Diagnosis and treatment of primary thyroid lymphoma from a surgical perspective: a multi-institutional study.

PURPOSE: Surgery of primary thyroid lymphoma (PTL) has been mostly limited to diagnostic work-up. This study aimed to further study its potential role. METHODS: This was a retrospective study from a multi-institutional registry of PTL patients. Clinical, diagnostic work-up (fine needle aspiration, FNA; core needle biopsy, CoreNB), contribution of surgery (open surgical biopsy, OpenSB; thyroidectomy), histology subtype, and outcome data were evaluated. RESULTS: Some 54 patients were studied. Diagnostic work-up included FNA in 47 patients, CoreNB in 11, and OpenSB in 21. CoreNB yielded the best sensitivity (90.9%). Thyroidectomy was performed in 14 patients with other diagnosis (incidental PTL), in 4 for diagnosis and in 4 for elective treatment of PTL. Incidental PTL was associated with not performed FNA nor CoreNB (OR 52.5; P = 0.008), mucosa-associated lymphoid tissue (MALT) subtype (OR 24.3; P = 0.012), and Hashimoto's thyroiditis (OR 11.1; P = 0.032). Lymphoma-related death (10 cases) mostly occurred within the first year after diagnosis and was associated with diffuse large B-cell (DLBC) subtype (OR 10.3; P = 0.018) and older patients (OR 1.08 for every 1-year increase; P = 0.010). There was a trend towards lower mortality rate in patients receiving thyroidectomy (2/22 versus 8/32, P = 0.172). CONCLUSION: Incidental PTL accounts for most of thyroid surgery cases and are associated with incomplete diagnostic work-up, Hashimoto's thyroiditis and MALT subtype. CoreNB appears to be the best tool for diagnosis. Most of PTL deaths occurred during the first year after diagnosis and mostly related to systemic treatment. Age and DLBC subtype are poor prognostic factors.

Isthmectomy: a conservative operation for solitary nodule of the thyroid isthmus.

PURPOSE: To assess the results obtained in patients with nontoxic uninodular goiter confined to the isthmus undergoing isthmectomy. METHODS: Between April 1994 and June 2006, 330 consecutive patients with nontoxic uninodular goiter underwent thyroidectomy at our institution. In 31 patients, lesions were limited to the thyroid isthmus with evidence of benign or undetermined pathology on ultrasound-guided fine-needle aspiration biopsy. Total isthmectomy was performed. RESULTS: Preoperatively, thyroid nodules on ultrasonography were solid in 26 patients and mixed with cystic and solid components in 2. The mean size of nodules was 2.43 (+/- 0.88) cm. No intraoperative or postoperative complications occurred. Histological examination showed nodular hyperplasia in 29 cases, follicular adenoma in 1 and papillary thyroid carcinoma in 1. The patient with papillary carcinoma underwent bilateral lobectomy 7 days later. A total of 24 patients (77.4%) attended clinical visits at follow-up (mean 70,57 months). Ultrasonographic scanning revealed thyroid nodules in 17 patients, in 16 of which nodules range from one to five (0.5 to 2 cm in size) and further surgery was not indicated. One patient with a 4-cm nodule and tracheal displacement found at ultrasonography 2 years after isthmectomy had inconclusive results of FNAB. This patient was re-operated for completion thyroidectomy, which was successfully performed without technical difficulties. The detection of recurrent nodules was independent of the time elapsed since thyroid isthmectomy. CONCLUSIONS: These findings document the feasibility and efficacy of isthmectomy in solitary thyroid nodules confined to the isthmus.

The effects of successful parathyroidectomy on clinical and biological manifestations of primary hyperparathyroidism.

PURPOSE: To assess changes of clinical manifestations, laboratory data, and bone mineral density after parathyroidectomy for primary hyperparathyroidism. METHODS: In 39 patients with symptomatic primary hyperparathyroidism undergoing parathyroidectomy, data of preoperative symptoms and bone densitometry were collected from the medical records. A telephone survey was used to collect information on postoperative symptoms and the patient's degree of satisfaction with the operation. Results of biochemical parameters before surgery, at the immediate postoperative period, and at late follow-up were compared. Differences of proportions were assessed with the chi-square test and differences in means with the one-way ANOVA and the Student's t test. RESULTS: A significant decrease was observed in the occurrence of renal colic and bone pain after parathyroidectomy. Calcium and PTH levels decreased and phosphorus levels increased significantly after the operation. 24-hour renal calcium excretion showed a statistically significant decrease in the immediate postoperative control and at follow-up in patients without renal colic, whereas in those with nephrolithiasis, significant differences were only observed at follow-up. Alkaline phosphatase decreased significantly in the immediate postoperative period, and bone densitometry improved in a 90% of the patients. Ninety-six percent of patients were satisfied with parathyroidectomy. CONCLUSIONS: In this clinical series, successful parathyroidectomy resulted in improvement of clinical manifestations, normalization of biochemical parameters, and a decrease in osteoporosis. Patients reported a high degree of satisfaction with parathyroidectomy.

