Chyle Leak After Axillary Node Clearance in Breast Cancer Surgery-A Rare Complication and a Proposed Management Strategy from the British and Italian Experience

BACKGROUND

Chyle leak after axillary surgery is a rare complication that lacks consensus and management guidelines. This study aimed to present the experiences of two centers in chyle leak management after axillary node clearance for breast cancer. Furthermore the authors provide a review of its pathophysiology and clinical diagnostic methods. They compare approaches for management of the axilla with those for other locations.

METHODS

A multicentre case series descriptive analysis of chyle leak after breast cancer axillary node clearance between 1 January 2013 and 31 May 2020 was performed.

RESULTS

The center in the United Kingdom and the center in Italy performed 655 and 4969 axillary node clearances, respectively. Four patients experienced chyle leaks. All the leaks had left-sided surgery (3 patients had level 3 clearances with mastectomy and implant-based breast reconstructions; 1 patient had level 2 clearance with therapeutic mammoplasty). All the leaks appeared within 3 days after surgery. Leak duration was between 11 and 29 days. The maximum daily output was 600 mL. All the leaks were treated conservatively with nutritional team support together with close drainage monitoring. The management strategy included a low-fat diet, a high-protein diet, total parenteral nutrition, and medium chain triglyceride supplements, as well as other elements. No negative effects on oncoplastic and reconstructive breast surgery wound-healing and no delays in adjuvant treatment were observed.

CONCLUSION

The incidence of chyle leak after breast cancer axillary node clearance was 0.07%. Early diagnosis and close monitoring together with conservative management involving nutritional team support can result in successful treatment of chyle leak without negative sequalae of breast cancer oncologic treatment.

Malignant phyllodes tumor of the breast: a systematic review

Phyllodes tumors (PT) are fibroepithelial neoplasms of the breast showing a peculiar leaf-like appearance. They account for 0.3 to 1% of all primary breast tumors and 2.5% of all fibroepithelial breast tumors. PT are classified into benign, borderline and malignant based upon their stromal morphology with a distribution of 60%, 20%, and 20%, respectively. Malignant PT of the breast constitute an uncommon challenging group of fibroepithelial neoplasms. They have a relatively high tendency to recur, although distant metastasis is uncommon, and nearly exclusive to malignant PT. Adequate surgical resection remains the standard approach to achieve maximal local control. Giant malignant PT are rare and a pose a diagnostic dilemma for pathologists, especially when comprised of sarcomatous elements. This review highlights the morphological features of PT detected in cytology and histology specimens and discusses diagnostic pitfalls and differential diagnosis.

Strategies for Breast Cancer Surgery During & After COVID-19 Pandemic

Background: In December 2019, a severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), also named “COVID-19”, has produced a global pandemic and has seriously affected many health systems around the world. Since the World Health Organization (WHO) declared the novel COVID-19 outbreak as a global pandemic, many international societies and groups of experts have published clinical guidelines and recommendations for surgical management of breast cancer patients in this time of crisis and issued COVID guidelines to prioritize surgery where time is critical and it cannot be deferred.Methods: In this study, we review current recommendations for breast cancer surgery during the COVID-19 pandemic and propose a plan for future waves of the current pandemic while minimizing the risk of the contagious disease and oversaturating the health systems regarding the burden of accumulating untreated disease.Results: We create a critical and constructive vision from learnt lessons for similar future situations and propose a moving forward plan during and after the COVID-19 pandemic.  Conclusion: Although in many parts of world, it would appear that now we are past the peak of the COVID-19 pandemic, we still face as uncertainty as to the future course of the pandemic and the challenges of the second wave. It is important to reappraise continuously the guidance and to emphasize the need for new protocols under new norms to continue to deliver breast cancer surgery safely.

Advances and controversies in management of breast ductal carcinoma in situ (DCIS)

Ductal carcinoma in situ (DCIS) is a non-obligate precursor of invasive breast cancer. It accounts for 25% of all breast cancers diagnosed, as a result of the expansion of breast cancer screening and is associated with a high survival rate. DCIS is particularly clinically challenging, due to its heterogeneous pathological and biological traits and its management is continually evolving towards more personalized and less aggressive therapies. This article suggests evidence-based guidelines for proper DCIS clinical management, which should be discussed within a multidisciplinary team in order to propose the most suitable approach in clinical practice, taking into account recent scientific studies. Here we include updated multidisciplinary treatment protocols and techniques in accordance with the most recent contributions published on this topic in the peer-reviewed medical literature, and we outline future perspectives.

