Backgrounds and aims
Nonrecurrent inferior laryngeal nerve (ILN) represents a risk factor for injury during neck surgery. It is associated to arterial abnormalities (absence of the brachiocephalic ...trunk and arteria lusoria) that can be identified by ultrasonography. The aim of the study was to verify the usefulness of preoperative ultrasonography in the research of nonrecurrent ILN by the means of identification of arterial abnormalities and the impact on ILN morbidity.
Patients and methods
The study included 750 patients who underwent neck surgery with right-side ILN dissection. A preoperative ultrasonography aimed to identify arterial abnormalities associated to nonrecurrent ILN was performed in 400 patients (Group A) while no preoperative attempts were performed in the remaining patients (Group B). Patients’ characteristics, time for intraoperative identification of the ILN, and morbidity were compared.
Results
Five and four nonrecurrent ILN were identified in groups A and B, respectively (
p
= NS). Preoperative ultrasonography correctly predicted nonrecurrent ILN in all cases (accuracy 100%). Nonrecurrent ILN palsy never occurred in group A, while three cases occurred in group B (
p
< 0.05). The mean time for intraoperative identification of both nonrecurrent and normally recurrent ILN was significantly shorter in group A (
p
< 0.01).
Conclusions
Preoperative ultrasonography can correctly identify nonrecurrent ILN, allowing earlier nerve identification and prevention of injuries.
Background Familial isolated hyperparathyroidism (FIHPT) is a rare syndrome linked to HRPT2 mutations, with a variable extent of parathyroid involvement. Extensive parathyroidectomy is usually ...indicated, but single-gland involvement is often reported. Recently, loss of parafibromin expression (caused by HRPT2 inactivating mutations) has been suggested as a distinguishing feature of FIHPT. This study aimed to evaluate the extent of parathyroid involvement and parafibromin expression in FIHPT. Methods Twelve patients from 3 FIHPT families underwent bilateral neck exploration, selective excision of macroscopically enlarged parathyroids, and biopsy of the remaining glands. Parafibromin expression was evaluated and compared with that in normal parathyroids and in adenomas arising in sporadic hyperparathyroidism. Results Pathology confirmed single-gland involvement in all cases (11 adenomas and 1 carcinoma). Limited parathyroidectomy achieved a cure in 91.6% (1 persistent case of parathyroid carcinoma). After a mean follow-up of 9.4 years, all remaining patients are disease free, although 3 underwent successful reoperation for single-gland long-term recurrence. Parafibromin expression was absent in all macroscopically affected glands from FIHPT patients, but present in normal parathyroids and in adenomas arising in sporadic hyperparathyroidism. Conclusions Loss of parafibromin expression is a distinguishing marker of parathyroid involvement in FIHPT. Single-gland involvement often occurs; limited parathyroidectomy is effective and achieves long disease-free periods.
Purpose
Parathyroidectomy for ectopic mediastinal hyperfunctioning glands could be performed by transcervical approach, sternotomy, thoracotomy, and recently by thoracoscopic and mediastinoscopic ...approaches. This study was aimed to analyze the results of traditional and video-assisted parathyroidectomy for mediastinal benign hyperfunctioning glands.
Methods
Fifty-one upper mediastinal exploration by a conventional cervicotomy, 12 by video-assisted approaches (two thoracoscopy and 10 transcervical mediastinoscopy) and six by sternotomy were performed in 63 patients with primary hyperparathyroidism.
Results
Video-assisted and sternotomic parathyroid explorations achieved biochemical cure in all cases; following conventional transcervical mediastinal exploration, a persistent hyperparathyroidism occurred in 11.8% of patients, who were subsequently cured by sternotomic approach. No complications occurred after video-assisted parathyroidectomy, while an overall morbidity rate of 50% and 10% was found after sternotomic and conventional cervicotomic approaches. Postoperative pain and hospital stay were significantly increased following sternotomy; patient's subjective cosmetic satisfaction was significantly higher after video-assisted and conventional cervicotomic approaches.
Conclusions
Conventional cervicotomic parathyroidectomy may achieve satisfactory results, especially for upper mediastinal glands. Sternotomic approaches are effective, but should be limited because of invasiveness and increased morbidity. In case of deep and lower hyperfunctioning mediastinal parathyroids, video-assisted approaches represent a less invasive, effective, and safe alternative and might be the technique of choice.
Objectives/Hypothesis
Right nonrecurrent inferior laryngeal nerve (NRLN) is an anatomical variant reported with a variable prevalence (0.3%–6%). It is associated with some arterial abnormalities ...(absence of the brachiocephalic trunk and presence of a right aberrant subclavian lusorian artery) that may be identified by preoperative ultrasonography (pUS). NRLN represents a major morbidity risk factor during neck surgery. The aim of this study was to verify pUS accuracy in predicting NRLN and to assess the impact of this technique on NRLN detection rate and laryngeal morbidity.
