Does antithrombotic prophylaxis worsen early outcomes of total thyroidectomy? - a retrospective cohort study.

BACKGROUND: Currently, there is no strong evidence on the effectiveness and safety of pharmacological antithrombotic prophylaxis in thyroid surgery. The aim of this study was to establish whether the prophylactic use of low-molecular-weight heparin (LMWH) could negatively affect the early outcomes of patients undergoing total thyroidectomy. METHODS: Data from patients submitted to total thyroidectomy between February 2013 and October 2017 were retrospectively collected and analysed. Only patients with indication to antithrombotic prophylaxis according to current guidelines were included in the study. Eligible cases were divided into two groups, which corresponded to two distinct periods of our surgical practice: Group A, which included 178 consecutive patients who were submitted to antithrombotic prophylaxis with LMWH, and Group B, which included 348 consecutive patients who did not receive prophylaxis. Primary endpoints were the incidence of post-operative cervical haematomas (POCH) and thromboembolic events. Secondary endpoint was the length of postoperative hospital stay. Statistical analysis was performed by using Student's t test for continuous variables and Chi-square test for categorical variables. A P value of less than 0.05 was considered statistically significant. RESULTS: The two groups of patients were comparable in terms of age, gender, thyroid disease, duration of surgery, and weight of the thyroid gland. Overall, no thromboembolic events were registered. The comparative analysis of the other outcome measures, showed no significant differences between the two groups (POCH: 2 cases (1.12%) in Group A vs 8 cases (2.30%) in Group B - p 0.349; Postoperative hospital stay: 2.90 ± 0.86 days in Group A vs 2.89 ± 0.99 days in Group B - p 0.908). CONCLUSIONS: Data from this study do not support or contraindicate the use of antithrombotic prophylaxis in thyroid surgery. However, since thyroidectomy is a closed-space procedure, and even modest bleeding may quickly result in airway compression and death by asphyxia, mechanical prophylaxis should be preferred to LMWH whenever possible. TRIAL REGISTRATION: ISRCTN ISRCTN12029395. Registered 05/02/2018 retrospectively registered.

Pseudoangiomatous stromal hyperplasia (PASH) presenting as axillary lump: case report and review of the literature.

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign mesenchymal breast lesion. There are extremely rare reports of PASH arising in accessory breast tissue. To date, in literature, fewer than 10 cases of PASH occurring in axillary region have been described. We report a case presenting as axillary lump in a young woman. A 20-year-old female presented to our surgical unit for a progressively growing and painful palpable mass of the right axilla for about a year. Before surgery an ultrasound was performed. The patient underwent local excision of the lesion under local anaesthesia. Through histological and immunohistochemical examination a pseudoangiomatous stromal hyperplasia (PASH) was diagnosed. At 6 months of followup the patient is free of disease. It is important to include PASH also in the differential diagnosis of axillary lumps. Histological examination of the surgical specimen and surgery represent, respectively, the mainstay for diagnosis and therapy.

Primary thyroid leiomyosarcoma: a case report and review of the literature.

Primary thyroid leiomyosarcoma (LMS) is an extremely rare tumor. We report a case of a 47-year-old male with a rapidly growing neck mass and disfagia. Preoperative investigations were diagnostic of anaplastic carcinoma. Total thyroidectomy with partial esophagectomy and dissection of right infrahyoid muscles was performed. Through histolological and immunohistochemical evaluations a primary thyroid high-grade LMS was diagnosed. At 2 months of follow-up a local recurrence was detected and consequently the patient was submitted to chemotherapy with partial response. He is still alive 9 months after surgery. Diagnosis of primary thyroid LMS is difficult due to its similarity to other more common thyroid tumors. To date, there is no standard therapy and prognosis is poor.

External hernia of the supravesical fossa: Rare or simply misidentified?

