Risk Factors for Hypoparathyroidism after Thyroid Surgery: A Single-Center Study.

BACKGROUND: Hypoparathyroidism is one of the most common complications after thyroidectomy. This study evaluated the incidence and potential risk factors for postoperative hypoparathyroidism after thyroid surgical procedures in a single high-volume center. METHODS: In this retrospective study, in all patients undergoing thyroid surgery from 2018 to 2021, a 6 h postoperative parathyroid hormone level (PTH) was evaluated. Patients were divided into two groups based on 6 h postoperative PTH levels (≤12 and >12 pg/mL). RESULTS: A total of 734 patients were enrolled in this study. Most patients (702, 95.6%) underwent a total thyroidectomy, while 32 patients underwent a lobectomy (4.4%). A total of 230 patients (31.3%) had a postoperative PTH level of <12 pg/mL. Postoperative temporary hypoparathyroidism was more frequently associated with female sex, age < 40 y, neck dissection, the yield of lymph node dissection, and incidental parathyroidectomy. Incidental parathyroidectomy was reported in 122 patients (16.6%) and was correlated with thyroid cancer and neck dissection. CONCLUSIONS: Young patients undergoing neck dissection and with incidental parathyroidectomy have the highest risk of postoperative hypoparathyroidism after thyroid surgery. However, incidental parathyroidectomy did not necessarily correlate with postoperative hypocalcemia, suggesting that the pathogenesis of this complication is multifactorial and may include an impaired blood supply to parathyroid glands during thyroid surgery.

Risk Factors for Low Levels of Parathyroid Hormone after Surgery for Thyroid Cancer: A Single Center Study.

BACKGROUND: Thyroidectomy is the definitive treatment for most patients with thyroid cancer. Hypoparathyroidism is the most frequent complication of thyroidectomy, and its pathogenesis is multifactorial. The aim of this study is to evaluate the patient- and surgical-related risk factors for hypoparathyroidism after surgery for thyroid cancer. METHODS: In this retrospective study, patients referred to surgery for thyroid cancer from 2016 to 2019 were enrolled. Preoperative serum calcium and parathyroid hormone (PTH) and postoperative 24 h PTH and calcium levels were evaluated. Demographic data, type of surgery, incidence of hypoparathyroidism and hypocalcemia were recorded for all the patients. Patients were divided into two groups based on post-operative PTH levels (≤12 and >12 pg/mL). RESULTS: A total of 189 patients were enrolled in this study. There were 146 women (87.3%) and 43 men (22.7%), with a mean age of 51.3 years. A total of 79 patients (41.7%) underwent a neck dissection. A total of 59 patients (31.1%) had a postoperative PTH level < 12 pg/mL. Female sex, neck dissection, the yield of lymph node dissection and incidental parathyroidectomy were significantly associated with postoperative hypoparathyroidism. Incidental parathyroidectomy was reported in 44 (23.2%) patients and was correlated with younger age (<40 years) and neck dissection. There was no difference in the rate of post-operative hypocalcemia between patients with incidental parathyroidectomy and those without. CONCLUSIONS: Young patients undergoing neck dissection and with incidental parathyroidectomy have the highest risk of postoperative hypoparathyroidism after surgery for thyroid cancer. However, a large proportion of patients without incidental parathyroidectomy may have temporary hypocalcemia, suggesting that impaired blood supply of parathyroid glands during their identification and dissection may play a relevant role.

Thyroid disease and cancer in kidney transplantation: a single-center analysis.

