol plasma concentrations were measured during the menstrual cycle in healthy control subjects (n = 12), in patients affected by anovulatory syndrome (n = 6), and in amenorrheic patients (n = 8). In the same patients, beta-EP and cortisol were also measured under treatment for the induction of ovulation with pulsatile luteinizing hormone-releasing hormone or human menopausal gonadotropin plus human chorionic gonadotropin administration. In spontaneous and pharmacologically induced ovulatory cycles, a significant preovulatory rise of plasma beta-EP levels was always evident. Constant levels were found in the other periods of ovulatory cycles and in the patients affected by anovulatory syndrome and primary amenorrhea. Cortisol levels did not show any significant change throughout the cycle, either in controls or in patients before or after treatment. This result suggests that when ovulation occurs, plasma beta-EP levels show a relevant rise, the physiologic significance of which remains to be elucidated.