Vitamin D Deficiency Reduces Postthyroidectomy Protracted Hypoparathyroidism Risk. Is Gland Preconditioning Possible?

Context: Hypoparathyroidism is the most frequent complication after total thyroidectomy (PT-hypoPTH). After 1 year, most patients recover parathyroid function; however, the implicated physiologic dynamics remain unknown. Vitamin D deficiency (VDD) is the main cause of secondary hyperparathyroidism. Whether this compensatory hyperparathyroidism could influence parathyroid function recovery (PFR) in the setting of PT-hypoPTH has not been studied. Objective: This work aimed to evaluate the effect of preoperative VDD on PFR. Methods: A retrospective study was conducted with a prospectively maintained database including patients undergoing a total thyroidectomy between May 2014 and June 2019. Preoperative vitamin D (25(OH)D) less than 20 mg/mL was defined as VDD. Intact PTH less than 14 pg/mL on postoperative day 1 was defined as PT-hypoPTH. Transient PT-hypoPTH displayed PFR within the first year (early recovery: < 30 days; protracted recovery: > 30 days) whereas definite PT-hypoPTH did not. Survival analysis evaluated the effect of preoperative VDD on PFR, and a binary logistic regression model identified associated factors. Results: A total of 397 patients were identified. The observed rates of transient, protracted, and definite PT-hypoPTH were 32.9%, 15.1%, and 5.2%, respectively. Rates of VDD were higher in the early-recovery PT-hypoPTH group (55.2% vs 31.5%; P = .01). Preoperative VDD was associated with faster PFR (19 vs 35 days; P = .03) and behaved as a protective factor for protracted PT-hypoPTH (odds ratio 0.47; 95% CI, 0.25-0.881; P = .016) in the multivariable analysis. Conclusion: Preoperative VDD could act as a preconditioning factor of the parathyroid glands prior to the surgical aggression exerted against them during surgery aiding PFR. Basic research studies and prospective clinical trials are needed to explain the underlying physiological mechanisms and to provide further evidence to improve clinical management.

Digital melanoma in Caucasians: a descriptive and survival study according to sublocation.

BACKGROUND AND OBJECTIVES: Digital melanoma is an uncommon form of acral melanoma that is anatomically restricted to the finger. The aim of this study is to provide specific epidemiological and clinical information about this subtype of melanoma, as well as to identify differences in recurrence and survival depending on the anatomical sublocation. PATIENTS AND METHODS: We describe a group of 45 Caucasian patients with digital melanoma divided into three groups: nail unit melanoma (group A), finger skin melanoma (group B), and those melanomas that involve both nail and adjacent skin (group C). RESULTS: The mean tumor thickness was 4.66 mm, and the most common histological subtype is acral lentiginous melanoma. Group C was more frequent in older men and was thicker and more frequently ulcerated (P < 0.05). In addition, patients in group C developed distant metastases more frequently and had a significantly lower median disease-free survival (26.60 months) compared with group A (69.47 months) and group B (89.81 months) (P < 0.05). CONCLUSIONS: According to our results, digital melanoma limited to nail apparatus or finger skin was associated with a better prognosis, while those affecting both nail apparatus and skin showed lower melanoma-specific survival.

Tiroidectomía sin incisión cervical por abordaje endoscópico biaxilo-biareolar. Primeras impresiones tras su introducción en una unidad especializada. Revisión de la literatura / Scarless neck thyroidectomy using bilateral axillo-breast approach: Initial impressions after introduction in a specialized unit and a review of the literature

