The impact of psychological distress on weight regain in post-bariatric patients during the COVID-19 pandemic: A latent profile analysis.

OBJECTIVE: The COVID-19 pandemic has caused a global health crisis disrupting healthcare delivery for people with severe obesity who have undergone bariatric surgery. This study examined the role of psychological distress during the first Italian COVID-19 lockdown in predicting post-operative outcomes in post-bariatric patients reaching the end of the 12-18 months follow-up during the lockdown. By using a person-centered approach, groups of patients with different psychological distress profiles were identified. We hypothesized that compared to post-bariatric patients with low psychological distress, post-bariatric patients with high psychological distress will be more at risk of weight regain. METHODS: A total of 67 patients (71.6% female, Mage = 45.9) participated in this observational retrospective cohort study. Patients' anthropometric data were gathered from medical records while the weight at the end of the lockdown through phone interviews. Psychological distress, operationalized with anxiety symptoms, depressive symptoms, and sleep disturbances, was assessed by an online self-report questionnaire. RESULTS: Significant differences were highlighted in the high and low psychological distressed group in weight changes, F(1,58) = 5.2, p < 0.001, η2 = 0.3. Specifically, compared to post-bariatric patients in the low psychological distress group, those in the high psychological distressed group reported weight regained (95% CI = 1.0, 2.6). CONCLUSION: Results highlight the need to target post-bariatric patients with high psychological distress who are at risk for weight regain during the COVID-19 pandemic. Interventions mitigating psychological distress and obesogenic behaviors during future pandemics or in post-COVID times are needed in vulnerable post-bariatric patients reporting high psychological distress.

[Papillary thyroid microcarcinoma. Long-term outcome in 587 cases compared with published data]. / Il microcarcinoma papillare della tiroide: nostra esperienza e letteratura a confronto.

AIM: Papillary thyroid microcarcinoma (PTMC), a tumor measuring =or<1 cm according to the World Health Organization (WHO) histologic classification, is the most common histologic variant of thyroid cancer. The aim of this study was to evaluate the long-term outcome of surgical treatment for PTMC at a single institution with a view to differentiate therapy options based on risk of progression of disease by comparing our results with those reported in the literature. METHODS: The study sample was a total of 587 cases of PTMC treated surgically at our institution between 1990 and 2006. PTMC was an incidental finding (PTMC-I) in 325 (55.4%) cases, diagnosed preoperatively (PTMC-D) at echography and needle-aspiration biopsy in 229 (39%), and occult with metastasis (PTMC-O) in 33 (5.6%). Patients were grouped into two classes (PTMC diameter =or>5 mm or <5 mm) and compared against prognostic factors: sex, age, type of PTMC (PTMC-I, PTMC-D, PTMC-O), extent of surgery, lymph node dissection, lymph node metastasis, iodine-131 (131-I) therapy, state of disease, relapses. These parameters were then compared against tumor size (PTMC diameter =or>5 mm or <5 mm), excluding cases of PTMC-O with metastasis. RESULTS: Comparison of the two groups divided by tumor size, across the entire sample and after PTMC-O cases were excluded, revealed significant differences in the type of PTMC, frequency of partial thyroidectomy, presence of lymph node metastasis, iodine-131 therapy, life status and recurrence rate. CONCLUSION: Published PTMC studies were analyzed for definition of the disease, incidence, therapy, prognosis, and follow-up results and compared with our data. The results of our analysis argue against use of the term ''microcarcinoma'' in the wider sense since the three PTMC categories (PTMC-I, PTMC-D, PTMC-O) present different behaviour patterns. When cases of PTMC-O with clinically manifest metastasis were excluded, none of the patients with PTMC <5 mm in diameter were reoperated for tumor recurrence and all are currently free of disease. In conclusion In PTMC <5 mm in diameter, whether PTMC-I and PTMC-D, and without evidence of lymph node involvement, partial thyroidectomy may be a viable approach to treatment. By contrast, occult PTMC with metastasis is prognostically important and should therefore be treated like tumors =or>5 mm in diameter.

Natural history, diagnosis, treatment and outcome of medullary thyroid cancer: 37 years experience on 157 patients.

