Showing papers in "Gland surgery in 2015"

Defining the syndromes of parathyroid failure after total thyroidectomy

Abstract: Acute and chronic parathyroid insufficiency syndromes are the most common complication after total thyroidectomy. Permanent hypoparathyroidism imposes an important medical burden on patient lifestyle due to the need for lifetime medication, regular visits and significant long-term costs. Its true prevalence has been underestimated due to lack of clear definitions, inadequate follow-up and conflicts of interest when reporting individual patient series. The aim of this review is to propose precise definitions for the different syndromes associated to parathyroid failure based on the follow-up and management of patients developing hypocalcemia (<8 mg/dL at 24 hours) after first-time total thyroidectomy for cancer or goiter at our unit. Short and long-term post-thyroidectomy parathyroid failure presents as three different metabolic syndromes: (I) postoperative hypocalcemia is defined as a s-Ca <8 mg/dL (<2 mmol/L) within 24 hours after surgery requiring calcium/vit D replacement therapy at the time of hospital discharge; (II) protracted hypoparathyroidism as a subnormal iPTH concentration (<13 pg/mL) and/or need for calcium/vit D replacement at 4-6 weeks; and (III) permanent hypoparathyroidism as a subnormal iPTH concentration (<13 pg/mL) and/or need for calcium/vit D replacement 1 year after total thyroidectomy. Each of these syndromes has its own pattern of recovery and should be approached with different therapeutic strategies.

Recurrence of papillary thyroid cancer after optimized surgery

Abstract: Recurrence of papillary thyroid cancer (PTC) after optimized surgery requires a full understanding of the disease, especially as it has changed in the last 15 years, what comprises optimized surgery, and the different types and implications of disease relapse that can be encountered. PTC has evolved to tumors that are much smaller than previously seen, largely due to various high quality imaging studies obtained for different reasons, but serendipitously identifying thyroid nodules that prove to be papillary thyroid microcarcinomas (PTMC). With rare exception, these cancers are cured by conservative surgery without additional therapy, and seldom result in recurrent disease. PTC is highly curable in 85% of cases because of its rather innocent biologic behavior. Therefore, the shift in emphasis from disease survival to recurrence is appropriate. As a result of three technologic advances—high-resolution ultrasound (US), recombinant TSH, and highly sensitive thyroglobulin (Tg)—disease relapse can be discovered when it is subclinical. Endocrinologists who largely control administration of radioactive iodine have used it to ablate barely detectable or even biochemically apparent disease, hoping to reduce recurrence and perhaps improve survival. Surgeons, in response to this new intense postoperative surveillance that has uncovered very small volume disease, have responded by utilizing US preoperatively to image this disease, and incorporated varying degrees of lymphadenectomy into their initial treatment algorithm. Bilateral thyroid resection— either total or near-total thyroidectomy—remains the standard for PTC >1 cm, although recent data has reemphasized the value of unilateral lobectomy in treating even some PTC measuring 1-4 cm. Therapeutic lymphadenectomy has universal approval, but when lymph nodes in the central neck are not worrisome to the surgeon’s intraoperative assessment, although that judgment in incorrect up to 50%, whether they should be excised has reached a central point of controversy. Disease relapse can occur individually or in combination of three different forms: lymph node metastasis (LNM), true soft tissue local recurrence, and distant disease. The latter two are worrisome for potentially life-threatening consequences whereas nodal metastases are often persistent from the initial operation, and mostly comprise a biologic nuisance rather than virulent disease. A moderate surgical approach of bilateral thyroid resection, with usual central neck nodal clearance, and lateral internal jugular lymphadenectomy for node-positive disease can be performed safely, and with about a 5% recurrence rate.

Management of anaplastic thyroid cancer

Abstract: Anaplastic thyroid cancer (ATC) is a deadly disease with a dismal prognosis. Molecular analyses of ATC tumors have yielded interesting results, which could help in understanding the underlying mechanisms of this aggressive disease process. Managing ATC can be challenging and includes rapid diagnosis, adequate staging, and interdisciplinary, multimodal treatments to optimize patient outcome. Treatments include surgical resection to gross negative margins when possible, as well as neo- or adjuvant treatment with chemotherapy or external beam radiation (XRT) for locoregional disease. New treatment strategies include evaluating the benefits of vascular disrupting agents and tyrosine kinase inhibitors for advanced ATC with driver mutations, which can be targeted. This review summarizes key concepts in managing ATC.

