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.

Prophylactic thyroidectomy in children with multiple endocrine neoplasia type 2.

BACKGROUND: In patients with multiple endocrine neoplasia type 2 (MEN2) syndrome, genetic testing offers early diagnosis, stratifies the risk of developing medullary thyroid cancer (MTC) and informs the timing of thyroidectomy. The efficacy of treatment, which depends on timely and safe surgery, is not well established. METHODS: This was a retrospective review of diagnostic and clinicopathological outcomes of prophylactic thyroidectomy in children with MEN2 between 1995 and 2013 in the UK. American Thyroid Association (ATA) 2009 guidelines were used as a benchmark for adequate treatment. RESULTS: Seventy-nine children from 16 centres underwent total thyroidectomy. Thirty-eight patients (48 per cent) underwent genetic testing and 36 (46 per cent) had an operation performed above the age recommended by the ATA 2009 guidelines; pathology showed MTC in 30 patients (38 per cent). Late surgery, above-normal preoperative calcitonin level and MTC on pathology correlated with late genetic testing. Twenty-five children had lymphadenectomy; these patients had more parathyroid glands excised (mean difference 0·61, 95 per cent c.i. 0·24 to 0·98; P = 0·001), and were more likely to have hypocalcaemia requiring medication (relative risk (RR) 3·12, 95 per cent c.i. 1·54 to 6·32; P = 0·002) and permanent hypoparathyroidism (RR 3·24, 1·29 to 8·11; P = 0·010) compared with those who underwent total thyroidectomy alone. Age did not influence the development of complications. CONCLUSION: Late genetic testing may preclude age-appropriate surgery, increasing the risk of operating when MTC has already developed. Early genetic testing and age-appropriate surgery may help avoid unnecessary lymphadenectomy and improve outcomes.

Inguino-scrotal herniation of the ureter containing stones.

BACKGROUND: Inguino-scrotal herniation of the ureter is a rare and difficult situation for a surgeon, especially if only recognized during inguinal hernia repair. METHODS: An 83-year-old gentleman, with a previous history of radiation treatment for squamous anal cancer, presented with a large left inguinoscrotal hernia causing occasional pain at the base of the scrotum. Follow-up, post-radiation therapy CT scan showed a hernia sac containing the bladder and large bowel. Calcifications in the sac were interpreted as bladder stones, in keeping with the history of left renal calculi. RESULTS: During hernia repair careful dissection revealed a herniated portion of the left ureter located alongside a large hernia sac, complicated by ureteral calculi. Following stones extraction and ureteral repair, hernia repair with mesh was successfully accomplished. Pathogenesis of ureteric herniation is reviewed. CONCLUSION: A herniated ureter is potentially a source of serious renal or ureteral complications. When discovered, ureteric hernias should be surgically repaired. If preoperative detection of a ureter herniation alongside an inguinal hernia is missed, awareness of the existence of this condition may help avoid iatrogenic ureteral damage injury during a complex hernioplasty. Documentation of unexplained, sizeable and distinct calcifications in an inguino-scrotal hernia sac, particularly in a patient with a history of urolithiasis, may suggest the presence of a herniated, calculus-filled ureter. In such cases, retrograde pyelograms may be considered for a definitive diagnosis prior to surgery.

The pull-through: back to the future.

BACKGROUND: Historically, colo-anal pull-through (P-T) has been the first surgical procedure adopted to facilitate a handmade lower anastomosis. Very popular around mid twentieth century, P-T has had poor diffusion, mainly as a consequence of the technical simplifications brought by staplers. Recent literature seems poor on this specific topic, despite description of P-T appears in published series during the reconstructive phase of total laparoscopic protectomies. A comeback of P-T has also been observed as an option with deferred anastomosis, to allow and protect a colo-anal anastomosis in situations at greater risk of dehiscence, avoiding a temporary faecal diversion. After reviewing the most significant aspects of classic techniques of P-T, we report our experience with transanal laparoscopic P-T for distal rectal cancer, presenting a new, modified P-T with deferred anastomosis aimed at improving defecatory compliance. PATIENTS AND METHODS: Between January 2008 and June 2011 we operated in 258 rectal cancers (0-14 cm from the anal verge), 62.79% of which by laparoscopic access (VL), with 218 restorative procedures (84.49%). The colo-anal anastomoses (CAA) were globally 68 (26.35%), of which 48 in VL procedures (70.58%). In 27 of these CAAs we utilised the P-T procedure, with immediate CAA (I-CAA) in 11 cases (all VL) and delayed CAA (D-CAA) in 16 (2 VL), by selective indications. All CAAs were manually fashioned; 6 D-CAA had the addition of a transverse coloplasty. Site of tumor was the lower rectum in 24 patients, with 21 patients receiving preoperative chemoradiation. RESULTS: There was no operative mortality. Early morbidity: DCAA: 3 pelvic abscesses with stoma formation. I-CAA: 1 intraoperative re-resection and colo-anal anastomosis with stoma formation for defective distal vascular supply. Late morbidity: anastomotic stenosis in 5/12 I-CAA and 4/14 D-CAA controlled by mechanical dilation. Function: 4/7 D-CAA and 4/6 I-CAA nearly complete functional recovery (Kirwan's 1 or 2). CONCLUSION: There are selective indications to P-T, when resection and anastomosis is not feasible in one step, or also as a primary restorative option in elective cases when a covering stoma is refused or dangerous.

