[Indications and technique for transoral thyroid gland and parathyroid gland surgery]

The conventional Kocher collar incision is the standard access to the thyroid and parathyroid glands. Although the incision length has been significantly shortened in recent years with this approach, there is increasing interest among patients in a surgical technique without visible scars in the décolleté. Transoral endoscopic thyroid gland surgery via the vestibular approach (TOETVA) is a modern technique that can be learned relatively quickly and leaves no visible scars because it is carried out exclusively through a natural orifice (natural orifice transluminal endoscopic surgery, NOTES). For retrieval of larger specimens, the transoral approach can be combined with a retroauricular access and thus covers a larger range of indications. The indications must be strictly followed, analogous to conventional surgery. Once the transoral access has been established, the operation is carried out as in open surgery but strictly from cranial to caudal. The classical complications are comparable to the results of conventional surgery. Specific complications include perioral, mandibular or cervical dysesthesia and hypesthesia.

Efficacy and safety of oncoplastic breast-conserving surgery versus conventional breast-conserving surgery: An updated meta-analysis

INTRODUCTION

Breast cancer is the most common cancer among women. The surgical treatment of breast cancer has transitioned progressively from radical mastectomy to breast-conserving surgery. In this meta-analysis, we are aiming to compare oncoplastic breast-conserving surgery (OS) with conventional breast-conserving surgery (BCS) in terms of efficacy and safety.

METHODS

We searched Medline, Web of Science, Embase, Cochrane databases, Clinicaltrial.gov, and CNKI until April 30, 2024. Data from cohort studies and randomized controlled trials (RCTs) were included. Outcomes included primary outcomes (re-excision, local recurrence, positive surgical margin, mastectomy), secondary outcomes and safety outcomes. The Cochrane Risk of Bias Assessment Tool and Newcastle-Ottawa Scale were used to evaluate the quality of outcomes.

RESULTS

Our study included 52 studies containing 46,835 patients. Primary outcomes comprise re-excision, local recurrence, positive surgical margin, and mastectomy, there were significant differences favoring OS over BCS (RR 0.68 [0.56, 0.82], RR 0.62 [0.47, 0.82], RR 0.76 [0.59, 0.98], RR 0.66 [0.44, 0.98] respectively), indicating superior efficacy of OS. Additionally, OS demonstrated significant aesthetic benefits (RR 1.17 [1.03, 1.33] and RR 1.34 [1.18, 1.52]). While total complications were significantly fewer in the OS group (RR 0.70 [0.53, 0.94]), the differences in specific complications were not significant. Furthermore, subgroup analyses were conducted based on nationality, sample size, quality, and type.

CONCLUSION

OS demonstrates either superior or at least comparable outcomes across various aspects when compared to BCS.

Crosstalk of methylation and tamoxifen in breast cancer (Review)

Tamoxifen is a widely used anti‑estrogen drug in the endocrine therapy of breast cancer (BC). It blocks estrogen signaling by competitively binding to estrogen receptor α (ERα), thereby inhibiting the growth of BC cells. However, with the long‑term application of tamoxifen, a subset of patients with BC have shown resistance to tamoxifen, which leads to low overall survival and progression‑free survival. The molecular mechanism of resistance is mainly due to downregulation of ERα expression and abnormal activation of the PI3K/AKT/mTOR signaling pathway. Moreover, the downregulation of targeted gene expression mediated by DNA methylation is an important regulatory mode to control protein expression. In the present review, methylation and tamoxifen are briefly introduced, followed by a focus on the effect of methylation on tamoxifen resistance and sensitivity. Finally, the clinical application of methylation for tamoxifen is described, including its use as a prognostic indicator. Finally, it is hypothesized that when methylation is used in combination with tamoxifen, it could recover the resistance of tamoxifen.

The Role of Density in Achieving Volume and Weight Symmetry in Breast Reconstruction

BACKGROUND

 Knowledge of tissue and implant density is crucial in obtaining both volume and weight symmetry in unilateral breast reconstruction. Therefore, the aim of this study was to determine and compare the density of abdominal and breast tissue specimens as well as of 5th generation breast implants.

METHODS

 Thirty-one breast tissue and 30 abdominal tissue specimens from 61 patients undergoing either mammaplasty or abdominoplasty as well as five different 5th generation breast implants were examined. Density (g/mL) was calculated by applying the water displacement method.

RESULTS

 The mean specimen density was 0.94 ± 0.02 g/mL for breast tissue and 0.94 ± 0.02 g/mL for abdominal tissue, showing no significant difference (p = 0.230). Breast tissue density significantly (p = 0.04) decreased with age, while abdominal tissue did not. A regression equation to calculate the density of breast tissue corrected for age (breast density [g/mL] = 0.975-0.0007 * age) is provided. Breast tissue density was not related to body mass index, past pregnancy, or a history of breastfeeding. The breast implants had a density ranging from 0.76 to 1.03 g/mL which differed significantly from breast tissue density (-0.19 g/mL [-19.8%] to +0.09 g/mL [+9.58%]; p ≤ 0.001).

CONCLUSION

 Our results support the suitability of abdominal-based perforator flaps in achieving both volume and weight symmetry in unilateral autologous breast reconstruction. Abdominal flap volume can be derived one-to-one from mastectomy weight. Further, given significant brand-dependent density differences, the potential to impose weight disbalances when performing unilateral implant-based reconstructions of large breasts should be considered.

The postsurgical pancreas

BACKGROUND

 Partial pancreatic resections are among the most complex surgical procedures in visceral tumor medicine and are associated with a high postoperative morbidity with a complication rate of 40-50 % of patients even in specialized centers.

METHODS

 Description of typical surgical resection procedures and the resulting postoperative anatomy, typical normal postoperative findings, common postoperative complications, and radiological findings.

RESULTS AND CONCLUSION

 CT is the most appropriate imaging technique for rapid and standardized visualization of postoperative anatomy and detection of clinically suspected complications after partial pancreatic resections. The most common complications are delayed gastric emptying, pancreatic fistula, acute pancreatitis, bile leakage, abscess, and hemorrhage. Radiologists must identify the typical surgical procedures, the postoperative anatomy, and normal postoperative findings as well as possible postoperative complications and know interventional treatment methods for common complications.

KEY POINTS

  · Morbidity after pancreatic surgery remains high.. · CT is the best method for visualizing postoperative anatomy and is used for early detection of complications.. · Pancreatic fistula is the most common relevant complication after pancreatic resection.. · The ability of a center to manage complications is crucial to ensure the success of therapy..

CITATION FORMAT

· Fischbach R, Peller M, Perez D et al. The postsurgical pancreas. Fortschr Röntgenstr 2024; 196: 1037 - 1045.

Oncologic Safety of Immediate Oncoplastic Surgery Compared with Standard Breast-Conserving Surgery for Patients with Invasive Lobular Carcinoma

BACKGROUND

Invasive lobular carcinoma (ILC) of the breast grows in a diffuse pattern, resulting in a high risk of positive margins at surgical resection. Oncoplastic approaches have been shown to reduce this risk, but concerns persist around the safety of immediate oncoplastic surgery for those with ILC. This study evaluated the short- and long-term oncologic outcomes of immediate oncoplastic surgery for patients with ILC.

METHODS

This study retrospectively analyzed an institutional database of stages I to III ILC patients who underwent breast-conserving surgery (BCS) with or without immediate oncoplastic surgery (oncoplastic closure or oncoplastic reduction mammoplasty [ORM]). The study compared positive margin rates, rates of successful BCS, and recurrence-free survival (RFS) by type of surgery.

RESULTS

For 494 patients the findings showed that the use of immediate ORM was associated with significantly lower odds of positive margins (odds ratio [OR], 0.34; 95 % confidence interval [CI], 0.17-0.66; p = 0.002). Both lumpectomy with oncoplastic closure and ORM were significantly associated with higher rates of successful BCS than standard lumpectomy (94.2 %, 87.8 %, and 73.9 %, respectively; p < 0.001). No difference in RFS was observed between those undergoing immediate oncoplastic surgery and those undergoing standard lumpectomy alone.

CONCLUSIONS

The patients with stages I to III ILC who underwent immediate oncoplastic surgery had significant benefits including lower odds of positive margins and higher rates of successful BCS, with both types of immediate oncoplastic surgery showing similar RFS compared with lumpectomy alone. This supports the oncologic safety of immediate oncoplastic surgery for diffusely growing tumors such as ILC, providing it an ideal option for patients desiring BCS.

Surgical site infection following pancreaticoduodenectomy in a referral cancer center in Mexico

BACKGROUND

Pancreaticoduodenectomy is the standard treatment for resectable periampullary cancer. Surgical site infections (SSI) are common complications with increased morbidity. The study aimed to describe the prevalence, risk factors, microbiology, and outcomes of SSI among patients undergoing pancreaticoduodenectomy.

METHODS

We conducted a retrospective study in a referral cancer center between January 2015 and June 2021. We analyzed baseline patient characteristics and SSI occurrence. Culture results and susceptibility patterns were described. Multivariate logistic regression was used to determine risk factors, proportional hazards model to evaluate mortality, and Kaplan-Meier analysis to assess long-term survival.