AIM: The analysis of a 37-year retrospective study on diagnosis, prognostic variables, treatment and outcome of a large group of medullary thyroid cancer (MTC) patients was conducted, in order to plan a possible evidence-based management process. METHODS: Between Jan 1967 to Dec 2004, 157 consecutive MTC patients underwent surgery in our centre: 60 males and 97 females, mean age 47.3 years (range 6-79). Total thyroidectomy was performed in 143 patients (91.1%); central compartment (CC) node dissection (level VI) in 41 patients; central plus lateral compartment (LC) node dissection (levels II, III, and IV) in 82 patients. Subtotal thyroidectomy was initially performed in 14 cases: 10 of them were re-operated because of persistence of elevated serum calcitonin levels. RESULTS: After a median post-surgical follow-up of 68 months (range 2-440 months), 42.9% of patients were living disease-free, 39.8% were living with disease, 3.1% were deceased due to causes different from MTC, and 3.2% were deceased due to MTC. The overall 10-year survival rate was 72%. At uni-variate statistical analysis (a) patient's age at initial treatment (>45 years; >/=45 years), (b) sporadic vs. hereditary MTC, (c) disease stage, and (d) the extent of surgical approach resulted as significant variables. Instead, at multivariate statistical analysis, only (a) patient's age at initial diagnosis, (b) disease stage, and (c) the extent of surgery resulted as significant and independent prognostic variables influencing survival. CONCLUSION: The presence of lymph node and distant metastases at first diagnosis significantly worsened prognosis and survival rate in our series. Early diagnosis of MTC is very important, allowing complete surgical cure in Stages I and II patients. Due to the relatively bad prognosis of MTC, especially for disease Stages III and IV, it appears reasonable to recommend radical surgery including total thyroidectomy plus CC lymphoadenectomy as the treatment of choice, plus LC lymphoadenectomy in patients with palpable and/or ultrasound enlarged neck lymph nodes.

Sentinel node mapping and biopsy in thyroid cancer: a surgical perspective.

The clinical role of sentinel node biopsy (SNB) in thyroid cancer remains an open matter in literature. The main reason of this fact is that nodal disease is considered a non-relevant prognostic factor by some authors in differentiated thyroid cancer (DTC). Aim of this study was to investigate the efficacy of radiocolloid lymphoscintigraphy and of hand held gamma probe procedure for SNB in patients with DTC and its potential clinical role. Forty-one consecutive pts with a small thyroid nodule highly suspected for malignancy at fine-needle aspiration cytology (FNAC) and without clinical and ultrasonographic (US) evidence of lymph node involvement entered the study. All patients underwent lymphoscintigraphy 3 hours before intervention using a 99mTc-nanocolloid solution. One single intratumoral injection of 4-9 MBq in 0.1-02 ml normal saline was obtained under US-guidance followed by a dynamic lymphoscintigraphy. After total thyroidectomy central and lateral compartments of the neck were scanned with a hand held gamma probe. The hottest node and any lymph node with a count rate of more than 10% of the hottest node were removed. SLNs were sent to frozen section analysis and a surgical enlargement of corresponding compartment was performed when at least one SLN was positive at histology. Preoperative lymphoscintigraphy was able to identify one node in six cases, two nodes in five cases, three nodes in 14 cases, four or more nodes in 16 cases. A papillary thyroid carcinoma (PTC) was diagnosed in 39 cases, a mixed papillary-medullary carcinoma in one case and a micro-follicular adenoma in one case. In 21/40 patients (pts) positive lymph nodes were found: in 16/21 patient one node showed micrometastasis only, in 5/21 patients more nodes were metastatic. In particular in 11 cases the first hottest node was involved (true SLN), in 10 cases a second or third hot lymph node was involved. In our preliminary experience lymphoscintigraphy with 99mTc-nanocolloid resulted highly sensitive: in fact at least one lymph node was visualized in all cases and the surgeon was able to detect by means of hand held probe during intervention al least one hot SLN in all cases. In 21/40 pts (more than 50% of cases) metastatic lymph nodes were found despite preoperative clinical and US examination negative for lymph node involvement. In prospective SLN technique might be proposed as a relevant tool in lymphoadenectomy decision in DTC patients with a small tumor.

Papillary thyroid microcarcinoma (PTMC): prognostic factors, management and outcome in 403 patients.

