The assessment of emotion reactivity: The Italian validation of the Perth Emotional Reactivity Scale-Short Form (PERS-S)

Emotion reactivity refers to the activation, intensity and duration of emotional responses to internal or external stimuli. It can be differentiated from emotion regulation since the former is the very first response to an emotional trigger, and the latter can be defined as a tool for maintaining one's arousal in a window of tolerance. Since, to date, there are no Italian self-report measures able to evaluate individuals' emotional reactivity, this study aimed to contribute to the Italian validation of the Perth Emotional Reactivity Scale-Short Form (PERS-S). The PERS-S is an 18-item self-report measure answered on a 5-point Likert scale that generates six subscale scores and two composite scores, with higher scores indicating higher levels of reactivity. Data from 768 individuals showed that the PERS-S had good to excellent goodness of fit. The internal consistency was high, with an overall reliability coefficient (Cronbach's α) of .87 and .86 for the negative and positive general scales, respectively. The PERS-S also demonstrated appropriate convergent validity, showing significant correlations with conceptually related measures, and acceptable divergent validity, showing minimal correlations with unrelated constructs. Finally, we evaluated the Test-Retest Reliability by administering the PERS-S to the same sample twice, with a 2-week interval. The significant correlations between the two PERS-S administrations suggest temporal stability. The Italian version of the PERS-S will enrich the repertoire of self-report measures for investigating the development and risk factors of mental health disorders and may have practical applications in clinical settings.

Assessing Resilience to Sleep Loss Among the Italian Population: A 13-Item Model of the Iowa Resistance to Sleeplessness Test (iREST)

Purpose

The present study aimed to validate the Italian version of the Iowa Resistance to Sleeplessness Test (iREST), a 16-item self-report assessing resilience to sleep debt in the affective, cognitive, and somatic domains.

Participants and Methods

We examined its factor structure, assessed internal consistency and criterion validity, and established test-retest reliability on 768 Italian native speakers (65.8% of women) with a mean age of 25.98 years old.

Results

Confirmatory factor analysis (CFA) revealed a new 13-item structure for the Italian iREST (iREST-13), demonstrating more satisfactory goodness-of-fit values, and exhibiting good internal consistency (Cronbach's α ranging from 0.73 to 0.89), relative to the 16-item original version. Results supported the iREST convergent validity, showing significant independence from established measures of sleep; low correlations with conceptually unrelated measures supported divergent validity, indicating that the iREST effectively measures resistance to sleeplessness without confounding with other constructs. Lastly, test-retest reliability was evaluated by administering the iREST to the same sample with a 2-week interval: the significant correlations supported its temporal stability.

Conclusion

Further studies are needed to evaluate the applicability of the iREST in diverse populations and explore its relationship with objective sleep measures. Nevertheless, the Italian iREST provides a valuable tool for assessing resistance to sleep loss, offering insights into individual differences in resilience. Additionally, the iREST can assist in identifying individuals who require interventions to enhance resilience to sleep debt, as well as help clinicians evaluate the impact of chronic sleep disruption and deliver targeted interventions.

The role of insomnia in the vulnerability to depressive and anxiety symptoms in atopic dermatitis adult patients

Atopic dermatitis (AD) is a common inflammatory chronic skin disease typically associated with atopic comorbidities and other non-atopic conditions such as sleep disturbances, and mood/anxiety disorders. A growing literature proposed a crucial role of sleep disturbances in the development of mental health problems in AD. We tested this assumption by mediation model analyses in adult AD patients.A total of 57 patients (mean age ± std. dev., 34.28 ± 13.07 years; 27 males; range 18-67 years) diagnosed with AD participated in a cross-sectional study. We evaluated self-perceived severity of AD, insomnia, depression, and anxiety symptoms using validated questionnaires: the Patient-Oriented Eczema Measure (POEM), the Insomnia Severity Index (ISI), the Beck Depression Inventory-second edition (BDI-II), and the Generalized Anxiety Disorder-7 scale (GAD-7), respectively. Two mediation models were performed, testing the mediation effect of insomnia symptoms on the relationship between AD severity and depression (model 1) and anxiety (model 2). AD symptoms, as expressed by POEM, were positively associated with insomnia, depression, and anxiety severity. Insomnia fully mediated the effect of AD severity on depression and anxiety. Specifically, insomnia accounted for 81.64% of the relationship between atopic eczema severity and depression, and for 81.84% of the effect of AD severity on anxiety symptoms. The present study proposed a critical role of insomnia in predisposing adult AD patients to experience depression and anxiety. Early interventions focused on treating sleep disturbances could indirectly be beneficial on mental health of patients with AD, counteracting the onset and exacerbation of anxiety and depression disorders.

Poor sleep quality, insomnia, and short sleep duration before infection predict long-term symptoms after COVID-19

BACKGROUND

Millions of COVID-19 survivors experience a wide range of long-term symptoms after acute infection, giving rise to serious public health concerns. To date, few risk factors for post-COVID-19 conditions have been determined. This study evaluated the role of pre-infection sleep quality/duration and insomnia severity in the incidence of long-term symptoms after COVID-19.

MATERIAL AND METHODS

This prospective study involved two assessments (April 2020 and 2022). At the baseline (April 2020), sleep quality/duration and insomnia symptoms in participants without current/prior SARS-CoV-2 infection were measured using the Pittsburgh Sleep Quality Index (PSQI) and the Insomnia Severity Index (ISI). At the follow-up (April 2022), we asked a group of COVID-19 survivors to retrospectively evaluate the presence of twenty-one symptoms (psychiatric, neurological, cognitive, bodily, and respiratory) that have been experienced one month (n = 713, infection in April 2020-February 2022) and three months after COVID-19 (n = 333, infection in April 2020-December 2021). In April 2022, participants also reported how many weeks passed to fully recover from COVID-19. Zero-inflated negative binomial models were used to estimate the effect of previous sleep on the number of long-term symptoms. Binomial logistic regressions were performed to evaluate the association between sleep variables, the incidence of each post-COVID-19 symptom, and the odds of recovery four/twelve weeks after infection.

RESULTS

Analyses highlighted a significant effect of pre-infection sleep on the number of symptoms one/three months after COVID-19. Previous higher PSQI and ISI scores, and shorter sleep duration significantly increased the risk of almost every long-term symptom at one/three months from COVID-19. Baseline sleep problems were also associated with longer recovery times to return to the pre-infection daily functioning level after COVID-19.

