VEGF-D and A Preoperative Serum Levels Predict Nodal and Distant Metastases in Differentiated Thyroid Cancer Patients.

BACKGROUND: Preoperative tumor aggressiveness biomarkers may help surgeons decide the extent of an operation. However, whether serum angiogenetic factors can be used to predict the prognosis of patients with differentiated thyroid cancer is still unclear. METHODS: Seventy-six DTC patients were prospectively recruited. Preoperative serum samples were collected and measured for Tie-2, Ang-1, Ang-2, VEGF-A, and VEGF-D levels. The potential correlations between their serum levels and clinicopathologic features as well as their prognoses were analyzed. RESULTS: Older age (>45 years old) and higher VEGF-A serum levels were independent predictors of extrathyroidal extension. The VEGF-D serum level was an independent factor for lymph node metastases and VEGF-A was an independent factor for distant metastases. None of these serum angiogenetic factors were significantly different between patients who were disease free and those with recurrences. The presence of lymph node metastases was the only independent factor for recurrence over the 2-year follow-up. CONCLUSION: Preoperative serum VEGF-A and VEGF-D levels were significantly elevated in DTC patients with distant and lymph node metastases. These findings, when combined with other clinicopathological factors, may help in surgical decisions.

High-level expression of CXCR4 in breast cancer is associated with early distant and bone metastases.

Metastasis is the most life-threatening complication in all cancers. The chemokine receptor 4 (CXCR4) is expressed at high levels in many breast-cancer tumors and may modulate metastasis. We compared the time-to-metastasis and the sites of metastasis between breast-cancer tumors expressing CXCR4 at high or low levels. We enrolled 191 early breast cancer patients in our study. The expression of CXCR4 was evaluated using immunohistochemical staining, and the patients were divided into low-level (CXCR4-) and high-level (CXCR4+) CXCR4 expression groups. Associations between the patients' level of CXCR4 expression and their basic clinical characteristics, time-to-metastasis, and metastatic sites were examined using a Cox proportional-hazards regression model. A total of 107 CXCR4+ patients (56 %) were identified. No statistical differences were evident in basic characteristics between the CXCR4+ and CXCR4- groups. The CXCR4+ group had a higher incidence of distant metastasis during the first year (10.3 % versus 1.1 %, P = 0.009) and shorter event-free survival (17.43 months versus 27.5 months, P = 0.026) than those of the CXCR4- group. The CXCR4+ group also had a higher incidence of bone metastasis (P = 0.008) than the CXCR4- group. No significant difference in metastasis sites in other organs was observed between the two groups. A high level of CXCR4 expression in breast cancer is associated with early distant and bone metastases. The CXCR4+ phenotype may be a useful predictor for the prevention of early treatment failure and bone metastasis in breast cancer patients. This retrospective study shows that a high expression of CXCR4 in breast cancer is associated with earlier distant metastasis and bone metastasis in breast cancer.

Modified LigaSure hemorrhoidectomy for the treatment of hemorrhoidal crisis.

PURPOSE: This study aimed at reporting a modified LigaSure technique for the treatment of acute hemorrhoidal crisis. METHODS: Consecutive patients with an acute hemorrhoidal crisis received a modified LigaSure hemorrhoidectomy. After removing the hemorrhoidal tissues above the welding line, scissors were used to undermine the anoderm to excise residual thrombosed hemorrhoidal tissue. The wound was approximated with a continuous 4-0 vicryl suture. RESULTS: Forty patients (mean age, 47.5 years; range 22.0-76.0 years) were included. The mean duration of the crisis, length of the operation, and follow-up were 2.0 days (range 1.0-5.0 days), 35.6 min (range 15.0-60.0 min), and 13.2 months (range 6-24 months), respectively. At the final follow-up, all patients were continent and there were no cases with anal stenosis, recurrent bleeding, prolapse, or thrombus. The mean pain score before surgery was 8.3, and was 4.4 and 3.2 on postoperative days 1 and 7, respectively. Complications within 30 days of surgery included two cases of urine retention, two cases bleeding, one wound infection and one case of fecal impaction, which all resolved with conservative treatment. The only late complication was one case of residual skin tags. CONCLUSIONS: The modified LigaSure hemorrhoidectomy offers rapid pain relief, early recovery, and low morbidity for patients with an acute hemorrhoidal crisis.

