Vestibular approach for thyroid surgery: a comprehensive review

The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is an innovative technique in thyroid surgery. This review compiles current research on TOETVA, covering its development, anatomical challenges, techniques, selection of suitable patients, results, complications, and future advancements. We performed a comprehensive literature review on PubMed, EMBASE, and Cochrane databases for articles published up to 15th March 2024. The search strategy included a combination of terms focused on "vestibular approach" and "thyroidectomy". The review underscores the necessity for preoperative planning and careful patient selection to reduce risks and enhance outcomes. It discusses the unique anatomical challenges of TOETVA, such as avoiding mental nerve damage and the complexities involved in creating a subplatysmal space. Outcomes of TOETVA, including surgical duration, complication rates, and recovery times, are compared favorably to traditional methods. The approach is particularly noted for high patient satisfaction and superior cosmetic results. Complications specific to TOETVA, like infection, bleeding, and potential harm to the recurrent laryngeal nerve, are recognized. Future research directions are discussed as well. In summary, TOETVA is a promising alternative for thyroidectomy with excellent cosmetic outcomes and patient satisfaction. Success relies on selective patient criteria, surgical expertise, and continuous research to refine the approach.

Knowledge, attitudes and practices of using Indocyanine Green (ICG) fluorescence in emergency surgery: an international web-based survey in the ARtificial Intelligence in Emergency and trauma Surgery (ARIES)-WSES project

Fluorescence imaging is a real-time intraoperative navigation modality to enhance surgical vision and it can guide emergency surgeons while performing difficult, high-risk surgical procedures. The aim of this study is to assess current knowledge, attitudes, and practices of emergency surgeons in the use of indocyanine green (ICG) in emergency settings. Between March 08, 2023 and April 10, 2023, a questionnaire composed of 27 multiple choice and open-ended questions was sent to 200 emergency surgeons who had previously joined the ARtificial Intelligence in Emergency and trauma Surgery (ARIES) project promoted by the WSES. The questionnaire was developed by an emergency surgeon with an interest in advanced technologies and artificial intelligence. The response rate was 96% (192/200). Responders affirmed that ICG fluorescence can support the performance of difficult surgical procedures in the emergency setting, particularly in the presence of severe inflammation and in evaluating bowel viability. Nevertheless, there were concerns regarding accessibility and availability of fluorescence imaging in emergency settings. Eighty-seven out of 192 (45.3%) respondents have a fluorescence imaging system of vision for both elective and emergency surgical procedures; 32.3% of respondents have this system solely for elective procedures; 21.4% of respondents do not have this system, 15% do not have experience with it, and 38% do not use this imaging in emergency surgery. Less than 1% (2/192) affirmed that ICG fluorescence changed always their intraoperative decision-making. Precision surgery effectively tailors surgical interventions to individual patient characteristics using advanced technology, data analysis and artificial intelligence. ICG fluorescence can serve as a valid and safe tool to guide emergency surgery in different scenarios, such as intestinal ischemia and severe acute cholecystitis. Due to the lack of high-level evidence within this field, a consensus of expert emergency surgeons is needed to encourage stakeholders to increase the availability of fluorescence imaging systems and to support emergency surgeons in implementing ICG fluorescence in their daily practice.

Recurrent gastric antral vascular ectasia: a single center experience

Introduction

Gastric antral vascular ectasia (GAVE) is a rare cause of chronic or acute gastrointestinal bleeding. This condition accounts for ∼4% of upper gastrointestinal bleeding cases. This disease is often associated with systemic diseases, such as liver cirrhosis, chronic kidney failure, autoimmune conditions, diabetes mellitus, hypothyroidism, and cardiovascular diseases. However, its etiopathogenesis remains controversial.

Materials and method

We retrospectively reviewed the cases of GAVE treated at our digestive surgery unit. A total of nine patients were identified with a male/female ratio of 1.25:1 and an average age of 75.51 years (SD ± 9.85). All patients underwent endoscopic argon plasma coagulation (APC) treatment. At the time of the review, data on eight patients were available after 36 months of follow-up.