Introducción: El abordaje extracervical para tiroidectomía es poco conocido en nuestro país. Su principal fin es evitar la cicatriz cervical, manteniendo el perfil de seguridad de la tiroidectomía convencional. El objetivo es comunicar nuestra experiencia tras los primeros 15 casos empleando el abordaje endoscópico biaxilo-biareolar (BA-BA) así como revisar los puntos críticos descritos en la literatura. Métodos: Entre junio de 2017 y junio de 2018 se realizaron 15 tiroidectomías endoscópicas empleando abordaje extracervical BA-BA, ubicando incisiones en pliegues axilares y bordes areolares. Las indicaciones fueron bocio benigno y nódulo sospechoso (Bethesda 3/4). Resultados: Los 15 casos (12 pacientes) se abordaron completamente por BA-BA. Se realizaron 5 tiroidectomías totales, 7 hemitiroidectomías y 3 totalizaciones. El tiempo quirúrgico medio para tiroidectomía total fue de 285min y para hemitiroidectomía, de 210 min. El tiempo medio de ingreso fue de 1,67 días. Con un seguimiento medio de 7,73 meses, la tasas de hipoparatiroidismo transitorio y definitivo fueron del 37% y del 0% y se produjo parálisis recurrencial transitoria en un caso. Tasa de disestesias centrotorácicas del 80%, leves y resueltas en el primer mes. El grado de satisfacción cosmética es muy elevado. Conclusión: Nuestra experiencia empleando el abordaje BA-BA es corta pero satisfactoria. Es un procedimiento reproducible que requiere experiencia en cirugía endocrina y endoscópica. Los abordajes extracervicales son una alternativa para pacientes seleccionados con especial preocupación por la cicatriz cervical y no pretenden desplazar a la tiroidectomía convencional, el gold estandard actual. Nuestra sociedad científica debe explorar estos abordajes para sentar indicaciones y limitaciones coherentes

Introduction: The extracervical approach for thyroidectomy remains widely unknown in our country. Its main aim is to avoid a cervical scar while maintaining the same safety profile of conventional thyroidectomy. The objective is to communicate our experience after the first 15 cases using the endoscopic bilateral axillo-breast approach (BABA) and to review critical points described in literature. Methods: Between June 2017 and June 2018, 15 endoscopic thyroidectomies were performed using the BABA extracervical approach, locating incisions in axillary folds and areolar borders. Indications were benign goiter and suspicious nodule (Bethesda 3 and 4). Results: All 15 cases (12 patients) were treated using the extracervical endoscopic technique. We performed 5 total thyroidectomies, 7 hemithyroidectomies and 3 completion thyroidectomies. Mean surgical time for total thyroidectomy was 285 minutes and 210 minutes for hemithyroidectomy. The average hospital stay was 1.67 days. With a mean follow-up of 7.73 months, rates of transient and definitive hypoparathyroidism were 37% and 0%, and transient recurrent nerve palsy occurred in one case. Anterior chest paraesthesia rate was 80%, which were mild and resolved within the first month. The degree of cosmetic satisfaction is very high. Conclusion: Our experience with endoscopic bilateral axillo-breast approach thyroidectomy is short but satisfactory. It is a reproducible procedure that requires extensive experience in endocrine and endoscopic surgery. Extracervical approaches are an alternative for selected patients who are especially concerned about cervical scarring and are not intended to displace conventional thyroidectomy, which is the current gold standard. Our Scientific Society should explore these approaches to establish coherent indications and limitations

Scarless neck thyroidectomy using bilateral axillo-breast approach: Initial impressions after introduction in a specialized unit and a review of the literature. / Tiroidectomía sin incisión cervical por abordaje endoscópico biaxilo-biareolar. Primeras impresiones tras su introducción en una unidad especializada. Revisión de la literatura.

INTRODUCTION: The extracervical approach for thyroidectomy remains widely unknown in our country. Its main aim is to avoid a cervical scar while maintaining the same safety profile of conventional thyroidectomy. The objective is to communicate our experience after the first 15 cases using the endoscopic bilateral axillo-breast approach (BABA) and to review critical points described in literature. METHODS: Between June 2017 and June 2018, 15 endoscopic thyroidectomies were performed using the BABA extracervical approach, locating incisions in axillary folds and areolar borders. Indications were benign goiter and suspicious nodule (Bethesda 3 and 4). RESULTS: All 15 cases (12 patients) were treated using the extracervical endoscopic technique. We performed 5 total thyroidectomies, 7 hemithyroidectomies and 3 completion thyroidectomies. Mean surgical time for total thyroidectomy was 285minutes and 210minutes for hemithyroidectomy. The average hospital stay was 1.67days. With a mean follow-up of 7.73months, rates of transient and definitive hypoparathyroidism were 37% and 0%, and transient recurrent nerve palsy occurred in one case. Anterior chest paraesthesia rate was 80%, which were mild and resolved within the first month. The degree of cosmetic satisfaction is very high. CONCLUSION: Our experience with endoscopic bilateral axillo-breast approach thyroidectomy is short but satisfactory. It is a reproducible procedure that requires extensive experience in endocrine and endoscopic surgery. Extracervical approaches are an alternative for selected patients who are especially concerned about cervical scarring and are not intended to displace conventional thyroidectomy, which is the current gold standard. Our Scientific Society should explore these approaches to establish coherent indications and limitations.

