Platelet Activation and Inflammation in Patients with Papillary Thyroid Cancer.

BACKGROUND: The primary endpoint was to analyze the preoperatory inflammatory markers and platelet indices in papillary thyroid cancer (PTC) patients compared with patients with benign thyroid pathology. The secondary endpoints were to analyze the relationship between these markers and the pathological features of PTC and to compare their pre- and postoperative levels in PTC patients. METHODS: In this retrospective case-control study, we analyzed the files of 1183 patients submitted to thyroidectomy between January 2012 and December 2018. A total of 234 patients with PTC (mean age 51.54 ± 13.10 years, 84.6% females) were compared with an age-, gender- and BMI-matched control group of 108 patients with histologic benign thyroid disorders. RESULTS: PTC patients had higher platelet count (PLT) (p = 0.011), plateletcrit (PCT) (p = 0.006), neutrophil (p = 0.022) and fibrinogen (p = 0.005) levels. Subgroup analysis showed that PTC females had higher PLT (p = 0.006), PCT (p < 0.001) and erythrocyte sedimentation rate (ESR) (p = 0.005), while males had higher neutrophil (p = 0.040) levels. Papillary thyroid cancer patients under 55 years had higher PLT (p < 0.001) and PCT (p = 0.010), while patients over 55 years had higher mean platelet volume (p = 0.032), neutrophil-to-lymphocyte ratio (p = 0.013), ESR (p = 0.005) and fibrinogen (p = 0.019) levels. Preoperative values for platelet indices and inflammatory markers were similar to the postoperative determinations in PTC patients. Fibrinogen (AUROC = 0.602, p = 0.02; cut-off = 327.5 mg/dL, Se = 53.8%, Sp = 62.9%) and PLT (AUROC = 0.584, p = 0.012; cut-off = 223.5 × 103/mm3, Se = 73.1%, Sp = 42.6%) were independent predictors of the presence of PTC. CONCLUSIONS: Our data show that fibrinogen and platelet count could be promising, inexpensive, independent predictors for the presence of PTC when compared with benign thyroid disorders.

The Tubercle of Zuckerkandl is Associated with Increased Rates of Transient Postoperative Hypocalcemia and Recurrent Laryngeal Nerve Palsy After Total Thyroidectomy.

The current concept of complete resection of thyroid parenchyma shifted the practice from subtotal thyroidectomy to total thyroidectomy for a wide range of benign and malignant thyroid affliction and brought the tubercle of Zuckerkandl once again into attention. This embryological remnant has been shown to have a constant relationship with the recurrent laryngeal nerve and the superior parathyroid gland and may be used as a landmark for safe dissection. In order to assess if the presence of the tubercle of Zukerkandl has an impact on the most important complications of thyroid surgery, we have prospectively studied 128 patients diagnosed with nodular goiter who underwent total thyroidectomy. Grade 0 or the absence of the tubercle of Zuckerkandl, according to Pellizo et al, was noted in 42 cases (32.8%). During surgery, we identified 38 grade 1 tubercles (29.7%), 31 grade 2 tubercles (24.2%) and 16 grade 3 tubercles (12.5%). Out of 11 bilateral tubercles, 4 were measured as grade 3.Of all 47 patients with grade 2 and 3 tubercles, 18 (38.3%) developed transient postoperative hypocalcemia (p 0.0001, r=0.47) and 10 (21.3%) transient postoperative nerve palsy (p=0.004, r=0.25). All patients fully recovered during follow-up. The tubercle of Zuckerkandl, when present and of significant macroscopic size is associated with increased rates of transient postoperative hypocalcemia and recurrent laryngeal nerve palsy.

Peritoneal Encapsulation - A Rare Cause of Small Bowel Obstruction.