Results

APC appears to be safe and effective for hemostasis of bleeding vascular ectasia. Only one (11.1%) patient required surgical intervention due to hemodynamic instability after multiple unsuccessful endoscopic treatments. No intraoperative and postoperative complication or bleeding relapse was experienced.

Discussion

Based on our findings, we concluded that endoscopic APC is technically simple, but requires multiple re-interventions due to the incidence of relapses. Furthermore, larger randomized studies should be conducted to assess the role of elective surgery as the first intervention in stable patients with severe pathology and the timing of surgery after failed endoscopic treatment.

Risk Factors for Hypoparathyroidism after Thyroid Surgery: A Single-Center Study

BACKGROUND

Hypoparathyroidism is one of the most common complications after thyroidectomy. This study evaluated the incidence and potential risk factors for postoperative hypoparathyroidism after thyroid surgical procedures in a single high-volume center.

METHODS

In this retrospective study, in all patients undergoing thyroid surgery from 2018 to 2021, a 6 h postoperative parathyroid hormone level (PTH) was evaluated. Patients were divided into two groups based on 6 h postoperative PTH levels (≤12 and >12 pg/mL).

RESULTS

A total of 734 patients were enrolled in this study. Most patients (702, 95.6%) underwent a total thyroidectomy, while 32 patients underwent a lobectomy (4.4%). A total of 230 patients (31.3%) had a postoperative PTH level of <12 pg/mL. Postoperative temporary hypoparathyroidism was more frequently associated with female sex, age < 40 y, neck dissection, the yield of lymph node dissection, and incidental parathyroidectomy. Incidental parathyroidectomy was reported in 122 patients (16.6%) and was correlated with thyroid cancer and neck dissection.

CONCLUSIONS

Young patients undergoing neck dissection and with incidental parathyroidectomy have the highest risk of postoperative hypoparathyroidism after thyroid surgery. However, incidental parathyroidectomy did not necessarily correlate with postoperative hypocalcemia, suggesting that the pathogenesis of this complication is multifactorial and may include an impaired blood supply to parathyroid glands during thyroid surgery.

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND

The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not.

METHODS

Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not.

RESULTS

A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001].

CONCLUSIONS

The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

Gallbladder hemorrhage–An uncommon surgical emergency: A case report

BACKGROUND

Gallbladder hemorrhage is a life-threatening disorder. Trauma (accidental or iatrogenic such as a percutaneous biopsy or cholecystectomy surgery), cholelithiasis, biliary tract parasitosis, vasculitis, vascular malformations, autoimmune and neoplastic diseases and coagulopathies have been described as causes of hemorrhage within the lumen of the gallbladder. The use of non-steroidal anti-inflammatory drugs and anticoagulants may represent a risk factor.

CASE SUMMARY

We report the case of a 76-year-old male patient. An urgent contrast computed tomography scan demonstrated relevant distension of the gallbladder filled with hyperdense non-homogeneous content. The gallbladder walls were of regular thickness. Near the anterior wall a focus of suspected active bleeding was observed. Due to the progressive decrease in hemoglobin despite three blood transfusions, this was an indication for urgent surgery.

CONCLUSION

Early diagnosis of this potentially fatal pathology is essential in order to plan a strategy and eventually proceed with urgent surgical treatment.

Is there a relationship between length of resection and lymph-node ratio in colorectal cancer?

Background

The prognosis of colorectal cancer depends on the number of positive lymph nodes (LN+) and the total number of lymph nodes resected (rLN). This represents the lymph-node ratio (LNR). The aim of our study is to assess how the length of the resected specimen (RL) influences the prognostic values of the LNR.

Methods

We conducted a retrospective study of all the patients operated on for colorectal cancer from 2000 to 2015 at our institution. Pathology details were analysed. The total number of rLN, the number of LN+, and the LNR were calculated and measured against the RL. The receiver-operating characteristic (ROC) curve of patients with LN+ was calculated.

