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.

Vía clínica de tiroidectomía / Clinical pathway for thyroidectomy

Las vías clínicas son planes detallados de asistencia aplicables al tratamiento de pacientes con variaciones en la práctica y un curso clínico predecible. Sin pretender sustituir el juicio clínico de los profesionales, buscan una mejora en la efectividad y la eficiencia. La vía clínica que presentamos es el resultado del trabajo colaborativo de las Secciones de Cirugía Endocrina y Gestión de Calidad de la Asociación Española de Cirujanos, que intenta aportar un marco para normalizar la realización de la tiroidectomía. Junto con documentos habituales de toda vía clínica (matriz temporal, hoja de variaciones e información, indicadores de evaluación, encuesta de satisfacción), incluye una revisión de la evidencia científica en torno a diferentes aspectos del pre, intra y posoperatorio de esta intervención, la más frecuentemente realizada en cirugía endocrina. Entre otros, analiza la profilaxis antibiótica y antitrombótica, la preparación preoperatoria en hipertiroidismo, la neuromonitorización intraoperatoria, los sistemas para hemostasia intraoperatoria y el tratamiento de la hipocalcemia posoperatoria

Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia

Clinical Pathway for Thyroidectomy.

Clinical pathways are care plans applicable to patient care procedures that present variations in practice and a predictable clinical course. They are designed not as a substitute for clinical judgment, but rather as a means to improve the effectiveness and efficiency of the procedures. This clinical pathway is the result of a collaborative work of the Sections of Endocrine Surgery and Quality Management of the Spanish Association of Surgeons. It attempts to provide a framework for standardizing the performance of thyroidectomy, the most frequently performed operation in endocrine surgery. Along with the usual documents of clinical pathways (temporary matrix, variance tracking and information sheets, assessment indicators and a satisfaction questionnaire) it includes a review of the scientific evidence around different aspects of pre, intra and postoperative management. Among others, antibiotic and antithrombotic prophylaxis, preoperative preparation in hyperthyroidism, intraoperative neuromonitoring and systems for obtaining hemostasis are included, along with management of postoperative hypocalcemia.

Colitis pseudomembranosa letal en paciente inmunocompetente / Lethal pseudomembranous colitis in an immunocompetent patient

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Abordaje del bocio endotorácico en mediastino posterior: incisión transcervical y toracotomía lateral / Best Approach for Posterior Mediastinal Goiter Removal: Transcervical Incision and Lateral Thoracotomy

La extirpación quirúrgica del bocio intratorácico puede realizarse a través de un abordaje cervical en la mayoría de los pacientes. La revisión de la literatura pone de manifiesto que los cirujanos experimentados precisan un abordaje extracervical en el 2-3% de los casos. A pesar de que el tratamiento quirúrgico del bocio retroesternal está bien definido, existe poca información acerca del abordaje quirúrgico de los bocios intratorácicos que se extienden más allá del cayado aórtico hacia el mediastino posterior. Presentamos 2 casos y proponemos una combinación de incisión cervical y toracotomía lateral con preservación muscular para la resección del bocio en el mediastino posterior. En este tipo de casos descartamos el uso de la esternotomía puesto que el mediastino posterior resulta inaccesible debido a la presencia del corazón y grandes vasos por delante de la masa tiroidea, lo cual podría llevar a realizar una peligrosa disección a ciegas. Según nuestra experiencia el abordaje transcervical combinado con la toracotomía está indicado para una resección completa y segura del bocio situado en el mediastino posterior

Surgical removal of intrathoracic goiter can be performed by a cervical approach in the majority of patients. Review of literature shows that experienced surgeons need to perform an extracervical approach in 2-3% of cases. In spite of surgical management of substernal goiter is well defined, there is little available information about surgical approach of intrathoracic goiters extending beyond the aortic arch into the posterior mediastinum. We report two cases and propose combination of cervical incision and muscle-sparing lateral thoracotomy for posterior mediastinal goiter removal. In such cases, we do not favor sternotomy as posterior mediastinum is inaccessible due to the presence of heart and great vessels anterior to the thyroidal mass that would lead to perform a perilous blind dissection. Based on our experience, transcervical and thoracotomy approach is indicated for a complete and safe posterior mediastinal goiter remova

Best approach for posterior mediastinal goiter removal: transcervical incision and lateral thoracotomy.

Surgical removal of intrathoracic goiter can be performed by a cervical approach in the majority of patients. Review of literature shows that experienced surgeons need to perform an extracervical approach in 2-3% of cases. In spite of surgical management of substernal goiter is well defined, there is little available information about surgical approach of intrathoracic goiters extending beyond the aortic arch into the posterior mediastinum. We report two cases and propose combination of cervical incision and muscle-sparing lateral thoracotomy for posterior mediastinal goiter removal. In such cases, we do not favour sternotomy as posterior mediastinum is inaccessible due to the presence of heart and great vessels anterior to the thyroidal mass that would lead to perform a perilous blind dissection. Based in our experience, transcervical and thoracotomy approach is indicated for a complete and safe posterior mediastinal goiter removal.

A forgotten method to induce experimental chronic renal failure in the rat by ligation of the renal parenchyma.

BACKGROUND: Animal models of chronic renal failure have been widely used in the experimental nephrology laboratories. The most common technique used is the 5/6 reduction of renal mass, either by surgical resection or by infarction. METHODS: In the present work, we describe a forgotten technique based in the ligation of the renal parenchyma in both renal poles. This technique combines the advantages of the resection model, like the reproducibility and homogeneity, with the ones of the infarction technique, like the absence of bleeding. RESULTS: 8 weeks after the procedure, animals showed a decrease in creatinine clearance together with an increase in plasma creatinine. Furthermore, glomeruli of animals with 5/6 nephrectomy showed a marked hypertrophy, with a glomerular volume significantly higher than control animals. Serum levels of parathyroid hormone were also increased, consistent with the development of secondary hyperparathyroidism. CONCLUSIONS: We conclude that the present technique is a valid and improved tool for the study of chronic renal failure.