How to Avoid and Manage Mental Nerve Injury in Transoral Thyroidectomy.

Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) represents an innovative and scarless technique for thyroid surgery. The procedure is conducted via a three-port technique at the oral vestibule using a 10mm port for the 30° endoscope and two additional 5mm ports for the dissecting and coagulating instruments. Patients meeting the following criteria can be considered as candidates for TOETVA: (a) an ultrasonographically (US) estimated thyroid diameter =10cm; (b) US-estimated gland volume =45mL; (c) nodule size =50mm; (d) presence of a benign tumor, such as a thyroid cyst or a single- or multinodular goiter; (e) Bethesda 3 and/or 4 categories, and (f) papillary microcar-cinoma without the evidence of metastasis. Beyond the classic complications of thyroid surgery, namely cervical hematoma, recurrent laryngeal nerve injury and hypoparathyroidism, novel consequences can occur as mental nerve (MN) injury. In this paper, leading experts in the field report on their current clinical experience with the TOETVA approach for thyroid gland surgery, with emphasis given to tips and tricks to avoid and manage MN injury.

Evaluation of cisplatin plasma levels in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Introduction Peritoneal surface malignancies have long been regarded as incurable, however, they can be treated with cytoreductive surgery in addition to hyperthermic intraperitoneal chemotherapy. This approach is associated with an increase in morbidity and mortality, unless hyperhydration is provided in a timely manner. Methods Cisplatin (CDDP) is the most widely used chemotherapeutic agent. Plasma levels of cisplatin (CDDP), a widely used chemotherapeutic agent, were measured before, during, and after the procedure. This was done in order to identify the window of highest risk as a function of drug concentrations, assuming a dose-dependent effect. Results Plasma levels of CDDP peak during perfusion. The concentration remains high until the 4th post-operative day and returns to pre-operative levels by the 7th post-operative day. Conclusions Our findings suggest that ensuring hyperhydration as well as infusing albumin and fresh frozen plasma may be of particular value for at least the first 4 days after the procedure.

[Aneurysms of the splenic artery: our experience]. / Aneurismi dell'arteria splenica: nostra esperienza.

Splenic artery aneurysms, although rare, are the most common visceral artery aneurysms with a high risk of rupture. The purpose of this retrospective study was to analyse our experience with such aneurysms. Eight patients (6 women, 2 men; mean age: 60.2 years; range: 33-76 years) with a diagnoses of splenic artery aneurysm were reviewed. Six patients were asymptomatic and two had chronic pancreatitis with left flank pain. The condition was diagnosed by ultrasonography and computed tomography. Five patients underwent surgery, two requiring splenectomy, and three patients were treated by embolisation. There were no postoperative deaths. Follow-up data were available for 7 patients, the mean follow-up period being 60 months (range: 2-72 months). Although open surgical repair remains the gold standard, endovascular techniques may, in selected cases, offer a viable alternative in high-risk patients with significant co-morbid conditions.

[Popliteal aneurysms: comparison of the results of elective and emergent treatment]. / Gli aneurismi poplitei. Comparazione tra risultati del trattamento in elezione e in urgenza.

The purpose of this study was to compare the outcomes of elective versus emergent operative repair of popliteal artery aneurysms. From 1988 to 2004, 108 popliteal aneurysms were repaired in 76 patients (mean age: 66 years; range: 42-86). Repair was elective in 70 cases - 19 asymptomatic (17%), 51 symptomatic (46%); and emergent in 38 cases; 12 of these with no identified outflow target vessel at initial arteriogram underwent intra-arterial thrombolysis. Proximal anastomosis was performed to the superficial femoral artery in 56 cases, to the popliteal artery in 24, to the common femoral artery in 28. Distal anastomosis was performed to the distal popliteal artery in 32 cases (29%) and to the infrapopliteal artery in 76 (70%). In the postoperative period, in the elective group one bypass was occluded and repaired, whereas in the emergent group 4 bypasses were occluded and amputated. During follow-up (mean duration: 57.8 months), in the elective group, 4 bypasses were revised, 5 occluded, and 2 amputated; in the emergent group, 5 bypasses were revised, and 3 were occluded and amputated. Primary patency was 98% and 79% in the elective group, as against 89% and 71% in the emergent group at 1 and 5 years, respectively. Limb salvage was 100% and 94% in the elective group, as against 89% and 81% in the emergent group at 1 and 5 years, respectively. The outcome is better with surgical treatment of elective popliteal aneurysms compared with emergency treated aneurysms. Aggressive reconstruction in patients with acute limb ischaemia is mandatory. Thrombolytic therapy may be useful in patients with no identified outflow target vessel.

[Symptomatic aorto-iliac aneurysm and situs viscerum inversus: case report]. / Aneurisma aorto-iliaco sintomatico e situs viscerum inversus: caso clinico.

