OBJECTIVE:To report the initial experience with videoscopic thyroidectomy using a cervical approach with median placement of the optical trocar and gas insufflation. PATIENTS AND METHODS:Retrospective study of the first 100 consecutive patients. RESULTS:Seven isthmectomies, 86 lobectomies, and 7 total thyroidectomies were performed. Parathyroidectomy for hyperparathyroidism was also performed in 3 patients. Mean operative time was 77 minutes. No post-operative subcutaneous emphysema was noted. Conversion to open surgery occurred in 10% of cases but the conversion rate decreased to 2.6% when the harmonic scalpel became available. Post-operative complications included one transient recurrent laryngeal nerve palsy. There were no hematomas and no hypocalcemia. The mean post-operative pain scale was 2.7 (on a visual scale of 1-10). Mean hospital stay was 1.5 days. The cosmetic result was considered excellent. CONCLUSIONS:Endoscopic total thyroidectomy aided by gas insufflation is technically feasible. The harmonic scalpel aids greatly in dissection and hemostasis. It is a valid option in the surgical management of thyroid disease but careful pre-operative selection of patients is mandatory.

The management of small, nonfunctioning pancreaticoduodenal endocrine tumors (NFPET) in multiple endocrine neoplasia type 1 (MEN1) patients is still controversial. We therefore investigated the effect of surgery on survival and tumor progression in MEN1 patients with NFPET ≤2 cm by analyzing data from the Groupe des Tumeurs Endocrines (GTE) registry.

Objective: To analyze the penetrance and clinical course of isolated nonfunctioning tumors of the pancreas (NFTP) in MEN 1 patients, and to propose a strategy for managing them.Summary Background Data: Pancreaticoduodenal tumors develop in a majority of MEN 1 patients and are a major cause of death. The natural history of NFTP is poorly defined, and no clear-cut guidelines have been widely accepted regarding treatment.Methods: Data on 108 patients with isolated NFTP among 579 MEN 1 patients from the French Endocrine Tumor Study Group (GTE) were analyzed. Survival rates were calculated using the Kaplan-Meier method.Results: The penetrance of NFTP was 34% at age 50, making it the most frequent pancreaticoduodenal tumor in MEN I patients. Forty-three patients (40%) underwent surgery, 32 of them curatively. No patient died because of surgery. Average life expectancy for patients with NFTP was shorter than that for MEN 1 patients who did not have pancreaticoduodenal tumors. Thirteen patients died during follow-up, 10 due to NFTP. Tumor size was correlated with the risks of metastasis and death. These risks were low for patients with tumors <= 20 mm.Conclusions: NFTP are currently the most common tumors of the pancreaticoduodenal region in patients with MEN 1. Prevention of tumor spread by surgery should be balanced with potential operative mortality and morbidity. We do not recommend routine surgery for NFTP <= 20 mm.

Les néoplasies endocriniennes multiples (NEM) sont des syndromes de prédisposition génétique aux tumeurs endocrines comprenant les NEM1, NEM2 et exceptionnellement les NEM4. Les NEM sont transmises par voie autosomique dominante avec une forte pénétrance. Une corrélation génotype/phénotype est classiquement retrouvée chez les patients ayant une NEM2 mais pas pour les NEM1. Les patients avec une NEM1, liée à une mutation inactivatrice du gène de la ménine, peuvent présenter : une hyperparathyroïdie primaire, un adénome hypophysaire, des tumeurs neuroendocrines (TNE) duodéno-pancréatiques et/ou bronchiques avec un surrisque de thymome, des tumeurs corticosurrénaliennes ; un sur-risque de cancer du sein et une atteinte cutanée caractéristique telle que les collagénomes, les lentiginomes et un sur-risque de cancer cutané. Ces patients nécessitent un suivi annuel au minimum. Le dépistage des enfants est proposé à partir de l’âge de 5 ans. Les patients avec une NEM2, liée à une mutation activatrice du proto-oncogène RET, présentent tous un carcinome médullaire thyroïdien (CMT) à un âge variable selon le génotype. Certains patients présentent un phéochromocytome (50 %) et une hyperparathyroïdie (20 %). Des formes pédiatriques avec un CMT agressif, une ganglioneuromatose et un syndrome marfanoïde existent (rare NEM2B). Certaines mutations sont associées à un risque de CMT agressif, justifiant une thyroïdectomie prophylactique avant l’âge de 6 mois. L’âge du dépistage génétique dépend du soustype de mutation chez le parent porteur de NEM2. Les NEM4, liées à une mutation du gène CDKN1B, sont rares, avec une pathogénie moins bien connue et leur suivi n’est pas bien codifié.Multiple endocrine neoplasia (MEN) are genetic predisposition syndromes to endocrine tumors including MEN1, MEN2 and exceptionally MEN4. MEN are transmitted in an autosomal dominant fashion with a high penetrance. Classically, there is no genotype/phenotype correlation for NEM1 whereas this is the case for NEM2. Patients with NEM1, linked to an inactivating mutation of the menin gene, may present with: primary hyperparathyroidism, pituitary adenoma, duodeno-pancreatic neuroendocrine tumors (NETs), bronchial tumors with an increased risk of thymoma, adrenal cortical tumors, an increased risk of breast cancer and characteristic skin involvement such as collagenomas, lentiginomas and an increased risk of skin cancer. These patients require at least annual follow-up. Screening of children is proposed from the age of 5 years. Patients with NEM2, linked to an activating mutation of the RET proto-oncogene, all present with medullary thyroid carcinoma (MTC) at a variable age depending on the genotype. Some patients present a pheochromocytoma (50 %) and hyperparathyroidism (20 %). Pediatric forms with aggressive CMT, ganglioneuromatosis and marfanoid syndrome exist (rare NEM2B). Some mutations are associated with a risk of aggressive CMT, justifying prophylactic thyroidectomy before 6 months of age. The age of genetic testing depends on the mutation subtype in the NEM2 parent. NEM4, related to a mutation in the CDKN1B gene, are rare, with a less well-known pathogenesis and their follow-up is not well codified.

