Ethical and medico-legal issues of TOETVA procedure and simulation on cadavers: a scoping review.

Conventional open thyroidectomy is still considered the gold standard for thyroid surgery. Transoral endoscopic thyroidectomy vestibular approach (also known as TOETVA) is often considered to be more advantageous than the other approaches, such as minimally invasive video assisted thyroidectomy, thyroidectomy via breast/axillary/retroauricular access, bilateral axillo-breast approach and axillo-bilateral breast approach. In this scoping review, we discuss the risks and the benefits of this surgical approach and its medico-legal and ethical implications, particularly focusing on the importance of practice on cadavers. Currently, there is little scientific evidence supporting TOETVA, since there are few papers on the comparison with the traditional open thyroidectomy that have been published and thus little data on the long-term outcomes of TOETVA are available. Since the better cosmetic outcome currently represents the main indication for this surgical technique, substantial medico-legal and ethical issues arise. Moreover, practice on cadavers can help surgeons to develop the technical and non-technical skills required to perform efficiently and safely this new surgical procedure.

Adrenalectomy for incidental and symptomatic phaeochromocytoma: retrospective multicentre study based on the Eurocrine® database.

BACKGROUND: Phaeochromocytoma is sometimes not diagnosed before surgery and may present as an adrenal incidentaloma. The aim of this study was to investigate differences in clinical presentation and perioperative outcome in patients with subclinical and symptomatic phaeochromocytoma, and in patients operated with and without preoperative α-blockade. METHODS: This was a retrospective observational study of patients with a histopathological diagnosis of phaeochromocytoma registered in Eurocrine®, the European registry for endocrine tumours, between 1 January 2015 and 31 March 2020. Patient characteristics, clinical presentation, tumour detection, and perioperative variables were analysed. RESULTS: Some 551 patients were included. Of these, 486 patients (88.2 per cent) had a preoperative diagnosis of phaeochromocytoma. Tumours were detected as incidentalomas in 239 patients (43.4 per cent) and 265 (48.1 per cent) had a preoperative diagnosis of hypertension. Preoperative α-blockade was more frequently used in patients with a known phaeochromocytoma (350, 90.9 per cent) than in patients with other indications for adrenalectomy (16, 31 per cent). Complications did not differ between patients who had surgery because of catecholamine excess compared with those who had other indications for surgery (19 (3.9 per cent) versus 2 (3 per cent); P = 0.785), nor did the conversion rate from minimally invasive to open surgery differ between the groups. There were no obvious differences in complications, according to the Clavien-Dindo classification, based on preoperative α-blockade or not. CONCLUSION: Subclinical phaeochromocytoma detected incidentally is common. A significant proportion of patients with phaeochromocytoma did not have α-blockade before surgery, without an apparent effect on complications.

Phaeochromocytoma is an unusual adrenal tumour with hormonal overproduction of catecholamines leading to a severe condition, including extreme hypertension in some situations. It is treated with surgery. Medical treatment before surgery is used to minimize surgical complications related to high blood pressure. A large proportion of phaeochromocytomas are detected incidentally, without symptoms, on radiological examination for other reasons. The aim of this study was to investigate differences in patient characteristics and surgical results in patients operated with or without symptoms of phaeochromocytoma. Patients registered in the large, European database, Eurocrine®, between 2015 and 2020 were included in the study. The study showed that phaeochromocytoma without symptoms is common. Medical treatment before surgery does not seem to affect complications.

European multicentre study on outcome of surgery for sporadic primary hyperparathyroidism.