BACKGROUND: Thyroid diseases are frequent in patients with end-stage renal disease, but data on renal transplant recipients are conflicting. This study evaluated the incidence of thyroid disease and cancer in a population of kidney transplant recipients performed in a single center. METHODS: Seven hundred sixty patients receiving a kidney transplantation between January 2000 and October 2017 were followed with thyroid ultrasonography to determine nodules together with thyroid hormone levels. Ultrasound-guided fine-needle aspiration citology (FNAc) was performed to the nodules > 10 mm . RESULTS: Two hundred four patients (26.8%) patients demonstrated functional or morphologic changes in the thyroid gland compared with pre-transplant period. Among the 204 patients with newly diagnosed thyroid disease, 165 patients had single or multiple nodular lesions less than 1 cm in diameter, and were followed yearly. Nodule size progression was observed in 23 patients (13.9%), and they underwent a FNAc. A total of sixty-two patients (30.3%) underwent FNAc. The biopsy samples were cytologically interpreted as benign in 20 patients (32.2%), suspicious in 40 patients (64.5%), or at high risk of cancer in 2 patients (3.2%). Forty-two patients underwent total thyroidectomy. At histological examination, 18 patients had a thyroid cancer (papillary cancer in 17 patients, follicular cancer in one). Thyroid cancer was more frequent in male patients with a mean time from transplant to diagnosis of 5.6 years. At a mean follow-up was 8 ± 1.2 years, all patients are alive with a normal functioning graft. CONCLUSIONS: Thyroid diseases are common in transplant recipients. Thyroid disease may evolve after transplantation, probably as a consequence of immunosuppression. A complete evaluation of thyroid disease is mandatory in kidney transplant recipients because early diagnosis and appropriate treatment of thyroid disease and cancer may significantly decrease the morbidity and mortality in these patients.

Role of Emerging Environmental Risk Factors in Thyroid Cancer: A Brief Review.

Environmental factors are recognized as risk factors of thyroid cancer in humans. Exposure to radiation, both from nuclear weapon or fallout or medical radiation, and to some organic and inorganic chemical toxicants represent a worldwide public health issue for their proven carcinogenicity. Halogenated compounds, such as organochlorines and pesticides, are able to disrupt thyroid function. Polychlorinated biphenyls and their metabolites and polybrominated diethyl ethers bind to thyroid, transport proteins, replace thyroxin, and disrupt thyroid function as phthalates and bisphenolates do, highly mimicking thyroid hormones. A better knowledge of environmental risks represents a very important tool for cancer prevention through true risks prevention and management. This approach is very important because of the epigenetic origin's theory of cancer. Therefore, the aim of this review was study the association between environmental agents and thyroid cancer promotion.

Hypocalcemia after thyroidectomy: iPTH levels and iPTH decline are predictive? Retrospective cohort study.

BACKGROUND: Hypocalcemia is the most common complication of thyroid surgery. The aim of this study was to determine the early predictive factors of postoperative hypocalcemia and to analyze their efficiency. METHODS: We performed a retrospective study of 345 consecutive patients who underwent total thyroidectomy at the Endocrine Surgery Department (Policlinico G. Rodolico Hospital of Catania) between January 2011 and November 2013. We measured serum intact parathormone (iPTH) levels preoperatively and 4 h after surgery. The threshold values of hypocalcemia for iPTH levels and iPTH relative decline were obtained by receiver operating curves (ROC) analysis. RESULTS: The incidence of hypocalcemia was 32.2% (111 of 345 patients). Our statistical analysis revealed that hypocalcemia rate was strongly correlated with the lower iPTH values and greater iPTH decline (P < 0.001). The threshold enabling prediction of hypocalcemia were 12,5 pg/mL for iPTH and 55,7% for relative iPTH decline. Patients with iPTH <12,5 pg/mL developed hypocalcemia in 58.6% of cases while those with iPTH ≥12,5 pg/dl in 18.8%. Among 175 patients with iPTH relative decline greater than 55,7% hypocalcemia was diagnosed in 91 cases (52%), while other 170 patients with iPTH relative decline less than 55,7% developed hypocalcemia only in 20 cases (11,7%). CONCLUSIONS: The decreased iPTH levels and increased iPTH relative decline resulted to be an accurate predictive factors of postoperative hypocalcemia. The early administration of Calcium and vitamin D in the high-risk patients should be put on in order to prevent the symptoms of hypocalcemia and to reduce the costs and duration of hospitalization.

Post-thyroidectomy hypoparathyroidism, what should we keep in mind?