AIM OF THE STUDY:To demonstrate the feasibility of endoscopic thyroidectomy for unilateral lobectomy and isthmectomy. MATERIAL AND METHODS:[corrected] This prospective study included 40 patients operated on between January 1999 and March 2005 by a total endoscopic approach. Only lobectomies and isthmectomies were performed for nodules inferior to 3 cm in diameter. RESULTS:Forty patients (36 females, 4 males) underwent 35 lobectomies and five isthmectomies. Twenty-four patients were operated on without ultrasonic shears (US) the rate of conversion in this group was 33%. Sixteen patients were operated on with US: the rate of conversion was 0%. In the second group, the operative time was decreasing to the half, range 45 to 90 minutes. In both the two groups, there were no morbidity: no extensive emphysema, no hematoma, no wound abscess, no cord vocal palsy. The median hospital stay was 1,75 days. After three months of follow up, all the patients were satisfied, especially concerning the cosmetic results and the short recovery time. CONCLUSIONS:Endoscopic thyroidectomy is feasible and safe for performing lobectomies and isthmectomies. In the near future, it could be extended to bilateral goitres in selected patients.

The discovery of a thoracic kidney in adult patients can lead to three diagnoses, yielding different prognoses and treatment. It can either mean traumatic or congenital diaphragmatic hernia, or a congenital ectopic kidney. Intrathoracic herniation of the left kidney trough a left diaphragmatic rupture is an exceptional discovery. We report the case of a 44 year-old man who met with a car accident 20 years ago, and presented abdominal pain. CT-scan showed an intrathoracic herniation of the left kidney trough a left posterior diaphragmatic rupture. Laparoscopic approach in lateral position showed a traumatic hernia of the left costo-diaphragmatic hiatus only containing the left kidney and its pedicle. After reduction of herniated left kidney into the abdomen, the hiatus was closed by non-resorbable prosthetic mesh. Postoperative course was uneventful.

Rapporter l’expérience initiale de la thyroïdectomie endoscopique avec un trocart optique médian et une insufflation gazeuse permanente.Étude rétrospective des 100 premiers patients consécutifs.Sept isthmectomies, 86 lobectomies et 7 thyroïdectomies totales ont été réalisées. Chez trois patients, une hyperparathyroïdie primaire associée a été traitée. La durée opératoire moyenne a été de 77 min (45 à 150 min). Il n’y a pas eu d’emphysème sous cutané postopératoire. Le taux de conversion était de 10 % (2,6 % après utilisation des ciseaux ultrasoniques). La morbidité postopératoire était une paralysie récurrentielle transitoire. Aucun hématome ni aucune hypocalcémie postopératoire n’ont été observés. Le score moyen de douleur postopératoire était de 2,7 (sur une échelle visuelle analogique 1 à 10). La durée moyenne d’hospitalisation a été de 1,5 jours. Le résultat esthétique a été considéré comme excellent.Une thyroïdectomie totalement endoscopique avec une insufflation gazeuse permanente est faisable. Les ciseaux ultrasoniques sont un bon moyen pour réaliser une dissection et des hémostases sûres. Cette technique est une option valide pour traiter des affections thyroïdiennes mais elle ne concerne qu’une faible proportion de patients en raison de la sélection préopératoire nécessaire.To report the initial experience with videoscopic thyroidectomy using a cervical approach with median placement of the optical trocar and gas insufflation.Retrospective study of the first 100 consecutive patients.Seven isthmectomies, 86 lobectomies, and 7 total thyroidectomies were performed. Parathyroidectomy for hyperparathyroidism was also performed in 3 patients.Mean operative time was 77 minutes. No post-operative subcutaneous emphysema was noted. Conversion to open surgery occurred in 10% of cases but the conversion rate decreased to 2.6% when the harmonic scalpel became available. Post-operative complications included one transient recurrent laryngeal nerve palsy. There were no hematomas and no hypocalcemia. The mean post-operative pain scale was 2.7 (on a visual scale of 1-10). Mean hospital stay was 1.5 days. The cosmetic result was considered excellent.Endoscopic total thyroidectomy aided by gas insufflation is technically feasible. The harmonic scalpel aids greatly in dissection and hemostasis. It is a valid option in the surgical management of thyroid disease but careful pre-operative selection of patients is mandatory.