Oncoplastic breast surgery: current strategies

Abstract: The surgical management of breast cancer has dramatically evolved over the past 20 years, with oncoplastic surgery gaining increased popularity. This field of breast surgery allows for complete resection of tumor, preservation of normal parenchyma tissue, and the use of local or regional tissue for immediate breast reconstruction at the time of partial mastectomy. These techniques extend the options for breast conservation surgery, improve aesthetic outcomes, have high patient satisfaction and result in better control of tumor margins. This article will detail the approach to evaluating and treating patients undergoing oncoplastic reconstruction. Different oncoplastic approaches will be described and applied to an oncoplastic reconstructive algorithm. Surgical complications, oncologic outcomes and aesthetic outcomes are reviewed.

Loss of signal in recurrent nerve neuromonitoring: causes and management.

Abstract: During recurrent laryngeal nerve (RLN) neuromonitoring in thyroid surgery, laryngeal electromyography (EMG) amplitude may be correlated with the number of muscle fibers participating in the polarization and these might be correlated with the function of RLN. If RLN is severely injured during the operation, most nerve fibers do not transmit nerve impulse and substantial decrease of EMG amplitude or loss of signal (LOS) will occur. True LOS at the end of an operation often indicates a postoperative fixed vocal cord, and the surgeon should consider the optimal contralateral surgery timing in patients with planned bilateral thyroid operation to avoid the disaster of bilateral vocal cord palsy. However, LOS recovery and false LOS may occur and may lead to an unnecessary 2 nd operation. Therefore, a reliable modality for intraoperative LOS evaluation and management would afford the surgeon real-time information that could help guide surgical procedure and planning. The updated causes, algorithm, and management of LOS during RLN neuromonitoring are reviewed and summarized.

Giant juvenile fibroadenoma: a systematic review with diagnostic and treatment recommendations.

Abstract: Introduction: Currently, there is a lack of clear guidelines regarding evaluation and management of giant juvenile fibroadenomas. The purpose of this study was to conduct a systematic review of giant juvenile fibroadenomas and to evaluate the most common diagnostic and therapeutic modalities. Methods: A systematic literature search of PubMed and MEDLINE databases was conducted in February 2014 to identify articles related to giant juvenile fibroadenomas. Pooled outcomes are reported. Results: Fifty-two articles (153 patients) met inclusion criteria. Mean age was 16.7 years old, with a mean lesion size of 11.2 cm. Most patients (86%) presented with a single breast mass. Imaging modalities included ultrasound in 72.5% and mammography in 26.1% of cases. Tissue diagnosis was obtained using a core needle biopsy in 18.3% of cases, fine-needle aspiration (FNA) in 25.5%, and excisional biopsy in 11.1% of patients. Surgical treatment was implemented in 98.7% of patients (mean time to treatment of 9.5 months, range, 3 days to 7 years). Surgical intervention included excision in all cases, of which four were mastectomies. Breast reconstruction was completed in 17.6% of cases. There were no postoperative complications. Conclusions: Diagnosis and treatment of giant juvenile fibroadenoma is heterogeneous. There is a paucity of data to support observation and non-operative treatment. The most common diagnostic modalities include core needle or excisional biopsy. The mainstay of treatment is complete excision with an emphasis on preserving the developing breast parenchyma and nipple areolar complex. Breast reconstruction is uncommon, but may be necessary in certain cases.

Transoral robotic thyroid surgery

Abstract: There is currently significant demand for minimally invasive thyroid surgery; however the majority of proposed surgical approaches necessitate a compromise between minimal tissue dissection with a visible cervical scar or extensive tissue dissection with a remote, hidden scar. The development of transoral endoscopic thyroid surgery however provides an approach which is truly minimally invasive, as it conceals the incision within the oral cavity without significantly increasing the amount of required dissection. The transoral endoscopic approach however presents multiple technical challenges, which could be overcome with the incorporation of a robotic operating system. This manuscript summarizes the literature on the feasibility and current clinical experience with transoral robotic thyroid surgery.

