Does mediastinal extension of the goiter increase morbidity of total thyroidectomy? A multicenter study of 19,662 patients.

PURPOSE: To compare the outcome in patients with cervical goiters and cervicomediastinal goiters (CMGs) undergoing total thyroidectomy using the cervical or extracervical approach. METHODS: This was a retrospective study conducted at six academic departments of general surgery and one endocrine-surgical unit in Italy. The study population consisted of 19,662 patients undergoing total thyroidectomy between 1999 and 2008, of whom 18,607 had cervical goiter (group A) and 1055 had CMG treated using a cervical approach (group B, n = 986) or manubriotomy (group C, n = 69). The main parameters of interest were symptoms, gender, age, operative time, duration of drain, length of hospital stay, malignancy and outcome. RESULTS: A split-sternal approach was required in 6.5% of cases of CMG. Malignancy was significantly more frequent in group B (22.4%) and group C (36.2%) versus group A (10.4%; both P < .001), and in group C versus group B (P = .009). Overall morbidity was significantly higher in groups B + C (35%), B (34.4%) and C (53.5%) versus group A (23.7%; P < .001). Statistically significant increases for group B + C versus group A were observed for transient hypocalcemia, permanent hypocalcemia, transient recurrent laryngeal nerve (RLN) palsies, permanent RLN palsies, phrenic nerve palsy, seroma/hematoma, and complications classified as other. With the exception of transient bilateral RLN palsy, all of these significant differences between group B + C versus group A were also observed for group B versus group A. CONCLUSIONS: Symptoms, malignancy, overall morbidity, hypoparathyroidism, RLN palsy and hematoma are increased in cases of substernal goiter.

[Artificial nutrition in severe acute pancreatitis: an evolving concept]. / La nutrizione artificiale nella pancreatite acuta grave. Un concetto in evoluzione.

We reviewed our series of consecutive cases of severe pancreatitis observed from 2002 to 2004, in order to verify how our actual therapeutic strategy improved prognosis. Seventeen patients with diagnosis of severe pancreatitis (SP) were admitted. On presumption of SP we inserted a naso-jejunal self-propelling feeding tube (SPT) in all but one patients, and an early enteral nutrition ( EEN ) was started. Severity of pancreatitis has been scored by APACHE II (> 8), IMRIE (> or = 3), and Balthazar Computed Tomography findings (> 30% necrosis). We always used a polymeric diet added with glutamine and fibres at initial rate of 20-30 ml/h until achievement of a full regimen of EEN, based on Harris-Benedict formula but no more than 30 kcal/kg/day. Only one patient has been submitted to surgical removal of infected necrosis. A patient died (5.8%) by dis-metabolic and septic state. From our experience we can state EEN is safe and useful to determine a favourable outcome on this dismal pathology, preserving the patient from infection, without significative alterations of nutritional index.

[Anorectal manometry: standardisation of the execution technique]. / La manometria anorettale: standardizzazione della tecnica di esecuzione.

Anorectal manometry is the basic investigation for the study of anorectal function. The lack of a standard execution technique and of any common definition of the manometric parameters constitutes a major limitation. The aim of the present study is to propose a standard technique for performing manometry. In addition we also focus on those manometric parameters that are easily identified and interpreted for the systematic study of a proctological patient. The protocol used is organised in three phases: (i) tests with a radial channel probe with continuous extraction, which provide information on the length of the anal canal and on the precise site of maximum pressure; (ii) tests with a radial channel probe with stationary extraction, which does not involve reflex contraction of the sphincter apparatus and therefore permits better evaluation of sphincter pressure when the muscles are relaxed as well as the identification of slow and ultra-slow waves; (iii) tests with a helicoidal probe and a balloon for the evaluation of the anorectal inhibitory reflex and of anorectal sensitivity. Using this protocol it is possible to perform manometry in less than 30 minutes and to define the importance of anorectal function with approximately 10 parameters which are easily identified and interpreted.

[Solid pseudo-papillary tumor of the pancreas: a case of a big abdominal mass in a young woman]. / Tumore solido pseudo-papillare del pancreas: il caso di una giovane donna con una voluminosa massa addominale.

Solid pseudo-papillary tumor of the pancreas is a rare tumor that occurs predominantly in young women. It often presents as a big abdominal mass whose preoperative diagnosis appears to be difficult. It is a low- grade malignancy tumor and surgery is the mainstay of treatment. The Authors report the case of a 40 year-old woman with an abdominal mass supposed to origin from the mesenterium, diagnosed as a solid pseudo-papillary tumor of the pancreas after histological examination and treated by enucleation. Moreover literature data about epidemiology, histogenesis, diagnosis and treatment are analysed.

High prevalence of acquired von Willebrand's syndrome in patients with thyroid diseases undergoing thyroid surgery.

BACKGROUND AND OBJECTIVES: Various coagulation abnormalities occur in patients with thyroid diseases. These abnormalities range from subclinical laboratory findings to hemorrhage or thromboembolism. However, the prevalence of hemostatic abnormalities in patients with thyroid diseases is still unclear. DESIGN AND METHODS: Between January 1999 and December 2003, 1342 consecutive patients with various thyroid diseases who were candidates for thyroid surgery underwent preoperative screening of hemostatic parameters including prothrombin time, activated partial thromboplastin time and platelet-related hemostasis with the PFA-100 platelet-function analyzer. RESULTS: Thirty-nine patients (2.9%) had abnormalities of the coagulation screening tests. Of these, 35 patients had von Willebrand's disease (type 1 in 33 cases and type 2A in 2 cases), 2 patients had decreased platelet aggregability, and 2 patients had coagulation factor XI deficiency. As all patients with coagulation abnormalities responded to subcutaneous desmopressin injection (0.3 microg/Kg BW), this drug was successfully used as surgical prophylaxis. INTERPRETATION AND CONCLUSIONS: Up to 3% of patients with thyroid diseases undergoing thyroid surgery have coagulation abnormalities, in most cases resembling von Willebrand's disease. Coagulation screening tests are needed in order to identify those patients at increased risk of bleeding.