A Narrative Review of Preventive Central Lymph Node Dissection in Patients With Papillary Thyroid Cancer - A Necessity or an Excess.

Objective: This review article summarises the latest evidence for preventive central lymph node dissection in patients with papillary thyroid cancer taking into account the possible complications and risk of recurrence. Background: Papillary thyroid cancer is the most frequent histological variant of malignant neoplasms of the thyroid gland. It accounts for about 80-85% of all cases of thyroid cancer. Despite good postoperative results and an excellent survival rate in comparison with many other malignant diseases, tumor metastases to the cervical lymph nodes are frequent. Most researchers agree that the presence of obvious metastases in the lymph nodes requires careful lymph node dissection. It was suggested to perform preventive routine lymphadenectomy in all patients with malignant thyroid diseases referred to surgery. Methods: It was performed the literature review using the "papillary thyroid cancer", "central lymph node dissection", "hypocalcemia", "recurrent laryngeal nerve paresis", "metastasis", "cancer recurrence" along with the MESH terms. The reference list of the articles was carefully reviewed as a potential source of information. The search was based on Medline, Scopus, Google Scholar, eLibrary engines. Selected publications were analyzed and their synthesis was used to write the review and analyse the role of preventive central lymph node dissection in patients with papillary thyroid cancer. Conclusions: The necessity of preventive central lymph node dissection in patients with differentiated papillary thyroid carcinoma is still controversial. There is much evidence that it increases the frequency of transient hypocalcemia. Due to the fact that this complication is temporary, its significance in clinical practice is debatable. It can also be assumed that an extant of surgery in the neck area is associated with an increased risk of recurrent laryngeal nerve injury. However, most studies indicate that this injury is associated more with thyroidectomy itself than with lymph node dissection. Recurrent laryngeal nerve dysfunction is also a temporary complication in the vast majority of cases. At the same time, a large amount of data shows that central lymph node dissection reduces the risk of thyroid cancer recurrence in two times.

Subacute thyroiditis after SARS-CoV-2 infection.

Viral infections are considered as etiologic factors of subacute thyroiditis. The true incidence of subacute thyroiditis, caused by SARS-CoV-2 infection, is probably considerable since it is often masked by more dramatic affection of the respiratory system. This report presents two female patients who developed de Quervain's thyroiditis after COVID-19 disease.

Laparoscopic liver resection with simultaneous diaphragm resection.

BACKGROUND: Liver resection or ablation remains the only curative treatment for patients with colorectal metastases. Simultaneous resection of tumors in the liver with invasion to the diaphragm is challenging and controversial. Therefore, we wanted to assess the safety of simultaneous laparoscopic liver and diaphragm resection (SLLDR) in a large single center. METHODS: Patients who underwent primary laparoscopic liver resection (LLR) for colorectal liver metastases at Oslo University Hospital between 2008 and 2019 were included in this study. Patients who underwent SLLDR (group 1) were compared to patients who underwent LLR only (group 2). Perioperative and oncologic outcomes were analyzed. RESULTS: A total of 467 patients were identified, of whom 12 patients needed a simultaneous diaphragm resection (group 1) while 455 underwent laparoscopic liver surgery alone (group 2). The conversion rate was 16.7% in group 1 and 2.4% in group 2 (P=0.040). In 10 of 12 (83.3%) cases the diaphragm resection was performed en bloc with the liver tumor. There was no significant difference in operative time, blood loss, resection margins, hospital stay or postoperative complications. One patient died within 30 postoperative days (0.2%) in group 2 and none in group 1. Overall survival was not statistically different between the groups. CONCLUSIONS: In selected patients, SLLDR can be performed safely with good surgical and oncological outcomes.

Does tumor size influence the outcome of laparoscopic distal pancreatectomy?

