Does antithrombotic prophylaxis worsen early outcomes of total thyroidectomy? - a retrospective cohort study.

BACKGROUND: Currently, there is no strong evidence on the effectiveness and safety of pharmacological antithrombotic prophylaxis in thyroid surgery. The aim of this study was to establish whether the prophylactic use of low-molecular-weight heparin (LMWH) could negatively affect the early outcomes of patients undergoing total thyroidectomy. METHODS: Data from patients submitted to total thyroidectomy between February 2013 and October 2017 were retrospectively collected and analysed. Only patients with indication to antithrombotic prophylaxis according to current guidelines were included in the study. Eligible cases were divided into two groups, which corresponded to two distinct periods of our surgical practice: Group A, which included 178 consecutive patients who were submitted to antithrombotic prophylaxis with LMWH, and Group B, which included 348 consecutive patients who did not receive prophylaxis. Primary endpoints were the incidence of post-operative cervical haematomas (POCH) and thromboembolic events. Secondary endpoint was the length of postoperative hospital stay. Statistical analysis was performed by using Student's t test for continuous variables and Chi-square test for categorical variables. A P value of less than 0.05 was considered statistically significant. RESULTS: The two groups of patients were comparable in terms of age, gender, thyroid disease, duration of surgery, and weight of the thyroid gland. Overall, no thromboembolic events were registered. The comparative analysis of the other outcome measures, showed no significant differences between the two groups (POCH: 2 cases (1.12%) in Group A vs 8 cases (2.30%) in Group B - p 0.349; Postoperative hospital stay: 2.90 ± 0.86 days in Group A vs 2.89 ± 0.99 days in Group B - p 0.908). CONCLUSIONS: Data from this study do not support or contraindicate the use of antithrombotic prophylaxis in thyroid surgery. However, since thyroidectomy is a closed-space procedure, and even modest bleeding may quickly result in airway compression and death by asphyxia, mechanical prophylaxis should be preferred to LMWH whenever possible. TRIAL REGISTRATION: ISRCTN ISRCTN12029395. Registered 05/02/2018 retrospectively registered.

High prevalence of papillary thyroid carcinoma in nodular Hashimoto's thyroiditis at the first diagnosis and during the follow-up.

BACKGROUND: The association between Hashimoto's thyroiditis (HT) and papillary thyroid carcinoma (PTC) remains to be elucidated. MATERIALS AND METHODS: A total of 484 HT patients were retrospectively subdivided into two groups: 243 without thyroid nodules, TNs (HTN-) and 241 with TNs (HTN+). Fine-needle aspiration cytology was available in 152 HTN+ patients. This group was compared to a group of 161 patients with nodular goiter (NG) without HT. Finally, 70 HTN+ and 37 NG patients underwent surgery. RESULTS: A very high prevalence of suspicious/malignant cytology (Thy 4-5) at the first diagnosis (38/124; 31%) and during the follow-up (6/28; 22%) was found in HTN+ group. In HTN- group, 22/130 (17%) patients developed TN, but none showed malignant features during the follow-up. HTN+ patients had higher prevalence of Thy 4-5 (44/152 = 28.9%) compared to NG patients (12/161 = 7.4%, p < 0.0001). Increased independent odds ratio (OR) for malignancy was conferred by serum TSH > 1.0 µUI/ml, [OR 1.93, 95% confidence interval (CI) 1.41-2.64, p < 0.0001], male sex (OR 3.44, CI 1.48-8.02, p = 0.004) and HT (OR 3.14; CI 1.08-9.31, p < 0.05). Malignant histology (mostly PTC) was confirmed higher in HTN+ (48/70, 68.6%) compared to NG (15/37, 40.5%; p < 0.05). Higher prevalence of extrathyroidal infiltration (24/48, 50%) and vascular invasion (25/48, 52%) was found in HTN+ vs NG (2/15, 1.3% p < 0.01), (3/16, 1.8% p < 0.05), respectively. CONCLUSIONS: This study confirms higher prevalence of suspicious/malignant cytology and PTC at histology in nodular HT compared to NG, without evidence of malignancy in non-nodular HT patients during the follow-up.