Results

Of the 670 patients included in our study, 337 were men (50.3%) and the mean age was 69.2 years. The correlation with prognosis of the LNR is greater than that of the LNR adjusted to RL (LNR/RL), both in subjects with positive nodes (n = 312) and in all cases (n = 670). The LNR presents a higher prognostic value than LNR/RL and RL in patients with LN+ except for metastatic recurrence, for which the predictive value appears slightly higher for LNR/RL. The statistical significance of the maximal divergence in Kaplan-Meier survival plots was demonstrated for the LNR (P = 0.043), not for LNR/RL (P = 0.373) and RL alone (P = 0.314).

Conclusion

An increase in RL causes an increase in the number of harvested lymph nodes without affecting the number of LN+, thus representing a confounding factor that could alter the prognostic value of the LNR. Prospective larger-scale studies are needed to confirm these findings.

The role of E-cadherin expression in the treatment of western undifferentiated early gastric cancer: Can a biological factor predict lymph node metastasis?

The use of endoscopic techniques to cure small sized, well differentiated early gastric cancer has been adopted worldwide. In the Eastern world, endoscopic resection is being increasingly utilized to treat small undifferentiated early gastric cancer according to the extended criteria proposed by the Japanese Gastric Cancer Associations. However, studies in the Western world reported in these tumors a rate of nodal metastasis ranging between 5% and 20%, that is higher of those observed in Eastern counterparts. A tool to predict the risk of nodal dissemination would be of great use to guide treatment toward endoscopic resection. In our study, we propose E-cadherin expression as a biological factor to predict lymph node involvement. We retrospectively reviewed the E-cadherin (E-cad) expression profile of all histological specimens of undifferentiated early gastric cancer from two Oncologic Departments and compared it with several tumor characteristics. A total of 39 patients with early gastric cancer met the inclusion criteria, of which 16 (41%) pT1a, and 23 (58.9%) pT1b SM1. Thirty-two patients (82%) underwent subtotal gastrectomy, whereas total gastrectomy was performed in only seven cases (17.9%). Patients were divided into two groups: low E-cad expression (E-cad 0/1+, 10 patients) and high E-cad expression (E-cad 2+/3+, 29 patients) according to the immunohistochemical assay (ICH). On univariate analysis, we found an association between low E-cad expression and low grading tumor (p = 0.019), pure undifferentiated histotype (PU-type) (p = 0.014), and lymph node involvement (N+) (p < 0.001). The association between low E-cad expression and lymph node metastasis was confirmed by multivariate analysis (OR = 14.5, 95% CI 3.46-60.76, p < 0.001). The loss of expression of E-cad may be a simple biological factor to predict lymph nodes metastasis in patients with undifferentiated early gastric cancer. Additional larger prospective studies are necessary to confirm these findings.

Curcumin, Hormesis and the Nervous System

Curcumin is a polyphenol compound extracted from the rhizome of Curcuma longa Linn (family Zingiberaceae) commonly used as a spice to color and flavor food. Several preclinical studies have suggested beneficial roles for curcumin as an adjuvant therapy in free radical-based diseases, mainly neurodegenerative disorders. Indeed, curcumin belongs to the family of hormetins and the enhancement of the cell stress response, mainly the heme oxygenase-1 system, is actually considered the common denominator for this dual response. However, evidence-based medicine has clearly demonstrated the lack of any therapeutic effect of curcumin to contrast the onset or progression of neurodegeneration and related diseases. Finally, the curcumin safety profile imposes a careful analysis of the risk/benefit balance prior to proposing chronic supplementation with curcumin.

Gastric GIST and prognostic models. Which is the best to predict survival after surgery?

BACKGROUND

Gastrointestinal Stromal Tumours (GIST) are the most frequent mesenchymal tumour of the alimentary tract. Their prognosis is largely variable as are their size, mitotic rate and site, the stomach being mostly affected. Several risk classifications have been proposed: two developed by the NIH, one proposed by the AFIP and one presented by the AJCC in 2010. The objective of this study is to compare the accuracy of the three prognostic models (AJCC, NIH and AFIP) with regard to survival after surgery, also based on the different surgical approaches.