CONCLUSIONS

This study suggested a prospective dose-dependent association between pre-infection sleep quality/quantity and insomnia severity with the manifestation of post-COVID-19 symptoms. Further research is warranted to determine whether preventively promoting sleep health may mitigate the COVID-19 sequelae, with substantial public health and societal implications.

The effects of bifrontal anodal transcranial direct current stimulation (tDCS) on sleepiness and vigilance in partially sleep-deprived subjects: A multidimensional study

In recent years, transcranial electrical stimulation techniques have demonstrated their ability to modulate our levels of sleepiness and vigilance. However, the outcomes differ among the specific aspects considered (physiological, behavioural or subjective). This study aimed to observe the effects of bifrontal anodal transcranial direct current stimulation. Specifically, we tested the ability of this stimulation protocol to reduce sleepiness and increase vigilance in partially sleep-deprived healthy participants. Twenty-three subjects underwent a within-subject sham-controlled stimulation protocol. We compared sleepiness and vigilance levels before and after the two stimulation conditions (active versus sham) by using behavioural (reaction-time task), subjective (self-report scales) and physiological (sleep-onset latency and electroencephalogram power [n = 20] during the Maintenance of Wakefulness Test) measures. We showed the efficacy of the active stimulation in reducing physiological sleepiness and preventing vigilance drop compared with the sham stimulation. Consistently, we observed a reduction of perceived sleepiness following the active stimulation for both self-report scales. However, the stimulation effect on subjective measures was not statistically significant probably due to the underpowered sample size for these measures, and to the possible influence of motivational and environmental factors. Our findings confirm the ability of this technique to influence vigilance and sleepiness, pointing out the potential for new treatment developments based on transcranial electrical stimulation.

Two years after lockdown: Longitudinal trajectories of sleep disturbances and mental health over the COVID-19 pandemic, and the effects of age, gender and chronotype

Since the first lockdown of Spring 2020, the COVID-19 contagion waves pervasively disrupted the sleep and mental health of the worldwide population. Notwithstanding the largest vaccination campaign in human history, the pandemic has continued to impact the everyday life of the general population for 2 years now. The present study provides the first evidence of the longitudinal trajectories of sleep disturbances and mental health throughout the pandemic in Italy, also describing the differential time course of age groups, genders and chronotypes. A total of 1062 Italians participated in a three-time-point longitudinal study covering two critical stages of the emergency (the first lockdown in April 2020 and the second partial lockdown in December 2020) and providing a long-term overview 2 years after the pandemic outbreak (April 2022). We administered validated questionnaires to evaluate sleep quality/habits, insomnia, depression, stress and anxiety symptoms. Analyses showed a gradual improvement in sleep disturbances, depression and anxiety. Conversely, sleep duration progressively decreased, particularly in evening-type and younger people. Participants reported substantial earlier bedtime and get-up time. Stress levels increased during December 2020 and then stabilised. This effect was stronger in the population groups apparently more resilient during the first lockdown (older people, men and morning-types). Our results describe a promising scenario 2 years after the pandemic onset. However, the improvements were relatively small, the perceived stress increased, and the re-establishment of pre-existing social/working dynamics led to general sleep curtailment. Further long-term monitoring is required to claim the end of the COVID-19 emergency on Italians' sleep and mental health.

The fall of vulnerability to sleep disturbances in evening chronotypes when working from home and its implications for depression

Eveningness is distinctively associated with sleep disturbances and depression symptoms due to the misalignment between biological and social clocks. The widespread imposition of remote working due to the COVID-19 pandemic allowed a more flexible sleep schedule. This scenario could promote sleep and mental health in evening-type subjects. We investigated the effect of working from home on sleep quality/quantity and insomnia symptoms within the morningness-eveningness continuum, and its indirect repercussions on depressive symptomatology. A total of 610 Italian office workers (mean age ± standard deviation, 35.47 ± 10.17 years) and 265 remote workers (40.31 ± 10.69 years) participated in a web-based survey during the second contagion wave of COVID-19 (28 November–11 December 2020). We evaluated chronotype, sleep quality/duration, insomnia, and depression symptoms through validated questionnaires. Three moderated mediation models were performed on cross-sectional data, testing the mediation effect of sleep variables on the association between morningness-eveningness continuum and depression symptoms, with working modality (office vs. remote working) as moderator of the relationship between chronotype and sleep variables. Remote working was associated with delayed bedtime and get-up time. Working modality moderated the chronotype effect on sleep variables, as eveningness was related to worse sleep disturbances and shorter sleep duration among the office workers only. Working modality also moderated the mediation of sleep variables between chronotype and depression. The above mediation vanished among remote workers. The present study suggests that evening-type people did not show their characteristic vulnerability to sleep problems when working from home. This result could imply a reduction of the proposed sleep-driven predisposition to depression of late chronotypes. A working environment complying with individual circadian preferences might ensure an adequate sleep quantity/quality for the evening-type population, promoting their mental health.

The Differential Impact of COVID-19 Lockdown on Sleep Quality, Insomnia, Depression, Stress, and Anxiety among Late Adolescents and Elderly in Italy

The restraining measures due to the COVID-19 outbreak deeply affected the general population's sleep health and psychological status. The current literature proposes young and older people as two particularly at-risk groups. However, the differential impact of the lockdown period in these specific age categories needs to be disentangled. Through a web-based survey adopting validated questionnaires, we evaluated and compared sleep quality/habits, insomnia, perceived stress, depression, and anxiety symptoms of Italian late adolescents (n = 670; mean age ± SD, 19.38 ± 0.74, 18-20 years) and elderly (n = 253; 68.18 ± 2.79, 65-75 years). Young respondents reported more severe insomnia symptoms, worse subjective sleep quality, longer sleep latency, higher daytime dysfunction, and a more prevalent disruption of sleep habits (bedtime, get-up time, nap) than the elderly. On the other hand, older participants showed shorter sleep duration, lower habitual sleep efficiency, and greater use of sleep medications. Finally, the younger population displayed higher levels of depression and perceived stress. Our findings indicate that the lockdown period had more pervasive repercussions on sleep and the mental health of late adolescents. The implementation of supportive strategies is encouraged for this vulnerable population group.