Minimally invasive parathyroid surgery

Abstract: Traditionally, bilateral cervical exploration for localization of all four parathyroid glands and removal of any that are grossly enlarged has been the standard surgical treatment for primary hyperparathyroidism (PHPT). With the advances in preoperative localization studies and greater public demand for less invasive procedures, novel targeted, minimally invasive techniques to the parathyroid glands have been described and practiced over the past 2 decades. Minimally invasive parathyroidectomy (MIP) can be done either through the standard Kocher incision, a smaller midline incision, with video assistance (purely endoscopic and video-assisted techniques), or through an ectopically placed, extracervical, incision. In current practice, once PHPT is diagnosed, preoperative evaluation using high-resolution radiographic imaging to localize the offending parathyroid gland is essential if MIP is to be considered. The imaging study results suggest where the surgeon should begin the focused procedure and serve as a road map to allow tailoring of an efficient, imaging-guided dissection while eliminating the unnecessary dissection of multiple glands or a bilateral exploration. Intraoperative parathyroid hormone (IOPTH) levels may be measured during the procedure, or a gamma probe used during radioguided parathyroidectomy, to ascertain that the correct gland has been excised and that no other hyperfunctional tissue is present. MIP has many advantages over the traditional bilateral, four-gland exploration. MIP can be performed using local anesthesia, requires less operative time, results in fewer complications, and offers an improved cosmetic result and greater patient satisfaction. Additional advantages of MIP are earlier hospital discharge and decreased overall associated costs. This article aims to address the considerations for accomplishing MIP, including the role of preoperative imaging studies, intraoperative adjuncts, and surgical techniques.

Breast reconstruction following conservative mastectomies: predictors of complications and outcomes

Abstract: Breast reconstruction can be performed using a variety of techniques, most commonly categorized into an alloplastic approach or an autologous tissue method. Both strategies have certain risk factors that influence reconstructive outcomes and complication rates. In alloplastic breast reconstruction, surgical outcomes and complication rates are negatively impacted by radiation, smoking, increased body mass index (BMI), hypertension, and prior breast conserving therapy. Surgical factors such as the type of implant material, undergoing immediate breast reconstruction, and the use of fat grafting can improve patient satisfaction and aesthetic outcomes. In autologous breast reconstruction, radiation, increased BMI, certain previous abdominal surgery, smoking, and delayed reconstruction are associated with higher complication rates. Though a pedicled transverse rectus abdominis myocutaneous (TRAM) flap is the most common type of flap used for autologous breast reconstruction, pedicled TRAMs are more likely to be associated with fat necrosis than a free TRAM or deep inferior epigastric perforator (DIEP) flap. Fat grafting can also be used to improve aesthetic outcomes in autologous reconstruction. This article focuses on factors, both patient and surgical, that are predictors of complications and outcomes in breast reconstruction.

Electrophysiological neural monitoring of the laryngeal nerves in thyroid surgery: review of the current literature.

Abstract: Recurrent laryngeal nerve (RLN) injury is one of the most common complications of thyroid surgery. RLN injury can cause vocal cord paralysis, affecting the patient's voice and the quality of life. Injury of the external branch of the superior laryngeal nerve (EBSLN) can cause cricothyroid muscle denervation affecting high vocal tones. Thus, securing the laryngeal nerves in these surgeries is of utmost importance. Visual identification of the nerves has long been the standard method for this precaution. Intraoperative neuromonitoring (IONM) has been introduced as a novel technology to improve the protection of the laryngeal nerves and reduce the rate of RLN injury. The aim of this article is to provide a brief description of the technique and review the literature to illustrate the value of IONM. IONM can provide early identification of anatomical variations and unusual nerve routes, which carry a higher risk of injury if not detected. IONM helps in prognosticating postoperative nerve function. Moreover, by detecting nerve injury intraoperatively, it aids in staging bilateral surgeries to avoid bilateral vocal cord paralysis and tracheostomy. The article will discuss the value of continuous IONM (C-IOMN) that may prevent nerve injury by detecting EMG waveform changes indicating impending nerve injury. Herein, we are also discussing anatomy of laryngeal nerves and aspects of its injury.