RESULTS

A total of 219 patients were enrolled in the study; 101 (46%) developed SSI. Independent factors for SSI were diabetes mellitus, preoperative albumin level, biliary drainage, biliary prostheses, and clinically relevant postoperative pancreatic fistula. The main pathogens were Enterobacteria and Enterococci. Multidrug-resistance rate in SSI was high but not associated with increased mortality. Infected patients had higher odds of sepsis, longer hospital stay and intensive care unit stay, and readmission rate. Neither 30-day mortality nor long-term survival was significantly different between infected and non-infected patients.

CONCLUSIONS

SSI prevalence among patients undergoing pancreaticoduodenectomy was high and largely caused by resistant microorganisms. Most risk factors were related to preoperative instrumentation of the biliary tree. SSI was associated with greater risk of unfavorable outcomes; however, survival was unaffected.

A Phase II Study Evaluating the Effect of Intensity Modulated Postmastectomy Radiation Therapy on Implant Failure Rates in Breast Cancer Patients With Immediate, 2-Stage Implant Reconstruction With an MRI Imaging Correlative Substudy

PURPOSE

Postmastectomy radiation therapy is a mainstay in the adjuvant treatment of node-positive breast cancer, but it poses risks for women with breast reconstruction. Multibeam intensity-modulated radiation therapy improves dose conformality and homogeneity, potentially reducing complications in breast cancer patients with implant-based reconstruction. To investigate this hypothesis, we conducted a single-arm phase 2 clinical trial of breast cancer patients who underwent mastectomy/axillary dissection and prosthesis-based reconstruction.

METHODS AND MATERIALS

The primary endpoint was the rate of implant failure (IF) within 24 months of permanent implant placement, which would be considered an improvement over historical controls if below 16%. IF was defined as removal leading to a flat chest wall or replacement with another reconstruction. Patients were analyzed in 2 cohorts. Cohort 1 (RT-PI) received radiation therapy to the permanent implant. Cohort 2 (RT-TE) received radiation therapy to the TE. IF rates, adverse events, and quality of life were analyzed. Follow-up/postradiation therapy assessments were compared with the baseline/preradiation therapy assessments at 3 to 10 weeks after exchange surgery. A subgroup underwent serial magnetic resonance imaging (MRI) sessions to explore the association between MRI-detected changes and capsular contracture, a known adverse effect of radiation therapy.

RESULTS

Between June 2014 and March 2017, 119 women were enrolled. Cohort 1 included 45 patients, and cohort 2 had 74 patients. Among 100 evaluable participants, 25 experienced IF during the study period. IF occurred in 8/42 (19%) and 17/58 (29%) in cohorts 1 and 2, respectively. Among the IFs, the majority were due to capsular contracture (13), infection (7), exposure (3), and other reasons (2). Morphologic shape features observed in longitudinal MRI images were associated with the development of Baker grade 3 to 4 contractures.

CONCLUSIONS

The rate of IF in reconstructed breast cancer patients treated with intensity-modulated radiation therapy was similar to, but not improved over, that observed with conventional, 3-dimensional-conformal methods. MRI features show promise for predicting capsular contracture but require validation in larger studies.

Cryotherapy in the Treatment of Early-Stage Breast Cancer

Breast cancer is one of the most common malignancies, affecting millions of people worldwide annually. The treatment paradigm for early-stage breast cancer is in flux. The focus is now on opportunities to de-escalation treatment to minimize morbidity and maximize patients' quality of life. Recently, percutaneous minimally invasive ablative techniques have been explored. Early trials in small population of patients demonstrated cryoablation to be effective, safe, and well-tolerated in an outpatient setting. Subsequent surgical resection was performed and the ablation success rate was the highest if the tumor was less than 1.5 cm and with < 25% ductal carcinoma in situ component. ACOSOG Alliance Z1072, a phase II trial with curative intent, demonstrated 100% ablation in all tumors smaller than 1 cm and 92% success in lesions without multifocal disease and less than 2 cm in size. There are ongoing prospective clinical trials to investigate the efficacy of cryoablation without surgical excision for treatment of early-stage breast cancer. FROST (Freezing Instead of Removal Of Small Tumors) started in 2016 is ongoing, ICE3 (Cryoablation of Low Risk Small Breast Cancer) started in 2014 just released 5 years results, and COOL-IT: Cryoablation vs Lumpectomy in T1 Breast Cancers is also ongoing. These prospective trials will expand our knowledge on the safety and value of cryoablation. It is crucial to understand the indications, technical nuances, and distinctive imaging findings for cryoablation as it has potential to revolutionize standard surgical practice.

[Modern thyroid surgery : Efficient and safe thyroidectomy technique]

After decades of bilateral "subtotal" and later "total" thyroidectomy, the extent of resection is now determined individually depending on the dominant thyroid condition. The leading indication by far in the study, documentation and quality center (StuDoQ) register of the Surgical Working Group Endocrinology (CAEK) is currently the suspicion of malignancy, which is followed by benign symptomatic nodular goiter, functional disorders and confirmed malignancy. The decision for an intervention as well as the extent of resection must be rigorously established. Aids for intraoperative nerve monitoring, vessel-sealing and parathyroid autofluorescence increase the safety of thyroid resections but also the complexity. The surgical technique of lobectomy using modern devices for vessel sealing is an intricate process in which the positioning, access to the neck and a modified sequence of dissection steps are equally important. While the usefulness of neuromonitoring is nowadays no longer in doubt, this is not yet so clear for other technologies. Above all, however, modern thyroid surgery is characterized by the knowledge of one's own results and a clear positioning to follow-ups. The selection of any surgical aid should be based on this knowledge.

Predicting gene signature in breast cancer patients with multiple machine learning models

AIMS

The aim of this study was to predict gene signatures in breast cancer patients using multiple machine learning models.

METHODS

In this study, we first collated and merged the datasets GSE54002 and GSE22820, obtaining a gene expression matrix comprising 16,820 genes (including 593 breast cancer (BC) samples and 26 normal control (NC) samples). Subsequently, we performed enrichment analyses using Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), and Disease Ontology (DO).

RESULTS

We identified 177 differentially expressed genes (DEGs), including 40 up-regulated and 137 down-regulated genes, through differential expression analysis. The GO enrichment results indicated that these genes are primarily involved in extracellular matrix organization, positive regulation of nervous system development, collagen-containing extracellular matrix, heparin binding, glycosaminoglycan binding, and Wnt protein binding, among others. KEGG enrichment analysis revealed that the DEGs were primarily associated with pathways such as focal adhesion, the PI3K-Akt signaling pathway, and human papillomavirus infection. DO enrichment analysis showed that the DEGs play a significant role in regulating diseases such as intestinal disorders, nephritis, and dermatitis. Further, through LASSO regression analysis and SVM-RFE algorithm analysis, we identified 9 key feature DEGs (CF-DEGs): ANGPTL7, TSHZ2, SDPR, CLCA4, PAMR1, MME, CXCL2, ADAMTS5, and KIT. Additionally, ROC curve analysis demonstrated that these CF-DEGs serve as a reliable diagnostic index. Finally, using the CIBERSORT algorithm, we analyzed the infiltration of immune cells and the associations between CF-DEGs and immune cell infiltration across all samples.

CONCLUSIONS

Our findings provide new insights into the molecular functions and metabolic pathways involved in breast cancer, potentially aiding in the discovery of new diagnostic and immunotherapeutic biomarkers.

Predicting efficacy of neoadjuvant chemotherapy in breast cancer patients with synthetic magnetic resonance imaging method MAGiC: An observational cohort study

OBJECTIVE

MAGnetic resonance Imaging Compilation (MAGiC) is typical method of synthetic magnetic resonance imaging (MRI). The present aimed to investigate the role of MAGiC parameters of relaxation time (T1), transverse relaxation time (T2) and proton density (PD) to predict the treatment efficacy of breast cancer patients after neoadjuvant chemotherapy (NAC).

METHODS

The present prospective cohort study enrolled 120 breast cancer patients who received NAC during 2021-2023. Demographic data and clinical characteristics including tumor node metastasis (TNM) stage, pathological type, molecular classification and lymph node metastasis were collected. The levels of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER-2) were measured. Patients were divided by treatment efficacy using the Miller-Payne grading as partial pathological response (pPR) group and pathological complete response (pCR). The values of MAGiC parameters of longitudinal T1, T2, and PD values were recorded.

RESULTS

In all 120 patients, 73 (60.83%) cases were with pPR and 47 (39.17%) cases were with pCR after treatment. T2 values were markedly lower in pPR patients compared with pCR patients. However, no significant difference was found for T1 and PD values. No significant correlation was observed between any of MAGiC parameters and HER-2, ER or PR. ROC curve showed T2 could be used for prediction of pPR with AUC 0.780. Lymph node metastasis and low levels of T2 were found as independent risk factors for pPR after treatment.

CONCLUSION

The T2 value parameter from MAGiC is an independent risk factor for pPR following NAC in breast cancer patients, suggesting its potential as a biomarker for predicting treatment efficacy.

Navigating the challenges: A case of iatrogenic cervical esophageal perforation following thyroid surgery

INTRODUCTION

Iatrogenic cervical esophageal perforation (ICEP) represents a rare and challenging surgical complication that results in significant morbidity and mortality. This is a case report of a cervical esophageal fistula that resulted from an iatrogenic perforation following thyroid surgery, treated with surgical repair followed by negative pressure wound therapy (NPWT).

