Total thyroidectomy in Basedow-Graves' disease treatment: our experience.

In the present study the authors, after a short historical description of the Basedow-Graves' disease, describe their case-study gathered over the last five years. They mention the most widely accepted hypothesis regarding disease's etiology, strongly linked to autoimmune disorders, and the role that some viral agents (Coksackie B and HTLV-II) may have in initiating autoantibody production and T cells activation in genetically predisposed individuals. Basic and clinical aspects of the diagnosis and disease treatment, highlighting the use of thyroidectomy, are addressed. They conclude that total thyroidectomy represents today the treatment of choice, which, after appropriate preparation to reach the euthyroidism condition, can ensure a successful cure.

Toxic multinodular goitre. Personal case histories and literature review.

The authors reviewed their own case histories of surgical thyreopathy over the last 20 years in order to establish how many multinodular goitre (MNG) patients developed hyperthyroidism during the follow-up period. In agreement with the findings reported in literature, the authors observed that 220 out of 1117 patients with MNG developed hyperthyroidism caused by the appearance of hyperfunctioning nodules after 6-18 years from the initial diagnosis of MNG.

Parathyroid carcinoma: case report.

The authors present a case of parathyroid carcinoma in a patient with primary hyperparathyroidism. Following a literature review, the clinical and diagnostic profile, treatment and prognosis of this rare disease are discussed.

Pancreatic pseudocyst: case report and short literature review.

We report a case of pancreatic pseudocyst secondary to acute necrotizing pancreatitis treated with open cystogastrostomy. Following a literature review, we stress the enormous benefits offered by modern diagnostic techniques, and especially imaging techniques, for the diagnosis and monitoring of this disease. Treatment should be delayed for at least six weeks, following which the drainage by open surgery offers the best results and lowest morbidity and mortality, followed by laparoscopy and endoscopy, indicated in particular cases and in patients where open surgery is contraindicated.

[Acute typhlitis associated with taxane-based chemotherapy]. / Tiflite acuta dopo trattamento chemioterapico con taxani.

A rare case of acute typhlitis is reported. The patient had undergone chemotherapy for a breast cancer. Clinical and diagnostic tools as well as general and topical care are examined.

[Recanalizing entero-rectal fistula post-colostomy for inoperable rectal cancer]. / Fistola entero-rettale ricanalizzante dopo colostomia sinistra definitiva per tumore del retto inoperabile.

The Authors report a case of a spontaneous intestinal 'recanalization' after 1 year since the palliative surgery (definitive colostomy) for rectal cancer in a 79 years-old patient.

The recurrent laryngeal nerve related to thyroid surgery.

BACKGROUND: Iatrogenic injury of inferior laryngeal nerve is one of the most serious concerns in thyroid surgery. Paralysis of vocal cords is a common sequela of thyroidectomy. It represents a serious complication inducing, when bilateral, serious functional sequelae such as phonatory, respiratory and psychological problems that limit working capacities and social relationships of patients. We carried out an intraoperative study aimed to define anatomical relationships between the recurrent laryngeal nerve and the adjacent structures (the inferior thyroid artery in particular), intraoperative identification of which may allow prevention of iatrogenic injuries of the laryngeal nerve. METHODS: One hundred ninety-two patients (165 females, 27 males whose age was between 18 and 90 years, median age 55) who had undergone thyroidectomy in our department in the last 3 years. Among them, 179 patients underwent total extracapsular thyroidectomy, and of the 13 remaining, 12 were completions of thyroidectomy in patients who had previously undergone a first thyroid surgical intervention and underwent istmo-lobectomy. RESULTS: Despite a systematic intraoperative search, we identified the recurrent laryngeal nerve in 158 of 192 patients (82.3%), while in the remaining 34 (17.7%), the recurrent laryngeal nerve was not identified. In 122 out of the 158 patients (77.2%) in whom the recurrent laryngeal nerve had been detected, the nerve was identified bilaterally: in 19 of 158 (12%) only on the right side; in 17 of 158 (10.7%) only on the left. Concerning the postoperative results we noticed only one case (0.5%) of recurrent laryngeal nerve injury for neoplastic infiltration of its own branch, one case (0.5%) of monolateral cordal hypomotility, and two cases (1.04%) of bilateral cordal hypomotility with temporary disphonia, which regressed in 6 months of time. CONCLUSION: The results of our study may confirm that iatrogenic injury to the recurrent laryngeal nerve, or to its branches, might be better avoided by searching, identifying, and exposing the nerve itself and by following its course with care. In our view, total extracapsular thyroidectomy, with systematic search for the nerve, is the best approach. We believe that deep knowledge of the thyroid region's surgical anatomy and the awareness of the extremely varying course of the recurrent laryngeal nerve and the inferior thyroid artery and their relations should be taken into account by surgeons.