BACKGROUND: External hernias of the supravesical fossa are considered rare, perhaps wrongly. Highlighting clinical and anatomical features could be useful for correct, preoperative diagnosis, thus avoiding the risk of complications such as incarceration. The study aims to demonstrate that the incidence of external protrusions of the supravesical fossa is higher that supposed. Probably, being mistaken for direct hernias, these hernia types are misidentified and not included in current classifications. This issue deserves attention due to the elevated risk of incarceration related to its distinctive structure. MATERIAL AND METHODS: 249 consecutive open anterior inguinal hernia procedures were analyzed. Hernias were categorized according to the Nyhus classification. A subgroup of direct hernias involved true hernias of the supravesical fossa. Multiple ipsilateral, as well as combined hernias having a multi-component structure, were also considered. RESULTS: 13 true hernias of the supravesical fossa and 19 multiple ipsilateral or combined hernias composed of direct and/or indirect hernia, together with one hernia of the supravesical fossa were identified. 4 true hernias of the supravesical fossa presented signs of incarceration. In three other combined protrusions, the herniated component of the supravesical fossa also showed incarceration of the visceral content. CONCLUSIONS: Hernias of the supravesical fossa would appear to be more frequent than imagined. These protrusions show a diverticular shape and the base is often tightened by the stiffer medial umbilical fold. This explains the apparently higher tendency to incarceration that distinguishes this hernia type. Preoperative signs of inguinal pain and irreducibility are pathognomonic for correct diagnosis. In these cases, surgical treatment in the short term is recommended.

Total thyroidectomy alone versus ipsilateral versus bilateral prophylactic central neck dissection in clinically node-negative differentiated thyroid carcinoma. A retrospective multicenter study.

BACKGROUND: Central neck dissection (CND) remains controversial in clinically node-negative differentiated thyroid carcinoma (DTC) patients. The aim of this multicenter retrospective study was to determine the rate of central neck metastases, the morbidity and the rate of recurrence in patients treated with total thyroidectomy (TT) alone or in combination with bilateral or ipsilateral CND. METHODS: The clinical records of 163 clinically node-negative consecutive DTC patients treated between January 2008 and December 2010 in three endocrine surgery referral units were retrospectively evaluated. The patients were divided into three groups: patients who had undergone TT alone (group A), TT with ipsilateral CND (group B), and TT with bilateral CND (group C). RESULTS: The respective incidences of transient hypoparathyroidism and unilateral recurrent nerve injury were 12.6% and 1% in group A, 23.3% and 3.3% in B, and 36.7% and 0% in C. Node metastases were observed in 8.7% in group A, 23.3% in B, and 63.3% in C. Locoregional recurrence was observed in 3.9% of patients in group A and in 0% in B and C. CONCLUSIONS: We found no statistically significant differences in the rates of locoregional recurrence between the three groups. Therefore, TT appears to be an adequate treatment for these patients; CND is associated with higher rates of transient hypoparathyroidism and cannot be considered the treatment of choice even if it could help for more appropriate selection of patients for RAI. Ipsilateral CND could be an interesting option considering the lower rate of hypocalcemia to be validated by further studies.

Surgical management of gynecomastia: experience of a general surgery center.

AIM: Gynecomastia is a common finding in male population of all ages. The aim of our study was to present our experience and goals in surgical treatment of gynecomastia. PATIENTS AND METHODS: Clinical records of patients affected by gynecomastia referred to our Department of Surgery between September 2008 and January 2015 were analyzed. 50 patients were included in this study. RESULTS: Gynecomastia was monolateral in 12 patients (24%) and bilateral in 38 (76%); idiopathic in 41 patients (82%) and secondary in 9 (18%). 39 patients (78%) underwent surgical operation under general anaesthesia, 11 (22%) under local anaesthesia. 3 patients (6%) presented recurrent disease. Webster technique was performed in 28 patients (56%), Davidson technique in 16 patients (32%); in 2 patients (4%) Pitanguy technique was performed and in 4 patients (8%) a mixed surgical technique was performed. Mean surgical time was 80.72±35.14 minutes, median postoperative stay was 1.46±0.88 days. 2 patients (4%) operated using Davidson technique developed a hematoma, 1 patient (2%) operated with the same technique developed hypertrophic scar. CONCLUSIONS: Several surgical techniques are described for surgical correction of gynecomastia. If performed by skilled general surgeons surgical treatment of gynecomastia is safe and permits to reach satisfactory aesthetic results.

Antibiotic prophylaxis for open mesh repair of groin hernia: systematic review and meta-analysis.