PRESENTATION OF CASE

A 43-year-old female was presented with an infected post-total thyroidectomy and bilateral radical neck dissection two weeks prior. Esophagography revealed contrast leakage from the anterolateral aspect of the esophagus at the level of C7-T1. Surgical debridement exposed large (4 × 1 cm) esophageal damage. The esophageal repair was performed using a sternocleidomastoids flap reinforced with BioGlue® followed by placement of a feeding tube through a gastrostomy. Subsequent mucus leakage was observed two weeks after the repair. Conservative approach using NPWT was used to promote wound closure. Over a 3-week period, serial imaging demonstrated fistula closure and complete wound healing by 8 weeks.

DISCUSSION

A delay in diagnosis and treatment for esophageal perforation leads to severe complications, highlighting the need for standardized treatment algorithms. Larger perforations illustrated in this case report require primary repair with muscle flaps. When reconstructive surgery fails, a follow-up conservative therapy utilizing proper NPWT was able to heal the leakage.

CONCLUSION

This case report illustrates rare but devastating potential complications from a commonly performed oncologic surgery. The involvement of a multidisciplinary team from the very first identification of surgical complications is crucial for ensuring proper treatment.

Effect of obstructive sleep apnea on postoperative delirium: a system review and meta-analysis

PURPOSE

To investigate the impact of obstructive sleep apnea (OSA) on postoperative delirium (PD), and evaluate the effectiveness of positive airway pressure (PAP) therapy on PD among OSA patients.

METHODS

We systematically searched Embase, Cochrane Library and PubMed databases from their establishment to November 27, 2022. A random-effects approach was employed to determine aggregated results. Subgroup and sensitivity analyses were carried out to investigate heterogeneity.

RESULTS

Sixteen eligible studies were included in the analysis. Thirteen studies revealed that OSA significantly elevated the likelihood of developing PD (OR = 1.71; 95%CI = 1.17 to 2.49; p = 0.005). Subgroup analysis according to delirium assessment scales showed that OSA did not exhibit an association with the incidence of PD assessed by the Confusion Assessment Method-Intensive Care Unit (OR = 1.14; 95%CI = 0.77 to 1.67; p = 0.51) but enhanced the likelihood of developing PD evaluated with other measurement scales (OR = 2.15; 95%CI = 1.44 to 3.19; p = 0.0002). Three additional studies explored the impact of PAP treatment on PD among OSA individuals, indicating no significant reduction in PD incidence with PAP use (OR = 0.58; 95%CI = 0.13 to 2.47; p = 0.46).

CONCLUSIONS

OSA may not be a risk factor for PD in critically ill patients in the intensive care unit, but may increase the likelihood of developing PD among individuals receiving regular care in the ward postoperatively. The efficacy of PAP therapy in decreasing PD incidence among OSA patients remains debatable.

Initial Experience With Ultra-High-Definition 3D Exoscope in Thyroid and Parathyroid Surgery

BACKGROUND

Operation with a 3D exoscope has recently been introduced in clinical practice. The exoscope consists of two cameras placed in front of the operative field. Images are shown on a large 3D screen with high resolution. The system can be used to enhance precise dissection and provides new possibilities for improved ergonomics, fluorescence, and other optical-guided modalities.

METHODS

Initial experience with the ultra-high-definition (4K) 3D exoscope in thyroid and parathyroid operations. The exoscope (OrbEyeTM) was mounted on a holding system (Olympus).

RESULTS

We used the exoscope in parathyroidectomy (N = 6) and thyroidectomy (N = 6). Immediate advantages and disadvantages were discussed and recorded. The learning curve for use of the exoscope may be shorter for surgeons with training in endoscopic or robotic procedures. There may be improved ergonomics compared with normal open-neck operations. Further, the optical guided operations can be used with fluorescence and have potential for different on-lay techniques in the future. The 4 K 3D image quality is state-of-art and is highly appreciated during fine surgical dissection and eliminates the need for loupes.

CONCLUSION

In several ways, using the ORBEYE™ in thyroid and parathyroid surgery provides the surgical team with a new and enhanced experience. This includes improved possibility for teaching, surgical ergonomics, and a 4K 3D camera with a powerful magnification system. However, it is not clear if utilization of these features would improve surgical outcomes. Furthermore, the ORBEYE™ lacks incorporation of parathyroid autofluorescence, and the current costs for the system do not facilitate general access to exoscope assisted operations.

Medical treatment of acromegaly - When the tumor size matters: A narrative review

Medical treatment of acromegaly is generally positioned as a second line of treatment after pituitary adenoma surgery. With the rising availability and variety of medications for acromegaly increases our understanding of their effectiveness and safety. Volume of the published data on the impact of medical therapy on biochemical control of acromegaly, contrasts a relative lack of publications which comprehensively address pituitary tumor alterations under different drug modalities. Assessment of changes in GH-secreting adenoma volume is often overshadowed by clinicians' focus on GH and IGF-I levels during acromegaly treatment. Close analysis of studies published in the last two decades, reveals that both an increase and decrease in somatotropinoma volume are possible during treatment with any of available drugs for acromegaly. Changes in pituitary tumor size may arise from the biological nature of adenoma itself, independently of the administered medications. Therefore, an individual approach is necessary in the treatment of patients with acromegaly, based on repeated insight to their clinical, biochemical, pathological and imaging characteristics. In this review, we summarize and comment how pituitary tumor size is affected by the treatment with all currently available drugs in acromegaly: long-acting somatostatin receptor ligands of the first generation (octreotide LAR and lanreotide autogel) and the second generation (pasireotide-LAR), as well as pegvisomant (PEG) and cabergoline (CAB).

Enhanced recovery after surgery (ERAS) guided gynecologic/oncology surgery - The patient's perspective

Objective

Enhanced recovery after surgery (ERAS) pathways have demonstrated improvements in outcomes following benign gynecologic and gynecologic oncology surgery. However, there is limited data reporting the benefit of ERAS from the patient's perspective. This study aimed to explore patient knowledge of and experience with ERAS-guided surgery.

Methods

This interpretive descriptive study included participants who had undergone ERAS-guided gynecologic and gynecologic oncology surgery in Alberta, Canada using convenience sampling. Semi-structured interviews explored patient knowledge of ERAS, overall experience with surgery and recommended changes for surgical care. An inductive thematic analysis was conducted.

Results

Eight females aged 26-76 years old participated in the study who had gynecologic (n = 4) and gynecologic oncology (n = 4) surgery. Six themes central to participant experience of ERAS-guided surgery were identified: patient expectations, individual motivation, values and support, healthcare provider communication, trust in healthcare providers, COVID-19 and care co-ordination. Overall, specific knowledge of ERAS was low. Expectations were set by previous experience of healthcare (previous surgery or occupation), as well as information provided by healthcare professionals. Participants whose expectations aligned with physical experience of ERAS provided favourable perspectives. Participants recommended improving the quality, relevance and availability of information and establishing accessible follow up strategies.

Conclusion

Based on the finding that knowledge about ERAS was minimal, we advocate for improved education pertaining to ERAS recommendations. Acknowledging patients' expertise and motivation to engage in their care maybe one strategy to improve compliance with ERAS guidelines and improve outcomes for both patients and the healthcare system.

Full of sound and fury

The subject of noise in the operating theatre was recognized as early as 1972 and has been compared to noise levels on a busy highway. While noise-induced hearing loss in orthopaedic surgery specifically has been recognized as early as the 1990s, it remains poorly studied. As a result, there has been renewed focus in this occupational hazard. Noise level is typically measured in decibels (dB), whereas noise adjusted for human perception uses A-weighted sound levels and is expressed in dBA. Mean operating theatre noise levels range between 51 and 75 dBA, with peak levels between 80 and 119 dBA. The greatest sources of noise emanate from powered surgical instruments, which can exceed levels as high as 140 dBA. Newer technology, such as robotic-assisted systems, contribute a potential new source of noise. This article is a narrative review of the deleterious effects of prolonged noise exposure, including noise-induced hearing loss in the operating theatre team and the patient, intraoperative miscommunication, and increased cognitive load and stress, all of which impact the surgical team's overall performance. Interventions to mitigate the effects of noise exposure include the use of quieter surgical equipment, the implementation of sound-absorbing personal protective equipment, or changes in communication protocols. Future research endeavours should use advanced research methods and embrace technological innovations to proactively mitigate the effects of operating theatre noise.

Feasibility and Safety of transoral robotic parathyroidectomy: Initial experience with a new approach for parathyroid surgery

BACKGROUND

We present the initial outcomes of transoral robotic parathyroidectomy (TORP) using the transoral vestibular approach in patients with primary hyperparathyroidism (PHPT).

METHOD

A retrospective case series analysis was performed on patients diagnosed with PHPT between October 2016 and July 2019 who underwent transoral robotic surgery for parathyroidectomy.

RESULTS

Thirteen patients (five males and eight females) successfully underwent TORP at our institution from October 2016 to July 2019. Eight patients underwent TORP alone, and five underwent TORP combined with transoral robotic thyroidectomy for papillary thyroid carcinoma. No intra- or postoperative complications were observed. Serum levels of parathyroid hormone, total calcium, and ionized calcium decreased to normal postoperatively and continued to decrease during the follow-up period.