Pseudoangiomatous stromal hyperplasia (PASH) presenting as axillary lump: case report and review of the literature.

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign mesenchymal breast lesion. There are extremely rare reports of PASH arising in accessory breast tissue. To date, in literature, fewer than 10 cases of PASH occurring in axillary region have been described. We report a case presenting as axillary lump in a young woman. A 20-year-old female presented to our surgical unit for a progressively growing and painful palpable mass of the right axilla for about a year. Before surgery an ultrasound was performed. The patient underwent local excision of the lesion under local anaesthesia. Through histological and immunohistochemical examination a pseudoangiomatous stromal hyperplasia (PASH) was diagnosed. At 6 months of followup the patient is free of disease. It is important to include PASH also in the differential diagnosis of axillary lumps. Histological examination of the surgical specimen and surgery represent, respectively, the mainstay for diagnosis and therapy.

Primary thyroid leiomyosarcoma: a case report and review of the literature.

Primary thyroid leiomyosarcoma (LMS) is an extremely rare tumor. We report a case of a 47-year-old male with a rapidly growing neck mass and disfagia. Preoperative investigations were diagnostic of anaplastic carcinoma. Total thyroidectomy with partial esophagectomy and dissection of right infrahyoid muscles was performed. Through histolological and immunohistochemical evaluations a primary thyroid high-grade LMS was diagnosed. At 2 months of follow-up a local recurrence was detected and consequently the patient was submitted to chemotherapy with partial response. He is still alive 9 months after surgery. Diagnosis of primary thyroid LMS is difficult due to its similarity to other more common thyroid tumors. To date, there is no standard therapy and prognosis is poor.

Gastric paraganglioma: case report and review of the literature.

Very few cases of gastric paragangliomas have been reported in the literature to date. We report a rare case of parietal gastric paraganglioma fortuitously detected during intraoperative exploration. A 82-years-old woman presented to our emergency room for abdominal pain. On physical examination abdomen was painful on palpation and Blumberg's sign was present. The laboratory exams showed a neutrophilia in absence of leukocytosis. Acute appendicitis was suspected and a laparoscopy was performed. At exploration, the vermiform appendix was normal while a lumpy, hard-fibrous and white-pinkish extraluminal lesion of the anterior wall of the gastric body near the greater curvature of about 2 cm in diameter was present. Laparoscopic resection of the gastric lesion was performed. The patient was discharged in good condition in the fourth postoperative day. Pathologic examination revealed a gangliocitic paraganglioma. The patient is alive and well without evidence of relapse 6 months after surgery. Gastric paraganglioma is a very rare tumor and its diagnosis is very difficult. Surgical excision is the treatment of choice which can be performed successfully with laparoscopy.

Surgical management of gynecomastia: experience of a general surgery center.

AIM: Gynecomastia is a common finding in male population of all ages. The aim of our study was to present our experience and goals in surgical treatment of gynecomastia. PATIENTS AND METHODS: Clinical records of patients affected by gynecomastia referred to our Department of Surgery between September 2008 and January 2015 were analyzed. 50 patients were included in this study. RESULTS: Gynecomastia was monolateral in 12 patients (24%) and bilateral in 38 (76%); idiopathic in 41 patients (82%) and secondary in 9 (18%). 39 patients (78%) underwent surgical operation under general anaesthesia, 11 (22%) under local anaesthesia. 3 patients (6%) presented recurrent disease. Webster technique was performed in 28 patients (56%), Davidson technique in 16 patients (32%); in 2 patients (4%) Pitanguy technique was performed and in 4 patients (8%) a mixed surgical technique was performed. Mean surgical time was 80.72±35.14 minutes, median postoperative stay was 1.46±0.88 days. 2 patients (4%) operated using Davidson technique developed a hematoma, 1 patient (2%) operated with the same technique developed hypertrophic scar. CONCLUSIONS: Several surgical techniques are described for surgical correction of gynecomastia. If performed by skilled general surgeons surgical treatment of gynecomastia is safe and permits to reach satisfactory aesthetic results.

Unexpected post-operative diagnosis of primary rectal melanoma. A case report.

