Zuckerkandl's tuberculum: an arrow pointing to the recurrent laryngeal nerve (constant anatomical landmark)
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Adult↗
Biomedical subjects
A Toniato
Publications and source records attributed to A Toniato.
Follicular neoplasms of the thyroid: diagnostic and operative management.
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Adenocarcinoma, Follicular↗
[Hypoparathyroidism after thyroidectomy. Analysis of a consecutive, recent series].
We analyzed a recent and consecutive series of 254 thyroidectomies performed during the last year to verify the incidence of post-thyroidectomy hypoparathyroidism. 249 patients were included in the study and were divided into 2 groups according to the extension of the thyroidectomy. In the first group of 49 patients treated by lobectomy no one developed hypoparathyroidism. In the second group of 200 patients, of which 53 were treated by subtotal and 147 by total thyroidectomy, postoperative hypoparathyroidism was found in 28 (14%) patients, but it was persistent (lasting six months or longer) in 8 (4%). Global incidence of postoperative hypoparathyroidism was statistically higher in total thyroidectomy vs subtotal thyroidectomy (17% vs 5.66%; p < 0.05); however persistent hypoparathyroidism incidence wasn't statistically higher in total thyroidectomy (5.4% vs 0%; p = n.s.). As far as thyroid disorders that require bilateral thyroidectomy Chi 2-test showed a trend of persistent hypoparathyroidism to be more frequent in patients operated on for Graves' disease and thyroid cancer than in other thyroid disorders.
Adolescent↗
[Papillary carcinoma of the thyroid. A uni- and multivariate analysis of the factors affecting the prognosis inclusive of surgical treatment].
METHODS: A total of 463, out of 677 patients operated on for papillary thyroid carcinoma between 1967-1995, were selected, on the basis of a 5-year minimal follow-up (max 28, mean 11.15 +/- 5.29), for uni and multivariate analysis of survival curves. Patient sex, age over and under 45 years, tumour size smaller and larger than 15 mm, stage, any TNM parameter, histological variety, surgical procedure on the thyroid and nodes were the factors assessed in order to express the prognosis. RESULTS: Male:female ratio was 1:3, the mean age 42.2 years; only 25.9% of patients presented with smaller than 15 mm tumor, about 57% with positive nodes and 8.85% with distant metastases; total or near total thyroidectomy was performed in 86% and nodal dissection in 70% of patients. The 5, 10, 15, 20 year survival rate resulted to be 96.94%, 94.36%, 91.38% and 88.69%; 23 patients, but none aged less than 45 years, died (poorly differentiated and locally advanced carcinoma). Age over 45 years, T4 and M+ stages resulted of high prognostic importance while nodal involvement, interrelated with T and M, showed no independent impact; stage gradually worsened but no difference was found between stage I and II. Adverse effect of male sex resulted from its interrelation with more advanced stages. The relapse rate was found higher in male sex and in patients aged over 45 years, interrelated with T and N extension: no tumor smaller than 15 mm recurred and no relation was found between recurrence and surgical procedure. CONCLUSIONS: Longer follow-up is needed to compare the higher curative effectiveness of total thyroidectomy and nodal dissection versus more conservative treatments.
Adolescent↗
Surgical treatment of papillary thyroid carcinoma: uni- and multivariate analysis of prognostic factors (TNM staging system included).
Out of 677 patients, who underwent surgery for papillary thyroid carcinoma between '67-'95, we selected for survival uni and multivariate analysis 463 patients with over 5 years of minimal follow up (max 28, mean 11.15 +/- 5.29). Patient's sex, age (over and under 45) tumour size (smaller and larger than 15 mm), stage, any TNM parameter, hystological variety, surgical procedure on the thyroid and nodes were the factors assessed in order to establish the prognosis. Male:female ratio was 1:3, average age 42.2 +/- 0.68; only 25.9% of the patients presented smaller than 15 mm tumors, about 57% positive nodes and 8.85% distant metastases; total or near total thyroidectomy was performed in 86% of the cases and nodal dissection in 68.47%. The 10, 15, 20 year survival rate resulted to be 94.36%, 91.38% and 88.69%; 23 patients (4.96%) died of poorly differentiated and locally advanced carcinoma, but none of them was younger than 45. Age over 45, T4 and M+ stage parameters and dedifferentiated histotype resulted of high value while nodal involvement, interrelated with T and M, showed no independent impact; stage gradually got worse but no difference was found between stage I and II, or T1 and T2. Surgical treatment has not resulted to affect survival, whereas lymphnodes involvement is correlated with complications. Adverse effect of male sex resulted from its interrelation with more advanced stages. A significantly higher relapse rate was found in males and in patients over 45, interrelated with T and N extension: no tumor smaller than 15 mm recurred and no relation was found between recurrence and surgical procedure. Longer follow-up is needed to compare the more conservative treatments with total thyroidectomy and nodal dissection.
