Do Italian surgeons use antibiotic prophylaxis in thyroid surgery? Results from a national study (UEC--Italian Endocrine Surgery Units Association).

Thyroid surgery is a clean procedure and therefore antibiotic prophylaxis is not routinely recommended by most international guidelines. However, antibiotics are often used in clinical practice. We enrolled 2926 patients who performed a thyroid surgical operation between the years 2009 and 2011 in the 38 centers of endocrine surgery that joined the UEC--Italian Endocrine Surgery Units Association. Antibiotic prophylaxis was used in 1132 interventions (38.7%). In case of antibiotic prophylaxis, cephalosporins or aminopenicillins ± beta lactamase inhibitors were employed. At logistic regression analysis the use of drainage or device and the presence of malignancy were independent predictors of antibiotic prophylaxis employment. In conclusion our study shows that antibiotic prophylaxis was not rarely used in clinical practice in the setting of thyroid surgery. Drainage apposition, use of device, and malignant disease were independent predictors for antibiotic prophylaxis employment. More data on everyday practice and infection rate in well-designed studies are warranted to provide definitive recommendations on the utility of antibiotic prophylaxis in this setting. According to our experience, we don't consider to be strictly necessary the antibiotic prophylaxis employment in order to reduce infection rate in thyroid surgery.

The administration of anesthetic in the thyroid pericapsular region increases the possibility of side effects during percutaneous laser photocoagulation of thyroid nodules.

BACKGROUND AND OBJECTIVE: Nodular thyroid disease is very frequent in iodine-deficient areas affecting at least 50% of the population. Percutaneous laser ablation (LA) represents an effective method and an alternative to conventional surgery. Since the first description of the LA methodology for thyroid nodules, various studies have suggested some modifications to increase the percentage of volume reduction of the nodules. One of these alternatives involves the injection of anesthetic in the pericapsular thyroid space with detachment of the capsule itself from the surrounding tissue. The aim of this study was to retrospectively evaluate whether using local anesthetic during LA is more effective in reducing volume size of treated nodules, and whether it causes fewer side effects than using no local anesthesia. STUDY DESIGN: A retrospective analysis was conducted on 100 LA procedures performed on 100 patients between January 2009 and December 2011. The patients were divided into two groups: Group A (n = 50) received Lidocaine around the capsule of the thyroid nodule and Group B (n = 50) did not receive any local anesthetic treatment. Before treatment, the median volume size of the nodules of the two groups was similar. RESULTS AND CONCLUSIONS: The results of our study demonstrate that the injection of local anesthetic does not help reduce nodule volume and that side effects (fever and pain) increase about threefold in the early hours following LA treatment. Thus, we do not recommend local anesthesia before LA of thyroid nodules.

Ultrasound-guided interstitial laser ablation for thyroid nodules is effective only at high total amounts of energy: results from a three-year pilot study.

OBJECTIVE: According to cross-sectional surveys, the prevalence of nontoxic nodular goiter appears to be higher in the adult population. Surgical intervention is indicated for the following: (a) progressive goiter growth, (b) compression of organs such as the trachea and esophagus, and (c) significant aesthetic disfigurement. Ultrasound-guided laser photocoagulation for the treatment of benign thyroid nodules is a viable alternative to traditional surgery. However, studies that have appeared in literature since the introduction of ultrasound-guided laser photocoagulation for the treatment of benign thyroid nodules report contradictory data concerning the energy required for nodule ablation. The aim of the present trial was to evaluate retrospectively the efficacy of percutaneous laser thermal ablation in 2 groups of patients, one treated with low, and the other with high, total amount of energy. DESIGN: Forty euthyroid patients were treated with 1 session of percutaneous laser photocoagulation treatment at low (median = 71 J/mL; 20 patients) and high (median = 578 J/mL; 20 patients) energy. The volume of the nodules was measured by the same investigator, blinded for treatment, using the ellipsoid formula before treatment, at 2, 4, 8, and 30 weeks, and every 6 months for 3 years thereafter. RESULTS: Thyroid nodule ablation is effective over time only if a sufficient amount of energy (>400-500 J/mL for the nodular tissue to be treated) is given, although it incurs proportionate side effects. CONCLUSIONS: Percutaneous laser thermal ablation is a viable alternative to traditional surgery for the treatment of benign nodular thyroid disease only if a sufficient amount of energy is delivered.

