Intraoperative parathyroid hormone (PTH) testing in patients with primary hyperparathyroidism and PTH levels in the normal range.

BACKGROUND: Primary hyperparathyroidism is a common endocrine disorder. Hypercalcemia with normal PTH levels is very unusual and can lead to diagnostic difficulties. There are very few very few studies in the literature and all with limited numerical samples. The goal of the present study was to determine the real incidence and characteristics of primary hyperparathyroidism with normal PTH and to evaluate if intraoperative PTH testing is useful in these patients. METHODS: We performed a retrospective review of 314 patients who had undergone parathyroidectomy to treat primary hyperparathyroidism between January 2002 and December 2016. Patients were divided in two groups according to biochemical preoperative findings: in Group A were included patients with normal serum PTH, in Group B those with increased serum PTH. RESULTS: Nine patients (3.7%) were included in group A and 235 in group B. Patients in group A were younger (51.5 ± 12.9 years vs 59.6 ± 12.5); preoperative serum calcium and the incidence of coexisting thyroid disease were similar between the two groups. Symptomatic patients were more frequent in Group A (77.8% vs 39.1%; p = 0.048). There were no significant differences regarding preoperative localization studies and surgical procedure. Intraoperative PTH determination demonstrated sensitivity of 86% in group A and 97% in group B, specificity and positive predictive value of 100% in both the groups, negative predictive value of 67% in group A and 79% in group B. Histopathological examination demonstrated a single gland disease in 8 (88.9%) patients in group A and a multi gland disease in 1 (11.1%), in group B single gland disease was found in 218 (92.8%) patients and multi gland disease in 17 (7.2%). Unsuccessful surgery with persistent or recurrent hyperparathyroidism occurred in 1 (11.1%) patient in group A and 4 (1.7%) in group B. CONCLUSIONS: Primary hyperparathyroidism with normal PTH is rare but physicians should be aware of this possibility in patients with hypercalcaemia. Patients with normal PTH levels are younger and more frequently symptomatic. Intraoperative PTH testing plays an important role in the operative management even in such patients.

Fixation-free incisional hernia repair in the elderly: our experience with a tentacle-shaped implant.

BACKGROUND: Incisional hernia in aged patients represents a challenge even for experienced surgeons. Besides increased risk of complications due to comorbidities, mesh fixation and assuring a sufficient mesh overlap of the defect are the main issues in carrying out the repair. AIMS: In order to assure broader coverage of the abdominal wall and a tension- and fixation-free repair, a specifically designed prosthesis was developed for the surgical treatment of incisional hernias. The results of a fixation-free incisional hernia repair carried out in elderly patients using a tentacle-shaped implant are reported herewith. METHODS: A tentacle-shaped flat mesh with a large central body and integrated arms was used to repair incisional hernia in 23 elderly patients. The mesh was placed fixation-free and secured in place through the friction exerted by the tentacles. All tentacle straps were positioned with a special passer needle. Implant placement was preperitoneal in 18 patients and retromuscular sublay in five. RESULTS: In a follow-up of 18 to 59 months (mean 36 months), four seromas occurred. Postoperative fast track helped avoid the typical complications affecting this patient subset. No infection, hematoma, chronic pain, mesh dislocation or recurrence have been reported to date. DISCUSSION: The tentacle strap system allowed for reduced skin incision thus minimizing surgical trauma and ensuring easier and faster implant placement. CONCLUSION: The tentacle arms of the implant ensured mesh stability and broad defect overlap. Besides a very low complication rate, none of the typical postoperative complications of aged patients occurred.

Follicular nodules (Thy3) of the thyroid: is total thyroidectomy the best option?

BACKGROUND: Identification of the best management strategy for nodules with Thy3 cytology presents particular problems for clinicians. This study investigates the ability of clinical, cytological and sonographic data to predict malignancy in indeterminate nodules with the scope of determining the need for total thyroidectomy in these patients. METHODS: The study population consisted of 249 cases presenting indeterminate nodules (Thy3): 198 females (79.5%) and 51 males (20.5%) with a mean age of 52.43 ± 13.68 years. All patients underwent total thyroidectomy. RESULTS: Malignancy was diagnosed in 87/249 patients (34.9%); thyroiditis co-existed in 119/249 cases (47.79%) and was associated with cancer in 40 cases (40/87; 45.98%). Of the sonographic characteristics, only echogenicity and the presence of irregular margins were identified as being statistically significant predictors of malignancy. 52/162 benign lesions (32.1%) and 54/87 malignant were hypoechoic (62.07%); irregular margins were present in 13/162 benign lesions (8.02%), and in 60/87 malignant lesions (68.97%). None of the clinical or cytological features, on the other hand, including age, gender, nodule size, the presence of microcalcifications or type 3 vascularization, were significantly associated with malignancy. CONCLUSIONS: The rate of malignancy in cytologically indeterminate lesions was high in the present study sample compared to other reported rates, and in a significant number of cases Hashimoto's thyroiditis was also detected. Thus, considering the fact that clinical and cytological features were found to be inaccurate predictors of malignancy, it is our opinion that surgery should always be recommended. Moreover, total thyroidectomy is advisable, being the most suitable procedure in cases of multiple lesions, hyperplastic nodular goiter, or thyroiditis; the high incidence of malignancy and the unreliability of intraoperative frozen section examination also support this preference for total over hemi-thyroidectomy.