AIM: To investigate an "optimal" therapeutic management of patients with papillary thyroid microcarcinoma (PTMC). METHODS: We evaluated a group of 403 consecutive patients affected by PTMC operated on by the same surgeon. Prognostic factors were evaluated by uni- and multivariate statistical analysis. RESULTS: After a mean follow-up of 8.5 years, 372 patients were living without disease (undetectable serum thyroglobulin levels), 24 patients were living with disease (increased serum thyroglobulin levels), 6 patients were deceased due to causes different from thyroid cancer, and 1 patient was deceased due to metastatic thyroid cancer. No statistically significant prognostic factor was found at uni- and multivariate analysis. However, it is worth noting that in patients with a larger primary tumour (size> or =5mm) and treated by partial thyroidectomy alone, the prevalence of recurrent disease was higher than in patients treated by total thyroidectomy and (131)I administration. CONCLUSION: It appears reasonable to perform total thyroidectomy (possibly associated with central compartment node dissection), (131)I whole body scan (followed by (131)I therapy when necessary) and TSH-suppressive hormonal therapy in patients with PTMC.

Tissue-specific transcriptional initiation and activity of steroid sulfatase complementing dehydroepiandrosterone sulfate uptake and intracrine steroid activations in human adipose tissue.

Expression analysis by reverse transcriptase (RT)-PCR indicates that human adipose tissue is not likely to perform de novo synthesis of steroid hormones from cholesterol because the mRNAs of cytochromes P450scc and P450c17, and of the steroidogenic-related proteins, steroidogenic acute regulatory protein and steroidogenic factor 1, were not detected. Instead, our data support an intracrine role of adipose tissue, in which adrenal dehydroepiandrosterone sulfate (DHEA-S), the most abundant circulating androgen in man, is selectively uptaken, desulfated, and converted into bioactive androgens and estrogens. Three organic anion-transporting polypeptides-B, -D, and -E, presumably involved in DHEA-S transmembrane transport, were demonstrated at the mRNA level. While sulfotransferase expression was not found, the occurrence of steroid sulfatase (STS), converting DHEA-S to DHEA, was established at the mRNA, protein and catalytic activity levels. The 5'-rapid amplification of cDNA ends analysis showed that STS transcription in adipose tissue is regulated by the use of two promoters which differ from the prevalent placental one. The adipose transcripts contain a distinct untranslated first exon, 0a or 0b, followed by a common partially translated exon 1b, and nine other exons that are also shared by the main placental transcript. The presence of an upstream open reading frame in the new transcript variants could lead to an N-terminal divergence restricted to the cleavable signal peptide and thus not interfering with the catalytic activity of the mature STS protein. The adipose transcripts are also present in the placenta as minor isoforms. Western blotting revealed the characteristic approximately 64 kDa band of STS in both the placenta and adipose tissue. The specific enzymatic activity of STS in adipocytes was 118 pmol/10(6) cells per hour, about 50-100 times lower than in the placenta. A similar rate of [3H] DHEA-S uptake plus desulfation was measured in preadipocytes and adipocytes, equivalent to 40-45 pmol/10(6) cells per hour. Thus, an excessive accumulation of fat may out-compete other peripheral organs that are also dependent on intracrine DHEA-S utilization, especially when the adrenal production is low or declining with aging.

[Sentinel lymph node procedure in thyroid carcinoma patients. Our experience]. / La procedura del linfonodo sentinella nel paziente con cancro della tiroide Nostra esperienza.

AIM: How far to extend surgical treatment of papillary thyroid carcinoma (PTC) is still an open question. A contribution may derive from intraoperative lymphatic mapping because, in other malignancies, the procedure has become an important aid in defining lymph node status. The aim of this study was to evaluate the feasibility of sentinel lymph node (SLN) mapping performed by intratumoural injection of vital blue dye to guide nodal dissection in PTC. METHODS: One hundred and ten patients were selected for the study, all of them had a preoperative diagnosis of PTC, but no clinical or ultrasonographic evidence of nodal involvement. Following cervicotomy and exposition of the thyroid gland, vital blue dye was injected into the malignant thyroid nodule. Subsequently, total thyroidectomy and lymph node dissection were carried out, and the thyroid, the SLN(s) and the other lymph nodes were sent for frozen section and definitive histologic evaluation. RESULTS: Intraoperative lymphatic mapping located sentinel lymph nodes in 74 cases (67.3%); the SLN was detected in the laterocervical compartment (LC) in 4 cases (5.4%), with the ''sick'' of the CC. In 23 of these 74 patients (31.1%) the SLN(s) were positive for micro-metastases and in 15 cases (65.2%) both the SLN and other resected nodes were found positive. In the 51 cases in whom the SLN was disease-free, the other nodes were also negative. Of the 36 cases in whom the SLN was not detected, in 4 cases (11.1%) a parathyroid gland was stained and in 1 case (2.8%) fibroadipous tissue was stained. To date, of the 23 patients with positive-SLN 22 patients are living without disease (95.6%), 1 patient is living with disease (4.4%); all patients with negative SLN are living without disease; of the 36 patients without staining of the SLN, 35 are living without disease (97.2%) and 1 patient is deceased for reasons different from PTC (2.8%). CONCLUSIONS: On the basis of this study, we underline some disadvantages in using Blue Patent V dye in SLN biopsy procedure as: a) the risk of disruption and interruption of the lymphatics from the tumour; b) blue dye uptake by a parathyroid gland which is successively mistakenly removed; c) the ''seak'' of the CC that doesn't permit to disclose SLN that lies outside the central compartment.