AIM: Anorectal melanoma (ARM) is a very uncommon and highly lethal malignancy. Due to its rarity and non-specific symptoms, preoperative diagnosis may be often erroneous and subsequent treatment inappropriate. We report a case of primary rectal melanoma and discuss the current diagnostic and therapeutic challenges. CASE REPORT: An 87-year-old man was admitted to our surgical unit with a history of progressive constipation, tenesmus, rectal bleeding and transanal mucous discharge. Preoperative investigations, including CT scan and colonoscopy with biopsy, were suggestive for locally advanced low rectal sarcoma and therefore the patient underwent abdominoperineal resection (APR). However, histopathological examination and immunohistochemistry resulted in a postoperative diagnosis of primary rectal melanoma. The patient died 6 months later due to local and systemic recurrence. CONCLUSION: ARM should always be considered when unusual anorectal lesions are discovered. Regardless of the pathological stage and the extent of surgery, prognosis of ARM remains poor. Thus, whenever feasible, wide local excision is now the preferred treatment, since it is associated with lower postoperative morbidity and better quality of life compared to APR. In our case, although the initial diagnosis was incorrect, APR was justified by the local invasiveness and large size of the tumor.

Guidelines for improvement of the procedural aspects of devices and surgical instruments in the operating theatre.

Surgical site infections are a major complication for patients undergoing surgical treatment and a significant cause of mortality and morbidity. Many international guidelines suggest measures for the prevention of surgical site infections (SSI) in perioperative processes and the decontamination of surgical devices and instruments. This document proposes guidelines for improving the perioperative setting in view of the devices and instrumentation required for surgical procedures, aiming to reduce contamination rates and improve clinical performance and management for patients undergoing surgical treatment. This document is intended for doctors, nurses and other practitioners involved in operating theatre procedures, resource management and clinical risk assessment processes, and the procurement, organisation, sterilisation and reprocessing of surgical instruments.

Optimisation of perioperative procedural factors to reduce the risk of surgical site infection in patients undergoing surgery: a systematic review.

Surgical site infections (SSI) are the leading cause of hospital readmission after surgical procedures with significant impact on post-operative morbidity and mortality. Modifiable risk factors for SSI include procedural aspects, which include the possibility of instrument contamination, the duration of the operation, the number of people present and the traffic in the room and the ventilation system of the operating theatre.The aim of this systematic review was to provide literature evidence on the relationship between features of surgical procedure sets and the frequency of SSI in patients undergoing surgical treatment, and to analyse how time frames of perioperative processes and operating theatre traffic vary in relation to the features of the procedure sets use, in order tooptimise infection control in OT. The results of the systematic review brought to light observational studies that can be divided into two categories: evidence of purely clinical significance and evidence of mainly organisational, managerial and financial significance. These two systems are largely interconnected, and reciprocally influence each other. The decision to use disposable devices and instruments has been accompanied by a lower incidence in surgical site infections and surgical revisions for remediation. A concomitant reduction in post-operative functional recovery time has also been observed. Also, the rationalisation of traditional surgical sets has also been observed in conjunction with outcomes of clinical significance.

Management of surgical diseases of thyroid gland indications of the United Italian Society of Endocrine Surgery (SIUEC).

A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health­care management protocol in thyroid surgery published in 2016, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 13 members of the SIUEC highly trained and experienced in thyroid surgery. The main topics concern clinical evaluation and preoperative workup, patient preparation for surgery, surgical treatment, non-surgical options, postoperative management, prevention and management of major complications, outpatient care and follow-up.

Secondary lipofilling after breast reconstruction with implants.