Demographic, psychological, chronobiological, and work-related predictors of sleep disturbances during the COVID-19 lockdown in Italy

The first COVID-19 contagion wave caused unprecedented restraining measures worldwide. In Italy, a period of generalized lockdown involving home confinement of the entire population was imposed for almost two months (9 March-3 May 2020). The present is the most extensive investigation aimed to unravel the demographic, psychological, chronobiological, and work-related predictors of sleep disturbances throughout the pandemic emergency. A total of 13,989 Italians completed a web-based survey during the confinement period (25 March-3 May). We collected demographic and lockdown-related work changes information, and we evaluated sleep quality, insomnia and depression symptoms, chronotype, perceived stress, and anxiety using validated questionnaires. The majority of the respondents reported a negative impact of confinement on their sleep and a delayed sleep phase. We highlighted an alarming prevalence of sleep disturbances during the lockdown. Main predictors of sleep disturbances identified by regression models were: female gender, advanced age, being a healthcare worker, living in southern Italy, confinement duration, and a higher level of depression, stress, and anxiety. The evening chronotype emerged as a vulnerability factor, while morning-type individuals showed a lower predisposition to sleep and psychological problems. Finally, working from home was associated with less severe sleep disturbances. Besides confirming the role of specific demographic and psychological factors in developing sleep disorders during the COVID-19 pandemic, we propose that circadian typologies could react differently to a particular period of reduced social jetlag. Moreover, our results suggest that working from home could play a protective role against the development of sleep disturbances during the current pandemic emergency.

Changes of evening exposure to electronic devices during the COVID-19 lockdown affect the time course of sleep disturbances

STUDY OBJECTIVES

During the coronavirus disease 2019 (COVID-19) lockdown, there was a worldwide increase in electronic devices' daily usage. Prolonged exposure to backlit screens before sleep influences the circadian system leading to negative consequences on sleep health. We investigated the relationship between changes in evening screen exposure and the time course of sleep disturbances during the home confinement period due to COVID-19.

METHODS

2,123 Italians (mean age ± standard deviation, 33.1 ± 11.6) were tested longitudinally during the third and the seventh week of lockdown. The web-based survey evaluated sleep quality and insomnia symptoms through the Pittsburgh Sleep Quality Index and the Insomnia Severity Index. The second assessment survey inquired about intervening changes in backlit screen exposure in the two hours before falling asleep.

RESULTS

Participants who increased electronic device usage showed decreased sleep quality, exacerbated insomnia symptoms, reduced sleep duration, prolonged sleep onset latency, and delayed bedtime and rising time. In this subgroup, the prevalence of poor sleepers and individuals reporting moderate/severe insomnia symptoms increased. Conversely, respondents reporting decreased screen exposure exhibited improved sleep quality and insomnia symptoms. In this subgroup, the prevalence of poor sleepers and moderate/severe insomniacs decreased. Respondents preserving screen time habits did not show variations of the sleep parameters.

CONCLUSIONS

Our investigation demonstrated a strong relationship between modifications of evening electronic device usage and time course of sleep disturbances during the lockdown period. Monitoring the potential impact of excessive evening exposure to backlit screens on sleep health is recommendable during the current period of restraining measures due to COVID-19.

The effect of 5 nights of sleep restriction on empathic propensity

Literature supports the existence of a significant relationship between sleep quality/quantity and empathy. However, empathic ability and empathic propensity are distinct constructs. Expression of empathic propensity depends on the subjective cognitive costs attributed to the empathic experience. Studies on the effects of the experimental reduction in sleep duration on empathic behaviour are still lacking. Therefore, we investigated the consequences of 5 consecutive nights of sleep restriction on empathic propensity. A total of 42 university students (mean [SEM] age 24.09 [0.65] years; 22 females) underwent a cross-over design consisting of 5 consecutive nights of regular sleep and 5 consecutive nights of sleep restriction with a maximum of 5 hr sleep/night. After each condition, all participants were evaluated using the Empathy Selection Task, a new test assessing the motivated avoidance of empathy for its associated cognitive costs. The results showed different effects of sleep restriction depending on the habitual way of responding in the empathic context. Participants with baseline high levels of empathic propensity reduced their empathic propensity after prolonged sleep restriction. Differently, participants who tended to avoid empathising already in the habitual sleep condition maintained their empathic behaviour unchanged after sleep curtailment. In conclusion, inter-individual variability should be taken into account when evaluating the effects of sleep restriction on empathic propensity. People with habitual higher tendency to empathise could choose to avoid empathic experience following several consecutive nights of inadequate sleep.

Gender-related time course of sleep disturbances and psychological symptoms during the COVID-19 lockdown: A longitudinal study on the Italian population

Italy was the first western hotspot of the COVID-19 pandemic. In order to contain the spread of the virus, the Italian Government imposed home confinement to the entire population for almost two months. The present study is the first large-scale longitudinal report of the sleep and mental health changes during the prolonged lockdown due to the COVID-19 outbreak. We focused on the gendered vulnerability in a sample of the Italian population since cross-sectional research identified women to be more at-risk than men during this unprecedented situation.

A total of 2701 individuals (mean age ± standard deviation, 32.37 ± 11.62; range, 18–82) participated in a web-based longitudinal survey consisting of two measurements. Participants were first-time recruited on social networks and via telephone messages through a snowball sampling and tested during the third week of the lockdown period. Subsequently, a follow-up evaluation was carried out during the seventh week of restraining measures. The survey assessed sleep quality, insomnia and depression symptoms, perceived stress, and anxiety, using the following questionnaires: the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, the Beck Depression Inventory-second edition, the 10-item Perceived Stress Scale, and the State-Anxiety Inventory.

Female gender showed the worst condition for all the examined dimensions in both the assessments. Nevertheless, at the follow-up women reported a reduction in insomnia and depression severity symptoms, perceived stress, and anxiety. On the other hand, male participants showed a worsening of sleep quality, insomnia symptoms, and perceived stress. Consequently, the gender prevalence gap of clinical conditions such as insomnia and depression was largely reduced under lockdown.