Thyroidectomy with energy-based devices: surgical outcomes and complications-comparison between Harmonic Focus, LigaSure Small Jaw and Thunderbeat Open Fine Jaw.

BACKGROUND: Being the thyroid gland a highly vascularized organ, achieving a meticulous hemostasis is essential to avoid serious complications. Currently, energy-based devices are widely used in thyroid surgery. The aim of this study was to compare Harmonic Focus (HF), LigaSure Small Jaw (LSJ) and Thunderbeat Open Fine Jaw (TB) in terms of surgical outcomes and complications. METHODS: Patients undergoing thyroidectomy in our Unit between January 2012 and June 2018 were retrospectively analyzed. According to the type of energy-device used, patients were divided into three groups: Group A (HF), Group B (LSJ) and Group C (TB). RESULTS: A total of 1,165 patients were included in this study: 1,012 in Group A, 96 in Group B and 57 in Group C. Demographic data and histopathological findings were comparable between the three groups. About the postoperative stay and complications, no statistically significant difference was found. The mean operative time was 89.41±20.60 minutes in Group A, 85.57±15.91 minutes in Group B and 78.07±17.67 minutes in Group C (P<0.01). However, the post-hoc test for all pairwise comparisons showed a statistically significant difference only between Group A and Group C. CONCLUSIONS: HF, LSJ and TB have proved to be safe and effective. The postoperative stay and complications were comparable between the three groups. Considering the limits of our investigation, further studies are needed to investigate the effect of TB on operative times.

Evaluation of accuracy of one-step nucleic acid amplification (OSNA) in diagnosis of lymph node metastases of papillary thyroid carcinoma. Diagnostic study.

BACKGROUND: The incidence of node metastases in papillary thyroid carcinoma (PTC) is high, ranging from 20% to 90%. Prophylactic central lymph node compartment dissection (CLND), suggested from the latest guidelines for high-risk tumors, meets resistance due to the high incidence of postoperative complications. Recently, new molecular biologic techniques, such as One Step Nucleic Acid Amplification (OSNA), have spread widely, allowing to quickly isolate, amplify and quantify mRNA encoding for proteins selectively present in neoplastic cells, as Cytokeratine-19. The aim of this study is to evaluate the application of OSNA to intraoperative diagnosis of node metastases of PTC. METHODS: We included in the study patients with preoperative diagnosis of PTC; from each patient one or more lymph nodes were collected. To assess OSNA accuracy, each lymph node was divided into two halves: the first one was analysed with histopathological and immunohistochemical examination, whereas the second was studied with OSNA. RESULTS: Twenty-six lymph nodes from 13 patients were included in the study. Overall, OSNA sensitivity was 87.5%, specificity 94.4%, positive predictive value 87.5%, negative predictive value 94.4% and accuracy 92.8%. DISCUSSION AND CONCLUSION: OSNA is effective in detecting lymph node metastases of PTC. Considering the high risk of complications in CLND, and the uncertain prognostic value of lymph node metastases of PTC, OSNA seems to be a promising tool to identify intraoperatively patients who may benefit from CLND.

Role of prophylactic central neck dissection in clinically node-negative differentiated thyroid cancer: assessment of the risk of regional recurrence.

Prophylactic central neck dissection in clinically node-negative patients remains controversial. The aim of this multicenter retrospective study was to determine the rate of metastases in the central neck in clinically node-negative differentiated thyroid cancer patients, to examine the morbidity, and to assess the risk of regional recurrence in patients treated with total thyroidectomy with concomitant bilateral or ipsilateral central neck dissection compared with those undergoing total thyroidectomy alone. 258 consecutive clinically node-negative patients were divided into three groups according to the procedures performed: total thyroidectomy only (group A), total thyroidectomy with concomitant ipsilateral central neck dissection (group B), and total thyroidectomy combined with bilateral central neck dissection (group C). Mean operative time and postoperative stay were shorter in Group A (p < 0.01). The incidence of postoperative transient hypoparathyroidism was lower in Group A (p = 0.03), whereas no differences in the incidence of permanent hypoparathyroidism and nerve palsy were present. Postoperative radioactive iodine administration was higher in group B and particularly C (p = 0.03) compared with group A. There were no statistically significant differences in terms of regional recurrence. Differentiated thyroid cancer has a high rate of central lymph node metastasis even in clinically node-negative patients; in the present study there was no statistically significant difference in the rates of locoregional recurrence between the three modalities of treatment. Total thyroidectomy appears to be an adequate treatment for clinically node-negative differentiated thyroid cancer. Prophylactic central neck dissection might be considered for differentiated thyroid cancer patients with large tumor size or extrathyroidal extension.