AIM: Hypoparathyroidism and the resulting hypocalcemia is a common iatrogenic complication following surgical procedures to the neck, and commonly, to the thyroid gland. The aim of this study was to review the available literature to summarize current data related to the development of hypoparathyroidism after thyroid surgery. MATERIALS AND METHODS: An analysis of the surgical literature was performed using the search engine EMBASE and PubMed with particular reference to the principal risk factors related to the post-thyroid surgery hypoparathyroidism. Moreover the medical records of 345 patients, who underwent thyroid surgery at the Section of Endocrine Surgery - Department of Medical and Surgical Sciences, Advanced Technologies "G. Ingrassia" University of Catania, Italy, were also examined. RESULTS: The definition of hypoparathyroidism varies widely in literature. There is a wide range of reported incidences of transient and permanent postoperative hypoparathyroidism in literature. Extensive surgery, malignant disease and concomitant central and/or lateral neck dissection, autoimmune or Grave's' disease and re-operation represent the most recognized risk factors. A wide consensus exists about transplanting a parathyroid gland when it seems to be nonviable. DISCUSSION: Although many improvements have been done in surgical technique, hypoparathyroidism seems to be one of the most common complication after total thyroidectomy. In this study we discuss the diagnosis methods and the importance of its early prediction regardless it is transient or permanent. Recovery time is under discussion: some author consider a gland permanent injury if restoring functionality does not occur within 6 months other 12 months. To assess the parathyroid gland function some authors have been using postoperative PTH level as a useful tool for predicting hypocalcemia. CONCLUSIONS: Many efforts are required to address the problem of a consensus on best define these complications. An early low PTH level after total thyroidectomy is associated with a high risk of permanent hypoparathyroidism and normal levels usually exclude long-term parathyroid glands dysfunction. However, the cost of the PTH assay may limit its widespread application. Despite the reassuring presence of new therapeutic strategies, intra-operative preservation of the parathyroid glands is the best prophylaxis to avoid postoperative hypocalcemia after total thyroidectomy. KEY WORDS: Hypoparathyroidism, Thyroid surgery.

Epigastrium: unusual site of incisional hernia from a 5 mm trocar.

The observation of an unusual case of incisional hernia, found in the epigastric zone at the site of a 5 mm trocar incision for a cholecystectomy, has caused us to describe it and to review the literature. C.A. is a male aged 59 and He came to our attention in 2014, complaining about the presence, for about three months, a swelling in the epigastric area, without occlusive symptoms. An objective examination showed an epigastric mass at the scar of the insertion site of a 5mm trocar during the cholecystectomy operation. The patient was hospitalized and underwent traditional surgery: incision at the scar; isolation of the extruded fatty tissue, which had no sac, identified as part of the round ligament, herniated through the residual incision of the previous operation. Based on experience acquired it is useful to make careful sutures of 5 mm incisions repairing peritoneal laceration. KEY WORDS: Epigastrium, General surgery, Incisional hernia, Laparoscopy, Trocar.

How to avoid and to manage post-operative complications in thyroid surgery.

Complications of thyroidectomy are hypoparathyroidism, recurrent laryngeal nerve palsy, and hemorrhage. These complications have a low incidence. Hypoparathyroidism is the most frequent complication of total thyroidectomy. Its incidence varies between 0.5 and 65%. This complication is also visible after reoperation for recurrent disease and in patients previously treated with radioiodine. Damage to the recurrent laryngeal nerve can be temporary or permanent, unilateral or bilateral. The bilateral lesion, associated with severe episodes of breathlessness, is a rare complication (0.4%). Intraoperative control of nerves is crucial to prevent damage. The hematoma creates an obstacle to venous and lymphatic flow and consequently breathing difficulties. The preventive hemostasis during surgery is important. Therapeutic treatment is described.

The thyroid disease in the elderly: Our experience.

