Gland surgery最新文献

[This corrects the article DOI: 10.21037/gs-23-182.].

Background: Surgical resection of locally advanced or borderline pancreatic ductal adenocarcinoma is a recognized procedure with curative intent performed in specialized oncology centers. Postoperative dysautonomia such as gastroparesis, mild hypotension, and diarrhea are common in elderly patients undergoing pancreaticoduodenectomy. A distinctive feature of our case, is the severing of an important sympathetic chain by the surgical procedure, leading to recurrent severe neurogenic shock. Locally advanced borderline tumor extension, aggressive maximal local tumor resection, and advanced age of the patient were the combined factors that explained the observed postoperative complication.

Case description: An 80-year-old woman underwent an elective R0 pancreaticoduodenectomy with total mesopancreas excision, distal gastrectomy and portal vein resection without relevant intraoperative and immediate postoperative complication. Pathology confirmed a 5.0 cm × 3.2 cm × 1.9 cm ductal adenocarcinoma in the head of the pancreas. After discharge, the patient returned to the emergency room complaining of nonspecific malaise, lipothymia, and cold sweating that was exacerbated by bowel movement attempts. During hospitalization, the patient experienced two additional severe hypotensive episodes with identical clinical presentation that required resuscitative measures in the intensive care unit (ICU). Because the third hypotensive episode developed without an obvious causal factor, apart from evacuation attempts, the hypothesis of neurogenic shock due to secondary splanchnic dysautonomia caused by extensive resection of the celiac plexus nerve structures after duodenopancreatectomy was considered.

Conclusions: This discussion is important, as it enables the care team to recognize this differential diagnosis and provide the best care for the patient. The patient was treated with sympathomimetics, fludrocortisone, and mechanisms to increase venous return when clinical improvement promptly occurred, allowing discharge from the hospital. Despite the challenging prognosis of the disease, we were able to provide the patient with moments at home with their family.

Background: Thyroid surgery is a common surgical procedure for the treatment of thyroid diseases, such as thyroid nodules, thyroid cancer, and hyperthyroidism. Despite significant advancements in surgical techniques and perioperative care, surgical site infection (SSI) remains a frequent postoperative complication, which can lead to prolonged hospital stays, increased medical costs, and decreased quality of life for patients. Identifying risk factors for SSI is crucial for developing effective prevention strategies. This study aimed to systematically investigate and quantify the incidence and risk factors associated with SSI following thyroid surgery through a meta-analysis and systematic review.

Methods: A comprehensive search strategy was employed across major databases [PubMed, Web of Science, Embase, Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Data] up to June 15, 2024. Additionally, we conducted a supplementary search for relevant literature up to October 4, 2024. Studies were selected based on stringent inclusion and exclusion criteria focusing on SSI risk factors in patients undergoing thyroid surgery. The methodological quality of eligible studies was critically appraised. Statistical analyses were conducted using Stata 15.1 with meta-analytic techniques to estimate means and standard deviations, and calculating odds ratio (OR) with 95% confidence interval (CI) using appropriate effect models. Publication bias was assessed using Egger's test.

Results: The systematic review and subsequent meta-analysis included nine studies (eight case-control and two cohort) involving a total of 127,467 patients, with 703 cases of postoperative SSI documented. Key findings indicated that prolonged surgical duration greater than 2 hours [OR =4.50; 95% CI: (2.74, 7.37); P<0.001], presence of comorbidities [OR =1.91; 95% CI: (1.16, 3.15); P=0.01], age greater than 50 years [OR =1.81; 95% CI: (1.24, 2.64); P=0.002], incision length greater than 5 cm [OR =2.79; 95% CI: (1.92, 4.04); P<0.001], lymph node dissection [OR =1.90; 95% CI: (1.28, 2.80); P=0.001], and male [OR =1.78; 95% CI: (1.38, 2.29); P<0.001] were significant risk factors for SSI after thyroid surgery. Conversely, male gender did not present a statistically significant association with SSI risk.