Our investigation pointed to a different time course of sleep and mental health between genders during the home confinement period. Women seemed to show greater long-term resilience during the lockdown. Meanwhile, the male gender emerges as the most vulnerable category to the extension of the restraining measures. Our results suggest that there is no “weaker gender” after a prolonged lockdown. Indeed, the Italian population transversely presented signs of psychological suffering and significant sleep disturbances after the protracted and stressful lockdown period due to the COVID-19 pandemic.

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Women maintain the most severe sleep and psychological disturbances during lockdown.

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Only men show a deterioration over time of sleep and psychological well-being.

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Women prove a greater long-term resilience to the extension of the home confinement.

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Gender gap of clinical insomnia and depression decreases after one month of lockdown.

Gastric Juice Nitrite and Bacteria in Gastroduodenal Disease and Resected Stomach

The N-nitroso-compounds and the bacteriological contamination of gastric juice could represent a risk factor for cancer of the stomach when the mucosal barrier is altered. In the unresected stomach and gastric stump, the hypo-achlorhydria and bilopancreatic reflux permit the development of bacterial flora and the production of N-nitroso-compounds in the presence of nitrite. A survey was performed on 71 patients: 15 normal controls, 31 with gastroduodenal disease (9 gastrites, 10 gastric ulcers, 10 duodenal ulcers, 7 neoplasias), 20 patients with gastric resection (8 BI, 12 BII), using an endoscopic-histopathologic control and a chemical-bacteriological analysis of the gastric juice. We studied the gastric juice for the following parameters: pH, concentration of nitrite, identification of bacterial type, count and nitrate-reductase activity. An inverse relationship was found between the concentration of nitrite and the hydrogen ion concentration. In the alkaline gastric juice, we identified aerobic bacteria with nitrate-reductase activity and anaerobic bacteria. The latter has the ability to transform biliary salts into carcinogenic and cocarcinogenic compounds and to catalyze the nitrosations. The chemicobacteriological characteristics of the gastric juice from gastric ulcers (Johnson type I), atrophic gastrites, and resected stomachs lead one to think that there is a risk of carcinogenesis brought about by the N-nitroso-compounds.

Extensive surgery and lymphadenectomy do not improve survival in primary melanoma of the anorectum: results from analysis of a large database (SEER)

AIM

Primary anorectal melanoma is a rare disease with a dismal prognosis due to early distant metastasis. The prognostic value of positive loco-regional lymph nodes and the impact of lymphadenectomy on overall survival are unclear. We have investigated this by analysis of data obtained from a national representative database, controlling for potential confounders.

METHODS

Data were retrieved from the Surveillance, Epidemiology and End Results (SEER) database. Multiple imputation analysis was performed to deal with missing data. Cox regression models were formulated using different prognostic factors including site of origin, gender, size, race, rate of lymph node metastasis (ratio between positive lymph node count and total lymph nodes harvested), extent of lymphadenectomy (none, level I etc.), age, type of surgery, stage of disease and administration of radiotherapy.

RESULTS

Our population was composed of 208 patients who underwent surgery between 1998 and 2012. Rate of lymph node metastasis (P = 0.027; hazard ratio 1.873, 95% CI 1.076-3.261) and race (P = 0.019; hazard ratio 2.291, 95% CI 1.148-4.575) were found to be independent predictors of survival.

CONCLUSION

Based on the data retrieved from the SEER database, metastasis to loco-regional lymph nodes is an important prognostic factor, but lymphadenectomy does not improve survival.

Thoracic Stop-Flow Perfusion in the Treatment of Refractory Non Small Cell Lung Cancer

This study was undertaken to determine the survival of patients with unresectable and refractory non small cell lung cancer (NSCLC) submitted to thoracic stop-flow perfusion (TSP). Forty-five patients with NSCLC confined to thoracic region entered the study. All 45 patients had been pretreated with some form of chemotherapy and had progression of disease. The cytostatic regimen was mitomycin 10 mg/m2, navelbine 25 mg/m2 and cisplatin 60 mg/m2. In 39/45 patients, immediately after TSP, hemofiltration was performed to reduce systemic side effects There were 16/45 responses to the first TSP (CR 0; PR 16): a response rate of 35.6%. Median time to progression was 4 months. Median survival was 7.5 months.1-year survival rate was 36.4%, 2-year survival rate was 14%, and 3-year survival rate was 5.7%.

Intestinal Intussusception by Monophasic Synovial Sarcoma: Case Report and Literature Review

INTRODUCTION

Synovial sarcomas are rare malignant tumors of soft tissues, arising mainly from periarticular structures. Gastrointestinal localizations are unusual presentation of these rare sarcomas.

METHODS

We present the case of a 56- years old man with monophasic synovial sarcoma, arising primarily from the ileum, and causing intussusception. A review of the literature was conducted to gather information about this rare sarcoma.

RESULTS

We found that the criteria normally used to determine the prognosis in patients with monophasic synovial sarcoma of soft tissue are poorly applicable for gastrointestinal localizations.

CONCLUSIONS

A better characterization of these tumors could identify them as a distinct entity, compared with monophasic synovial sarcomas of soft tissues.

Propensity adjusted appraisal of the surgical strategy for appendiceal carcinoids

BACKGROUND

The treatment algorithm for appendiceal carcinoids is based on tumor size. We wanted to verify whether right hemicolectomy confers a survival advantage compared with appendectomy in patients with tumors larger than 2 cm.

METHODS

Data regarding patients with primary carcinoid tumors of the appendix were collected from the Surveillance, Epidemiology, and End Results program database. A propensity score with respect to surgical intervention was calculated with a binary logistic regression including gender, stage of disease, and age as covariates. The groups were matched with a 1:1 ratio, using the nearest neighbor algorithm. A Cox proportional hazards model adjusted for propensity score was implemented to assess the impact of surgical intervention on overall survival.

RESULTS

Only stage of disease differed between the groups (p = 0.011). After matching, based on the propensity score, our series was constituted of 109 patients undergoing appendectomy and 109 undergoing right hemicolectomy. The type of surgical intervention failed to reach statistical significance.

CONCLUSIONS

Right hemicolectomy did not seem to confer any survival advantage on patients with appendiceal carcinoids with a diameter >2 cm. For this reason, tumor size should not be considered an absolute indication for right hemicolectomy.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery

BACKGROUND

The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR).

METHODS

Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity.

