Thyroidectomy via unilateral axillo-breast approach (UABA) with gas insufflation: prospective multicentre European study.

BACKGROUND: Extracervical approaches for thyroidectomy are seldom explored in the western population. The objective of this study was to evaluate the outcomes of hemithyroidectomy via endoscopic unilateral axillo-breast approach (UABA) with gas insufflation. METHOD: Consecutive patients undergoing UABA hemithyroidectomy for symptomatic benign or cytologically indeterminate nodules (Bethesda III lesions) of less than 5 cm from July 2015 to December 2020 at three European institutions were included. Patients were excluded if presenting with a BMI more than 25 kg/m2, had previous neck surgery and/or radiation, had bilateral thyroid lesions, retrosternal goitre, Hashimoto thyroiditis or Graves' disease. Follow-up was carried out at 2 weeks, 3 months and 1 year. Outcomes of interest were surgical (including operating time, mean duration of hospital stay and complications) and self-assessed cosmetic outcomes. RESULTS: Out of 984 patients treated with hemithyroidectomy during the study interval, 253 were selected, including 214 women and 39 men. Patients' mean age was of 46.6 years with a mean BMI of 22.57. Mean operating time was 72.9 minutes. A transient recurrent laryngeal nerve injury was reported in 3.6 per cent of the patients, but none was persistent. Transient pectoral/cervical hypoesthesia was noted in 24.1 per cent of patients, with no permanent hypoesthesia. Skin burns and subcutaneous hematoma developed in 2.4 per cent and 2 per cent of patients but resolved within the third month after surgery. There was no tracheal/oesophageal perforation, conversion to open surgery or reoperation. The final pathology revealed 241 benign nodules, nine underlying papillary thyroid carcinomas, and three cases of follicular carcinoma. Hospital discharge was achieved on the first in 68.8 per cent of the patients and on the second postoperative day in 31.2 per cent of the cases. All patients were satisfied with the cosmetic aspect. CONCLUSION: In selected patients, UABA with gas insufflation for hemithyroidectomy could be performed for the treatment of unilateral thyroid pathologies.

Changes in anorectal morphologic and functional parameters after fistula-in-ano surgery.

PURPOSE: This study aimed to analyze changes in anal continence and morphologic and functional anorectal variables after fistula-in-ano surgery in a patient series with a high rate of complex fistulas. METHODS: One hundred twenty patients with a mean age of 46.9 (standard deviation, 12.8) years were prospectively analyzed by evaluating anal continence, results of endoanal ultrasound examination and anorectal manometry, and pudendal nerve terminal motor latency before and after fistula-in-ano surgery. RESULTS: Forty-three patients (35.8%) were referred for recurrent fistulas; fistulas in and 70 (58.3%) were considered complex. Preoperatively, 17 patients (14.2%) presented with impaired continence. At follow-up, 59 patients (49.2%) had some degree of incontinence (P < 0.001). The techniques that most affected continence were rectal advancement flap and fistulotomy. Endoanal ultrasound examination showed that the number of patients with internal anal sphincter defects increased from 37 (30.8%) to 78 (74.3%) after surgery (P < 0.001); those with external anal sphincter defects increased from 17 (15.9%) to 34 (32.4%) (P < 0.001). Techniques most associated with increases in internal anal sphincter defects were fistulotomy (P < 0.003) and rectal advancement flap (P < 0.004). Anal manometry showed significant decreases in maximal resting pressure and maximum squeeze pressure in patients with previous incontinence (P < 0.001), and in those with internal anal sphincter defects (P < 0.001). Fistulotomy decreased both resting pressure (P < 0.004) and squeeze pressure (P < 0.007), whereas rectal advancement flap significantly reduced only resting pressure. Pudendal nerve latency did not differentiate continent and incontinent patients, and showed no postoperative change. CONCLUSIONS: Anal continence is significantly affected after fistula-in-ano surgery, mainly because of sphincteric lesions that affect anal canal pressures and that can be imaged with endoanal ultrasound. It is important to preoperatively recognize sphincter defects to allow adequate surgical treatment.