BACKGROUND: Several Authors have reported on the use of lipoinjection as a low-risk and low-morbidity procedure that gives good results for the correction of soft-tissue defects. AIM: The purpose of this study was to review our caseload of fat grafting after breast reconstruction with prosthesis. PATIENTS AND METHODS: Between January 2008 and December 2011, 20 patients were treated for breast asymmetries with secondary autologous fat injection after nipple-sparing, skin-sparing and skin-reducing mastectomies breast reconstruction in our Departments. Exclusion criteria was postoperative radiotherapy. In order to assess aesthetic satisfaction, patients and an independent plastic surgeon filled an evaluation form (VAS = 1-10) preoperatively one and six months after surgery. RESULTS: In postoperative days no major complications occurred. Donor sites looks completely healthy and no scars were evident. The average values of aesthetic satisfaction in patients (VAS) were 5.2 (range 3-7) preoperatively, 7.9 (range 5-9) one month post-operatively and 7.2 six months postoperatively (range 5-9). Values reported by the surgeon team were an average of 4.9 (range 4-6) preoperatively, 7.6 after one month (range 6-9) and 7.1 after six months (range 5-9). CONCLUSIONS: Acquired contour deformities of the reconstructed breast are relatively common and independent from the technique used. Therefore, they present a frequent therapeutic challenge to reconstructive surgeons. Lipomodelling offers an "easy to perform" and predictable cosmetic solution to these patients. An objective examination of aesthetic results, in addition to our clinical analysis shows a significant improvement of cosmetic outcomes; moreover, all patients were satisfied for their final appearance.

Intraoperative parathyroid hormone assay during focused parathyroidectomy for primary hyperparathyroidism: is it really mandatory?

AIM: Intraoperative parathyroid hormone (PTH) assay has become an essential tool in focused parathyroid surgery. The aim of this study was to evaluate the present role of intraoperative PTH monitoring during focused parathyroidectomy for primary hyperparathyroidism in our experience. METHODS: One hundred sixty-one patients were submitted to focused parathyroidectomy with rapid intraoperative Parathyroid hormone assay monitoring. RESULTS: A >50% decrease of PTH occurred in 147 patients (91.3%); in this group persistent hypercalcemia was found in 1; in the remaining 14 (8.7%) values of PTH decreased less than 50% and bilateral neck exploration was performed. An additional pathologic parathyroid was removed in 8 cases, a third in one; in the other five further neck exploration was negative and in four of these persistent postoperative hypercalcemia was demonstrated. In 136 patients >50% decrease of PTH was obtained after 10 minutes, in the other 11 after 20. The overall operative success of the patients was 96.9% with a 5.6% incidence of multiglandular disease. Intraoperative parathormone monitoring changed the operative management in 8.7% of cases. Intraoperative parathormone monitoring was accurate in predicting operative success or failure in 98.7% of patients, with a sensitivity of 99.3%, a specificity of 92.8%, a positive predictive value of 99.3% and a negative predictive value of 92.8%. DISCUSSION AND CONCLUSION: The measurement of intraoperative PTH represents a useful tool to assist the surgeon during parathyroid surgery and its routine use significantly improves cure rates of focused parathyroidectomy. We believe that the use intraoperative PTH is still mandatory in focused parathyroidectomy avoiding relapses and consequent reintervention.

Risk factors in reoperative thyroid surgery for recurrent goitre: our experience.

AIM: Reoperative thyroid surgery is an uncommon operation associated with a higher complication rate; we reviewed our series of patients on whom reoperative thyroid surgery was performed. METHOD: 106 patients had a thyroid reoperation for recurrent multinodular goiter (93 patients), recurrent thyrotoxicosis (3) or suspected malignancy (10); bilateral completion thyroidectomy was performed in 68 cases, lobectomy in 36, removal of a mediastinal recurrence and of a pyramidal remnant in 1 patient respectively. RESULTS: Temporary hypoparathyroidism occurred in 41 patients (38.67%), definitive in 7 (6.6%), transient recurrent laryngeal nerve palsy in 5 (4.71%), permanent nerve palsy in 1 (0.94%); in 3 cases (2.83%) surgical revision of haemostasis was necessary for postoperative haemorrhage. After monolateral surgery we had 13 cases of transient hypoparathyroidism (34.21%), 2 of definitive (5.26%) and 1 transient recurrent laryngeal nerve palsy (2.63%); after bilateral surgery we had 29 cases of transient hypoparathyroidism (42.64%), 5 of definitive (7.35%), 4 of transient recurrent laryngeal nerve palsy (5.88%), 1 of definitive (1.47%) and 3 of postoperative bleeding (4.41%). CONCLUSIONS: Reoperative thyroid surgery is a technical challenge with a high incidence of complications. Scarring, edema and friability of the tissues together with distortion of the landmarks make reoperative surgery hazardous. A higher risk of complications is described when previous surgery has been performed on both sides. Total thyroidectomy should be considered the procedure of choice for benign multinodular goiter eliminating the potential of a reoperation. Whenever necessary, reoperative thyroidectomy may be performed safely with little morbidity in experienced hands.

