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Management of surgical diseases of Primary Hyperparathyroidism: indications of the United Italian Society of Endocrine Surgery (SIUEC). Updates Surg 2024; 76:743-755. [PMID: 38622315 DOI: 10.1007/s13304-024-01796-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/25/2024] [Indexed: 04/17/2024]
Abstract
A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in parathyroid surgery published in 2014, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 12 members of the SIUEC highly trained and experienced in thyroid and parathyroid surgery. The main topics concern diagnostic test and localization studies, mode of admission and waiting time, therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications), hospital discharge and patient information, outpatient care and follow-up, outpatient initial management of patients with pHPT.
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Impact of Intermittent Intraoperative Neuromonitoring (IONM) on the Learning Curve for Total Thyroidectomy by Residents in General Surgery. Surg Innov 2024:15533506241248974. [PMID: 38632109 DOI: 10.1177/15533506241248974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Recurrent laryngeal nerve (RNL) identification constitutes the standard in thyroidectomy. Intraoperative nerve monitoring (IONM) has been introduced as a complementary tool for RLN functionality evaluation. The aim of this study is to establish how routine use of IONM can affect the learning curve (LC) in thyroidectomy. METHODS Patients undergoing total thyroidectomy performed by surgery residents in their learning curve course in 2 academic hospitals, were divided into 2 groups: Group A, including 150 thyroidectomies performed without IONM by 3 different residents, and Group B, including 150 procedures with routine use of intermittent IONM, by other 3 different residents. LC was measured by comparing operative time (OT), its stabilization during the development of the LC, perioperative complication rate. RESULTS As previously demonstrated, the LC was achieved after 30 procedures, in both groups, with no differences due to the use of IONM. Similarly, there were no significant differences among the 2 groups, and between subgroups independently matched, for both OT and complications, even when comparing RLN palsy. Direct nerve visualization and IONM assessment rates were comparable in all groups, and no bilateral RLN palsy (transient or permanent) were reported. No case of interrupted procedure to unilateral lobectomy, due to evidence of RLN injury, was reported. CONCLUSIONS The study demonstrates that the use of IONM thyroid surgery, despite requiring a specific training with experienced surgeons, does not particularly affect the learning curve of residents approaching this kind of surgery, and for this reason its routine use should be encouraged even for trainees.
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Case report: The use of PRP in the treatment of diabetic foot: case series and a review of the literature. Front Endocrinol (Lausanne) 2023; 14:1286907. [PMID: 38170077 PMCID: PMC10760803 DOI: 10.3389/fendo.2023.1286907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
Background Diabetes mellitus is a prevalent chronic condition that significantly impacts global health. Diabetic foot complications, such as foot ulcers, pose a substantial burden on individuals with diabetes and can lead to serious consequences, including amputation. Platelet-rich plasma (PRP) has emerged as a promising therapeutic approach for enhancing the healing of diabetic foot ulcers. Methods In our study, we treated 12 patients with chronic diabetic ulcers using PRP injections administered at three-week intervals. Our objective was to assess the reduction in wound size and the rate of complete healing at 6 months after the start of the treatment. Additionally, we conducted a comprehensive literature review to contextualize our findings. Results Out of the 12 patients, 8 achieved complete healing of their diabetic foot ulcers, while the remaining four showed significant improvement with more than 50% reduction in the initial lesion size. 3 patients developed mild irritation at the inoculation site. These outcomes, combined with the evidence from published studies, highlight the effectiveness of PRP in promoting the healing of diabetic foot ulcers. Conclusion In conclusion, our study demonstrates the potential of platelet-rich plasma (PRP) as a successful therapeutic option for enhancing the healing process of chronic diabetic foot ulcers. The favorable outcomes observed, including a high rate of complete healing and significant wound size reduction, underscore the value of PRP treatment in managing this challenging complication. Further research and larger studies may provide additional insights into the mechanisms and long-term benefits of PRP in diabetic wound healing.
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Ultrasound-guided Transversus Abdominis Plane Block is Effective as Laparoscopic Trocar site infiltration in Postoperative Pain Management in Patients Undergoing Adrenal Surgery. Am Surg 2023; 89:4401-4405. [PMID: 35797715 DOI: 10.1177/00031348221114035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pain management in patients undergoing laparoscopy is still a matter of debate as several techniques have been proposed to reduce postoperative analgesic consumption and improve recovery. Among these, transversus abdominis plane (TAP) block is considered as safe, effective, and easy to perform under ultrasound guidance; even so, recently laparoscopically guided trocar site anesthetic infiltration has been proposed as a "surgeon-dependent alternative to TAP block." The aim of this evaluation is to compare these analgesic techniques in the setting of laparoscopic adrenalectomy. METHODS This is a retrospective evaluation of a prospectively maintained database. Patients were divided into two groups: Group A patients received laparoscopic-assisted trocar site infiltration of ropivacaine; Group B patients received bilateral ultrasound-guided TAP block with ropivacaine. All patients received 24 h infusion of 20 mg morphine postoperatively; pain was checked at 6, 24 and 48 h after surgery. A rescue analgesia was given if numerical rating scale (NRS) score was > 4 or on patient request. RESULTS One hundred and three patients were enrolled in the evaluation (57 in group A and 46 in group B). There were no differences in operative time, complications and postoperative stay, and no complications related to trocar site infiltration. There were no differences in NRS at 6, 24, and 48 hours as well as in patients requiring further analgesic administration. CONCLUSIONS Laparoscopic-guided trocar site ropivacaine infiltration has similar pain outcomes compared to ultrasound-guided TAP block in the management of postoperative pain in patients undergoing laparoscopic adrenalectomy. Since there is no difference among these techniques, the decision can be based on surgeon or anesthesiologist preference.
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The management of locally advanced, ulcerated breast cancer in a menopausal woman: a case report. Ann Med Surg (Lond) 2023; 85:5176-5178. [PMID: 37811082 PMCID: PMC10553047 DOI: 10.1097/ms9.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/07/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction and importance This case report presents the clinical details of a 46-year-old postmenopausal woman who was diagnosed with a locally advanced, ulcerated, hormone receptor-positive, HER2-negative stage 2B lobular carcinoma of the breast. The complexity of the case necessitated a multidisciplinary, personalized approach. Case presentation The patient, a postmenopausal woman, presented with locally advanced lobular carcinoma of the breast. The tumor was of significant size and exhibited ulceration. Given the hormone receptor-positive status of the tumor, a comprehensive treatment plan was formulated, taking into account the patient's overall health and potential tolerance to treatment. Surgical removal of the tumor was performed, followed by adjuvant therapy with aromatase inhibitors. Clinical discussion The complexity of this case highlights the importance of a personalized and patient-centered strategy in managing breast cancer. The patient's menopausal status, tumor characteristics, and potential tolerance to treatment were crucial factors that influenced the treatment plan. The successful outcome of the treatment and the patient's ability to tolerate the therapy underscores the significance of individualized treatment planning. Conclusion This case report emphasizes the necessity for a comprehensive and patient-centered approach to managing complex cases of breast cancer. The findings support the development of personalized therapeutic strategies aimed at improving patient outcomes and quality of life. The successful treatment of the locally advanced, ulcerated lobular carcinoma of the breast in this postmenopausal patient further highlights the importance of considering individual factors and tailoring treatment plans accordingly.
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Management of surgical diseases of thyroid gland indications of the United Italian Society of Endocrine Surgery (SIUEC). Updates Surg 2023; 75:1393-1417. [PMID: 37198359 PMCID: PMC10435599 DOI: 10.1007/s13304-023-01522-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/23/2023] [Indexed: 05/19/2023]
Abstract
A task force of the United Italian society of Endocrine Surgery (SIUEC) was commissioned to review the position statement on diagnostic, therapeutic and health‑care management protocol in thyroid surgery published in 2016, at the light of new technologies, recent oncological concepts, and tailored approaches. The objective of this publication was to support surgeons with modern rational protocols of treatment that can be shared by health-care professionals, taking into account important clinical, healthcare and therapeutic aspects, as well as potential sequelae and complications. The task force consists of 13 members of the SIUEC highly trained and experienced in thyroid surgery. The main topics concern clinical evaluation and preoperative workup, patient preparation for surgery, surgical treatment, non-surgical options, postoperative management, prevention and management of major complications, outpatient care and follow-up.