INTRODUCTION: The number of elderly people in Italy is growing, so it is important to study the presentation of diseases in these subjects. MATERIALS AND METHODS: We selected 1362 patients who underwent thyroidectomy for different thyroid diseases from January 2008 to December 2014. The patients weredivided into two groups, according to the age. The patients aged 65 years and over were included in the group A, and the patients under the age of 65 years were included in the group B. DISCUSSION: Thyroid diseases in the elderly often present with atypical symptoms which are very similar to symptoms of the aging process. In elderly hypothyroidism occurs frequently sub-clinically and hyperthyroidism is often presented with cardiovascular symptoms. In our study we evaluated the differences in incidence of thyroid diseases in the elderly and in the younger groups of patients. CONCLUSION: The data analyzed in this study showed that in the elderly we have a reduced secretion and metabolization of thyroid hormones. The symptomatology in the elderly is nonspecific and can create a delay in the correct diagnosis.

Comparison between Focus Harmonic scalpel and other hemostatic techniques in open thyroidectomy: A systematic review and meta-analysis.

BACKGROUND: The purpose of this review was to compare the efficacy and surgical outcomes of total thyroidectomy between the Focus Harmonic scalpel (Ethicon, Cincinnati, OH) and other hemostatic procedures. METHODS: An extensive search was conducted using the PubMed and Cochrane databases from January 2008 to October 2014. Operating time, blood loss, pain, complications, and hospital stay were evaluated. RESULTS: When compared with conventional techniques or LigaSure Precise Vessel Sealing System (Medtronic, Minneapolis, MN), the use of the Focus Harmonic scalpel reduced operative time by 22,428 minutes and blood loss by 13,914 mL. Length of hospital stay was significantly shorter in the Focus Harmonic scalpel group with a mean reduction of 0.410 days. CONCLUSION: According to our meta-analysis, when comparing the Focus Harmonic scalpel versus conventional techniques, it seems evident that the use of this device in thyroid surgery is associated with a mean reduction in operating time, blood loss, and hospital stay, without any increase in pain and complications. There was no appreciable difference between the Focus Harmonic scalpel and the LigaSure Precise Vessel Sealing System. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1578, 2016.

Synchronous ileal neuroendocrine tumor: diagnosis and treatment. A case report and review of the literature.

INTRODUCTION: The majority of neuroendocrine tumors (NET) are located in the gastrointestinal tract (67.5%) and in the bronchopulmonary (25.3%). CASE REPORT: CA, female, 42 years old, profuse diarrhea about two months, cramping for increased peristalsis, vomiting and weight loss. The patient, diagnosed with ileal neuroendocrine tumor, by colonoscopy with biopsy of lesion, therefore came in our unit to be subjected to surgical therapy. Plasma assay Chromogranin A was performed: 160 ng / ml (nv: 15-100 ng / ml). The patient underwent surgery of right hemicolectomy. DISCUSSION: Neuroendocrine tumors although are rare diseases, have an increasing impact, probably by virtue of improved diagnostic methods. In case of profuse diarrhea should be suspected a neuroendocrine tumor. Certainly the diagnosis of certainty is given by histological examination (biopsy or resected nodule). CONCLUSION: After surgical excision is necessary to perform the follow-up of chromogranin A, and, if not executed, perform nuclear medicine examinations such as Octreoscan and PET. KEY-WORDS: Chromogranin A, Neuroendocrine tumor, Octreoscan.

Thyroidectomy: Natural drainage or negative drainage? Experience with randomized single-center study.

AIM: The aim is to investigate, in relation to the volume of blood drained, which type drainage to use after thyroidectomy natural drainage or negative drainage. MATERIAL OF STUDY: 141 patients who underwent total thyroidectomy for multinodular thyroid disease between 22 November 2012 and 7 November 2013 were included in the present study. For the 141 patients a randomized method was used with closed circuit natural drainage (59 cases) or negative drainage (82 cases). The evaluation of the drained volume was performed 24, 48 and 72 hours following surgery. RESULTS: The amount of blood drained during the first 24 hours of the postoperative period averaged 78.59 ml in patients with a negative drain and 54.24 ml in those under natural drainage. After 48 hours, the total volume in the first group was 117.98 ml, while in the second group it was 85.18 ml. In cases where the observation was prolonged up to 72 hours, the average volume was 217 ml in the 10 cases of negative drainage and 117.5 ml in the 4 cases of natural drainage. CONCLUSION: The difference in blood volume observed between the two groups of patients with natural drainage and negative drainage, leads us to conclude that the best drainage in thyroidectomy is the natural one, diverging from the older concept of the use of negative drainage in superficial cavities.