CONCLUSION

This study suggests that TORP holds promise for the treatment of patients with PHPT with the advantages of the robotic procedure, including dynamic visualization and meticulous dissection.

Sodium Butyrate Inhibits the Malignant Proliferation of Colon Cancer Cells via the miR-183/DNAJB4 Axis

Colorectal carcinoma (CRC) is one of the most common malignant tumors in the digestive tract. It was found that butyric acid could inhibit the expression of miR-183 to slow down malignant progression of CRC in the early stage. However, its regulatory mechanism remains unclear. This study screened the IC50 value of butyrate on inhibition of CRC cells malignant progression. Its inhibitory effects were detected by MTT assay, colony formation experiment, Transwell migration experiment, and apoptosis evaluation by flow cytometry. Next, the expressions of miR-183 and DNAJB4 were, respectively, determined in butyrate treated and miR-183 analog or si-DNAJB4-transfected CRC cells to further detect the role of upregulated miR-183 or silencing DNAJB4 in CRC cells malignant progression. Subsequently, the targeted regulatory relationship between miR-183 and si-DNAJB4 was confirmed by bioinformatic prediction tools and double luciferase report genes analysis method. The regulatory mechanism of butyrate on miR-183/DNAJB4 axis signal pathway was evaluated in molecular level, and verified in nude mouse xerograft tumor model and immunohistochemical analysis tests of Ki67 positive rates. The results displayed that butyrate with increased concentration can hinder the proliferation and improve apoptosis of CRC cells by decreasing the expression of miR-183. Thus, butyrate reduces miR-183 expression and increases DNAJB4 expression via the miR-183/DNAJB4 axis, ultimately inhibiting the malignant progression and increasing apoptosis of CRC. While over expression of miR-183 downregulate the expression of DNAJB4, which can reverse the inhibitory effect of butyrate.

Navigating the Future of 3D Laparoscopic Liver Surgeries: Visualization of Internal Anatomy on Laparoscopic Images With Augmented Reality

INTRODUCTION

Liver tumor resection requires precise localization of tumors and blood vessels. Despite advancements in 3-dimensional (3D) visualization for laparoscopic surgeries, challenges persist. We developed and evaluated an augmented reality (AR) system that overlays preoperative 3D models onto laparoscopic images, offering crucial support for 3D visualization during laparoscopic liver surgeries.

METHODS

Anatomic liver structures from preoperative computed tomography scans were segmented using open-source software including 3D Slicer and Maya 2022 for 3D model editing. A registration system was created with 3D visualization software utilizing a stereo registration input system to overlay the virtual liver onto laparoscopic images during surgical procedures. A controller was customized using a modified keyboard to facilitate manual alignment of the virtual liver with the laparoscopic image. The AR system was evaluated by 3 experienced surgeons who performed manual registration for a total of 27 images from 7 clinical cases. The evaluation criteria included registration time; measured in minutes, and accuracy; measured using the Dice similarity coefficient.

RESULTS

The overall mean registration time was 2.4±1.7 minutes (range: 0.3 to 9.5 min), and the overall mean registration accuracy was 93.8%±4.9% (range: 80.9% to 99.7%).

CONCLUSION

Our validated AR system has the potential to effectively enable the prediction of internal hepatic anatomic structures during 3D laparoscopic liver resection, and may enhance 3D visualization for select laparoscopic liver surgeries.

Laterality of Radiation Therapy in Breast Cancer is Not Associated With Increased Risk of Coronary Artery Disease in the Contemporary Era

Purpose

External beam radiation therapy (EBRT) is a critical component of breast cancer (BC) therapy. Given the improvement in technology in the contemporary era, we hypothesized that there is no difference in the development of or worsening of existing coronary artery disease (CAD) in patients with BC receiving left versus right-sided radiation.

Methods and Materials

For the meta-analysis portion of our study, we searched PubMed, Web of Science, and Scopus and included studies from January 1999 to September 2022. CAD was identified using a homogenous metric across multiple studies included. We computed the risk ratio (RR) for included studies using a random effects model. For the institutional cohort portion of our study, we selected high cardiovascular-risk patients who received diagnoses of BC between 2010 and 2022 if they met our inclusion criteria. We performed a Cox proportional hazards model with stepwise adjustment.

Results

A pooled random effects model with 9 studies showed that patients with left-sided BC receiving EBRT had a 10% increased risk of CAD when compared with patients with right-sided BC receiving EBRT (RR, 1.10; 95% CI, 1.02-1.18; P = .01). However, subgroup analysis of 6 studies that included patients diagnosed after 1980 did not show a significant difference in CAD based on BC laterality (RR, 1.07; 95% CI, 0.95-1.20; P = .27). For the institutional cohort portion of the study, we found that patients with left-sided BC who received EBRT did not have a significantly higher risk of CAD when compared with their right-sided counterparts (hazard ratios [HR], 0.73; 95% CI, 0.34-1.54; P = .402).

Conclusions

Our study suggests a historical trend of increased CAD in BC patients receiving left-sided EBRT. Data from patients diagnosed after 2010 in our institutional cohort did not show a significant difference, emphasizing that modern EBRT regimens are safe, and laterality of BC does not affect CAD outcomes in the short term after a BC diagnosis.

A Review of the Indications, Outcomes, and Postoperative Management After Total and Completion Pancreatectomy for Pancreatic Cancer: More Is Not Necessarily Better

With improvements in surgical technique and advances in pancreatic endocrine and exocrine replacement therapy, the indications for, and threshold to perform, total or completion pancreatectomy in the modern surgical era are ever evolving. The following review will evaluate such indications for pancreatic cancer including pancreatic ductal adenocarcinoma and intraductal papillary mucinous neoplasms. The authors also review the literature on oncologic outcomes of total and completion pancreatectomy for pancreatic cancer. Finally, they discuss the quality of life and postoperative management of the a-pancreatic state.

Gender-affirming DIEP Flap Breast Augmentation

Implant-based techniques have been the mainstay of gender-affirming breast augmentation (GABA). Here we describe a novel autologous technique for GABA. We provide a single-patient case report of gender-affirming deep inferior epigastric artery perforator (DIEP) flap breast augmentation. World Professional Association for Transgender Health guidelines were followed according to Standards of Care, version 8. Prepectoral tissue expanders were placed at the time of the patient's facial feminization surgery. DIEP flaps were then used for bilateral breast augmentation. Planned revisions were made about 5 months later. Breast augmentation was performed successfully with DIEP flaps, and the patient was satisfied with her outcome. No complications occurred. Anatomic differences to cisgender women were noted, including relatively thick musculature of the abdominal wall and chest as well as tight anterior abdominal fascial closure. Advantages compared with implant-based GABA were also noted, including feminization of the abdomen and avoidance of potential implant related complications. We report a novel approach to GABA. Our approach borrows well-established techniques with demonstrated efficacy and high satisfaction in postmastectomy breast reconstruction and even cosmetic purposes. However, sex- and hormone-influenced anatomic differences required some modifications compared with postmastectomy DIEP flap reconstruction.

Innovative imaging approaches for neuroendocrine tumor characterization: Combined dual energy CT and perfusion protocol implementation

The article addresses the diagnostic value of the combined use of computed tomography (CT) perfusion and dual-energy CT (DECT) in patients with neuroendocrine tumors. It emphasizes the heterogeneity and complexity of these neoplasms, primarily affecting the gastrointestinal tract, bronchopulmonary system, and pancreas. While conventional CT is widely employed in their diagnosis, the combination of CT perfusion and dual-energy CT offers greater precision, particularly in detecting synchronous tumors and characterizing their vascularization. A clinical case of a patient with chronic abdominal symptoms, whose diagnosis was facilitated using both combined techniques, is presented. The discussion explores how CT perfusion assesses tumor vascularization and how dual-energy CT improves soft tissue differentiation, resulting in increased diagnostic accuracy. It is highlighted that this approach not only enhances detection rates but also positively impacts clinical management and healthcare costs. Therefore, the importance of considering these advanced tools in the diagnosis of neuroendocrine tumors to improve diagnostic precision and efficiency in patient care is underscored.

Clinical outcomes of outpatient thyroidectomy: A systematic review and single-arm meta-analysis

BACKGROUND

The aim of this meta-analysis is to investigate the safety of outpatient thyroidectomy based on 24-h and same-day discharge criteria.

METHODS

CENTRAL, Embase, PubMed, and Scopus were searched. A meta-analysis of selected studies was performed. The review was registered prospectively with PROSPERO (CRD42022361134).

RESULTS

Thirty-one studies met the eligibility criteria, with a total of 74328 patients undergoing thyroidectomy in an outpatient setting based on 24-h discharge criteria. Overall postoperative complications after outpatient thyroidectomies were 5.7% (95%CI: 0.049-0.065; I2 ​= ​97.3%), consisting of hematoma (0.4%; 95%CI: 0.003-0.005; I2 ​= ​83.4%), recurrent laryngeal nerve injury (0.4%; 95%CI: 0.003-0.006; I2 ​= ​93.5%), and hypocalcemia (1.6%; 95%CI: 0.012-0.019; I2 ​= ​93.7%). The rate of readmission was 1.1% (95%CI: 0.007-0.015; I2 ​= ​95.4%). Results were similar for same-day criteria.

