THYROID METASTASIS FROM CLEAR CELL CARCINOMA OF THE KIDNEY 16 YEARS AFTER NEPHRECTOMY.

The thyroid gland is one of the most vascularized organs in the body. However, metastatic disease to the thyroid gland is rare. When it does occur kidney is the most common primary tumor site, followed by melanoma, lung, breast, esophagus, uterus and colon carcinoma. We describe the case of an isolated thyroid metastasis from clear cell renal carcinoma occurring 16 years after nephrectomy. An 82 years-old woman presented for the recent growth of a right thyroid nodule, diagnosed 3 years before, when a fine needle aspiration biopsy found a benign cytology suggesting a well-differentiated follicular thyroid adenoma. Her medical history included type 2 diabetes mellitus, atrial fibrillation and a right nephrectomy for a clear cell renal carcinoma done 16 years before. The patient has lost weight but she was otherwise asymptomatic. The right lobe goiter was painless, firm, and mobile with deglutition, without signs of local compression or latero-cervical lymphadenopathy. Thyroid ultrasonography revealed an enlarged (9.9 cm) macronodular right lobe, with multiple cystic areas, with normal left lobe and a thrombus in the right internal jugular vein. Thyroid function tests were normal. The patient was suspected of thyroid carcinoma and underwent a near total thyroidectomy. Histopathological examination revealed a metastasis of clear cell renal carcinoma in the right thyroid gland lobe (8.5/5/5 cm). Further imaging showed no primary tumor or other metastases. Metastatic renal carcinoma to the thyroid should be considered in any patient presenting with a thyroid mass and a medical history of operated renal cell carcinoma, since it can occur up to 25 years after nephrectomy.

Lessons learned from the first 50 thyroidectomies with Harmonic Focus Curved Shears - technical note.

Precise and safe hemostasis is necessary for successful thyroid surgery. In this respect, the advent of the ultrasonic surgical device Harmonic Focus Curved Shears (HFCS) from Ethicon Endo-Surgery constituted a major progress in the domain by its multiple capabilities of dissection, grasping, vessel sealing and transecting. The paper presents the initial experience of 50 cases with this device of a surgical team with special interest in endocrine surgery, mostly thyroid and parathyroid. The thyroid conditions for which surgery was indicated were: diffuse toxic goiter in 8 patients; multinodular toxic and nontoxic goiter in 30 patients; autonomous nodule in 2 patients; 2 patients with benign nodules at fine needle aspiration biopsy (FNAB); 4 patients with nodules positive for carcinoma at FNAB, among them 2 with unilateral cervical lymph nodes enlargement; 4 patients with highly suspect nodule on FNAB. The types of surgery performed were 4 hemithyroidectomies and 46 total thyroidectomies, 2 in association with unilateral functional neck dissections. We had 4 intraoperative hemorrhagic incidents, all in the first 15 cases and imputable to lack of expertise and improper usage of the device. We registered the following noticeable postoperative complications: 1 cervical hematoma from an arteriolar source in sternothyroid muscle demanding prompt reintervention; 8 hypocalcemias and 2 vocal cord paresis, none of which permanent. We remarked several advantages with HFCS: no necessity of changing instruments, fluentness of the intervention and more comfort for the operating team, reduced operating time, safe hemostasis. Some important tips and tricks with the usage of the instrument are presented.

Non-recurrent inferior laryngeal nerve: case report and review of the literature.

Total thyroidectomy is nowadays the operation of choice in the majority of endocrine surgery centers, whether the pathology is benign or malignant. To obtain good results, a thorough knowledge of local anatomy and a profound respect for hemostasis are necessary. Routine, at least visual, identification of the inferior laryngeal nerve (ILN) is considered gold standard and is strongly recommended. Surgeons are generally aware of the variations the nerve can have, especially on the right side. Although very rare, one such variation, with possible great impact on outcomes, is the non-recurrent route of the nerve. We present the case of a middle-aged woman with a multinodular goiter scheduled for elective surgery. During total thyroidectomy, on the right side, we were not able to find the inferior laryngeal nerve in its usual position, using the customary anatomical landmarks. Instead, we encountered it emerging directly from the right vagus nerve, at a rather right angle and entering the larynx as a unique non-bifurcating nerve. Thus, it could be spared from any injury and protected, although it could have been easily confounded with a vascular structure, given its transverse course.We think it is never overmuch to repeat that the routine identification and exposure of the inferior laryngeal nerve is a must for the thyroid surgeon in order to safely preserve its integrity.