BACKGROUND: International multicentre outcome studies of surgery for primary hyperparathyroidism (pHPT), especially for rate of conversion to bilateral neck surgery and persistent hypercalcaemia, are scarce. METHODS: Eurocrine® is a European database for endocrine surgery. Data are entered according to predefined data fields. Outcomes for patients who underwent first surgery for sporadic pHPT were analysed. Multivariable analysis was performed to identify risk factors for adverse outcome using Cox regression with constant follow-up. RESULTS: A total of 5861 patients were registered between 2015 and 2018. Preoperative localization procedures were used in most patients, with moderate sensitivity. Intraoperative parathyroid hormone (ioPTH) measurement was used in three-quarters of patients. Bilateral surgery was performed in 1574 patients (26·9 per cent). Among 4683 patients (79·7 per cent) for whom unilateral or focused operation was planned, the procedure was converted to bilateral surgery in 396 (8·5 per cent). The risk of conversion decreased with the use of ioPTH monitoring (relative risk (RR) 0·77). Persistent hypercalcaemia was registered in 253 patients (4·3 per cent), and was less likely with the use of two (RR 0·55) or three (RR 0·44) localization procedures. In patients with a concordant localized single lesion, the rate of persistent hypercalcaemia was 2·5 per cent. The risk of persistent hypercalcaemia decreased with the use of ioPTH measurement, but was increased in patients with negative localization procedures and conversion to bilateral surgery. CONCLUSION: The use of ioPTH measurement decreased the risk of conversion and persistent hypercalcaemia. The use of two or three localization procedures decreased the risk of persistent hypercalcaemia; in patients with a concordant single lesion, the risk of persistent hypercalcaemia was low.

Prognostic factors of survival and recurrence pattern in differentiated thyroid cancer: a retrospective study from Western Turkey.

OBJECTIVES: The aim of this study was to determine prognostic factors in patients with well-differentiated thyroid cancer (WDTC). METHODS: This retrospective study included 181 well-differentiated thyroid cancer patients who were operated between Decembers 1996-2007. Total of 181 patients [139 (76.8%) women and 42 (23.2%) men with a mean age of 46.3 years] who were subjected to a complete follow-up, were enrolled in the study. The mean follow-up period was 7.1 years (range 3.1 to 14.9 years). Medical records were reviewed regarding to age, gender, extent of surgery, tumor size, multifocality, clinical stage, capsule infiltration, extracapsular invasion, histological type, lymph node metastasis, distant metastasis, radioactive iodine treatment and prognosis. RESULTS: During follow-up, in 41 (22.6%) patients locoregional recurrences were detected and 5 (2.7%) patients passed away. Determined statistically significant prognostic factors were as follows; tumor size (histopathologically), extent of surgery, histological type, lymph node metastasis, tumor invasion (capsule and extracapsular) and clinical stage. CONCLUSIONS: Well-differentiated thyroid cancer is a disease with good prognosis when detected early and appropriate treatment applied. Despite the prognosis, it is good to apply the right treatment and reduce recurrence and mortality rates, prognostic factors are well known and must be considered in patient management.

The pharmacodynamic effects of rocuronium during general anesthesia in patients with type 2 diabetes mellitus.

AIM: The aim of this prospective study was to investigate whether the neuromuscular response to rocuronium is affected by the presence of type 2 diabetes mellitus. METHODS: Neuromuscular functions were measured after the administration of 0.6 mg/kg rocuronium with train-of-four stimulations in patients with type 2 diabetes mellitus (DM, N=14) and without diabetes mellitus (control, N=14) during isoflurane based general anesthesia. The onset time, clinical duration and recovery index of rocuronium were compared in the two groups. RESULTS: The mean onset time (136 +/- 40 vs 118 +/- 20 s), clinical duration (51 +/- 11 vs 48 +/- 11 min) and recovery index (6.0 +/- 2.5 vs 5.9 +/- 1.4 min) of the neuromuscular block were not significantly different between the DM and control groups, respectively (p>0.05). CONCLUSIONS: The present study has proven that the rocuronium-induced neuromuscular block was not affected in patients with type 2 diabetes mellitus during isoflurane based general anesthesia.

Co-existence of gastrointestinal stromal tumors with malign epithelial tumors: a report of two cases.

AIM: To emphasize the importance of a detailed observation for incidental simultaneous tumoral masses during surgery for gastrointestinal stromal tumors (GISTs) at any location in the gastrointestinal system. CASE PRESENTATIONS: Case 1: a 39-year-old female patient with an esophageal squamous cell carcinoma and a synchronous small intestinal GIST discovered incidentally during esophagectomy. Case 2: a 73-year-old female patient with a gastric GIST and a synchronous colorectal cancer detected incidentally during gastrectomy. In both cases, immunohistochemical examinations of the resected specimens confirmed the coexistences of GISTs and epithelial malignancies. CONCLUSION: The coexistences of GISTs with epithelial tumors have been increasing in recent years. In any case of a GIST or gastrointestinal adenocarcinoma, the surgeon should be alert to recognize a possible coexistent tumor with different histological origin.