Comparison of safety, efficacy, and patient satisfaction with thermal ablation versus endoscopic thyroidectomy for benign thyroid nodules in a propensity-matched cohort.

BACKGROUND: Thyroid nodules (TNs) often require intervention due to symptomatic or cosmetic concerns. Radiofrequency ablation (RFA) has shown promise as a treatment option, offering potential advantages without neck scars. Recently, the scarless treatment alternative of transoral endoscopic thyroidectomy vestibular approach (TOETVA) has emerged. When surgery can be performed in a scarless manner, it remains unclear whether ablation is still the preferred treatment choice. This study aims to compare the safety, efficacy, and patient satisfaction of RFA and TOETVA. STUDY DESIGN: A retrospective data analysis was conducted on patients treated with RFA or TOETVA for unilateral benign TNs between December 2016 and September 2021. Propensity score matching was employed to create comparable groups. Various clinicopathologic parameters, treatment outcomes, and costs were assessed. RESULTS: Of the 2814 nonfunctional thyroid nodules treated during this period, 642 were benign and unilateral. A total of 121 and 100 patients underwent thermal ablation and transoral endoscopic thyroidectomy, respectively. After matching, 84 patients were selected for each group. Both RFA and TOETVA demonstrated low complication rates, with unique complications associated with each procedure. Treatment time (30.8±13.6 vs. 120.7±36.5 min, P <0.0001) was shorter in the RFA group. Patient satisfaction (significant improvement: 89.3% vs. 61.9%, P <0.0001) and cosmetic results (cosmetic score 1-2: 100.0% vs. 54.76%, P <0.0001) favored TOETVA. RFA was found to be less costly for a single treatment, but the cost of retreatment should be considered. The histological diagnoses post-TOETVA revealed malignancies in 9 out of 84 cases, underscoring the significance of follow-up assessments. CONCLUSION: Scarless procedures, RFA and TOETVA, are effective for treating unilateral benign TNs, each with unique advantages and drawbacks. While RFA is cheaper for a single treatment, TOETVA offers superior cosmetic results and patient satisfaction. Further research is needed to evaluate long-term safety and cost-effectiveness. It is crucial to remain vigilant about the possibility of malignancy despite benign cytology pre-treatment.

Synergic evacuation device helps smoke control during endoscopic thyroid surgery.

BACKGROUND: Surgical plumes in small cavities, such as transoral endoscopic thyroid surgery, have never been satisfactorily resolved. We aimed to study the use of a smoke evacuation system and evaluate its efficacy, including the field of view and operating time. STUDY DESIGN: We retrospectively reviewed 327 consecutive patients who underwent endoscopic thyroidectomy. They were separated into 2 groups based on whether the smoke evacuation system was used. To reduce the possible experience bias, only patients 4 months before and after implementing the evacuation system were included. Recorded endoscopic videos were evaluated, including the field of view, the incidence of scope clearance, and time spent during air-pocket creation. RESULTS: Overall, there were 64 patients with a median age of 43.59 years and a median body mass index of 22.87 kg/m2, including 54 women, 21 thyroid cancers, and 61 hemithyroidectomies. The operative duration was comparable between the groups. The group where the evacuation system was used scored more as good in terms of endoscopic views (8/32, 25% vs 1/32, 3.13%, P = .01), fewer incidences of endoscope lens pull out for clearance (3.5 vs 6.0 times, P < .01), less time for clear view after energy device activation (2.67 vs 5.00 seconds, P < .01), and less time spent (8.67 vs 12.38 minutes, P < .01) during air-pocket creation. CONCLUSION: In conjunction with the synergy function of energy devices, evacuators enhance the field of view and optimize the time spent in the real clinical setting of low-pressure and small-space endoscopic thyroid procedures, in addition to the benefit of reducing smoke harm.

Synchronous adenocarcinomas of the colon presenting as synchronous colocolic intussusceptions in an adult.

