Scarless Completion Thyroidectomy After Initial Transoral Approach for Differentiated Thyroid Cancer: How and When to Start?

BACKGROUND: With growing literature, the feasibility of transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been confirmed as a valid method for managing differentiated thyroid cancer. Completion thyroidectomy (CT) is recommended in patients who have been diagnosed with differentiated thyroid cancer after unilateral lobectomy by TOETVA. In this retrospective study, the authors addressed the critical questions of how and when to do the second operation of CT to avoid a neck scar. MATERIALS AND METHODS: The authors retrospectively reviewed our patients who had received TOETVA in our hospital from August 2016 to December 2019. Those who received CT after initial TOETVA as cTOETVA were further separated according to the approaching methods. Demographic data, operative variables, and postoperative variables were collected and analyzed. RESULTS: A total of 97 patients were enrolled using TOETVA. Malignancies were present in 42 patients (43.3%) using TOETVA. There were 3 approaching methods of cTOETVA and separated into reopen transcervical approach (re-TCA), retransoral TOETVA (re-TOETVA), and transaxillary approach (TAA) groups. There were no significant complications among patients for cTOETVA. Of the 8 patients for the cTOETVA, 3 received re-TCA, 3 re-TOETVA, and 2 TAA. CONCLUSIONS: The outcomes are encouraging and demonstrate the feasibility of scarless completion thyroidectomy after initial TOETVA. The re-TOETVA procedure should be completed within 14 days after the initial TOETVA procedure, TAA beyond 14 days, and re-TCA may be completed at any time. The cTOETVA techniques using re-TOETVA or TAA have better cosmetic results than re-TCA in oncological equivalency.

Prognostic value of sarcopenia in patients with colorectal liver metastases undergoing hepatic resection.

The prognostic significance of sarcopenia has been widely studied in different cancer patients. This study aimed to analyze the influence of sarcopenia on long-term survival in patients with colorectal liver metastasis (CRLM) undergoing hepatic resection. A retrospective analysis of 182 patients undergoing hepatic resection for CRLM was performed. Sarcopenia was determinedusing the Hounsfield unit average calculation (HUAC), a measure of muscle quality-muscledensity at preoperative abdominal computed tomography scans. Sarcopenia was defined as an HUAC score of less than 22 HU calculated using receiver operating characteristic analysis. The prognostic relevance of clinical variables and overall survival (OS) and recurrence-free survival (RFS) was evaluated. Patients with sarcopenia were older (p < 0.001) and had higher prevalence of diabetics (p = 0.004), higher body mass index (BMI) (p < 0.001) and neutrophil-to-lymphocyte ratio (p = 0.026) compared to those without. Sarcopenia was not significantly associated with OS and RFS. Multivariate Cox's regression analysis showed that multinodularity (>3) (hazard ratio (HR) 2.736; 95% confidence interval (CI), 1.631-4.589; p < 0.001), high CEA level (≥20 ng/ml) (HR 1.793; 95% CI, 1.092-2.945; p = 0.021) and blood loss (≥300 cc) (HR1.793; 95% CI, 1.084-2.964; p = 0.023) were independent factors associated with OS. In subgroup analyses, sarcopenia was a significant factor of poor OS in the patients with multinodularity by univariate (p = 0.002) and multivariate analyses(HR 3.571; 95% CI, 1.508-8.403; p = 0.004). Multinodularity (>3) (HR 1.750; 95% CI, 1.066-2.872; p = 0.027), high aspartate aminotransferase level (HR 1.024; 95% CI, 1.003-1.046; p = 0.025) and male gender (HR 1.688; 95% CI, 1.036-2.748; p = 0.035) were independent factors of RFS. In conclusion, despite no significance in whole cohort, sarcopenia was predictive of worse OS in patients with multiple CRLM after partial hepatectomy.

Clinical Outcomes of Tuberculosis in Recipients After Living Donor Liver Transplantation.