Italian Group for Lap-Band System: results of multicenter study on patients with BMI < or =35 kg/m2.

BACKGROUND: The Lap-Band System is the most common bariatric operation world-wide. Current selection criteria do not include patients with BMI < or = 35. We report the Italian multicentre experience with BMI < or = 35 kg/m(2) over the last 5 years. PATIENTS AND METHODS: Data were obtained from 27 centres involved in the Italian Collaborative Study Group for Lap-Band System. Detailed information was collected on a specially created electronic data sheet (MS Access 2000) on patients operated in Italy since January 1996. Items regarding patients with BMI < or = 35 were selected. Data were expressed as mean +/- SD except as otherwise indicated. RESULTS: 225 (6.8%) out of 3,319 Lap-Band patients were recruited from the data-base. 15 patients, previously submitted to another bariatric procedure (BIB =14; VBG= 1) were excluded. 210 patients were eligible for study (34M/176F, mean age 38.19+/-11.8, range 17-66 years, mean BMI 33.9+/-1.1, range 25.1-35 kg/m(2), mean excess weight 29.5+/-7.1, range 8-41). 199 comorbidities were diagnosed preoperatively in 55/210 patients (26.2%). 1 patient (0.4%) (35 F) died 20 months postoperatively from sepsis following perforation of dilated gastric pouch. There were no conversions to laparotomy. Postoperative complications presented in 17/210 patients (8.1%). Follow-up was obtained at 6, 12, 24, 36, 48 and 60 months. At these time periods, mean BMI was 31.1+/-2.15, 29.7+/-2.19, 28.7+/-3.8, 26.7+/-4.3, 27.9+/-3.2, and 28.2+/-0.9 kg/m(2) respectively. Co-morbidities completely resolved 1 year postoperatively in 49/55 patients (89.1%). At 60 months follow-up, only 1 patient (0.4%) has a BMI >30. CONCLUSIONS: Although surgical indications for BMI < or = 35 remain questionable, the Lap-Band in this study demonstrated that all but 1 patient achieved normal weight, and most lost their co-morbidities with a very low mortality rate.

The Italian Group for LAP-BAND: predictive value of initial body mass index for weight loss after 5 years of follow-up.

BACKGROUND: Laparoscopic of the LAP-BAND System placement stage of obesity is a safe operation, but its indication in terms of stage of obesity is controversial. The aim of this study was to evaluate the 5 years stage of obesity results for weight loss in patients with varying preoperative ranges of body mass index (BMI). METHODS: Data were obtained from the Italian Collaborative Study Group for LAP-BAND System (GILB) registry. Detailed information was collected on a specifically created database (MS Access 2000) for patients operated on in Italy from January 1996 to 2003. Patients operated on between January 1996 and December 1997 were allocated to four groups according to preoperative BMI range: 30-39.9 kg/m(2) (group A), 40-49.9 kg/m(2) (group B), 50-59.9 kg/m(2) (group C), and =60 kg/m(2) (group D) percent estimated weight loss respectively. Postoperative complications, mortality, BMI, BMI loss, and (%EWL) were considered in each group. Data are expressed as mean +/- SD, except as otherwise indicated. Statistical analysis was done by means of Fisher's exact test, and p < 0.05 was considered significant. RESULTS: After 5 years from LAP-BAND System surgery, 573 of 3,562 patients were eligible for the study. One hundred fifty-five of 573 (27.0%) were lost to follow-up, 24 of 418 (5.7%) underwent band removal due to complications (gastric pouch dilation, band erosion), eight of 418 (1.9%) were converted to other bariatric procedures, five of 418 (1.2%) died of causes not related to the operation or the band, and 381 of 573 (66.5%) were available for follow-up. Based on 96, 214, 64, and seven patients their preoperative BMI, Were allocated to groups A, B, C, and D, respectively. At time of follow-up mean BMI was 27.5 +/- 5.2 in group A, 31.6 +/- 4.7 in group B, 37.6 +/- 17.3 in group C, and 41.4 +/- 6.9 kg/m(2) in group D. Mean BMI loss was 9.8 +/- 5.4, 12.9 +/- 5.2, 15.8 +/- 8.1, and 23.2 +/- 4.9 kg/m(2), respectively, in groups A, B, C, and D. Mean %EWL at the same time was 54.6 +/- 32.3 in group A, 54.1 +/- 17.2 in group B, 51.6 +/- 35 in group C, and 59.l +/- 17.1 in group D. CONCLUSION: Initial BMI in this series did not correlate with %EWL 5 years after the operation. In fact %EWL was almost the same in each group, independent of preoperative weight. Initial BMI was an accurate indicator of the results obtained 5 years after LAP-BAND in group C (50-59.9 kg/m(2)) and D (=60 kg/m(2)) patients, who remained morbidly obese despite their %EWL.