Intussusception is uncommon in adults. To our knowledge, synchronous colocolic intussusceptions have never been reported in the literature. Here we described the case of a 59-year-old female of synchronous colocolic intussusceptions presenting as acute abdomen that was diagnosed by CT preoperatively. Laparotomy with radical right hemicolectomy and sigmoidectomy was undertaken without reduction of the invagination due to a significant risk of associated malignancy. The final diagnosis was synchronous adenocarcinoma of proximal transverse colon and sigmoid colon without lymph nodes or distant metastasis. The patient had an uneventful recovery. The case also emphasizes the importance of thorough exploration during surgery for bowel invagination since synchronous events may occur.

Transcutaneous Laryngeal Ultrasonography for Assessing Vocal Cord Twitch Response in Thyroid Operation during Predissection Vagus Nerve Stimulation.

BACKGROUND: In this study, we aimed to report our experience with the use of intraoperative transcutaneous laryngeal ultrasonography (TLUSG) to evaluate the vocal cord twitch response during predissection vagus nerve stimulation in thyroid surgeries and examine the reliability of this technique when compared with that of laryngeal twitch palpation (LTP). STUDY DESIGN: The prospective data collection of consecutive patients who underwent open thyroidectomy with intraoperative neuromonitoring (IONM) was reviewed retrospectively. We recorded the electromyographic activity and assessed the vocal cord twitch response on LTP, TLUSG. We compared the accessibility, sensitivity, and specificity of the techniques. RESULTS: A total of 110 patients (38 men and 72 women) with 134 nerves at risk were enrolled. The vocal cord was assessable by TLUSG in 103 (93.6%) patients and by LTP in 64 (59.1%) patients. Two patients showed negative predissection IONM signal but positive on TLUSG and the presence of laryngeal twitch response confirmed by laryngoscopy. Fourteen patients showed positive IONM signals and presence of the vocal cord twitch response on TLUSG but not on LTP. The sensitivity and specificity were 70.21% and 100%, respectively, for LTP, and those both were 100% for TLUSG. For patients who could be assessed using both techniques, TLUSG had better accuracy than LTP (100% vs 80.33%, p = 0.0005). CONCLUSIONS: The innovative intraoperative application of TLUSG is better for evaluating the laryngeal twitch response than LTP. This technique provides practical troubleshooting guidance for patients with no IONM signals during predissection vagus nerve stimulation.

Serum vascular endothelial growth factor-D levels correlate with cervical lymph node metastases in papillary thyroid carcinoma.

The aim of this multicenter study was to evaluate the clinical relevance of serum vascular endothelial growth factor-D (VEGF-D) in papillary thyroid carcinoma (PTC). This prospective study consisted of 74 patients with primary PTC and 15 patients with benign thyroid nodules treated from 2008 to 2009. VEGF-D concentration was compared with patient clinicopathologic features and lymph node metastases. There was no significant difference in mean serum VEGF-D levels between the PTC and benign thyroid nodule groups. Within the PTC group, serum VEGF-D levels were significantly higher in patients with lymph node metastases than in patients without metastases (241.92 vs. 213.89 pg/ml, respectively; P = 0.035). Receiver operating characteristic curve analysis revealed that preoperative serum VEGF-D levels were predictive of lymph node metastases in the patients >45 years. Serum VEGF-D level that was correlated with the presence of cervical lymph node metastases in PTC patients might be a useful prognostic indicator.

Preoperative Serum Macrophage Migration Inhibitory Factor Level Correlates with Surgical Difficulty and Outcome in Patients with Autoimmune Thyroiditis.

Surgical treatment for autoimmune thyroid disease is theoretically risky due to its chronic inflammatory status. This study aimed to investigate the correlation between preoperative serum migration inhibitory factor (MIF) levels and the difficulty of thyroidectomy in patients with autoimmune thyroiditis. Forty-four patients (average age: 54 years) were prospectively recruited: 30 with autoimmune thyroiditis and 14 with nodular goiter. Preoperative serum samples were collected to measure MIF levels. The difficulty of thyroidectomy was evaluated using a 20-point thyroidectomy difficulty scale (TDS) scoring system. The potential correlations between MIF levels and clinicopathological features as well as postoperative complications were analyzed. Preoperative serum thyroid-stimulating hormone (TSH), TSH receptor antibody, thyroid peroxidase antibodies levels, TDS score, and serum MIF levels were significantly higher in the autoimmune thyroiditis group than those in the goiter group. MIF levels were significantly associated with postoperative transient recurrent laryngeal nerve injury and hypoparathyroidism. MIF levels were positively correlated with TDS score, operation time, and blood loss in the autoimmune thyroiditis group. Increased preoperative serum MIF levels are associated with higher TDS scores, operation time, blood loss, and postoperative complications. Preoperative serum MIF level may be a useful predictor of difficult thyroidectomy and help surgeons provide better preoperative management.

