Duplex ultrasound and magnetic resonance imaging of the supra-aortic arches in patients with non recurrent inferior laryngeal nerve: a comparative study.

BACKGROUND: Non-recurrent inferior laryngeal nerve (NRILN) is usually discovered during thyroid surgery. It is often associated with vascular abnormalities that can be detected with magnetic resonance imaging (MRI) or duplex ultrasound scan. The aim of this study was to compare the diagnostic sensitivity of ultrasonography with MRI to identify the vascular abnormalities associated to NRILN. PATIENTS AND METHODS: We revised 2713 total thyroidectomies to select patients with NRILN. The NRILN was identified in 17 patients (0,6%). A postoperative ultrasonic duplex scanning and a MRI was performed in 15 cases as 2 patients refused to submit to the exams. RESULTS: At MRI an unique origin of common carotid trunk and a concomitant aberrant retroesophageal subclavian right artery was showed in 11 patients. In 2 cases vascular abnormality consisted in separated origin of supra-aortic arteries. At duplex ultrasound scan only in 2 patients was impossible to identify vascular abnormalities detected at MRI. Tthe diagnostic sensitivity of duplex ultrasound was 84,6%. CONCLUSIONS: Preoperative duplex ultrasound is a non invasive method with high diagnostic sensitivity that can easily complete the preoperative thyroid ultrasonography.

Uni-centric localization of Castleman's disease treated with laparoscopic and traditional approach. Report of two cases.

Castleman's disease (CD) is a rare lymphoproliferative disorder. Clinically CD has been subdivided in two forms: uni-centric and multicentric. The uni-centric type is limited to a single anatomic lymph-node-bearing region. The present report describes two cases of uni-centric CD: the first was an abdominal localization treated with a laparoscopic approach; the second was a submaxillary localization treated with a classical approach. In case 1 the laparoscopic approach permitted to reach diagnosis, not clear after diagnostic imaging procedures, and enabled a total and excellent resolution of the pathology because our patient, after eight months of follow up, has had no evidence of recurrence of the disease. In case 2 we want to highlight that CD should be considered in the differential diagnosis of a solitary neck mass and that the surgical treatment is diagnostic and curative at the same time.

Tumor-induced hypophosphatemic osteomalacia associated with tertiary hyperparathyroidism: a case report.

BACKGROUND: Tumor-induced hypophosphatemic osteomalacia is a syndrome characterized by urinary phosphate wasting related to the presence of a slowly-growing tumor of mesenchymal origin. The characteristic laboratory findings are normal serum calcium, marked hypophosphatemia, increased serum alkaline phosphatase, markedly reduced renal tubular reabsorption of phosphorus and inappropriately low levels of 1,25-dihydroxyvitamin D [1,25-(OH)2D]. CASE PRESENTATION: A 65-year-old woman presented with a 17-year clinical history of musculoskeletal pain, muscular weakness in the pelvic girdle, spontaneous fractures and difficulty in walking. Over the ensuing years the patient suffered other multiple spontaneous fractures, surgically treated, and the muscular pains worsened until she became bedridden. During the years before hospital admission the patient received treatment with clodronate, oral calcium salts and vitamin D therapy. Standard laboratory, ultrasonography and scintigraphic findings provided a "convenient" diagnosis of primary hyperparathyroidism, but the low plasma level of phosphorus induced to perform an Indium111-octreotide scintigraphy. Scintigraphy visualized an area of pathologic increased signal uptake in the left groin, consistent with a mass containing a high density of somatostatin receptors. After surgery, histologic examination and immunostaining of the resected specimen indicated an hemangiopericytoma. Nevertheless, the persistently low blood phosphorus level, in association with the increased serum calcium and PTH levels, were attributed to the prolonged phosphate therapy the patient underwent over the years, and the persisting abnormal laboratory indexes indicated the development of a tertiary hyperparathyroidism. We performed a subtotal parathyroidectomy and intraoperative assay of serum PTH showed that levels had diminished by more than 80% from preoperative values. Over the ensuing months Ca+2, PTH and serum phosphorus values returned to normal, and the pain symptoms disappeared. CONCLUSIONS: Tumour-induced osteomalacia is a very rare syndrome associated in 5% of cases with tertiary hyperparathyroidism due to long-term therapy with phosphorus and vitamin D. The initial diagnosis of primary hyperparathyroidism, confirmed by the parathyroid MIBI-scintigraphy, would lead us to an inappropriate surgical treatment. Therefore we want to stress the importance of In111-octreotide scintigraphy in detecting tumours, rich in somatostatin receptors, in presence of an hypophosphatemic syndrome.