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Nodular cutaneous metastasis of the leg in advanced urothelial bladder carcinoma: a case report and systematic literature review. Front Oncol 2023; 13:1216725. [PMID: 37675233 PMCID: PMC10477776 DOI: 10.3389/fonc.2023.1216725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/02/2023] [Indexed: 09/08/2023] Open
Abstract
Cutaneous metastases from urothelial carcinoma (UC) are very rare and indicate advanced disease with a poor prognosis. A 63-year-old female patient with a history of urothelial bladder carcinoma, treated 2 months prior with radical cystectomy and adjuvant gemcitabine and cisplatin (GC) therapy, presented a skin lesion localized in the lower third of the right leg. Punch biopsy revealed carcinomatous metastasis whose urothelial origin was confirmed by immunohistochemical analysis. 18-FDG PET-CT showed the spread of metastases to the lung and left ischium. Our review focuses on the time between surgery and skin metastasis, localization, and prognosis after metastasis diagnosis. In many cases, skin metastases occur within one year of initial UC surgery and in most cases occur on the abdominal wall. Local wide excision of metastasis should be considered in selected cases; however, chemotherapy remains the main treatment.
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Atypical parathyroid tumor: clinical and parathyroid hormone response to surgical treatment. Ann Surg Treat Res 2023; 105:76-81. [PMID: 37564944 PMCID: PMC10409632 DOI: 10.4174/astr.2023.105.2.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/09/2023] [Accepted: 07/12/2023] [Indexed: 08/12/2023] Open
Abstract
Purpose Primary hyperparathyroidism (PHPT) is caused by typical adenoma (TA), multiglandular disease (MD), or parathyroid carcinoma (PC), and in a smaller percentage of cases by atypical parathyroid tumor (APT). The objective of this study is the retrospective analysis of clinical features and parathyroid hormone (PTH)/calcium response to surgery in patients who underwent parathyroidectomy for symptomatic PHPT with histological evidence of APT. Methods We retrospectively reviewed our institutional experience in the management of PHPT from January 2016 to December 2021 focusing on those patients presenting APTs. We analyzed the clinical features of this disease and PTH/calcium response to surgical treatment in APTs compared to the other pathological conditions causing PHPT. Results In a cohort of 125 patients with PHPT we found 112 TAs (89.6%), 6 APTs (4.8%), 6 PCs (4.8%), and only 1 MD (0.8%). APTs in comparison to other parathyroid diseases showed peculiar features such as adhesion to the surrounding structures and a frequent intrathyroidal location, which may justify thyroid loboistmectomy adopted in most of the observed cases. APTs showed significantly higher preoperative PTH values compared to TA + MD and were relevant to PC. Conclusion Due to its rarity, there is a lack of specific indications in the management of APTs. Biochemical features observed in APT and PC can be related to similar biological behavior. However, some specific features observed preoperatively in some cases of PHPT might suggest presence of an APT, which could be helpful mostly in surgical and postoperative management. Further studies are required to confirm the results of the present preliminary report.
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Definition of learning curve for thyroidectomy: systematic review on the different approaches. Gland Surg 2023; 12:989-1006. [PMID: 37727342 PMCID: PMC10506114 DOI: 10.21037/gs-22-730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/29/2023] [Indexed: 09/21/2023]
Abstract
Background Thyroidectomy is one of the most common surgical procedures carried out worldwide and it has evolved in recent years with alternative approaches. With the advent of minimally invasive techniques, the learning curve (LC) concept has become a fundamental "dogma". Methods A literature search, according to the PRISMA guidelines, was performed via PubMed (MEDLINE), Scopus, Cochrane Library, EMBASE, and Web of Science. Only studies assessing the learning process to thyroidectomy (including hemi- and total thyroidectomy), reporting a minimum of 30 procedures and describing clearly the minimum number of performances required to achieve proficiency and the main evaluation items used to establish it, were included. Conventional, endoscopic and robotic approaches were separately analyzed. Only English-language studies were considered. Results Forty-five relevant studies were selected for the analysis [respectively 16 concerning robotic thyroidectomy (RT), 22 endoscopic thyroidectomy (ET), 6 mini-invasive video assisted thyroidectomy (MIVAT), 1 conventional thyroidectomy (CT)]. The number of procedures required for a single surgeon to achieve competence and the parameters used to define surgical proficiency were fully investigated for each individual technique. Conclusions Our research shows how the current literature lacks an objective definition of the LC concept. The heterogeneity of analysis methodologies and parameters evaluated, the various surgical techniques and training background of single surgeons, make it impossible to draw univocal results. Future studies should consider confounding factors and establish criteria that should be consensually recognized in the assessment of surgical performances and skills.
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Sentinel Lymph Node Detection in Breast Cancer: An Innovative Technique. Diagnostics (Basel) 2023; 13:2030. [PMID: 37370925 DOI: 10.3390/diagnostics13122030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: Sentinel lymph node biopsy is important in the search for metastases, especially in patients with malignant breast disease. Our study proposed new techniques to prevent complications such as possible postoperative seroma formation, pain or hypoesthesia of the axillary cord and medial arm surface, as well as motor deficits, to avoid disabling outcomes and presents initial data from our experience with the sentinel lymph node biopsy technique. (2) Methods: We mainly used two radioactive tracer detection techniques and a new technique using a radiotracer called Sentimag-magtrace. The positive lymph node was located and removed to perform histologic analysis. In our study, we evaluate 100 patients who underwent breast cancer surgery. (3) Results: We calculated the identification rates of the different methods of sentinel lymph node detection and found that it was 88.9% using radioactive tracers vs. 89.5% using the magnetic tracer technology (Sentimag). (4) Conclusions: Thus, this technique avoids radiation exposure for both patients and health care providers, and can reduce costs and time.
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Laparoscopic transversus abdominis plane block is useful in pain relief after laparoscopic stapled repair of diastasis recti and ventral hernia. J Minim Access Surg 2023; 19:207-211. [PMID: 37056085 PMCID: PMC10246641 DOI: 10.4103/jmas.jmas_111_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/08/2022] [Accepted: 10/17/2022] [Indexed: 01/22/2023] Open
Abstract
Background There is still no consensus on perioperative pain control techniques in patients undergoing laparoscopic surgery; protocols of conventional therapy can be improved by the use of perioperative anaesthesiologic techniques, such as epidural or loco-regional analgesic administration as transversus abdominis plane (TAP) block. The aim of this evaluation was to investigate the role of laparoscopic-assisted TAP block during repair of diastasis recti associated with primary midline hernias in term of post-operative pain relief. Materials and Methods This was a retrospective evaluation of a prospectively maintained database including patients undergoing laparoscopic repair of diastasis recti associated with primary ventral hernia. Patients were divided into two groups: Group A patients (n = 34) received laparoscopic-assisted bilateral TAP-block of 7.5 mg/ml ropivacaine for each side and Group B patients (n = 29) received conventional post-operative therapy. All patients received 24 h infusion of 20 mg morphine; pain was checked at 6, 24 and 48 h after surgery by numeric rating scale (NRS) score. A rescue analgesia by was given if NRS score was >4 or on patient request. Results No differences in operative time, complications and post-operative stay, no complications related to TAP-block technique were found. Post-operative pain scores (determined by NRS) were found to be significantly different between groups. Group A patients showed a significant reduction in NRS score at 6, 24 and 48 h (P < 0.005) and in the number of patients requiring further analgesic drugs administration (P < 0.005) compared to Group B patients. Conclusions Laparoscopic-guided TAP-block can be considered safe and effective in the management of post-operative pain and in the reduction of analgesic need in patients undergoing laparoscopic repair of diastasis recti and ventral hernias. The non-randomised nature of the study and the lack of a consistent series of patients require further evaluations.
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Sutures in general surgery. New materials and advice. Ann Ital Chir 2023; 94:649-653. [PMID: 38131379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
The suture thread used in digestive surgery must have several characteristics, including resistance to tension until the anastomosis coalescence, rapid absorption to avoid complications, biocompatibility and ease of handling. The preference is for monofilament polymers as they offer greater guarantees in biliary-digestive anastomoses. Suturing with synthetic polymers and mechanical devices such as staplers are the most suitable techniques. It is believed that staplers may become the gold standard technique in robotic surgery based on their experience and experimental data. In general, the goal is to use materials that minimize the risk of post-operative complications and offer maximum reliability in the anastomosis. KEY WORD: Suture material, Stapler.