Adolescent↗
Guidelines for the diagnosis of thyroid carcinoma.
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Carcinoma↗
[Which thyroidectomy in Basedow disease?].
One hundred and seventy patients with Graves' disease underwent thyroidectomy between 1987 and 1994 (10.5% of all thyroidectomies performed in the same period). Female/male ratio was 9/1; mean age 55.2 years and average period between diagnosis and surgical treatment 5.3 years. The average thyroid weight was 230 g (range 90-950 g). Thyroidectomy was subtotal in 110 and total in 60 patients, 5 of which had been previously treated elsewhere from 5 to 33 years before. Malignancy was incidentally found in 2.35% of patients. The complication rate resulted higher in total thyroidectomies than in subtotal procedures (bleeding 0.9% vs 5.4%, transient hypoparathyroidism 4.5% vs 12.7%, recurrent nerve lesion 0.45% vs 2.72%) however the differences were not statistically significant; this probably because both the procedures were carried out with the same technique for parathyroid gland and recurrent nerve safety. The need of repeated surgery increased the risk. In opposition to total thyroidectomy, subtotal thyroidectomy does not doom to complete and permanent replacement therapy (96.4% of hypothyroidism at 2 months, 72.6% at 4 years), but in this series it failed to achieve remission in 2 patients who maintained a mild hyperthyroidism and in one more patient who developed a relapse 4 years later. Serum TSI meaning is not clear, but preoperative positivity suggests a wider resection and postoperative persistence a closer follow-up by functional assessment. In conclusion surgical procedures for Graves' disease range from subtotal to total thyroidectomy but for a safe outcome the choice depends more on the intraoperative troubles of each single case than on theoretic advantages.
Adolescent↗
[Post-thyroidectomy hypocalcemia and ligation of the inferior thyroid artery trunk].
The effect of bilateral truncal ligation of the inferior thyroid artery on parathyroid function is prospectively analyzed in two homogeneous groups of 10 patients treated by total thyroidectomy, with (G1) and without (G2) truncal ligation, comparing immediately postoperative and late serum calcium levels. A significant decrease in mean calcemic levels (minimal ones 2.1, with n.v. 2.1-2.6 mmol/l) was observed in both groups no longer than in the first postoperative days. There was no significant difference in global (clinical + laboratory) hypocalcemia rate (G1 = 0-30% vs G2 = 10-40% respectively); nevertheless hypocalcemia was noted paradoxically to occur more frequently in G-2 patients, out of which one developed a permanent hypoparathyroidism.
Adult↗
The extent of surgery for thyroid medullary cancer.
AIMS: Evaluation of the impact of the extent of primary surgery and reintervention on the outcome of patients with medullary thyroid carcinoma. METHODS: Seventy-two patients with medullary thyroid carcinoma (MTC) were surgically treated between 1967 and 1992. RESULTS: Fifty-five cases were sporadic, 5 patients had MEN 2A, 4 MEN 2B syndrome and 8 familial non-MEN MTC; 1 patient had stage I disease, 30 patients stage II, 36 stage III and 5 stage IV. Sixty-four had their initial treatment at our center, and 8 came for subsequent treatment. At first treatment, 8 patients were subjected to partial thyroidectomy, 10 to total thyroidectomy, 53 to total thyroidectomy with neck dissection, and 1 to only radical neck dissection; postoperative serum calcitonin (Ct) levels returned to normal in 3, 6 and 27 patients, respectively. In the patient with only radical neck dissection, Ct levels remained elevated. No patient with Ct normalization after surgery became responsive to pentagastrin in the follow-up. Thirteen patients had a reoperation due to nodal relapse. At a mean follow-up of 5.7 years (6-252 months), the 10-year survival rate was 84.5% with a significant difference between patients under and over 40 years of age (96.4 vs 57%), between stage I-II (100%) and stage III, IV (83.8%, 0% respectively). At the last follow-up, 36 (50%) patients were alive and disease free and 26 were alive with disease (15 with distant metastases). Of the 10 deaths, 7 were due to tumor recurrence, 3 to 120 months after surgery. CONCLUSIONS: Data suggest that an earlier diagnosis rather than more extensive surgery could improve survival and reduce recurrences. However, the least treatment required is total thyroidectomy plus central neck and upper mediastinum clearance and in addition, according to the extent of nodal involvement, mono- or bilateral neck dissection. To avoid ineffective reoperation due to distant (mainly liver) micrometastases, persistent residual microscopic disease requires a more aggressive restaging.