We report a case of infrarenal symptomatic aorto-iliac aneurysm in a patient with acute abdominal pain. The patient was admitted to the emergency care unit for abdominal pain and CT scans showing an infrarenal aorto-iliac aneurysm in a situs viscerum inversus (SVI) totalis syndrome. The patient underwent open aneurysm repair with an aorto-iliac bifurcated graft. This case shows that situs viscerum inversus cannot be considered a technical problem for the surgical treatment of abdominal aortic aneurysm.

[Aneurysm of the abdominal aorta associated with an ectopic pelvic kidney and abnormal vascularisation: a case report]. / Aneurisma dell'aorta addominale associato a rene ectopico e anomala vascolarizzazione: caso clinico.

Renal malformations during surgery for repair of an abdominal aortic aneurysm are a rare occurrence that can create technical problems during the operation in terms of preservation of renal parenchyma and vascularisation. A case of abdominal aortic aneurysmectomy associated with an ectopic pelvic kidney is presented. Preoperative diagnosis is necessary in order to plan the surgical technique to be employed in each anatomical variant encountered.

[Comparison between magnetic resonance angiography and duplex ultrasound for preoperative planning of lower limb revascularisation]. / Comparazione tra angio-RMN ed ecocolordoppler nella diagnostica preoperatoria delle rivascolarizzazioni degli arti inferiori.

The purpose of this study was to compare magnetic resonance angiography with duplex ultrasound for defining anatomical features relevant to performing lower limb revascularisation. From June 2003 to June 2004, 30 consecutive patients with chronic lower limb ischaemia underwent magnetic resonance angiography and duplex ultrasound investigations before undergoing lower limb revascularisation procedures. The mean age was 72 years (range: 45-93). Indications for the procedure included resting pain (6 cases), ischaemic ulcer (8 cases), and gangrene (16 cases). We compared magnetic resonance angiography and duplex ultrasonography findings and the differences in the aorto-iliac, femoro-popliteal and infrapoliteal segments were noted. Magnetic resonance angiography and duplex ultrasound findings agreed in 13/15 cases (86%) in the aorto-iliac segment, in 14/17 (82%) in the femoro-popliteal segment, and in 8/11 (74%) in the infrapopliteal segment. In all, duplex ultrasound agreed with intraoperative findings in 97% of cases while magnetic resonance angiography agreed in 81%. These data show that magnetic resonance angiography is less accurate than duplex ultrasound in the infrapopliteal segment. Adeguate training is necessary before duplex ultrasound can be used as the only preoperative imaging procedure.

Wernicke encephalopathy as rare complication of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Peritoneal carcinomatosis of gastric origin is a frequent event with poor survival. A new promising approach is the association of the Cytoreductive Surgery (CRS) with the Hyperthermic Intraperitoneal Chemotherapy (HIPEC), which yet is characterized by high morbidity and mortality. We report, to our knowledge, the first case of Wernicke Encephalopathy (WE) complicating CRS plus HIPEC. WE, caused by a deficiency of thiamine, is characterized by ataxia, ocular motor cranial neuropathies and changes in consciousness. METHODS: A patient affected by gastric cancer with peritoneal seeding, submitted to CRS plus HIPEC, in 4th post-operative day had manifested the appearance of flapping tremors, with positive manoeuvre of Mingazzini, impaired vision and mental confusion. The brain Magnetic Resonance Imaging (MRI) confirmed the clinical suspicion of WE. Even though the appropriate therapy was promptly applied, the patient died in 10th post-operative day. CONCLUSION: WE is an uncommon neurological disorder. Only 16% of these patients inadequately treated recover fully, with a mortality rate of 10-20%. We consider useful to report this case, because it is the first time that WE is correlated to CRS plus HIPEC.

[Retroperitoneal approach in the treatment of supra- and infrarenal aortic aneurysms]. / L'accesso retroperitoneale nel trattamento degli aneurismi dell'aorta sopra e infrarenale.

The retroperitoneal approach for the treatment of thoracoabdominal type IV and infrarenal aortic aneurysms is an accepted alternative to thoraco-phrenolaparotomy. The purpose of this retrospective study was to report our experience and results in terms of respiratory and renal complications. From January 1997 to December 2003, 48 patients (36 with thoracoabdominal type IV and 12 with infrarenal aortic aneurysms) were treated by a retroperitoneal extrapleural approach in intercostal space X or XI. We performed 40 aorto-aortic and 8 aorto-basilar reconstructions. The perioperative mortality was 2%. Postoperative respiratory insufficiency was 8%, and postoperative renal insufficiency 12%. Permanent dialysis was necessary in 4% of cases. The survival rates were 98%, 89.4% and 58.7 at 1, 5 and 7 years, respectively. Retroperitoneal extrapleural access with a partial phrenotomy results in a significantly reduced incidence of postoperative respiratory complications.

[Intraoperative recovery of blood in surgery of infrarenal abdominal aortic aneurysm]. / Risparmio intraoperatorio di sangue nella chirurgia degli aneurismi dell'aorta addominale sottorenale.