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is a safe procedure, but its role in resection of large pancreatic lesions has been questioned. METHODS: Patients who underwent LDP for pancreatic solitary tumors in 1997-2017 were included in this study. The patients were divided into three groups in accordance with tumor size: <3.5 cm (group I); from 3.5 cm to 7.0 cm (group II), and ≥7 cm (group III). RESULTS: 218, 146 and 58 patients were identified in the groups I, II and III. Median tumor size in the groups I, II and III was 20, 47 and 81.5 mm (p < 0.001). Nine procedures (2.1%) were converted including 1(0.5%), 5(3.4%) and 3(5.2%) in the groups I, II and III (p = 0.036). Median operative time was longer in the group III compared with the groups I and II - 195 vs 158 and 159 min (p = 0.005). Median blood loss did not differ. Regression analysis revealed correlation between tumor size and operative time (R = 0.103; P = 0.035) and no correlation between tumor size and blood loss (R = 0.075; P = 0.125). Hospital stay was 5 days, similar in all groups.Postoperative morbidity was similar - 38.5, 32 and 34% in the group I, II and III. CONCLUSION: LDP can be safely performed laparoscopically with outcomes similar to those for smaller tumors.

Evaluation Criteria and Surgical Technique for Transoral Access to the Thyroid Gland: Experimental Study.

Background: The development of endoscopic techniques motivated surgeons to search for alternative and more cosmetic approaches for thyroid and parathyroid surgery. Several variations of transoral access to the anterior neck areas were applied in recent years. One of them is a premandibular access proposed by Nakajo et al, it is performed through the oral vestibule by creating the working space by means of the lifting method. Materials and methods: Nineteen unfixed human cadavers were used to develop the endoscopic access to the thyroid gland and surgical techniques of its resection. The Nakajo access was modified by altering the spatial location of the working instruments, resulting in practically no impact on the cosmetic outcome but providing a more comfortable operation for the thyroid gland. We determined evaluation criteria of the cadaver model before initiation of the experimental trial. Parameters that influence on alteration of these criteria were registered. Results: Of the 19 operated objects, the first 7 were used to practice the access technique from the incision in the oral vestibule to the thyroid gland in order to evaluate the possibility of endoscopic dissection of the important anatomical. The next 12 surgeries were carried out by manipulating the thyroid gland in the settings maximally close to real. Access implied good cosmetic results, less surgical traumatic due to a smaller area of detachment of the musculocutaneous flap. Conclusions: The achieved results show feasibility of introducing the described modification of transoral thyroidectomy into clinical practice.

Thrombodynamics-A new global hemostasis assay for heparin monitoring in patients under the anticoagulant treatment.

BACKGROUND: Heparin therapy and prophylaxis may be accompanied by bleeding and thrombotic complications due to individual responses to treatment. Dosage control based on standard laboratory assays poorly reflects the effect of the therapy. The aim of our work was to compare the heparin sensitivity of new thrombodynamics (TD) assay with sensitivity of other standard and global coagulation tests available to date. STUDY POPULATION AND METHODS: A total of 296 patients with high risk of venous thromboembolism (deep vein thrombosis (DVT), early postoperative period, hemoblastosis) were enrolled in the study. We used a case-crossover design to evaluate the sensitivity of new thrombodynamics assay (TD) to the hemostatic state before and after unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) therapy/prophylaxis and to compare it with the activated partial thromboplastin time (APTT), anti-Xa activity test, thrombin generation test (TGT) and thromboelastography (TEG). A receiver operating characteristic (ROC) curve analysis was used to evaluate changes before and after heparin prophylaxis and therapy. Blood was sampled before heparin injection, at the time of maximal blood heparin concentration and before the next injection. RESULTS: Hypercoagulation before the start of heparin treatment was detected by TD, TGT and TEG but not by APTT. The area under the ROC curve (AUC) was maximal for TD and anti-Xa, intermediate for TGT and TEG and minimal for APTT. CONCLUSIONS: These results indicate that TD has a high sensitivity to the effects of UFH and LMWH after both prophylactic and therapeutic regimes and may be used for heparin monitoring.

Safety and efficacy of daptomycin as first-line treatment for complicated skin and soft tissue infections in elderly patients: an open-label, multicentre, randomized phase IIIb trial.