Results of the Italian multicenter study on 239 super-obese patients treated by adjustable gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is the most common bariatric operation. This study is a retrospective analysis of the multicenter Italian experience in patients with BMI > 50 over the last 4 years. METHODS: An electronic data sheet made for LAGB-operated patients since January 1996, was mailed and e-mailed to all surgeons involved in this kind of procedure in Italy. Items regarding patients with BMI > 50 were selected. Analysis used Fisher's exact test and logarithmic regression analysis (P < 0.05 significant). Data were expressed as mean +/- SD. RESULTS: 239 patients (13.3%), out of 1,797 Lap-Band operated patients entered the study (179F / 60M), with mean age 37.6 +/- 11.3 years (19-69) and mean BMI 54.6 +/- 4.8 (50.1-83.6). Laparotomic conversion rate was 5.4% (44/239). Postoperative complications occurred in 24 / 239 patients (9.0%). Follow-up was obtained in 218 / 218, 198 / 198, 121 /147, 75 / 93, 30 / 38 LAGB patients at 6,12, 24, 36, and 48 months respectively. At these time periods, mean BMI was 46.7, 43.9, 42.2, 41.9, and 39.3 kg/m2. At the same intervals, mean %EWL was 24.1, 34.1, 38.8, 38.9, and 52.9%. The number of patients with < 25% EWL at 12, 24, 36, and 48 months follow-up were 34, 10, 4, and 0. Serious co-morbidities (189 in 124 of 239, 57%) had completely resolved 1 year postoperatively in 74 / 124 of the patients (59.6%). CONCLUSION: Although super-obese patients following the LAGB remain obese with BMI > 35, in the short-term most lose their co-morbidities, with a very low morbidity and mortality rate.

[Reoperation of medullary thyroid carcinoma: long-term results]. / Réintervention pour carcinome médullaire de la thyroïde: résultats à long terme.

STUDY AIM: The impact of iterative surgery in medullary thyroid carcinoma is still debated. The study aim was to evaluate long-term results following reoperation for residual or recurrent medullary thyroid carcinoma. PATIENTS AND METHOD: Among the 136 patients operated on in our centre for medullary thyroid carcinoma (MTC) between 1970 and 2000, 25 patients (10 men and 15 women) were reoperated on for locoregional residual or recurrent lesions. Their mean age was 46 years (range: 19-73 years). The MTC was sporadic in 21 patients and familial in 4: NEM 2A (n = 3), NEM 2B (n = 1). In 11 patients (44%) operated in another centre, the first procedure was a total thyroidectomy; in 2 patients (8%) a total thyroidectomy with central lymphadenectomy was performed, and in 12 patients (48%) a total thyroidectomy with central and jugulo-carotid lymphadenectomy. After the first operation, 6 patients (24%) were classified stage II, 15 (60%) stage III and 4 (16%) stage IV. Basal and post-stimulation calcitonin dosages were performed for all the patients before and after reoperation. RESULTS: Thirty three reoperations were performed. In 24 cases, the recurrence was located in the laterocervical site; in 5 cases, the lymph node involvement was both central and laterocervical, in 2 cases, there was a mediastinal involvement and in 2 cases a spinal involvement. After reoperation, the calcitonin rate became normal in 4 patients (16%); in the other 21 (84%), the calcitonin rate was still high. With a mean 110 month--follow-up (range: 320-12 months), 4 patients (16%) were alive without disease, 2 (8%) died of their disease, 19 (76%) were alive with their disease, five of them with hypercalcitonemia without detectable metastasis. In addition to patients having metastasis at the time of reoperation, seven developed metastases secondarily (liver, bone, lung). CONCLUSION: Biological cure of medullary thyroid carcinoma is rarely obtained with reoperation. Reoperations may reduce progression of the disease in selected patients. Complete removal of the lesions at the time of the first procedure must be the ideal treatment for medullary thyroid carcinoma.