RESULTS

There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07).

CONCLUSION

Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

"Acute abdomen": early laparoscopy or active laparotomic-laparoscopic observation?

BACKGROUND/AIMS

Acute abdomen accounts for 13-40% of all emergency surgical admissions. The aim of this prospective randomized controlled study was to examine the role of early laparoscopy in the management of acute abdomen compared with the more traditional active observation.

METHODOLOGY

From July 1993 to August 2004, 522 patients consecutively, admitted with "acute abdomen", were randomized to either early laparoscopy (260 patients) (group 1) or active observation and non-invasive investigation (262 patients) (group 2). Baseline investigations included a full blood count, a pregnancy test in women of reproductive age, chest and/or abdominal radiograph if indicated clinically.

RESULTS

Sixty-two patients in the laparoscopy group underwent a total of 116 radiological investigations compared with a total of 558 investigations in all patients in the observation group (P < 0.05). In the observation group 34.7% of patients remained without a clear diagnosis compared with 4.2% of patients in the early laparoscopic group (P < 0.0001). The morbidity rate was 1.1% in group 1 and 27% in group 2 (P < 0.0001). The duration of hospital stay was significantly shorter in group 1 (3.1 vs. 7.3 days) (P < 0.01). Eight patients in group 1 required readmission (total readmission 46 days) compared with 58 patients in group 2 who stayed a total of 201 days (P < 0.05).

CONCLUSIONS

Early laparoscopy is valuable in the management of acute abdomen. It provides a significantly higher diagnostic accuracy and a better improvement in quality of life than the more traditional approach observation.

Effects of cholecystectomy (laparoscopic versus open) on PMN-elastase

BACKGROUND/AIMS

Polymorphonuclear leukocytes (PMN) are well recognized as being the principal cells in inflammatory response reaction. During the surgical procedures there is a massive release of elastase (PMN-elastase) from the neutrophils, along with other proteinases. Therefore the measurement of the PMN-elastase might be a useful indicator of the degree of surgical trauma. Laparoscopic cholecystectomy (LC) is a so-called "mini-invasive" surgical procedure and on the basis of this consideration the aim of the present prospective, non-randomized study, is to examine (a) whether the serum levels of PMN-elastase concentration are modified and how, in patients undergoing LC compared to patients undergoing open cholecystectomy (OC), (b) whether these findings are indicative of an increased risk to develop infectious complications and therefore whether they are clinically significant.

METHODOLOGY

Plasma granulocyte elastase was determined photometrically, using an immune-activation immunoassay, in 86 patients (42 patients underwent OC and 44 LC). The levels of C reactive protein (CRP), an acute phase protein, were measured using a competitive CRP ELISA kit. Blood samples were collected from all patients a day before operation and at days 1, 3, 6 and 12 after operation. We established a reference range for elastase by measuring the serum elastase concentration in 68 normal control patients without gallbladder cholelithiasis or other diseases.

RESULTS

On day, 1, 3 and 6 after surgery, patients that underwent OC showed a significant increase (p < 0.05) in plasma elastase concentration, while it was almost unchanged in LC patients. The mean values of the serum CRP on p.o. days 1, 3 and 6 were also significantly lower in the LC group than those in OC group (p < 0.05). We recorded three cases (7.1%) of postoperative infections in the "open" group. The CRP concentration remained high for 1, 3 and 6 days and normalized 10-12 days after surgery while the PMN-elastase normalized after 13, 14 and 16 days.

CONCLUSIONS

The peripheral leukocyte function may be better preserved after LC in comparison to OC. Laparoscopic surgery, associated with a small skin incision and the avoidance of open laparotomy, can thus minimize surgical stress, and provide more favorable postoperative conditions for patients. Indeed excessive and prolonged post-injury elevations of PMN-elastase and CRP are associated with increased morbidity. Moreover, the PMN-elastase is a more sensible marker of inflammation in comparison to the CRP.

Hypoxic abdominal stop-flow perfusion in the treatment of advanced pancreatic cancer: a phase II evaluation/trial

In the past decade, some authors have reported objective responses and prolonged median survival times using hypoxic abdominal perfusion (HAP) for the treatment of advanced pancreatic cancer. However, these promising results have not been confirmed by others, making it difficult to define the effectiveness of this loco-regional chemotherapy. The aim of this study, therefore, was to evaluate the response rate, time to disease progression and overall survival following HAP treatment of 22 consecutive patients with advanced pancreatic tumors. Within the period from 1999 to 2003, 22 patients with histological diagnosis of unresectable stage III/IV pancreatic cancer, not responsive to systemic chemotherapy, were treated with mitomycin C 30mg/m(2) and cisplatin 60mg/m(2) by HAP (stop flow technique). Immediately after perfusion, hemofiltration was performed to reduce systemic side toxic effects. Responses were assessed by CT-scan 30days from the end of treatment. Minor or partial responses were confirmed by a second CT-scan 4weeks later. Following 26 treatment cycles no death or technical complications were recorded; four patients (18.2%) achieved a partial response, 2 (9.1%) a minimal response and 13 (59.1%) stable disease. The remaining 3 patients (13.6%) showed progression of the disease. The median time to disease progression was 3 months (range 1-10). The median survival time from the start of regional chemotherapy was 6 months (range 1.9-16), with a 1-year survival rate of 9%. Our data show that HAP is a relatively effective second-line treatment for advanced stage pancreatic cancer with a low complication rate. We do not concur with the opinion of others that HAP is an inactive treatment approach. However, taking into account the invasiveness of this procedure, and associated morbidity and cost, HAP would not appear to be preferable to less invasive loco-regional chemotherapeutic alternatives.

[Parathyroidectomy: bilateral exploration of the neck vs minimally invasive radioguided treatment]

AIM

In the therapy of primary hyperparathyroidism, the first surgical intervention, if efficacious, can remarkably reduce the incidence of persistence and relapses which are approximately about 5%. At present, the surgical approach of choice should involve the bilateral exploration of the neck.