Practice Patterns and Learning Curve in Transoral Endoscopic Thyroidectomy Vestibular Approach With Neuromonitoring.

Objectives: Intraoperative neuromonitoring has not been routinely applied in early experience with the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Because the preparation and surgical interventions are much different from conventional thyroidectomies, most endocrine surgeons willing to adapt to TOETVA lack access to information regarding the practice pattern and proficiency in the learning curve. We aimed to investigate the outcomes and to define the learning curve for TOETVA in this study. Methods: A retrospective analysis was used on patients who underwent TOETVA at our hospital between December 2016 and July 2019. The cumulative sum graphic model was used to implement the learning curve as a surrogate for procedural proficiency. Results: The 119 patients had a mean age of 44.65 years and a mean body mass index of 22.49 k/m2, including 107 women, 20 thyroiditis, and 106 hemithyroidectomy. The learning curve revealed two phases, an initial (35 cases) and a mature (84 cases) phase, for surgeons based on operation time (144.2 vs. 114.2 min, p = 0.0001). There were more bilateral thyroidectomies (15.5% vs. 0, p = 0.0100), larger indicated nodules (6.06 cm3vs. 3.32 cm3, p = 0.0468), or larger thyroids to resect (16.38 cm3vs. 8.75 cm3, p = 0.0001) in the mature phase. Procedure-related complications decreased significantly in the mature phase in comparison to the initial phase (3.57% vs. 31.43%, p = 0.0001). Conclusions: The learning curve of TOETVA with neuromonitoring is 35 cases. With the accumulation of proficiency, the indications will expand. Step-by-step improvements from the experience of each case can reduce procedure-related complications.

Comparison of surgical outcome between conventional open thyroidectomy and endoscopic thyroidectomy through axillo-breast approach.

OBJECTIVE: Minimally invasive thyroidectomy can be categorized into either video-assisted method or remote access thyroidectomy (RAT). Although RAT provided excellent cosmetic results, some debate about the advantages and disadvantages remains in different countries. Thus, this study aimed to compare the surgical results between endoscopic thyroid surgery and conventional thyroidectomy. MATERIALS AND METHODS: The study retrospectively reviewed the conventional and endoscopic thyroidectomy performed at our institution from September 2011 to July 2012. Overall, 30 patients were recruited for this study. The patients were divided into two groups: Group O (open group, n = 15) and Group E (endoscopic group, n = 15). Postoperative outcomes (including wound pain, swallowing disturbance, and chest wall paresthesia) and complications were analyzed and assessed. RESULTS: The endoscopic group was associated with longer operation time and hospital stay. The visual analog scale (VAS) score of surgical wound pain was significantly higher in the open group in 1-week postoperation. However, the VAS score of swallowing disturbance was significantly higher in the endoscopic group in 1-week postoperation. More than half of the patients (53%) had chest wall paresthesia within 1-month postoperation in the endoscopic group. No surgical complications occurred in both groups. CONCLUSION: Although endoscopic thyroidectomy provides excellent cosmetic results in thyroid surgery, higher immediate postoperative pain, and prolonged chest wall paresthesia compared with those in conventional surgery are a concern and warrant careful patient selection.

Diffuse FDG uptake in acute prostatitis.

Whole body bone scan and abdominal computed tomography (CT) of a 77-year-old man with intractable back pain revealed a destructive bone lesion in the lumbar spine. The F-18 FDG PET/CT scan, performed under the impression of an unknown primary cancer, showed diffusely intense FDG uptake in the enlarged prostate and mild FDG uptake in the lumbar spine. The patient had pyuria and mild fever during admission. Laboratory findings showed elevation of the serum prostate specific antigen (95.69 ng/ml). Blood culture yielded Klebsiella pneumoniae. The prostate biopsy showed acute inflammation with no malignancy and the lumbar spine biopsy showed chronic osteomyelitis.