Incidental parathyroid adenomas with normocalcemia discovered during thyroid operations: report of three cases.

We report three cases of parathyroid adenoma incidentally discovered during a total thyroidectomy. No patients showed any clinical or chemical features that led us to suspect a hyperparathyroidism condition before operation, but a macroscopically enlarged parathyroid was discovered during the dissection and it was removed in all three cases. All patients had a single adenoma confirmed by a histological analysis. Calcemia decreased after operation in every case but only one patient needed temporary adjunctive therapy. No permanent hypoparathyroidism or recurrent hyperparathyroidism was observed. We recommend that any enlarged parathyroid discovered during neck surgery should thus be removed in order to avoid the risks of future surgical procedures due to successive bouts of clinical hyperparathyroidism.

Familial papillary carcinoma of the thyroid: a report of nine first-degree relatives of four families.

The authors report the occurrence of papillary carcinoma of the thyroid in nine first-degree relatives of four families among a consecutive series of 97 patients with papillary carcinoma of the thyroid who were operated on from 1991 to 1998. Total thyroidectomy was performed in all cases. All patients are alive without evidence of disease after a mean follow-up period of 43 months. Since in our series familial papillary carcinoma of the thyroid was found in 9.3% of patients, we suggest an adequate screening among first-degree relatives of all patients with papillary thyroid carcinoma. Because of reported aggressive behaviour of familial papillary carcinoma of the thyroid, aggressive surgical treatment plus post-operative thyroid remnant ablation with radio-iodine should be warranted in all patients.

Surgical treatment of paragangliomas of the carotid body and other rare localisations.

BACKGROUND: Cervical paragangliomas are uncommon benign or malignant neoplasms, deriving from stem cells of the neural crest. Compared to all the tumors of the head and neck, they occur less frequently. They can be found in any part of the body where there are sympathetic ganglia including chemoreceptors, suprarenal medulla, retroperitoneal ganglia and the extreme branches of the vagus nerves. It is not easy nowadays to define properly their biological behaviour, the possible multicentric location and the association with Multiple Endocrine Neoplasms; this is considered particularly important and occurs in 42 per cent of the cases of familial neoplasms of the paraganglion system. METHODS: After a review of recent diagnostic, pathological and clinical findings, the authors report their experience, between 1970-1995, of 10 patients affected by sporadic paraganglioma and 1 by familial multicentric neoplasm localised in the carotid bodies of both sides, left vagus nerve and left hypoglossus nerve. All patients but one were treated by a curative resection of the neoplasm. In one case only an explorative laparatomy was possible because of visceral and vascular involvement. RESULTS: There is no mortality. There are no modifications in arterial blood pressure and catecholamine values in all patients. The complications were a recurrential palsy in a patient operated on for vagal paraganglioma; a recurrential palsy and temporary dysarthria in the patient affected by multiple familial paraganglioma; another patient operated on for carotid body paraganglioma showed a cerebral ischemic lesion which caused a slightly transitory facial-brachial motor deficit on the right side and speech impairment. CONCLUSIONS: We can venture to say that any type of cervical, mediastinal or retroperitoneal swelling in persons belonging to a genetically prone family must be first of all considered a possible paraganglioma. For this reason the patient with more than one growth of this type, whether synchronous or not, must undergo genetic investigation, along with the rest of his family.

Total versus subtotal thyroidectomy in the management of multinodular goiter.

BACKGROUND: The choice between subtotal and total thyroidectomy for multinodular goiter is controversial. MATERIAL AND METHODS: Subtotal and total thyroidectomy have been respectively performed in 108 and 451 euthyroid patients with multinodular goiter. RESULTS: After subtotal and total thyroidectomy, transient recurrent laryngeal nerve (RLN) palsy occurred in 1 patient (0.9%) and 3 (0.6%), transient asymptomatic hypoparathyroidism in 27 (25%) and 131 (29%), and transient symptomatic hypoparathyroidism in 2 (1.8%) and 13 (2.9%), respectively (P = NS). After subtotal thyroidectomy, recurrence occurred in 27 patients (26%) Re-operation in 14 patients resulted in transient RLN palsy in 2 patients (14%), transient asymptomatic hypoparathyroidism in 6 (43 %) and transient symptomatic hypoparathyroidism in 2 (14%). CONCLUSIONS: The failure to demonstrate any 'hormonal advantage' in preserving thyroid tissue by subtotal thyroidectomy, and the low morbidity rate and no need for re-operation after primary total thyroidectomy, make the latter the procedure of choice for the management of non-toxic multinodular goiter.