Atypical Ductal Hyperplasia after Vacuum-Assisted Breast Biopsy: Can We Reduce the Upgrade to Breast Cancer to an Acceptable Rate?

(1) Background: to evaluate which factors can reduce the upgrade rate of atypical ductal hyperplasia (ADH) to in situ or invasive carcinoma in patients who underwent vacuum-assisted breast biopsy (VABB) and subsequent surgical excision. (2) Methods: 2955 VABBs were reviewed; 141 patients with a diagnosis of ADH were selected for subsequent surgical excision. The association between patients’ characteristics and the upgrade rate to breast cancer was evaluated in both univariate and multivariate analyses. (3) Results: the upgrade rates to ductal carcinoma in situ (DCIS) and invasive carcinoma (IC) were, respectively, 29.1% and 7.8%. The pooled upgrade rate to DCIS or IC was statistically lower at univariate analysis, considering the following parameters: complete removal of the lesion (p-value < 0.001); BIRADS ≤ 4a (p-value < 0.001); size of the lesion ≤15 mm (p-value: 0.002); age of the patients <50 years (p-value: 0.035). (4) Conclusions: the overall upgrade rate of ADH to DCIS or IC is high and, as already known, surgery should be recommended. However, ADH cases should always be discussed in multidisciplinary meetings: some parameters appear to be related to a lower upgrade rate. Patients presenting these parameters could be strictly followed up to avoid overtreatment.

Update on the Feasibility and Progress on Robotic Breast Surgery

BACKGROUND

Robotic nipple-sparing mastectomy (RNSM) may allow for more precise anatomic dissection and improved cosmetic outcomes over conventional open nipple-sparing mastectomy; however, data regarding the feasibility and safety of the procedure are limited.

OBJECTIVE

The aim of this study was to present and discuss perioperative surgical outcomes and early oncologic follow-up data on consecutive patients undergoing RNSM from June 2014 to January 2019.

METHODS

Patients underwent RNSM and immediate robotic breast reconstruction through an axillary incision at a single institution. Perioperative data, complications at 3 months postoperatively, pathological data, and adjuvant therapies were recorded. Local recurrence-free, disease-free, and overall survival were analyzed.

RESULTS

Overall, 73 women underwent 94 RNSM procedures. Indications were invasive breast cancer in 39 patients, ductal carcinoma in situ in 17 patients, and BRCA mutation in 17 patients. Mean surgery time was 3 h and 32 min. One-step reconstruction with implant occurred in 89.4% of procedures. The rate of complications requiring reoperation was 4.3%, and the rate of flap or nipple necrosis was 1.1%. Median follow-up was 19 months (range 3.1-44.8). No local recurrences occurred. Overall survival at 12, 24, or 60 months was 98% (95% confidence interval 86-100%).

CONCLUSION

We observed a low complication rate in 94 consecutive RNSM procedures, demonstrating the procedure is technically feasible and safe. We found no early local failures at 19 months follow-up. Long-term follow-up is needed to confirm oncologic safety. Future clinical trials to study the advantages and disadvantages of RNSM are warranted.

Intra-operative radiotherapy management for breast cancer treatment in patients with pseudoxanthoma elasticum: A case report

Pseudoxanthoma elasticum is a systemic metabolic disease presenting calcifications and progressive fragmentation of elastic fibers. Actually, no targeted therapies are available for the treatment; only prevention of complications is possible. Classically, pseudoxanthoma elasticum is a "benign" disease, without cancer association. Herein, we reported a singular association of pseudoxanthoma elasticum with breast carcinoma, describing the clinical management, in particular intra-operative treatment, focusing on intra-operative radiotherapy since no specific guidelines are available in literature.

Feasibility of lymphoscintigraphy for sentinel node identification after neo-adjuvant therapy

AIM

To assess the sentinel-node identification rate at lymphoscintigraphy and its technical feasibility after neo-adjuvant treatments.

MATERIAL OF STUDY

Between 2000 and 2013, 444 consecutive patients affected by primary locally advanced breast cancer were enrolled in this study. All individuals were candidate for neo-adjuvant treatments and for lymphoscintigraphy before surgery.

RESULTS

The median age was 44 years at onset; almost one sentinel node was identified during lymphoscintigraphy in 430 cases. The detection rate at lymphoscintigraphy was 96.9% (95% CI, 94.8-98.1%). Considering the correlation between specific treatments and sentinel node identification rate, we verified that the detection rate did not vary significantly (p=0.53) according to the type of neo-adjuvant therapies administered to the patients.

