Harmonic scalpel versus traditional ligation in axillary dissection for breast cancer: a retrospective multivariate analysis

Introduction: The aim of this pilot retrospective study is to evaluate the complication rate in patients after axillary dissection comparing preparation with harmonic scalpel vs traditional ligation technique, and to analyse risk factors for complications occurrence. Methods: 144 patients with 148 axillary dissections operated in a single centre between January 2014 and 2019 were included into the study. Axillary dissection was performed using harmonic scalpel in 73 and absorbable ligations in 70 cases. Results: Seroma formation was observed in 41 patients (56.2%) in the harmonic scalpel group and in 21 patients (30.0%) in the ligations group (p=0.003). The mean period from the surgery to drain removal was 4.0 days in the harmonic scalpel group and 3.0 days in the ligations group (p<0.001). The mean amount of the drained fluid after mastectomy was 300.9 ml in the harmonic scalpel group and 168.7 ml in the ligations group (p=0.005); after breast conserving surgery, it was 241.9 ml and 107.4 ml, respectively (p =0.023). Conclusion: In comparison with traditional ligations with absorbable material, axillary dissection using harmonic scalpel significantly increases the risk of postoperative seroma formation, prolongs the time from the surgery to drain removal, and increases the amount of drained fluid.ut any suspicion of nodal involvement, hemithyroidectomy is considered to be a sufficient procedure or the method of choice, respectively.

History of thyroid surgery

The authors present an outline of the development of thyroid surgery from the ancient times to the beginning of the 20th century, when the definitive surgical technique have been developed and the physiologic and pathopfysiologic consequences of thyroid resections have been described. The key representatives, as well as the contribution of the most influential czech surgeons are mentioned.

Endoscopic approaches in head and neck endocrine surgery − introduction of TOETVA (TransOral Endoscopic Thyroidectomy by Vestibular Approach) into clinical use at the Department of Surgery of the University Hospital in Brno

Transoral endoscopic surgery of the thyroid and parathyroid glands is a modification of neck surgery using natural orifices. The classic approach in neck surgery is the gold standard, which we modified in 2007 by introducing Minimally Invasive Video-Assisted Thyroidectomy/Parathyroidectomy (MIVAT/P). We have been using TransOral Endoscopic Thyroidectomy/Parathyroidectomy by Vestibular Approach (TOETVA/TOEPVA) since the end of the last year and have operated on four patients. This method is more attractive for patients because it does not leave a visible scar on the neck, which is common in MIVAT/P. TOETVA is a promising procedure with many advantages, such as healing without visible scars, less pain, minimally invasive dissection and a clear operating field to both thyroid lobes and parathyroid glands. Presentation of the first case. Patients indicated for TOETVA must meet certain criteria – nodule(s) up to 3.5 cm, gland volume up to 30 ml, benign FNAB, papillary, follicular carcinoma not advanced, well differentiated, up to the nodule size of 10 mm with 1 lymph node up to 10 mm. The contraindications include a large goiter, previous neck surgery, history of thyroiditis, lymphadenopathy of the neck, advanced thyroid cancer. Relative contraindications include previous radiotherapy to the throat, Grave´s disease, and obese patients with a short neck. Intraoperative findings may result in a modification of the procedure. TOETVA is an excellent choice for selected patients who want to avoid a neck incision. This method provides the benefit of using standard endoscopic instruments and techniques. It is a safe and effective procedure that provides a good cosmetic result and considerable comfort in terms of clarity of the operating field by zooming in with an endoscopic camera. Longer operating times become shorter due to the learning curve effect.

Differentiated thyroid microcarcinoma − current perspective

Introduction: Differentiated thyroid cancer (DTC) has a good prognosis and low mortality despite its growing incidence, which is particularly the case of microcarcinomas (T1a – up to 10 mm). Methods: Retrospective analysis of overall survival of patients in the group of thyroid gland surgeries for differentiated forms of microcarcinoma in the period of 2006–2015 up to the present. An overview of contemporary therapeutic methods is included. Results: Thyroid cancer was detected in 144 cases out of the total of 1820 patients with thyreopathy undergoing surgery (8%); DTC microcarcinoma was detected in 65 cases (45.1%) of all carcinomas. The papillary form was diagnosed in 59 cases (51.8% of all papillary cases), and the follicular form was found in 6 cases (37.5% of all follicular cases). Two cases of Hürthle cells cancer were found, both in a stage higher than T1. Overall 10-year survival of carcinomas >T1 was 86%, reaching 90% in the microcarcinoma group (Gehan Wilcoxon test: p=0.10675). Conclusion: Differentiated microcarcinoma shows a very good overall survival. Provided that other criteria are satisfied, particularly unifocal occurrence without spreading through the gland casing and without any suspicion of nodal involvement, hemithyroidectomy is considered to be a sufficient procedure or the method of choice, respectively.