Conclusions: Surgical duration greater than 2 hours, presence of comorbidities, age greater than 50 years, incision length greater than 5 cm, lymph node dissection, and male emerge as critical risk factors for SSI in patients recovering from thyroid surgery. However, the small number of included articles and the lack of differentiation between OR, risk ratio (RR), and hazard ratio (HR) are limitations of this analysis.

Background: Calcitonin-negative medullary thyroid carcinoma (CNMTC), a rare form of MTC characterized by classic histopathology with normal serum calcitonin levels, presents a diagnostic challenge. This systematic review aims to summarize the clinical and pathological features of CNMTC and evaluate the utility of alternative biochemical markers.

Methods: Eligibility criteria for this systematic review included patients with a confirmed histopathological diagnosis of medullary thyroid carcinoma (MTC), normal preoperative serum calcitonin levels, or negative immunohistochemical (IHC) stain for calcitonin. A comprehensive electronic search strategy was employed on PubMed, Scopus, and Embase databases from January 1^st, 1950, to March 9^th, 2023.

Results: This systematic review consists of 32 studies with 101 patients (66% females, 33% males) with a mean age of 52.2 years. All patients had a preoperative serum calcitonin level below the upper reference limit. Out of 101 patients, only seven underwent the Pentagastrin Stimulation Test (PST), only two patients had elevated calcitonin levels after stimulation. A total of 59 patients were tested for carcinoembryonic antigen (CEA) levels, and the majority tested normal (n=51, 86.4%). A total of 57 patients (61.2%) were found to have positive IHC staining on operative specimens for calcitonin. No recurrence was reported in the majority of cases, only 10 patients (9.9%) experienced recurrence.

Conclusions: Despite the rarity of CNMTC, it is crucial to maintain a high level of suspicion when evaluating thyroid nodules. Total thyroidectomy with central neck dissection remains as the primary treatment. A multimarker approach may improve the sensitivity and specificity of CNMTC diagnosis and surveillance, particularly when calcitonin and CEA levels are inconclusive.

Background: Breast cancer is one of the most common malignant tumors, occurring in the mammary glands, which often metastasizes to bones, lungs, and liver. However, pituitary metastasis (PM) originating from breast cancer is a rare phenomenon that can easily be mistaken for benign pituitary macroadenoma.

Case description: This report details two cases of middle-aged and elderly Chinese women who presented with serious neurological symptoms, each with a history of breast malignancy. Both patients underwent magnetic resonance imaging (MRI), which showed a lesion in the sellar region, suggesting a pituitary adenoma. In one case, intraoperative frozen biopsy samples initially suggested a benign pituitary macroadenoma. However, post-surgical resection and permanent pathology combined with immunohistochemical stains confirmed both cases as symptomatic PM from breast cancer. Following surgery, one patient had a favorable postoperative prognosis, while the other unfortunately succumbed to systemic disease progression 5 months later.

Conclusions: A history of a malignancy should raise the suspicion for metastatic disease in patients presenting with a lesion in the sellar region accompanied by symptoms. Due to its low incidence, diagnosing PM preoperatively is challenging. This case report aims to raise awareness among healthcare providers that this condition is crucial for timely and accurate diagnosis.

Background: Although lenvatinib is effective for unresectable thyroid carcinoma, it may cause adverse events owing to rapid tumor shrinkage or necrosis. Pneumothorax during lenvatinib therapy is rare. However, once it occurs, it can become a refractory and fatal complication. Herein, we report two cases of thyroid carcinoma with malignant pleurisy treated with lenvatinib and discuss treatment strategies to prevent pneumothorax.

