Occult cancer after thyroidectomy for benign thyroid disorders. Is total thyroidectomy justified based on these grounds?

Background

It is well known that thyroid nodules are common among the general population. Despite the fact that only 4–8% are clinically detectable, a higher percentage ranging between 13–67% are identified with ultrasonography. Many studies have shown that malignancy can be detected in 5% of these nodules irrespective of their size. Nowadays, total thyroidectomy seems to be the most appropriate operation, even for benign thyroid diseases. We conducted this prospective study in order to assess the true incidence of occult thyroid cancer in benign thyroid disease specimens and explore any associated factors. Finally, we wanted to appraise whether total thyroidectomy is indeed justified based on these grounds.

Materials and methods

From March 2010 to March 2014, we operated on 114 patients for benign thyroid pathology; the patients had a mean age of 52.24 years (17–81 years). Thirty patients were eventually found to have occult cancer (19 microcarcinomas and 11 macrocarcinomas).We compared the patients with and without cancer in order to determine any predictive factors.

Results

Only the underlying histology was found to be related to the presence of cancer. Patients with cancer had a higher than expected percentage of Hashimoto thyroiditis while patients without cancer were found to have a greater than anticipated percentage of nodular hyperplasia. None of the other quantitative or qualitative factors were found to be a significant predictor of cancer.

Conclusion

After performing a proper workup as indicated by the guidelines, a high risk for occult thyroid cancer still remains (at least in the Greek population), which justifies the selection of total thyroidectomy for the management of benign thyroid pathologies. Only the underlying histology is associated with the presence of cancer since Hashimoto thyroiditis seems to be a risk factor.

     

Epidemiology and management of trauma patients in a Greek multispecialty hospital in the absence of a dedicated trauma center

Purpose

In the absence of dedicated trauma centers, surgical emergency departments in hospitals assigned as trauma centers accept a huge load of trauma patients. In this audit, we aim to document and assess the epidemiologic data of trauma patients and their injuries in order to give a picture of the impact of trauma in the workload of a surgical department in the Greek healthcare system.

Methods

During a period of 2 years, we managed 6,041 trauma patients in the accident and emergency (A&E) department based on the Advanced Trauma Life Support (ATLS) protocols. We retrospectively reviewed the emergency department registry and the admissions.

Results

47.56 % of the patients seen in the A&E department were trauma patients. The mean age of the trauma patients was 44.52 years (range 15–106 years). The majority were men (60.4 %). The leading cause of trauma was motor and vehicle accidents, followed by slip and fall accidents, physical assault, fall from height, and vehicle pedestrian accidents. The majority of the patients were discharged from the hospital. Only 29 (4.6 %) out of 624 patients who were admitted to the general surgery department underwent an operation, while the rest were admitted for observation. On the other hand, patients were admitted to other departments only when surgical treatment was necessary.

Conclusions

In the absence of level one trauma centers, in multispecialty urban hospitals, the coordination of trauma burdens the general surgery team. This has financial and administrative implications. The collection of important epidemiologic data from these hospitals is mandatory in order to develop national prevention measures against injuries.     

A comparison of segmental vs subtotal/total colectomy for colonic Crohn''s disease: a meta-analysis

OBJECTIVE: Using meta-analytical techniques the present study evaluated differences in short-term and long-term outcomes of adult patients with colonic Crohn's disease who underwent either colectomy with ileorectal anastomosis (IRA) or segmental colectomy (SC). METHODS: Comparative studies published between 1988 and 2002, of subtotal/total colectomy and ileorectal anastomosis vs segmental colectomy, were used. The study end points included were surgical and overall recurrence, time to recurrence, postoperative morbidity and incidence of permanent stoma. Random and fixed-effect meta-analytical models were used to evaluate the study outcomes. Sensitivity analysis, funnel plot and meta-regressive techniques were carried out to explain the heterogeneity and selection bias between the studies. RESULTS: Six studies, consisting of a total of 488 patients (223 IRA and 265 SC) were included. Analysis of the data suggested that there was no significant difference between IRA and SC in recurrence of Crohn's disease. Time to recurrence was longer in the IRA group by 4.4 years (95% CI: 3.1-5.8), P < 0.001. There was no difference between the incidence of postoperative complications (OR = 1.4., 95% CI 0.16-12.74) or the need for a permanent stoma between the two groups (OR = 2.75, 95% CI 0.78-9.71). Patients with two or more colonic segments involved were associated with lower re-operation rate in the IRA group, a difference which did not reach statistical significance (P = 0.177). CONCLUSIONS: Both procedures were equally effective as treatment options for colonic Crohn's disease however, patients in the SC group exhibited recurrence earlier than those in the IRA group. The choice of operation is dependent on the extent of colonic disease, with a trend towards better outcomes with IRA for two or more colonic segments involved. Since no prospective randomised study has been undertaken, a clear view about which approach is more suitable for localised colonic Crohn's disease cannot be obtained.     