Current perspectives on radiation therapy in autologous and prosthetic breast reconstruction

Abstract: Background: Postmastectomy radiation therapy (PMRT) has a well-established deleterious effect on both prosthetic and autologous breast reconstruction. The purpose of this study was to perform a literature review of the effects of PMRT on breast reconstruction and to determine predictive or protective factors for complications. Methods: The MEDLINE and EMBASE databases were reviewed for articles published between January 2008 and January 2015 including the keywords “breast reconstruction” and “radiation therapy” to identify manuscripts focused on the effects of radiation on both prosthetic and autologous breast reconstruction. This subgroup of articles was reviewed in detail. Results: Three hundred and twenty articles were identified and 43 papers underwent full text review. The 16 papers provided level III evidence; 10 manuscripts provided level I or II evidence. Seventeen case series provided level IV evidence and were included because they presented novel perspectives. The majority of studies focused on the injurious effects of radiation therapy and increased complications and concomitant lower patient satisfaction. Conclusions: Prosthetic based breast reconstruction and immediate autologous reconstruction are associated with lower patient satisfaction in the setting of radiation therapy. Autologous reconstructions can improve patient satisfaction as well as lower revision surgery and long term complications when performed in a delayed fashion after PMRT.

Recovery of laryngeal function after intraoperative injury to the recurrent laryngeal nerve

Abstract: Loss of function in the recurrent laryngeal nerve (RLN) during thyroid/parathyroid surgery, despite a macroscopically intact nerve, is a challenge which highlights the sensitivity and complexity of laryngeal innervation. Furthermore, the uncertain prognosis stresses a lack of capability to diagnose the reason behind the impaired function. There is a great deal of literature considering risk factors, surgical technique and mechanisms outside the nerve affecting the incidence of RLN paresis during surgery. To be able to prognosticate recovery in cases of laryngeal dysfunction and voice changes after thyroid surgery, the surgeon would first need to define the presence, location, and type of laryngeal nerve injury. There is little data describing the events within the nerve and the neurobiological reasons for the impaired function related to potential recovery and prognosis. In addition, very little data has been presented in order to clarify any differences between the transient and permanent injury of the RLN. This review aims, from an anatomical and neurobiological perspective, to provide an update on the current understandings of surgically-induced injury to the laryngeal nerves.

Fat grafting and breast reconstruction: tips for ensuring predictability.

Abstract: Autologous fat grafting is widely used in breast surgery to refine and optimize aesthetic outcomes. Despite its widespread use, obtaining predictable, reliable, and consistent outcomes remains a significant challenge and is influenced by the technique used for procurement, processing, and placement of the fat. At present, there is no published consensus on the optimal technique. The purpose of this article is to review current techniques at each stage of fat grafting and provide tips on best practices based on the published literature as well as our extensive clinical experience.

Extended thoracodorsal artery perforator flap for breast reconstruction.

Abstract: A total of 45 patients underwent partial or total autologous breast reconstruction after skin-sparing mastectomy, skin-reducing mastectomy, and quadrantectomy using a thoracodorsal artery perforator (TDAP) flap. The detailed surgical technique with its variations is explained in this report. The propeller, flip-over, conventional perforator, and muscle-sparing flaps have been described and evaluated. The flaps were partially or completely de-epithelialized. The conventional TDAP can be enlarged or “extended” as the traditional latissimus dorsi musculocutaneous (LD-MC) flap by incorporating the superior and inferior fat compartments. It can be referred to as the “extended TDAP flap”. This technique augments the flap volume. In addition, this flap can serve as a scaffold for lipofilling to obtain autologous breast reconstruction in medium to large cases. There were two complete failures due to technical errors during flap elevation. Distal partial tissue suffering was observed in four flaps. These flaps were longer than usual; they reached the midline of the back. It is advisable to discard the distal medial quarter of the flap when it is designed up to the midline to avoid steatonecrosis or fibrosis. A retrospective analysis of the 39 flaps that survived completely revealed a satisfactory result in 82% of the cases. The main disadvantage of this procedure is the final scar. The TDAP flap is a reliable and safe method for partial or total breast autologous reconstruction.

Evolution and update on current devices for prosthetic breast reconstruction

Abstract: Over the past decade, the leading breast reconstruction modality has shifted from autologous tissue to implants. This trend reversal is multi-factorial but includes increasing bilateral mastectomies and the more widespread acceptance of implants due to stringent quality and safety regulatory surveillance by the US Food and Drug Administration (FDA). Since 2012, the US FDA has approved several new implant styles, shapes and textures, increasing the choices for patients and surgeons. Predictable, superior aesthetic results after prosthetic breast reconstruction are attainable, but require thoughtful planning, precise surgical technique and appropriate device selection based on several different patient and surgeon parameters, such as patient desires, body mass index, breast shape, mastectomy flap quality and tissue based bio-dimensional assessment. This article briefly reviews historic devices used in prosthetic breast reconstruction beginning in the 1960s through the modern generation devices used today. We reflect on the rigorous hurdles endured over the last several decades leading to the approval of silicone gel devices, along with their well-established safety and efficacy. The various implant characteristics can affect feel and performance of the device. The many different styles and features of implants and expanders are described emphasizing surgical indications, advantages and disadvantages of each device.