CONCLUSIONS

Our results demonstrated that lymphoscintigraphy for sentinel node identification is a safe and feasible procedure after neo-adjuvant therapies, independently of treatment types.

KEY WORDS

Breast Cancer, Neo-Adjuvant Treatment, Sentinel lymphnode biopsy, Lymphoscintigraphy.

Surgical management of the pancreatic stump following pancreato-duodenectomy

Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.

Emergency pancreaticoduodenectomy: When is it needed? A dual non-trauma centre experience and literature review

INTRODUCTION

Emergency pancreaticoduodenectomy (EPD) has been very rarely reported in literature as a lifesaving procedure for complex pancreatic injury, uncontrollable hemorrhage from ulcers and tumors, descending duodenal perforations, and severe infection. The aim of this study was to analyze the experience of two non-trauma centers and to review the literature concerning emergency pancreaticoduodenectomy.

METHODS

From January 2005 to December 2014, from a population of 169 PD (92 females and 77 males; mean age: 61.3, range 23-81) 5 patients (3%; 2 females and 3 males; mean age: 57.8, range: 42-74) underwent EPD for non-traumatic disease performed at two Academic Units of the University of Bari.

RESULTS

The emergency pancreaticoduodenectomy subgroup of patients showed an overall morbidity of 80%, and mortality of 40%. In 80% (4/5) of patients treated by emergency pancreaticoduodenectomy, the pancreatic remnant was not reconstructed, and in 20% (1/5) a pancreaticojejunostomy was performed.

CONCLUSION

Emergency pancreaticoduodenectomy is an effective life-saving operation reservable to pancreatoduodenal trauma, perforations, and bleeding, unmanageable by a less invasive approach. It should be preferentially approached by surgeons with a high level of experience in hepatobiliary and pancreatic surgery and in trauma centers too, but it should also be in the armamentarium of general surgeons performing hepato-pancreato-biliary surgery.

Impact of pericardium bovine patch (Tutomesh(®)) on incisional hernia treatment in contaminated or potentially contaminated fields: retrospective comparative study

PURPOSE

This retrospective comparative study analyzes the outcome of patients affected by incisional hernia in potentially contaminated or contaminated field, treated by three operative techniques.

METHODS

152 patients (62 M:90 F; mean age 65 ± 14 years) underwent incisional hernia repair (January 2002-January 2012) in complicated settings. Criteria of inclusion in the study were represented by the following causes of admission: mesh rejection/infection, obstruction without gangrene but with possible peritoneal bacterial translocation, obstruction with gangrene, enterocutaneous fistula or simultaneous presence of ileo- or colostomy. The patients were divided into three groups: A (n = 76), treated with primary closure technique; B and C (n = 38 each), with reinforcement by synthetic or pericardium bovine mesh (Tutomesh(®)), respectively. The prosthetic groups were divided into Onlay and Sublay subgroups.

RESULTS

Significant decreases in C vs A were observed for wound infection (3 vs 37%) and recurrence (0 vs 14%), and in C vs B for wound infection (3 vs 53%), seroma (0 vs 34%) and recurrence (0 vs 16%). Patients with concomitant bowel resection (BR) (43%) showed (all P < 0.05) an increase of overall morbidity (55 vs 33%) and wound infection rate (42 vs 24%) compared to cases without BR. Morbidity presented no significant differences in C-Onlay or Sublay subgroups. B-Sublay subgroup has (all P < 0.05) lower overall morbidity (20 vs 75%), wound infection (10 vs 68%) and seroma (0 vs 46%) than B-Onlay.

CONCLUSIONS

The pericardium bovine patch seems to be safe and effective to successfully repair ventral hernia in potentially contaminated operative fields, especially in association with bowel resection.

Bovine pericardium patch wrapping intestinal anastomosis improves healing process and prevents leakage in a pig model