Intraoperative neuromonitoring in thyroid surgery: Is the two-staged thyroidectomy justified?

BACKGROUND: The aim of this study was to evaluate the diagnostic accuracy of intraoperative neuromonitoring (IONM) in predicting postoperative nerve function during thyroid surgery and its consequent ability to assist the surgeon in intraoperative decision making. MATERIALS AND METHODS: A total of 2365 consecutive patients were submitted to thyroidectomy by the same surgical team. Group A included 1356 patients (2712 nerves at risk) in whom IONM was utilized, and Group B included 1009 patients (2018 nerves at risk) in whom IONM was not utilized. RESULTS: In Group A, loss of signal (LOS) was observed in 37 patients; there were 29 true positive, 1317 true negative, 8 false positive, and 2 false negative cases. Accuracy was 99.3%, positive predictive value was 78.4%, negative predictive value was 99.8%, sensitivity was 93.6%, and specificity was 99.4%. A total of 29 (2.1%) cases of unilateral paralysis were observed, 23 (1.7%) of which were transient and 6 (0.4%) of which were permanent. Bilateral palsy was observed in two (0.1%) cases requiring a tracheostomy. In Group A, 31 (2.3%) injuries were observed, 25 (1.8%) of which were transient and 6 (0.4%) of which were permanent. In Group B, 26 (2.6%) unilateral paralysis cases were observed, 20 (2%) of which were transient and 6 (0.6%) of which were permanent; bilateral palsy was observed in 2 (0.2%) cases. In Group B, 28 (2.8%) injuries were observed, 21 (2.1%) of which were transient and 7 (0.7%) of which were permanent. Differences between the two groups were not statistically significant. CONCLUSIONS: Our results show that IONM has a very high sensitivity and negative predictive value, but also good specificity and positive predictive value. For these reasons, in selected patients with LOS, the surgical strategy should be reconsidered. However, patients need to be informed preoperatively about potential strategy changes during the planned bilateral surgery. Future larger and multicenter studies are needed to confirm the benefits of this therapeutic strategy.

Controversies in the management of parathyroid carcinoma: A case series and review of the literature.

Parathyroid carcinoma is a rare malignancy representing less than 1% of primary hyperparathyroidism cases. Its management is controversial due to lack of large-scale, multicentric studies. We report 8 new cases of parathyroid carcinoma and review the literature. Preoperative diagnosis of carcinoma was possible in 2 (25%) cases. Unclear surgical margins were present in 5 (62.5%) patients; 4 of them underwent subsequent re-exploration and ipsilateral hemithyroidectomy, in one case associated to central lymph node dissection. Recurrent disease is reported in 2 (25%) patients. Considering the high incidence of local recurrence in case of unclear surgical margins, a re-exploration with ipsilateral hemithyroidectomy is indicated in these patients. A neck dissection should be performed only in case of clinically involved lymph nodes, avoiding prophylactic lymphectomy. An aggressive approach is indicated in case of local or distant recurrence to reduce hypercalcemia.

Interpretation of intraoperative recurrent laryngeal nerve monitoring signals: The importance of a correct standardization.

INTRODUCTION: Despite the increasingly broad use of intraoperative neuromonitoring, review of the literature and clinical experience confirms there is little uniformity in application of and results across different centers. The aim of this study was to evaluate the ability of intraoperative neuromonitoring with a standardized evaluation of the signals to predict the postoperative functional outcome and its role in reducing the postoperative recurrent nerve palsy rates. METHODS: 2365 consecutive patients underwent thyroidectomy by a single surgical team: in 1356 patients (group A) with intraoperative neuromonitoring, in 1009 (Group B) without it. RESULTS: In group A a loss of signal was observed in 37 cases: we had 29 true positive cases, 1317 true negative, 8 false positive, and 2 false negative. Accuracy was 99.26%, positive predictive value 78.38%, negative predictive value 99.85%, sensitivity 93.55%, and specificity 99.4%. 29 unilateral nerve paralysis were observed (2.13%), 23 (1.69%) transient and 6 (0.44%) permanent. In group B 26 unilateral paralysis were observed (2.57%), 20 (1.98%) transient and 6 permanent (0.59%) Differences were not statistically significant. CONCLUSIONS: Intraoperative neuromonitoring is highly predictive of the postoperative nerve function. We obtained a very high sensitivity and negative predictive value, but also a good specificity and positive predictive value. For these reasons, in selected patients with loss of signal, the surgical strategy can be reconsidered. On the other hand, this study failed to demonstrate a statistically significant decrease in the nerve paralysis rate. Further studies are needed to better evaluate the real benefit of this technique.