Peritoneal encapsulation (PE) is a rare anatomic anomaly which occurs due to an accessory peritoneal sac covering the small bowel which can cause chronic recurrent abdominal pain and even small bowel obstruction, most often in children or patients with no previous surgical history. The diagnosis is usually made during surgery, but recently it has been suggested that mindful examination of the abdominal CT may be helpful in considering PE beforehand. We present the case of a 21-year old patient who was admitted due to intense abdominal pain, asymmetrical abdominal distension, air fluid levels on the abdominal X-ray, but no specific findings on the abdominal CT. He underwent emergency surgery and PE was found and the peritoneal sac was excised. The postoperative course was uneventful. Histopathologic examination of the specimen confirmed the diagnosis. PE is often misdiagnosed as abdominal cocoon or sclerosing encapsulating peritonitis, but it is a pathology with a much lower rate of recurrence and postoperative complications, which can be treated successfully if the surgeon is aware of this pathology when making the differential diagnosis.

Laparoscopic Partial Adrenalectomy.

Laparoscopic adrenalectomy became the gold standard for adrenal disease, from incidentaloma to cancer. Partial adrenalectomy is difficult to accept due to its technical difficulties as well as hemorrhagic risk and a consensus has not been reached. On the other hand, in selected cases of benign adrenal tumors, adrenalectomy may be futile, partial resections being perfectly justified and with lower hemorrhagic risks. For functioning tumors smaller than 3 cm with an anterior or lateral location, partial adrenalectomy may be indicated. The key points reside in adenoma identification, preservation of the remaining glandular parenchyma and its blood supply with dissection in the space between the adenoma and the normal parenchyma. Laparoscopic partial adrenalectomy is feasible and effective for the treatment of benign tumors. Although partial resections have clear-cut advantages over conventional adrenalectomy especially for bilateral tumors, it remains a difficult intervention.

The Laparoscopic Approach of Small Bowel Obstruction--The Experience of a Primary Center.

INTRODUCTION: Small bowel obstruction represents up to 16% of surgical emergencies. Mortality and morbidity depend on early recognition, correct diagnosis and timely surgical management. The most frequent causes of small bowel obstruction are adhesions, malignant tumors, hernias and volvulus. Although laparoscopic surgery is not promoted for the management of small bowel obstruction, it may address many of the mentioned causes. In the same time, it represents a useful diagnostic tool that does not affect the integrity of the abdominal wall. MATERIALS AND METHODS: The current study resumes the experience of a medium volume primary center. Between March 2010 and October 2015, 38 patients were diagnosed with small bowel obstruction and suffered laparoscopic interventions. In 7 cases conversion to open surgery was necessary. RESULTS: Mortality was 0% and specific morbidity was 12%. The mean operating time was 87.2 minutes with wide variations depending on etiology and the mean postoperative hospital stay was 4.7 days. CONCLUSION: The laparoscopic approach of small bowel disease is feasible and safe in selected cases and offers evident benefits regarding to the integrity of the abdominal wall, rapid return of bowel function and shorter hospital stay.

Selective Intraoperative Cholangiography in Laparoscopic Cholecystectomy.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is probably one of the most frequent surgical procedure performed worldwide. Intraoperative cholangiography (IOC) is required more often than in open procedures due to the need to clarify the anatomy or to diagnose common bile duct (CBD) stones. AIM: The present study analyzes the value of IOC performed on selective basis following preoperative and intraoperative criteria. Our experience covers 15 years of surgical activity in Elias Surgery Department and, as a result of a continuous scientific concern on the matter, we developed a set of criteria that are analyzed and discussed. MATERIAL AND METHOD: We studied the patients subjected to LC in our department between January 2013 and December 2014. A group of 945 patients was analyzed; IOC was performed in 147 cases. All IOC were selective procedures. The criteria were divided in two groups: Preoperative criteria (clinical, lab tests and imaging findings); Intraoperative criteria (dilated biliary ducts and obscure biliary anatomy). RESULTS: IOC was performed in 147 cases. We had a positive result, a finding that changed surgical management of the patient after IOC in over 50% of cases. The biliary tree anatomy was cleared in 100% of cases. IOC required a median period of time of 11 minutes. There were no complications caused by IOC. CONCLUSIONS: Intraoperative cholangiography, performed either routinely or selectively, represents an important tool in diagnosing unsuspected CBD stones during laparoscopic cholecystectomy. Criteria for selective IOC may significantly reduce the number of useless cholangiograms and are to be considered in daily practice. The main predictive factors used for selective intraoperative cholangiography in our study were: history of jaundice, elevated values of ALP, GGTP, SGO, SGP, and CBD diameter.