Retrosternal goiter

Introduction: Retrosternal goiter is an enlarged thyroid mass of which more than 50% is located in the mediastinum. Indications for surgery of retrosternal goiter include ineffective pharmacological treatment, mechanical syndrome, suspicion of malignancy and thyrotoxicosis. Computed tomography is the gold standard in the diagnosis of retrosternal goiter. The surgery can be performed from a cervical incision, using sternotomy or thoracotomy. Methods: The aim of our study was to evaluate our own group of retrosternal goiters. In 2011–2019, 1739 thyroid surgeries were performed at the 3rd Department of Surgery, University Hospital Motol, Prague. We retrospectively followed the age, gender, retrosternal spreading, postoperative complications (especially hypocalcemia, bleeding and dysphonia) and the definitive histological finding. Results: Retrosternal goiters were presented in 202 (19.2%) of the total of 1739 thyroid surgery patients. Sternotomy was performed in 31 patients. Women (61%) predominated over men (39%). The mean operating time was 125 minutes. We did not detect any serious postoperative bleeding necessitating surgical revision. Temporary hypocalcemia was observed in 10 patients (32%) based on laboratory testing. Unilateral iatrogenic vocal cord paresis was observed in 6 patients (19.4%) and was permanent in 3 patients (9.3%). One patient passed away soon after the operation, nevertheless the death was related to a simultaneously planned cardiothoracic procedure. Conclusion: The retrosternal goiter can be removed using the cervical approach in most cases. Total thyroidectomy using sternotomy is associated with higher morbidity and mortality, higher blood loss and longer hospital stay; nevertheless, it does not increase the risk of long-term postoperative complications. Procedures requiring sternotomy or thoracotomy should be done at centers experienced in these types of procedures.

Papillary thyroid microcarcinoma and papillary thyreoid cancer at the Department of Surgery, EUC Clinic Zlín

Introduction: Papillary thyroid cancer (PTC), especially micropapillary variant (MPTC), is the most common thyroid malignancy. Biological behavior is not aggressive and the patient’s prognosis is satisfactory. The objective of our comparative retrospective study was to evaluate whether the incidence is rising in the Region of Zlín and if less extensive approach was adopted by Czech endocrinologists. Methods: We compared 2 groups from years 2005–2008 and 2014–2018. The incidence of thyroid cancer, the PTC and the MPTC, the extent of the surgery and the lymphadenectomy, number of removed lymph nodes and the number of positive lymph nodes were observed. Results: We gathered 1353 patients in group 1. We found 220 malignancies (16.3%), 180 (81.8%) were PTC with MPTC variant in 44.4% (80 patients). All patients underwent a total thyroidectomy. We made 18 central and 10 lateral lymphadenectomies, 280 lymph nodes were collected with metastasis in 29,3 %. In group 2 with 1569 patients we found 318 (20.3%) carcinomas, PTC in 302 (94.6%) cases. The MPTC accounted for 215 (67.4%) cases. 10 patients with MPTC underwent hemithyroidectomy only. Numbers of central and lateral lymphadenectomies rose to 52 and 24 respectively. We gathered 376 lymph nodes with proven metastasis in 44.4% of these nodes. Conclusion: Both, the incidence and the frequency of PTC and MPTC are rising in our region. However, the number of less invasive procedures is not increasing significantly despite representing a sufficient way of treatment. We need wider adoption of these evidence-based recommendations by indicating endocrinologists in the Czech Republic.