Study Design
Retrospective.
Methods
The study included 1,477 patients undergoing thyroid and parathyroid surgery with right‐side inferior laryngeal nerve exploration. pUS was performed in 878 patients (pUS group); no preoperative attempts were performed in the remaining 599 patients (controls). Demographics, disease type, intraoperative inferior laryngeal nerve anatomy, and laryngeal morbidity were compared.
Results
No differences occurred between the two groups concerning demographics and disease type. NRLN was detected in 17 patients (1.9%) of the pUS group and in four patients (0.6%) of controls (P < 0.05). pUS predicted NRLN in all cases, with an overall accuracy > 98%. Overall laryngeal nerves morbidity was 1.8% in the pUS group and 4.2% in the controls (P < 0.05). NRLN palsy never occurred in the pUS group, whereas it occurred three times in the controls (P < 0.005).
Conclusion
NRLN is accurately predicted by pUS. It occurs more frequently than expected because it may be misdiagnosed when no preoperative suspicion is available. Preoperative NRLN detection by pUS prevents inferior laryngeal nerve injuries.
Level of Evidence
2b. Laryngoscope, 125:1743–1747, 2015
Purpose
The aim of this retrospective study was to analyze the early and long-term outcomes of the surgical treatment of primary aldosteronism (PA), the most common surgically correctable cause of ...endocrine hypertension.
Methods
Serum Potassium levels, blood pressure values, and aldosterone/renin ratio (ARR) were assessed in 128 patients undergoing unilateral adrenalectomy for PA, before and after surgery. The role of lateralizing techniques and the relationship between outcome and histopathology findings were also evaluated.
Results
Biochemical cure of PA (ARR and kalemia normalization) was achieved in 95 % of patients, at early follow-up. Single aldosterone-producing adenoma, multinodular hyperplasia, and diffuse hyperplasia were found in 46, 45, and 9 % of the patients, respectively. No relationship between histopathology and persistence or recurrence of PA was found. The use of further lateralizing techniques in addition to computed tomography or magnetic resonance was the main predictor of PA cure (
p
= 0.02); adrenal venous sampling (AVS) was more accurate than scintigraphy in PA lateralization (
p
< 0.05). After surgery, hypertension was cured in 55 % and improved in 36 % of patients. Female gender, a lower number of antihypertensive drugs, and a shorter duration of hypertension were the main predictors of hypertension cure. At long-term, recurrent PA occurred in 3.7 % of cases.
Conclusions
Early diagnosis and correct lateralization of hyperaldosteronism by means of AVS are keys to achieve surgical cure of PA and PA-related hypertension. PA may be also caused by unilateral hyperplasia, which may be cured by unilateral adrenalectomy. Recurrences of PA are rare, although a prolonged follow-up is required.
Non-recurrent laryngeal nerve (NRLN) is a rare anatomical variant (0.3-6%) that is associated with some arterial abnormalities (absence of the brachiocephalic trunk and presence of a right aberrant ...subclavian lusorian artery). The availability of a preoperative diagnosis of NRLN may reduce the risk of nerve injuries. Preoperative ultrasonography (US) has been suggested as a reliable diagnostic tool to detect the arterial abnormalities associated with NRLN, but the literature is relatively scarce. This paper was aimed to review the literature, in order to offer an up to-date on this technique and its results.
A web search, focusing on humans, was performed by PubMed database, including papers published up to August 2016, using the key words "ultrasonography" AND "non-recurrent laryngeal nerve" or "nonrecurrent laryngeal nerve".
Eight papers, including 3,740 patients who underwent neck US for the detection of NRLN were selected. Only five studies focused on the preoperative use of US. The incidence of NRLN varied between 0.4% and 1.94%. The sensitivity and specificity varied between 99-100% and 41-100%, respectively.
US is a simple, non-invasive and cost-effective method to detect NRLN, also if its accuracy is not absolute. It may be used preoperatively and to prevent the intraoperative nerve damage, since the risk of NRLN palsies is significantly reduced when a preoperative diagnosis is available.