Persistent hypercalcitoninemia in patients with medullary thyroid cancer.

Medullary thyroid carcinoma is a highly malignant and progressive disease. Surgery is the only effective treatment. Calcitonin is a significant marker for medullary thyroid carcinoma, and due to its sensitivity it represents a useful tool for the follow-up. The outcome of patients affected by medullary thyroid carcinoma depends on tumor size, lymph node involvement, and adequacy of primary surgical management. In the present study, the authors reviewed their own experience in the cure of medullary thyroid carcinoma. Forty-one patients operated for sporadic medullary thyroid carcinoma were included. Indications for surgery, inclusive of lymphectomy techniques, timing of redo surgery, and the meaning of calcitonin levels in highlighting disease are extensively discussed. Patients with elevated calcitonin levels and favorable outcome are considered, together with the various diagnostic tools to be employed during patient workup.

Surgical treatment of intrathyroid metastases: preliminary results of a multicentric study.

BACKGROUND: Intrathyroid metastases (ITM) are rare and usually have a dismal prognosis. The aim of this study was to detect which neoplasms metastasize most often to the thyroid gland, their clinical features and treatment options. MATERIALS AND METHODS: Retrospective analysis of clinical files of 17,122 patients submitted to surgery for thyroid disease between 1995 and 2005. Twenty-five patients (median age 61 years) were affected by ITM. RESULTS: The site of the primary tumor was: kidney (15), lung (4), colon (3), breast (1), melanoma (1), and unknown in 1 patient. Ten patients (40%) complained of preoperative symptoms, in the others, thyroid involvement was incidentally discovered during the follow-up for the primary cancer. Twenty patients (80%) underwent total thyroidectomy, 3 received thyroid lobectomy and 2 palliative procedures. Morbidity was 16%, mortality was nil. The median follow-up was 24 months. CONCLUSION: ITM should always be suspected in any patient with a previous history of malignancy. Fine-needle agobiopsy (FNAB) with immunohistochemical stains may help in preoperative workup. A long delay between the primary tumor and the recurrence warrants surgery and total thyroidectomy seems to be the treatment of choice because of the multifocality of metastasis to the thyroid gland.

[Molecular medicine in thyroid surgery]. / Medicina molecolare in chirurgia della tiroide.

Cancer originates from a single cell which, through the acquisition of mutations in genes for key growth and survival factors, undergoes clonal expansion. Study of the genome allowed the detection of genes whose mutation is involved in tumour formation. In detail, in most thyroid neoplasms we are now able to identify the genes which cause cancer initiation. Moreover, correlations between mutations and clinico-pathological features of the tumours have been revealed. Thus, the genetic study of tumours is not anymore only a scientific curiosity, but a useful tool for the formulation of the more efficacious therapeutic and follow-up strategies. In this review we will summarize the more recent molecular medicine acquisitions in the thyroid cancer field and will describe their present and eventually future impact on the activity of the endocrine surgeon.

[Non-recurrent inferior laryngeal nerves and sympathetic-inferior laryngeal anastomotic branches: 6 years' personal experience]. / Il nervo laringeo inferiore non ricorrente e le anastomosi con il simpatico cervicale. La nostra esperienza di 6 anni.

