Thyroid Surgery: To Drain or Not to Drain, That Is the Problem - A Randomized Clinical Trial.

PURPOSE: We conducted a prospective, randomized study to evaluate the necessity of drainage after thyroid surgery. METHODS: The patients (n = 215) were randomly assigned to be treated with suction drains (group 1; n = 108) or not (group 2; n = 107). RESULTS: The postoperative pain scores were significantly lower in the non-drained group than in the drained group of patients at postoperative days 0 and at 1. Hematomas, seromas, wound infections, transient biochemical hypoparathyroidism, and transient damage of the recurrent laryngeal nerve occurred more frequently in the drained group than in the non-drained group. The mean hospital stay was significantly shorter in the non-drained group than in the drained group. CONCLUSIONS: Routine drain emplacement after thyroidectomy is unnecessary.

Laparoscopic floppy Nissen fundoplication: 11-year follow-up.

BACKGROUND: There are few published reports on the outcomes of ≥ 10 years after a laparoscopic floppy Nissen fundoplication (LFNF). MATERIALS AND METHODS: From April 1994 to January 2012, 567 patients underwent LFNF and the outcomes of 211 cases were determined (from April 1994 to October 2000). RESULTS: Outcomes at ≥ 11 years after surgery was available for 178 patients (84.3%) of which 167 (93.8%) had no heartburn or mild heartburn, 8 (4.5%) had moderate heartburn, and 3 had (1.7%) severe heartburn. Dysphagia was nonexistent or mild in 153 (85.9%), whereas the remaining 14.1% presented moderate to severe symptoms. Reports of 69.1% patients showed none or mild symptoms of abdominal bloating, that of 23% patients showed moderate discomfort, and reports of 7.8% showed severe bloating. Satisfaction score was 8.6 (of 10). A further surgical procedure was required for 7 patients (3.9%): 4 for recurrent reflux and 3 for dysphagia (2 for a tight wrap and 1 for a tight esophageal hiatus). Postoperative dysphagia sufficient for an endoscopic dilatation was observed in 4 patients (2.3%), where 3 were successfully managed with a single dilatation procedure and the last patient underwent several dilatations before adequate swallowing. CONCLUSION: LFNF is an effective long-term treatment for gastroesophageal reflux disease, yielding similar results to open fundoplication.

A prospective randomized study of systemic inflammation and immune response after laparoscopic nissen fundoplication performed with standard and low-pressure pneumoperitoneum.

BACKGROUND: The aim of this study was to compare changes in the systemic inflammation and immune response in the early postoperative (p.o.) period after laparoscopic Nissen fundoplication (LNF) was performed with standard-pressure and low-pressure carbon dioxide pneumoperitoneum. MATERIALS AND METHODS: We studied 68 patients with documented gastroesophageal reflux disease and who underwent a LNF: 35 using standard-pressure (12 to 14 mmHg) and 33 low-pressure (6 to 8 mmHg) pneumoperitoneum. White blood cells, peripheral lymphocytes subpopulation, human leukocyte antigen-DR, neutrophil elastase, interleukin (IL)-6 and IL-1, and C-reactive protein were investigated. RESULTS: A significantly higher concentration of neutrophil elastase, IL-6 and IL-1, and C-reactive protein was detected postoperatively in the standard-pressure group of patients in comparison with the low-pressure group (P<0.05). A statistically significant change in human leukocyte antigen-DR expression was recorded p.o. at 24 hours, as a reduction of this antigen expressed on monocyte surface in patients from standard group; no changes were noted in low-pressure group patients (P<0.05). CONCLUSIONS: This study demonstrated that reducing the pressure of the pneumoperitoneum to 6 to 8 mm Hg during LNF is reduced p.o. inflammatory response and avoided p.o. immunosuppression.

Peritonitis from perforated appendicitis: stress response after laparoscopic or open treatment.

Elevated intra-abdominal pressure during laparoscopy may promote systemic inflammatory response. In patients with generalized peritonitis from perforated appendicitis, we sought to compare acute phase response and immunologic status from laparoscopic and open approach. One hundred and forty-seven consecutive patients underwent appendectomy for perforated appendicitis (73 patients had laparoscopic appendectomy and 74 patients had open appendectomy. Bacteremia, endotoxemia, white blood cells, peripheral lymphocytes subpopulation, human leukocyte antigen-DR (HLA-DR), neutrophil-elastase, interleukin-1 and 6 (IL-1 and 6), and C-reactive protein were investigated. One hour after intervention, bacteremia was significantly higher in the open group compared with the laparoscopic group (P < 0.05). A significantly higher concentration of systemic endotoxin was detected intraoperatively in the open group of patients in comparison with the laparoscopic group (P < 0.05). Laparotomy caused a significant increase in neutrophil concentration, neutrophil-elastase, IL-1 and 6, and C-reactive protein and a decrease of HLA-DR. We recorded 6 cases (8.1%) of intra-abdominal abscess in the open group and one (1.3%) in the laparoscopic group (P < 0.05). Open appendectomy, in case of peritonitis, increased the incidence of bacteremia, endotoxemia, and systemic inflammation compared with laparoscopic appendectomy. Early enhanced postoperative systemic inflammation may cause lower transient immunologic defense after laparotomy (decrease of HLA-DR), leading to enhanced sepsis in these patients.

New ultrasonic dissector versus conventional hemostasis in thyroid surgery: a randomized prospective study.