Aneurisma esplénico asociado a una fístula arteriovenosa hiliar / Splenic Aneurism Associated with a Hilar Arteriovenous Fistula

Los aneurismas esplénicos son los aneurismas viscerales más frecuentes. Habitualmente son asintomáticos y se diagnostican de forma incidental al realizar estudios de imagen por otra patología. Su importancia clínica radica en la posibilidad de ruptura y la elevada mortalidad que ello implica. La mayoría de los aneurismas son únicos y de pequeño tamaño. La presencia de una fístula arteriovenosa hiliar o intraesplénica asociada es excepcional y suele estar en relación con traumatismos, cirugías previas, infecciones o ser de origen congénito. Presentamos el caso de un aneurisma intraesplénico asociado a una fístula arteriovenosa en el hilio, tratado satisfactoriamente mediante abordaje laparoscópico (AU)

Splenic aneurisms are the most frequent visceral aneurisms. These aneurisms are usually asymptomatic and are diagnosed incidentally by imaging studies performed for other diseases. The clinical importance of these entities lies in the possibility of rupture, leading to high mortality. Most aneurisms are single and small-sized. The presence of an associated hilar or intrasplenic arteriovenous fistula is exceptional and is usually related to trauma, prior surgery, or infections; a congenital origin may also be involved. We present a case of intrasplenic aneurism associated with a hilar arteriovenous fistula, which was satisfactorily treated through the laparoscopic approach (AU)

[Splenic aneurism associated with a hilar arteriovenous fistula]. / Aneurisma esplénico asociado a una fístula arteriovenosa hiliar.

Splenic aneurisms are the most frequent visceral aneurisms. These aneurisms are usually asymptomatic and are diagnosed incidentally by imaging studies performed for other diseases. The clinical importance of these entities lies in the possibility of rupture, leading to high mortality. Most aneurisms are single and small-sized. The presence of an associated hilar or intrasplenic arteriovenous fistula is exceptional and is usually related to trauma, prior surgery, or infections; a congenital origin may also be involved. We present a case of intrasplenic aneurism associated with a hilar arteriovenous fistula, which was satisfactorily treated through the laparoscopic approach.

Mapeo linfático y biopsia del ganglio centinela en el melanoma cutáneo / Lymphatic mapping and sentinel lymph node biopsy on cutaneous malignant melanoma

La biopsia del ganglio centinela es un método diagnóstico introducido recientemente en el manejo del melanoma. Está indicada en los enfermos con melanoma localizado con un Breslow mayor de 0,75- 1 mm. Permite el estadiaje histológico de los ganglios regionales en fases iniciales mediante una técnica quirúrgica poco agresiva, con escasas complicaciones. La detección precoz de micrometástasis ganglionares permite realizar una linfadenectomía terapéutica inmediata, sin esperar a que el enfermo presente metástasis ganglionares clínicamente evidentes, mejorando su supervivencia. Para que la biopsia del ganglio centinela sea efectiva es necesario realizar de forma coordinada los siguientes procesos: 1) determinación preoperatoria de los ganglios linfáticos regionales, y dentro de ellos una aproximación sobre el número y localización del o los ganglios centinela (linfografía isotópica dinámica); 2) localización intraoperatoria (mapeo linfático) y extirpación del ganglio centinela, y 3) evaluación patológica cuidadosa del ganglio centinela obtenido para detectar la presencia de células tumorales. La utilidad diagnóstica y pronóstica está fuera de duda y actualmente se está investigando la utilidad terapéutica como método quirúrgico ganglionar único (AU)