Carcinoma, Medullary↗
[Description of two cases of retrobrachiocephalic thymus gland].
We report two rare cases of thymus gland found behind the left brachiocephalic vein, in young women undergoing thymectomy for myasthenia gravis. Our observations are included among the thymic anatomical variants. After a review of the literature on the subject, we discuss both the diagnostic role of new radiological techniques (CT, NRM) and the choice of surgical approach to these variants.
Adult↗
[Epidemiology and risk factors in thyroid carcinoma].
Thyroid carcinoma represents less than 2% cancers although there is an increasing incidence, mainly of the papillary variety, due in part to improved diagnostic procedures. In contrast there is a remarkably higher prevalence of occult foci in detailed autopsy studies (up to 34%) suggesting the possibility of a spontaneous regression for most of them. Only 1-2% of latent tumours grow larger and become clinically important through environmental, genetic and cellular factors (two-mutational event model by Knudson). Each single histological subgroup has different influencing factors: X ray exposure, iodide diet intake, coexisting (autoimmune and non) thyroid disease such as thyroiditis, Graves' disease, goitre, dyshormonogenesis, heredity and altered cellular oncogenes have been considered. Of a series of 715 thyroid cancers operated on between 1967 and 1992 we analyze sex ratio, mean age, radiation exposure, coexisting thyroid disease, familial occurrence.
Adenocarcinoma, Follicular↗
[Reoperation in differentiated carcinoma of the thyroid gland].
A series of 112 patients reoperated on for differentiated thyroid cancer is analyzed; 60 patients (38 with papillary and 22 with follicular cancer) underwent ex-principio to completion of a non total thyroidectomy and 52 (37 with papillary and 15 with follicular cancer) to repeat surgery for local relapse. At a mean follow-up of 8.7 years, all the 38 patients with papillary cancer reoperated on for completion are alive and disease-free, while of those with follicular cancer 4 are dead, 2 are alive with carcinoma and 16 (72.7%) are disease free. A reoperation for relapse was performed on the thyroid in 11, on the thyroid and nodes in 23 patients (all had initially received partial thyroidectomy), and on nodes alone in 28 patients. At a mean follow-up of 10.2 years, 20 patients (54%) with papillary and 7 (46.6%) with follicular cancer are alive and disease-free, 8 patients with papillary and 1 with follicular cancer are alive with disease and the remainder are dead due to the tumour. Although there is no sure evidence that total thyroidectomy provides higher survival and fewer recurrences, since many factors, predominantly age influence the prognosis, total thyroidectomy is recommended as a minimal procedure to avoid less safe and less radical subsequent reoperation.
Adenocarcinoma, Follicular↗
[Lateral access in thyroidectomy. Technique and indications].
The technique of thyroidectomy, systematically carried out, by the authors, with a lateral approach since 1987 in thyroid reoperations for benign and malignant relapses and sometimes even in primary operations, is presented. The authors point out that lateral way is both technically advantageous in reoperations and moreover oncologically in prethyroid muscles's malignant involvement, but it does not represent an alternative to median access that, in the first instance, is the elective one. Because of the lateral vascular ligatures, in order to preserve the recurrent nerve, its location is mandatory.
Humans↗
[Medullary thyroid carcinoma: prognostic factors].
Fifty-one patients treated by total thyroidectomy plus nodal neck dissection of necessity for medullary thyroid carcinoma (MTC) with a minimum follow-up of 10 years (mean 14.5, max 22 years) were divided into three groups according to the outcome (alive disease-free; alive with disease; dead) and were compared in order to analyze the prognostic factors of MTC. Twenty years actuarial survival rate for age at diagnosis less than 50 years versus age over 50 (90% vs 45%) as well as for stage II versus stage III (85% vs 55%) was statistically different (p < 0.005 and p < 0.05 respectively). About 60% of recurrences were observed within 5 years after surgical treatment. Recurrence rate for stage III (70%) versus stage II (20%) was statistically different, but it was not for the age. Survival rate for patients with bony metastases (50% at 1 and 30% at 3 years) versus patients with other than bony metastases (100% at 10 years) was statistically different.