Treatment of ocular toxocariasis with albendezole: A case report

BackgroundToxocara canis is a parasite that can infect the eye and create a significant inflammatory response that can be detrimental to the patient's vision. Its clinical presentation can mimic other causes of uveitis, and its diagnosis and treatment can be challenging. Prompt and accurate diagnosis of ocular toxocariasis is essential to prevent permanent visual loss.Case ReportA 7-year-old Hispanic boy presented to the clinic with complaints of reduced visual acuity in the left eye. After a careful evaluation of his ocular health, he had ocular toxocariasis diagnosed and confirmed by enzyme-linked immunosorbent assay testing. Treatment with the anthelmintic, albendazole, and oral steroids was initiated. There was initial improvement of the vitritis with significant vitreous debris. However, 2 years later, reactivation occurred, and a vitrectomy was required. This case report reviews the management of a patient with active ocular toxocariasis, including clinical findings and treatment options.ConclusionsThe differential diagnosis of ocular toxocariasis and review of the available treatments are presented.     

Glutathione peroxidase-1 plays a major role in protecting against angiotensin II-induced vascular dysfunction

Levels of reactive oxygen species, including hydrogen peroxide(,) increase in blood vessels during hypertension and in response to angiotensin II (Ang II). Although glutathione peroxidases are known to metabolize hydrogen peroxide, the role of glutathione peroxidase during hypertension is poorly defined. We tested the hypothesis that glutathione peroxidase-1 protects against Ang II-induced endothelial dysfunction. Responses of carotid arteries from Gpx1-deficient (Gpx1(+/-) and Gpx1(-/-)) and Gpx1 transgenic mice, and their respective littermate controls, were examined in vitro after overnight incubation with either vehicle or Ang II. Under control conditions, relaxation to acetylcholine (ACh; an endothelium-dependent agonist) was similar in control, Gpx1(+/-), and Gpx1 transgenic mice, whereas in Gpx1(-/-) mice, responses to ACh were impaired. In control mice, ACh-induced vasorelaxation was not affected by 1 nmol/L of Ang II. In contrast, relaxation to ACh in arteries from Gpx1(+/-) mice was inhibited by approximately 60% after treatment with 1 nmol/L of Ang II, indicating that Gpx1 haploinsufficiency markedly enhances Ang II-induced endothelial dysfunction. A higher concentration of Ang II (10 nmol/L) selectively impaired relaxation to ACh in arteries from control mice, and this effect was prevented in arteries from Gpx1 transgenic mice or in arteries from control mice treated with polyethylene glycol-catalase (which degrades hydrogen peroxide). Thus, genetic and pharmacological evidence suggests a major role for glutathione peroxidase-1 and hydrogen peroxide in Ang II-induced effects on vascular function.     

Atypical anaphylactic reaction to Patent Blue during sentinel lymph node biopsy for breast cancer

INTRODUCTION

We present an unusual case of severe anaphylaxis to Patent Blue dye with atypical clinical features during sentinel lymph node biopsy (SLNB). The medical personnel involved with sentinel node biopsies should be alert, and familiar with this unusual entity. We also present current data from the literature.

CASE REPORT

During a wide local excision for primary breast cancer and SLNB, and early during the operation, the patient became severely tachycardic and hypotensive without any signs of urticaria, rash, oedema, or bronchospasm. Resuscitation required the addition of noradrenaline infusion followed by an overnight admission to the intensive care unit. Raised serum tryptase levels supported the diagnosis of anaphylactic shock while skin tests showed a severe reaction to Patent Blue dye.

CONCLUSIONS

Severe, life-threatening anaphylaxis to Patent Blue dye may present without obvious previous exposure to the dye and without the cardinal signs of oedema, urticaria and bronchospasm making the diagnosis and management of such cases challenging. Correct diagnosis and identification of the causative factor is important and requires a specific set of laboratory tests that are not commonly requested in every-day medical practice. It is not clear from the literature whether the condition is common enough to justify pre-operative prophylactic or diagnostic measures.     

Combined laparoscopic and endoscopic approach for the management of two ingested sewing needles: one migrated into the liver and one stuck in the duodenum

In this paper, we present the case of a 35-year-old Caucasian female, instituted for depression, who swallowed two sewing needles. Despite the fact that the patient on presentation was asymptomatic with a normal clinical examination and blood tests, the workup revealed a contained perforation of the upper gastrointestinal tract (GI) and a migration of one needle to the liver. Moreover, the endoscopy alone failed to remove the other needle, which was stuck in the duodenal wall and, therefore, a combined endoscopic and laparoscopic approach was successfully applied to remove both needles through the abdominal wall. The postoperative recovery was immediate and the patient was discharged after 24 hours. Our aim in this study was, to introduce a combined laparoscopic and endoscopic approach for the removal of any sharp object that gets stuck in the stomach or duodenal wall. Such a technique can be used in difficult cases where endoscopy alone fails to remove sharp objects that get stuck in the alimentary track and where the risk of complications is high. Moreover, we want to discuss the safety and efficacy of the laparoscopic approach in the management of the rare cases of migrated sharp objects from the upper GI tract to the abdominal cavity, provided there is a good preoperative localization. This combined technique has shown excellent results; it is safe and easy to perform and a laparotomy can be avoided. Moreover, the laparoscopic approach is a safe, efficient approach to remove those sharp objects that have migrated into the peritoneal cavity.