CONCLUSIONS

Our analysis demonstrated that outpatient thyroidectomy is a safe procedure in the management of thyroid disease for selected patients.

Radioactive iodine ablation therapy reduces the risk of recurrent disease in pediatric differentiated thyroid carcinoma

BACKGROUND

While radioactive iodine (RAI) therapy in older adults with differentiated thyroid carcinoma (DTC) reduces recurrence, data in pediatrics remain limited. We conducted a meta-analysis to quantify outcomes and recurrence risk with RAI versus thyroidectomy alone in the pediatric population.

METHODS

Systematic literature review identified 34 retrospective studies including 2913 DTC patients under age 22 years (published 2005-2023). Meta-analysis calculated pooled rates of disease persistence and recurrence. Relative risk ratios compared odds of recurrence with RAI versus no RAI.

RESULTS

Patients had mean age 14.7 years (95 % CI, 14.2-15.2) and were 75.9 % female (95 % CI, 73.8-78.1 %). Majority (90.2 %) received RAI. Pooled persistence rate was 30.3 % (95 % CI, 21.7-39.5 %); higher with RAI (31.5 %; 95 % CI, 22.4-41.3 %) than no RAI (4.5 %; 95 % CI, 0.0-18.7 %) (OR 3.28; 95 % CI,1.82-5.91; p < 0.001). Recurrence rate was 8.97 % (95 % CI, 4.78-14.3 %). Those with RAI had 53.1 % lower recurrence risk versus no RAI (RR 0.47; 95 % CI, 0.27-0.82; p = 0.007). Median follow-up was 7.2 years (95 % CI, 5.8-8.5 years), with no association between follow-up duration and recurrence (r = -0.053; p = 0.80).

CONCLUSIONS

RAI therapy as an adjunct to thyroidectomy is associated with a significantly lower risk of long-term recurrence in pediatric DTC. These findings advocate for the use of RAI in preventing recurrence among high-risk pediatric patients with DTC.

Breast reconstruction with TiLOOP® Bra: Another arrow in plastic surgeons' quiver?

BACKGROUND

The use of lower-pole sling products has made immediate breast reconstruction a feasible option in women undergoing skin-nipple sparing and skin-reducing mastectomies. To date, available data on the comparative efficacy of biological and synthetic meshes regarding postoperative complications are scattered and limited.

METHODS

A systematic literature search was performed to screen three different databases (PubMed, Web of Sciences, and Embase) using the following keywords: "breast reconstruction" AND "TiLOOP®" OR "Titanium-Coated Polypropylene Mesh" OR "TCPM". The perioperative and demographic characteristics of patients, complications profiles, and patient-reported outcomes were considered.

RESULTS

We initially identified 234 articles, of which only 41, including 3923 patients and 5042 reconstructed breasts, fully satisfied the inclusion criteria.

CONCLUSION

TiLOOP® Bra could be considered a safe and aesthetically valid alternative to Acellular Dermal Matrices (ADMs) in non-smokers patients undergoing skin-nipple sparing and skin-reducing mastectomies and immediate reconstruction. In such populations, complications are more likely to develop in patients with extreme body mass index values. The incidence of seroma with TiLOOP® Bra is comparable to that of ADMs as it is the beneficial effect in radiated patients, where TiLOOP® Bra seems superior to implant alone reconstruction. It has a good bio-integration with host tissues and resistance to infections in patients with a weakened immune system as a consequence of oncologic perioperative treatments.

State of art of robotic prostatectomy: the way we do it in Catalonia, Spain

INTRODUCTION AND OBJECTIVE

Robotic-assisted laparoscopic prostatectomy (PLAR) seems to improve functional outcomes, however there is not a consensus of a standard procedure. The aim of this study was to identify the PLAR "state of art" in Catalonia, Spain.

MATERIAL AND METHODS

This was a cross-sectional survey-based study conducted among urologists across Catalonia, Spain. The survey was distributed through online platforms and the professional urology society. All statistical analyses were performed using Stata software, v20.

RESULTS

59 urologists completed the survey, revealing PLAR as the most commonly used technique (79.7%). Most urologist (70%) create the pneumoperitoneum using a controlled incision with direct access and 78.3% use the Airseal technology. The intraperitoneal approach is performed in >90% of cases. Endopelvic fascia preservation is not routinely performed. 34.5% of the survey not perform the dorsal vein complex suture. All preserves the bladder neck when oncologically safe. Nerve-vascular bundles bleeding control is performed using standard coagulation or suturing. 34% performed posterior reconstruction. Only use hemostatic devices when evident bleeding and 70% does not routinely left a drainage. Multivariable analysis showed that center volume had a significant independent association with dorsal venous complex suturing (OR 0.073, 95%CI 0.07-0.826), nerve-vascular bundles suturing hemostasis (OR 11.67, 95%CI 1.07-127.60) and endopelvic fascia preservation (OR 13.64, 95%CI 1.087-201.27), but there was no correlation with time the bladder catheter or days hospitalized.

CONCLUSIONS

The study provides an overview of the state of PLAR in Catalonia, Spain, showing significant variability and reflecting a commitment to advancing surgical technology and patient care.

Identifying suitable candidates for pancreaticoduodenectomy with extended lymphadenectomy for pancreatic ductal adenocarcinoma

BACKGROUND

To evaluate long-term quality of life and survival in pancreatic ductal adenocarcinoma (PDAC) patients after pancreatoduodenectomy with extended lymphadenectomy (PDEL) and identify candidates.

METHODS

Patients with resectable PDAC with ≥1 examined lymph node (LN) during pancreatoduodenectomy (PD), and were divided into the PD with standard lymphadenectomy (PDSL) and PDEL groups. Perioperative data, long-term quality of life and survival were compared, and the prognostic effect of LNs ± in every peripancreatic station were analysed.

RESULTS

Screening 446 PDAC patients, 237 and 126 were included in the PDSL and PDEL groups, respectively. The PDEL group showed a longer operation time, greater intraoperative blood loss, severe diarrhoea, a higher incidence of grade III complications. Notably, the PDEL patients experienced significant relief from low back pain and diarrhoea, with an obvious survival advantage (p = 0.037), especially in patients with preoperative tumor contact with vascular and pathological N0; however, LNs+ in any station (No. 8p, 12, 14, or 16) were associated with a poorer prognosis. The vascular reconstruction, T and N stage were independent risk factors for survival.

CONCLUSION

PDEL can relieve symptoms and prolong the survival of PDAC patients with acceptable complications, and EL should be performed regardless of preoperative LN enlargement.

Use of Diagnostic Laparoscopy and Peritoneal Washings for Pancreatic Cancer

Pancreatic adenocarcinoma is an aggressive malignancy that often presents with advanced disease. Accurate staging is essential for treatment planning and shared decision-making with patients. Staging laparoscopy is a minimally invasive procedure that can detect radiographically occult metastatic disease. Its routine use with the collection of peritoneal washings in patients with pancreatic cancer remains controversial. We, herein, review the current literature concerning staging laparoscopy and peritoneal washings in patients with pancreatic cancer.

Revisiting surgical margins for invasive breast cancer patients treated with breast conservation therapy - Evidence for adopting a 1 mm negative width

Clinical trials have demonstrated conclusively the non-inferiority of breast-conserving surgery followed by breast radiation therapy (BCT) compared with mastectomy for the treatment of early-stage invasive breast cancer (BC). The definition of the required surgical margin to ensure adequate removal of the cancer by BCT to obtain an acceptable low local recurrence (LR) rate remains controversial. Meta-analyses published by Houssami et al. in 2010 and 2014 demonstrated significantly lower LR rates for patients with a negative margin compared with those with positive (ink on tumour) or close (defined as ≤1 mm or ≤2 mm) margins. Neither meta-analysis addressed whether 'no ink on tumour' was adequate to define a negative margin because of a lack of data. Nevertheless, in 2014, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) with advice from pathologists reviewed these data together and published guidelines recommending that a margin of 'no ink on tumour' was sufficient to define a clear margin in BCT. Subsequently, clinical practice has varied with some national and international bodies endorsing 'no ink on tumour', whilst others have recommended a ≥1 mm margin as acceptable margins for BCT. A more recent meta-analysis conducted by Bundred and colleagues in 2022 did have sufficient data to compare 'no ink on tumour' and 1 mm and concluded that 1 mm rather than 'no ink on tumour', should be used as a minimum negative margin, and recommended that international guidelines be revised. The current review presents a balanced assessment of the evidence relating margin width and local recurrence after BCT. This review concludes that guidelines should consider re-defining a negative margin as ≥1 mm rather than 'no ink on tumour' in the context of BCT, recognising there will be variation to tailor therapy for any individual patient situation to ensure optimal patient care.

Key points of surgical anatomy for endoscopic thyroidectomy via a gasless unilateral axillary approach

PURPOSE

Endoscopic thyroidectomy utilizing the Gasless Unilateral Axillary Approach (GUA) offers distinct advantages including clear visibility, simple manipulation, safe oncological outcomes. This technique eliminates postoperative neck scarring, ensures concealed surgical incisions, and minimizes postoperative swallowing discomfort.

METHODS

We retrospectively reviewed 150 surgical videos to document key anatomical features and their variations during this procedure.