Clinicopathological review of pancreatoblastoma in adults.

Abstract: Pancreatoblastoma (PB) is a rare malignant neoplasm of the pancreas with unknown etiology. It occurs mostly in the pediatric population with very rare documented cases in adults. This is a review of the case reports of the adult pancreatoblastoma in the literature. A total of 35 cases were identified and reviewed with the mean age of 41 years (range, 18-78 years) and the male sex accounted for 51.4% of the cases. Adult Pancreatoblastoma seem to have a predilection for the head of the pancreas which accounted for approximately 49% of the cases reviewed with an average size of 8 cm (range, 1.8-20 cm). The median follow up for patients was 15 months (range, 1-108 months) Metastatic disease and local infiltration of surrounding tissues is common with poor prognosis in adult patients. Preoperative diagnosis is difficult because of the unhelpful tumor markers in adults and the cellular heterogeneity of the tumor which makes fine needle aspiration cytology unreliable. Histopathological review of the tumor is essential for diagnosis. Pancreatoblastomas should be considered a differential diagnosis of solid and cystic pancreatic neoplasms. Surgical resection of the tumor is the treatment of choice with a variable combination with radiotherapy and chemotherapy.

Prediction of ipsilateral and contralateral central lymph node metastasis in unilateral papillary thyroid carcinoma: a retrospective study.

Abstract: Background: Prophylactic central lymph node dissection (CLND) in patients with papillary thyroid carcinoma (PTC) remains controversial and predictive factors for central lymph node (CLN) metastasis in unilateral PTC cases are not well defined. The aims of this study were to evaluate the rate of ipsilateral and contralateral CLN metastasis and to determine the clinicopathologic factors predictive for ipsilateral and contralateral CLN metastasis in unilateral PTC cases. Methods: We retrospectively reviewed 218 PTC patients with clinically negative-node neck who have received total thyroidectomy with bilateral CLND. Pearson χ 2 test or Fisher exact test and multivariate analysis were used to evaluate relationships between CLN metastasis and demographic factors such as age, sex and the clinicopathologic factors. Results: Ipsilateral and contralateral CLN metastasis were present in 47.7% (104/218) and 13.3% (29/218), respectively. Multivariate analysis showed that tumor size (>1 cm) (P=0.016; OR, 2.005) and age Conclusions: CLN metastasis was common in PTC patients with clinically node-negative neck and the most common pattern of CLN metastasis was ipsilateral CLN metastasis. Prophylactic ipsilateral CLND may be an optional procedure and should be considered for patients with a tumor size >1 cm. Therapeutic bilateral CLND should be considered in patients with a tumor size >1 cm and especially, if there exists prelaryngeal LN or ipsilateral CLN metastasis on frozen section analysis.

Management of pancreatic neuroendocrine tumors in patients with MEN 1

Abstract: Pancreatic neuroendocrine tumors (PNETs) are frequent and can be non-functional (NF) in patients with multiple endocrine neoplasia type 1 (MEN1). Their identification is of clinical importance because malignant PNETs are reported to be the most common cause of death in patients with MEN1. Once the diagnosis of MEN1 is established in an individual based on clinical manifestations and/or genetic testing results, an active surveillance program is instituted for early detection and treatment of MEN1-associated disease. Ultrasonography, endoscopic ultrasonography (EUS), CT, MRI, selective arterial angiography and somatostatin receptor scintigraphy are all used for localization of tumors. Managing PNETs can be challenging and includes diagnosis, surveillance, adequate staging, and interdisciplinary, multimodal treatments to optimize patient outcome. Treatment includes surgical resection for loco-regional disease, as well as liver directed and targeted chemotherapies for advanced progressive disease. To date, the recommendation for surgical resection in NF-PNETs is based on tumor size, as a higher rate of metastases was found in patients with larger tumors. This review summarizes key concepts in managing PNETs in patients with MEN1.

Comparative analysis of fluorescent angiography, computed tomographic angiography and magnetic resonance angiography for planning autologous breast reconstruction.