The role of allopurinol on oxidative stress in experimental hyperthyroidism.

AIM: During hyperthyroidism, production of free oxygen radicals derives, where xanthine oxidase may also play an important role. Allopurinol, a xanthine oxidase inhibitor, has a significant effect on thyrotoxicosis-related oxidative stress. However, the relationship between thyroid hormones, oxidative stress parameters and allopurinol remains to be explored. METHODS: Forty-two Wistar albino rats were divided into three groups. Rats in group A served as negative controls, while group B had untreated thyrotoxicosis and group C received allopurinol. Hyperthyroidism was induced by daily 0.2 mg/kg L-thyroxine intraperitoneally in groups B and C; 40 mg/kg allopurinol were given daily intraperitoneally. Efficacy of the treatment was assessed after 72 h and 21 days, by measuring serum xanthine oxidase (XO), malondialdehyde (MDA), glutathione (GSH), glutathione reductase (GR), glutathione peroxidase (GPx) and nitric oxide derivates (NO*x). RESULTS: In both time periods, serum XO, MDA, GSH and NO*x levels were significantly increased after thyroid hormone induction (p<0.05). Levels of XO, MDA and NO*x decreased with allopurinol treatment (p<0.05). There was a remarkable decrease in triiodothyronine levels in group C after 72 h (p<0.05), and in both triiodothyronine and thyroxine levels in group C after 21 days (p<0.05). There was no difference between groups B and C in means of serum GSH, GR and GPx levels (p>0.05). CONCLUSIONS: This study suggests an association between allopurinol and the biosynthesis of thyroid hormones. Allopurinol prevents the hyperthyroid state, which is mediated predominantly by triiodothyronine and not by XO. This issue has to be questioned in further studies where allopurinol is administered in control subjects.

Experimental comparison of meshes for rectal prolapse surgery.

AIM: The aim of this experimental study is to investigate the foreign body tissue created by the meshes that are used for rectopexy. METHOD: Sixty rats were divided equally into 5 groups. Four mesh types (Surgipro, Ivalon, Gore-Tex and Vypro) were implanted into the retroperitoneal area except for the sham group. After a 5-week follow-up period, all animals were sacrificed. Specimens were evaluated macroscopically by using scoring systems and biochemically by determining tissue hydroxyproline and nitric oxide levels. RESULTS: The most evident foreign body reaction was observed in the Ivalon group, which showed higher 'macroscopic adhesion' scores (p < 0.005), although there were no significant differences in tissue hydroxyproline and nitric oxide levels between the groups (p > 0.05). CONCLUSION: In rectal prolapse surgery, selecting the ideal mesh type is unclear, depending on evidence-based results. In the present study, we could not prove which mesh was definitely superior to the other, macroscopically, histologically and biochemically. The findings of this experimental rat model suggest that implantation of all 4 types of meshes are suitable for posterior rectopexy.

Do clinical and immunohistochemical findings of pure mucinous breast carcinoma differ from mixed mucinous breast carcinoma?

Mucinous carcinoma of the breast is a relatively rare histologic type with two subtypes: pure and mixed. It has a favourable prognosis with a low risk of axillary metastases. The prognosis for pure mucinous carcinoma (PMC) was much better than for the mixed mucinous carcinoma (MMC). The aim of the study is to determine suitable candidates for breast or axillary conservation in mucinous carcinoma subtypes. The slides of 26 pure and 23 mixed mucinous carcinomas of the breast were evaluated. The clinical, pathological and immunohistochemical features between PMCs and MMCs were compared. MMC displayed greater metastatic potential (p < 0.05), p53 positivity (p < 0.05) and c-erbB-2 positivity (p <0.001) than PMCs. PMCs smaller than 2 cm had less metastatic capacity and extranodal invasion compared to MMCs smaller than 2 cm (p < 0.001 and p < 0.01, respectively). MMCs smaller than 2 cm displayed weaker ER positivity but greater c-erbB-2 positivity than PMCs smaller than 2 cm (p < 0.01). In conclusion, MMC had worse prognostic factors than PMC with both types of mucinous carcinoma showing similar ER and PR positive status. Even if PMCs and especially smaller PMCs display more favourable prognostic features, including less axillary lymph node involvement, it is appropriate to use sentinel lymph node biopsy to make better axillary assessment.

Can preoperative diagnosis affect the choice of treatment in Amyand's hernia? Report of a case.