[Laparoscopic surgery for small bowel obstruction]. / Abordul laparoscopic al ocluziei intestinului subtire.

At the beginning of the laparoscopic surgery, intestinal obstruction was considered an absolute contraindication for this approach, because of the high risk of injuring the bowel. Today, the increased experience allows to apply this method in certain selected cases of small intestine obstruction. We realised a retrospective study, over a period of 7 and a half years (January 1997 - June 2004), regarding the patients admitted and treated in our department for small intestine obstruction, both by open surgery (88 cases) and by laparoscopic surgery (11 cases). We compared the preoperative characteristics of the two subgroups, highlighting the importance of a careful selection of the cases for the success of the laparoscopic approach. We analysed the postoperative evolution of these patients (return of bowel function, postoperative wound evolution, hospital stay, socioeconomic reintegration), which allowed us to draw the conclusion that some of the patients with obstruction of the small intestine may benefit from the advantages of the mini-invasive surgery.

[Intraabdominal malignant pathology missed at laparoscopic cholecystectomy]. / Patologie maligna abdominala omisa la colecistectomia laparoscopica.

Due to its overwhelming benefits, laparoscopic cholecystectomy represents the "gold standard" for the treatment of symptomatic gallbladder stones. Allowing us to quickly solve an easy to diagnose pathology (by ultrasonography), in some cases it may lead us to mis-diagnose some major intraabdominal pathology, perhaps by a superficial interpretation of our clinical examination and para-clinic investigation data. Studying the archives of our clinic from January 1995 up to December 2003, we found 15 cases of intraabdominal neoplasia diagnosed in the year that followed laparoscopic cholecystectomy: 7 colorectal cancers, 4 pancreatic cancers, 2 gastric carcinomas, one uterine and one adrenocortical malignancies. Among these, 6 cases were in an advanced stage--because of local invasion or distant metastases--without the possibility of radical, curative surgery. Only 4 of the 15 cholecystectomies were performed for acute cholecystitis. The average age was 56.3 years, under the age when such malignancies have the maximum incidence.

[Transperitoneal laparoscopic right sympathectomy]. / Simpatectomia lombara dreapta laparoscopica pe cale transperitoneala.

Laparoscopic lumbar transperitoneal sympathectomy represents the miniinvasive approach of laterocolic procedure Adson-Diez. It is suitable to laparoscopic surgery, has a good reproducibility and it is more advantageous than total retroperitoneal approach because of a larger working space.

[Conversions and reinterventions in laparoscopic cholecystectomy]. / Conversii si reinterventii în colecistectomia laparoscopica.

From the introduction of the laparoscopy in our clinic, more and more of the cholecystectomies, reaching over 50% are done by this technique. Based upon the accumulation of an already important experience, the paper tries to analyze the situations in which, during or after laparoscopic cholecystectomy, intraoperative conversions (deliberate or of necessity) or reinterventions were necessary. We present a global view of the number of these cases and also (an in detail) analysis of the causes the imposed such decisions and of the solutions adopted. The percentages of 5.55 conversions and 1.49 reinterventions seem reasonable and acceptable in comparison with the initial results published by some experience surgeons in the field of laparoscopic surgery.

[Right laparoscopic lumbar sympathectomy]. / Simpatectomie lombara dreapta laparoscopica.

Laparoscopic lumbar sympathectomy was performed on a young man with thromboangiitis obliterans (Buerger's disease). The surgeons disposition, trocars placement and dissection technique are described in detail. The retroperitoneal approach was done in a manner similar to laparoscopic properitoneal hernia repair. The operation can be carried out with common laparoscopic equipment (for cholecystectomy) and offers the benefits of minimally invasive surgery.

[Laparoscopic treatment of transhiatal gastric hernia]. / Cura laparoscopica a herniei gastrice transhiatale.

The paper is referring to the laparoscopic cure of the gastric transhiatal hernia. The first part is a short comment on the way to establish the need for surgery and to choose the adequate procedure. Then the main tactical aspects of the laparoscopic Nissen fundoplication are discussed. Finally the technique of the operation is detailed. Six patients were operated on with good results.