Minimally invasive video-assisted thyroidectomy: multiinstitutional experience

Minimally invasive video-assisted thyroidectomy (MIVAT) was described in 1998. In this study we collected the experience of four third-level referral centers that adopted this technique. A total of 336 patients (279 females, 57 males) were selected for MIVAT. Selection criteria were thyroid volume <15 ml, nodules not exceeding 3.5 cm of diameter, and an absence of thyroiditis, previous neck surgery, or previous irradiation. The procedure, totally gasless, is carried out through a 15 mm central incision above the sternal notch. Dissection is performed under endoscopic vision using conventional and endoscopic instruments. The mean operating time was 69.4 ± 30.6 minutes for lobectomy (range 20–150 minutes) and 87.4 ± 43.5 minutes for total thyroidectomy (range 30–220 minutes). The mean postoperative stay was 1.9 ± 0.8 days. Postoperative complications were 7 transient and 1 definitive recurrent nerve palsies and 11 cases of hypoparathyroidism (9 transient, 2 definitive). Conversion to open surgery was necessary in 15 patients (4.5%). This study confirms in a large number of cases the safety and feasibility of MIVAT, even in different surgical settings where similar results were achieved. The complication rate was not different from that of standard thyroidectomy. Although the operating time appears longer than with conventional procedures, the learning curve demonstrates a sharp decrease with increasing experience and the introduction of new technologies. The number of patients eligible for this approach remains low, thereby limiting its use, but it should be considered a valid option in selected surgical centers, offering some advantages to patients in terms of cosmetic results and postoperative distress.     

Childhood discoid lupus erythematosus: a Tunisian retrospective study of 16 cases

Discoid lupus erythematosus (DLE) is uncommon in children. The clinical features of childhood DLE are similar to those of adult DLE in presentation and chronic course. However, children have a particularly high level of transition to systemic disease. We undertook a retrospective study of 16 children with DLE ranging in age from 2 to 15 years, seen over a 9-year period. Six were less than 10 years old at the onset of the disease. The sex ratio was equal. The frequency of childhood DLE was about 7% of the total number of DLE patients seen in our department. Photosensitivity was defined as a clinical history of induction or exacerbation of discoid lesions following sun exposure, and was present in 81% of patients. There was no progression to systemic lupus erythematosus (SLE); an average follow-up time was 10.5 months (2-30 months). We would like to emphasize the increased frequency of childhood DLE in our country and the importance of photosensitivity. However, follow-up data regarding transition to SLE is lacking, therefore we are unable to offer a prognosis to our patients.     

Nail toxicity related to taxanes

A 70-year-old woman with non-small-cell lung cancer developed severe nail toxicity while she was being treated with docetaxel at three-week intervals. Docetaxel is a chemotherapeutic agent of the taxane family. Taxanes are well known to cause nail changes, but mainly when used on a weekly basis.     

Relevant factors in mitral valve reconstructive surgery. Report of 150 cases

150 patients had mitral valve repair for mitral valve incompetence. There were 57 males and 93 females with a mean age of 22 years, 39% were less than 15 years of age. 60% of the patients were in Class II NYHA and 40% in Class III and IV. According to Carpentier's classification, isolated type I was present in 18 patients (12%), type II in 98 patients (64%) and type III in 34 cases (24%). Mitral repair included correction of valve prolapse, valvular enlargement with pericardial patch and annuloplasty with semi-rigid ring in 128 cases and PTFE patch along the posterior leaflet in 12 cases. The perioperative mortality rate was 2.6% (4 patients). All patients had early post-operative echocardiography. According to this, mitral regurgitation was absent or tiny in 135 patients (92%), grade II in 10 cases and grade III in 2 cases. It was moderate or important in twelve patients (8%). In the late post-operative period, three patients were lost to follow-up. All the others patients were reoperated upon for mitral dysfunction in a mean time of 37 months. The reason for reoperation was in the majority of the cases the recurrence of mitral regurgitation related to increase of valvular and sub valvular disease. The late mortality rate is 7% (10 patients). Out of 126 reviewed survivors on the long run, 71 patients (56%) are asymptomatic in class I, 53 patients (42%) in class II and 2 patients in class III NYHA. Mitral valvuloplasty is the preferred procedure in mitral insufficiency surgical management. It is associated to a low early mortality and morbidity rate. Despite the need for reoperation in about 10% of the cases in the long follow-up, mitral repair offers a good quality of life without anticoagulant treatment.     

Association between the G protein beta3 subunit 825t allele and radial artery hypertrophy

The GNB3 C825T gene polymorphism has recently been identified and associated with hypertension, obesity and left ventricular hypertrophy. The aim of the study was to determine the relationship between the C825T polymorphism of the gene encoding for the G protein beta3 subunit (GNB3 C825T) and vascular hypertrophy. We studied a cohort of 306 subjects (age 49 +/- 12 years) without evidence of cardiovascular disease and never treated with cardiovascular drugs. Vascular phenotypes were evaluated for the common carotid and radial arteries using high-resolution echo-tracking devices. Genotype frequencies were in agreement with the Hardy-Weinberg equilibrium. For the radial artery, mean wall thickness was significantly higher in subjects carrying the 825T allele than in CC genotype subjects (240 +/- 54 microm for CT genotype and 241 +/- 53 microm for TT genotype vs. 222 +/- 52 microm for CC genotype, p = 0.01). The frequency of the 825T allele was significantly different in subjects with (52%) and without (35%) radial artery hypertrophy (chi(2) = 10.88, p < 0.001). The relative risk of radial artery hypertrophy in subjects carrying the 825T allele compared with those with the CC genotype was 3.02 (95% CI 1.53- 5.95). A logistic regression analysis indicated that the positive and significant association between the 825T allele and radial artery hypertrophy was independent of age, blood pressure, gender and BMI. In contrast, no association between genotypes and carotid artery wall thickening was observed. These results suggest that some genetic characteristics determine in part the patterns of radial artery geometrical changes. As the 825T allele is associated with vascular hypertrophy of a muscular artery but not with structural changes of an elastic artery, we hypothesize that the 825T allele may be a genetic marker of arteriolosclerosis.     