Failure of intestinal anastomosis is a major complication following abdominal surgery. Biological materials have been introduced as reinforcement of abdominal wall hernia in contaminated setting. An innovative application of biological patch is its use as reinforcement of gastrointestinal anastomosis. The aim of study was to verify whether the bovine pericardium patch improves the healing of anastomosis, when in vivo wrapping the suture line of pig intestinal anastomosis, avoiding leakage in the event of deliberately incomplete suture. Forty-three pigs were randomly divided: Group 1 (control, n = 14): hand-sewn ileo-ileal and colo-colic anastomosis; Group 2 (n = 14): standard anastomosis wrapped by pericardium bovine patch; Group 3 (n = 1) and 4 (n = 14): one suture was deliberately incomplete and also wrapped by patch in the last one. Intraoperative evaluation, histological, biochemical, tensiometric and electrophysiological studies of intestinal specimens were performed at 48 h, 7 and 90 days after. In groups 2 and 4, no leak, stenosis, abscess, peritonitis, mesh displacement or shrinkage were found and adhesion rate decreased compared to control. Biochemical studies showed mitochondrial function improvement in colic wrapped anastomosis. Tensiometric evaluations suggested that the patch preserves the colic contractility similar to the controls. Electrophysiological results demonstrated that the patch also improves the mucosal function restoring almost normal transport properties. Use of pericardium bovine patch as reinforcement of intestinal anastomosis is safe and effective, significantly improving the healing process. Data of prevention of acute peritonitis and leakage in cases of iatrogenic perforation of anastomoses, covered with patch, is unpublished.

Floating left innominate vein neoplastic thrombus: a rare case of mediastinal extension of follicular thyroid carcinoma

OBJECTIVE

We report a case of advanced follicular thyroid cancer with innominate vein involvement. To our knowledge, this seems to be the first case treated in emergency surgery, reported in literature.

METHOD

A 59-year-old woman with a five-year history of a large and mainly right-sided cervical mass presented with dyspnea, unilateral arm swelling, facial flushing, and venous congestion. An emergency computed tomography scan revealed a thyroid mass extending into the upper mediastinum with displacement and compression of the right jugular vein and carotid artery and apparent adherence to the superior vena cava and left innominate vein.

RESULTS

An emergency total thyroidectomy was performed by means of a sternotomy. The lower portion of the retrosternal goiter projected directly into the left innominate vein, with tumor floating in its lumen. Removal of the neoplastic thrombus was performed, through an incision in the vein, en bloc with the thyroid mass. Both goiter and thrombus were completely replaced by follicular carcinoma.

CONCLUSIONS

Accurate preoperative assessment through contrast-enhanced computed tomography is strongly suggested in the presence of enlarged thyroid gland extending into the mediastinum whenever angioinvasion is suspected. This could prevent blinded maneuvers such as digital externalization of the thoracic component of the gland, which can be fatal in cases of cervico-mediastinal goiter extending into great cervical or mediastinal veins.

Retrospective comparison of Traditional vs. LigaSure impact dissection during pancreatoduodenectomy: how to save money by using an expensive device

Pancreatoduodenectomy is an exceptional procedure that requires an extensive dissection of the supramesocolic region extended to the first jejunal limb. Lymphadenectomy, required for cancer, increases the dissection surface. The extensive preparation of the area is traditionally conducted with bipolar ormonopolar instruments, while clips, ligatures, and sutures are used for haemostasis. LigaSure™ vessel sealing(LSVS; Valleylab, Boulder, CO) is a technology that obtains vessel closure by using the body's own collagen and elastin to create a permanent fusion zone. This is obtained by a combination of forceps pressure and radio frequency. This effect has been improved by the introduction of the Force Triad™ (Valleylab, Boulder,CO) energy platform, controlled by TissueFect™ (Valleylab, Boulder, CO) sensing technology. With this device, the surgeon is able to fuse vessels up to 7 mm, lymphatics, tissue bundles, and pulmonary vasculature in a fast-seal cycle of almost 4 seconds. In our daily practice of open surgery we observe a rapid improvement of abdominal drainage output with a drastic reduction of protein loss. Its practical significance is, in our opinion, that we obtain a rapid recovery of normal serum protein levels with a low number of blood/plasmasac transfusions and a real improvement of anastomosis healing. Moreover, the efficacy and the speed of work of the device allow us to reduce the operating time significantly but safely. We performed a retrospective analysis of the data of 20 pancreatic resections conducted both with traditional dissection and with the Liga-Sure Impact device with Force Triad platform in order to verify whether observed data were real. Our clinical results show that the use of the LigaSure Impact device with Force Triad energy platform is really useful in open surgery to save operating time, number of postoperative days, and hemoderivate administration.

The "BASE-FIRST" technique in laparoscopic appendectomy

BACKGROUND:

Appendicitis is the most common cause of acute abdomen, and appendectomy is the most frequent surgical procedure performed in the world. In recent times, laparoscopic appendectomy has been gaining increasing consensus, although comparison with traditional open surgery is still debated. Recent reports seem to agree in recognizing laparoscopy as the favourable approach in cases of non-complicated appendicitis, in women and in obese patients. The use of a linear stapler to close the appendiceal stump also seems to guarantee a dramatic decrease of complications and this observation could be the rationale for considering the laparoscopic approach to also be safe in complicated appendicitis. In these cases, dissection of the mesoappendix and isolation of the viscum could be very difficult and could cause complications. By proposing this technique using a laparoscopic approach, we try to permit a simple and safe section of the appendix leaving the detachment from vessels and from the neighbourhood to a second moment.