What should a surgeon known about genetic background of thyroid cancer

Thyroid cancer is the most common endocrine malignancy, the treatment is multidisciplinary and multimodal. Thyroid tumors are heterogeneous in origin, morphology, biological behavior and therapeutic options. Substantial advances in diagnostic methods for thyroid cancer have led to detection of earlier stages of the disease that have the possibility of targeted therapeutic treatment and improved patient prognosis. In addition to surgical treatment, hormonal suppression and radioiodine therapy, targeted molecular therapy, which requires genetic testing, has come to the fore in recent decades. In the summary, we present an overview of current knowledge on the genetic background of individual types of thyroid carcinomas and the possibilities of therapeuticintervention.

Role of extracorporeal life support in thoracic surgery

Besides the conventional extracorporeal circulation, commonly used in cardiac surgery, the methods of extracorporeal life support (ECLS) have been applied ever more frequently in thoracic surgery in recent years. The most commonly used modalities of such supports include extracorporeal membrane oxygenation (ECMO) and the Novalung interventional lung assist device (iLA). Successful application of ECLS has led to its more frequent use in general thoracic surgery, especially as a tool to treat hypercapnia and to ensure oxygenation and haemodynamic support. However, these methods are essential in lung transplant programmes; without their help, in most cases, it would not be possible to perform the transplantatioz or prevent the severe complications associated with critical primary graft dysfunction. Additionally, the extracorporeal circulation also facilitates the performing of specific surgical procedures that would not be feasible under standard conditions or would be associated with an inadequate risk. The application of extracorporeal life supports can fundamentally increase the level of resection when treating advanced intrathoracic malignancies that are in close contact with the heart and large vessels or even directly extend into them. Without the possibility of resecting such structures en bloc, together with the tumour, and, thus, achieving an R0 resection, these malignant tumours are often directly contraindicated for surgery or are operated non-radically, i.e. unsuccessfully. Complete tumour resection is the most important prognostic factor in the surgery.

Postoperative chylothorax − review

The spectrum of causes of chylothorax is wide, including an injury to the thoracic duct in various thoracosurgical procedures, especially in esophageal, alung and heart surgery. Late diagnosis or inadequate treatment of chylothorax still has a high rate of morbidity and mortality. This is mainly related to high losses of chyle which is rich in minerals, plasma proteins, fats and lymphocytes. The most serious effects are mineral breakdown, malnutrition and immunodeficiency. Early diagnosis and adequate therapy are essential. The strategy is based on the type of primary operation, the volume of chyle secretion and its duration. The authors present an overview of the issue of chylothorax from its etiology of origin to its anatomy, physiology, pathophysiology, symptomatology, diagnosis and therapy.

Pulmonary arteriovenous malformation managed by VATS lobectomy

Introduction: Pulmonary arteriovenous malformation (PAVM) is formed by abnormal connections between pulmonary arteries and veins that bypass the pulmonary capillaries and transport deoxygenated blood through pulmonary veins to the left heart. This causes insufficient oxygenation of blood in the lungs. This condition remains symptomless for a long period of time. The most common symptoms include shortness of breath on exertion, nosebleeds, increased fatigue and a gradual development of cyanosis. Paradoxical embolism in the brain is a serious complication; it can present with a stroke or a brain abscess. Treatment of the disease consists of embolization of the pathological vascular connections, surgical resection of the affected pulmonary parenchyma and management of concomitant manifestations of the disease. PAVM in most common cases arises as a result of an autosomal dominant hereditary disorder referred to as hereditary hemorrhagic telangiectasia. Case report: In our communication, we document the diagnostic and therapeutic management in a young patient diagnosed with PAVM after falling off his bicycle. Based on comprehensive assessments, AV malformations with a 40% shunt of the pulmonary circulation were detected. An angiographic procedure was not an appropriate option considering the type and extent of the condition. Therefore, video-assisted thoracic resection of the affected pulmonary lobe was indicated. Conclusion: PAVM is a rare finding. PAVM should be ruled out in all patients with hereditary hemorrhagic telangiectasia (HHT) signs in the oral cavity. Contrast sonography of the heart and contract CT of the chest are the methods of choice for the diagnosis. Conservative or pharmacological treatment fails to improve the patient’s status. The condition is usually managed by embolization. Cases where PAVM is rather extensive or diffuse, where endovascular management would be inappropriate, can be well managed using endoscopic resection adequate to the extent of the condition.