The sentinel node procedure with Patent Blue V dye in the surgical treatment of papillary thyroid carcinoma.

How far to extend the surgical treatment of papillary thyroid carcinoma (PTC) is still an open question. A contribution may come from intra-operative lymphatic mapping because, in other malignancies, the procedure has become an important aid in defining lymph node status. To assess the feasibility of using the sentinel lymph node (SLN) technique with the intratumoral injection of Patent Blue V dye to guide nodal dissection in PTC, 29 patients with a preoperative diagnosis of PTC and no clinical or ultrasonographic evidence of nodal involvement underwent cervicotomy and exposure of the thyroid gland, followed by Patent Blue V dye injection into the thyroid nodule. Total thyroidectomy was subsequently performed, resecting the lymph nodes at levels III, IV, VI and VII. The thyroid, SLN and the other lymph nodes were snap-frozen and submitted for both intra-operative and subsequent definitive pathological evaluation. Intra-operative lymphatic mapping located the SLN in 22/29 patients (75.9%) and the SLN revealed neoplastic involvement in 4/22 (18.2%); other lymph nodes were also positive in 2 cases. In the 18 patients whose SLNs were not metastatic, the other nodes were also disease-free. The SLN technique thus seems helpful in avoiding unnecessary lymph node dissection in PTC without spread to the SLN.

Technique and results of laparoscopic adrenalectomy.

The aim of this report is to evaluate the benefits of laparoscopic adrenalectomy in terms of perioperative morbidity, complications and patients recuperation. We reviewed our experience with laparoscopic adrenalectomy in 47 consecutive patients who underwent adrenalectomy over a 4-year period. We used the lateral transperitoneal approach in all cases. The indications for adrenalectomy were Conn's adenoma in 24 patients, pheochromocytoma in 11, Cushing's syndrome in 3 and incidental adrenal tumour in 9. The average duration of surgery was 130 min (range, 60-300 min) and average adrenal gland size was 3.4 cm (range, 1.2-8 cm). Conversion from laparoscopy to laparotomy was necessary in three patients (6.4%), and postoperative complications occurred in two patients. There was no mortality. Laparoscopic adrenalectomy can be considered the method of choice for managing almost all adrenal masses, because of its low morbidity and short postoperative recovery. The main difficulty is to identify the adrenal gland, so several technical procedures are suggested.

[Radio-guided parathyroidectomy. A prospective study in 54 patients with primary hyperparathyroidism]. / Paratiroidectomia radioguidata. Studio prospettico in 54 pazienti affetti da iperparatirodismo primitivo.

BACKGROUND: The contribution of nuclear-medical mapping using 99mTc-MIBI (MIBI) and the use of an intraoperative probe in primary hyperparathyroidism (I degrees HPT) surgery was evaluated prospectively in a series of patients undergoing parathyroidectomy. METHODS: Fifty-four patients, who were operated between May 1999 and July 2000, under-went a systematic preoperative evaluation using scintigraphy with a dual tracer 99Tc04/MIBI and image subtraction, and high-resolution neck ecotomography. Surgery was performed using a mini-invasive technique through an incision measuring 2-2.5 cm at the base of the neck in 46 patients; the other 8 patients underwent open surgery with bilateral exploration of the neck. MIBI was injected intravenously in the operating theatre following the induction of anesthesia and after 32 minutes on average, radioactivity was measured using a manual gamma probe. Radioactivity was also counted intraoperatively at the tip of the lung contralateral to the pathological gland, a parameter used as the base activity (B), in the presumed seat of the hyperfunctioning parathyroid (P), in correspondence with healthy thyroid tissue (T) and any associated thyroid nodes (N). Radioactivity was also recorded at the level of the empty parathyroid compartment after removal of the corresponding gland, and on the parathyroid removed ex vivo . RESULTS: The ratio between the three main parameters, T/B, P/B and P/T was respectively 1.6 (range=1.5 - 1.8), 2.7 (range=1.6-4.0) and 1.6 (range=1.1-2.8). In 4 cases (7.4%), the small size of the parathyroids, adjacent to thyroid nodes, meant that the parathyroid measurement of MIBI was smaller than the thyroid measurement. The histological finding was consistent with: single parathyroid adenoma in 49 cases, multiple adenomas in 3 cases, parathyroid carcinoma in 2 cases. Rapid intraoperative PTH normalised in all patients. CONCLUSIONS: The significant difference in radioactivity levels recorded in the patients, showed that the technique is useful to the surgeon as a means of intraoperative assay for hyperfunctioning parathyroids, even if it cannot obviously replace experience or the value of preoperative scientigraphic and ecotomographic imaging.