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Achieving the learning curve in total thyroidectomy: a prospective evaluation on resident's training by CUSUM and KPSS analysis. Ann R Coll Surg Engl 2022; 104:414-420. [PMID: 35175830 PMCID: PMC9157995 DOI: 10.1308/rcsann.2021.0318] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Total thyroidectomy (TT) is one of the most common procedures among general and endocrine surgeons worldwide. The conventional approach by neck incision is still the most frequently used, despite the growth of mini-invasive approaches. Controversies exist about the optimal learning curve for resident surgeons approaching this procedure. The aim of this study was to compare TT performed by experienced surgeons and residents in two academic hospitals, to define the correct shape of the specific learning curve. METHODS Between January 2016 and December 2018 patients undergoing TT in two academic departments were prospectively enrolled. In each department patients were divided into four groups: a reference group (A), consisting of 50 consecutive patients operated on by a senior surgeon, and three other groups (B, C, D) of 50 patients each where thyroidectomy was carried out by three different general surgery residents in their last 3 years of residency, respectively. Data were analysed by CUSUM and KPSS tests in order to compare operative time (OT) and its stabilisation during the learning curve. RESULTS Data from CUSUM test reported that residents could perform TT with OT similar to the senior surgeon after approximately 25-30 procedures, while the KPSS test showed that residents became more stable after 30 procedures, with no increase in perioperative complications. CONCLUSIONS This prospective study shows how a specific training in thyroid surgery can be reliable thanks to experienced tutors, and confirmed that the effect of dedicated and programmed training may result in positive outcomes for patients requiring thyroidectomy.
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A Case Report of Multiple Gastrointestinal Stromal Tumors: Imaging Findings, Surgical Approach, and Review of the Literature. Front Surg 2022; 9:886135. [PMID: 36017517 PMCID: PMC9396543 DOI: 10.3389/fsurg.2022.886135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/25/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Multiple gastrointestinal stromal tumors (GISTs) are rare tumors. Differential diagnosis between metastatic and multiple GISTs represents a challenge for a proper workup, prediction prognosis, and therapeutic strategy. Case presentation We present the case of 67-year-old man with computed tomography (CT) evidence of multiple exophytic lesions in the abdomen, reaching diameters ranging from 1 to 9 cm, without any signs of organs infiltration, and resulting positive at 18F-FDG-PET/CT. Laparoscopic biopsy revealed multiple GISTs, and surgical resection by using an open approach was performed to achieve radicality. Moreover, an extensive review of the current literature was performed. Results Small GISTs (<5 cm) can be treated by the laparoscopic approach, while in the case of large GISTs (>5 cm), tumor location and size should be taken into account to reach the stage of radical surgery avoiding tumor rupture. For metastatic GISTs, Imatinib represents the first choice of treatment, and surgery should be considered only in a few selected cases when all lesions are resectable. Conclusion Sporadic multiple GISTs are a rare event, imaging findings are not specific for GISTs, and biopsy requires a secure diagnosis and proper management. In the case of large lesions, with a high risk of vessels injury, laparotomy excision should be considered to achieve radicality and to avoid tumor rupture.
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Robot-Assisted Liver Resection and Cholecystectomy Using Indocyanine-Green for Intrahepatic Cholangiocarcinoma, in a Very Rare Anatomical Anomaly of ‘Bipartite Liver’. Surg Innov 2022; 29:488-493. [DOI: 10.1177/15533506221081116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Robotic hepatobiliary surgery has significantly developed worldwide with substantial clinical results. Hepatobiliary anatomical anomalies increase the complexity of hepatobiliary resection with a relevant risk of iatrogenic lesions. Among congenital liver anomalies, the ‘bipartite liver’ is an extremely rare condition which might be associated with complex surgical dissection of the hepatic hilum. We herein report a rare case of congenital ‘bipartite liver’ associated with a cholangiocarcinoma of segment VI and calculous cholecystitis. The patient underwent robot-assisted segmentectomy and cholecystectomy with the use of indocyanine-green cholangiography and intraoperative ultrasound. A challenging hilar dissection was performed using this approach. To the best of our knowledge, this is the first case reported that describes a robot-assisted liver resection and cholecystectomy in a patient having a cholangiocarcinoma associated with this rare liver anomaly. The robotic approach was safe and effective and the 3D preoperative imaging, as well as the intraoperative green-indocyanine cholangiography was extremely useful, especially during hilar dissection and cholecystectomy.
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Laparoscopic-Guided Ropivacaine Trocar-Site Infiltration Can Improve Post-Operative Pain Control after Laparoscopic Adrenalectomy. Surg Innov 2021; 29:747-751. [PMID: 34861813 DOI: 10.1177/15533506211057967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is no consensus on pain control in patients undergoing laparoscopy; nowadays, conventional therapy may be improved by transversus abdominis plane block. The aim of this evaluation is to investigate the role of laparoscopic-assisted trocar-site ropivacaine infiltration during adrenalectomy in pain control. METHODS This is a retrospective evaluation of a prospectively maintained database including patients undergoing adrenalectomy. Patients were divided into 2 groups: Group A patients received laparoscopic-assisted trocar-site infiltration of 7.5 mg/mL ropivacaine and Group B patients did not receive any infiltration. All patients received a 24-hour infusion of 20 mg morphine; pain was checked at 6, 24, and 48 hours after surgery by Visual Analogue Scale (VAS) score. A rescue analgesia by was given if VAS score was > 4 or on patient request. RESULTS No differences in operative time, complications, and post-operative stay and no complications related to trocar-site infiltration were found. 6-hour and 48-hour VAS scores were not found to be significantly different between groups, even if a slight decrease in VAS score in Group A was reported. Group A showed significant reduction in VAS score at 24 hours (2.44 +/- .41 vs 3.01 +/- .78, P < .005) and in the number of patients requiring further analgesic drugs administration (40.6% vs 57.8%, P < .005). CONCLUSIONS Laparoscopic-guided trocar-site ropivacaine infiltration can be considered safe and effective in the management of post-operative pain and in the reduction of analgesic need in patients undergoing laparoscopic adrenalectomy. The retrospective nature of the study and the lack of a consistent series of patients require further evaluations.
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Robotic surgery for colorectal liver metastases resection: A systematic review. Int J Med Robot 2021; 17:e2330. [PMID: 34498805 DOI: 10.1002/rcs.2330] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/10/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The role of robotic surgery for colorectal cancer liver metastases (CRCLMs) has never been investigated in large series. METHODS A systematic literature review was carried out on PubMed and Cochrane libraries. RESULTS We selected nine studies between 2008 and 2021. Two hundred sixty-two patients were included. One hundred thirty-one patients underwent simultaneous resections. The mean blood loss was 309.4 ml (range, 200-450 ml), the mean operative time was 250.5 min (range, 198.5-449.0 min). The mean length of hospital stay was 7.98 days (range, 4.5 to 12 days). The overall postoperative mortality was 0.4%. The overall morbidity rate was 37.0%, Clavien-Dindo grade III-IV complications were 8.4%. The mean 3-year overall survival was 55.25% (range, 44.4-66.1%), the mean 3-year disease free survival was 37% (range, 33.3-41.9%) CONCLUSION: We can conclude that robotic-assisted surgery might be considered as a technical upgrade option for minimally invasive approach to CRCLM resections even for simultaneous operations and challenging cases.
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Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project. World J Emerg Surg 2021; 16:35. [PMID: 34215310 PMCID: PMC8254305 DOI: 10.1186/s13017-021-00378-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.
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Robotic Transanal Total Mesorectal Excision (RTaTME): State of the Art. J Pers Med 2021; 11:jpm11060584. [PMID: 34205596 PMCID: PMC8233761 DOI: 10.3390/jpm11060584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/05/2021] [Accepted: 06/15/2021] [Indexed: 12/30/2022] Open
Abstract
Total mesorectal excision (TME) is the gold standard technique for the surgical management of rectal cancer. The transanal approach to the mesorectum was introduced to overcome the technical difficulties related to the distal rectal dissection. Since its inception, interest in transanal mesorectal excision has grown exponentially and it appears that the benefits are maximal in patients with mid-low rectal cancer where anatomical and pathological features represent the greatest challenges. Current evidence demonstrates that this approach is safe and feasible, with oncological and functional outcome comparable to conventional approaches, but with specific complications related to the technique. Robotics might potentially simplify the technical steps of distal rectal dissection, with a shorter learning curve compared to the laparoscopic transanal approach, but with higher costs. The objective of this review is to critically analyze the available literature concerning robotic transanal TME in order to define its role in the management of rectal cancer and to depict future perspectives in this field of research.