METHODS

A retrospective review of all cases of gastric GIST's performed at the General and Breast Surgery Unit of the Department of General Surgery the University of Catania and at the "Gemelli" General Surgery Unit of Taormina Hospital, Italy between 2001 and 2016 was conducted. The cases were reviewed and re- classified according to the three prognostic models. Analysis of data, including Kaplan-Meyer survival curves, was performed using SPSS version 21.0.

RESULTS

Among a total of 1,625 gastrectomies and gastric resections were found 25 primary GIST's patients, 13 females, and 12 males, with a mean age 63 years. Cancer size varied between 1.5 cm and 37 cm and number of mitosis between 2 and 50/50 HPF. A total of 12 (48%) underwent sub-total gastrectomy (STG), seven (28%) underwent a wedge resection (WR), and 6 (12%) total Gastrectomy (TG). Twenty-three patients (92%) are currently alive at a follow up of 18 months to 17 years, and only two patients died during the long term follow-up. Both patients were AFIP high risk (6b), AJCC stage IV, already metastatic at the time of surgery. Both patients underwent total extended gastrectomy and therapy with imatinib, but died 8 and 9 years after surgery. Recurrences have been observed in 2 patients (8%), with high risk according to AFIP (6a) with AJCC stage IIIa disease.

CONCLUSIONS

In localized GISTs R0 surgical resection is the standard therapy as it leads to excellent outcomes. Our findings suggest that all the three classifications considered are adequate to achieve a correct prognostic evaluation.

KEY WORDS

GIST, Prognostic factors, Prognostic models.

Acellular dermal matrix for breast reconstruction after surgery for giant dermatofibrosarcoma protuberans

INTRODUCTION

Dermatofibrosarcoma protuberans (DFSP) is a rare neoplasm that exceptionally can affect the breast, always originating from skin and dermis, so imposing large sacrifice of skin. Only few cases have been reported of intraparenchymal DFS. We describe a unique case of giant intraparenchymal DFS that required removal of all the gland and reconstructive surgery.

CASE REPORT

A 34 years old woman presents with a quickly growing breast mass, about 12 cm, with radiological features suggestive for giant fibroadenoma or mesenchymal neoplasm. The histology showed a Dermatofibrosarcoma protuberans infiltrating the surrounding parenchyma. The need for radicalization imposed, due to the size of the tumour, a nipple sparing mastectomy. The reconstruction has been performed using a new type of Acellular Dermal Matrix (ADM) mesh to wrap the prosthesis that has been placed and fixed over the great pectoral muscle.

RESULTS

The final histologic report showed that the residual parenchyma and the skin removed were free from neoplastic infiltration. The patient is free from recurrence at 24 months from the surgery and the cosmetic result is excellent.

DISCUSSION AND CONCLUSIONS

The treatment of DFSP should be aimed to prevent local recurrence, that are usually located in the scar or very close to it. Large size DFS can impose even mastectomy. If skin is not compromised like in this case, a nipple sparing mastectomy is suitable and the one time reconstruction with ADM wrapping of the prosthesis and fixation over the muscle can help to spare time, avoid complications and pain medication and reach excellent cosmetic resu.

KEY WORDS

Acellular Dermal Matrix (ADM) mesh, Protuberans, Breast neoplasms, Dermatofibrosarcoma, Mastectomy, Nipple sparing, reconstructive surgery.

Laparoscopic repair of incisional hernia. Risk factors for the conversion

INTRODUCTION

Some factors may affect the conversion to open of the laparoscopic treatment of incisional hernia. Their presence can help to choose the most appropriate technique identifying patients at high risk conversion.

METHODS

A retrospective study has been performed on a cohort of 306 patients, selected among those undergone to elective laparoscopic surgery for post incisional hernia between 2005 and 2015. Only symptomatic patients with single site wall defect, diameter between 5 and 10 cm, ASA ≤3, have been included. Patients were divided in 2 groups, Laparoscopic (L) and Converted (C) and preoperatory data were evaluated and statistically analyzed.