METHODS

In the light of the high sensibility (91%) and specificity (98.8%) in the localization of parathyroid adenomas obtained by the parathyroid 99mTc-MIBI scintigraphy, we submitted, prospective and at random, between January 2001 and July 2004, 69 patients with primary hyperparathyroidism, to a conventional surgical treatment (bilateral exploration of the neck: 35 patients) or minimally-invasive approach (minimally invasive radioguided parathyroidectomy: 34 patients). This method consists of the injection of 50 mCi of 99mTc Sestamibi 2 h before the operation and the execution of parathyroid scintigraphy. When the adenoma is evident, we perform an incision of about 4 cm in the neck, 2 cm over the jugulum and the surgical dissection is guided by a probe showing the emission of gamma rays.

RESULTS

The parameters considered in order to compare the 2 groups, i.e. operating time, hospital stay and time of recovery were reduced in a significant way in the group submitted to the minimally invasive radioguided parathyroidectomy (MIRP). There were no complications in the 2 groups. In the follow-up we did not observe cases of persistence or relapses.

CONCLUSIONS

Therefore, we can confirm that the minimally invasive radioguided parathyroidectomy is a safe and efficacious method as well as the bilateral exploration of the neck. Moreover, cost reduction may convince many surgeons to consider MIRP the <<gold standard>> in the management of primary hyperparathyroidism.

[Silicone occlusive sheeting vs silicone cushion for the treatment of hypertrophic and keloid scars. A prospective-randomized study]

BACKGROUND

Silicone gel and silicone occlusive sheeting are widely used at present for the treatment of hypertrophic and keloid scars. In recent studies the possibility was raised that static electricity generated by friction activated silicone sheeting could be the reason for this effect, and that it can, with time, cause involution of hypertrophic and keloid scars. Objective of this study was to test this hypothesis and to observe weather a continuous and also an increased negatively charged static electric field will shorten the treatment period. A silicone cushion was developed with the purpose of increasing a negative static-electric charge to accelerate the regression process.

METHODS

From November 2001 to June 2002 we studied in a prospective randomized study, 72 patients with hypertrophic an keloid scars. The trial extended over a 8-month period. 37 patients underwent silicone occlusive sheeting, the remaining 35 patients underwent silicone cushion (Clinicel).

RESULTS

Treatment with the silicone cushions yielded 74,2% cessation of itching and burning followed by pallor and flattening of the scar, some markedly so, over a few weeks to 5 months period. Additional 25,7% had their scars resolved in up to 8 months of treatment. Four patients (11,4%) who add recalcitrant scars with little response to the use of the silicone cushion were given intralesional corticosteroid injections, in addiction to the use of the cushion, resulting in a fairly rayed resolution of these scars over a period of 2 months. Treatment with the silicone occlusive sheeting yielded 52,3% itching and burning cessation followed by pallor and flattening of the scar, some markedly so, over a few weeks to 5 months period. Additional 22,1% had their scars resolved in up to 8 months of treatment. In conclusion by comparing the results of this trial using silicone cushions for the treatment of hypertrophic and keloid scars with those obtained using silicone gel or occlusive sheeting, a much faster response was demonstrated.

A comparison of serum interleukin-6 concentrations in patients treated by cholecystectomy via laparotomy or laparoscopy

BACKGROUND/AIMS

Interleukin-6 (IL-6), a multifunctional cytokine, is expressed by various cells after many stimuli. This cytokine release is related, among other things, to the extent of the surgically-induced trauma. Laparoscopic cholecystectomy (LC) is a so-called "mini-invasive" surgical procedure and, on the basis of this consideration, the aim of the present prospective non-randomized study, is to examine (a) whether the IL-6 is modified and how, in patients after LC compared to patients undergoing open cholecystectomy (OC), (b) whether these findings are indicative of an increased risk to develop infectious complications and whether they are therefore clinically significant.

METHODOLOGY

Circulating IL-6 level was measured using a random access chemiluminescense-immunoassay system in 71 patients before the operation (time 0) and 1, 2, 3, 6, 24 and 48 hours after the beginning of the operation. Thirty-five patients underwent OC and 36 LC.

RESULTS

The increase in the serum IL-6 during LC was found to be significantly smaller than that during OC and resulted in a smaller extent of postoperative elevations for C-reactive protein. We recorded three cases (8.5%) of postoperative infections in the "open" group and IL-6 concentration normalized only 6 days after surgery.

CONCLUSIONS

An increase in the serum IL-6 level during LC is lower in comparison to OC and results in lower postoperative elevation in C-reactive protein. Laparoscopic surgery, associated with a small skin incision and the avoidance of open laparotomy, can thus minimize surgical stress, and provide more favorable postoperative conditions for patients. Indeed excessive and prolonged post-injury elevations are associated with increased morbidity.

Changes in the blood coagulation, fibrinolysis, and cytokine profile during laparoscopic and open cholecystectomy

BACKGROUND

It has long been known that a hypercoagulability state develops after surgery. A surge in circulating cytokine levels is also commonly found in the postoperative period. These cytokines have all been shown to be capable of inducing a hypercoagulability state. Recently laparoscopic cholecystectomy (LC) has been introduced, and its advantages over the open procedure seem related to the reduced surgical trauma. LC is associated with a diminished acute-phase response compared with the open procedure. Our present knowledge on the influence of laparoscopic upon coagulation and fibrinolysis is incomplete and based on a few studies.

METHODS

The aim of this prospective, nonrandomized study was to investigate hemostatic system alterations in patients who undergo open and laparoscopic cholecystectomy. In addition we also measured the plasma cytokine profile to explore any relationship between changes in plasma cytokine levels and postoperative coagulation profile. Between September 1999 and April 2002, 71 patients were nonrandomly assigned to open (group 1) or laparoscopic cholecystectomy (group 2). All patients from group 1 were operated by a surgical team different from ours, who prefers the OC procedure. The patients with acute cholecystitis were excluded. Prothrombin fragment 1.2 (F1.2), thrombin-antithrombin (TAT), fibrinogen, soluble fibrin, antithrombin III (AT), protein C, plasminogen, and D-dimer levels were measured at baseline and at 1, 24, 48, and 72 h postoperatively. Serial serum levels of IL-1beta and IL-6 were measured by colorimetric enzyme-linked immunosorbent assay (ELISA).

RESULTS

Plasma levels of F1.2, TAT, fibrinogen, soluble fibrin, and D-dimer increased significantly in group 1. Plasma levels of AT, protein C, and plasminogen decreased in both groups. In the OC group, the serum IL-3 and IL-6 levels began to significantly increased as early as 1 h from the beginning of the operation, revealing a peak at the sixth hour. When IL-6 and IL-1 levels were markedly elevated also, F1.2, fibrinogen, and soluble fibrin levels were increased.