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An unusual case of genital filariasis of the testicular tunics in an Italian patient. Ann Saudi Med 2021; 41:186-189. [PMID: 34085543 PMCID: PMC8176374 DOI: 10.5144/0256-4947.2021.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
At least 27 million men present with urogenital manifestations of genital filariasis (GF). Although there is a large burden of GF in residents in endemic regions, infection in short-term travellers and in non-endemic areas is rare. We report the case of a 75-year-old Italian man referred to our institution for a testicular discomfort. Clinical examination and ultrasound detected a mass of 40×18 mm in the scrotum without signs of varicocele, hydrocele and testicular or epididymal abnormalities. After ineffective medical treatment, the patient underwent surgical excision. Histology demonstrated filarial granuloma with thick cuticles pathognomonic of an adult worm in the testicular tunics. Surgery has a fundamental role in localized cases of GF to remove nematodes from the fibrotic nodules. The present manuscript describes a singular case of GF observed in Italy in a non-immigrant patient with evidence of remnants of an adult worm in the testicular tunics. SIMILAR CASES PUBLISHED: 11.
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Ischemic colitis with non-gangrenous, stenotic evolution following hemorrhagic shock A case report and review of the literature. Ann Ital Chir 2021; 10:S2239253X21033922. [PMID: 33843722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Ischemic colitis (IC) accounts for more of the half of total diagnosis of gastrointestinal ischemia. It is a challenging condition due to non-specificity of the symptoms at onset, inconstant behaviour and a wide range of clinical gravity with a different therapeutic approach. A classification of IC into gangrenous, stricturing and transient forms can be considered. CASE REPORT In the presented case, due to hypovolemic hemorrhagic shock, the patient developed a progressive IC without gangrene but slowly evolving in multiple colonic strictures with general serious clinical condition. Endoscopy was used to confirm diagnosis and to tempt a pneumatic stricture dilation which resulted ineffective. A diverting stoma was required and an elective subtotal colectomy was carried out after resolution of the acute phase. CONCLUSIONS IC may present with a large spectrum of clinical conditions. In acute shocked patients it must be always considered when a complicated abdominal picture is present. Immediate surgery is not always required considering the spontaneous resolutions of the milder forms. Strictures are the most frequent evolution following the intermediate nongangrenous presentation and initially they can be treated conservatively with postponed tailored resection after the healing of the diffuse mucosal injuries. KEY WORDS Ischemic, colitis, Shock, Stricture.
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Metastases to the breast. A clinical series from a single institution experience with review of the literature. Ann Ital Chir 2021; 92:141-148. [PMID: 34031289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Breast metastases although rare are challenging for diagnostic difficulties and management. Treatment differs according to morphological, immunophenotipycal and biologic features of the primary tumor and their general behaviour is extremely different compared to primary breast cancer. The most frequent primary tumors include melanoma, lymphomas, gynecological, pulmonary, head and neck, gastroenteric and urinary tract cancers. Patient's prognosis is poor being generally associated to disseminated systemic disease with limited survival despite the effects of systemic treatment. PATIENTS AND METHODS We report the analysis of the diagnostic and therapeutic approach on the institutional experience of four cases of breast metastases originating from melanoma, pulmonary adenocarcinoma and differentiated thyroid carcinomas. CONCLUSIONS The management of breast secondarisms requires focused diagnosis and evaluation in order to provide an adequate treatment with a multidisciplinary approach especially when the primary tumor is unknown. KEY WORDS Breast metastases, Melanoma, Pulmonary, Thyroid.
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Role of Leptin in Neoplastic and Biliary Tree Disease. In Vivo 2020; 34:2485-2490. [PMID: 32871776 DOI: 10.21873/invivo.12064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND/AIM Leptin is a small hormone of protein nature, it is strongly involved in the regulation of lipid metabolism and its functioning mechanism is not yet well known or whether or not it is actually secreted by cholangiocytes, nor if the biliary tree expresses its receptors. In the past, various studies have tried to correlate leptin levels with certain neoplasms. The aim of this study was to demonstrate that serum leptin values can become a new sensitive and specific serum marker for cholangiocarcinoma. MATERIALS AND METHODS Seventy-two patients with gallbladder stones, hepatolithiasis with benign biliary stenosis, cholangiocarcinoma, and a group of patients without hepato-biliary diseases were enrolled in the study. In all cases blood and bile samples were collected for evaluation of leptin levels and liver biopsies were performed to confirm diagnosis. In all patients, both ultrasound and cholangio-magnetic resonance imaging (MRI) were performed to complete the diagnostic procedure. RESULTS Twenty-two patients were affected by cholangiocarcinoma, 50 by benign biliary disease (35 cholelithiasis and 6 hepatolithiasis and 9 by inflammatory biliary stenosis). The mean values of serum leptin in patients with cholangiocarcinoma were 19.28±8.76 ng/ml, significantly higher than those observed in non-neoplastic biliary diseases. CONCLUSION Serum leptin levels might be a useful marker to differentiate patients with cholangiocarcinoma from those with biliary lithiasis and inflammatory stenosis.
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Preservation of left colic artery with lymph node dissection of IMA root during laparoscopic surgery for rectosigmoid cancer. Results of a retrospective analysis. LA CLINICA TERAPEUTICA 2019; 170:e124-e128. [PMID: 30993308 DOI: 10.7417/ct.2019.2121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND During sigmoid or rectal cancer surgery, dissection of lymph-nodes at the origin of inferior mesenteric artery is mandatory. Nevertheless, ligation of the origin of IMA should compromise blood supply to left colon and affect anastomosis. The aim of this retrospective evaluation is to compare high IMA ligation and low IMA ligation with preservation of LCA and skeletonization of the origin of IMA during laparoscopic colorectal resection. METHODS All 120 patients included were affected by clinically M-0 sigmoid or rectal cancer. A laparoscopic colorectal resection with low or high ligature of IMA was performed. Low ligation was carried out with lymphadenectomy of the arterial root. Patients were divided in 2 groups according to type of treatment: Group A, high IMA ligation (N=65), Group B, low ligation with lymphadenectomy of IMA root (N=55). RESULTS Preoperatively 59 patients had stage I, 42 patients had stage II and 19 patients had stage III tumor. A mean of 20.3 +/- 4.5 lymph nodes were removed in group A patients and 18.9 +/- 9.1 in group B patients, and this difference was not statistically significant. Operative time, intraoperative and postoperative complication rates were not different between the two group. CONCLUSIONS Low IMA ligation combined with lymph-node dissection at its origin is safe and effective, not time consuming and not associated to increased risk of complications and nerve damage. This technique can be considered as alternative to standard high IMA ligation in selected patients.
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Advanced hemostasis in axillary lymph node dissection for locally advanced breast cancer: new technology devices compared in the prevention of seroma formation. BMC Surg 2019; 18:125. [PMID: 31074399 PMCID: PMC7402581 DOI: 10.1186/s12893-018-0454-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/05/2018] [Indexed: 11/10/2022] Open
Abstract
Background Breast cancer is the most frequent neoplasm in women. Axillary lymph nodes dissection represents the treatment of choice in locally advanced breast cancer for prognostic and curative purposes. Seroma formation, an abnormal collection of fluid in the dead space of the axilla, is described in Literature with a wide range of incidence (3–85%). It is a source of significant morbidity and discomfort. The aim of the study is to compare the different haemostasis devices used in breast surgery, investigating the eventual superiority of an instrument among the others in terms of intraoperative and postoperative outcome, especially of seroma formation. Methods Clinical cases of female patients undergone axillary lymph nodes dissection for local advanced breast cancer between January 2013 and July 2017 at the Surgery Unit of University of Campania “Luigi Vanvitelli” were retrospectively reviewed. Patients were divided into four groups, according to device utilized during surgery: Electrocautery, Harmonic Scalpel, LigaSure and Thunderbeat. All patients underwent II level axillary lymph nodes dissection associated to radical mastectomy or quadrantectomy. Results One hundred consecutives patients were enrolled in the study. Intra-operative blood loss resulted statistically significant different (P < 0,01) between the Electrocautery group (94,7 ml) and the Thunderbeat group (57,2 ml), while the Harmonic Scalpel group and the Ligasure group, despite presented a lower amount of blood loss, did not differ significantly. Drainage volume resulted significantly lower (P = 0,002) in the comparison between the Electrocautery group and the Thunderbeat group; the Ligasure group and Harmonic Scapel group showed no difference between them and Electrocautery group. About the seroma formation, the Electrocautery group resulted affected by the highest seroma formation rate (64%). Seroma incidence in Harmonic Scalpel group was 24%, in Ligasure group was 44%, while Thunderbeat group showed the lowest presentation of seroma with 16%. Conclusions In patients affected by breast cancer requiring axillary lymphnodes dissection, the use of advanced hemostasis devices is highly desirable. Among the non-traditional tools, Thunderbeat resulted to be superior in terms of reduction of intra-operative blood loss and post-operative drainage output, moreover associated to a substantial reduction of postoperative seroma incidence.