MATERIALS AND METHODS:

We report our initial experience including the first 50 cases and proposing our personal technique of laparoscopic appendectomy.

RESULTS AND CONCLUSION:

We recorded only one intraoperative haemorrhage, one bladder perforation due to trocar insertion and no conversion. Our goal is to standardize and simplify the laparoscopic approach in order to give any surgeon, even non-expert ones, a simple way to remove the viscum especially in complicated pictures.

Emergency total thyroidectomy due to non traumatic disease. Experience of a surgical unit and literature review

Background

Acute respiratory failure due to thyroid compression or invasion of the tracheal lumen is a surgical emergency requiring urgent management. The aim of this paper is to describe a series of six patients treated successfully in the emergency setting with total thyroidectomy due to ingravescent dyspnoea and asphyxia, as well as review related data reported in literature.

Methods

During 2005-2010, of 919 patients treated by total thyroidectomy at our Academic Hospital, 6 (0.7%; 4 females and 2 men, mean age: 68.7 years, range 42-81 years) were treated in emergency. All the emergency operations were performed for life-threatening respiratory distress. The clinical picture at admission, clinical features, type of surgery, outcomes and complications are described. Mean duration of surgery was 146 minutes (range: 53-260).

Results

In 3/6 (50%) a manubriotomy was necessary due to the extension of the mass into the upper mediastinum. In all cases total thyroidectomy was performed. In one case (16.7%) a parathyroid gland transplantation and in another one (16.7%) a tracheotomy was necessary due to a condition of tracheomalacia. Mean post-operative hospital stay was 6.5 days (range: 2-10 days). Histology revealed malignancy in 4/6 cases (66.7%), showing 3 primitive, and 1 secondary tumors. Morbidity consisted of 1 transient recurrent laryngeal palsy, 3 transient postoperative hypoparathyroidism, and 4 pleural effusions, treated by medical therapy in 3 and by drains in one. There was no mortality.

Conclusion

On the basis of our experience and of literature review, we strongly advocate elective surgery for patients with thyroid disease at the first signs of tracheal compression. When an acute airway distress appears, an emergency life-threatening total thyroidectomy is recommended in a high-volume centre.

Nutritional support in patients with acute pancreatitis

Pancreatitis is a diffuse systemic immuno-inflammatory response to a localized process of auto-digestion within the pancreatic gland, caused by premature activation of proteolytic digestive enzymes. According to the ATLANTA criteria (1992) we recognized a mild and a severe acute pancreatitis (SAP ) . Mortality rate in SAP account up to the 20 percent and most complications and deaths are due to an inflammatory immune response to pancreatic necrosis and/or infection. Patients affected by SAP rapidly incur accelerated catabolism and thus nutritional support is essential, especially in the earliest period of the disease. Recent observations show that the route of nutritional support may also affect disease severity and its course. In this view several important questions about nutritional support need to be addressed : indication , timing, enteral vs parenteral and composition . With this review we analyze the state-of-the-art and we present a decisional flow chart to better manage the nutritional support in SAP.

Nutritional support in patients with acute pancreatitis

Pancreatitis is a diffuse systemic immuno-inflammatory response to a localized process of auto-digestion within the pancreatic gland, caused by premature activation of proteolytic digestive enzymes. According to the ATLANTA criteria (1992) we recognized a mild and a severe acute pancreatitis (SAP ) . Mortality rate in SAP account up to the 20 percent and most complications and deaths are due to an inflammatory immune response to pancreatic necrosis and/or infection. Patients affected by SAP rapidly incur accelerated catabolism and thus nutritional support is essential, especially in the earliest period of the disease. Recent observations show that the route of nutritional support may also affect disease severity and its course. In this view several important questions about nutritional support need to be addressed : indication , timing, enteral vs parenteral and composition . With this review we analyze the state-of-the-art and we present a decisional flow chart to better manage the nutritional support in SAP.

