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Conservative treatment of chylous fistulas following neck surgery
No full textChylous fistula following an injury of the thoracic duct during neck surgery is an uncommon complication, its occurrence being higher with radical neck dissections. The treatment is controversial: usually conservative as first choice, surgical in case of persistence despite adequate medical treatment or in case of high output. The conservative management has a good success rate, but it is usually long and expensive, so several attempts to shorten it have been made. We present a case of postoperative chylous fistula in which octreotide administration was added to conventional conservative treatment, with resolution in four days. We also review the other reported cases in which the association of somatostatin to standard conservative treatment has been applied and we discuss the results. A 41 years old lady was referred to our Department for diagnostic resection of a left supraclavicular node swelling. FNAC was consistent with primary lymphatic disease. The patient underwent biopsy under general anaesthesia. Neoplastic tissue was involving as a single block both the supraclavicular and jugular lymphatic chains, and was partially resected. No intraoperative chyle leak was noted. The next morning the patient started oral feeding and 12 hours later 250 cc of white, milky fluid were collected. We started total parenteral nutrition (TPN), converted the drain from suction to gravity, adopted a semi-seated posture and applied pressure dressings. In order to reduce maximally the intestinal secretions we also started e.v. somatostatin (2 mg /day). At the end of first p.o. day the drain collected further 300 cc of chylous fluid. We then shifted to subcutaneous octreotide (0,1 mg x 3 /die). The output dropped to 60 cc (2nd p.o.), 30 cc (3rd p.o.). By 4th day the drain was nearly empty and in 6th day p.o. the patient was allowed to restart semiliquid oral feeding and, after a fatty meal test, the drain was removed and parenteral support and hormonal treatment were stopped. By day 8th the lady left the hospital.
When the chylous fistula is recognised only postoperatively (usually after resuming oral feeding), first line treatment is usually conservative. It may lasts several weeks, is associated to high costs and is tedious to the patient. Nevertheless it has a good success rate, thus limiting the number of surgical re-exploration. SMS and its long acting analogues could act synergically with TPN in reducing gastrointestinal secretions, and allowing both the collapse of transected edge(s) of the duct and a correct repairing action of the naturally occurring inflammatory processes. According to our and other reported experiences, early association of octreotide to TPN seems to resolve chylous leaks in a few days, thus sensibly reducing in-hospital stay and related costs
Minimally invasive video-assisted thyroidectomy: five years of experience.
No full textBackground In the last decade, development of videolaparoscopic surgery allowed several operations to be performed with minimally invasive techniques, making them less invasive and painful. Neck surgery was also involved in this effort, in spite of the skepticism shown by some authors. Study design Minimally invasive video-assisted thyroidectomy was developed in 1998, and since then, about 600 operations have been performed. Access was the same as was previously described for parathyroidectomy; it was based on a small central incision (1.5 cm) and on external retraction without neck insufflation. Results From July 1998 to October 2003, 579 patients were selected from 5,450 for minimally invasive video-assisted thyroidectomy. The operation consisted of a total thyroidectomy in 312 patients and lobectomy in 267 patients. Mean operative time was 41 ± 19.5 minutes (range 15 to 120 minutes) for lobectomy and 51.6 ± 18.8 minutes (range 30 to 140 minutes) for total thyroidectomy. Postoperative hospital stay was 24 hours (overnight discharge) for all patients. Complications were postoperative bleeding (0.1%), recurrent nerve palsy (1.3%), and definitive hypoparathyroidism (0.2%). Conclusions After 5 years of experience using this approach for various indications, we achieved a good esthetic result with an operative time comparable to that of conventional open surgery. Minimally invasive video-assisted thyroidectomy was found to be a safe operation, with advantages over traditional procedures represented by better cosmetic outcomes and postoperative course, as demonstrated by visual analogue scales and statistically analyzed numeric scales
Randomized clinical trial comparing regional and gereral anaesthesia in minimally invasive video-assisted parathyroidectomy
No full textAbstract
Background:
This randomized clinical trial was performed in a single institution to compare the results of minimally invasive video-assisted parathyroidectomy (MIVAP) conducted under regional anaesthesia (RA) or general anaesthesia (GA).
Methods:
Fifty-one patients undergoing MIVAP for primary hyperparathyroidism were assigned randomly to either RA (26 patients) or GA (25). RA involved a bilateral deep cervical block, and local infiltration of the incision site with a mixture of 0·25 per cent lignocaine and 0·15 per cent bupivacaine. GA was induced by intravenous administration of propofol, remifentanil and rocuronium bromide.
Results:
The two groups were matched for age, sex, adenoma size, and preoperative serum calcium and parathyroid hormone levels. The interval from skin incision to closure was similar in the two groups (27·6 and 25·8 min for RA and GA respectively), whereas the total operating time (from induction of anaesthesia to return to the ward) was significantly lower with RA (72·1 versus 90·2 min; P = 0·001). The postoperative requirement for pain medication, measured in terms of amount of ketorolac administered at the request of the patient, was significantly lower in the RA group (28·5 versus 80 mg/day; P < 0·001).