RESULTS

The GUA endoscopic thyroidectomy, which approaches from the contralateral side, presents significant difficulties in identifying anatomical structures, especially anatomical abnormalities in the contralateral neck, while constructing feasible operative fields. This article offers an in-depth discussion of the anatomical challenges, pitfalls, and viable strategies associated with this surgery, particularly for less experienced surgeons.

CONCLUSIONS

Given the intricate interplay of muscular, vascular, and neural anatomical structures, novices in surgery must be well-acquainted with the underlying anatomy to minimize potential complications.

PPAR-γ agonist pioglitazone and the risks of malignancy among type2 diabetes mellitus patients

AIMS

PPAR-gamma shows promise in inhibiting malignancy cell progression. However, pioglitazone, the sole current PPAR-gamma agonist, was reported to have risks of bladder cancer in previous clinical researches. This study is aimed to assess the influence of pioglitazone on the development of tumors.

METHODS

By using Taiwan's National Health Insurance Research Database, this nested case-control study identified incident type2 diabetes initiating metformin treatment between 2000 and 2014, and then categorized into two groups based on whether they developed malignancies after enrollment or not. The index date was defined as the date of malignancy diagnosis in the cancer group or a matched date in the non-cancer group. We analyzed the exposure to pioglitazone preceding the index date.

RESULTS

47,931 patients in the cancer group and 47,931 patients in the matched non-cancer group were included. The non-cancer group exhibited a significantly higher rate of pioglitazone prescription before the index date for overall malignancies (odds ratios for pioglitazone use were 0.91, 0.92, 0.94, and 0.93 in the first, second, third, and fourth years before the index date). For breast cancer and prostate cancer, pioglitazone was frequently prescribed in the non-cancer group, whereas for pancreatic cancer, pioglitazone use was more common in the cancer group.

CONCLUSIONS

PPAR-gamma agonists may be associated with reduced risks of overall malignancies, particularly for breast and prostate cancers. However, it may be linked to an elevated risk of pancreatic cancer.

Track recurrence after remote-access thyroid surgeries: A systematic review

BACKGROUND

Remote-access thyroidectomies have gained popularity, but track recurrence, which is the implantation of thyroid tissue or lesions along the surgical access route, has been reported in case studies. This systematic review aims to review cases of track recurrence following remote-access thyroidectomies.

METHODS

A comprehensive literature search was conducted using PubMed, the Web of Science, the Cochrane Library, and Google Scholar to identify case reports on track recurrence after endoscopic or robotic thyroidectomy up to June 2024. Data included patient demographics, details of the initial surgery and diagnosis, methods and timing of recurrence detection, and management strategies.

RESULTS

The search yielded 1578 articles, of which 17 case reports comprising 18 patients were included. The patients (16 females and two males) had a mean age of 34.6 ± 14.9 years. The mean size of initial tumors was 3.9 ± 1.2 cm, with diagnoses of eight cancers and 10 benign lesions. The initial surgeries included 12 endoscopic and six robotic procedures. Track recurrence was most often detected by palpable nodules followed by routine imaging and elevated serum Tg levels. The interval between initial surgery and recurrence ranged from 3 months to 8 years. Management varied from surgical resection and radioactive iodine therapy to close observation. There were no further recurrences in all but one case postoperatively.

CONCLUSION

Track recurrence after remote-access thyroidectomy is rare but significant. Proper surgical techniques, careful handling of thyroid tissue, and rigorous postoperative monitoring are essential to minimize this risk. Awareness and prompt management of track recurrence may lead to favorable outcomes.

FBXO2 promotes the progression of papillary thyroid carcinoma through the p53 pathway

Emerging evidence have demonstrated that F-box only protein 2 (FBXO2) is intimately associated with malignant tumor development and occurrence. However, neither the functions nor the molecular mechanisms underlying FBXO2 have been determined in the papillary thyroid carcinoma (PTC). The quantitative real-time PCR (qRT-PCR), western blotting and immunohistochemistry were carried out to detect the FBXO2 expression in PTC tissues. CCK-8 assay, EdU assay and flow cytometry were used to assess cell proliferation, cell cycle and apoptosis. The trans-well assay was conducted to determine the cell invasiveness. The effect of FBXO2 on PTC cell proliferation in vivo was observed through a subcutaneous tumor formation experiment in nude mice. Immunoprecipitation were conducted to detect the interaction between FBXO2 and p53. The ubiquitination assays were conducted to assess the regulation of p53 ubiquitination by FBXO2. FBXO2 was overexpressed in both PTC tissues and cell lines. FBXO2 expression positively correlated with PTC tumor size, lymphatic metastasis, and extramembranous invasion. Furthermore, silencing FBXO2 inhibited PTC cell proliferation and promoted apoptosis. The overexpression of FBXO2 significantly promotes PTC cell proliferation. Mechanistic studies revealed that FBXO2 could directly bind to p53 and promote its ubiquitination degradation. Knockdown of p53 partially reversed the progression arrest induced by FBXO2 Knockdown in PTC cells. FBXO2 knockdown inhibited PTC cell proliferation and promoted apoptosis by targeting p53 for ubiquitination and degradation. This process represents a research foundation for its diagnostic and therapeutic applications.

Advancing Reduction Mammaplasty Surgery: Advancements and Outcomes with Tumescent Local Anaesthesia

BACKGROUND

Tumescent local anaesthesia (TLA) is a method of anaesthesia used for surgical procedures that involves the infusion of a saline solution containing lidocaine, sodium bicarbonate, and epinephrine. This anaesthetic technique is designed to achieve both vasoconstriction and anaesthesia. In this article, we present a modified TLA protocol specifically adapted for reduction mammaplasty, based on an analysis of clinical case histories collected over the past few years.

METHODS

During the period from 2012 to 2022, we performed a reduction mammaplasty procedure in 120 patients employing tumescent local anaesthesia (TLA). The composition of the tumescent solution included 25 mL of 2% lidocaine, 8 mEq of sodium bicarbonate, and 1 mL of epinephrine (1 mg/1 mL) in 1000 mL of 0.9% saline solution. The solution was injected diffusely throughout the mammary gland.

RESULTS

The average volume of tumescent solution infiltrated during TLA was 350 mL per breast. There were no cases of adrenaline or lidocaine toxicity, and no patients required conversion to general anaesthesia. No patient received sedation. Patients reported no pain or discomfort during pre-operative infiltration or during surgery. No reinterventions were necessary because of short-term complications. Among the complications, there were 4 cases of hematoma (3,3%), 3 cases of seroma (2,55%), 10 cases of wound dehiscence (8,3%), 5 cases of asymmetry (4,1%), 9 cases of T-junction breakdown (7,5%), 2 cases of (partial) nipple necrosis (1,6%), and 3 cases of liponecrosis (2,5%). No cases of infection or total nipple-areola loss were reported. The follow-up period was between 30 days and 1 year.

CONCLUSIONS

Reduction mammaplasty is a viable surgical option for women with macromastia seeking to enhance their physiognomy. It is imperative that patients fully understand the potential benefits and risks associated with the procedure and consult with healthcare professionals specialising in this field. The use of tumescent local anaesthesia (TLA) has been confirmed as a safe and effective methodology to perform reduction mammaplasty, ensuring adequate pain control with minimal post-operative complications and resulting in a high degree of patient satisfaction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BRAF V600E mutation in thyroid carcinoma: a large-scale study in Han Chinese population

BACKGROUND

The prevalence of genetic mutations in thyroid cancer varies significantly among different ethnic backgrounds. The present study aimed to investigate the clinical potential of BRAF V600E in a large group of homogenous Han Chinese patients.

METHODS

From 2018 to 2021, 6232 thyroid disease patients who underwent thyroidectomy at our hospital were enrolled. We measured the diagnostic value of BRAF and plotted ROC curves. Patients with full clinical-pathological data were selected and divided into the BRAF mutation and wild type groups. We conducted univariate and multivariate analyses to quantify the differences in potential predictive factors of papillary thyroid carcinoma (PTC) patients between the groups. Kaplan-Meier survival analysis was used to estimate overall recurrence and recurrence rate.

RESULTS

The prevalence of BRAF V600E mutation was 86.0% in PTCs. The sensitivity and specificity of BRAF mutation for diagnosing PTC from suspicious lesions were 85.5% and 100%, respectively. The sensitivity and specificity of BRAF analysis in the indeterminate cytology group were 72.5% and 100%, respectively. BRAF mutation showed an independent association with older age, negative HT, larger tumor size, extrathyroidal extension, and multifocality in PTCs. In micro-PTCs (tumor size ≤ 1), the mutation was also positively correlated with progressive phenotypes of extrathyroidal extension and multifocality. BRAF mutation was associated with poorer recurrence-free probability in Kaplan-Meier survival analysis.

CONCLUSIONS

This large single-center study reveals that BRAF V600E is highly prevalent in the Han Chinese population and demonstrates BRAF V600E mutation testing has high diagnostic accuracy and its strong association with the progress of aggressiveness in PTCs and a higher probability of recurrence. BRAF mutation can serve as an accurate marker for diagnosis and decision-making with great value.