Hypercalcaemic crisis due to primary hyperparathyroidism - a systematic literature review and case report

Hypercalcaemic crisis is an uncommon and potentially life-threatening manifestation of primary hyperparathyroidism, and it is associated with rapid deterioration of the central nervous system, and cardiac, gastrointestinal, and renal function. We present the case of a 76 year-old man in a sudden coma due to hypercalcaemic crisis as a first manifestation of primary hyperparathyroidism. At first, the patient was treated conservatively, his mental status gradually improved in the next three days. On the ninth day after the initiation of therapy, a minimally invasive radio-guided parathyroidectomy was performed. Histologically, the tumour consisted of densely arranged chief cells immunohistochemically positive for PTH antigens, suggesting adenoma. Calcaemia level and PTH were normalised in the immediate postoperative period. A systematic review was performed by consulting PubMed MEDLINE for publications from 1958 to 2011. This review found a total of 499 reported cases of hypercalcaemic crisis due to primary hyperparathyroidism. Manifestations are neurological alterations, and cardiac, renal and gastrointestinal dysfunctions associated with markedly elevated serum calcium and parathyroid hormone levels. The most frequent histology is the parathyroid adenoma. In untreated cases, mortality is 100%. Despite advances in its management, the mortality rate is still 93.5% in patients treated only conservatively. Medical therapy followed by expeditious parathyroidectomy should be considered as the treatment of choice for patients affected by hypercalcaemic crisis due to a primary hyperparathyroidism.

Does mediastinal extension of the goiter increase morbidity of total thyroidectomy? A multicenter study of 19,662 patients

PURPOSE

To compare the outcome in patients with cervical goiters and cervicomediastinal goiters (CMGs) undergoing total thyroidectomy using the cervical or extracervical approach.

METHODS

This was a retrospective study conducted at six academic departments of general surgery and one endocrine-surgical unit in Italy. The study population consisted of 19,662 patients undergoing total thyroidectomy between 1999 and 2008, of whom 18,607 had cervical goiter (group A) and 1055 had CMG treated using a cervical approach (group B, n = 986) or manubriotomy (group C, n = 69). The main parameters of interest were symptoms, gender, age, operative time, duration of drain, length of hospital stay, malignancy and outcome.

RESULTS

A split-sternal approach was required in 6.5% of cases of CMG. Malignancy was significantly more frequent in group B (22.4%) and group C (36.2%) versus group A (10.4%; both P < .001), and in group C versus group B (P = .009). Overall morbidity was significantly higher in groups B + C (35%), B (34.4%) and C (53.5%) versus group A (23.7%; P < .001). Statistically significant increases for group B + C versus group A were observed for transient hypocalcemia, permanent hypocalcemia, transient recurrent laryngeal nerve (RLN) palsies, permanent RLN palsies, phrenic nerve palsy, seroma/hematoma, and complications classified as other. With the exception of transient bilateral RLN palsy, all of these significant differences between group B + C versus group A were also observed for group B versus group A.

CONCLUSIONS

Symptoms, malignancy, overall morbidity, hypoparathyroidism, RLN palsy and hematoma are increased in cases of substernal goiter.

Management of mucinous cystic neoplasms of the pancreas

The purpose of this study was to investigate the actual management of mucinous cystic neoplasm (MCN) of the pancreas. A systematic review was performed in December 2009 by consulting PubMed MEDLINE for publications and matching the key words “pancreatic mucinous cystic neoplasm”, “pancreatic mucinous cystic tumour”, “pancreatic mucinous cystic mass”, “pancreatic cyst”, and “pancreatic cystic neoplasm” to identify English language articles describing the diagnosis and treatment of the mucinous cystic neoplasm of the pancreas. In total, 16 322 references ranging from January 1969 to December 2009 were analysed and 77 articles were identified. No articles published before 1996 were selected because MCNs were not previously considered to be a completely autonomous disease. Definition, epidemiology, anatomopathological findings, clinical presentation, preoperative evaluation, treatment and prognosis were reviewed. MCNs are pancreatic mucin-producing cysts with a distinctive ovarian-type stroma localized in the body-tail of the gland and occurring in middle-aged females. The majority of MCNs are slow growing and asymptomatic. The prevalence of invasive carcinoma varies between 6% and 55%. Preoperative diagnosis depends on a combination of clinical features, tumor markers, computed tomography (CT), magnetic resonance imaging, endoscopic ultrasound with cyst fluid analysis, and positron emission tomography-CT. Surgery is indicated for all MCNs.

Combined cardiac surgery and total thyroidectomy: our experience and review of the literature

BACKGROUND

The prevalence of thyroid disease in patients with cardiac disease can be as high as 11.2%. Combined thyroid and cardiovascular surgery has rarely been reported.