Case description: The first case involved a 78-year-old male with papillary thyroid carcinoma and malignant bilateral pleural effusion. He underwent pleurodesis with talc for the left pleural effusion due to respiratory distress, and lenvatinib therapy was initiated. Forty days after lenvatinib therapy, the patient developed a right pneumothorax and underwent surgery for a prolonged air leak. However, the left pneumothorax was prevented by pleurodesis. During surgery, the visceral pleura was fragile, and repair of the pulmonary fistula was difficult. Pathological examination revealed an anaplastic carcinoma in the visceral pleura. The air leak disappeared 20 days after surgery; however, the patient died 22 days after surgery due to progression of the underlying disease. The second case involved a 65-year-old female with a poorly differentiated thyroid carcinoma and lung metastasis. She underwent ablation with 30 mCi ¹³¹I after total thyroidectomy, and there was no accumulation in the metastatic sites. Chest computed tomography (CT) revealed the progression of malignant pleurisy in the right thoracic cavity, and iodine-resistant disease was confirmed. She was treated with lenvatinib after talc pleurodesis and showed good progress without any adverse events.

Conclusions: The presence of malignant pleurisy results in a risk of developing lenvatinib-associated pneumothorax. Therefore, pleurodesis should be considered before lenvatinib therapy for thyroid carcinomas with malignant pleurisy.

Microwave ablation (MWA) is a novel modality for thermal ablation (TA) to treat benign and malignant thyroid nodules, mostly papillary thyroid cancer (PTC). Compared to surgery, TA is less invasive and less painful, has faster recovery, better cosmetic outcomes, and fewer complications. TA techniques have been evolving over the past decade to be more energy efficient, precise, and produce long-lasting results. The general approach is similar between various TA techniques. However, each technique has uniqueness in its energy delivery and, thus, risk profile and outcomes. MWA has a few critical technical differences that make it safer for patients with surgical implants and cardiac comorbidities. It has proven effective in treating benign thyroid nodules (BTNs) in adults and pediatric populations with benign and malignant lesions. The clinical and theoretical outcomes of MWA compared to other thermal ablative techniques, such as radiofrequency ablation (RFA) and laser ablation (LA), have been investigated in some studies and meta-analyses. Minimally invasive procedures such as MWA are an important tool for the management of thyroid lesions. Thus, it is crucial for clinicians to be equipped with the knowledge to use these tools. In this review, we provide a clinical review detailing the technical differences and clinical outcomes for the three major TA techniques-MWA, RFA, and LA.

Although the most common procedure for breast reconstruction in Argentina is tissue expansion and implant devices, autologous tissue is frequently utilized. Deep inferior epigastric artery perforator flap (DIEP) is the gold standard for autologous breast reconstruction and, whenever possible, it is the first option. However, there are clinical or other circumstances, when a local or vicinity flaps for autologous reconstruction is preferred, even if exists a surgical and hospital facility for doing microsurgical procedures. The purpose of this manuscript is to describe our experience with the use of local and vicinity flaps for volume and surface replacement in different requirements-autologous breast reconstructions post oncologic resections, volume replacement in weight loss patients and implant-explantation cases. We have utilized the modification of latissimus dorsi musculocutaneous flap (LD) described by Hammond with excellent results and high patient satisfaction. Thoraco-dorsal artery perforator flap is indicated on skin sparing mastectomies (SSMs), immediate reconstruction of the nipple areolar complex and simultaneous coverage of an implant or tissue expander, in irradiated or to be irradiated patients. Lateral intercostal artery perforator (LICAP) flap has gained popularity because the unique position of the perforator at the lower lateral corner of the breast. It allows harvesting immediate vicinity tissue and easy rotation to the breast mound. We have used a modification towards the lateral thoracic wall of the anterior intercostal artery perforator flap for volume reconstruction after implant explantation.in patients who required volume preservation. Medial intercostal artery perforator flap is advantageous whenever the sub-mammary tissue can be used deepithelialized for volume reconstruction with a medial base. The same submammary area harvested as a medially based flap can be irrigated by the LICAP as a reverse LICAP flap that might be designed toward any direction from the piercing point of its perforator. The rest of the donor areas described for breast autologous reconstruction are rarely reported. When surgical facilities and adequate surgical teams are available, the lower abdominal wall is the main donor area, and DIEP, the most common technique utilized.