BACKGROUND This study aimed to determine clinical outcomes using various drugs during tuberculosis (TB) treatment among living donor liver transplant (LDLT) recipients with TB and to assess the impact of performing LDLT in patients with active TB at the time of LDLT. MATERIAL AND METHODS Out of 1313 LDLT performed from June 1994 to May 2016, 26 (2%) adult patients diagnosed with active TB were included in this study. Active TB was diagnosed using either TB culture, PCR, and/or tissue biopsy. RESULTS The median age was 56 years and the male/female ratio was 1.6: 1. Most patients had pulmonary TB (69.2%), followed by extrapulmonary and disseminated TB (15.4% each). Fourteen (53.8%) patients underwent LDLT even with the presence of active TB. All patients concurrently received anti-TB [Rifampicin-based: 13 (50%); Rifabutin-based: 12 (46.2%); INH-based: 1 (3.8%)] and immunosuppressive drugs [Tacrolimus-based: 6 (23%); Sirolimus/Everolimus-based: 20 (77%)]. During treatment, adverse drug reactions (ADR) occurred in 34.6% of patients: acute rejection in 6 (23.1%), hepatotoxicity in 2 (7.7%), and blurred vision in 1 (3.8%). Twenty-three (88%) patients completed their TB treatment. Neither TB recurrence nor TB-specific mortality were observed. Three (11.5%) patients died of non-TB-related causes. The overall 5-year survival rate was 86.2%. Patients with ADRs had a higher incidence of incomplete TB treatment (log-rank: p=0.012). Furthermore, patients with incomplete treatment were significantly associated with decreased overall survival (log-rank: p<0.001). Immunosuppressive and anti-TB drugs used during TB treatment and performing LDLT in patients with active TB at the time of LDLT were not associated with ADRs and overall survival. CONCLUSIONS Outcomes are generally favorable with intensive peri-operative evaluation and surveillance. ADRs and incomplete TB treatment may result in poor prognosis and increased mortality rates.

What is the Appropriate Nodular Diameter in Thyroid Cancer for Extraction by Transoral Endoscopic Thyroidectomy Vestibular Approach Without Breaking the Specimens? A Surgicopathologic Study.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a novel technique with better cosmetic results. However, extraction of a large malignant thyroid nodule from the central incision of TOETVA necessitates breaking it into pieces to avoid mental nerve injury, a situation that may violate a proper oncological surgery. In this study, we sought the appropriate nodular diameter in thyroid cancer to be removed in an intact status through the central incision of the TOETVA technique. A total of 27 cases of thyroid nodules were operated using the TOETVA technique from Aug 2016 to July 2017. Excluding 10 benign goiters, the specimens of 17 thyroid cancer cases were divided into intact (group T, n=7) and fragmented (group F, n=10), with a median nodular diameter of 18.35 and 30.30 mm, respectively. Receiver operating characteristic (ROC) curve analysis revealed that the safest nodular diameter is 20 mm, with 100% sensitivity and 87.5% specificity.

Prediction of the Development of Persistent Massive Ascites After Living Donor Liver Transplantation Using a Perioperative Risk Score.

BACKGROUND: Persistent massive ascites (PMAS) longer than 14 days after living donor liver transplantation is not uncommon and associated with worse outcome. A predictive risk scoring system was constructed after analysis of recipient, graft, and surgery-related factors. METHODS: We retrospectively reviewed adult living donor liver transplantation recipients from 2005 to 2011 after excluding cases that experienced any intervention for perioperative vascular-related events. Two groups were identified, PMAS and non-PMAS. The score was constructed from significant factors using weighted odds ratios (OR). RESULTS: The study population included 439 recipients. Persistent massive ascites was evident in 74 cases (17%). Five significant risk predictors were identified in multivariate analysis: pretransplant serum creatinine greater than 1.5 mg/dL (OR, 5.693; weighted OR, 2), recipient spleen to graft volume ratio greater than 1.3 (OR, 4.466; weighted OR, 2), left lobe graft (OR, 3.196; weighted OR, 1), more than 1000 mL ascites at laparotomy (OR, 2.541; weighted OR, 1), and graft recipient weight ratio less than 0.8 (OR, 2.419; weighted OR, 1). The clinical scoring system was constructed and ranged from 0 to 7. Receiver operating characteristic analysis showed an area under the curve (0.778, P < 0.001). Internal validation of the score showed an area under the curve of 0.783. The 5- and 10-year survival rates for the non-PMAS versus the PMAS groups were 89% and 84% versus 81% and 48%, respectively (P = 0.001). CONCLUSIONS: The PMAS score is a predictive pretransplant clinical tool. A Clinical cutoff score of 4 might be decision-changing. Pretransplant correction of renal functions, deciding to harvest a large graft and/or consideration of splenic artery embolization could reduce the risk of PMAS.