Abstract: Background: The high incidence of breast cancer and growing number of breast cancer patients undergoing mastectomy has led to breast reconstruction becoming an important part of holistic treatment for these patients. In planning autologous reconstructions, preoperative assessment of donor site microvascular anatomy with advanced imaging modalities has assisted in the appropriate selection of flap donor site, individual perforators, and lead to an overall improvement in flap outcomes. In this review, we compare the accuracy of fluorescent angiography, computed tomographic angiography (CTA), and magnetic resonance angiography (MRA) and their impact on clinical outcomes. Methods: A review of the published English literature dating from 1950 to 2015 using databases, such as PubMed, Medline, Web of Science, and EMBASE was undertaken. Results: Fluorescent angiography is technically limited by its inability to evaluate deep-lying perforators and hence, it has a minimal role in the preoperative setting. However, it may be useful intraoperatively in evaluating microvascular anastomotic patency and the mastectomy skin perfusion. CTA is currently widely considered the standard, due to its high accuracy and reliability. Multiple studies have demonstrated its ability to improve clinical outcomes, such as operative length and flap complications. However, concerns surrounding exposure to radiation and nephrotoxic contrast agents exist. MRA has been explored, however despite recent advances, the image quality of MRA is considered inferior to CTA. Conclusions: Preoperative imaging is an essential component in planning autologous breast reconstruction. Fluorescent angiography presents minimal role as a preoperative imaging modality, but may be a useful intraoperative adjunct to assess the anastomosis and the mastectomy skin perfusion. Currently, CTA is the gold standard preoperatively. MRA has a role, particularly for women of younger age, iodine allergy, and renal impairment.

Lymphatic mapping and lymphedema surgery in the breast cancer patient

Abstract: Upper limb lymphedema can be an unfortunate sequela following the oncologic treatment of breast cancer. The surgical treatment of lymphedema has had a recent renewed clinical interest paralleling innovative descriptions of surgical techniques and imaging modalities. In addition, an improved understanding of the physiology and pathophysiology of lymphedema has allowed improved translation to the clinical condition. Various surgical options exist to decrease the symptom-burden of upper limb lymphedema, including vascularized lymph node (VLN) transfer, lymphovenous bypass (LVB), liposuction, lymphatic grafting, and excisional procedures. Modern imaging techniques help to improve the consistency and accuracy of these surgical treatment options. A multi-modal treatment plan utilizing non-operative and surgical therapies has the potential to improve various factors related to overall patient quality of life. This review details all of the current operative treatment strategies and modern imaging modalities used in the treatment of lymphedema.

The current status of intraoperative iPTH assay in surgery for primary hyperparathyroidism

Abstract: Intraoperative intact parathyroid hormone (iPTH) monitoring has been accepted by many centers specializing in parathyroid surgery as a useful adjunct during surgery for primary hyperparathyroidism. This method can be utilized in three discreet modes of application: (I) to guide surgical decisions during parathyroidectomy in one of the following clinical contexts: (i) to confirm complete removal of all hyperfunctioning parathyroid tissue, which allows for termination of surgery with confidence that the hyperparathyroid state has been successfully corrected; (ii) to identify patients with additional hyperfunctioning parathyroid tissue following the incomplete removal of diseased parathyroid/s, which necessitates extended neck exploration in order to minimize the risk of operative failure; (II) to differentiate parathyroid from non-parathyroid tissue by iPTH measurement in the fine-needle aspiration washout; (III) to lateralize the side of the neck harboring hyperfunctioning parathyroid tissue by determination of jugular venous gradient in patients with negative or discordant preoperative imaging studies, in order to increase the number of patients eligible for unilateral neck exploration. There are many advantages of minimally invasive parathyroidectomy guided by intraoperative iPTH monitoring, including focused dissection in order to remove the image-indexed parathyroid adenoma with a similar or even higher operative success rate, lower prevalence of complications and shorter operative time when compared to conventional bilateral neck exploration. However, to achieve such excellent results, the surgeon needs to be aware of hormone dynamics during parathyroidectomy and carefully choose the protocol and interpretation criteria that best fit the individual practice. Understanding the nuances of intraoperative iPTH monitoring allows the surgeon for achieving intraoperative confidence in predicting operative success and preventing failure in cases of unsuspected multiglandular disease, while safely limiting neck exploration in the majority of patients with sporadic primary hyperparathyroidism. Thus, parathyroidectomy guided by intraoperative iPTH monitoring for the management of sporadic primary hyperparathyroidism is an ideal option for the treatment of this disease entity. However, the cost-benefit aspects of the standard application of this method still remain a matter of controversy.