Cystic pancreatic neuroendocrine tumors: To date a diagnostic challenge.

OBJECTIVE: Cystic PNETs are an uncommon neoplasms increasingly detected in current clinical practice which often present a diagnostic challenges to both the experienced radiologist and pathologist. The aim of this study was to review the available literature to summarize current data that compare and evaluate both the clinical and pathologic features of cystic pancreatic neuroendocrine tumors. MATERIALS AND METHODS: A systematic review of the current literature was performed using the search engines EMBASE and PubMed to identify all studies reporting on cystic pancreatic neuroendocrine tumors. The MeSH search terms used were "cystic pancreatic neuroendocrine tumors", "endocrine neoplasms", and "pancreatic cysts". Multiple combinations of the keywords and MeSH terms were used. RESULTS: The clinical evaluation of cystic pancreatic lesions appears to suffer from same limitations despite the improvement in the diagnostic tools. Subsequently, we highlight diagnostic pitfalls and differential diagnosis of these cystic tumors. In this review we discuss current advances in the application of the imaging modalities and characteristics features with special emphasize on endoscopic ultrasound (EUS), and EUS guide fine needle aspiration (EUS-FNA). CONCLUSIONS: Cystic neuroendocrine tumor in the pancreas underlines the clinical impact of endoscopic ultrasound in the work-up of patients with unclear lesions in the pancreas. EUS-FNA cytology and cyst fluid analysis is a useful adjunct to abdominal imaging for the diagnosis of pancreatic cystic lesions. Due to the evident diagnostic difficulties, we hypothesize that cyst fluid characteristics, including cytomorphological features, is the most accurate test to achieve a preoperative diagnosis and to provide a basis for prognostic prediction.

The use of FOCUS Harmonic scalpel compared to conventional haemostasis (knot and tie ligation) for thyroid surgery: a prospective randomized study.

Haemostasis is crucial in thyroid surgery to avoid intraoperative and postoperative complications. In the present study, we evaluated the efficiency and the safety of Harmonic scalpel when compared to conventional suture ligation in open total thyroidectomy. We enrolled 265 patients who underwent total thyroidectomy for multinodular disease since October 2011 up to October 2013. They were randomized into two groups: 141 in group HS (Harmonic Scalpel), 124 in group CT (Conventional tecnique). We recorded the following data: operative time, post-operative blood loss, length of hospital stay and complications. The patients were monitored for 48 hours after surgery. Several differences were observed between the two groups (HS vs CT): the use of Harmonic scalpel was associated to a significant reduction of surgical operative time (110 min in CT vs 79.36 min in HS, p = 0.00001) and also associated to a lower blood loss (97.38 ml in CT vs 68.72 ml in HS, p = 0.00001). The length of stay was significantly shorter in the HS group (2.75 days in CT vs 1.93 days in HS) Complication rate was similar in the two groups. According to our experience, the Harmonic scalpel represents a safe alternative to conventional haemostasis in thyroid surgery, allowing for a significant reduction of operative time, blood loss and hospitalization. The rate of complication demonstrated no significant difference among the two groups.

Spontaneous rupture of an umbilical hernia in a cirrhotic patient with ascites A case report and review of the literature.

The authors, report a case of spontaneous rupture of an umbilical hernia in a cirrhotic patient with ascites and perform a literature review. Their results and the published data suggest that it is preferable to perform elective surgery after stabilization of the ascites and the patient's general condition in order to prevent complications and mortality. KEY WORDS: Ascites, Hernioplasty, Spontaneous hernia rupture.