BACKGROUND: Daptomycin has proven efficacy in patients with Gram-positive complicated skin and soft tissue infections (cSSTIs), including those caused by Staphylococcus aureus, regardless of methicillin susceptibility. OBJECTIVE: This study was undertaken to evaluate the efficacy and safety of daptomycin in elderly patients. STUDY DESIGN: This was an open-label, multicentre, randomized phase IIIb study conducted in hospitalized patients PATIENTS: Patients aged ≥65 years with a diagnosis of Gram-positive cSSTIs with or without bacteraemia were included. In addition, infections were required to be of sufficient severity to require inpatient hospitalization and treatment with parenteral antibiotics for at least 96 h. The main exclusion criterion was the presence of a non-complicated SSTI that could heal by itself or be cured by surgical removal of the site of infection. INTERVENTION: Patients were randomized (2:1) to intravenous daptomycin or pooled intravenous standard therapies (semi-synthetic penicillin or vancomycin, referred to as the 'comparator'). Duration of treatment was between 5 and 14 days for cSSTIs without bacteraemia and between 10 and 28 days for cSSTIs with bacteraemia. MAIN OUTCOME MEASURE: The primary objective was descriptive comparison of clinical success in clinically evaluable patients at test of cure, 7-14 days post treatment. Secondary objectives were microbiological outcome, duration of treatment and safety. RESULTS: In total, 120 patients were randomized (81 to daptomycin; 39 to the comparator) and 102 patients completed the study. Baseline characteristics were similar between the two groups. Common infections included cellulitis, ulcers and abscesses; six patients had bacteraemia [five documented (daptomycin, n = 3; comparator, n = 2); and one suspected (daptomycin, n = 1)]. Test-of-cure clinical success rates were numerically higher for daptomycin than for the comparator [89.0 % (65/73) vs. 83.3 % (25/30); odds ratio 1.65 (95 % confidence interval 0.49-5.54)]. For patients with S. aureus infections, cure rates were 89.7 % (35/39) versus 69.2 % (9/13), respectively; percentage points difference, 20.5 (95 % confidence interval -12.2 to 50.9)]. Rates of adverse events (AEs) and serious AEs were similar in both treatment arms; however, discontinuation rates for AEs/serious AEs were lower for daptomycin than for the comparator (3.8 % vs. 10.0 %). Three serious AEs were considered to be related to the study drug: one case each of pancytopenia (semi-synthetic penicillin), renal failure (vancomycin) and asymptomatic increase in creatine phosphokinase concentrations (daptomycin). CONCLUSION: In elderly patients, for whom data were previously limited, the efficacy and safety of daptomycin have been confirmed, including for infections caused by S. aureus, regardless of methicillin susceptibility.

Minilaparotomy removal of giant gastric trichobezoar in a female teenager.

While small gastric trichobezoars may be removed via gastroscopy, large trichobezoars require surgical removal by gastrotomy through abdominal incision. We present a case of a successful minilaparotomy removal of a giant (2500-g) gastric trichobezoar in a 15-year-old girl with marginal psychological disturbances.

Mini-laparotomy cholecystectomy: technique, outcomes: a prospective study.

BACKGROUND: The last decades have been characterized by a rapid growth in minimally invasive techniques for acute and chronic cholecystitis. The aim of our study was to analyze 10 years of experience with the mini-laparotomy cholecystectomy. METHODS: From 1994 to 2004, we performed 2295 mini-laparotomy cholecystectomies, including 1028 patients with acute and 1267 patients with chronic cholecystitis. There were 1780 women and 515 men. We utilized a special surgical tool kit with a system of circular and small hook-retractors incorporating an illuminator and long surgical instruments. Our surgical approach was carried out using a 3-5 cm longitudinal incision located immediately above the gallbladder with a muscle splitting technique. RESULTS: The mean time of operation was 64.5+/-24.5 min and the conversion rate was 3.7%. Intraoperative complications occurred in 25 cases (1.1%), including 4 cases (0.17%) of biliary tract injury. Cholecystectomy was combined with intervention on the choledochus and the papilla of Vater in 133 patients with choledocholithiasis. Postoperative complications developed in 4.1%. Five hundred and five patients (22%) required opioid analgesics on the first postoperative day. The mortality rate was 0.17%. The mortalities involved patients who had severe concomitant diseases and required urgent surgery for acute cholecystitis. Patients operated for acute cholecystitis had significantly higher rates of postoperative complications (5.8% vs. 2.8%), need for opioids (25.5% vs. 19.2%) and mortality (0.39% vs. 0%). CONCLUSIONS: Mini-laparotomy cholecystectomy is an alternative to laparoscopic approach in the surgical treatment of acute and chronic cholecystitis.