Nipple areola complex sparing mastectomy

Abstract: Breast conservative therapy (BCT) is established as a safe option for most women with early breast cancer (BC). The best conservative mastectomy that can be performed, when mastectomy is unavoidable, is nipple-areola-complex sparing mastectomy (NSM), which allows the complete glandular dissection preserving the skin envelope and the nipple areola complex. In the treatment of BC, the cosmetic outcomes have become fundamental goals, as well as oncologic control. NSM is nowadays considered an alternative technique to improve the overall quality of life for women allowing excellent cosmetic results because it provides a natural appearing breast. The breast surgeon must pay attention to details and skin incision must be planned to minimize vascular impairment to the skin and the nipple. Preservation of the blood supply to the nipple is one of the most important concern during NSM because nipple or areolar necrosis is a well-described complication of this surgery. Another issue associated with the nipple preservation and the surgical technique is oncological safety related to nipple-areola-complex (NAC) involvement in patients with invasive BC. The authors present their experience on 252 NSM performed in the Breast Surgery Unit in Forli. Careful selection of patients for this surgical procedure is imperative and many patients are not ideal candidates for this procedure because of concerns about nipple-areolar viability as women with significant large/ptotic breast, pre-existing breast scars and history of active cigarette smoking. To extend the benefits of nipple preservation to patients who are perceived to be at higher risk for nipple necrosis the authors describe technical modifications of NSM to allow nipple preservation and obtain good cosmetic outcomes.

Abdominal perforator vs. muscle sparing flaps for breast reconstruction.

Abstract: Abdominally based free flaps have become the mainstay for women that desire to use their own tissue as a means of breast reconstruction after mastectomy. As the techniques have evolved, significant effort has been invested in finding the best means of minimizing morbidity to the abdominal donor site while ensuring a viable reconstructed breast that is aesthetically pleasing. This manuscript reviews and compares the muscle sparing free transverse rectus abdominis myocutaneous (MsfTRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps, regarding flap success rate, operative times, abdominal donor site morbidity and residual functionality, hospital lengths of stay and associated costs, impact of co-morbid conditions, and resilience after adjuvant radiation treatment.

Current opinions on indications and algorithms for acellular dermal matrix use in primary prosthetic breast reconstruction.

Abstract: Acellular dermal matrix (ADM) is widely used in primary prosthetic breast reconstruction. Many indications and contraindications to use ADM have been reported in the literature, and their use varies by institution and surgeon. Developing rational, tested algorithms to determine when ADM is appropriate can significantly improve surgical outcomes and reduce costs associated with ADM use. We review the important indications and contraindications, and discuss the algorithms that have been put forth so far. Further research into algorithmic decision-making for ADM use will allow optimized balancing of cost with risk and benefit.

Oncological safety of prophylactic breast surgery: skin-sparing and nipple-sparing versus total mastectomy.

Abstract: Women with a BRCA1/2 gene mutation and others with a high breast cancer risk may opt for bilateral prophylactic mastectomy. To allow for immediate breast reconstruction the skin envelope is left in situ with or without the nipple-areola complex (NAC). Although possibly leading to a more natural aesthetic outcome than the conventional total mastectomy, so-called skin-sparing mastectomies (SSM) and nipple-sparing mastectomies (NSM) may leave some breast glandular tissue in situ. The oncological risk associated with remaining breast glandular tissue is unclear. We present a case of primary breast cancer after prophylactic mastectomy followed by a review of the literature on remaining breast glandular tissue after various mastectomy techniques and oncological safety of prophylactic mastectomies.

Current strategies with 1-stage prosthetic breast reconstruction.

Abstract: Background: 1-stage prosthetic breast reconstruction is gaining traction as a preferred method of breast reconstruction in select patients who undergo mastectomy for cancer or prevention. Methods: Critical elements to the procedure including patient selection, technique, surgical judgment, and postoperative care were reviewed. Results: Outcomes series reveal that in properly selected patients, direct-to-implant (DTI) reconstruction has similar low rates of complications and high rates of patient satisfaction compared to traditional 2-stage reconstruction. Conclusions: 1-stage prosthetic breast reconstruction may be the procedure of choice in select patients undergoing mastectomy. Advantages include the potential for the entire reconstructive process to be complete in one surgery, the quick return to normal activities, and lack of donor site morbidity.

