Efficacy and safety of preoperative preparation with Lugol's iodine solution in euthyroid patients with Graves' disease (LIGRADIS Trial): Study protocol for a multicenter randomized trial.

BACKGROUND: Currently, both the American Thyroid Association and the European Thyroid Association recommend preoperative preparation with Lugol's Solution (LS) for patients undergoing thyroidectomy for Graves' Disease (GD), but their recommendations are based on low-quality evidence. The LIGRADIS trial aims to provide evidence either to support or refute the systematic use of LS in euthyroid patients undergoing thyroidectomy for GD. METHODS: A multicenter randomized controlled trial will be performed. Patients ≥18 years of age, diagnosed with GD, treated with antithyroid drugs, euthyroid and proposed for total thyroidectomy will be eligible for inclusion. Exclusion criteria will be prior thyroid or parathyroid surgery, hyperparathyroidism that requires associated parathyroidectomy, thyroid cancer that requires adding a lymph node dissection, iodine allergy, consumption of lithium or amiodarone, medically unfit patients (ASA-IV), breastfeeding women, preoperative vocal cord palsy and planned endoscopic, video-assisted or remote access surgery.Between January 2020 and January 2022, 270 patients will be randomized for either receiving or not preoperative preparation with LS. Researchers will be blinded to treatment assignment. The primary outcome will be the rate of postoperative complications: hypoparathyroidism, recurrent laryngeal nerve injury, hematoma, surgical site infection or death. Secondary outcomes will be intraoperative events (Thyroidectomy Difficulty Scale score, blood loss, recurrent laryngeal nerve neuromonitoring signal loss), operative time, postoperative length of stay, hospital readmissions, permanent complications and adverse events associated to LS. CONCLUSIONS: There is no conclusive evidence supporting the benefits of preoperative treatment with LS in this setting. This trial aims to provide new insights into future Clinical Practice Guidelines recommendations. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03980132.

Laparoscopy-induced severe renal failure after appendectomy.

Laparoscopy has gained importance in the abdominal emergency surgery field. Acute appendicitis is one of the major indications for emergency surgery, being laparoscopy the gold standard approach. We report a case of a 39-years-old female presenting with acute kidney injury (AKI) after laparoscopy. Differential diagnosis was considered with prerenal AKI etiology due to sepsis and low fluid input, however this was ruled out due to absence of electrolyte imbalance and no correlation with septic parameters. Laparoscopy CO2 pneumoperitoneum can potentially lead to multiple organ failure, including renal. Laparoscopy induced AKI is related with both hormonal stimuli for renal vasoconstriction and increased intra-abdominal pressure, causing hypoxemia and tubular renal injury. In conclusion, very few cases of laparoscopy induced AKI in young patients with no previous renal disease have been reported. Surgeons must consider this complication in the differential diagnosis of postoperative AKI.

Time to parathyroid function recovery in patients with protracted hypoparathyroidism after total thyroidectomy.

OBJECTIVE: Hypocalcaemia is the most common adverse effect after total thyroidectomy. It recovers in about two-thirds of the patients within the first postoperative month. Little is known, however, about recovery of the parathyroid function (RPF) after this time period. The aim of the present study was to investigate the time to RPF in patients with protracted (>1 month) hypoparathyroidism after total thyroidectomy. DESIGN: Cohort prospective observational study. METHODS: Adult patients undergoing total thyroidectomy for goitre or thyroid cancer. Cases with protracted hypoparathyroidism were studied for RPF during the following months. Time to RPF and variables associated with RPF or permanent hypoparathyroidism were recorded. RESULTS: Out of 854 patients undergoing total thyroidectomy, 142 developed protracted hypoparathyroidism. Of these, 36 (4.2% of the entire cohort) developed permanent hypoparathyroidism and 106 recovered: 73 before 6 months, 21 within 6-12 months and 12 after 1 year follow-up. Variables significantly associated with RPF were the number of parathyroid glands remaining in situ (not autografted nor inadvertently resected) and a serum calcium concentration >2.25 mmol/L at one postoperative month. Late RPF (>6 months) was associated with surgery for thyroid cancer. RPF was still possible after one year in patients with four parathyroid glands preserved in situ and serum calcium concentration at one month >2.25 mmol/L. CONCLUSIONS: Permanent hypoparathyroidism should not be diagnosed in patients requiring replacement therapy for more than six months, especially if the four parathyroid glands were preserved.