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The role of prophylactic central compartment lymph node dissection in elderly patients with differentiated thyroid cancer: a multicentric study. BMC Surg 2019; 18:110. [PMID: 31074400 PMCID: PMC7402571 DOI: 10.1186/s12893-018-0433-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/29/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Prophylactic central neck lymph-nodes dissection is still a topic of major debate in Literature. There is a lack of randomized controlled trials proving advantages in its application in terms of overall survival and local recurrence. Due to the recent rapid increase of elderly population, differentiated tumor carcinoma diagnosis increased in patients over 65 years old. The aim of this study was to compare recurrence rate, complications rate and histological features of tumors in elderly population. METHODS A retrospective study was carried out collecting data from 371 patients with differentiated thyroid cancer without clinical evidence of lymph-nodes involvement in three Italian referral centers from 2005 to 2015. All patients were aged ≥ 65 years and were divided in two groups based on the performed surgery (total thyroidectomy alone or associated with central lymph-nodes dissection). Moreover, patients were stratified according to the age between 65 and 74 years old and over 75 years old. RESULTS Total thyroidectomy alone was performed in 184 patients (group A) and total thyroidectomy with prophylactic central neck dissection was performed in 187 cases (group B). There was a statistically significant difference in complications between the groups in terms of neck hematoma (0.5% group A vs 3.7% group B), temporary hypoparathyroidism (11.4% group A vs 21.4% group B), and temporary unilateral recurrent nerve injury (1.5% group A vs 6.4% group B). Lymph nodes recurrence rate was 9.2% in group A and 8.5% in group B, with no statistically significant difference. There was a statistically significant difference in patients over 75 years old in terms of temporary hypoparathyroidism (24% group A vs 11% group B), permanent hypoparathyroidism (2,7% group A vs 0,3% group B) and recurrent nerve injury (9,5% group A vs 2% group B). CONCLUSIONS The role of prophylactic central neck dissection is still controversial, especially in elderly patients, and an aggressive surgical approach should be carefully evaluated. The Authors reported a similar low recurrence rate between total thyroidectomy and total thyroidectomy associated with prophylactic central neck dissection, with increased postoperative complications in the lymphadenectomy group and in patients over 75 years old, advocating a tailored surgical approach in elderly population.
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Follicular proliferation TIR3B: the role of total thyroidectomy vs lobectomy. BMC Surg 2019; 18:22. [PMID: 31074384 PMCID: PMC7402575 DOI: 10.1186/s12893-019-0485-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 02/08/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND TIR3B thyroid nodules are considered to be at risk of malignancy (15-30%) but guidelines recommend conservative surgery with lobectomy with primary diagnostic porpoise. Risk stratification mainly based on ultrasound, elastography and genetic mutations usually may influences the surgical approach. METHODS We retrospectively analyzed 52 cases of TIR3B underwent between 2015 and 2017 total thyroidectomy (TT) and lobectomy (L), focusing mainly on the observed rate of malignancy. Chi-squared test and Fisher's exact probability test were used for analysis, considering a P values less than 0.05 as significant. RESULTS Out of 52 patients 49 underwent TT and 3 L. In TT group a multinodular goiter was associated in 67.3% of patients. Malignancy rate was 81.6 and 33.3% respectively after TT and L (P 0.003). Multicentric and contralateral tumors were detected respectively in 36.7% and in 32.6% of patients underwent TT. No main post-operative complications were registered. CONCLUSIONS Ultrasound and elastography are useful to define within the TIR3B group those lesions at higher risk and therefore requiring a more radical approach. TT seems an appropriate approach to TIR3B lesions, especially in multinodular goiter, considering the incidence of malignancy with probably higher rate than previously reported.
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Surgical intervention for intestinal typhoid perforation. G Chir 2019; 40:105-111. [PMID: 31131808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
AIM Typhoid perforation is the most fatal complication of typhoid fever in developing countries and is most often caused by the bacteria Salmonella Typhi. There are conflicting views as to which type of surgical intervention gives the best outcome. The aim of this study was to determine the mortality associated with the different types of surgical interventions employed in patients with typhoid perforation. METHOD This was a retrospective review of the medical records of adult and paediatric surgical patients treated in the general and paediatric surgical units of the Korle Bu Teaching Hospital. Information was obtained from medical records at the Korle Bu Teaching Hospital in Accra, Ghana, between January 2009 and April 2012. The data was analysed using IBM SPSS Statistics version 20 and 22. RESULTS 133 patients (median age of 21 years, 72.2% males) with typhoid perforation were included in the study. The typhoid perforation specific mortality rate was 12.8%. Males had a significantly lower mortality rate (7.3%) compared to females (27%). Simple bowel closure (85.7% of total) was the most common surgical intervention performed and patients operated upon with this method had a significantly lower mortality rate (9.6%) compared to patients with bowel resection (31.6%). CONCLUSIONS In this study, patients treated with intestinal resection were more likely to die from typhoid perforation and female gender was a risk factor for death. Simple bowel closure was the predominant surgical procedure.
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Abstract
RATIONALE Retroperitoneal colonic perforation is a rare cause of retroperitoneal abscess. It presents, more frequently in frail elderly patients, with heterogeneous signs and symptoms which hamper the clinical diagnosis. Subcutaneous emphysema with pneumomediastinum and iliopsoas muscle abscess are unusual signs. Colonic retroperitoneal perforation may be consequent to diverticulitis or locally advanced colon cancer. Due to the anatomy of the retroperitoneal space and different physiopathology, diverticular perforation may present with air and pus collection; on the other hand perforated colon cancer may cause groin mass and psoas abscess. We reported 2 cases of colonic retroperitoneal perforation from diverticulitis and locally advanced colon cancer, respectively. Aim of this report is to improve differential diagnosis based on clinical signs. PATIENTS' CONCERNS A 71-year-old man presented with pain in his left side, fatigue, fever, nausea, massive subcutaneous emphysema of the neck, and Blumberg sign in the left iliac fossa. A 67-year-old man presented with abdominal pain, sub-occlusion, left groin mass, left groin, and lower limb pain during walking, negative Blumberg sign. DIAGNOSIS In the first patient the computerized tomography revealed pneumoperitoneum, gas in the mesosigma, pneumomediastinum, wall thickening of the descending colon, and retroperitoneal collection from diverticular perforation. In the second patient abdominal CT scan found thickening of the sigmoid colon adherent to the iliopsoas and fluid collection. INTERVENTIONS In the first patient, a left hemicolectomy extending to the transverse colon, followed by a toilette and debridement of the retroperitoneum were performed. In the second patient, tumor of descending colon perforated in the retroperitoneum with iliopsoas abscess was treated with left hemicolectomy and a drainage of the abscess. OUTCOMES The first patient underwent right colectomy with ileostomy in the 7 postoperative day for large bowel necrosis. He died of sepsis 2 days after. The second patient had regular postoperative and he is still alive. LESSONS The spread of retroperitoneal abscess in complicated colonic diverticulitis is different from that in advanced colonic cancer. The former can present with a subcutaneous emphysema, the latter with a groin mass. Hence a thorough clinical examination and radiological studies are needed to diagnose these conditions.
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Perforated vs. nonperforated acute appendicitis: evaluation of short-term surgical outcomes in an elderly population. MINERVA CHIR 2018; 74:374-378. [PMID: 30306768 DOI: 10.23736/s0026-4733.18.07715-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute appendicitis is a common acute surgical abdominal condition and despite the majority of cases are observed in children and young adults, its occurrence in the elderly seems to be increasing, with a higher risk of perforation. The aim of this study was to evaluate the surgical outcomes following appendectomy for acute appendicitis in the elderly, making a comparison between perforated and nonperforated groups regarding operative time, hospital stay and postoperative complications. METHODS The medical records of 48 patients over the age of 60 years who had a pathologically confirmed diagnosis of acute appendicitis from January 2011 to December 2016 were retrospectively reviewed. Patients were grouped into those with perforated and those with non-perforated appendicitis (NPA) and a comparison was made between both groups regarding demography, operative time, length of hospital stay and postoperative complications. RESULTS From 48 patients over 60 years diagnosed with acute appendicitis, a PA was removed from 10 patients (20.8%). The PA group consisted of 3 males and 7 females, and their mean age was 71.6 years (range 65-84). The NPA group included 22 males and 16 females, and their mean age was 76.5 years (range 63-96). The mean operative time was 58±18.7 minutes and 43.3±9.9 minutes in the perforated and nonperforated groups respectively, with statistically significant difference (P=0.0013). The mean length of hospital stay was similar in the PA group and in the NPA group, being 6.5±1.8 days and 5.4±1.8 days respectively, but these differences were not statistically significant (P=0.093). The frequency of postoperative complications was similar in both groups as they were observed in 3 patients (30%) of the PA group and 10 patients (26%) of the NPA group (P=0.2488). No postoperative intraabdominal abscess was observed in both groups and there was no death after the surgery. CONCLUSIONS PA, despite requiring a longer mean operative time, in our series is not producing a longer hospital stay or more postoperative complications compared to NPA. The non-operative management of uncomplicated appendicitis is a reasonable option in frail patients in order to avoid the burden of morbidity related to operation, nevertheless surgery remains the standard of care in all age groups.