Reproducibility of histological diagnoses and diagnostic accuracy of non palpable breast lesions.

Twelve pathologists independently examined and classified a set of 25 cases of non palpable breast lesions selected from the archival files of the Pathology Department in Florence. A final consensus diagnosis was reached for all cases at a slide seminar. Individual diagnoses were first combined in 3 broad categories (benign lesion, in situ and invasive carcinoma), then compared to each other and then to the "consensus". Results show that among these 12 pathologists there was complete agreement in 14 cases. Discrepancies for the other 11 cases varied in the number of pathologists and diagnostic categories involved. Overall agreement was excellent (median kappa 0.86) but cases of potentially harmful errors were evident. The authors discuss these findings in the frame of a breast cancer screening program planning.

Amyand's hernia: case report and review of the literature.

The authors report a case of gangrenous acute appendicitis in the sac of an inguinal hernia (Amyand's hernia). After a review of the literature, they emphasise the extreme rarity of the case reported, they underline how the clinical picture is highly similar to that of a strangulated inguinal hernia. They affirm that appendicectomy and hernioplasty may be performed at the same time, since the repair of the hernia should be performed without prosthesis implantation due to the contamination of the operating field.

240 hepatocellular carcinomas: ultrasound features, tumor size, cytologic and histologic patterns, serum alpha-fetoprotein and HBs Ag.

Two hundred and forty cases of hepatocellular carcinomas (HCC), diagnosed by ultrasonography and fine needle biopsy, were studied. The following parameters were investigated: 1. echo features (240 cases) - hypoechoic, 54; hyperechoic, 56; complex, 112; isoechoic with halo, 18; 2. tumor size (240 cases) - single tumor under 4.5 cm, 30; single tumor over 4.5 cm, 74; multiple masses or diffuse, 136; 3. cytologic pattern (240 cases) - well and medium differentiated, 144; pleomorphic, 43; poorly differentiated, 28; unclassified, 25; 4. histologic pattern (157 cases) - trabecular, 74; solid, 42; acinar, 1; mixed, 2; unclassified, 38; 5. alpha-fetoprotein (AFP) level (185 cases) - under 20 ng/ml, 79; between 20 and 320 ng/ml, 40; over 320 ng/ml, 66; 6. HBs Ag (208 cases) - present in 56 cases; 7. cirrhosis (102 cases) - present in 79 cases. Some of the above parameters were correlated with one another. There was: 1. a highly significant frequency of the hypoechoic feature among small HCC; 2. a percentage of AFP-producing tumors increasing with tumor size; 3. no relationship between AFP production and cytologic or histologic pattern; 4. no relationship between tumor size and cytologic or histologic pattern. However, among the small HCC, all the 9 HCC with a diameter of less than 3 cm showed a trabecular pattern and well-differentiated cells. Cirrhosis was present in every patient with a small HCC. Since the discovery of a small HCC is an incidental ultrasonographic finding in the context of severe liver disease, ultrasonographic monitoring of cirrhotic patients is the best available strategy to screen for small HCC.

Fine needle aspiration cytology of Kaposi's sarcoma in lymph nodes. A case report.

A case of Kaposi's sarcoma in lymph nodes aspirated by fine needle is presented. The cytologic findings were highly suggestive of Kaposi's sarcoma, and the histologic examination confirmed the diagnosis. It was then discovered that the patient was homosexual. Viral studies did not reveal the presence of HTLV virus.

[Cytologic aspiration biopsy in the diagnosis and therapy of solitary cystic nodular thyropathies]. / La cito-biopsia aspirativa nella diagnosi e nella terapia delle tireopatie nodulari cistiche solitarie.

Between January and December 1983, 36 patients with single and benign cystic thyroid nodules underwent fine needle aspiration. They received, after fine needle aspiration, medical treatment (antiinflammatory drugs and L-T4). Clinical and ultrasonographic follow-up was performed either 6 and 18 months after FNA, to evaluate the lesion evolution. The six-month follow-up demonstrated no ultrasonographic signs of cystic lesion in 11 cases (30.6%); a decreased volume in 21 (58.3%) and four recurrences (11.1%), which underwent surgical treatment (lobectomy). In 21 patients with persistent lesions at 18 month follow-up, a cystic reduction in a 79.9% rate was documented. These data suggests the diagnostic importance of FNA and the safety of this method not only to surgical selection of patients, but also to the treatment of benign thyroid cysts.

[Changes in the levels of reverse triiodothyronine (rT3) during and after surgery of the thyroid gland]. / Variazioni dei livelli di reverse-T3 (rT3) nel corso e dopo interventi chirurgici sulla tiroide.