Paragangliomas of the carotid body and other rare localisation.

Cervical paragangliomas are uncommon benign or malignant neoplasms, originated by stem cells of neural crest. It is not easy nowadays to define properly their biological behaviour, the possible multiple location and the association with Multiple Endocrine Neoplasms. After a wide review about recent diagnostic, pathological and clinical acquisition, authors report their caseload of 10 patients affected by sporadic paragangliomas and 1 by familial multiple neoplasm localised in carotid bodies of both sides, left vagus nerve and left hypoglossus nerve. All patients but one were treated by a curative resection of the neoplasm. In one case only an explorative laparatomy was possible because of the visceral and vascular involvement.

Insular carcinoma of the thyroid. A report of 8 cases.

Insular carcinoma of the thyroid (ICT) is an uncommon malignancy with intermediate morphology and behaviour between well-differentiated and anaplastic thyroid carcinoma. Eight patients with ICT underwent total thyroidectomy. A modified neck dissection was carried out in six of them. Cervical lymph nodes metastases were detected during surgery in six patients or at scintigraphy in two patients who did not undergo neck dissection. Postoperatively, a patient developed diffuse metastases not detected by 131I whole-body scintigraphy and she died of disease 6 months later despite radio- and chemotherapy. Another patient had distant metastases detected by 131I whole-body scintigraphy and successfully treated by radioiodine ablative therapy. Unfortunately, she developed other distant metastases with no 131I uptake and died of disease 23 months later despite chemotherapy. After a mean follow-up of 5.5 years, 6 patients (75%) were alive without evidence of disease. These observations confirmed the aggressiveness of ICTs that sometimes are not responsive to current available therapies. The frequent occurrence of metastases to the regional lymph node calls on for a modified neck dissection in all patients with ICT.

Surgical treatment of paragangliomas of the neck.

Of a total of 5,700 surgical procedures on the neck performed at our Institution between 1984 and 1995, 13 operations (0.22%) have been done on 11 patients with 16 cervical paragangliomas. A woman underwent resection of synchronous bilateral carotid body tumours and of an intravagal paraganglioma. Ten years later, after preoperative angiographic embolization, she underwent resection of a paraganglioma of the left hypoglossal nerve. Her sister, at age 21, underwent resection of a carotid body tumour and, respectively 19 and 20 years later, of a right and left intravagal paraganglioma. An interposition graft for replacement of the carotid bifurcation was necessary in one patient only. During resection of a left carotid body tumour, acute hypotension occurred resulting in an ischemic lesion of the right temporal lobe. Postoperatively, she also complained of respiratory distress that responded to medical therapy with difficulty. The related neurologic symptoms completely resolved three months after surgery. The operation for a paraganglioma of the left hypoglossal nerve resulted in a temporary motor deficit of the tongue and in permanent considerable difficulty in swallowing. Unilateral recurrent nerve palsy occurred in two patients. No patients during the postoperative follow-up showed signs of local recurrence or metastatic disease. In conclusion, surgery is an effective treatment for cervical paraganglioma, but because of the high surgical complication rate, an experienced and skilled surgeon is called on to optimize outcome. An adequate perioperative care is advisable.

[Paraganglioma in the case records of the III Surgical Clinical Institute]. / I paragangliomi nella casistica dell'istituto di III Clinica Chirurgica (1970-1995).

Cervical paragangliomas are uncommon benign or malignant neoplasms, originated from the stem cells of the neural crest. Up to date it is still not easy to define properly their biological behaviour, the possible multicentric location and the association with Multiple Endocrine Neoplasias. After a wide review of recent diagnostic, pathological and clinical notions, the Authors report their experience, from 1970 to 1995, of 10 patients affected by sporadic paraganglioma and 1 by familial multicentric neoplasm localized on carotid bodies of both sides, left vagus nerve and left hypoglossus nerve. All patients but one were treated by a curative resection of the neoplasm; in one case only an explorative laparotomy was possible because of the visceral and vascular involvement.