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MMP7 Modulation by Short- and Long-term Radiotherapy in Patients with Rectal Cancer. ACTA ACUST UNITED AC 2018; 32:133-138. [PMID: 29275310 DOI: 10.21873/invivo.11215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 11/09/2017] [Accepted: 11/16/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND/AIM Matrix metalloproteinase 7 (MMP7) expression is highly associated with colorectal cancer and modulates tumour growth and invasion. Radiation injury induces inflammation with increases in MMP7 and in transforming growth factor beta (TGFβ). The aim of this study was to investigate the effect on MMP7 and TGFβ. expression in patients with rectal cancer undergoing different regimens of neoadjuvant radiotherapy (RT). PATIENTS AND METHODS We studied 53 patients in three RT treatment groups receiving RT of 25 Gy, long-term RT 50 Gy and controls receiving no RT. Three biopsies were obtained from each patient during the treatments: before RT, after RT and after surgery. Tissue samples were formalin fixed, paraffin embedded and tissue microarrays were constructed and stained for MMP7 and TGFβ. Mann-Whitney U-tests and Wilcoxon Z-tests were used to determine differences between patients before and after RT, and after surgery, as well as between the RT groups. RESULTS In all three patient groups, increases of MMP7 and TGFβ expression were observed after surgery. MMP7 expression was significantly increased in patients receiving short-term RT but TGFβ expression was not affected by RT. CONCLUSION 50 Gy Irradiation of rectal cancer gives less tumour activation of MMP7, whilst it is up-regulated by 25 Gy and surgery regardless of RT.
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Predictivity of clinical, laboratory and imaging findings in diagnostic definition of palpable thyroid nodules. A multicenter prospective study. Endocrine 2018; 61:43-50. [PMID: 29569123 PMCID: PMC5997121 DOI: 10.1007/s12020-018-1577-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/04/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE To assess the role of clinical, biochemical, and morphological parameters, as added to cytology, for improving pre-surgical diagnosis of palpable thyroid nodules. METHODS Patients with a palpable thyroid nodule were eligible if surgical intervention was indicated after a positive or suspicious for malignancy FNAC (TIR 4-5 according to the 2007 Italian SIAPEC-IAP classification), or two inconclusive FNAC at a ≥3 months interval, or a negative FNAC associated with one or more risk factor. Reference standard was histological malignancy diagnosis. Likelihood ratios of malignancy, sensitivity, specificity, negative (NPV), and positive predictive value (PPV) were described. Multiple correspondence analysis (MCA) and logistic regression were applied. RESULTS Cancer was found in 433/902 (48%) patients. Considering TIR4-5 only as positive cytology, specificity, and PPV were high (94 and 91%) but sensitivity and NPV were low (61 and 72%); conversely, including TIR3 among positive, sensitivity and NPV were higher (88 and 82%) while specificity and PPV decreased (52 and 63%). Ultrasonographic size ≥3 cm was independently associated with benignity among TIR2 cases (OR of malignancy 0.37, 95% CI 0.18-0.78). In TIR3 cases the hard consistency of small nodules was associated with malignity (OR: 3.51, 95% CI 1.84-6.70, p < 0.001), while size alone, irrespective of consistency, was not diagnostically informative. No other significant association was found in TIR2 and TIR3. CONCLUSIONS The combination of cytology with clinical and ultrasonographic parameters may improve diagnostic definition of palpable thyroid nodules. However, the need for innovative diagnostic tools is still high.
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Modified Paul-Mikulicz jejunostomy in frail geriatric patients undergoing emergency small bowel resection. MINERVA CHIR 2018; 74:121-125. [PMID: 29795063 DOI: 10.23736/s0026-4733.18.07714-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Proximal or extended bowel resections are sometimes necessary during emergency surgery of the small bowel and call for creating a high small bowel stomy as a part of damage control surgery. Secondary restoration of intestinal continuity in the frail geriatric patient, further weakened by subsequent severe malabsorption may be prohibitive. METHODS Six patients underwent emergency small bowel resection for proximal jejunal disease (83.3% high-grade adhesive SBO and 16.7% jejunal diverticulitis complicated with perforation). With the intention to avoid end jejunostomy and the need for repeat laparotomy for bowel continuity restoration we modified the classic Paul-Mikulicz jejunostomy. RESULTS The postoperative course was uneventful in four patients whose general condition improved considerably. At six-month follow-up, neither patients required parenteral nutrition. CONCLUSIONS This modified stoma can have the advantage of allowing a partial passage of the enteric contents, reducing the degree of malabsorption, and rendering jejunostomy reversal easy to perform later.
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Recurrent esophageal stricture from previous caustic ingestion treated with 40-year self-dilation: case report and review of literature. BMC Gastroenterol 2018; 18:68. [PMID: 29788901 PMCID: PMC5964928 DOI: 10.1186/s12876-018-0801-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 05/15/2018] [Indexed: 12/14/2022] Open
Abstract
Background Corrosive esophageal strictures are common. The severity of the strictures depends on type, quantity, duration of contact and concentration of the caustic substance ingested. Endoscopic balloon dilation and endoscopic bougienage are a cornerstone in the management of the benign esophageal strictures and are the most widely used treatments, but are expensive and invasive procedures. Case Presentation We report the case of an 82-year-old patient with a corrosive esophageal stricture treated for over 40 years by means of home self-bougienage. The procedure has been carried out for the longest lapse of time described in literature, with an excellent control of symptoms. In the case reported, after being carried out for more than 40 years, self-dilation allowed good quality of life and symptoms management, ensuring an excellent nutritional status. Conclusions Following an adequate patient training, self-dilatation can be a safe and effective option of treatment, avoiding frequent expensive hospital admissions for endoscopic esophageal dilatation.
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Single center experience with laparoscopic adrenalectomy on a large clinical series. BMC Surg 2018; 18:2. [PMID: 29325527 PMCID: PMC5765650 DOI: 10.1186/s12893-017-0333-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 12/26/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Laparoscopic adrenalectomy is considered the gold standard technique for the treatment of benign small and medium size adrenal masses (<6 cm), due to low morbidity rate, short hospitalization and patient rapid recovery. The aim of our study is to analyse the feasibility and efficiency of this surgical approach in a broad spectrum of adrenal gland pathologies. METHODS Pre-operative, intra-operative and post-operative data from 126 patients undergone laparoscopic adrenalectomy between January 2003 and December 2015 were retrospectively collected and reviewed. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques. Doxazosin was preoperatively administered in case of pheochromocytoma while spironolactone and potassium were employed to treat Conn's disease. Laparoscopic adrenalectomies were all performed by the same surgeon (CG). First 30 procedures were considered as learning curve adrenalectomies. RESULTS One hundred twenty-six patients were included in the study. Functioning tumors were diagnosed in 84 patients, 27 patients were affected by pheochromocytomas, 29 by Conn's disease, 28 by Cushing disease. Surgery mean operative time was 137.33 min (range 100-180) during the learning curve adrenalectomies and 96.5 min (range 75-110) in subsequent procedures. Mean blood loss was respectively 160.2 ml (range 60-280) and 90.5 ml (range 50-200) in the first 30 procedures and the subsequent ones. Only one conversion to open surgery occurred. No post-operative major complications were observed, while minor complications occurred in 8 patients (0,79%). In 83 out of 84 functioning neoplasms, laparoscopic adrenalectomy was effective in normalization of endocrine profile. CONCLUSIONS Laparoscopic adrenalectomy is a safe and feasible procedure, even for functioning masses and pheochromocytomas. A multidisciplinary team including endocrinologists, endocrine surgeons and anaesthesiologists, is recommended in the management of adrenal pathology, and adrenal surgery should be performed in referral high volume centers. A thirty-procedures learning curve is recommended to improve surgical outcomes.