The thyroid activity of twenty euthyroid patients, with single or multiple "cold" nodules was investigated, with determination of seric T3, T4, reverse-T3 (rT3) and TSH. The blood-drags were performed respectively, during (with seric samples from the inferior thyroid vein ipsilateral to the affected lobe) and after (1, 3 and 7 days) surgery. The results of this study--and particularly the significative decrease of T3 and the rapid rT3 increase, either during or after operation - suggests a condition similar to the described "Low T3 syndrome", as expression of both the stress determined by surgery and the correlated thyroid metabolic "adaptation". The clinical and biochemical euthyroidism, expressed by normal levels of TSH in all the samples, confirm the persistence of normal feed-back mechanism by the diencephalon-hypophysis-thyroid axis, even in stress conditions.

[Current orientation in the surgical treatment of cancer of the thyroid]. / Attuali orientamenti nel trattamento chirurgico del cancro della tiroide.

The authors reviewed their series of thyroid cancers and analyzed possible factors of the low incidence of these neoplasms in their experience. They outline the importance of total thyroidectomy which must be performed as soon as possible. Cervical lymphadenectomy must be reserved only to papillary cancers in which intraoperative histologic examination give the evidence of multiple metastasis of cervical nodes.

[Solitary and multiple thyroid nodular pathology (results of 1,300 surgical interventions)]. / Patologia nodulare tiroidea solitaria e multipla (risultati di 1.300 interventi chirurgici).

To evaluate the results of single and multinodular thyropathies surgical treatment, 1.300 cases operated on from january 1974 to december 1987 were reviewed. 842 patients (64.7%) were female; the average age was 41 +/- 2.4 year. Thyroid pathology was represented by solitary nodule in 643 cases (49.4%); multinodular goitre in 559 cases (43.0%) (377 euthyroid, with multinodular lesions extended to the entire gland; 182, hyperthyroid); retrosternal goitre in 78 cases (5.9%); recurrent goitre in 20 cases (1.5%). The patients underwent to: total thyroidectomy (525 cases); subtotal thyroidectomy (132 cases); total lobectomy (322 cases); subtotal lobectomy (321 cases). Post-operative follow-up (clinical exam; T3, T4, TSH, calcemia and phosphatemia) was performed at 3, 6, 12, 18 and 24 months after surgery). The overall mortality was 0.13 percent (two deaths, respectively after total = 0.1% and subtotal thyroidectomy = 0.7%). Immediate postoperative complications were: recurrent palsy (9 cases: 0.6%; acute respiratory failure with temporary tracheostomy (10 cases: 0.7%); hypoparathyroidism (3 cases: 0.2%). Late sequelae (1-3 year) were: recurrent nerve palsy in 7 patients (0.5%); hypoparathyroidism in one case (0.07%). 46 patients (34.8%) which underwent subtotal thyroidectomy were hypothyroid to T3, T4, TSH tests (1 year). Such sub-clinic pathology required levo-thyroxin treatment. New concepts on the pathogenesis of multinodular goitre (growth autonomy of goitre human tissue; the lack of levo-thyroxin therapy to prevent relapses after subtotal thyroidectomy) and the results drawed from the revision of this series seems confirm the indication to lobectomy for solitary "cold" nodules and thyroidectomy for treatment of normo and hyperthyroid multinodular goitre.

[Indications for preventive tracheostomy in the surgical treatment of non-neoplastic thyroid disease]. / Indicazioni alla tracheostomia precauzionale nella chirurgia delle tireopatie non neoplastiche.

In thyroid surgery, an emergency tracheostomy is mandatory, as is well known, in acute pre- and postoperative asphyxia due to obstruction of the upper airways, especially in cases of malignant tumours. In particular conditions, in the presence of benign thyroid disease and when there is no reduction in the laryngo-tracheal lumen, tracheostomy has an important precautionary function following total thyroidectomy. The authors describe their experience with 6 patients treated by precautionary tracheostomy after total thyroidectomy for benign thyroid disease, analysing the indications and the advantages of this method.

[Intestinal recanalization 16 years after Hartmann's operation]. / Ricanalizzazione intestinale dopo 16 anni dall'intervento secondo Hartmann.

The authors report a case of a surgical intestinal recanalization after 16 years since a Hartmann's intervention. After some considerations on the results they obtained in similar cases, the Authors call attention on this specific clinical case. They come to the conclusion that a successful surgical recanalization--although the difficult availability of the remaining rectal stump--is possible even if a long period has passed since a Hartmann's intervention was performed. In fact the rectal stump and the sphincter apparatus, even if excluded from the fecal transit for a long while, retain largely their specific functional activities and show a marked ability for an effective sensitive-motor restoration.

[Surgery of inguinal hernia in the elderly]. / La chirurgia dell'ernia inguinale nel paziente geriatrico.

The authors report their 14 years experiences with inguinal hernia repair in elderly. The result were compared with young (< 75 years old), and confirmed that there were no significant differences between the 2 groups. The study confirmed the safety and effectiveness of the "tension-free" technique under local anaesthesia, which is proposed as the treatment of choice in elderly.