Failure of fragmented parathyroid gland autotransplantation to prevent permanent hypoparathyroidism after total thyroidectomy.

PURPOSE: Parathyroid autotransplantation during total thyroidectomy leads to higher rates of postoperative hypocalcaemia. It has been argued, however, that it prevents permanent hypoparathyroidism. The impact of autografted normal parathyroid gland fragments on long-term parathyroid status has not been assessed properly. To clarify this, the short- and long-term parathyroid function was assessed in patients with three glands remaining in situ after total thyroidectomy, in whom the fourth gland was either autotransplanted (Tx) or accidentally resected (AR). METHODS: Consecutive patients (n = 669) undergoing first-time total thyroidectomy were prospectively studied recording the number of parathyroid glands remaining in situ: PGRIS =4-(glands autografted + glands in the specimen). The study was focused on the subgroup of 186 patients with three parathyroid glands remaining in situ as a result of either accidental resection (AR, n = 76) or autotransplantation into the sternocleidomastoid muscle (Tx, n = 110). Prevalence of postoperative hypocalcaemia, protracted, and permanent hypoparathyroidism were compared between the two groups. Demographic, disease-related, laboratory, and surgical variables were recorded. All patients were followed for at least 1 year. RESULTS: Both groups were comparable in terms of disease and extent of surgery. Mean postoperative serum calcium was the same (AR: 1.97 ± 0.2 vs Tx: 1.97 ± 0.22 mmol/L). Rates of protracted (AR: 24% vs Tx: 25.5%) and permanent hypoparathyroidism (AR: 5.3% vs Tx: 7.3%) were similar in both groups. CONCLUSIONS: The prevalence of parathyroid failure syndromes after total thyroidectomy was similar whether a parathyroid gland was inadvertently excised or autotransplanted. Autotransplantation did not influence the permanent hypoparathyroidism rate.

Inadvertent parathyroidectomy during total thyroidectomy and central neck dissection for papillary thyroid carcinoma.

BACKGROUND: The main drawback of central neck lymph node dissection is postoperative parathyroid failure. Little information is available concerning inadvertent resection of the parathyroid glands in this setting and its relationship to postoperative hypoparathyroidism. Our aim was to determine the prevalence of inadvertent parathyroidectomy during total thyroidectomy and central neck dissection for papillary thyroid cancer and its impact on short-and long-term parathyroid function. METHODS: This was a prospective observational study of consecutive patients undergoing first-time total thyroidectomy with a central neck dissection for papillary carcinoma >10 mm. Prevalence and risk factors for inadvertent parathyroidectomy were recorded. Serum calcium and intact parathyroid hormone concentrations were determined 24 hours after operation and then periodically in patients developing postoperative hypocalcemia. All patients were followed for a minimum of one year. RESULTS: Whole gland (n = 33) or microscopic parathyroid fragments (n = 14) were identified in 47/170 (28%) operative specimens. The lower parathyroid glands were involved more often. Variables influencing inadvertent parathyroidectomy were extrathyroidal extension of the tumor and therapeutic lymphadenectomy. Neither lateral neck dissection nor the number of lymph nodes retrieved affected the rate of inadvertent parathyroid resection. Postoperative hypocalcemia and permanent hypoparathyroidism were more frequent after inadvertent parathyroidectomy (64% vs 46% and 15% vs 4%; P ≤ .03 each). CONCLUSION: Inadvertent parathyroidectomy during total thyroidectomy with central neck dissection for papillary thyroid carcinoma is common and involves the inferior glands more frequently in patients with extended resections and clinical N1a disease. Inadvertent resection of parathyroid glands is associated with greater rates of postoperative hypocalcemia and permanent hypoparathyroidism.

A rare presentation of gallstones: Bouveret´s syndrome, a case report.

CT images and endoscopic findings in a case of Bouveret's syndrome.

Síndrome de Bouveret / A rare presentation of gallstones: Bouveret´s syndrome, a case report

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Obstructive jaundice caused by a pancreaticoduodenal pseudoaneurysm.

Obstructive jaundice caused by a pancreaticoduodenal pseudoaneurysm, probably related to a chronic pancreatitis.

Ictericia obstructiva por pseudoaneurisma de arteria pancreaticoduodenal / Obstructive jaundice caused by a pancreaticoduodenal pseudoaneurysm

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