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Unintentional recurrent laryngeal nerve injuries following thyroidectomy: Is it the surgeon who pays the bill? Int J Surg 2018; 41 Suppl 1:S55-S59. [PMID: 28506414 DOI: 10.1016/j.ijsu.2017.01.112] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/27/2017] [Accepted: 01/30/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Thyroidectomy is one of the most common intervention in general surgery and, after the turn of the century, its rate has sharply increased, along with a worldwide increased incidence of differentiated thyroid cancers. Therefore, injuries of the recurrent laryngeal nerve have become one of the most frequent cause of surgical malpractice claims, mostly following surgery for benign pathology. MAIN BODY Even if the incidence of definitive paralysis is generally lower than 3%, during the last 20 years in Italy, the number of claims for damages has sharply raised. As a consequence, a lot of defensive medicine has been caused by this issue, and a witch-hunt has been accordingly triggered, so determining mostly a painful and lasting frustration for the surgeons, who sometimes are compelled to pay a lot of money for increasing insurance premiums and lawyers fees. Recurrent laryngeal nerve injury should be considered as a potentially catastrophic predictable but not preventable event, rather than the result of a surgical mistake. CONCLUSION Purposes of the Authors are analyzing incidence, conditions of risk, and mechanisms of recurrent laryngeal nerve injuries, underlining notes of surgical technique and defining medical practice recommendations useful to reduce the risk of malpractice lawsuits and judgments against surgeons.
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Correct information to patients undergoing breast-conserving surgery: the medicolegal significance. G Chir 2017; 38:61-65. [PMID: 28691668 DOI: 10.11138/gchir/2017.38.2.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many of the women newly diagnosed with breast cancer not have access to all the information they need to make the surgical and treatment choices that are most appropriate for them. Research clearly shows that lumpectomy and other breast-conserving surgeries are just as safe as mastectomy for most women with early stage disease, and yet approximately half will undergo the more disfiguring procedures, but many healthy women who have strong family histories of breast cancer consider prophylactic mastectomies, and their decisions are also based on very limited information, because there are few studies showing the effectiveness of that procedure. This paper delineates how to avoid limited information and biased recommendations is important for a conscious and informed choice by the patients.
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Timing and extension of lymphadenectomy in medullary thyroid carcinoma: A case series from a single institution. Int J Surg 2017; 41 Suppl 1:S70-S74. [DOI: 10.1016/j.ijsu.2017.04.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 04/05/2017] [Accepted: 04/12/2017] [Indexed: 02/07/2023]
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Current Indications for Surgical Treatment of Primary Hyperparathyroidism in the Elderly. Am Surg 2017; 83:296-302. [PMID: 28316315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This study presents the results of surgery in the elderly for primary hyperparathyroidism (PHPT) from a single institution's experience. We retrospectively analyzed 898 cases of surgically treated PHPT, divided into two groups: 135 elderly patients (A) and 763 patients younger than 65 years (B). PHPT was symptomatic in 68.8 per cent patients in group A and in 81.6 per cent in group B. Unilateral temporary recurrent laryngeal nerve palsy was observed in 0.9 per cent in group A and 0.1 per cent in group B (P > 0.05). No cervical hematomas, mortality or major cardiovascular, neurological, respiratory or metabolic postoperative complications were registered. All the patients evaluated at one year had improvement in the quality of life, with increase of bone mineral density (BMD) in 85.6 per cent and 79.8 per cent of patients in groups A and B, with no significant differences between symptomatic and asymptomatic patients. Parathyroidectomy in elderly PHPT patients is safe, with rate of morbidity similar to what observed in younger individuals. Further investigations are recommended to confirm the role of surgery as an effective approach in elderly PHPT patients.
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Surgery for colorectal cancer in elderly: a comparative analysis of risk factor in elective and urgency surgery. Aging Clin Exp Res 2017; 29:65-71. [PMID: 27837462 DOI: 10.1007/s40520-016-0642-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/12/2016] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Colon cancer therapy is primarily surgical. Advanced age does not represent a contraindication to surgery. We analyse the results of surgery in ultra 75 patients undergoing surgery for colorectal cancer by examining the correlation between the comorbidity and any post-operative complications. MATERIALS AND METHODS We surgically treated 66 patients for colorectal cancer, aged over 75. The examined subjects were compromised for various reasons. We have evaluated the different influences of risk factors in elective and urgency operation. DISCUSSION Several studies have shown that age alone is not a significant prognostic factor in survival after colonic surgery. The assessment of general conditions in elderly patients, as demonstrated by the literature, is a fundamental moment in the management of colorectal cancer. CONCLUSIONS The surgical choice should be made case by case (custom-made), not based on age only.
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Surgical treatment of secondary hyperparathyroidism in elderly patients: an institutional experience. Aging Clin Exp Res 2017; 29:23-28. [PMID: 27830521 DOI: 10.1007/s40520-016-0669-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/01/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Secondary hyperparathyroidism in elderly fragile patients presents clinical difficulties due to severity of symptoms and related comorbidity. The optimal surgical approach for this group of patients is still debated. AIM The aim of the study was to define the optimal technique of parathyroidectomy in elderly patients with secondary hyperparathyroidism. METHODS Retrospective analysis in a series of 253 patients including 35 elderly individuals at a single institution was carried out. Postoperative parathyroid hormone decrease, surgical complications and symptoms control were analyzed for all patients in relation to the types of parathyroidectomy performed. RESULTS In elderly patients, total parathyroidectomy was the most used approach. Subtotal parathyroidectomy was mostly reserved for younger patients suitable for kidney transplantation. No elderly patients treated with total parathyroidectomy were autotransplanted. No significant difference in surgical complications was observed between younger and elderly patients and considering the different procedures. Adequate symptom control after surgery was achieved in almost 90% of patients. A limited rate of recurrence requiring repeat surgery was observed only after subtotal parathyroidectomy. DISCUSSION Considering the features of all types of parathyroidectomy, very low recurrence rate, contained postoperative hypocalcemia and limited complications following total parathyroidectomy, might represent specific advantages for elderly patients. CONCLUSIONS Total parathyroidectomy without parathyroid transplantation is safe for elderly patients with secondary hyperparathyroidism and a good alternative to the well-established total parathyroidectomy with autografting.
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Cost-effectiveness analysis of the temporary percutaneous ileostomy for faecal diversion after colorectal resection in elderly. Aging Clin Exp Res 2017; 29:47-53. [PMID: 27832466 DOI: 10.1007/s40520-016-0658-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/12/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery. AIMS We analyse the outcomes and the costs of the TPI in protecting low colorectal anastomosis in elderly, compared to the CLI. METHODS Data of patients underwent elective anterior rectal resection for rectal cancer with extra-peritoneal colorectal anastomosis protected by ileostomy from January 2011 to December 2015 were reviewed. Sixty-one out of 132 patients were older than 70; 35 underwent faecal diversion by TPI and 26 by CLI. RESULTS The two groups resulted homogenous about age, sex, operative time, short-term post-operative complications. None of the patients reported anastomotic leakage. The hospital stay and the cost for the first surgical procedure did not show statistically significant differences between TPI and CLI. When comparing the overall hospital stay and costs the differences are statistically significant: the TPI showed a shorter hospital stay (12.4 vs 19.3 days, -35.7%) and a lower cost of hospitalization (7954.0 vs 14,372.1€, -44.7%), compared to CLI. DISCUSSION The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of TPI, especially in elderly. CONCLUSION The TPI not only improved the post-operative outcome of the patients, but also allowed a remarkable saving for the National Health System.
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Pancreas preserving surgery for duodenal gastrointestinal stromal tumor removal. MINERVA CHIR 2016; 71:281-285. [PMID: 27356148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND We reported our experience with high-risk, non-metastatic second portion duodenal gastrointestinal stromal tumor (GIST)s in patients who underwent 1-month neoadjuvant cycles with imatinib therapy followed by pancreas-preserving surgery and 12-month of adjuvant chemotherapic regimen including imatinib. This study was conducted to evaluate the short and long-term results. METHODS The study was conducted between January 2010 and May 2015. Medical charts and operative logbooks of patients were retrospectively reviewed. RESULTS Nine patients form the basis of the current analysis. All patients underwent curative resection with pancreas preservation, and all specimens had histologically negative margins. The median follow-up was 35 months. Eight patients were alive, 1 patient died for myocardial infarction at a mean follow-up of 10 months, 1 patient had a recurrence at a mean follow-up of 32 months and no patients developed distant metastases. CONCLUSIONS We are confident to suggest the use of neoadjuvant and adjuvant Imatinib therapy to those patients affected with D2, high-risk, duodenal GISTs to allow a limited resection.