L. BrunaudLes cancers de la thyroïde sont les cancers endocriniens les plus fréquents. Les métastases ganglionnaires cervicales des carcinomes papillaires sont retrouvées chez 20 à 60 % des patients. Aucune étude prospective randomisée ne permet de définir clairement en 2008 si un curage prophylactique doit être ou non réalisé lors de la chirurgie initiale en raison de la faible prévalence et de la faible mortalité associées aux carcinomes papillaires. En conséquence, le curage prophylactique reste une attitude controversée. Les arguments en faveur et contre cette attitude sont discutés dans ce travail ainsi que les données des consensus français et internationaux.L. BrunaudThyroid cancers are the most common endocrine cancer. Cervical lymph node metastases are observed in 20 to 60% of patients with papillary thyroid cancer. In 2008, no prospective randomized study has defined whether prophylactic central neck dissection should be performed during initial surgery for papillary thyroid cancer. Prophylactic lymph node dissection remains controversial. Pros and cons for routine lymph node dissection of the central cervical compartment are discussed in this review of the literature which includes data from international and French consensus conferences.

Le développement de techniques d’imagerie performantes pour localiser les adénomes parathyroïdiens (scintigraphie au MIBI et échographie), la miniaturisation des instruments de chirurgie et l’utilisation du dosage peropératoire de la parathormone ont entraîné le développement de techniques mini-invasives pour la chirurgie de l’hyperparathyroïdie primaire. Ces techniques sont de plus en plus utilisées. Une étude [1] rapportait que parmi les chirurgiens de l’International Association of Endocrine Surgery, 59 % utilisent les techniques mini-invasives (92 % d’entre eux utilisent les abords locaux, 22 % une technique vidéo-assistée et 12 % une technique totalement endoscopique) pour la chirurgie des parathyroïdes. Ces techniques ont dans un deuxième temps été transposées à la chirurgie thyroïdienne. Nous n’aborderons ici que les techniques réalisées par voie cervicale et nécessitant une assistance vidéo pendant tout ou partie de l’opération. Sont donc exclus les abords axillaires, sous mammaires et les variantes utilisant un suspenseur de paroi [2].

Purpose. - The aim of this study was to retrospectively report clinical manifestations, type of treatment, survival rate of thyroid metastases from renal carcinoma.Patients and methods. - Seven patients were retrospectively collected from files of different Burgundy's hospitals. All renal and thyroid gland specimens were controlled by the anatomopathologist.Results. - Tumors occurred in four women and three men (mean age: 66 years). Symptoms were generally a solitary mass. The metastatic tumor to the thyroid gland was the initial presentation of renal carcinoma in one case. In the other cases, patients had documented previous evidence of renal carcinoma as remotely 8.1 years before the thyroid metastases. Thyroglobulin immunohistochemistry was always negative in the foci of metastatic renal carcinoma. All patients had surgical resection of there metastasis. The majority of patients died with disseminated malignancies (mean: 38.1 months after there thyroid resection). Three patients are still alive, one after a complementary pancreatic resection for a secondary pancreatic metastasis and one other with cervical and mediastinal lymph node recurrence.Conclusions. - Surgical treatment of the metastatic disease is suggested, as this may prolonged patient survival. (C) 2003 Elsevier SAS. Tous droits reserves.

OBJECTIVES:Various treatments of the Levator ani syndrome (LVAS) have been proposed. None of them alleviate symptoms in more than 20% of the cases. A new approach combining massages of the coccygeus muscle with physical treatment of frequently associated pelvic joint disorders was assessed. The outcome of the Irritable Bowel Syndrome (IBS) that is frequently associated was also studied.METHODS:One hundred and one patients (76 females and 25 males, mean age: 54 years) with a diagnosis of LVAS were studied prospectively over one year. Massages were given with a patient lying on the left side. Physical treatment of the pelvic joint disorders was given at the end of each massage session.RESULTS:Forty-seven patients (46.5%) suffered both from LVAS and IBS. A mean of less than 2 sessions of treatment was necessary. Sixty-nine per cent of the patients were LVAS-free at 6 months (p<0.0001) and 10% were improved. At 12 months, 62% were still free of symptoms and 10% improved (p=0.37). A comparable trend according to the Rome II criteria was found in the IBS-patient group (53% IBS free initially, 78% at 6 months [p=0.00001], 72% at 12 months [p=1]). There was a significant correlation between the favorable outcome of IBS and the LVAS at 6 and 12 months. All IBS-free patients were LVAS-free at 6 months.CONCLUSION:The LVAS may be cured or alleviated in 72% of the cases at 12 months with one to 2 sessions. This new comprehensive treatment suggests the role of a muscular and osteoligamentary etiology in the LVAS. Since most of IBS benefitted from such treament, it is logical to suspect a mutual pathogeny and to screen for LVAS in all such patients.