[Riedel's thyroiditis: a case report and review of the literature]. / La tiroidite di Riedel: descrizione di un caso clinico e revisione della letteratura.

Riedel's thyroiditis is a very rare disease of unknown aetiology, occasionally associated with retroperitoneal and mediastinal fibrosis. It is a benign condition, but may be confused with an anaplastic carcinoma of the thyroid. The differential diagnosis with anaplastic carcinoma is assured only by intraoperative biopsy. The Authors report a clinical case: symptoms were a progressive enlargement of the thyroid gland, left recurrential palsy, dyspnoea and dysphagia. The surgical treatment was total thyroidectomy, performed with bilateral neurolysis of recurrent nerves. The patient was also under adjuvant corticosteroid treatment.

[Thyroid carcinoma. Retrospective analysis of case records of the III. Surgery Department at the Umberto I Clinics in Rome in the years 1990-93]. / Il carcinoma tiroideo. Analisi retrospettiva da una casistica della III Clinica Chirurgica (anni 1990-1993) del Policlinico Umberto I di Roma.

BACKGROUND: The aim of this investigation was to ascertain: 1) temporal trends in the incidence of thyroid carcinoma between 1990-1993; 2) regional differences in the incidence and histotype among the five provinces of Latium; 3) identification of risk factors, particularly of a preexisting thyroid tumour (goitre). METHODS: Records of patients submitted to thyroid surgery at the Istitute of III Clinica Chirurgica dell'Università "La Sapienza" di Roma have been reviewed and a questionnaire filled-in. RESULTS: In the period 1990-1993, 144 cases of thyroid carcinomas were operated; 77.7% of those resided in the Latium region. Average age was 43 +/- 16.2, F:M = 3:1. During the four years observation period there was an increase in all surgical interventions and proportionally increased also thyroid surgery (hyperplasia, thyroiditis, hyperthyroidism and thyroid cancer). Thyroid cancer was found in 10% of thyroid patients, this proportion remains constant in the period 1990-1992, in 1993 rising to 14% (p = 0.032). Differences of incidence although not significant were found in the five provinces of Latium. A higher proportion of follicular histotypes was found in the province of Frosinone (FR vs RM, 20 vs 13.5% p = 0.45). A previous goitre, standing for period of three or more years, was reported in the records of 25% of patients. Seven percent of patients have been previously submitted to a partial thyroidectomy for benign thyroid disease, most of those being operated for thyroid adenoma (8 out 10 cases). CONCLUSION: During a four year period of observation an increase of thyroid carcinoma was observed only in 1993. This increase cannot be attributed to an increase in the incidence of thyroid carcinoma. The province of Frosinone, known to be an endemic area, shows a proportion of the follicular histotype higher than that of other provinces. Goiter precedes malignant thyroid neoplasia in a high proportion of patients (25%). Follicular adenoma found frequently at the histology of patients operated for benign thyroid disease suggesting a transformation from benign to a malignant condition.

Hepatic echinococcus disease: our experience over 22 years.

BACKGROUND/AIMS: It is important to single out the indications for surgery of hydatid disease of the liver at an early stage. For this, a fully comprehensive diagnostic work up of the patient is required. Surgery represents the most effective therapy and involves resection of the cysts and their outer capsule. This must be as complete as possible. MATERIAL AND METHODS: Between 1970 and June 1992, 95 patients received this combined treatment for hydatid disease although only those presenting from 1985 were followed up. RESULTS: No serious complications were noted apart from pyrexia due to secondary cholangitis or reactive pleuritis. This responded quickly to antibiotics and there was no mortality. No cases of relapse occurred although one case did show evidence of reappearance of the disease on serological testing alone, all other tests being negative. CONCLUSION: The most effective treatment for echinococcus cystic disease of the liver is radical surgery. Results are best when surgery is combined with medical therapy of benzoimidazole drugs given pre- and post-operatively. From our experience, we are now confident that surgical treatment must always be preceded and then followed by treatment with benzoimidazole antihelminthics.

[Total thyroidectomy technique: suggestions and proposals of surgical practice]. / Tecnica della tiroidectomia totale. Suggerimenti e proposte di pratica chirurgica.