CONCLUSIONS

Only mild hypercoagulability was observed in patients who had undergone laparoscopic cholecystectomy. The cytokine surge was correlated with hypercoagulability. There was in fact a positive correlation between IL-6 level and hypercoagulability. The correlation between cytokine levels and coagulation activation may be related to the type of surgery performed. Further studies are required to investigate these issues.

Hypoxic pelvic perfusion with mitomycin C using a simplified balloon-occlusion technique in the treatment of patients with unresectable locally recurrent rectal cancer

HYPOTHESIS

To evaluate the role of hypoxic pelvic perfusion in providing therapeutic options for palliation without relevant complications in a homogeneous group of patients with unresectable locally recurrent rectal cancer who are nonresponders or have disease progression after the standard treatments.

DESIGN

Nonrandomized and noncontrolled phase II experimental study.

SETTING

University hospital, L'Aquila, and the National Cancer Institute, Naples and Milan, Italy.

PATIENTS

Eleven patients had symptomatic unresectable pelvic recurrent rectal cancer. The mean +/- SD product of the 2 maximum perpendicular diameters of the recurrent cancer was 24.2 +/- 11.0 cm(2) (range, 10-48 cm(2)). Tumor fixation to the pelvic side walls or proximal sacrum were the main criteria for unresectability. All patients were free from extrapelvic disease and had a life expectancy longer than 3 months.

INTERVENTION

Patients were submitted to one course of pelvic perfusion with mitomycin C (MMC) (25 mg/m(2)) by means of a simplified balloon occlusion technique. A pharmacokinetic evaluation of the procedure was also performed.

MAIN OUTCOME MEASURES

Response rate and time to disease progression were the primary endpoints; overall survival was the secondary endpoint.

RESULTS

Mean +/- SD value of the ratios of pelvic MMC area under the plasma concentration curve (0 to 20 minutes) (AUC(0-20)) to systemic MMC AUC(0-20) was 13.30 +/- 6.52. During the procedures there were no technical, hemodynamic, or vascular complications, and no deaths occurred during surgery or in the postoperative period. The response rate was 36.3% (95% confidence interval [CI], 6.5%-66.1%). Pain response rate was 45.4% (95% CI, 16.6%-76.2%). Median survival was 12.2 months (range, 5.7-19.5 months). Median time to disease progression was 6 months (range, 3-8 months). Two-year overall survival was 9.1%.

CONCLUSIONS

Hypoxic pelvic perfusion with MMC is a safe and good palliative treatment for patients with unresectable locally recurrent rectal cancer. Further studies are necessary to establish if a different sequence in the multimodular treatment of these patients could be more useful.

Evaluation of the Maruyama computer program accuracy for preoperative estimation of lymph node metastases from gastric cancer

Controversy still exists about the optimal lymph node (LN) dissection for potentially curable gastric cancer. For rational LN dissection it is important to know the incidence of metastasis at each LN station. For this purpose a computer program was developed using data from 4302 primary gastric cancers treated at the National Cancer Center Hospital in Tokyo between 1969 and 1989. To evaluate the accuracy of the computer program, the differences between the individual reports generated by the computer and the stored data were investigated in 282 Italian patients submitted to curative gastrectomy and D2 or more extended LN dissections for gastric cancer. Receiver operating characteristic (ROC) analysis was used to assess the sensitivity and specificity of the program for predicting LN metastases in each of the 16 regional LN stations. The computer program showed good predictive ability for LN metastases in most of the 16 LN stations, as the areas under the curve ranged from 0.741 (station 15) to 0.944 (station 8), with a mean of 0.856. A critical cutoff point of 18% of the program's expected percentage was the value maximizing the validity of the prediction. Using an "absolute" cutoff point of 0%, the overall rate of false-negative (FN) predictions in 176 N+ patients was 11.9%; of these, 11 (6.2%) were absolute FNs, in which the program totally failed to estimate LN metastases; the remaining 10 cases (5.7%) were relative FNs because the specific prediction was positive for a different depth of stomach invasion. The low number of D3/D4 lymph-adenectomies in the historical database may affect the low estimate of metastases to N3/N4 nodes generated by the program. Based on these data, the program predicts with good accuracy the extent of LN metastases from gastric cancer, but it is not recommended for directing the surgeon to perform more extensive lymphadenectomy.

Significance of duplex/colour Doppler sonography in hepatic arterial chemotherapy for patients with liver metastases from colorectal carcinoma

AIMS

The aim of the study was to evaluate the importance of duplex/colour Doppler ultrasound in a protocol of hepatic regional chemotherapy, by measuring the blood flow in the hepatic artery, portal vein, hepatic veins, and inferior caval vein of patients with unresectable liver metastases from colorectal carcinoma.

METHODS

Thirty-nine consecutive subjects were selected for this study, including 21 patients who had unresectable histologically confirmed liver metastases from colorectal carcinoma (Group A), and 18 asymptomatic volunteers as normal controls (Group B). All subjects of Groups A and B were examined using duplex/colour Doppler sonography. After the ultrasound study, all patients of Group A were submitted to the administration of high dose mitomycin C into the hepatic artery, with concomitant detoxication of post-hepatic venous blood.

RESULTS

The mean value of the hepatic artery blood flow was significantly higher (P=0.0009) in liver metastases patients (361 ml/min, SEM=24 ml/min) than in normal controls (245 ml/min, SEM=20 ml/min). Also, the mean Doppler perfusion index was higher in liver metastases patients than in normal controls. For each patient of Group A, the total dose of mitomycin C to be infused was calculated based on the blood flow in the hepatic artery. In this way the concentration of mitomycin C in the hepatic artery was always greater than 3 microg/ml. The duration of detoxication was calculated based on the blood flow in the inferior caval vein. For two patients only, the blood flow was lower than 1000 ml/min, with the necessity to protract the duration of detoxication over 2 hours.

CONCLUSIONS

The measurement of the blood flow in hepatic vessels of patients with liver metastases seems to be very important in establishing the total dose of drug which has to be infused in hepatic arterial chemotherapy, and to determine the duration of concomitant detoxication of post-hepatic venous blood.