Strangulated small bowel evisceration after intraperitoneal drainage.

We report an exceptional case of strangulated small bowel evisceration through an intraperitoneal drainage after open cholecystectomy. It is a recognized but rare complication of surgical procedures. The drainage must be sited carefully and when necessary. If possible, drains of less than 10 mm external diameter should generally be used.

Actividad de las enzimas hepáticas en la colecistectomía laparoscópica / Liver enzymes levels after laparoscopic cholecistectomy

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Microanastomosis venosas directas mediante cuff extraluminal / Direct venous microanastomoses with an extraluminal cuff

Introducción. Las microanastomosis venosas son más difíciles de realizar que las arteriales debido a las características de la pared venosa. La técnica habitual es la sutura con puntos sueltos, pero presenta los inconvenientes de una duración excesiva y la presencia de gran cantidad de material de sutura desde el punto de vista anastomótico. La técnica del cuff extraluminal para la realización de estas microanastomosis puede evitar estas complicaciones. Materiales y métodos. Se realizan 30 microanastomosis en la vena yugular interna de la rata Sprague-Dawley mediante la colocación de un cuff extraluminal de silicona, y se determina la duración, la permeabilidad inmediata (tanto en la primera hora como al mes) y sus posibles complicaciones. Se realiza además un estudio histológico a los quince días y al mes de su realización. Resultados. Duración media de las anastomosis: 6,77 minutos. Permeabilidad al mes del 83,3 por ciento. Destaca la presencia de tres trombosis y dos dehiscencias.El estudio histológico revela una escasa alteración parietal con una marcada hiperplasia subendotelial. Conclusiones. La técnica de microanastomosis venosas con un cuff extraluminal es una técnica rápida y fácil de realizar, y presenta unas tasas de permeabilidad altas (83,3 por ciento), a pesar de que se genera una tensión excesiva dentro de la línea de anastomosis debido al acortamiento vascular que se produce (AU)

Microanastomosis venosa yuguloyugular contralateral. Un nuevo modelo experimental / Contralateral jugular-jugular venous microanastomosis. A new experimental model

Introducción. Las microanastomosis venosas son de difícil realización, fundamentalmente por las características de la pared venosa. Objetivo. Ofrecer una técnica que evite las frecuentes complicaciones, y diseñar un nuevo modelo experimental. Materiales y métodos. Se utiliza la rata albina Sprague-Dowley. Tras cervicotomía en T invertida y disección de las dos venas yugulares externas, se mide la longitud de ambas desde sus extremos mandibular y clavicular. Se procede a la ligadura del extremo proximal de una yugular y el extremo distal de la contralateral, y se mide la longitud de las venas yugulares, así como la distancia entre las dos secciones vasculares. Se realiza una microanastomosis terminoterminal yuguloyugular contralateral en 10 animales, cinco mediante la técnica habitual de puntos sueltos y otros cinco con la utilización de un cuff extraluminal. Resultados. Longitud de cada vena yugular externa de 18 mm (ñ 1 mm). La distancia entre ambas secciones venosas fue de 25 mm. Se consiguió 5 mm de longitud añadida, útil para la microanastomosis.Todas las microanastomosis fueron permeables. Discusión. Con este nuevo modelo experimental se consigue una longitud venosa suficiente para realizar anastomosis directas fácilmente movilizables, permitiendo técnicas que obliguen a acortamiento de los segmentos venosos, y que se eviten los fallos anastomóticos secundarios a la tensión longitudinal y lesión de la pared vascular. Si se emplea un cuff extraluminal la anastomosis queda sin tensión, a pesar de la eversión y del telescopaje necesario (AU)

[Venous microanastomoses by extraluminal cuff versus standard technique]. / Microanastomosi venosa diretta con cuff extraluminale versus sutura standard.