Restorative proctectomy with colon pouch-anal anastomosis by laparoscopic transanal pull-through: an available option for low rectal cancer?

BACKGROUND: There are sporadic reports, with different verdicts, of restorative proctectomy by laparoscopic transanal pull-through (LTPT) without the use of a minilaparotomy for a part of the procedure. This study aimed to explore the applicability and advantages of LTPT with colon pouch-anal anastomosis for low rectal cancer, and to evaluate the results. METHODS: From January 2002 to July 2003, 10 of 12 patients (6 men and 4 women) undergoing a laparoscopic procedure for low rectal cancer (<6 cm from the anal verge) underwent LTPT. The mean age of these patients was 58 years. The results have been compared with those for 12 similar non-pull-through procedures performed during the same period. RESULTS: There was no operative mortality. An anastomotic leakage and a hemorrhagic gastropathy occurred in the LTPT group. During a mean follow-up period of 18 months (range, 12-26 months), there was no local relapse. Four patients manifested moderate incontinence. No significant differences in functional outcome were observed between the LTPT and control groups. CONCLUSION: The authors' experience supports use of the LTPT procedure with colonic pouch-anal anastomosis for selected lower rectal cancers with indications for a laparoscopic approach as an appropriate and reproducible surgical treatment.

[Role of intersphincter resection among the surgical options for cancer of the distal rectum]. / Il ruolo della resezione intersfinterica fra le opzioni chirurgiche per il cancro del retto distale.

The surgical treatment of low rectal cancer has yet to be standardised. The aims of the study were to define the curative role of intersphincteric resection and to evaluate its indications and functional results through a retrospective clinical experience. From 1988 to 2000, out of 783 operations for primary rectal cancers (resectability rate 96%; restorative resections 83% and APR 10%) an intersphincteric resection was performed in 48 patients (31 male, 17 female, average age 62) for tumours located at a mean distance of 4.5 cm from the anal verge. Clinical stage: 27 T3 (56.3%), 12 T2, 5 T4 and 4 T1. All the operations were rated R0. TME with N-S, endo-anal distal transection and manual colo-anal anastomosis with a protective stoma were systematically performed. The mean follow-up was 46 months (range: 12-80). Functional results were evaluated with a prospective standardised questionnaire. There was no hospital mortality (30 days). The total morbidity rate was 22% with anastomotic leakage (clinical or X-ray evidence) in 12.5%. Four anal stenoses needed dilatation. Only one local recurrence six years after operation (2.1%). Nine patients died of systemic metastases within 3 years of surgery; the others are still alive and disease-free. Minor faecal incontinence with frequency and urgency occurred in 68.7% of cases at 3 months after protective stoma closure and in 37.5% after 6 months. After one year continence was good in 85.4% of survivors. Only one case required a permanent stoma for poststenotic total incontinence. The best functional results were achieved by colonic pouch reconstruction. For selected low rectal cancers (T2/T3) without voluntary sphincter infiltration, intersphincteric resection is safe and effective for oncological and functional purposes. The procedure requires accuracy in dissecting the anorectal junction. Preoperative radiotherapy may increase the indications for intersphincteric resection as well as the availability of a disease-free margin. A manual colo-anal anastomosis with colonic pouch interposition is strongly recommended.

[Optimal reconstruction after resection of the rectum in cancer surgery]. / Sulla ricostruzione ottimale dopo escissione del retto per cancro.

The efficacy of colon-J-pouch anal anastomosis (CPAA) in reducing defecatory frequency and urgency and the incidence of anastomotic fistulas has been proved by several studies but only as compared to straight colo-anal anastomosis (CAA) of the end-to-end type. We investigated the role played by the colon pouch in the strict sense, without the influence of a different CAA model, in a randomised prospective study comparing CPAA and straight side-to-end CAA. Over the period from 1994 to 1998 we selected 66 of 118 patients operated on for rectal cancer: a CPAA was constructed in 35 (group P) and a direct side-to-end CAA in 31 (group D). The two groups were well matched for surgeon, type of patient, stage of disease and incidence of radiotherapy and presented no differences in operative mortality, general and anastomotic morbidity, or need for reoperation. Functional results: after 3, 12 and 36 months, defecatory frequency > or = 4 movements/day was observed in 93.4, 67.7 and 41.6% of cases, respectively, in group D as against 25.7, 14.2 and 13%, respectively, in group P (P < 0.05), while defecatory urgency was recorded in 77.4, 35.4 and 27.9% of cases, respectively, in group D as against 34.2, 17.1 and 9%, respectively, in group P (p < 0.05). In the long term, incontinence was also significantly lower in group P. The colon pouch improves sphincter rehabilitation after anal recanalization compared to straight side-to-end CAA. It does not affect anastomotic morbidity but affords a protective effect on function in irradiated patients. CPAA proves to be the optimal reconstruction option after excision of the rectum.