The incidence and possible association of inferior laryngeal nerve and sympathetic anastomotic branch anomalies were evaluated in this study. Non-recurrent inferior laryngeal nerves stem from vascular anomalies involving the right subclavian artery and aortic arches during embryological development. These anomalies usually have no functional consequences (except for occasional dysphagia), but are potentially dangerous during thyroid surgery, occurring in about 1% of cases. Sympathetic-inferior laryngeal anastomotic branches are described in about 1.5% of cases, and may be confused with non-recurrent inferior laryngeal nerves. 1473 patients submitted to total thyroidectomy for benign disease over the period 2001-2006 were evaluated. Four non-recurrent inferior laryngeal nerves (incidence: 0.27%) and 11 sympathetic-inferior laryingeal anastomotic branches (incidence: 0.74%) were observed. Out of a total of 25 definitive inferior laryngeal nerve lesions, 1 occurred in a case of non-recurrent inferior laryngeal nerve. Awareness of the anatomical anomalies described and accurate surgical technique, including a constant search for the inferior laryngeal nerve, are the requirements for identification of non-recurrent inferior laryngeal nerves and sympathetic-inferior laryngeal anastomotic branches. During the pre-operative workup, ultrasonographic study of the right subclavian artery may be advisable in order to rule out alterations of its origin and course.

[Intraoperative ultrasonography in the surgery of recurrence of well differentiated thyroid cancer]. / L'ecografia intraoperatoria nella chirurgia delle recidive del cancro differenziato della tiroide.

Surgical resection is the only curative treatment option for local recurrence of well differentiated thyroid cancer. In our experience, we found that intraoperative ultrasonography can be of significant help in facilitating the localisation and complete resection of lesions. From 2005 to 2006, 12 patients with well differentiated thyroid tumour recurrences underwent intraoperative ultrasonography. Recurrences were easily identified and resected in all patients. Postoperative thyreoglobulin was not detected. Intraoperative ulrasonography can be of significant help in the identification of well differeniated thyroid tumour recurrences, particularly when the cancer is smaller than 10 mm in diameter, and can facilitate a more radical excision of the tumour.

[Diagnostic-therapeutic pathways as instruments of clinical management: experience at the S. Maria Hospital in Terni]. / Percorsi diagnostico-terapeutici quale strumento del governo clinico. Esperienza dell'Azienda Ospedaliera S. Maria di Terni.

Diagnostic-therapeutic itineraries and treatment profiles are instruments of clinical management. The authors report on their experience with the experimental creation of such itineraries in thyroid nodular pathology. These are the fruit of collaboration between the management team, endocrinological surgeons, and the hospital computer staff. The drawing-up of guidelines in the hospital setting allows the systematic organisation of clinical activities to be accomplished in the health-care facility, quantifying costs for all diseases in order to be able to plan and implement changes in resources and staff utilisation. Application of the method, in addition, helps to develop a common language among hospital doctors and nurses, facilitates proper communication with patients, and ensures adequate patient information regarding the clinical itinerary the patient will have to take for his or her condition.

[Quality sharing between the national health service and citizens: a diagnostic and therapeutic planning experience at the "S. Maria" Hospital in Terni]. / La qualità condivisa fra servizio sanitario nazionale e cittadini: Esperienza di un percorso diagnostico terapeutico nell'azienda ospedaliera "S. Maria" di Terni.

The Diagnostic and Therapeutic Programs are instruments of clinical management. The authors report on their experience with the construction of a Diagnostic and Therapeutic Program in the field of breast cancer. This is the result of collaboration between the Breast Unit, an administrative team and a computer team at the "S. Maria" Hospital in Terni. The implementation of the guidelines in the hospital setting makes it possible to systematise the clinical activities, to quantify the economic impact for each disease, and to plan any changes in the use of resources. The application of this method, moreover, makes it possible to develop a common language between medical and nursing staff which can be easily understood by the patients and to inform patients adequately with regard to the diagnostic and therapeutic program they will have to comply with for their respective conditions.

[Role of minimally invasive surgery in the treatment of primary hyperparathyroidism]. / Ruolo della chirurgia mininvasiva nel trattamento dell'iperparatiroidismo primitivo.

The minimally invasive approach to parathyroid surgery is considered an efficient alternative to traditional cervicotomy when the pre-operative diagnostic work-up indicates a single parathyroid adenoma. Imaging techniques (ultrasound, SPECT), on the one hand, and intraoperative diagnostic techniques (radio-guided surgery, intraoperative parathyroid hormone assay), on the other, contribute to the success and development of specialized centres which prefer to use this type of surgery. The postoperative pain control and aesthetic results achieved with these techniques are today the main subjects of interest in the minimally invasive approach.