A randomized trial of hemithyroidectomy versus Dunhill for the surgical management of asymmetrical multinodular goiter.

OBJECTIVE: To assess the immediate and long-term clinical results of 2 different surgical procedures for the treatment of asymmetrical multinodular goiter (AMG). BACKGROUND: Half of the patients presenting with a single benign thyroid nodule have contralateral subclinical disease. There is a controversy whether these patients should be treated with hemithyroidectomy (HMT) or with a more extensive procedure. METHODS: Adult patients with a benign unilateral dominant nodule and contralateral nodule(s) with a diameter of less than 10 mm detected on neck ultrasonography were randomized to HMT or Dunhill (DUN). Rates of complications, remnant growth, incidental carcinoma, and reoperation were assessed. RESULTS: A total of 118 patients (F/M:110/8, mean age 43 years) were included and randomized: 65 to HMT and 53 to DUN. After randomization, 28 patients were excluded leaving 47 HMT and 43 DUN long-term (55 ± 35 months) evaluable patients. Mean nodule size was 38 and 6 mm for the dominant and contralateral nodules, respectively. No differences were found in operative time, accidental parathyroidectomy, parathyroid autotransplantation, or wound complications. Transient hypocalcemia was more common in DUN (30% vs 8%; P < 0.001). No permanent complications were observed. At the last follow-up visit, thyroid-stimulating hormone was similar in both groups. Remnant growth (20 vs 0%; P < 0.001), appearance of new nodules (55 vs 14%; P < 0.001), and overall reoperation rate (9.2 vs 1.8%, P = 0.2) were more common in HMT, mostly because of undiagnosed cancer requiring completion thyroidectomy. Thirty percent of HMTs developed hypothyroidism and required long-term T4 supplementation. CONCLUSIONS: DUN appears superior to HMT for the treatment of AMG in terms of early reoperation for missed carcinomas and disease progression. Both procedures have a similarly uneventful postoperative course.

Effect of a high-fat diet on 24-h pattern of circulating levels of prolactin, luteinizing hormone, testosterone, corticosterone, thyroid-stimulating hormone and glucose, and pineal melatonin content, in rats.

Circadian rhythmicity is affected in obese subjects. This article analyzes the effect of a high-fat diet (35% fat) on 24-h changes circulating prolactin, luteinizing hormone (LH), testosterone, corticosterone, thyroid-stimulating hormone (TSH) and glucose, and pineal melatonin content, in rats. When body weight of rats reached the values of morbid obesity, the animals were sacrificed at six different time intervals throughout a 24-h cycle, together with age-matched controls fed a normal diet (4% fat). Plasma hormone levels were measured by specific radioimmunoassays and glucose concentration by an automated glucose oxidase method. In rats under a high-fat diet, a significant disruption of the 24-h pattern of plasma TSH, LH, and testosterone and a slight disruption of prolactin rhythm were found. Additionally, high-fat fed rats showed significantly lower total values of plasma TSH and testosterone and absence of correlation between testosterone and circulating LH levels. Plasma corticosterone levels increased significantly in high-fat fed rats and their 24-h variation became blunted. In obese animals, a significant hyperglycemia developed, individual plasma glucose values correlating with circulating corticosterone in high-fat fed rats only. The amplitude of the nocturnal pineal melatonin peak decreased significantly in high-fat fed rats. The results underlie the significant effects that obesity has on circadian organization of hormone secretion.

Increased mortality and morbidity associated with thyroidectomy for intrathoracic goiters reaching the carina tracheae.

HYPOTHESIS: Complications associated with thyroidectomy for intrathoracic goiters have been underestimated because of the lack of a precise definition of high-risk patients. DESIGN: Retrospective multicenter multinational review of medical records and radiographic images of patients who underwent thyroidectomy for intrathoracic goiters reaching the carina tracheae. Demographic, clinical, operative, anatomical, and pathological data were recorded. RESULTS: There were 35 patients (mean +/- SE age, 63 +/- 11 years) included in the study. In 4 patients, the goiter was asymptomatic; 10 patients had dysphagia, 24 patients had dyspnea, and 3 patients had superior vena cava syndrome. A median sternotomy was required in 12 patients and a right-sided thoracotomy in 1 patient. The mean +/- SE operative time was 145 +/- 72 minutes (range, 50-360 minutes). Transient hypoparathyroidism developed in 13 patients. Four patients experienced transient hoarseness, and 1 patient had permanent vocal cord paralysis. There were no significant differences between the proportion of patients who underwent or did not undergo sternotomy or thoracotomy regarding vocal cord dysfunction (2 [15%] of 13 patients vs 3 [13%] of 22 patients) or hypoparathyroidism (5 [38%] of 13 vs 6 [28%] of 22 patients). The mean postoperative hospital stay was 10 days (range, 2-84 days). Four patients required reoperation. Two patients died. Nine of 14 patients with thyroid glands weighing at least 260 g required sternotomy vs 3 of 14 patients with thyroid glands weighing less than 260 g (P = .02). Overall, 18 [52%] of 35 patients were discharged without any complication. CONCLUSION: Intrathoracic goiters reaching the carina tracheae carry a high unreported risk of sternotomy, postoperative complications, reoperation, and death.

Indicadores de calidad en cirugía bariátrica y criterios de éxito a largo plazo / Quality indicators in bariatric surgery and criteria for long-term success

Se revisa el estado actual de los conceptos que definen una buena técnica bariátrica y se actualizan la forma de presentación de los resultados ponderales y los criterios de éxito a largo plazo. Los conceptos enunciados por Fobi y Baltasar siguen estando vigentes para definir una técnica quirúrgica correcta: a) segura, con una morbilidad menor del 10 por ciento y una mortalidad inferior al 1 por ciento; b) efectiva, con pérdidas del exceso de peso superior al 50 por ciento en más del 75 por ciento de los pacientes a los 5 años de seguimiento; c) reproducible con facilidad, de tal forma que los resultados de los distintos centros que la realicen sean comparables; d) con porcentajes de revisión menores del 2 por ciento anual; e) que ofrezca una buena calidad de vida, o que no la altere de una forma manifiesta, por la imposibilidad de realizar una ingesta adecuada, presencia de vómitos de repetición o diarreas permanentes; f) con efectos secundarios mínimos sobre órganos o sistemas, y g) fácilmente reversible. El análisis de la pérdida ponderal debe realizarse exclusivamente utilizando el porcentaje del exceso de peso perdido y/o los cambios en el índice de masa corporal expresados como porcentaje de índice de masa corporal perdido o porcentaje del exceso de índice de masa corporal perdido. Asimismo, se recomienda indicar la desviación estándar de la medida calculada (no los límites máximo y mínimo), el número de pacientes seguidos y el número de pacientes utilizados en cada momento del estudio. Global o individualizadamente, los resultados deben ser separados en los obesos mórbidos y superobesos, y en situaciones más específicas habría que considerar otros subgrupos, según la edad, la etnia, el estado socioeconómico, las comorbilidades específicas, si se trata de una operación inicial o de una reoperación o una comparación entre la técnica original y la realizada con una modificación técnica importante. El tiempo mínimo para la valoración de los resultados debe ser de 5 años. Los resultados no deben valorarse sólo según las modificaciones ponderales, sino que deben tenerse en cuenta la evolución de las comorbilidades y los factores derivados del propio paciente que, en conjunto, definen la calidad de vida utilizando el sistema BAROS, aunque éste debe ser revisado (AU)

Bypass biliopancreático. Comentario / Biliopancreatic bypass. Comment

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