Stop-flow in mediastinum and thorax for resistant lymphoma

BACKGROUND/AIMS

Management of patients with heavily pretreated malignant lymphoma failing frontline treatment and salvage high-dose chemotherapy and autologous peripheral stem cell rescue, is problematic. A pilot study was conducted to evaluate isolated thoracic perfusion of drugs by means of stopflow technique.

METHODOLOGY

Six patients were enrolled in the study; diagnoses included 4 advanced Hodgkin's disease, 1 primary mediastinal B-cell lymphoma, and 1 anaplastic large cell lymphoma. Patients were aged 18-37 years; 4 presented with bulky mediastinum. They had never achieved a complete response since all had progressed from front-line treatment, and 3 had even failed salvage high-dose chemotherapy with autologous peripheral stem cell rescue. Cisplatin (100 mg/m2) and melphalan (35 mg/m2) were used. Carmustine (100 mg/m2) were added to these 2 drugs and cytarabine (2000 mg/m2) in patients not previously treated by carmustine, etoposide, cytarabine, and melphalan. Epidoxorubicin (70 mg/m2) was added in patients who previously received a suboptimal dosage of antracycline. Drugs were delivered monthly via aortic perfusion performed by means of Aigner's stop-flow technique.

RESULTS

Overall 13 cycles of perfusional chemotherapy were administered with a median number of 2 cycles. During the procedures there were no technical, hemodynamic, or vascular complications, and no deaths occurred during surgery. After 1 month, 6 (100%) objective responses after isolated thoracic perfusion were recorded, 3 (50%) of which were complete. Tolerance to therapy was excellent. Hematological toxicity was mild and transfusional support was needed only in one course. At the last follow-up, 2 patients are alive (1 complete response and 1 very good partial response, maintained).

CONCLUSIONS

This new therapeutical approach seems very active in recurrent/refractory malignant lymphoma and may play an important role in this setting.

Remifentanil vs. fentanyl during interventional rigid bronchoscopy under general anaesthesia and spontaneous assisted ventilation

The treatment of tracheo-bronchial diseases with rigid bronchoscopy requires general anaesthesia without tracheal intubation. Spontaneous assisted ventilation is a safe modality of ventilation. In this study the use of remifentanil and fentanyl is compared during rigid bronchoscopy with spontaneous assisted ventilation. Ninety high-risk patients received fentanyl or remifentanil with propofol for general anaesthesia. During the maintenance fentanyl was delivered at 6.1 +/- 4.6 micrograms kg-1 h-1 and remifentanil at 0.15 +/- 0.07 microgram kg-1 min-1. The same degree of intra-operative respiratory acidosis with similar good operating conditions resulted in both groups. Patients treated with remifentanil recovered more quickly compared with those in the fentanyl group (3.8 +/- 2 vs. 10.4 +/- 9.2 min, P < 0.001). In conclusion, the use of remifentanil during rigid bronchoscopy under general anaesthesia with spontaneous assisted ventilation is safe and assures good operating conditions. Moreover, remifentanil permits a more rapid recovery than fentanyl. The dose of remifentanil is higher than previously described for spontaneously breathing patients.

N-nitroso compounds and Helicobacter pylori in the gastric remnant

AIMS AND BACKGROUND

The aims of this study were to investigate the role of N-nitroso compounds (NOC) and Helicobacter pylori (H. pylori) in gastric stump carcinogenesis.

METHODS AND STUDY DESIGN

Analyses of biochemical parameters such as pH and NOC concentration were carried out on 65 fasting gastric juice samples obtained at endoscopy from 45 patients previously submitted to partial gastrectomy for benign peptic ulcer disease (23 Billroth I, 22 Billroth II/Reichel-Polya) and 20 normal controls. Biopsy specimens were taken to determine histology and H. pylori status.

RESULTS

Significantly higher mean pH values and NOC concentrations were found in partial gastrectomies compared to normal controls. In relation to surgical methods, higher mean pH values and NOC concentrations were observed in the gastric juice of patients with Billroth II compared to Billroth I gastrectomies. Independently of the type of surgical reconstruction, higher mean NOC levels were recorded in patients with more severe histological changes and H. pylori infection.

CONCLUSIONS

All these data suggest that high levels of NOC in gastric juice and H. pylori infection could be cofactors in gastric stump carcinogenesis.

Work of breathing-tidal volume relationship: analysis on an in vitro model and clinical implications

OBJECTIVE

Work of breathing (WoB) is currently employed to assess the afterload on the respiratory muscles and to estimate the energy expenditure for breathing. Since WoB depends on the ventilated tidal volume (TV), WoB*L(-1), the indicized form of WoB has been employed as a measure of WoB which is independent of TV. Actually, the independence of WoB*L(-1) from the ventilated TV has never been demonstrated. The aim of this study was to verify the predicted TV-independence of WoB*L(-1) on an in vitro model.

METHODS

Our experimental model was constituted as follows: two endotracheal tubes, with internal diameter measuring respectively 6.5 and 8.5 mm, were alternatively connected with two rubber balloons whose compliance was respectively 0.02 and 0.06 L/hPa; the system was mechanically ventilated at ten different tidal volumes, ranging from 0.3-1 l. Flow rate was kept constant (35 l/m) during the whole experiment.

RESULTS

Both elastic components of the model showed a static volume-pressure relationship which was linear in the experimental range of TV. In all combinations of resistance and compliance WoB increased quadratically whereas WoB*L(-1) increased linearly with the growing TV (p < 0.001).

CONCLUSIONS

These results demonstrate the TV-dependence of WoB*L(-1) and suggest that WoB*L(-1), if TV changes, cannot be considered as an index of respiratory muscle afterload and should not be used as a guide for weaning patients from the mechanical ventilation. Finally, we introduced a new parameter (WoB1L) which seems to be a more TV-independent measure of respiratory work.

[Laparoscopic adrenalectomy: technical knowledge in lateral position]

Laparoscopic approach to adrenal glands present to the patient the advantages of a lower invasivity respect to anterior or posterior thoracoabdominal access. Thanks to the minor pain occurring after the operation, the rapid gain and canalization, the brief hospitalization and the better aesthetic result. This method is to prefer to the others.