RESULTS

The L group accounted for 228 patients and C group for 78 patients. The univariate analysis showed that risk factor for conversion included BMI ≥ 30, Smoking, Diabetes mellitus, Prior emergency surgery. Age > 60 years was associate with lower risk of conversion.

CONCLUSIONS

The result of this retrospective study allows us to say that the choice of the technique, in the presence of multiple risk factors, should be carefully assessed and discussed with the patient. A prospective study with a larger number of patients would allow a better definition of the risk determined by individual factors and the development of a score that could be used in practice to simplify the risk assessment KEY WORDS: Conversion to open surgery, Incisional hernia, Laparoscopy, Risk factors.

Total Thyroidectomy: the first, the best. The recurrent goiter issue

BACKGROUND

Redo surgery for recurrent goiter is still now, even in experienced hands, followed by higher morbidity than primary total thyroidectomy. Suppressive Levothyroxine therapy failed to improve the recurrence rate, while inducing a subclinical hyperthyroidism. Aim of this study is to verify morbidity after total thyroidectomy for benign thyroid diseases, both primary and after recurrence.

MATERIALS AND METHODS

A series of 20 cases of total thyroidectomy for recurrent benign diseases (RG), performed between January 2001 and December 2013 was compared with 225 cases of primary total thyroidectomy (PT) . Cancers, even incidentally diagnosed, were excluded. At least a 12 months follow up was accomplished. Due to the small size of the sample for RG, statistical analysis was performed by Fisher test only.

RESULTS

Postoperative complications were Transient hypocalcemia: 5 (25%) in RG and 18 (8%) in PT, Permanent hypocalcemia only 2 (10%) in RG (significant for p <0,05), Transient RLN deficit 5 (25 %) in RG and 6 (2.6%) in PT (significant for p< 0.05).

CONCLUSIONS

Differences in incidence of perioperative complications cannot be advocated to justify a less than total thyroidectomy even in benign disease setting. The need for a redo surgery with its burden of morbidity is per se a good reason to avoid a conservative surgery. Further, suppressive therapy with Levothyroxine often fails to avoid recurrence, inducing in some cases a specific morbidity. Our experience confirms the results of our previous experiences and of literature on this topic: the best management of recurrent goiter is its prevention by primary total thyroidectomy.

A pilot study about the oncologic safety of colonic self-expandable metal stents (SEMS) in obstructive colon cancer: is occlusion always better than "silent" perforation?

OBJECTIVE

To evaluate the oncologic safety of colonic self-expandable metal stents (SEMS) in obstructive colon cancer.

PATIENTS AND METHODS

We retrospectively reviewed all the patients who were treated with endoscopic placement of a self-expandable metallic stent (SEMS) at our institution.

RESULTS

A total of 26 patients were identified during the study period, of which 24 patients (92.30%) were treated with SEMS as a bridge-to-surgery and 2 (7.69%) as palliation. In 22 cases (80.76%), the stenosis was localized to the left side. Clinical success with resolution of bowel obstructions was achieved in 22 (84.61%) patients within a short period of time. Among patients treated successfully with SEMS insertion as bridge to surgery (n = 22), 20 (90.9%) underwent one-stage surgery with primary anastomosis while 2 patients (9.09%) underwent colostomy due to intraoperative evidence of a covered perforation by cancer tissue in the pelvis. Patients with subclinical perforation developed an early peritoneal carcinomatosis, 10 patients treated with curative intent subsequently developed liver metastasis after 24 months.

CONCLUSIONS

We reported an overall poor outcome among patients treated with the insertion of SEMS. This led us to think that, in some cases, occlusion may be better than a "silent" perforation.

Comparison between Focus Harmonic scalpel and other hemostatic techniques in open thyroidectomy: A systematic review and meta-analysis

BACKGROUND

The purpose of this review was to compare the efficacy and surgical outcomes of total thyroidectomy between the Focus Harmonic scalpel (Ethicon, Cincinnati, OH) and other hemostatic procedures.