Actuarial Analysis↗
[Somatostatin in the treatment of lymphorrhea after lateral neck dissection].
A new pharmacological effect of somatostatin has been verified in the treatment of lymphorrea due to a thoracic duct injury, produced during left lateral neck dissection. The drug (stilamin 3 mcg/kg/h in continuous venous infusion) allowed in 3 case a strongly decrease of the lymphatic loss within 24 hours and the complete depletion within 6 days. Further studies are required to clarify the dynamic effects of the drug in this complication.
Adolescent↗
Dermatan sulphate: a safe approach to prevention of postoperative deep vein thrombosis.
To assess the efficacy and safety of dermatan sulphate (MF 701) in preventing postoperative deep vein thrombosis (DVT), 324 patients aged 40 years or over undergoing elective major general surgical operations were included in a randomized trial comparing MF 701 (100 mg intramuscularly once a day) with unfractionated calcium heparin (UFH, 5000 units subcutaneously three times daily). Both treatments were initiated before operation and continued until discharge. In all, 316 patients were included in the analysis (MF 701, 157; UFH, 159). Serial impedance plethysmography was performed in all patients; a 125I-radiolabelled fibrinogen uptake test was added to impedance plethysmography in a randomized subsample of 62 patients (MF 701, 28; UFH, 34). Positivity in either test was confirmed where possible by venography. DVT was diagnosed by venography or, when this could not be performed, by positivity of either impedance plethysmography or fibrinogen uptake test. The incidence of DVT was 3.1 per cent (patients receiving MF 701) and 1.6 per cent (those receiving UFH) in patients undergoing impedance plethysmography alone, and 7.1 and 11.8 per cent, respectively, in those undergoing both impedance plethysmography and fibrinogen uptake test; in neither case was the difference between treatments statistically significant. There were five in-hospital deaths, two in patients receiving MF 701 and three in patients on UFH. The incidence of clinically overt haemorrhage was 5.7 per cent in patients on MF 701 and 17.6 per cent in those on UFH (P less than 0.01). Postoperative transfusions and reoperations due to bleeding were significantly less frequent in patients receiving MF 701. Mortality rates at 3 months were similar for the two treatment groups. Compared with standard prophylaxis using UFH, MF 701 showed a similar efficacy with a significantly greater safety.
Adult↗
[Surgical emergency in thyroid disease: acute respiratory failure caused by tracheal obstruction].
Diagnostic and therapeutic approach to emergency due to acute and severe respiratory compromise by thyroid goiters with tracheal obstruction is discussed. Such an alarming condition was observed in 5 (2.3%) out of 215 mediastinal goiters operated between 1967-91. Retrospective and critical analysis of these cases pointed out that preventive removal of a large goiter is the best prophylaxis; first management is not surgical, although urgent features. Admission to intensive care center and endotracheal intubation allow an adequate interpretation of the pathologic condition and operative troubles and risks. Diagnostic investigations, effective and kept to a minimum (chest x-ray, tracheo-laryngoscopy, TAC), must be carried out without delaying thyroidectomy and prolonging intubation for days. The extraction of goiter is nearly always performable by the cervicotomic way. Whenever necessary endotracheal intubation obviates the need of tracheostomy for solving transient postoperative complications such as laryngeal oedema, local hematoma and recurrent nerves stupor.
Acute Disease↗
[Isolated rupture of the right hemidiaphragm with complete herniation of the liver into the thorax. Considerations of diagnosis and therapy].
The Authors report a case of right diaphragmatic hernia due to road-traffic accident. They discuss the problems of early diagnosis because it is delayed for multiple associated lesions or a low index of suspicion. The ratio of laceration of the left side to that of the right is twenty to one. The clinical and diagnostic data best able to lead to a rapid preoperative diagnosis are considered. The Authors recommended early operative treatment and the thoracic approach; thoracoabdominal incisions are more suitable whenever abdominal lesions are coexisting. The Authors stress the use of safety belts with three point fastener which have significantly decreases cranial and abdominal lesions, particularly if associated with two rolls up.
Accidents, Traffic↗