Results of 666 consecutive patients treated with LigaSure hemorrhoidectomy for symptomatic prolapsed hemorrhoids with a minimum follow-up of 2 years.

BACKGROUND: Our aim is to report the outcomes of hemorrhoidectomy performed via LigaSure™ with a minimum follow-up of 2 years. METHODS: A total of 666 patients underwent hemorrhoidectomy for symptomatic prolapsed hemorrhoids (grade III and IV) via LigaSure between June 2006 and June 2008. Patient demographic and operative data were collected and analyzed. RESULTS: The mean patient age was 45.4 ± 11.1 years (x ± SD; range, 22-77), and approximately 72% had grade III hemorrhoids. All procedures were performed without complications. The operative time was 18.7 ± 4.1 minutes (range, 9-43), and hospital stay was 1.5 ± 0.6 days (range, 1-4). There was no immediate postoperative bleeding or other procedure-related complications. Twelve (1.8%) patients required urinary catheterization for a maximum of 1 day, and 21 (3.2%) patients had delayed postoperative bleeding. Most cases of bleeding resolved spontaneously; 3 patients (0.4%) required reoperation. A total of 645 patients (96.6%) responded to a follow-up telephone interview at a mean of 36 months (range, 24-49) after hemorrhoidectomy. After 1 year postoperatively, 2 patients received additional excisions for residual skin tags, 1 was treated for an anal stricture, 1 was treated for an anal fistula, and 3 were treated for anal fissures. Minor incontinence (flatus) was present in 11 (1.7%) patients, and 13 (2.0%) experienced mild bleeding caused by residual hemorrhoids; 1 patient underwent rubber-band ligation, and the others were successfully treated medically. No recurrent prolapse or persistent anal pain occurred during the follow-up period. The overall recurrence rate at 2-years follow-up was 3.1%. CONCLUSION: The long-term recurrence rate after hemorrhoidectomy with LigaSure is low and comparable with conventional hemorrhoidectomy.

Single-incision laparoscopic surgery using a homemade transumbilical port for synchronous colon and hepatic lesions: a case report.

Single-incision laparoscopic surgery (SILS) is an emerging technique and has been utilized in various abdominal surgeries. Herein, we reported a case of synchronous colon and hepatic lesions that underwent right hemicolectomy and wedge resection of the liver by SILS. To the best of our knowledge, this is the first case report of synchronous colon and liver resection with SILS using homemade transumbilical port.

Shedding-induced gap formation contributes to gut barrier dysfunction in endotoxemia.

BACKGROUND: The intestinal mucosa exhibits high turnover rates with a balance of shedding and the migration of epithelial cells to maintain gut barrier function. Systemic diseases such as sepsis and major thermal injury accelerate the rate of cell shedding, subsequent gap formation, and gut barrier dysfunction. However, the detailed changes of intestinal villi in barrier dysfunction have not been well described. METHODS: In this study, intestinal barrier dysfunctions were induced through the injection of lipopolysaccharide (LPS) in C57BL/6 mice. Intravital images of the small intestine were observed with multiphoton microscopy for cellular dynamics analysis. The changes of epithelial cells shedding, gap formation, goblet cells, and intestinal leaks were observed, calculated, and analyzed. RESULTS: Endotoxemia enhanced chromatin condensation, accelerated migration, and increased the shedding of intestinal epithelial cells compared with the control group. Furthermore, LPS-induced shedding resulted in gap formation and subsequent intestinal leaks. In total, 40% of intestinal leaks were through gaps, and 60% were through paracellular spaces. Although LPS injection significantly increased the leaks in gaps and paracellular spaces, it did not change the percentage of leaks in gaps and paracellular spaces compared with the control group. CONCLUSION: We conclude that endotoxemia causes gut barrier dysfunction by increasing epithelium shedding, gaps, and intestinal leaks. However, the effect of the impairment of local barrier maintenance on the distribution of intestinal leaks in gaps and paracellular spaces is minimal.