Amyand's hernia (AH) is defined as an appendix located in the inguinal hernia sac. Most cases are diagnosed intraoperatively and might undergo appendectomy besides hernia repair. Computerized tomography is effective in the preoperative diagnosis. Meanwhile, the number of reports concerning the preoperative diagnosis of AH is increasing. There is no standard protocol for the management of AH. Factors such as the presence of an inflamed appendix, contamination of the surgical field, patient age and anatomic features of the tissue are important determinants for appropriate surgery. Herein, we report an adult male patient with AH.

Completion thyroidectomy for thyroid cancer.

BACKGROUND: Whether thyroid re-operations are associated with an increased complication risk is controversial. The aim of this study was to perform a retrospective analysis of patients undergoing re-operative surgery of the thyroid. We analyzed the safety and the impact of delay on complications before undertaking radicalization thyroidectomy. MATERIAL AND METHODS: From January 1996 to July 2002, 150 consecutive patients with thyroid cancer were treated in our institution. A total of 62 patients underwent completion thyroidectomy. Twenty-seven had undergone their initial operation in our centre. Medical and pathologic data were obtained retropectively. RESULTS: Pathological examination of the specimen after completion surgery revealed malignancy in a total of 35% of 62 patients. The time interval between initial surgery and completion thyroidectomy ranged from 5 days to 24 months (mean 3.1 months). Complications after re-operation were transient recurrent nerve injury in 1.6%, transient hypoparathyroidism in 4.8%, permanent hypoparathyroidism in 1.6% and chylous discharge in 1.6% of the patients. There was no significant difference between complication rates in patients operated on within 90 days or those operated on after this period (p > 0.05). CONCLUSIONS: This study suggests that completion thyroidectomy is safe in the hands of experienced endocrine surgeons and the timing of re-operation has no impact on the development of complications.

Is testicular perfusion influenced during laparoscopic inguinal hernia surgery?

BACKGROUND: The influence of laparoscopic inguinal hernia surgery is still unclear. The aim of this study was to compare the possible early effects of laparoscopic and open inguinal hernia repair on testicular perfusion. METHODS: In this prospective trial, 44 patients underwent mesh repair of a primary inguinal hernia assigned to one of two procedures: open anterior mesh repair (n = 29) or a laparoscopic totally extraperitoneal approach (n = 15). Doppler ultrasound was used to determine the hemodynamic characteristics of the testicular blood flow. RESULTS: No statistically significant differences were found between the two groups in terms of Doppler flow parameters for the preoperative, very early (day 1), and early postoperative (day 7) periods. When Doppler flow parameters of the testicular artery were compared in the conventional group, statistically significant differences were found between preoperative and very early postoperative values (p < 0.05). Meanwhile, comparison among flow parameters of the testicular, capsular, and intratesticular arteries of the laparoscopic group showed statistically significant differences between preoperative and very early postoperative and between preoperative and early postoperative values (p < 0.05). There were no statistically differences in postoperative complications between the two groups. CONCLUSION: Testicular blood flow is influenced during laparoscopic inguinal hernia surgery. Whether changes in flow parameters remain in the late postoperative period, and whether they have an impact on complications will be evaluated in further studies.

Does pharmaconutrition with L-arginine and/or alpha-tocopherol improve the gut barrier in bile duct ligated rats?

BACKGROUND/AIM: Nitric oxide supplementation and antioxidant therapy modulate gut barrier function, but the relationships between enhanced nitric oxide production, antioxidant administration, and biliary obstruction remain unclear. We evaluated the role of nitric oxide and alpha-tocopherol supplementation in bile duct ligated rats. METHODS: Fifty male Wistar albino rats underwent sham operation (group I; control animals) or bile duct ligation (groups II, III, IV, and V). The ligation groups received the following regimens: standard pellet diet (group II), pellet diet plus intramuscularly administered alpha-tocopherol (group III), and L-arginine-enriched pellet diet without (group IV) or with (group V) alpha-tocopherol. Nitric oxide, malondialdehyde, and alpha-tocopherol concentrations were assessed at the end of 3 weeks. Liver and intestinal samples were scored histologically. Mesenteric lymph node and liver cultures were assessed for bacterial translocation. RESULTS: The liver malondialdehyde concentration was highest in group III. The nitric oxide content in the liver was higher in groups III and V, as were the blood alpha-tocopherol levels. Bacterial translocation was evident following bile duct ligation, but did not differ among the treatment groups. Intestinal histology revealed that group III had the lowest villus height, that group V had the least villus count, and that group II had the highest mucous cell count. The fibrosis scores were higher in groups IV and V. CONCLUSIONS: An obvious effect of alpha-tocopherol (with or without L-arginine) on the gut barrier could not be demonstrated. Moreover, the L-arginine-enriched diet promoted fibrosis in the liver. Thus, while biliary duct obstruction triggers bacterial translocation, nitric oxide and/or alpha-tocopherol supplementation did not seem to improve the gut barrier in our model.