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Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation. Open Med (Wars) 2016; 11:298-306. [PMID: 28352812 PMCID: PMC5329845 DOI: 10.1515/med-2016-0058] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 07/07/2016] [Indexed: 11/15/2022] Open
Abstract
Aim of the present paper is the review of the principal complications associated to endocrine neck surgery considering how expertise, full adoption of guidelines, appropriate technology and proper informed consent may limit the medicolegal claims at the light of the incoming new regulation of the medical professional legal responsibility. A literature search, using the Medline/PubMed database for full-length papers, was used. Postoperative recurrent laryngeal nerve (RLN) palsy and hypoparathy-roidism remain the principal causes of surgical malpractice claims . In the procedure of neck lymphadenctomy intra-operative haemorrhage, thoracic duct injury, injuries to loco-regional nerves can be observed and can be source of claims. After many years of increased medicolegal litigations, the Italian government is proposing a drastic change in the regulations of supposed medical malpractice in order to guarantee the patient's right to a safe treatment and in the meantime to defend clinicians from often unmotivated and prejudicial legal cases. Surgical errors and complications in neck surgery are a relevant clinical issue. Only the combination of surgical and clinical expertise, application of guidelines, appropriate technology and a routinely use of specific informed consent can contain potential medicolegal implications.
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Role of prophylactic central compartment lymph node dissection in clinically N0 differentiated thyroid cancer patients: analysis of risk factors and review of modern trends. World J Surg Oncol 2016; 14:149. [PMID: 27185169 PMCID: PMC4869299 DOI: 10.1186/s12957-016-0879-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 04/21/2016] [Indexed: 12/17/2022] Open
Abstract
In the last years, especially thanks to a large diffusion of ultrasound-guided FNBs, a surprising increased incidence of differentiated thyroid cancer (DTC), "small" tumors and microcarcinomas have been reported in the international series. This led endocrinologists and surgeons to search for "tailored" and "less aggressive" therapeutic protocols avoiding risky morbidity and useless "overtreatment". Considering the most recent guidelines of referral endocrine societies, we analyzed the role of routine or so-called prophylactic central compartment lymph node dissection (RCLD), also considering its benefits and risks. Literature data showed that the debate is still open and the surgeons are divided between proponents and opponents of its use. Even if lymph node metastases are commonly observed, and in up to 90% of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is subject to intensive research and the best indications of lymph node dissection are still controversial. Identification of prognostic factors for central compartment metastases could assist surgeons in determining whether to perform RLCD. Considering available evidence, a general agreement to definitely reserve RCLD to "high-risk" cases was observed. More clinical researches, in order to identify risk factors of meaningful predictive power and prospective long-term randomized trials, should be useful to validate this selective approach.
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Complications of Neck Dissections in Papillary Thyroid Carcinoma: A Modified Procedure to Reduce Parathyroid Morbidity. In Vivo 2016; 30:303-308. [PMID: 27107089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 03/03/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND/AIM Hypoparathyroidism is the most significant morbidity after neck dissection for thyroid cancer. Addition of lateral neck dissection (ND) to central ND combined with total thyroidectomy (TT) increases the risk of postoperative hypoparathyroidism compared to TT plus central ND. The aim of this study was to verify if a modified procedure and different access to the neck for lateral ND may improve safety. PATIENTS AND METHODS In 62 patients with papillary thyroid cancer (PTC) undergoing TT plus central and lateral ND between 2010 and 2013, lateral ND was performed as first step approaching the neck via extrathyroideal space. Calcium in serum and parathormone (PTH) were determined preoperatively, intraoperatively and during the follow-up. RESULTS Twenty patients (32%) developed postoperative hypocalcemia. Calcium levels and PTH completely recovered for 58 out of 62 patients from 3 to 6 months after surgery. After a mean of 12 months' follow-up, only four patients (6.5%) had developed permanent hypoparathyroidism. The incidence of parathyroid complication after TT plus central ND and lateral ND did not differ from postoperative hypoparathyroidim after TT plus central ND. CONCLUSION The presented surgical procedure may provide a better outcome in terms of parathyroid morbidity.
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Abstract
INTRODUCTION Breast myoblastoma or granular cell tumor involving the breast parenchyma has been described in detail for the first time since Abrikossoff in 1931. The location of this injury to the breast is very rare, accounting for between 5% and 15% of all cases of cancer of the granular cells. We present our experience regarding the identification of two cases because of the relative rarity of this tumor. It is often confused with breast cancer on clinical and radiological, and its diagnosis can then be difficult for physicians, radiologists and pathologists. PRESENTATION OF CASES We report the cases of two young women who came to our attention because of the presence of mass shoveled breast, mobile and accompanied by pain cycle independent. In both cases, mammography and ultrasound revealed the presence of heterogeneous mass and irregular, but in one of two such mass located at the Union of external quadrants of the left breast and was in contact with his serratus anterior and suspicion for malignancy. In both cases the 'histology combined with immunohistochemical study proved to be a granular cell tumor. CONCLUSION Although a granular cell tumor of the breast is a rare tumor breast, should be considered in the differential diagnosis of benign and malignant lesions. Surgeons and pathologists should keep in mind when considering a granular cell tumor cells with abundant granular cytoplasm containing materials to avoid misdiagnosing breast cancer, which could lead to unnecessary surgery.
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Breast cancer and reconstruction: can surgical technique, reconstructive time and adjuvant treatment influence the result? Ann Ital Chir 2016; 87:S0003469X16024118. [PMID: 27319738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Some techniques for the total reconstruction of the breast, regardless of the complexity, have specific complications, with varying degrees of morbidity. Therefore, we wanted to identify the most frequent complications of the main techniques used for breast reconstruction, and compare the relation to the relevant independent variables. METHODS Our study was conducted by examining the medical records of patients who had received complete reconstruction of the breast after a mastectomy due to breast cancer from January 2008 to December 2010, with a minimum follow-up of 3 years postoperatively. The data collected, such as the time of intervention, reconstruction techniques, operating time, and adjuvant treatment, were statistically correlated to the presence of complications. RESULTS Of the 40 total breast reconstructions analyzed, the technique in which they were used expanders followed by replacement with implants showed the lowest prevalence of complications (16.7%, p <0.000). Some surgical techniques have shown particular complications. The operative time for transplant transverse rectus abdominis musculocutaneous flap (363.57 ± 59.91 min) was significantly higher than that required for the techniques that use alloplastic materials (155.71 ± 38.02 min, p = 0, 01), but similar to that for the latissimus dorsi flap (309.69 ± 77.66 min). The operative time, the timing of reconstructive surgery, and type of adjuvant treatment was not correlated with the incidence of complications. CONCLUSIONS Each technique has its indications, contraindications and complications. The application of each technique must be tailored to the individual characteristics of each patient. KEY WORDS Adjuvant treatment, Reconstructive surgery, Results, Surgical procedure.
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Surgical approach to mediastinal goiter: An update based on a retrospective cohort study. Int J Surg 2015; 28 Suppl 1:S42-6. [PMID: 26708863 DOI: 10.1016/j.ijsu.2015.12.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/06/2015] [Accepted: 05/20/2015] [Indexed: 10/22/2022]
Abstract
AIM Surgery for mediastinal goiters (MG) is indicated for compression symptoms and risk of malignancy. Total thyroidectomy by cervicotomy is universally considered the standard surgical approach to MG. In selected cases sternotomy or a thoracotomy are used. Options of the operative technique and practical surgical problems are analysed. METHODS A retrospective analysis of twenty-eight-years on 1767 cases of MG in a referral centre for endocrine surgery was carried out. All patients underwent standard preoperative study and CT based surgical planning. Surgery was performed by an experienced surgical team with standard technique via cervical approach or in selected case via sternotomy or thoracotomy. Clinical records were examined. RESULTS Total thyroidectomy was performed in all cases. A cervical approach was used in almost 99% of patients. Significant shorter surgical time was observed for surgery via the cervical approach vs sternotomy and thoracotomy. Benign struma was observed in 1503 patients and a carcinoma in 264. We observed postoperative bleeding in 0.5% of cases, permanent monolateral recurrent laryngeal nerve palsy occurred in 1.3%, bilateral palsy in 0.6%, transient and permanent hypoparathyroidism in 14% and 4.1% respectively. CONCLUSION MG may be approached by a cervicotomic access only with a clear knowledge of potential risk and complications of the surgical manoeuvres. Sternotomy or of a thoracotomy are indicated only in selected cases but their inapplicability may be really dangerous in those MG not otherwise resectable. MG should be referred only to specialized centre.
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