Total thyroidectomy at present depicts a diffuse surgical procedure in the management of benign and malignant disease of thyroid gland. It is followed by a low incidence of iatrogenic damages (nervous lesions or permanent hypoparathyroidism), just like subtotal thyroidectomy and lower than surgery for nodular recurrences. Authors present the surgical technique they follow to perform total thyroidectomy, used in over 400 cases of benign thyroid diseases operated since 1986. The most important points of this surgical procedures are represented by exposure and sparing of inferior laryngeal nerve and by preservation of parathyroid function. Parathyroid glands can be exposed to direct surgical trauma but, more often, they are injured by damage of their vascular supply. To avoid this complication, vascular ligations of inferior thyroid artery have to be done never on the trunk of the artery, but on its branches just near the glandular capsula. Sparing of inferior laryngeal nerves comports the exposure of this structure for all its cervical course especially in the terminal edge, when the nerve is nearest to the gland. Systematical application of illustrated procedure has produced no operative mortality, no inferior laryngeal nerve permanent palsy, transient hoarseness in 0.5%, and transient symptomatic hypocalcemia in 2.7%.

[Lateral cervical metastases from unknown primary]. / Le metastasi laterocervicali precessive.

The authors report their experience about cervical metastasis of unknown primitive neoplasms. Epidemiology, histological type and topography are exposed. Primaries which are responsible, in a high incidence, of the preceding cervical localizations are described. Diagnostic iter, non-invasive/low-price clinical and instrumental procedures, advanced endoscopic and radiologic procedures are discussed. 64 patients were treated. Only in one case we could diagnose the primitive site of the neoplasm with non-invasive procedures. The other cases (63 patients) underwent the excision-biopsy of the cervical nodes. In 52 cases we have been able to define the primitive site of the neoplasm. 11 patients, in which the primary was unknown, underwent the radiotherapy of the cervical nodes and the eventual primitive "foci"; we had no survival, on the average, after six months for the diffuse dissemination of the neoplastic disease.

[The Soupault-Bucaillle operation in the treatment of Billroth II gastric resection syndrome]. / L'intervento di Soupault e Bucaille nel trattamento della sindrome da gastroresezione sec. Billroth II.

The study analyzes the benefits related to the gastroduodenojejunoplasty (GDJP) according to Soupault & Bucaille, adopted as the corrective treatment of the Billroth II gastric resection syndrome in those cases resistant to the dieting-pharmacological supports. Our experience is based on 18 cases (13 males, 5 females, mean age 39 yrs), treated from 1982 to 1987 with GDJP for a gastric resection syndrome. The patients were observed 5 years after their resection: 10 presented with an atrophic gastritis/gastric atrophy and all had a diffuse acute phlogosis in presence of biliary storage. Manual anastomoses were performed in the first 8 cases, while staplers were used in the remaining cases. Results were quite satisfying; no operative mortality or specific complications, nor pain and biliary vomiting were registered; 14 patients over 18 (77%) gained weight significantly; only 1 patient reported low-intense early "dumping-like" symptoms easily controlled by medical therapy. Endoscopy showed no biliary reflux in all cases. Biopsies of the stump, carried on before and after the GDJP intervention, showed a marked reduction of the inflammatory aspects in 76% (13) of the patients. Among the 10 patients with atrophic gastritis/gastric atrophy, only 2 (20%) presented a significant increase in the number of gastric parietal cells and gastric principal cells.

[Anastomosis or closure of the pancreatic stump after duodenopancreatectomy?]. / Anastomosi o chiusura del moncone pancreatico dopo duodenocefalopancreatectomia?

From 1986 to June 1990, 10 pancreaticoduodenectomies were performed in our Department (VIII Patologia Chirurgica, Università "La Sapienza", Roma). The reconstructive sequence was based on the pancreaticojejunal anastomosis (2 end-to-end pancreaticojejunostomies after invagination, 3 end-to-side Wirsung jejunostomies) in 5 patients. The pancreatic stump was sutured using a 50mm linear stapler in the remaining 5 patients. There was a high incidence (75%) of fistulization after direct suture of the pancreatic stump, although related mortality was null. Among patients treated with pancreaticojejunal anastomosis, a fistula on the end-to-end pancreaticojejunostomy with exitus of the patient, was registered in 1 case. On principle, we believe a end-to-side Wirsung jejunostomy should be performed after pancreaticoduodenectomy. When a safe anastomosis of the pancreatic stump cannot be performed (because of the soft parenchyma, easily lacerable) the technique of the direct suture with stapler is advisable.