National Trends and In-Hospital Outcomes for Immediate Implant-Based Versus Autologous-Based Breast Reconstruction: A Propensity Score-Matched Analysis

BACKGROUND

Breast reconstruction consists primarily of two methods: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). Each of these methods has its advantages and disadvantages. The current study used the National Inpatient Sample (NIS), the largest inpatient database in the United States, to explore the trends, complications, and disparities in the use of IBR and ABR.

METHODS

The current study used the NIS database from 2016 to 2020, including the International Classification of Diseases, 10th version (ICD-10) codes. A propensity score-matching (1:1) analysis was used to match the IBR and ABR groups.

RESULTS

The percentage of breast reconstruction increased from 58.8% in 2016 to 63.4% by 2020. The trend of ABR was upward, and the trend of IBR was downward. In addition, the ABR group had significantly higher rates of cardiovascular complications (odds ratio [OR], 1.29), respiratory complications (OR, 4.26), vascular complications requiring surgery (OR, 7.82), blood transfusions (OR, 3.44), vasopressor need (OR, 1.409), and acute kidney injury (OR, 1.68). However, the ABR group had significantly lower rates of wound infection (OR, 0.430), wound dehiscence (OR, 0.213), wound seroma (OR, 0.602), and sepsis (OR, 0.252). A significant disparity was found in using ABR for different subgroups based on age, hospital teaching status, racial background, socioeconomic status, and hospital bed size.

CONCLUSION

The current study showed an upward trend in the utilization of ABR and a downward trend for IBR. Although ABR had a higher rate of pulmonary, cardiovascular, vascular, and bleeding complications, it had a lower rate of wound-related complications.

Artificial intelligence-based pathological application to predict regional lymph node metastasis in Papillary Thyroid Cancer

In this study, a model for predicting lymph node metastasis in papillary thyroid cancer was trained using pathology images from the TCGA(The Cancer Genome Atlas) public dataset of papillary thyroid cancer, and a front-end inference model was trained using our center's dataset based on the concept of probabilistic propagation of nodes in graph neural networks. Effectively predicting whether a tumor will spread to regional lymph nodes using a single pathological image is the capacity of the model described above. This study demonstrates that regional lymph nodes in papillary thyroid cancer are a common and predictable occurrence, providing valuable ideas for future research. Now we publish the above research process and code for further study by other researchers, and we also make the above inference algorithm public at the URL: http:// thyroid-diseases-research.com/, with the hope that other researchers will validate it and provide us with ideas or datasets for further study.

The application value of two-dimensional ultrasound combined with contrast-enhanced ultrasound in the differential diagnosis of benign, borderline, and malignant ovarian epithelial tumors

OBJECTIVE

The aim of this study was to explore the clinical application value of two-dimensional ultrasound (2D-US) combined with contrast-enhanced ultrasonography (CEUS) in the differential diagnosis of benign, borderline ovarian tumors (BOTs), and malignant ovarian epithelial tumors (OETs).

METHODS

The clinical data of 108 patients who underwent surgery for pathologically confirmed of OETs at Peking University People's Hospital between December 2018 and November 2023 were retrospectively studied. The diagnostic value of 2D-US combined with CEUS for diagnosing OETs was analyzed using chi-square tests, receiver operating characteristic (ROC) curves, and random forest models.

RESULTS

Among the 108 cases of OETs, 23 were benign, 34 were BOTs, and 51 were malignant. Chi-square tests confirmed that the perfusion pattern of the contrast agent plays an important role in the differential diagnosis of OETs. Compared with those in the benign group, the BOTs were not significantly different in terms of perfusion phase and enhancement intensity, but the regression time of the BOTs was earlier (P < 0.05). Compared with the BOTs, the malignant tumors group showed earlier perfusion and higher enhancement intensity, with no significant difference in regression time. The ROC curve results indicated that the combined diagnostic efficiency of 2D-US and CEUS in distinguishing OETs was significantly higher than that of a single diagnostic technique in terms of sensitivity, specificity, accuracy, and AUC. The random forest model results revealed that among the various parameters used in the differential diagnosis of OETs, the perfusion pattern was the most significant factor.

CONCLUSION

2D-US combined with CEUS helps improve the differential diagnostic efficiency for benign, BOTs, and malignant OETs.

Molecular genetics, therapeutics and RET inhibitor resistance for medullary thyroid carcinoma and future perspectives

Medullary thyroid carcinoma (MTC) is a rare type of thyroid malignancy that accounts for approximately 1-2% of all thyroid cancers (TCs). MTC include hereditary and sporadic cases, the former derived from a germline mutation of rearrangement during transfection (RET) proto-oncogene, whereas somatic RET mutations are frequently present in the latter. Surgery is the standard treatment for early stage MTC, and the 10-year survival rate of early MTC is over 80%. While for metastatic MTC, chemotherapy showing low response rate, and there was a lack of effective systemic therapies in the past. Due to the high risk (ca. 15-20%) of distant metastasis and limited systemic therapies, the 10-year survival rate of patients with advanced MTC was only 10-40% from the time of first metastasis. Over the past decade, targeted therapy for RET has developed rapidly, bringing hopes to patients with advanced and progressive MTC. Two multi-kinase inhibitors (MKIs) including Cabozantinib and Vandetanib have been shown to increase progression-free survival (PFS) for patients with metastatic MTC and have been approved as choices of first-line treatment. However, these MKIs have not prolonged overall survival (OS) and their utility is limited due to high rates of off-target toxicities. Recently, new generation TKIs, including Selpercatinib and Pralsetinib, have demonstrated highly selective efficacy against RET and more favorable side effect profiles, and gained approval as second-line treatment options. Despite the ongoing development of RET inhibitors, the management of advanced and progressive MTC remains challenging, drug resistance remains the main reason for treatment failure, and the mechanisms are still unclear. Besides, new promising therapeutic approaches, such as novel drug combinations and next generation RET inhibitors are under development. Herein, we overview the pathogenesis, molecular genetics and current management approaches of MTC, and focus on the recent advances of RET inhibitors, summarize the current situation and unmet needs of these RET inhibitors in MTC, and provide an overview of novel strategies for optimizing therapeutic effects.

Induced Pluripotent Stem Cell-Derived Parathyroid Organoids Resemble Parathyroid Morphology and Function

The primary role of the parathyroid glands is to maintain calcium homeostasis through the secretion of parathyroid hormone (PTH). The limited proliferative capacity and differentiation of parathyroid cells hinder the generation of cell therapy options. In this study, parathyroid organoids are successfully generated from human-induced pluripotent stem cells (hiPSCs). At the end of the 20 days of differentiation, the parathyroid organoids exhibited distinct parathyroid morphology. Stereomicroscope, scanning electron microscopy (SEM), and transmission electron microscopy (TEM) analysis demonstrated the 3D arrangement of the cell layers in which intracellular structures of parathyroid cells resemble human parathyroid cellular morphology. Comprehensive molecular analyses, including RNA sequencing (RNA-Seq) and liquid chromatography/mass spectrometry (LC-MS/MS), confirmed the expression of key parathyroid-related markers. Protein expression of CasR, CxCr4, Gcm2, and PTH are observed in parathyroid organoids. Parathyroid organoids secrete PTH, demonstrate active intercellular calcium signaling, and induce osteogenic differentiation via their secretome. The tissue integration potential of parathyroid organoids is determined by transplantation into parathyroidectomized rats. The organoid transplanted animals showed significant elevations in PTH-related markers (CasR, CxCr4, Foxn1, Gcm2, and PTH). PTH secretion is detected in organoid-transplanted animals. The findings represent a significant advancement in parathyroid organoid culture and may offer a cellular therapy for treating PTH-related diseases, including hypoparathyroidism.

Application of three-dimensional visualization technology in early surgical repair of bile duct injury during laparoscopic cholecystectomy

OBJECTIVE

This study aimed to explore the application value of three-dimensional (3D) visualization technology in the early surgical repair of bile duct injury during laparoscopic cholecystectomy (LC).

METHODS

A retrospective analysis was conducted on the clinical data of 15 patients who underwent early surgical repair of bile duct injury during LC with the assistance of 3D visualization technology at the Hepatobiliary Surgery Department of Ningxia Hui Autonomous Region People's Hospital from January 2019 to December 2022. Postoperative efficacy and long-term follow-up outcomes were summarized.

RESULTS

Before the repair surgery, 15 cases of bile duct injury during LC were evaluated using 3D visualization technology according to the Strasberg-Bismuth classification: 2 cases of type C, 4 of type E1, 3 of type E2, 3 of type E3, and 3 of type E4. Intraoperative findings were consistent with the 3D visualization reconstruction results, and all patients successfully underwent hepaticojejunostomy using Roux-en-Y anastomosis guided by the 3D visualization navigation. The time interval between LC and bile duct repair surgery ranged from 5 to 28 (14.2 ± 9.7) days. The surgical time was between 120 and 190 (156.40 ± 23.92) min, and estimated blood loss ranged from 80 to 250 (119.66 ± 47.60) mL. The length of hospital stay ranged from 12 to 25 days (median: 16 days). One patient experienced mild bile leakage after the operation, which healed with conservative treatment. All patients were followed up for 12-56 months (median: 34 months) without any loss to follow-up. During the follow-up period, no complications, such as anastomotic stricture or stone formation, were observed.