METHODS

Ten patients (6 female, 4 male, age range 51-73 years) had total thyroidectomy and cardiac surgery in the same procedure in our surgical department. Six patients had coronary artery disease; four patients had valvulopathy. The thyroid goiter was retrosternal in 6 patients.

RESULTS

Mean stay in the intensive care unit was 46.4 hours; the postoperative course was complicated by transient right laryngeal nerve palsy in one case and by transient hypocalcemia in the patients in whom a parathyroid autotransplantation was performed (n = 3). There was one case of hemodynamic compromise needing vasoactive drug support; the mean hospital stay was 8.4 days.

CONCLUSIONS

Our experience and our review of the literature suggest that a single-stage procedure is safe and feasible and must be preferred to different operations as it has an acceptable peri-operative and anesthesiological risk.

A single-surgeon randomized trial comparing sutures, N-butyl-2-cyanoacrylate and human fibrin glue for mesh fixation during primary inguinal hernia repair

BACKGROUND

We sought to determine the efficacy of sutures, human fibrin glue and N-butyl-2-cyanoacrylate for mesh fixation in patients undergoing the plug and mesh procedure for groin hernia.

METHODS

A total of 156 patients with 167 inguinal hernias (11 bilateral) underwent a plug and mesh procedure and were randomly assigned to received either sutures (n = 59 hernias), human fibrin glue (n = 52) or N-butyl-2-cyanoacrylate (n = 56) for mesh fixation.

RESULTS

The overall morbidity rate was 38.98% in the suture group, 9.62% in the fibrin glue group and 10.71% in the N-butyl-2-cyanoacrylate group (suture v. fibrin glue, p < 0.001; suture v. N-butyl-2-cyanoacrylate, p < 0.001). There was no significant difference in morbidity between the fibrin glue and N-butyl-2-cyanoacrylate groups. Overall, short-term morbidity was significantly higher in the suture group (27.12%) than in the fibrin glue (9.62%, p = 0.01) or N-butyl-2-cyanoacrylate (8.93%, p = 0.004) groups, but there was no significant difference between the fibrin glue and N-butyl-2-cyanoacrylate groups. There was no significant difference between the groups in terms of mean postoperative stay (32.6 h in the suture group v. 30.8 h in the fibrin glue group v. 32.0 h in the N-butyl-2-cyanoacrylate group) or mean time to return to work (20.4 d in the suture group v. 20.3 d in the fibrin glue group v. 19.8 d in the N-butyl-2-cyanoacrylate group). Overall, long-term morbidity was significantly higher in the suture group (11.86%) than in the fibrin glue (0%, p = 0.001) or N-butyl-2-cyanoacrylate (1.78%, p = 0.03) groups. There was no recurrence in any of the groups. Two cases (3.39%) of chronic groin pain were reported in patients in the suture group. A sensation of extraneous body was reported in 5 (8.47%) patients who received sutures and in 1 (1.78%) patient in the N-butyl-2-cyanoacrylate group; there were no reported cases in the fibrin glue group (suture v. fibrin glue, p = 0.01; suture v. N-butyl-2-cyanoacrylate, p = 0.03; fibrin glue v. N-butyl-2-cyanoacrylate, p = 0.30).

CONCLUSION

The use of human fibrin glue or N-butyl-2-cyanoacrylate is better tolerated than sutures in tension-free inguinal open repair using the plug and mesh technique in terms of overall immediate results, and there is a better trend in the long-term data.

Parathyroid hormone-related peptide and primary hyperparathyroidism

The parathyroid hormone-related peptide (PTHrP) has been shown to be the major pathogenic factor to humoral hypercalcemia of malignancy (HHM). The presence of PTHrP in many normal tissues and in normal or abnormal parathyroids has been described in literature and its role has been investigated. PTHrP release from parathyroid cells into the extracellular space has been demonstrated to depend on the extracellular calcium concentration. The hormone binds to PTH type 1 Receptor (PTH1R) with a high affinity, as well as parathyroid hormone (PTH). These hormones' amino-terminal (1-34) peptide fragments are considered sufficient to achieve efficient receptor activation and action on mineral ion homeostasis. Generally, diagnosis of primary hyperparathyroidism (PHPT) is based on hypercalcaemia and elevated levels of PTH. The advent of intact-PTH immunoradiometric assay allowed us to distinguish PHPT from non-parathyroid-dependent hypercalcaemia, but the presentation of normal PTH level and hypercalcaemia due to a parathyroid adenoma is possible. The aim of the study is to identify the relationship between the production of PTHrP without malignancy and the diagnosis of PHPT by a systematic review.