Pancreatic Castleman's tumour: an unusual case.

We present an uncommon case of hyaline vascular type Castleman's disease mimicking a pancreatic tumour. A 56-year-old woman with constitutional symptoms was investigated. Pre-operative interventions failed to produce a definitive diagnosis. Surgical excision was performed and the tumour was diagnosed to be the hyaline vascular type of Castleman's disease histopathologically. Pancreatic Castleman's disease should remain a consideration in the differential diagnosis of a pancreatic mass.

Laparoscopically assisted transhiatal resection for malignancies of the distal esophagus.

BACKGROUND: Resection of the esophagus remains the only curative therapy for esophageal cancer. Conventional resections are right-side thoracotomy in combination with laparotomy, gastric tube creation, and the transhiatal approach according to Orringer. This study evaluated laparoscopically assisted transhiatal esophagus resection, which offers perfect visualization of the esophagus during mediastinal dissection without the necessity of a thoracotomy. METHODS: In this study, 25 laparoscopically assisted transhiatal esophagus resections were compared with a historical control group consisting of 20 open transhiatal esophagus resections. RESULTS: Nine laparoscopically assisted resections (36%) were converted to open procedures. The operating time was longer in the laparoscopically assisted group (300 vs 257 min; p < 0.05), but laparoscopically assisted esophagus resection was associated with less blood loss (600 vs 900 ml; p < 0.05) and shorter intensive care unit stay (1 vs 2 days; p < 0.05). There were no differences in morbidity, mortality, and hospital stay. During a shorter follow-up time for the laparoscopic group (17 vs 54 months), 11 patients (44%) in the laparoscopically assisted group and 10 (50%) patients in the open group had recurrence of the disease. CONCLUSIONS: Laparoscopically assisted transhiatal esophagus resection is a safe procedure with important advantages, as compared with the open procedure, such as less blood loss and shorter intensive care unit stay. At this point, the oncologic consequences are not clear.

Anesthesiological hazards during laparoscopic transhiatal esophageal resection: a case control study of the laparoscopic-assisted vs the conventional approach.

BACKGROUND: Interest for minimal invasive approach of esophagus resection is increasing. Today, a minimally invasive transhiatal esophagectomy is possible and is accepted widespread. Since cardiopulmonary changes during laparoscopic dissection of the mediastinum has not been studied yet we assessed the anesthesiological consequences of pneumothorax during laparoscopic mediastinal dissection. METHODS: In this case control study, 25 laparoscopically assisted transhiatal espohagus resections were compared with a control group consisting of 20 open transhiatal esophagus resections. Patient characteristics and intraoperative haemodynamic, respiratory, and ventilatory parameters were assessed. RESULTS: The laparoscopic assisted procedure was performed successfully in 12 of the 20 patients. The duration of the laparoscopic assisted procedure, compared to the open group was significantly longer (p<0.05). Intraoperative blood loss was significantly less in the laparoscopic group (p<0.05). Mediastinal dissection resulted in entry of the pleura in 84% of the open and 93% of the laparoscopic assisted procedure. Carbonedioxide pneumothorax resulted in increased end-tidal CO2)and airway pressure levels and decreased lung compliance. Airway pressure showed a significant difference between the groups (p<0.05). Hemodynamic parameters did not differ between groups significantly. There were no differences in postoperative cardiopulmonary complications. CONCLUSIONS: Laparoscopic assisted transhiatal esophagectomy is a safe procedure and has no increased risk of postoperative cardiopulmonary complications compared to thr conventional approach. The anesthesiologist and the surgeon must be aware of the potential risk of pleural injury to manage cardiopulmonary compromises and minimize complications.