An apparent primitive mass of the mesentery: A case report.

INTRODUCTION: Neuroendocrine tumours (NETs) are rare tumors. 55% of NETs originate in the gastrointestinal tract and the liver is the most common site of distant metastases. Serum chromogranin A is the most common biomarker for assessing the extent of disease and monitoring treatment; carcinoid syndrome occurs in 19% of NETs and is characterized by chronic diarrhea or flushing. Primary mesenteric NETs are rare and have been described only in case reports in literature; our case is an apparent primary mesenteric NETs with a surgical program to remove the mesenteric mass and subrenal interaortocaval and retrocaval lymphadenectomies. PATIENT CONCERNS: A 73-year old man came to us because he had been experiencing abdominal pain for a year and he had recently developed diabetes mellitus. He was an active smoker with arterial hypertension. DIAGNOSIS: After a computed tomography scan and 68 Gallium-positron emission tomography, a diagnosis of what appeared to be a primary mesenteric NET with retrocaval and interaortocaval lymph nodes was made. Laparoscopic biopsy showed NET G2 positive for serotonin, chromogranin A, synaptophysin. INTERVENTIONS: The intraoperative finding of a primitive ileum-NET changed the surgical program. We removed the mesenteric mass with the lymph nodes of the superior mesenteric vessel and the middle distal ileum along with the cecum. OUTCOMES: The postoperative course was normal, and the patient was discharged on the seventh postoperative day without signs of short bowel syndrome. Follow-up at 6 months revealed no evidence of short bowel syndrome or disease progression. CONCLUSION: 68 Gallium-positron emission tomography does not show NETs smaller than 0.5 mm. Accurate palpation of the intestine is essential during surgery for NETs for two reasons: to find the primitive, and because of the risk of multiple intestinal primitives.

Early intact PTH (iPTH) is an early predictor of postoperative hypocalcemia for a safer and earlier hospital discharge: an analysis on 260 total thyroidectomies.

BACKGROUND: Hypocalcemia is the most frequent complication after thyroidectomy. Serum calcium levels are reliable only 48-72 hours postoperatively. Early intact PTH (iPTH) has been proposed as early predictor of postoperative hypocalcemia. Our aim is to assess the ability of iPTH in predicting postoperative hypocalcemia. METHODS: Two hundred and sixty patients underwent thyroidectomy with postoperative iPTH evaluation. The iPTH samplings were early performed after thyroidectomy. The calcium levels were dosed postoperatively. Age, sex, clinical diagnosis, obesity, comorbidities, previous neck surgery, preoperative therapy, type of surgery, dissectors used, lymphadenectomy, post-operative complications, reoperation and histological diagnosis were considered. The primary end-point was the postoperative hospital stay. The secondary end-points were serum calcium and iPTH. Three iPTH cut-offs were tested to assess which was the best value (10.0, 15.0, and 20.0 pg/mL). RESULTS: The iPTH cut-off value of 10.0 pg/mL was the most accurate and specific for hypocalcemia. Comparing the iPTH value with the different values of calcium respectively 24 and 48 hours after surgery, a statistically stronger association with the serum calcium levels 48 hours postoperatively has been shown. iPTH ≥10 pg/mL 3-6 hours after surgery was strongly correlated to early discharge. CONCLUSIONS: The correlation of iPTH with hypocalcemia is significant since a few hours after surgery and the value of iPTH ≥10 pg/mL is able to select those patients for a safe and early discharge. The use of the iPTH might avoid unnecessary extensions of hospitalization.

Recurrent laryngeal nerve management in thyroid surgery: consequences of routine visualization, application of intermittent, standardized and continuous nerve monitoring.

The objective is to compare the consequences of routine visualization (RV) and the application of intermitted (I-IONM), standardized (S-IONM), and continuous monitoring (C-IONM) of recurrent laryngeal nerve (RLN) management. RV includes that 698 RLNs managed solely with visual identification. In a second period 777, RLNs were handled by the I-IONM. The third period 768 RLNs monitoring was performed according to the standards. C-IONM via VN stimulation included 626 RLNs. The following issues were analyzed and compared per each period study: RLN identification rate, branching detection, assessment of NRLN, intraoperative recognizable nerve damage, stage thyroidectomy rate, transient or definitive lesions, bilateral nerve palsy, and recovery time. Significance for nerve identification rate was achieved (p = 0.03) when the statistical analysis was applied between RV vs. S-IONM and C-IONM. Extralaryngeal bifurcation was identified in 21, 44, 43, and 46 of RLN dissected, respectively, per period (p = 0.005). The incidence of paralysis in identified and unidentified RLN was 3.8 % (107/2806) and 82 % (52/63), respectively. Rates of temporary/permanent RLNP were 16.7/1.7, 5/1.1, 4.5/1, and 3.1/0 % per period study, respectively (p = 0.07). Recognizable intraoperatively nerve damage was, respectively, 15, 45, 100, and 100 % for period study (p = 0.03). The recovery of injured nerves was significantly faster in C-IONM group. S-IONM and C-IONM cumulate 40-stage procedures. The standardized technique, guidelines adherences, and C-IONM allowed to (1) increase RLN identification; (2) reduce the severity of injuries in terms of (a) reset bilateral RLNP, (b) faster recovery time, and

Recurrent laryngeal nerve injury in thyroid surgery: Clinical pathways and resources consumption.