AIM: Venous microanastomoses are more difficult to carry out in comparison with the arterial ones, because of the characteristics of the vascular wall. The suture with loose stitches is the usual surgical technique, but it has 2 disadvantages: a long time of execution and the presence of foreign material in the anastomosis. To avoid these complications, we an extraluminal silicone cuff has been used. METHODS: We performed 70 microanastomoses on the internal jugular vein of Sprague-Dawley rats with these 2 techniques, estimating the immediate and late permeability and postoperative complications. Moreover, a histological study of all the anastomoses was carried out on the 15th day and after 1 mo from the intervention. RESULTS: The mean time requested to perform the microanastomosis is significatively shorter when using the extraluminal cuff. The late permeability with standard suture is 97% and 77% with the cuff. The number of complications with standard suture is significatively lower than with cuff, where rates of 20% of dehiscence and 14% of trombosis were observed. The histological study showed a poor alteration of the vascular wall, with important subendothelial hypertrophy on cuff microanastomosis and a great permanent histopatologic alteration if the standard technique had been used. CONCLUSIONS: The suture with loose stiches is a very good technique to use for this type of microanastomosis, even if the extraluminal cuff can be used in microanastomosis of a free graft or when it is necessary to perform more than 1 microanastomosis.

Subtotal thyroidectomy with transposition of the remnant gland to the subcutaneous space. A new alternative technique in benign thyroid disease.

BACKGROUND: Thyroidectomy is the preferred surgical option for the treatment of benign disease of the thyroid in a wide rage of indications. Controversy exists concerning the extent of the primary excision for optimal results. A subtotal thyroidectomy with transposition of the thyroid remnant to the subcutaneous space prevents thyroid hormone supplementation for life and laryngeal nerve damage during a re-operation. METHODS: We present the case of a 42-year-old female with nontoxic multinodular goitre who underwent subtotal thyroidectomy in which a thyroid remnant of the left upper pole was placed subcutaneously through a buttonhole incision at the junction of the left sternocleidomastoid and the pre-thyroidal muscles. The remnant of thyroid nourished by the vascular pedicle of the superior pole vessels was sutured to the pre-thyroidal muscles. RESULTS: One month after operation, the remnant was palpated as a small well-limited mass without signs of inflammation and thyroid function tests were normal. A contrast-enhanced computed tomography (CT) scan confirmed the subcutaneous position of the thyroid tissue without pathological signs. The scintigraphy showed uptake radioactivity by the transported thyroid remnant. One year after operation the patient was clinically euthyroid with TSH and T4 levels within normal limits. CONCLUSIONS: This report documents the feasibility and efficacy of subtotal thyroidectomy with transposition of the thyroid remnant to the subcutaneous space in multinodular goitre.

[Verneuil's disease or perianal hydradenitis suppurativa]. / La malattia di Verneuil o idrosiadenite suppurativa perianale.

Verneuil's disease or perianal hidradenitis suppurativa is a chronic suppurative disease with a tendency to fistulization and sclerosis, developing on the subcutaneous tissue, on apocrine glands. The perianal location is the most frequent, and the elective therapy in such case is surgery. A case of perianal Verneuil's disease of great size, invalidating for the patient, in which medical therapy failed, making necessary an aggressive surgical treatment is reported. The therapeutical possibilities of this disease and its possible complications, are discussed.

[Intraperitoneal hemorrhage caused by cavernous hemangioma of the small intestine]. / Hemorragia intraperitoneal por hemangioma cavernoso de intestino delgado.

We report a case of hemorrhage into the abdominal cavity due to the rupture of an intestinal cavernous hemangioma. Out of the 30 published cases from 1976 to 1993 dealing with hemangioma of the small intestine, none presented with intraperitoneal bleeding.

[Perforation of small intestine diverticulum in Ehlers-Danlos syndrome]. / Perforación de divertículo de intestino delgado en el síndrome de Ehlers-Danlos.

We report a case of acute abdomen in a patient previously diagnosed of Ehlers-Danlos syndrome. The pneumoperitoneum on the chest x-ray demanded urgent operative intervention. Laparotomy revealed two diverticula perforations in the small bowel. Perforation in the colon is common; however only two cases of small bowel perforation have been reported so far.

[Pelvic fibromatosis, as a cause of abdominal mass]. / Fibromatosis pélvica, como causa de masa abdominal.

Pelvic fibromatosis was found in a 26-year-old patient who was operated on for a possible uterine myoma. The histopathological diagnosis revealed an idiopathic retroperitoneal fibrosis. A second operation was performed in order to complete the exercise of the mass. Immunohistochemical techniques backed the initial diagnosis of pelvic fibromatosis.