BACKGROUND: The ultrasonic dissector (UD) is an instrument that uses vibration to coagulate and cut tissue simultaneously. The main advantage of a UD instrument compared with a standard electrosurgical device is represented by minimal lateral thermic tissue damage allowing a wide application in thyroid surgery. A new UD (NUD), with a tip smaller than 5 mm, might enable a more precise dissection near vital structures such as parathyroid glands and recurrent laryngeal nerve. To evaluate the NUD during thyroid surgery, a prospective randomized study was performed using the new device versus traditional procedures. SUBJECTS AND METHODS: Two hundred sixty-one patients underwent various thyroid surgical procedures; they were randomly assigned (130 in the NUD group and 131 in the conventional hemostasis [CH] group). The two surgical groups were compared in age, sex, diagnosis, thyroid size, operative time, drainage volume during the first 24-48 hours after surgery, and complications (hypoparathyroidism, damage of the recurrent laryngeal nerve, and postoperative pain). RESULTS: The two groups were similar regarding age, sex, numbers of lobectomies and total thyroidectomies, and numbers of focal and diffuse pathologies. Mean ± standard deviation operative time was shorter in the NUD group compared with the CH group for both lobectomy (70 ± 21 minutes versus 99 ± 27 minutes; P<.01) and total thyroidectomy (91 ± 37 minutes versus 121 ± 42 minutes; P=.01) procedures. No difference was found regarding the amount of drainage volume for different procedures (P=not significant). Postoperative transient (P=.01) and definitive (P=.01) hypoparathyroidism occurred more frequently in the CH group than in the NUD group. There was a significant difference regarding the transient damage of the recurrent laryngeal nerve: 7 patients (5.3%) in the NUD group and 13 patients (9.8%) in the CH group (P=.01). There was no difference regarding definitive damage to the recurrent laryngeal nerve and pain. CONCLUSION: This NUD may reduce the rate of complications (transient and definitive hypocalcemia, transient damage of the recurrent laryngeal nerve) and operative time.

Cholecystectomy for gallbladder disease in elderly aged 80 years and over.

BACKGROUND/AIMS: Patients aged 80 years and over show greater risk of complicated gallbladder diseases and associated comorbidities. The aim of the study is to evaluate the prognosis after laparoscopic or open cholecystectomy in these patients. METHODOLOGY: 100 patients aged between 80 and 92 years (group 1) and 241 patients aged between 70 and 79 years (group 2), undergoing cholecystectomy for gallbladder disease, are the subject of the study. Types of disease and surgery and p.o. morbidity and mortality have been evaluated. RESULTS: The patients of group 1 have shown a significant greater incidence of p.o. morbidity (20%) than group 2 (2.3%) (chi2 = 39.5; p < 0.001), regardless to the type of cholecystectomy. Endoscopic sphincterotomy for lithiasis of common biliary duct seems an important risk factor (chi2 = 7.1; p < 0.001). In group 2, the morbidity rate after laparoscopic cholecystectomy was lesser than after open surgery (X2=5.3; p < 0.02). In both groups, postoperative hospital stay was longer after open cholecystectomy and endoscopic sphincterotomy. CONCLUSIONS: Patients aged 80 years and over, undergoing cholecystectomy, specially after endoscopic sphinterotomy., have a greater risk of p.o. morbidity and mortality than younger. Laparoscopic and open cholecystectomy seems to bear the same poor p.o. prognosis.

Acute ischaemic colitis: outcome in elderly patients.

The Authors report the results of the management of ischaemic colitis in a surgical unit dedicated to elderly patients. Sixty-two elderly patients affected by ischaemic colitis were observed consecutively in the Surgery Unit of the University of L'Aquila from 1986 to 2004. The clinical records of the patients were retrospectively reviewed in order to assess clinical, biohumoral, endoscopic and x-ray findings pre- dictive of the most suitable type of treatment. Clinical follow-up was performed to evaluate the long-term prognosis after a mean period of 8 years post-treatment. Forty-six patients (74.1%) were treated by medical therapy only for a mean period of 7 days with a positive outcome and no mortality. Sixteen patients (25.9%) underwent surgery. Postoperative morbidity and mortality rates were 62.5% and 43.7%, respectively. Absence of bowel sounds (chi2 = 61.9, p < 0.001), ileus (chi2 = 17.8, p < 0.001) and air fluid levels in plain abdominal x-rays (chi2 = 18.6, p < 0.001) were risk factors for surgery. At follow-up a favourable outcome, without findings of recurrent acute or chronic ischaemic colitis, was observed in 55 patients. In conclusion, the results seem to suggest that medical therapy is the mainstay of treatment for acute ischaemic colitis in elderly patients with good clinical results. Peritonitis is an indication for surgery.

Spontaneous hematoma of the mesocolon.

Spontaneous hematoma of the mesocolon is a rare condition, mainly due to the rupture of a colic artery aneurysm. The authors report on two cases of spontaneous hematoma of the mesocolon and examine the relevant literature. The clinical presentation in our patients was, as indicated in the literature, non-specific, with the occurrence of acute abdomen (case 1) or mild abdominal pain (case 2). Only diagnostic imaging (contrast-enhanced CT scan) is capable of yielding an accurate diagnosis, specifying the size and location of the hematoma. A palpable mass or hemoperitoneum due to rupture should be regarded as late signs of presentation. Early diagnosis is of the utmost importance in order to avoid the by no means negligible mortality reported in such instances or ischaemic bowel wall complications.