Isolated inguinal endometriosis. Case report with ultrasonographic preoperative diagnosis.

Inguinal endometriosis is rare and accounts for 0.3-0.6% of patients affected by endometriosis. A correct preoperative diagnosis is rare. Diagnosis is frequently made by histologic examination. A 36-year-old nulliparous woman presented with a painful mass in her right groin of 2 years duration. The pain fluctuated according to the menstrual period. Physical examination revealed an elastic hard mobile mass measuring 2 x 2 cm in the right inguinal region. Ultrasound examination confirmed a hypoechoic tumor in the right inguinal region with poorly defined boundaries and perilesional and intralesional vascular flow suspect for endometriosis. Wide excision of the lump with a part of the round ligament was carried out. Histology showed endometrial glands and stroma within the fibrous tissue. The patient had an uneventful recovery and was discharged the next day. After surgery, the pain disappeared completely. No signs of recurrence occurred at approximately 16 months after the surgery. Although rare, extrapelvic endometriosis should be considered in the differential diagnosis in women of reproductive age presenting with an inguinal mass, especially if the groin mass is associated in size and tenderness with menstrual variability. US appearance is very useful in diagnosis so ultrasonography can be considered the examination of choice.

Hemithyroidectomy versus total thyroidectomy in the intermediate-risk differentiated thyroid cancer: the Italian Societies of Endocrine Surgeons and Surgical Oncology Multicentric Study.

The surgical treatment of the intermediate-risk DTC (1-4 cm) remains still controversial. We analyzed the current practice in Italy regarding the surgical management of intermediate-risk unilateral DTC to evaluate risk factors for recurrence and to identify a group of patients to whom propose a total thyroidectomy (TT) vs. hemithyroidectomy (HT). Among 1896 patients operated for thyroid cancer between January 2017 and December 2019, we evaluated 564 (29.7%) patients with unilateral intermediate-risk DTC (1-4 cm) without contralateral nodular lesions on the preoperative exams, chronic autoimmune thyroiditis, familiarity or radiance exposure. Data were collected retrospectively from the clinical register from 16 referral centers. The patients were followed for at least 14 months (median time 29.21 months). In our cohort 499 patients (88.4%) underwent total thyroidectomy whereas 65 patients (11.6%) underwent hemithyroidectomy. 151 (26.8%) patients had a multifocal DTC of whom 57 (10.1%) were bilateral. 21/66 (32.3%) patients were reoperated within 2 months from the first intervention (completion thyroidectomy). Three patients (3/564) developed regional lymph node recurrence 2 years after surgery and required a lymph nodal neck dissection. The single factor related to the risk of reoperation was the histological diameter (HR = 1.05 (1.00-1-09), p = 0.026). Risk stratification is the key to differentiating treatment options and achieving better outcomes. According to the present study, tumor diameter is a strong predictive risk factor to proper choose initial surgical management for intermediate-risk DTC.

[New techniques in parathyroid surgery]. / Nuove Tecniche nella chirurgia delle paratiroidi.

The diseases of parathyroid glands have assumed a growing importance for innovations in diagnosis and surgery which have enabled a more precise identification and therapy. Use of Sesta-MIBI scintigraphy allows a correct localization of the adenoma; the introduction of intraoperative monitoring of intact parathyroid hormone made possible unilateral neck exploration with a mini-incision above the adenoma. The emergence of videotechnology has led the innovation of endoscopic parathyroidectomy, realized for the first time in 1996 and subsequently performed without the use of CO2. Currently, the SPECT scintigraphy allows a three-dimensional vision of the adenoma and is the more precise localization study, allowing to use mini-invasive access. Prerequisite for the use of minimally invasive techniques is the determination of intraoperative PTH, possible with various techniques. Our experience is based on 135 patients undergoing parathyroidectomy in the last 8 years with 5 cases of persistent hyperparathyroidism submitted to reoperation, an average hospital stay of 2 days and only 6 complications (1 bleeding and 5 temporary hypoparathyroidisms). The use of new technologies in parathyroid surgery can achieve optimal results, a better cosmetic result and quicker postoperative recovery, with a low incidence of recurrence and complications.