METHODS

An extensive search was conducted using the PubMed and Cochrane databases from January 2008 to October 2014. Operating time, blood loss, pain, complications, and hospital stay were evaluated.

RESULTS

When compared with conventional techniques or LigaSure Precise Vessel Sealing System (Medtronic, Minneapolis, MN), the use of the Focus Harmonic scalpel reduced operative time by 22,428 minutes and blood loss by 13,914 mL. Length of hospital stay was significantly shorter in the Focus Harmonic scalpel group with a mean reduction of 0.410 days.

CONCLUSION

According to our meta-analysis, when comparing the Focus Harmonic scalpel versus conventional techniques, it seems evident that the use of this device in thyroid surgery is associated with a mean reduction in operating time, blood loss, and hospital stay, without any increase in pain and complications. There was no appreciable difference between the Focus Harmonic scalpel and the LigaSure Precise Vessel Sealing System. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1578, 2016.

The role of HIPEC in the treatment of peritoneal carcinomatosis from gastric cancer: between lights and shadows

Gastric cancer is one of the most dreadful neoplastic diseases and remains the second cause of cancer death worldwide. Patients who develop peritoneal metastasis have a poor prognosis, with a median survival of less than 6 months. Despite being the cause of 60% of deaths from gastric cancer, peritoneal metastasis can still be considered a local disease and a local multidisciplinary approach can improve the prognosis even in this end-stage disease. At present, hyperthermic intraperitoneal chemotherapy (HIPEC) is the most widely accepted treatment for peritoneal surface diseases and can be performed in patients with different stages of cancer and with various antitumoral drugs. We performed a systematic review of the current status of HIPEC in the treatment of gastric peritoneal metastasis in an attempt to obtain answers to the questions that still remain: do results differ with these different methods? Does HIPEC exert a significant effect on the intracavitary delivery of drugs? Which patients should be treated and which should not? What can we expect from this approach in terms of survival, morbidity, and mortality? On reviewing the literature, despite the lack of trials comparing the different methods, we found that HIPEC has been shown to be an effective tool whenever a complete or an almost complete resection of the peritoneal implants can be performed. Therefore, it is advisable to refer all at-risk patients to specialized centers to be enrolled in randomized trials to achieve truly reliable results.

Lymph node evaluation in gallbladder cancer: which role in the prognostic and therapeutic aspects. Update of the literature

OBJECTIVE

The widespread use of laparoscopy has changed the outcome of gallbladder cancer as a consequence of increasing referral and incidental discovering of earlier stages cancer. Nevertheless, GBC is still associated with a poor prognosis and lymphnodal involvement is a main prognostic factor, important both for staging and for evaluating surgery quality. No consensus exists about the extension of lymphadenectomy to be performed nor about contraindications to extensive resection. A review of literature was so designed to identify the actual role, extension and limits of lymphadenectomy.

MATERIALS AND METHODS

A search on Pubmed and Scopus has been performed using the following keywords: gallbladder cancer, gallbladder neoplasm, surgery, laparoscopy, lymphadenectomy to evaluate the prognostic and the therapeutic role of the lymphadenectomy in gallbladder cancer. The retrieved articles were analyzed aimed to evaluate the impact of lymphectomy and of its extension on overall and disease free survival.

RESULTS

 Although no consensus still exists over the extension of ideal lymphadenectomy, some points are already clearly established: a part from T1a neoplasms, that do not require further surgery, and T1b for which a regional lymphectomy (N1) is safe and mandatory, more advanced stages require a more aggressive surgery but the fate of paraortic nodal station is still under evaluation. In fact some Authors still believe that the involvement of these nodes determine a so poor prognosis to make uselessly risky their surgical aggression. Other Authors conversely, show that there is not any difference in survival, among node positive patients, between paraortic node positive and no paraortic node positive patients.