Importancia de la exploración física y técnicas de imagen en la valoración diagnóstica de las fístulas de ano / Importance of physical examination and imaging techniques in the diagnosis of anorectal fistulae

Objetivos: Se diseña un estudio para valorar el papel de exploración clínica y métodos de imagen en el diagnóstico de la fístula de ano. Material y métodos: Efectuamos un estudio observacional con recogida prospectiva de datos en 120 pacientes, mediante evaluación clínica por un explorador experimentado (EE), un cirujano sin especial dedicación a la coloproctología (EC) y una exploración con anestesia (EQ), ultrasonografía endoanal (UEA) y resonancia magnética (RM), usando como referencia los hallazgos durante la cirugía. Resultados: La EQ fue significativamente mejor que la del EE o EC para detección de orificio interno (OFI), trayecto primario y cavidades abscesuales (CA). La UEA fue significativamente más sensible y exacta que el EE para identificar OFI y CA, pero no respecto a la EQ. La RM fue más sensible que el EE en la identificación de OFI, trayectos transesfinterianos, supraesfinterianos y CA sin diferencias significativas con la UEA, y más sensible que la EQ para detectar CA. Conclusiones: La exploración bajo anestesia sigue teniendo un importante lugar en la evaluación de pacientes con fístula de ano. Los métodos de imagen son complemento ocasional de una valoración clínica que puede ayudar a los menos experimentados a decidir el tratamiento apropiado y fundamentalmente cuando se sospecha de una fístula compleja (AU)

Aim: The study was designed to determine the role of clinical examination and imaging techniques in the diagnosis of anorectal fistula. Material and methods: We performed an observational study with prospective recruiting using the data of 120 patients, by means of clinical evaluation by an experienced coloproctologist surgeon (EE), a surgeon without special training in coloproctology (CE), and examination under anaesthesia (SE), endoanal ultrasound (EAU) and magnetic resonance (MR), using the surgical findings as a reference. Results: SE was significantly better than EE or CE for detecting an internal opening (IO), primary track and abscess cavities (AC). EAU was significantly more sensitive and accurate than the EE in identifying an IO, and AC, but not compared to the SE. MR was more sensitive than the EE in the identification of the IO, transphincter and suprasphincter tracks and AC with no significant differences compared to EAU, and more sensitive than the SE to detect AC. Conclusions: Examination under anaesthesia still has a place in the evaluation of anorectal fistula. Imaging methods are an occasional complement to a clinical evaluation that can help the less experienced to decide the appropriate treatment, particularly when a complex fistula is suspected (AU)

[Importance of physical examination and imaging techniques in the diagnosis of anorectal fistulae]. / Importancia de la exploración física y técnicas de imagen en la valoración diagnóstica de las fístulas de ano.

AIM: The study was designed to determine the role of clinical examination and imaging techniques in the diagnosis of anorectal fistula. MATERIAL AND METHODS: We performed an observational study with prospective recruiting using the data of 120 patients, by means of clinical evaluation by an experienced coloproctologist surgeon (EE), a surgeon without special training in coloproctology (CE), and examination under anaesthesia (SE), endoanal ultrasound (EAU) and magnetic resonance (MR), using the surgical findings as a reference. RESULTS: SE was significantly better than EE or CE for detecting an internal opening (IO), primary track and abscess cavities (AC). EAU was significantly more sensitive and accurate than the EE in identifying an IO, and AC, but not compared to the SE. MR was more sensitive than the EE in the identification of the IO, transphincter and suprasphincter tracks and AC with no significant differences compared to EAU, and more sensitive than the SE to detect AC. CONCLUSIONS: Examination under anaesthesia still has a place in the evaluation of anorectal fistula. Imaging methods are an occasional complement to a clinical evaluation that can help the less experienced to decide the appropriate treatment, particularly when a complex fistula is suspected.