Porencephaly and Periventricular Encephalitis in a 4-month-old Puppy: Detection of Canine Parvovirus Type 2 and Potential Role in Brain Lesions.

A 4-month-old puppy died after showing intracranial signs a few days after a suspected viral enteritis. Grossly, the right cerebral hemisphere had a large irregular cavity external to the internal capsule. Histopathological examination revealed a cystic lesion in the right hemisphere and non-suppurative inflammation of the diencephalon and periaqueductal nervous tissue. Porencephaly associated with periventricular non-suppurative encephalitis was diagnosed. A nested polymerase chain reaction (PCR) identified the presence of parvovirus DNA in the brain and real-time PCR typed this as canine parvovirus (CPV) type 2a. Immunohistochemistry revealed the presence of CPV antigen in the cytoplasm of scattered cells in the subependymal layers and choroid plexus epithelium. The porencephaly was not associated with inflammatory lesions or CPV antigen and was considered to have preceded the neurological signs. In contrast, the detection of CPV antigen in the subependymal layers and choroid plexus epithelium supported the association of this virus with the periventricular encephalitis.

Tentacle-shaped mesh for fixation-free repair of umbilical hernias.

PURPOSE: Mesh fixation and broad overlap represent an open issue in umbilical hernia repair. A proprietary-designed implant with tentacle straps at its boundary has been developed to ensure a suture-free repair and a broader coverage of the abdominal wall. The study describes the results of umbilical hernia procedures carried out with the tentacle-shaped implant and the related surgical technique. METHODS: A proprietary tentacle-shaped flat mesh having a central body with integrated radiating arms at its edge was used to repair large umbilical hernias in 62 patients. The implant was placed in preperitoneal sublay. The friction of the straps, crossing the abdominal wall thanks to a special needle passer, was intended to assure adequate grip to hold the implant in place assuring a fixation-free procedure and broad overlap of the hernia defect. RESULTS: In a mean follow-up of 48 months (range 10-62 months), 4 seromas and 2 ischemia of the navel skin occurred. No infections, hematomas, chronic pain, mesh dislocation, or recurrence has been reported. CONCLUSIONS: The tentacle strap system of the prosthesis effectively ensured an easier implant placement avoiding the need for suturing the mesh. The arms of the implant ensured a proper orientation and stabilization of the mesh in association with a broad defect overlap. The specifically developed surgical procedure showed a quick postoperative recovery, a very low complication rate, and no recurrences even in the long term.

Lipoma of the fossa femoralis mimicking a femoral hernia. Report of 2 cases.

INTRODUCTION: Lipoma of the femoral fossa is uncommon. Often asymptomatic, femoral lipoma may growth within the circumscribed space of the femoral fossa causing pain and discomfort. A worsening pain caused by a lipomatous mass in the femoral area is a clinical feature that can mislead the diagnosis, resembling the more common condition of femoral hernia. METHODS: Two cases of symptomatic lipomas of the femoral fossa mimicking an incarcerated femoral hernia are presented. In both, Caucasian female, patients clinical examination and ultrasound of the femoral region revealed a painful neoplasm suspected for incarcerated femoral hernia. RESULTS: Intraoperatively, a mass of encapsulated fat arising from the bottom of the fossa femoralis was found. No visceral protrusion through the femoral ring could be documented. The neoplasms were removed in toto. Histology of the excised specimens evidenced the diagnosis of femoral lipomas suffering by chronic compressive damages. In a midterm postoperative follow up, both patients were symptom- free. DISCUSION: A correct preoperative diagnosis of femoral lipoma is challenging, even following an accurate diagnostic pathway. The cases highlighted herewith seem to confirm that lipoma of the femoral fossa can be mistaken with a femoral hernia. CONCLUSIONS: The clinical and histological features evidenced could result helpful in the differentiation of a lipomatous mass of the femoral fossa from a genuine femoral hernia.