Systematic use of recurrent laryngeal nerve neuromonitoring changes the operative strategy in planned bilateral thyroidectomy.

BACKGROUND: One of the worst complications in thyroid surgery is bilateral recurrent laryngeal nerve paralysis, which can lead to transient or definitive tracheotomy. METHODS: We implemented a strict standard operative procedure beginning in January 2010 and modified our operative procedure. In all patients undergoing bilateral operation, we begin with the largest side or with the cancerous/suspicious side without dissecting the contralateral side. If the intraoperative neuromonitoring (IONM) signal is lost after stimulation of the vagus nerve at the end of the first side, we stop the procedure after the unilateral lobectomy, even if the recurrent nerve is anatomically intact and regardless of malignancy. If the IONM signal is lost, serial laryngoscopies are performed until recovery or definitive recurrent laryngeal nerve palsy is demonstrated. We report here our results in patients with loss of the IONM signal after lobectomy and discuss the medical implications for benign and malignant thyroid conditions. RESULTS: Since January 2010, the operation has been stopped at the first side in 9 out of 220 planned bilateral thyroidectomies. There were five benign thyroid conditions and four thyroid cancers, including three papillary thyroid cancers and one bilateral medullary thyroid cancer in a patient with multiple endocrine neoplasia 2a. In two patients, it was a false-positive IONM loss. One of these two patients had the other lobe removed at day 3. In seven patients the laryngoscopy demonstrated total or partial laryngeal nerve palsy at day 1, but the recurrent nerve function recovered fully in all patients between 1 and 4 months postoperatively. All cancer patients were operated on the other side within 3 days to 3 months; one patient with a benign condition is being followed conservatively. One of the eight re-operated patients had transient recurrent nerve palsy postoperatively. CONCLUSION: In our opinion, the systematic use of IONM and the change in operative strategy will lead to an almost 0% rate of bilateral laryngeal nerve palsy, at least in benign thyroid conditions. A loss of signal after the first side should prompt a halt in the procedure, even in cases of malignancies.

Survival after lung metastasectomy in colorectal cancer patients with previously resected liver metastases.

BACKGROUND: Resection of hepatic metastases is indicated in selected stage IV colorectal cancer (CRC) patients. A minority will eventually develop pulmonary metastases and may undergo lung surgery with curative intent. The aims of the present study were to assess clinical outcome and identify parameters predicting survival after pulmonary metastasectomy in patients who underwent prior resection of hepatic CRC metastases. METHODS: We performed a retrospective analysis of 27 consecutive patients (median age 62 years; range: 33-75 years) who underwent resection of pulmonary metastases after previous hepatic metastasectomy from CRC in two institutions from 1996 to 2009. All patients underwent complete resection (R0) for both colorectal and hepatic metastases. RESULTS: Median follow-up was 32 months (range: 3-69 months) after resection of lung metastases and 65 months (range: 19-146 months) after resection of primary CRC. Three- and 5-year overall survival rates after lung surgery were 56 and 39%, respectively, and median survival was 46 months (95% CI 35-57). Median disease-free survival after pulmonary metastasectomy was 13 months (95% CI 5-21). At the time of last follow-up, seven patients (26%) had no evidence of recurrent disease and 6 of these 7 patients presented initially with a single lung metastasis. CONCLUSIONS: Resection of lung metastases from CRC patients may result in prolonged survival, even after previous hepatic metastasectomy. Yet, prolonged disease-free survival remains the exception, and seems to occur only in patients with a single lung lesion.

A lung segmentectomy performed with 3D reconstruction images available on the operating table with an iPad.

Anatomic lung segmentectomy is the procedure of choice in a growing number of patients, either because the lesion is small and/or because of poor lung function. The procedure requires a good knowledge of intrapulmonary anatomy. However, the experience for the different types of segmentectomy is not easy to obtain during thoracic surgical training due to the relatively small number of patients. Any help to better visualize and apprehend the anatomy pre- and intraoperatively is useful for training, teaching and for performing safer surgical procedures. This paper describes an anatomic segmentectomy procedure (upper segment of the left lower lobe) performed with the assistance of an iPad tablet used during the intervention to display and manipulate 3D images reconstructed prior to the surgery with the Open Source OsiriX software.

Preoperative embolization of hypervascular Castleman's disease of the mediastinum.

We report the case of a 31-year-old woman with mediastinal Castleman's disease of the hyaline vascular type. This large tumor was safely resected after arterial embolization. We describe the steps of this interventional procedure and discuss related necessary precautions.

Establishment of permanent cell lines purified from human mesothelioma: morphological aspects, new marker expression and karyotypic analysis.

This study reports the establishment of three major subtypes of human mesothelioma cells in tissue culture, i.e. the epithelioid, sarcomatoid and biphasic forms, and compares their phenotypic and biological characteristics. Primary cells isolated from biopsies or pleural exudates were subcultured for over 50 passages. We evaluated immunoreactivity using various mesothelial markers related to histological patterns of these cell lines. For epithelioid cells, calretinin and cytokeratin were found to be useful and easily interpretable markers as for control mesothelial cells. The biphasic form was only partially positive and the sarcomatoid type negative. Vimentin was expressed by all cell lines. BerEP4, a specific marker for adenocarcinoma, was negative. Interestingly, while the macrophage marker CD14 was negative, immunoreactivity for a mature macrophage marker (CD68) was expressed by all cell types, suggesting that this marker might constitute an additional tool useful in the differential diagnosis of mesothelioma. At the ultrastructural level, a cell surface rich in microvilli confirmed their mesothelial origin. PCR analysis revealed that none of the cell lines contained SV40 DNA. Karyotypic analyses showed more complex abnormalities in the epithelioid subtype than in the sarcomatoid form. These cell lines may be useful in the study of cellular, molecular and genetic aspects of the disease.

Ten years of lung transplantation in Switzerland: results of the Swiss Lung Transplant Registry.

OBJECTIVE: Lung transplantation has evolved from an experimental procedure to a viable therapeutic option in many countries. In Switzerland, the first lung transplant was performed in November 1992, more than ten years after the first successful procedure world-wide. Thenceforward, a prospective national lung transplant registry was established, principally to enable quality control. PATIENTS: The data of all patients transplanted in the two Swiss Lung Transplant centres Zurich University Hospital and Centre de Romandie (Geneva-Lausanne) were analysed. RESULTS: In 10 years 242 lung transplants have been performed. Underlying lung diseases were cystic fibrosis including bronchiectasis (32%), emphysema (32%), parenchymal disorders (19%), pulmonary hypertension (11%) and lymphangioleiomyomatosis (3%). There were only 3% redo procedures. The 1, 5 and 9 year survival rates were 77% (95% CI 72-82), 64% (95% CI 57-71) and 56% (95% CI 45-67), respectively. The 5 year survival rate of patients transplanted since 1998 was 72% (95% CI 64-80). Multivariate Cox regression analysis revealed that survival was significantly better in this group compared to those transplanted before 1998 (HR 0.44, 0.26-0.75). Patients aged 60 years and older (HR 5.67, 95% CI 2.50-12.89) and those with pulmonary hypertension (HR 2.01, 95% CI 1.10-3.65) had a significantly worse prognosis The most frequent causes of death were infections (29%), bronchiolitis obliterans syndrome (25%) and multiple organ failure (14%). CONCLUSION: The 10-year Swiss experience of lung transplantation compares favourably with the international data. The best results are obtained in cystic fibrosis, pulmonary emphysema and parenchymal disorders.