[Radiation exposure and thyroid cancer]. / Radiazioni ionizzanti e cancro tiroideo.

Thyroid cancer is the most common malignant tumor of the endocrine system. The most frequent type of thyroid malignancy is papillary carcinoma. Thyroid cancer's incidence rates have increased over the last three decades throughout the world. Numerous studies have documented that radiation exposure is a well-established risk factor for the thyroid cancer. It has been reported that exposure to external medical radiation or to external and internal radiation from atomic bomb explosions, nuclear tests or nuclear accidents leads to an increased risk for thyroid cancer. The risk of thyroid cancer is maximal during the first years of life and decreases with increasing age at exposure due to morphologic and functional heterogeneity in the thyroid tissue of children and adults. Also it has been indicated that iodine deficiency increases the risk of the thyroid cancer related to radioactive iodines in case of exposure to radioactive iodines in childhood and the stable iodine supplementation reduces this risk. Ionizing radiation produces a range of mutations in irradiated cells of the thyroid. The prevalence of RET/PTC mutations is significantly higher in papillary carcinomas from childhood patients with the precedent history of radiation.

Brachial thrombosis in a premature neonate. A case report.

Arterial injuries in infants are rare and in most cases are of iatrogenic origin as a consequence of catheterization, venipuncture or arterial blood sampling. These lesions require an accurate, noninvasive clinical diagnosis and prompt exploration and reconstruction using microvascular techniques to restore perfusion and to avoid morbidity and even mortality. We present a 3-day-old infant with a brachial artery thrombosis by a white thrombus as a consequence of an unsuccessful attempt to introduce an intravascular catheter. A microvascular reconstruction was performed, with complete restoration of the blood flow. Any suspected vascular injury needs immediate clinical and diagnostic assessment in order to avoid potential life-threatening complications. Surgery is mandatory in case of extensive arterial injuries, in case of inadequate distal blood supply or in case of progressive worsening of ischemic clinical findings.

Huge fibroid (g. 3.000) removed during cesarean section with uterus preservation. A case report.

Removal of a giant fibroid during a caesarean section is very rare. We report a case of multiple myomectomy among which a huge myomas (cm 22, weight 3.000 g) in a 44 years old nullipara at 38 weeks. A 10 cm long suprapubic transversal incision according to Pfannenstiel on spinal anaesthesia was done; a female baby weighing 2.285 g, with Apgar score 9/10 was born. Owing to the uterine hypotonia following foetal extraction, myomectomy with womb preservation was carried out. Postoperative course was regular for mother and newborn too.

Chylous ascites following laparoscopic living donor nephrectomy. Case report.

Kidney transplantation is a therapeutic option of choice for patients with end-stage disease. Laparoscopic living donor nephrectomy (LLDN) is a less invasive alternative to the open procedure to increase the number of renal donors. However, several studies have reported that this technique requires a long learning curve, and that the complication rate varies from 6.4% to 16.5%. Among these, chylous ascites (CA) is a severe and rare complications of LLDN. The treatment option for this condition is primarily conservative. Surgery is considered after failure of conservative treatment and its role, however, remains controversial. We report a case of CA as a complication of laparoscopic donor nephrectomy. A 44 year old woman underwent LLDN of the left kidney. There were no intraoperative or immediate postoperative complications and the patient was discharged home on postoperative day 3. Two weeks after discharge, the patient returned for a routine follow-up visit and presented with abdominal distension, discomfort, and dyspnea. A CT scan of the abdomen with oral and intravenous contrast revealed significant ascites in all four quadrants of abdomen and pelvis. An ultrasound guided paracentesis was performed, and 7 L of chyle was aspirated Conservative management with medium chain triglyceride and spironolactone was immediately initiated; the symptoms improved after paracentesis, and the CA completely resolved after 3 days of therapy. However, to prevent recurrence, the patient consumed a low-fat medium chain triglyceride diet for 6 months. CA needs to be considered as a potential severe and rare complication of LLDN, and conservative management should be proposed to all patients, reserving the surgical treatment to treatment failure.