Surgically-induced bile duct injury is followed by early hepatic oxidative stress. A preliminary experimental study in rats

BACKGROUND/AIMS

To study in the rat whether oxidative stress appears early in a model of short-term cholestasis induced by bile duct ligation.

METHODOLOGY

Adult male rats underwent proximal bile duct ligation; controls underwent a sham operation. Animals were sacrificed at days 0, 1, 3, 7 and 10. Livers were removed for histological studies and biochemical analysis.

RESULTS

GSH and PSH levels declined earlier in mitochondria than cytosol. Data were analyzed for statistical significance by ANOVA analysis.

CONCLUSIONS

This study represents an experimental model which helps in the interpretation of the damage induced by bile duct injury in humans emphasizing an early detection of bile duct injury after surgery to ensure appropriate treatment and optimal patient outcome.

Multiple pancreaticoduodenal penetrating gunshot trauma evolving into acute necrotizing pancreatitis. A combined surgical and minimally invasive approach

CONTEXT

Shotgun injuries are the cause of increasing surgical problems related to the proliferation of firearms. Gunshot pancreaticoduodenal traumas are unusual in urban trauma units. Their management remains complex because of the absence of standardized, universal guidelines for treatment and the high incidence of associated lesions of major vessels as well as of other gastrointestinal structures. Surgical treatment is still controversial, and the possibilities offered by the safe and effective mini-invasive techniques seem to open new, articulated perspectives for the treatment of pancreaticoduodenal injury complications.

CASE REPORT

We present the case of a 27-year-old man with multiple penetrating gunshot trauma evolving into acute necrotizing pancreatitis, treated by combining a surgical with a mini-invasive approach. At admission, he presented a Glasgow Coma Score of 4 due to severe hemorrhagic shock. First, surgical hemostasis, duodenogastric resection, multiple intestinal resections, peripancreatic and thoracic drainage were carried out as emergency procedures. On the 12th postoperative day, the patient underwent re-surgery with toilette, external duodenal drainage with Foley tube and peripancreatic drainage repositioning as a result of a duodenal perforation due to acute necrotizing pancreatitis. Eight days later, following the accidental removal of the peripancreatic drains, a CT scan was done showing a considerable collection of fluid in the epiploon retrocavity. Percutaneous CT-guided drainage was performed by inserting an 8.5 Fr pigtail catheter, thus avoiding further re-operation. The patient was successfully discharged on the 80th postoperative day.

CONCLUSIONS

The treatment of multiple pancreaticoduodenal penetrating gunshot traumas should focus on multidisciplinary surgical and minimally invasive treatment to optimize organ recovery.

Bowel obstruction caused by primitive fibromuscular hyperplasia of the seminal vesicle in the elderly

A 79-year-old man with a 1-day history of increasing abdominal pain, decreased bowel activity, and abdominal distension was evaluated in emergency. Transabdominal pelvic ultrasonography and computerized tomography scans of the abdomen and pelvis showed the presence of a large pelvic multiloculated cystic mass between the bladder and rectum. At laparotomy, an extraperitoneal cystic lesion that was 20 cm in diameter was found to be compressing the bladder anteriorly and the rectum posteriorly. Definitive pathological diagnosis was fibromuscular hyperplasia of the seminal vesicle. The etiology of the cyst was most likely congenital, because a postoperative vesiculo-deferentography excluded the diagnosis of seminal stones. Prostatic disease was also excluded by a transrectal ultrasonograph. The patient's recovery was uneventful, and he was discharged on the seventh postoperative day. This is the first bowel obstruction caused by a congenital seminal vesicle cyst in the elderly reported in the literature.

Emergency surgery for acute respiratory failure secondary to spontaneous thyroid hemorrhage

A 42-year-old woman was evaluated for an emergency at our surgical department for acute dyspnea associated with a spontaneous and rapidly enlarging mass of the neck. Clinical examination revealed a large, firm, nonfluctuant thyroid swelling on the right side of the neck. An urgent computerized tomography scan showed a hematoma within the right lobe of the thyroid and tracheal deviation with marked luminal narrowing. Because of the rapid progression of respiratory distress, endotracheal intubation by flexible laryngoscopy revealing normal vocal cords function and emergency total thyroidectomy were performed. During the operation, the thyroid gland showed a huge, edematous, nonfluctuant, rubbery, firm swelling with easy bleeding on touch, but the capsule appeared to be intact without rupture. Microscopic examination revealed a colloid multinodular goiter with massive parenchymal hemorrhage. Recovery was uneventful, and the patient was discharged 2 days after the operation.