CONCLUSIONS

The prognosis of gallbladder cancer remains poor because in most patients the diagnosis is made at an advanced stage. Complete surgical resection provides the only curative treatment option in this disease. In order to improve long-term outcome, several surgeons have advocated aggressive surgical resection, including major hepatectomy, pancreatoduodenectomy and extended lymphadenectomy. Even a para-aortic nodal disease shouldn't discourage from pursuing this objective.

Laparoscopic cholecystectomy: ultrasonic energy versus monopolar electrosurgical energy

OBJECTIVE

Nowadays, laparoscopic cholecystectomy (LC) is undoubtedly considered the "gold standard" in the surgical treatment of symptomatic gallstones, gallbladder adenomas and acute cholecystitis. Among the alternative energy sources proposed (monopolar, bipolar electric scalpel, radiofrequency sealers) with the aim to dissect and/or seal, the ultrasonic energy has been frequently adopted, however without a widespread acceptance among surgeons for routine or emergency laparoscopic cholecystectomy. This study investigates the possible beneficial aspects of ultrasonic dissection and its efficacy in the closure of the cystic artery and duct.

PATIENTS AND METHODS

Patients were retrospectively divided into 2 groups according to the instruments used for division of the cystic artery and duct as well as for dissection of the liver bed: 121 patients in whom dissection and coagulation were performed using monopolar coagulation and 43 patients who were all treated with the ultrasonically activated scalpel harmonic ACE (Ethicon Endo-Surgery) as the sole instrument used in the whole procedure.

RESULTS

The mean operative time, was significantly shorter in the harmonic group than in the traditional group (35.36 + 10.15 min vs. 55.6+12.10 vs. respectively; p < 0.0001). The rate of gallbladder perforation was significantly higher in the traditional group than in the harmonic group 20.66% (25 patients) vs. 6.98% (3 patients), respectively; p < 0.05). Intraoperative volume blood loss was significantly more in the traditional group than in the HS group (29.32+14.21 vs. 12.41+8.22; p < 0.0001). The mean amount of postoperative drainage was not significantly different among the two group (18.41+6.54 vs. 15.96+8.69 ml, p > 0.05). No considerable visceral injury has been recorded in either group. The postoperative parameters observed included postoperative hospital stay and morbidity for each group. The hospital stay was not significantly shorter in harmonic group (48.15+4.29 vs. 49.06+2.94 h, p > 0.05). The overall morbidity rate was 14.02 % (not significant).

CONCLUSIONS

The use of the harmonic scalpel shows some statistically significant advantages limited to a few intraoperative parameters. We conclude that a wider use of harmonic scalpel not offers such advantages to make it the reference technique.

Laparoscopic treatment of intrasplenic pancreatic pseudocyst

INTRODUCTION

Pseudocyst formation commonly follows pancreatitis, but erosion into the spleen is rare and potentially life threatening. We report a case of an intrasplenic pancreatic pseudocyst treated laparoscopically with distal pancreatectomy and splenectomy.

METHODS

A 50 year old male with a history of chronic alcoholic pancreatitis, presented with abdominal pain for 3 months, worsening over the past several days. A CT scan showed a broad 9 cm subcapsular fluid collection suspicious for an intra-splenic pseudocyst. The patient underwent laparoscopic distal pancreatectomy and splenectomy.

RESULTS

There were no intraoperative complications and the patient was discharged on day 8. The final pathology revealed a benign cystic lesion measuring 9 x 6 x 3 cm that was not communicating with the pancreatic duct, and 2 smaller pseudocysts in the pancreatic body and tail. A previous scan did not reveal any abnormalities in the spleen, and showed the other pancreatic pseudocysts. At 8 month follow up the patients was symptom free, with no new pseudocysts.

CONCLUSIONS

Splenic parenchyma involvement is an unusual complication of pancreatic pseudocyst. The optimal treatment is controversial. Percutaneous drainage carries a high recurrence rate and risk of hemorrhage. Open surgery is effective, but associated with significant morbidity. Laparoscopy offers an effective method of treatment without the potential complication of a large abdominal incision.