The aim of the study was to evaluate the possibility of reducing the blood loss during elective surgery for abdominal aortic aneurysms using particular intraoperative surgical expedients. From 1993 to 1999, 200 patients were recruited into the study. We performed 90 aorto-aortic, 84 aorto-bisiliac, 4 aorto-iliac-femoral, 12 aorto-bisiliac-hypogastric, and 10 aorto-bifemoral reconstructions. Several surgical techniques were used and are described in detail. The mortality rate was 3.5%. Haemoglobinaemia 24 hours after the operation had decreased by 2.5 +/- 0.9 g/dl. In 67% of cases the estimated blood loss was lower than 300 ml. There were no transfusions in 44% of cases, and autologous transfusions in 17%. The average estimated blood loss was 350 ml, with mean reinfusion of 0.98 blood units. Our study suggests the possibility (44%) of avoiding the use of blood transfusions thanks to intraoperative blood saving by means of particular surgical techniques.

[Varicose vein recurrence after surgery of the sapheno-femoral junction: color Doppler ultrasonography study]. / Le recidive varicose dopo chirurgia della giunzione safeno femorale: studio mediante ecocolor-duplex.

The aim of this study was to evaluate the accuracy and sensitivity of colour Doppler ultrasonography for the diagnosis of postoperative recurrent varicose veins in patients submitted to surgical ligation of the saphenofemoral junction with a view to classifying the recurrences according to the causes. We studied 401 lower limbs in the orthostatic position with colour Doppler ultrasonography in 318 patients (64 M and 254 F) presenting postoperative varicose vein recurrence during the follow-up (12-60 months). We evaluated the type of reflux at the inguinal level under the Valsalva manoeuvre and divided them into 5 types. We observed an incomplete crossectomy (type 1) in 23.2% of the cases; an incontinent saphenofemoral junction, intact and in an anatomical site in 12.5% (type 2); a major tributary (double saphena) originating from the common femoral vein near to the crossectomy site in 10.2% (type 3); neovascularization in 9.7% (type 4) and the presence of a number of major tributaries from the veins of the perineal and pudendal region or from the abdominal parietal veins in 44.4% (type 5). In all cases it was possible to note and classify the type of recurrence. Colour Doppler ultrasonography is an accurate, reliable tool for the diagnosis and classification of postoperative varicose vein recurrences in patients submitted to surgical obliteration of the saphenofemoral junction. It is decisive in the preoperative evaluation and follow-up of patients. In our experience, more than one half of the cases of recurrence were not due to an error of surgical technique.

[Abdominal artery aneurysm and associated surgical abdominal diseases: towards optimal timing]. / Aneurismi dell'aorta addominale e patologie chirurgiche addominali associate: evoluzione del timing.

The purpose of this study was to assess which modalities offered the best timing in the treatment of abdominal aortic aneurysms associated with other abdominal surgical diseases. From January 1984 to December 2002, 372 patients underwent surgery for abdominal aortic aneurysms, 350 men (94%) and 22 women (6%), mean age 72 years. Of these 10% were operated on urgently. The traditional open technique was used in 307 patients, and the endovascular method in the remaining 65 cases. In 40 patients (11%) we observed other associated abdominal diseases which were treated during the same operation in 34 cases (85%). We had three deaths in the 34 cases treated in the same operation (9%). In the remaining cases no perioperative mortality was registered. There were no cases of prosthesis infection. The mean hospital stay was 9 days. Simultaneous treatment appears, on the one hand, to carry an increased operative risk and increased mortality and, on the other, to present the advantage of having to perform only one surgical procedure. The advent of the endovascular method allows us to postpone the treatment of the associated disease without increasing the technical difficulty of the second operation.

Outcome of iatrogenic injuries to the abdominal and pelvic veins.

PURPOSE: To analyze the management and outcome of iatrogenic injuries to the abdominal and pelvic veins. METHODS: We reviewed a series of patients who sustained iatrogenic vein injuries between 1989 and 2004. RESULTS: Thirty patients (21 men and 9 women ranging in age from 38 to 82 years; mean age, 53.6 years) sustained major vein injuries during general (46%), gynecological (20%), orthopedic (13%), colorectal (10%), or urologic (10%) operations. The following veins were injured: inferior vena cava (n=10), portal vein (n=4), iliac vein (n=15), and renal vein (n=1). The following types of repair were carried out: venorrhaphy (56%), end-to-end anastomosis (10%), and an interposition graft (33%). Seven patients (23%) died of injury-related causes and 18 (60%) suffered major injury-related complications, including bleeding requiring repeat exploration (n=7), disseminated vascular coagulopathy (DIC; n=5), venous thrombosis (n=4), and lower limb arterial ischemia (n=2). There were two cases of late venous thrombosis. CONCLUSION: Iatrogenic vein injuries can occur during radical surgery for cancer and are associated with high morbidity and mortality as a result of massive bleeding. Rapid vascular control and venous repair improve early and late outcome.