[Prevention and treatment of intra- and post-operative complications in thyroid surgery]. / Prevenzione e trattamento delle complicanze intra- e post-operatorie in chirurgia tiroidea.

Frequency of complications in thyroid surgery is evaluated in a series of patients treated during a recent period lasting one year (1997). The records of 455 patients consecutively operated on were analyzed: 396 patients were affected by benign disorders and 59 by thyroid carcinoma. Total thyroidectomy was performed in 158 cases, near subtotal thyroidectomy in 94, thyroid totalization for recurrent disease in 21 and lobectomy in 182 ones. Post-operative haemorrhage, such to require surgical re-exploration of the thyroid bed, occurred in 2 patients (0.4%), both after total thyroidectomy for hyperfunctioning goiter. Recurrent laryngeal lesion has been observed in 2 patients (0.4% of all patients), both after total thyroidectomy for cervico-mediastinal goiter. Transient hypoparathyroidism occurred in 48 patients (10.5%), while definitive one in 9 (1.9%), of which 5 after total thyroidectomy, 2 after subtotal thyroidectomy and 2 after reoperation. Haemorrhage nearly always occurs in the first postoperative hours and gravity is conditioned by tracheal compression exercised by the haematoma. An aspirative drainage located in thyroid bed and a not hermetic closure of the middle line help a precocious diagnosis and sometimes avoid a surgical re-exploration. Some technical surgical devices permit to reduce the risk of inferior laryngeal nerve palsy. Hypoparathyroidism, often transient, is a complication of bilateral thyroid surgery, but unavoidable when more extensive thyroid surgery is required.

Preoperative assessment of thyroid nodules: the surgeon's point of view.

A selective approach to patients with thyroid nodules, in order to differentiate between negative findings and uncertain or positive results requiring surgery, has been outlined. Fine needle aspiration biopsy (FNAB) is the most reliable and cost-effective technique currently available to distinguish benign from malignant thyroid disease. In those lesions diagnosed by FNAB as 'follicular lesions', radionuclide scanning, serum calcitonin and CEA determination, color doppler ultrasonography and the response to TSH suppressive therapy may be of assistance. Despite such screening procedures, the majority of follicular lesions remain indeterminate, and surgery is therefore necessary before a correct diagnosis can be made.

Parathyroid imaging with pertechnetate plus perchlorate/MIBI subtraction scintigraphy: a fast and effective technique.