Tall cell carcinoma arising in a thyroglossal duct cyst: A case report.

INTRODUCTION: Thyroglossal duct cyst carcinomas are extremely rare and their clinical presentation is similar to that of benign cysts. The diagnosis is based on physical examination, laboratory tests, and most importantly multiple imaging techniques (ultrasonography, computed tomography and magnetic resonance imaging), and fine needle aspiration cytology. PRESENTATION OF CASE: We report a very unusual case of a tall cell variant of papillary carcinoma arising in a thyroglossal duct cyst in association with a follicular variant of papillary microcarcinoma and a tall cell variant of papillary carcinoma arising from the thyroid gland. DISCUSSION: Although rarely described in the medical literature, ectopic thyroid tissue present in the thyroglossal duct cyst could be involved in the development of a poorly differentiated carcinoma. The frequent observation of an associated primitive thyroid carcinoma makes surgical management of thyroid gland controversial. CONCLUSION: For the optimal management of this rare pathological condition, a comprehensive preoperative evaluation and meticulous intra-operative appraisal are fundamental.

The use of a biologic topical haemostatic agent (TachoSil(®)) for the prevention of postoperative bleeding in patients on antithrombotic therapy undergoing thyroid surgery: A randomised controlled pilot trial.

INTRODUCTION: Anticoagulants and antiplatelet agents are well-known risk factors for post-operative bleeding. The aim of this prospective, randomized pilot study was to evaluate the effectiveness of a topical haemostatic agent, namely TachoSil, for the prevention of postoperative bleeding in patients on antithrombotic therapy undergoing thyroidectomy. Perioperative management and some distinctive aspects of cervical haematomas were also discussed. METHODS: Between January 2012 and May 2014, all patients taking vitamin K antagonists (VKAs) or acetyl salicylic acid (ASA) scheduled for total thyroidectomy were enrolled and randomly allocated to group 1 (standard haemostasis) and group 2 (standard haemostasis + TachoSil). Antithrombotic drugs were always suspended prior to surgery and, when indicated, replaced by bridging anticoagulation with low-molecular-weight heparin. The primary endpoint was the incidence of postoperative cervical haematomas. RESULTS: A total of 70 patients were included in the study, representing 8.5% (70/820) of all patients who underwent thyroidectomies in the same period. The overall rate of post-operative cervical haematoma was 7.1% (5/70) and reached 14.8% (4/27) in patients on VKA therapy. All but one occurred more than 24 h after surgery (32nd hour, 8th, 10th, and 13th days). Group 1 (37 patients) and group 2 (33 patients) were well-matched according to clinical and demographic features. Postoperative haematoma was observed in 2/37 patients (5.4%) recruited in the Group 1 and 3/33 patients (9.1%) recruited in the Group 2 (P = 0.661). CONCLUSIONS: Patients taking antithrombotic drugs represent a major problem in thyroid surgery. The incidence of bleeding after thyroidectomy is significantly high and the use of TachoSil do not seem effective in preventing its occurrence. However, larger multicenter study is needed to confirm these results.

Controversies in the surgical management of thyroid follicular neoplasms. Retrospective analysis of 721 patients.

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions, is still controversial. Analysing and comparing the experience of two units for endocrine surgery, we retrospectively evaluated 721 patients, surgically treated after a follicular neoplasm diagnosis. Total thyroidectomy was routinely performed in one Institution, while in the other one it was selectively carried out. The main criteria leading to hemythyroidectomy were a single nodule, the age ≤45 years, the absence of thyroiditis or clinical/intraoperative suspicion of malignancy. Total thyroidectomy was performed in 402/721 patients (55.7%), hemythyroidectomy in 319/721 cases (44.2%) and a completion thyroidectomy in 51/319 cases (15.9%). The overall malignancy rate was 24% (176/721 patients), respectively 16% (51/319 patients) following hemythyroidectomy, and 31% (125/402 patients) following total thyroidectomy. Definitive recurrent laryngeal nerve paralysis and permanent hypoparathyroidism were not reported in hemythyroidectomy patients in which lower mean hospitalization and costs were observed. Considering the low-risk of follicular neoplasm solitary lesions, hemythyroidectomy is still the safest standard of care with lower hospitalization and costs. In case of multiglandular disease or thyroiditis, that might be associated with a higher risk of cancer, total thyroidectomy should be recommended. Further investigation is warranted to achieve a better preoperative follicular neoplasm diagnostic accuracy in order to reduce the amount of unnecessary surgical operations with a diagnostic aim.