PURPOSE: A meta-analysis was performed to asses whether antibiotic prophylaxis is effective in reducing the incidence of surgical site infection (SSI) after open mesh repair of groin hernia. METHODS: A literature search for randomized controlled trials (RCT) evaluating the effectiveness of antibiotic prophylaxis in adult patients undergoing open mesh repair of groin hernia was performed in November 2015. Incidence of overall and deep SSI was considered as primary and secondary outcome measures, respectively. Only studies with a clear definition of SSI and a follow-up of at least 1 month were included. Effect size from each RCT was computed as odds ratio (OR) and 95 % confidence interval (CI) and then data were pooled using a random-effects model. RESULTS: Sixteen RCTs with a total number of 5519 patients were included in the meta-analysis. Considering all the RCTs, antibiotic prophylaxis significantly reduced the overall incidence of SSI from 4.8 % to 3.2 % [OR 0.68, 95 % CI (0.51-0.91)]. However, after removal of two outlier studies, which were identified by evaluating the standardized residual, the result of the meta-analysis became non-significant [OR 0.76, 95 % CI (0.56-1.02)]. The incidence of deep SSI was very low (0-0.7 %) and the effect of antibiotic prophylaxis was not significant [OR 0.80, 95 % CI (0.32-1.99)]. CONCLUSIONS: The results of this meta-analysis do not support the routine use of antibiotic prophylaxis for the open mesh repair of groin hernia. In clinical settings with unexpectedly high rates of SSIs, the appropriateness of surgical asepsis should be carefully checked.

Tailored anterior tension-free repair for the treatment of recurrent inguinal hernia previously repaired by anterior approach.

PURPOSE: The purpose of this study is to describe our policy in selecting different types of anaesthesia and anterior tension-free techniques for the repair of recurrent inguinal hernias previously treated by anterior approach and to evaluate early and late outcomes. METHODS: The medical records of 111 patients who underwent recurrent inguinal hernia repair by anterior approach in the period 2000-2013 were reviewed. Fifty patients (45 %) were over 70 years old and 63 (56.7 %) had one or more co-morbidities. Hernias with large defects were the most frequently observed (59.5 %), and no-mesh techniques were the most frequent failed repair (75.7 %). Different anterior tension-free techniques and types of anaesthesia were used, depending on hernia and patient characteristics. Seventy-three patients (65.8 %) were operated on an outpatient basis. RESULTS: Mean follow-up period was 89 months (range 10-183). No perioperative deaths, medical events, or visceral injuries were recorded. Early postoperative complications occurred in 11 patients: 4 haematomas (3.6 %), 5 seromas (4.5 %), 1 superficial wound infection (0.9 %) and 1 ischemic orchitis (0.9 %). Late complications consisted in 3 cases of chronic moderate pain (3.2 %) and 2 re-recurrences (2.1 %). CONCLUSIONS: Recurrent inguinal hernia previously treated by open anterior technique can be repaired using the same approach, often on an outpatient basis, with a low rate of recurrence and postoperative complications. To be safe and effective, the repair should be performed by appropriately trained surgeons, well versed in the use of different types of anaesthesia and surgical techniques depending on patient and hernia characteristics.

Differentiated thyroid cancer: feasibility of loboisthmectomy in an endemic region.

AIM: The aim of the present retrospective study was to assess the feasibility of loboisthmectomy for the treatment of differentiated thyroid cancer in a endemic area, evaluating the histopathological features and the results of a case series of 1154 patients. PATIENTS AND METHODS: The clinical records of 1154 patients submitted to total thyroidectomy in our Department were retrospectively reviewed to analyze the histopathological characters and the results. RESULTS: In 1044 cases (90.5%) a papillary cancer was observed, in 110 (9.5%) a follicular carcinoma; microcarcinomas were 399 (34.5%). Multifocality was present in 323 cases (28%), in 142 unilateral (12.3%) and in 181 bilateral (15.7%). Thyroiditis coexisted in 472 patients (40.9%), multinodular goiter in 404 (35%), Graves' disease in 48 (4.1%), and multinodular toxic goiter in 38 (3.3%). Complications were: postoperative bleeding in 20 patients (1.7%), transient unilateral vocal cord paralysis in 20 (1.7%) definitive in 10 (0.86%), a transient bilateral paralysis in 1 (0.08%), a transient hypoparathyroidism in 351 (30.4%), and a definitive in 24 (2.07%). Nodal recurrence occurred in 25 patients (2.16%). CONCLUSIONS: Total thyroidectomy remains the safest treatment in differentiated thyroid cancer, especially if performed in high volume centers in which complications can be minimized. Loboisthmectomy can be a viable and safe alternative in small (< 1 cm) unifocal tumors in patients at low risk. Loboisthmectomy is limited in endemic areas by the association with other thyroid diseases. A correct and detailed information of the patient is essential before planning surgery.

Intraoperative recurrent laryngeal nerve monitoring in thyroid surgery: is it really useful?