CONCLUSION

The application of 3D visualization technology for preoperative evaluation and intraoperative navigation can accurately and effectively facilitate early surgical repair of bile duct injury during LC and has clinical value for promotion and application.

Does the use of Acellular Dermal Matrices (ADM) in women undergoing pre-pectoral implant-based breast reconstruction increase operative success versus non-use of ADM in the same setting? A systematic review

BACKGROUND

Breast cancer is the most common malignancy among women in the UK. Reconstruction - of which implant-based breast reconstruction (IBBR) is the most common - forms a core part of surgical management of breast cancer. More recently, pre-pectoral IBBR has become common as technology and operative techniques have evolved. Many surgeons use acellular dermal matrix (ADM) in reconstruction however there is little evidence in literature that this improves surgical outcomes. This review will assess available evidence for surgical outcomes for breast reconstructions using ADM versus non-use of ADM.

METHODS

A database search was performed of Ovid Medline, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (2012-2022). Studies were screened using inclusion and exclusion criteria. Risk of Bias was assessed using the Newcastle Ottawa scale and ROBIS tools. Analysis and meta-analysis were performed.

RESULTS

This review included 22 studies (3822 breast reconstructions). No significant difference between overall complications and failure rates between ADM and non-ADM use was demonstrated. Capsular contracture, wound dehiscence and implant rippling had significant differences however these results demonstrated high heterogeneity thus wider generalisation may be inaccurate. Patient quality of life scores were not recorded consistently or comparably between papers.

CONCLUSIONS

This review suggests a lack of significant differences in most complications between ADM use and non-use for pre-pectoral IBBR. If no increase in complications exists between groups, this has significant implications for surgical and legislative decision-making. There is, however, inadequate evidence available on the topic and further research is required.

Explainable machine learning model for predicting paratracheal lymph node metastasis in cN0 papillary thyroid cancer

Prophylactic dissection of paratracheal lymph nodes in clinically lymph node-negative (cN0) papillary thyroid carcinoma (PTC) remains controversial. This study aims to integrate preoperative and intraoperative variables to compare traditional nomograms and machine learning (ML) models, developing and validating an interpretable predictive model for paratracheal lymph node metastasis (PLNM) in cN0 PTC patients. We retrospectively selected 3213 PTC patients treated at the First Affiliated Hospital of Chongqing Medical University from 2016 to 2020. They were randomly divided into the training and test datasets with a 7:3 ratio. The 533 PTC patients treated at the Guangyuan Central Hospital from 2019 to 2022 were used as an external test sets. We developed and validated nine ML models using 10-fold cross-validation and grid search for hyperparameter tuning. The predictive performance was evaluated using ROC curves, decision curve analysis (DCA), calibration curves, and precision-recall curves. The best model was compared to a traditional logistic regression-based nomogram. The XGBoost model achieved AUC values of 0.935, 0.857, and 0.775 in the training, validation, and test sets, respectively, significantly outperforming the traditional nomogram model with AUCs of 0.85, 0.844, and 0.769, respectively. SHapley Additive exPlanations (SHAP)-based visualization identified the top 10 predictive features of the XGBoost model, and a web-based calculator was created based on these features. ML is a reliable tool for predicting PLNM in cN0 PTC patients. The SHAP method provides valuable insights into the XGBoost model, and the resultant web-based calculator is a clinically useful tool to assist in the surgical planning for paratracheal lymph node dissection.

Non-Diagnostic Fine Needle Aspiration of Thyroid Nodules: Review of Pre-disposing Factors

BACKGROUND

Fine needle aspiration (FNA) of thyroid nodules is the gold standard screening test for thyroid malignancy. Unfortunately, FNA may produce insufficient material for diagnosis. If nodules requiring FNA with a higher risk for non-diagnostic (ND) cytology could be identified pre-procedure, this might allow better patient guidance and potentially facilitate an altered approach to FNA.

SUMMARY

The literature investigating risk factors for ND cytology was reviewed, including studies of patient factors, sonographic or nodule factors, and procedural factors. Twenty-five studies that included assessment of at least two potential factors in ND outcomes for initial FNA were identified. Individual factors were evaluated in terms of the general consensus of studies reporting either a positive significant association with ND cytology or no association.

CONCLUSION

Most patient and nodule factors lack consensus as far as their association with ND cytology across these studies. However, a number of study design improvements suggested by this review could realistically be incorporated into higher powered future studies. Novel factors such as tissue composition anterior to the nodule or the age of the patient could also be investigated in future work. Operator experiences is the most convincing procedural factor, and approaches to future studies of the FNA technique itself are proposed. That said, the factors with consensus amongst studies can be seen leading candidates for this future research, and the published studies illuminate a number of as yet unexplored factors that could in many cases be studied retrospectively.

Near-Infrared Autofluorescence Signatures of Single- vs Multigland Disease in Primary Hyperparathyroidism

Importance

The success of parathyroidectomy depends on accurate intraoperative localization and identification of all diseased glands in parathyroid exploration based on surgeon expertise to prevent persistent hyperparathyroidism. Near-infrared autofluorescence (NIRAF) imaging has recently emerged as a promising adjunctive intraoperative tool for localizing parathyroid glands; however, its potential utility in the assessment of parathyroid glands has yet to be established.

Objective

To analyze the differences in NIRAF signatures of parathyroid glands in single vs multiple glands in primary hyperparathyroidism (pHPT).

Design, Setting, and Participants

This prospective diagnostic study analyzed in vivo NIRAF images of parathyroid glands obtained during parathyroidectomies between November 18, 2019, and December 31, 2023, at a single tertiary referral center. Pixel intensities of the images were measured using third-party software. Patients who underwent parathyroidectomy for sporadic pHPT using a second-generation NIRAF imaging device were included. Patients with multiple endocrine neoplasm disorders were excluded. In vivo NIRAF images obtained during the procedures were analyzed.

Exposure

Near-infrared autofluorescence imaging during parathyroidectomy.

Main Outcomes and Measures

The primary outcomes were the autofluorescence intensity and heterogeneity of single adenomas and multigland disease (ie, double adenomas and 3- or 4-gland hyperplasia) in sporadic pHPT. Normalized autofluorescence intensity was calculated by dividing the mean pixel intensity of the parathyroid gland by the background tissue. A heterogeneity index was calculated by dividing the standard deviation by the mean pixel intensity of the gland. The secondary outcome was the visibility of each parathyroid gland on NIRAF imaging before it became apparent to the naked eye during exploration.

Results

A total of 1287 in vivo NIRAF images obtained from 377 patients (median [IQR] age, 66 [56-73] years; 299 female [79.3%]) were analyzed. Of all patients, 230 (61.0%) had a single adenoma, 91 (24.1%) had double adenomas, and 56 (14.9%) had 3- or 4-gland hyperplasia. A mean (SD) of 3.4 (1.1) parathyroid glands were identified in the procedures. A comparison of 581 diseased glands (45.1%) and 706 normal glands (54.9%) showed a lower median normalized autofluorescence intensity of 2.09 (95% CI, 1.07-4.01) vs 2.66 (95% CI, 1.43-4.20; effect size = 0.36) and higher heterogeneity index of 0.18 (95% CI, 0.07-0.41) vs 0.11 (95% CI, 0.01-0.27; effect size = 0.45), respectively. Of diseased glands, single adenomas (233 [40.1%]) vs double adenomas (187 [32.2%]) and 3- or 4-gland hyperplasia (161 [27.7%]) had a lower median autofluorescence intensity of 1.92 (95% CI, 1.02-4.44) vs 2.22 (95% CI, 1.10-3.97; effect size = 0.21), respectively. On receiver operating characteristic analysis, the optimal autofluorescence intensity threshold to differentiate between single adenomas vs multigland disease was 2.14, with a sensitivity of 64.4%, specificity of 58.1%, and area under the curve of 0.626.

Conclusions and Relevance

These findings suggest that parathyroid glands in single- vs multigland disease may exhibit different autofluorescence characteristics. Although the effect size was modest, the differences identified should be kept in mind when assessing the parathyroid glands during surgical exploration.

New challenges in scar therapy: the novel scar therapy strategies based on nanotechnology

The pathological mechanism of pathological scar is highly complex, encompassing the abnormalities of diverse cytokines, signaling pathways and regulatory factors. To discover more preferable scar treatment options, a variety of distinct approaches have been utilized clinically. Nevertheless, these treatments possess certain side effects and are inclined to relapse. Presently, pathological scar treatment remains a clinical conundrum, and there is an urgent demand for treatment methods that are safe, less traumatic and have lower recurrence rates. New drug delivery systems, novel therapeutic drugs and therapy strategies can enable drugs to permeate the skin effectively, decrease side effects, enhance drug efficacy and even achieve pain-free self-administration. Currently, novel nanotechnologies such as nanomicroneedles, photodynamics mediated by novel photosensitizers, bioelectrical stimulation and 3D printed dressings have been developed for the effective treatment of pathological scars. Additionally, innovative nanoscale fillers, including nano-fat and engineered exosomes, can serve as novel therapeutic agents for the efficient treatment of pathological scars. The intervention of nanomaterials can enhance drug absorption, stabilize and safeguard the active ingredients of drugs, delay or control drug release and enhance bioavailability. This article reviews these new treatment strategies for scar to explore novel approaches for efficient and safe for keloid treatment.