We set up a modified technetium-99m (Tc-99m) pertechnetate/Tc-99m MIBI (Tc-MIBI) subtraction scintigraphy for parathyroid imaging by introducing the use of potassium perchlorate (KCLO4). Initially, the effect of KCLO4 on technetium thyroid wash-out was evaluated in five healthy volunteers: 40-minute dynamic studies of the thyroid were obtained 20 minutes after the injection of technetium 150 MBq (4 mCi), both in baseline conditions and after the oral administration of 400 mg KCLO4. After an average latency time of 10.5 minutes, KCLO4 administration resulted in fast and relevant technetium thyroid wash-out with a mean half-time of 16.2 minutes (the half-time was 142.8 minutes in baseline conditions), and a 40-minute reduction of thyroid activity of 78% (it was 14% in baseline conditions). Based on these findings, a new Tc-MIBI subtraction procedure was established as follows: 1) 150 MBq technetium (4 mCi) injection; 2) 400 mg KCLO4 administered orally; 3) patient neck immobilization; 4) acquisition of a 5-minute technetium thyroid scan; 5) 500 MBq MIBI (13.5 mCi) injection; 6) acquisition of a sequence of seven MIBI images, each lasting 5 minutes; and 7) processing (image realignment when necessary, background subtraction, normalization of MIBI images to the maximum pixel count of the technetium image, and subtraction of the technetium image from the MIBI images). In addition, high-resolution neck ultrasound (US) was performed in all cases on the same day as the scintigraphic evaluation. Eighteen consecutive patients with primary hyperparathyroidism were enrolled in the study. Tc-MIBI scintigraphy revealed a single adenoma in all cases and US showed this finding in 15 of 18 cases (83.3%). Furthermore, in three patients, a thyroid nodule associated with hyperparathyroidism was detected by technetium thyroid scans and neck US. In all patients, the parathyroid adenoma was easily identified on both the 20- to 40-minute MIBI and subtracted (MIBI-Tc) images. Regarding the scintigraphic parameters, no difference was found between parathyroid adenomas located in the region of the thyroid bed or in ectopic sites and in parathyroid adenomas with a retrothyroid location. Surgical findings confirmed the presence of a single parathyroid adenoma in all cases. In the three patients with a concomitant thyroid nodule, thyroid lobectomy was performed. These preliminary data suggest that 1) double-tracer subtraction scintigraphy, combined with neck US, appears to be the preferable preoperative imaging procedure in hyperparathyroidism patients with concomitant thyroid nodular disease, 2) in the Tc-MIBI parathyroid scan, the use of KCLO4 results in a rapid and relevant technetium thyroid clearance, improving the quality of MIBI images and making the visualization of parathyroid adenomas, particularly those located behind the thyroid gland, easier.

Laparoscopic versus open adrenalectomy: outcome in 35 consecutive patients.

BACKGROUND: The use of minimally invasive techniques in the surgical treatment of adrenal masses has been used to remove a wide variety of adrenal tumors. AIMS: We have reviewed our experience with laparoscopic adrenalectomy and compared laparoscopic vs. open surgical approach. METHODS: The outcome of 35 consecutive patients who underwent adrenalectomy over a 3-year period has been analyzed retrospectively. Differences in operating time, blood loss, period of hospitalization, use of parenteral analgesia, resumption of oral feeding, complications, and time to return to normal activity after 18 coelioscopic vs. 17 open consecutive adrenalectomies have been considered. RESULTS: The average operative time was longer (mean 160 vs. 148 min, p = 0.48) and postoperative complications lower (4 vs. 5 cases, p =0.73), although not statistically significant, for the laparoscopic compared to the open surgical approach, whereas blood loss (30 vs. 165 ml; p = 0.01), postoperative analgesia (3.4 vs. 5.0 days, p = 0.02), time to restart oral feeding (3.0 vs. 4.7 days, p = 0.001), average time of hospitalization (4.5 vs. 9.6 days, p = 0.001), time to return to normal activity (21 vs. 37 days, p = 0.001) were all statistically significant. CONCLUSIONS: Laparoscopic adrenalectomy can be considered the method of choice for managing almost all adrenal masses, because of its lower morbidity and shorter postoperative recovery.

[Hypoparathyroidism after thyroidectomy. Analysis of a consecutive, recent series]. / Ipoparatiroidismo dopo tiroidectomia. Verifica di una serie consecutiva e recente.

We analyzed a recent and consecutive series of 254 thyroidectomies performed during the last year to verify the incidence of post-thyroidectomy hypoparathyroidism. 249 patients were included in the study and were divided into 2 groups according to the extension of the thyroidectomy. In the first group of 49 patients treated by lobectomy no one developed hypoparathyroidism. In the second group of 200 patients, of which 53 were treated by subtotal and 147 by total thyroidectomy, postoperative hypoparathyroidism was found in 28 (14%) patients, but it was persistent (lasting six months or longer) in 8 (4%). Global incidence of postoperative hypoparathyroidism was statistically higher in total thyroidectomy vs subtotal thyroidectomy (17% vs 5.66%; p < 0.05); however persistent hypoparathyroidism incidence wasn't statistically higher in total thyroidectomy (5.4% vs 0%; p = n.s.). As far as thyroid disorders that require bilateral thyroidectomy Chi 2-test showed a trend of persistent hypoparathyroidism to be more frequent in patients operated on for Graves' disease and thyroid cancer than in other thyroid disorders.