Blood pressure is correlated with vitamin d(3) serum levels in dialysis patients

BACKGROUND/AIMS: The blood pressure, the most influencing factor in cardiovascular disease in end-stage renal failure patients, follows a seasonal variation during the year. Since vitamin D(3) is known to be related to sun exposure, we wanted to evaluate the putative participation of the vitamin D(3) metabolism in blood pressure modifications. METHODS: We studied 22 stable hemodialysis patients (11 females and 11 males, mean age +/- SD 56 +/- 1 year) who had been continuously treated in our dialysis unit for more than 1 year between 1994 and 1997 and did not receive pulse vitamin D(3) treatment. Supine systolic and diastolic blood pressures were measured before every dialysis session (>12,000 measurements) and the intact parathormone (iPTH), 25-hydroxyvitamin D(3) [25(OH)D(3)], and 1,25-dihydroxyvitamin D(3) [1,25(OH)(2)D(3)] levels every 3 months (>300 determinations). The mean values of blood pressure per season and per patient were taken for analysis using a 4-year longitudinal study design. RESULTS: The blood pressure varied during the years studied following a seasonal trend. It was highest during autumn and tended to decrease during spring and warmer months. Systolic as well as diastolic blood pressures were significantly correlated with the 25(OH)D(3) levels (p = 0.0291 and p = 0.0327, respectively). No correlation was observed between blood pressure and 1,25(OH)(2)D(3) or iPTH levels. CONCLUSION: There is a link between blood pressure and 25(OH)D(3) level. This interrelation is not secondary to a iPTH modulation. Although it cannot be excluded that vitamin D(3) and blood pressure vary following a third factor with seasonal variations, since vitamin D(3) varies during the year, mainly following sun exposure, we suggest that vitamin D(3) is one of the factors participating in the seasonal variation of the blood pressure. Other factors known to control the blood pressure and particularly the extracellular volume overload may also participate.     

Sacral neuromodulation in functional urinary retention: an effective way to restore voiding

OBJECTIVE: To determine the long-term efficacy and complications of sacral nerve stimulation as an alternative therapy for functional unobstructive urinary retention, often considered to be psychogenic and effectively treated by clean intermittent catheterization, but for which pelvic floor dysfunction has been recognized as a possible cause. PATIENTS AND METHODS: Twenty patients (17 women and three men, mean age 48 years) with idiopathic, unobstructive functional urinary retention and in whom other forms of therapy had failed, had a pulse generator implanted (Medtronic, Minneapolis, MN, USA) and a sacral nerve implant. Their mean duration of symptoms was 68 months; 13 patients had chronic pelvic and perineal pain associated with their obstructive voiding symptoms. All patients were managed with clean intermittent catheterization and pharmacological therapy (alpha-blockers) before the procedure. All patients had a percutaneous nerve evaluation before the permanent implant, which showed> 50% improvement in their symptoms. All patients were evaluated at 1, 6 12, 18 and 24 months, then yearly thereafter. The results were assessed both subjectively by patient's symptoms and objectively by checking the postvoid residual volume (PVR) and voided volume. RESULTS: Eighteen patients were able to void spontaneously with a mean increase in voided volume from 48 to 198 mL, and a significant decrease in PVR from 315 to 60 mL. Eighteen of the patients had a > or = 50% improvement in their symptoms and said they would recommend the therapy to a friend or relative. Complications occurred in six patients. CONCLUSION: Sacral nerve stimulation is an effective and durable new approach to functional urinary retention, with few associated complications. Test stimulation provides a valuable tool for selecting patients.     

Common bile duct obstruction secondary to a balloon separated from a Fogarty vascular embolectomy catheter during laparoscopic cholecystectomy

Laparoscopic instrumentation of the common bile duct (CBD) via the transcystic route or through direct choledochotomy seems to be safe, but in rare cases, complications such as pancreatitis, bile duct damage, and hemorrhage from cystic artery may occur. We report an unusual complication with this approach. A 62-year-old man with gallbladder stones presented with obstructive jaundice, mild pancreatitis, and a dilated CBD. He underwent laparoscopic cholecystectomy with an intraoperative cholangiogram through the cystic duct. A small stone seen in the CBD was removed using a 6-Fr vascular Fogarty catheter. Two days later, he became jaundiced again with a rising bilirubin. An endoscopic retrograde cholangiogram showed a 1.5-cm round filling defect floating in a dilated CBD. A sphincterotomy was performed, and a balloon catheter was inflated proximally and pulled down. To our surprise, the filling defect was a crystal clear object, which we finally realized was a fully inflated Fogarty catheter balloon. The balloon spontaneously deflated while being caught with a basket. Surgeons should be aware of this possible complication, and every effort should be made to verify that the balloon still is in place after removal of the embolectomy catheter. Whether vascular embolectomy catheter balloons are appropriate for stone removal or more rigid balloons should be used needs further evaluation.