AIM: The aim of this study was to evaluate the ability of intraoperative recurrent laryngeal nerve monitoring to predict the postoperative functional outcome and the potential role of this technique in reducing the postoperative nerve palsy rate. MATERIALS AND METHODS: Between June 2007 and December 2011, 1693 consecutive patients who underwent thyroidectomy by a single surgical team were evaluated. We compared patients who have had a neuromonitoring and patients who have undergone surgery with the only visualization. Patients in which NIM was not utilized (Group A) were 942 against the others 751 (group B). RESULTS: In group A there were 28 recurrent laryngeal nerve injuries (2.97%) of which 21 were transients (2.22%) and 7 were permanents (0.74%). In group B there were 20 recurrent laryngeal nerve injuries (2.66%) of which 14 (1.86%) transients and 6 (0.8%) permanents. Differences between the two groups were not statistically significative. CONCLUSIONS: The technique of intraoperative neuromonitoring in thyroid surgery is safe and reliable in excluding postoperative recurrent laryngeal nerve palsy; it has high accuracy, specificity, sensitivity and negative predictive value. Neuromonitoring is useful to identify the recurrent laryngeal nerve and it can be a useful adjunctive technique for reassuring surgeons of the functional integrity of the nerve but it does not decrease the incidence of injuries compared with visualization alone. Its application can be particularly recommended for high-risk thyroidectomies.

Intraoperative parathyroid hormone assay during focused parathyroidectomy for primary hyperparathyroidism: is it really mandatory?

AIM: Intraoperative parathyroid hormone (PTH) assay has become an essential tool in focused parathyroid surgery. The aim of this study was to evaluate the present role of intraoperative PTH monitoring during focused parathyroidectomy for primary hyperparathyroidism in our experience. METHODS: One hundred sixty-one patients were submitted to focused parathyroidectomy with rapid intraoperative Parathyroid hormone assay monitoring. RESULTS: A >50% decrease of PTH occurred in 147 patients (91.3%); in this group persistent hypercalcemia was found in 1; in the remaining 14 (8.7%) values of PTH decreased less than 50% and bilateral neck exploration was performed. An additional pathologic parathyroid was removed in 8 cases, a third in one; in the other five further neck exploration was negative and in four of these persistent postoperative hypercalcemia was demonstrated. In 136 patients >50% decrease of PTH was obtained after 10 minutes, in the other 11 after 20. The overall operative success of the patients was 96.9% with a 5.6% incidence of multiglandular disease. Intraoperative parathormone monitoring changed the operative management in 8.7% of cases. Intraoperative parathormone monitoring was accurate in predicting operative success or failure in 98.7% of patients, with a sensitivity of 99.3%, a specificity of 92.8%, a positive predictive value of 99.3% and a negative predictive value of 92.8%. DISCUSSION AND CONCLUSION: The measurement of intraoperative PTH represents a useful tool to assist the surgeon during parathyroid surgery and its routine use significantly improves cure rates of focused parathyroidectomy. We believe that the use intraoperative PTH is still mandatory in focused parathyroidectomy avoiding relapses and consequent reintervention.

Risk factors in reoperative thyroid surgery for recurrent goitre: our experience.

AIM: Reoperative thyroid surgery is an uncommon operation associated with a higher complication rate; we reviewed our series of patients on whom reoperative thyroid surgery was performed. METHOD: 106 patients had a thyroid reoperation for recurrent multinodular goiter (93 patients), recurrent thyrotoxicosis (3) or suspected malignancy (10); bilateral completion thyroidectomy was performed in 68 cases, lobectomy in 36, removal of a mediastinal recurrence and of a pyramidal remnant in 1 patient respectively. RESULTS: Temporary hypoparathyroidism occurred in 41 patients (38.67%), definitive in 7 (6.6%), transient recurrent laryngeal nerve palsy in 5 (4.71%), permanent nerve palsy in 1 (0.94%); in 3 cases (2.83%) surgical revision of haemostasis was necessary for postoperative haemorrhage. After monolateral surgery we had 13 cases of transient hypoparathyroidism (34.21%), 2 of definitive (5.26%) and 1 transient recurrent laryngeal nerve palsy (2.63%); after bilateral surgery we had 29 cases of transient hypoparathyroidism (42.64%), 5 of definitive (7.35%), 4 of transient recurrent laryngeal nerve palsy (5.88%), 1 of definitive (1.47%) and 3 of postoperative bleeding (4.41%). CONCLUSIONS: Reoperative thyroid surgery is a technical challenge with a high incidence of complications. Scarring, edema and friability of the tissues together with distortion of the landmarks make reoperative surgery hazardous. A higher risk of complications is described when previous surgery has been performed on both sides. Total thyroidectomy should be considered the procedure of choice for benign multinodular goiter eliminating the potential of a reoperation. Whenever necessary, reoperative thyroidectomy may be performed safely with little morbidity in experienced hands.