Robotic transaxillary thyroid surgery.

Abstract: Recent technological advances have led to a rapid progress in endocrine surgery. With the advent of minimally invasive techniques in thyroid surgery, robot-assisted transaxillary thyroid surgery (RATS) has emerged as one of the most promising approaches. Its main advantages are improved cosmetic outcome, avoiding cervical incisions, increased patient satisfaction, improved visualization, arms articulations, eliminating surgeon's natural tremor, thereby increasing precision. The main disadvantages are longer operative time, and increased cost compared to conventional thyroidectomy, as well as potential injuries to the brachial plexus, skin flap, esophagus, and trachea. Large-scale studies, mainly from South-Korea, have proved that in skilled hands, RATS is a safe alternative to conservative thyroidectomy and should be presented to patients with aesthetic concerns. As with any new emerging technique, careful patient selection is crucial, and further evidence must be sought to confirm its indications.

Diffuse dermal angiomatosis of the breast: a series of 22 cases from a single institution.

Abstract: Background: Diffuse dermal angiomatosis (DDA) is a rare cutaneous disorder that can affect the breast. A total of nine cases of breast involvement have been described in the literature, but there is currently no consensus in the best therapeutic approach. The objective of this study was to examine patient outcomes with such therapies in women diagnosed with DDA of the breast. Methods: Consecutive cases of DDA of the breast were retrospectively reviewed including patient demographic variables, diagnostic criteria and type of therapies. A successful outcome was defined as complete healing of chronic open breast wounds and absence of disease recurrence after cessation of therapy. Results: Twenty-two women (mean age, 48.4 years) diagnosed with DDA of the breast were identified between 2004 and 2012. The diagnosis was confirmed with skin biopsy in 12 patients and clinical diagnosis in the remaining ten patients. The majority of patients were obese [68.2% (15/22), average body mass index (BMI), 36.9 kg/m 2 ] and at the time of diagnosis, 27.3% of patients were active smokers (6/22). Only two patients (9.1%) received isotretinoin, neither had full recovery and both patients showed recurrence when taken off of therapy. Other medical therapies showed less to no improvement. Two patients underwent successful surgical treatment. One patient had a successful outcome following breast reduction, although her postoperative course was complicated with delayed wound healing. The other patient presented with recurrence of DDA following breast reduction, and was successfully managed with bilateral simple mastectomies. Conclusions: Our findings suggest that DDA of the breast is associated with macromastia, obesity and tobacco use. Isotretinoin therapy is published as having favorable outcomes to other therapies, but in this series only appears to reduce symptoms rather than eradicate DDA. Our findings indicate that other medical therapies have been attempted with limited success. Surgical management of DDA of the breast may provide definitive treatment.

Current strategies with 2-staged prosthetic breast reconstruction

Abstract: Over the last decade, prosthetic-based breast reconstruction has been revolutionized with technological advancements. Reconstructive surgeons now have a multitude of prosthetic devices and tissue expanders, tools for intraoperative perfusion analysis, implantable bioprosthetic materials and a technique for autoaugmentation within their armamentarium to reconstruct natural breasts today like never before.

Transaxillary single-incision robotic neck dissection for metastatic thyroid cancer.

Abstract: In head and neck area, neck dissection (ND) is one of the most complex and precision-needed procedure. The long cervical scar and post-operative neck discomfort have been also inevitable brands after this procedure. Heretofore, few dare to try endoscopic surgical technique to the ND mainly due to its complexity and jeopardy of complication. Although, there have been several reports about the endoscopic approaches for functional ND or ND, they had so many technical and instrumental limitations. The dexterities of the surgical robotics have advanced the techniques of endoscopic surgery, and have facilitated the most precise and delicate endoscopic surgical procedure in head and neck area. The technical feasibility and early surgical outcomes of robotic ND using the transaxillary approach for the management of metastatic thyroid cancer have already been reported as satisfactory. Robotic ND can allow complete compartment-oriented lymph node (LN) dissection without any fatal complications, or compromising oncologic principles. We previously described a novel method of robotic thyroidectomy with ND using a gasless transaxillary approach for metastatic thyroid cancer, and here, we firstly introduce a less invasive robotic procedure which has been modified from the original one, which we refer to as the transaxillary single-incision robotic ND.