Endocrine tumors of thyroid, adrenal and parathyroid glands may be due to germline and inheritable mutations in 5–30% of patients. Medullary Thyroid Carcinoma, Pheochromocytoma, Paraganglioma, and ...Familial Primary Hyperparathyroidism are the most frequent entity. Hereditary endocrine tumors usually have a suggestive familial history; they occur earlier than sporadic variants, are multifocal, and have increased recurrence rates. They may be present as isolated variant or associated to other neoplasms in a syndromic setting. Genetic diagnosis should be preferably available before surgery because specific and targeted operative management are needed to achieve the best chance of cure. This review was aimed to discuss the surgical approaches for some of the most frequent hereditary endocrine tumors of thyroid, adrenal and parathyroid glands, focusing on medullary thyroid carcinoma, Pheochromocytoma, Paraganglioma and hereditary primary hyperparathyroidism (pHPT). Hereditary Medullary Thyroid Carcinoma is caused by
RET
mutations, and may be associated to Pheochromocytomas in MEN 2 setting. Total thyroidectomy and at least central neck nodal dissection is required. The availability of genetic screening allows prophylactic or early surgery in asymptomatic patients, with subsequent definitive cure. Hereditary Pheochromocytomas may be present in several syndromes (MEN 2, VHL, NF1, Paraganglioma/Pheochromocytoma syndrome); it may involve both adrenals; in these cases, a cortical sparing adrenalectomy should be performed to avoid permanent hypocorticosurrenalism. Hereditary Primary Hyperparathyroidism may frequently occur associated to MEN 1, MEN 2A, MEN 4, Hyperparathyroidism-Jaw Tumor Syndrome; it may involve all the parathyroid glands, requiring subtotal parathyroidectomy or total parathyroidectomy plus autotransplantation. In some cases, a selective parathyroidectomy might be performed.
Abstract Background Adrenal ganglioneuroma (AGN) is a rare tumor that originates from the gangliar cells of the sympathetic nervous system. It represents less than 5% of all adrenal masses. AGN ...occurs as a large mass, with benign behavior and no relevant symptoms and hormonal secretion, but it is often misdiagnosed because the preoperative radiological diagnosis is generally challenging. The aim of the present paper is to report the experience of a tertiary referral academic center regarding the management of AGN and review the relevant literature. Methods The demographic, diagnostic, surgical, and pathological findings of 666 consecutive patients who were adrenalectomized at the Padua Endocrine Surgery Unit between 1990 and 2015 were retrospectively reviewed in order to focus on AGN. Results The pathology confirmed AGN in 10 patients (1.5% of cases; median age 35 years, range 19–73). The diagnosis was incidental and never available before surgery. Eight patients were asymptomatic, two presented lower back and abdominal pain. The mass was non-secreting in all cases. Preoperative imaging techniques were inconclusive about the nature of the mass in all cases. The median size of the tumor was 55 mm (range 30–80). The laparoscopic approach was performed in 60% of cases. No recurrences occurred after surgery at a median follow-up of 10 years (range 1.7–18.2). Conclusion The diagnosis of AGN may be challenging and most often occurs after surgery, since it is frequently confirmed by histological examination. Radical excision may be achieved by laparoscopic adrenalectomy, with a subsequent definitive cure and excellent prognosis at long term follow up.
Primary aldosteronism (PA) is the most common cause of endocrine hypertension; it has been reported in more than 11% of referred hypertensive patients. PA may be caused by unilateral adrenal ...involvement aldosterone producing adenoma (APA) or unilateral adrenal hyperplasia (UAH), and bilateral disease (idiopathic adrenal hyperplasia). Only patients with unilateral adrenal hypersecretion may be cured by unilateral adrenalectomy, while patients with bilateral and non-surgically correctable PA are usually treated by mineralocorticoid receptor antagonists; thus the distinction between unilateral and bilateral aldosterone hypersecretion is crucial. Most experts agree that the referral diagnostic test for lateralization of aldosterone hypersecretion should be adrenal venous sampling (AVS) because the interpretation of other imaging techniques computed tomography (CT), magnetic resonance imaging (MRI) and scintigraphy may lead to inappropriate treatment. Adrenalectomy represents the elective treatment in unilateral PA variants. Laparoscopic surgery, using transperitoneal or retroperitoneal approaches, is the preferred strategy. Otherwise, the indications to laparoscopic unilateral total or partial adrenalectomy in patients with unilateral PA remain controversial. Adrenalectomy is highly successful in curing the PA, with correction of hypokalemia in virtually all patients, cure of hypertension in about 30-60% of cases, and a marked improvement of blood pressure values in the remaining patients. Interestingly, in several papers the outcomes of surgery focus only on blood pressure changes and the normalization of serum potassium levels is often used as a surrogate of PA recovery. However, the goal of surgery is the normalization of aldosterone, because chronically elevated levels of this hormone can lead to cardiovascular complications, independently from blood pressure levels. Thus, we strongly advocate the need of considering the postoperative normalization of aldosterone-renin ratio (ARR) as the main endpoint for determining outcomes of PA.
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