BACKGROUND: The impact of recurrent laryngeal nerve (RLN) injury management in thyroid surgery seems to be relevant to patients, National Healthcare System (NHS), and society. METHODS: We studied resource consumption in the management of patients with RLN injury versus noninjured patients investigating 3 perspectives (patients, NHS, and society) in 5 clinical pathways. RESULTS: Direct medical costs supported by the NHS range from a minimum of euro (€) 79.46 to a maximum of € 3261.95. From the patient's perspective, the direct medical costs supported by the patient increased from a minimum of € 3.60 to a maximum of € 499.45. Productivity losses were accounted in € 156 per day per patient. From the NHS perspective, the percentage increase ranged from 43.25% to 98.14%. From the patient's perspective, it ranged from 51.52% to 80.60%. CONCLUSION: The analysis shows a significant economic impact of RLN injury management, which varies depending on the damage, duration, and severity. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Continuous Intraoperative Neuromonitoring (C-IONM) Technique with the Automatic Periodic Stimulating (APS) Accessory for Conventional and Endoscopic Thyroid Surgery.

One of the most important trends in intraoperative neural monitoring (IONM) in thyroid surgery is currently the real-time monitoring of the vagus nerve (VN) in order to prevent recurrent laryngeal nerve (RLN) iatrogenic damages. Notably, continuous intraoperative neuromonitoring (C-IONM) seems to be superior to intermitted intraoperative neural monitoring (I-IONM) because it enhances standardization by permanent vagus nerve (VN) stimulation, and it provides entire and constant RLN function monitoring as the surgeon dissects and removes the thyroid gland. It also has to be highlighted that the surgical maneuvers for the automatic periodic stimulating (APS) placement must be accurate and standardized in order to avoid a potential iatrogenic morbidity on the VN function. We recommend the experienced surgeon be very careful in each step, with cautious dissection. With this review article we provide a comprehensive analyses of C-IONM technique with the APS accessory for conventional and endoscopic thyroid surgery.

Surgical strategy for primary hyperparathyreoidism with thyroid hemiagenesis.

BACKGROUND: Thyroid hemiagenesis is a rare congenital anomaly, and still more rarely associated with primary hyperparathyroidism (pHPT). Due to the embryologic pathways of the thyroid and parathyroid glands, it remains unclear whether or not thyroid hemiagenesis may be linked to ipsilateral parathyroid agenesis, and consequently, surgical strategy for thyroid hemiagenesis associated pHPT (THAP) does not only depend on preoperative localization but also on the thyroid anomaly. METHODS: Including the present case report, a total of nine cases with THAP retrieved from the literature were reviewed. Seven of nine cases had thyroid hemiagenesis on the left side, three out of nine showed a parathyroid adenoma on the contralateral side to the thyroid hemiagenesis. CONCLUSIONS: Based on these cases, it can be concluded that the embryologic pathways of the thyroid and parathyroid glands are different, and in cases of THAP, parathyroid exploration should follow standard recommendations for pHPT surgery.

Web-based information on intraoperative neuromonitoring in thyroid surgery.

BACKGROUND: This is a preliminary analysis of intraoperative neuromonitoring (IONM)-related websites available to the general public with respect to thyroid surgery. METHODS: Four key terms and/or phrases (neuromonitoring AND thyroid AND neck surgery, intraoperative neuromonitoring, intraoperative electrophysiological monitoring, IONM) were entered separately into the search engines Google.com, Yahoo.com and Bing.com. The first 50 results obtained for each search procedure were evaluated. Websites were evaluated for content quality using the validated DISCERN rating instrument. Readability was graded by the Flesch Reading Ease Score and the Flesch-Kincaid Grade Level. RESULTS: The results were related to scientific publications in most cases (64%). A large percentage (59%) of the servers are located in the USA. The main language used is English (91%); only 19% of the websites are multilingual or in other languages. 58% of the sites were rated as excellent to good and 42% as fair to poor. The median Flesch Reading Ease Score was 49.6; the median Flesch-Kincaid Grade Level was 13.85. CONCLUSIONS: World Wide Web information about IONM in thyroid surgery is too specific and difficult and poorly accessible to the general public.

The safety of energy-based devices in open thyroidectomy: a prospective, randomised study comparing the LigaSure™ (LF1212) and the Harmonic® FOCUS.

PURPOSE: The options for haemostasis and dissection during modern thyroid surgery include the use of a bipolar vessel sealing system and ultrasonic technology. The aim of this study was to compare these energy-based devices (EBDs) with respect to their use in open thyroidectomy. METHODS: The FOCUS Shear (F) and LigaSure LF1212 (L) were evaluated. A total of 182 consecutive patients scheduled for open thyroidectomy were prospectively randomised into two similarly sized groups. The parameters of operative time, morbidity, incision length, postoperative pain and hospital stay were analysed. RESULTS: The main clinically primary endpoints of the two devices were identical in the study as the rate of nerve lesions, bleeding, drainage, operative time and postoperative calcium concentration with no significant differences with respect to the instrument utilised. The mean length of the incision was greater in the F group (p < 0.05). Patients in the F group were more likely to complain of pain while swallowing (p < 0.001). Early postoperative measurements of intact parathyroid hormone plasma levels revealed that although the levels were within the reference range, they were significantly lower in the F group (p < 0.001). Oral calcium supplementation was significantly higher and more prolonged in the F group. CONCLUSIONS: The present study demonstrated no significant difference in the rates of postoperative morbidity associated with these two different EBDs used. Differences in clinically less significant were founded and focused on.