Conclusion:
MIVAP performed under RA was associated with a shorter overall operating time and a reduced need for postoperative pain relief. Copyright © 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd
Minimally invasive video-assisted thyroidectomy: five years of experience
No full textAbstract
Background In the last decade, development of videolaparoscopic surgery allowed several operations to be performed with minimally invasive techniques, making them less invasive and painful. Neck surgery was also involved in this effort, in spite of the skepticism shown by some authors. Study design Minimally invasive video-assisted thyroidectomy was developed in 1998, and since then, about 600 operations have been performed. Access was the same as was previously described for parathyroidectomy; it was based on a small central incision (1.5 cm) and on external retraction without neck insufflation. Results From July 1998 to October 2003, 579 patients were selected from 5,450 for minimally invasive video-assisted thyroidectomy. The operation consisted of a total thyroidectomy in 312 patients and lobectomy in 267 patients. Mean operative time was 41 ± 19.5 minutes (range 15 to 120 minutes) for lobectomy and 51.6 ± 18.8 minutes (range 30 to 140 minutes) for total thyroidectomy. Postoperative hospital stay was 24 hours (overnight discharge) for all patients. Complications were postoperative bleeding (0.1%), recurrent nerve palsy (1.3%), and definitive hypoparathyroidism (0.2%). Conclusions After 5 years of experience using this approach for various indications, we achieved a good esthetic result with an operative time comparable to that of conventional open surgery. Minimally invasive video-assisted thyroidectomy was found to be a safe operation, with advantages over traditional procedures represented by better cosmetic outcomes and postoperative course, as demonstrated by visual analogue scales and statistically analyzed numeric scales. © 2004 by the American College of Surgeons.
Indexed keywords
EMTREE medical terms: adolescent; adult; aeration; aged; article; controlled study; hospital discharge; hospitalization; human; hypoparathyroidism; laparoscopy; lobectomy; major clinical study; minimally invasive surgery; operation duration; parathyroidectomy; postoperative complication; postoperative hemorrhage; priority journal; recurrent laryngeal nerve palsy; safety; school child; statistical analysis; thyroidectomy; treatment outcome; videorecorder; visual analog scale
MeSH: Adolescent; Adult; Aged; Child; Female; Humans; Male; Middle Aged; Postoperative Complications; Surgical Procedures, Minimally Invasive; Thyroidectomy; Time Factors; Video-Assisted Surgery
Medline is the source for the MeSH terms of this document
Breast Animation Deformity: A Retrospective Study on Long-Term and Patient-Reported Breast-Q Outcomes
No full textBackground We evaluated the aesthetic outcomes and quality of life of patients who underwent neurotomy of the lateral and medial branch of the pectoralis nerve for animation deformity after breast reconstruction. Material and Methods Health-related quality of life questionnaire and cosmetic outcome evaluation were conducted using the preoperative and the postoperative BREAST-Q modules for reconstructive surgery. An external author also assessed the general aesthetic outcome before and after surgery. Results Sixty-two patients with animation deformity after breast reconstruction were enrolled: 43 in group 1 (second-stage breast reconstruction), 10 in group 2 (permanent breast prosthesis), and 9 in group 3 (Baker III-IV capsular contraction). Patients scored high level of satisfaction with outcome concerning all aspects of the survey. Overall satisfaction with breast was significantly increased after surgery in all the 3 groups, whereas physical well-being was improved in group 1 and group 3 and psychosocial well-being was improved in group 1. General outcome evaluation by an external author, compared with the preoperative condition, also showed significant improvement. Conclusions Section of the lateral and medial branches of the pectoralis nerve represents an easy and reproducible technique, associated with low morbidity and very good results in terms of patient satisfaction, comfort, and hospitalization
FAP associated cribriform morular variant of PTC: striking female prevalence and indolent course.
No full textA papillary thyroid carcinoma (PTC) is reported in 18 patients with FAP, all females.
The diagnosis was concomitant in 1/3, whereas in 1/3 FAP preceded and 1/3 was subsequent.
A cribiform morular variant (CMV) of PTC was present in 2 patients.
The germline APC mutation was detected in 16 out of 18: 5’ to codon 1220 in 14 and in codon 1309 in 2.
Even if CMV-PTC is associated with FAP in more than 50% of cases, not all FAP associated PTC show this variant.
FAP associated PTC occurs quite exclusively in females and has a good prognosis.
On the contrary, sporadic CMV-PTC often occurs in males and tends to have an aggressive behavior.
Therefore, caution is suggested before stating that, despite similar features, these tumors should be regarded as a single entity
Familial adenomatous polyposis associated papillary thyroid carcinoma shows an indolent course and usually but not always, belongs to the cribriform-morular variant of papillary thyroid carcinoma.
No full textLoco/regional versus general anaesthesia in minimally invasive video-assisted parathyroidectomy(VAP):a randomised double arm prospective trial
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