Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BACKGROUND

Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.

METHODS

This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.

RESULTS

564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.

CONCLUSIONS

After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Mini-invasive video-assisted thyroidectomy vs robot-assisted transaxillary thryoidectomy: analisys and comparison of safety and outcomes

Thyroid surgery is characterized by large volumes and typically affects a young female population. Mini-invasive or remote access surgical techniques are born driven by the desire to improve aesthetic outcomes of the traditional technique, following technological advances that have upset the surgical world in the last 20 years. In our multicenter, retrospective observational study, we first compared an endoscopic technique with a robotic one: minimally invasive video-assisted thyroidectomy (MIVAT) and robot-assisted transaxillary thyroidectomy (RATT). We evaluated intraoperative features, complications, and cosmetic outcomes in a cohort of 609 patients. The efficacy and safety of these techniques are proven by a large literature and the comparison made in our study does not show inferiority of one technique compared to the other. Even the aesthetic results tend to be equal in the long term. It is desirable that further prospective and randomized studies are conducted to evaluate the outcomes of these procedures and the cost-benefit ratio.

The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review

PURPOSE

Pneumatosis intestinalis is a radiological finding with incompletely understood pathogenesis. To date, there are no protocols to guide surgical intervention.

METHODS

A systematic review of literature, according to PRISMA criteria, was performed. Medline and PubMed were consulted to identify articles reporting on the items "emergency surgery, pneumatosis coli, and pneumatosis intestinalis" from January 2010 up to March 2022. This study has not been registered in relevant databases.

RESULTS

A total of 1673 patients were included. The average age was 67.1 ± 17.6 years. The etiology was unknown in 802 (47.9%) patients. Hemodynamic instability (246/1673-14.7% of the patients) was associated with bowel ischemia, necrosis, or perforation (p = 0.019). Conservative management was performed in 824 (49.2%) patients. Surgery was performed 619 (36.9%) times, especially in unstable patients with bowel ischemia signs, lactate levels greater than 2 mmol/L, and PVG (p = 0.0026). In 155 cases, surgery was performed without pathological findings.

CONCLUSIONS

Many variables should be considered in the approach to patients with pneumatosis intestinalis. The challenge facing the surgeons is in truly identifying those who really would benefit and need surgical intervention. The watch and wait policy as a first step seems reasonable, reserving surgery only for patients who are unstable or with high suspicion of bowel ischemia, necrosis, or perforation.

Conservative management of complicated colonic diverticulitis: long-term results

BACKGROUND

The management of recurrent diverticulitis after initial non-operative treatment remains controversial. Recurrences after medical treatment have been described up to 36% but only 3 to 5% develop complicated disease.

AIM

To investigate the effectiveness of conservative treatment during a prolonged follow-up after first episode of complicated diverticulitis.

METHODS

This retrospective single-center study describes the conservative management and outcomes of 207 with complicated acute colonic diverticulitis treated at Parma University Hospital from 1 January 2012 until 31 December 2019. The follow-up was performed until December 2020. Diverticulitis severity was staged according to WSES CT driven classification for acute diverticulitis.

RESULTS

We enrolled 207 patients (118 males, 89 females). The mean age was 59 ± 14.5 years. CT scan of the abdomen was always performed. Almost all patients were treated with bowel rest and antibiotics (98.5%). Percutaneous drainage of abscessed diverticulitis was performed 12 times (5.7%). Average follow-up was 48 ± 28.8 months. 79 patients had new episodes of diverticulitis (38.1%) and 23 patients had high severity new episodes (11.1%). 11 patients underwent surgery (7.7%). Lower CT-Stages showed a higher recurrence rate (P = 0.002). Grade III diverticulitis showed a lower recurrence rate (P = 0.007). Patients with chronic NSAID use showed a higher incidence of high severity new episodes (P = 0.039). No recurrence rate differences were noted among patients with or without home therapy (P > 0.05).

CONCLUSIONS

Non-operative treatment is an effective and safe option in selected patients with complicated diverticulitis. The recurrence's severity is generally lower than the previous episodes and this can justify the conservative management.

Malignancy risk in Bethesda class IV thyroid nodules in an iodine deficient region

Background

According to the latest guidelines, in patients with high-risk nodules with indeterminate cytology, diagnostic lobectomy should be the preferable surgical approach in the absence of factors that suggest a total thyroidectomy.

Methods

This retrospective observational study has as its main aim the evaluation of the cases that underwent surgery, for Bethesda class IV nodules in our iodocarent geographical area. Particular attention was paid to carcinoma incidence, preoperative nodule size, histological characteristics of the neoplasm, surgical approach and eventual need of radiometabolic treatment. A total of 320 patients were included that underwent surgery for Bethesda IV nodules, between January 2010 and December 2020, at the General Surgical Clinic of the University Hospital of Parma, Italy.

Results

A total of 230 total thyroidectomies (71.9%) and 90 lobectomies (28.1%) were performed. Our data showed a strong impact of the 2015 ATA Guidelines on the surgical approach choice, with a progressive propensity towards a conservative approach and an increase of lobectomies from 7.2% to 41.5% after the new guidelines introduction. However, in our sample the percentage of lobectomies remains below 50%; this data is certainly influenced by the number of cases of multinodular pathology, often bilateral, in our geographical area. The nodules malignancy rate resulted 28.8%. Our data showed that increasing size correlated with an increasing malignancy rate (P<0.01), and follicular carcinomas were found to be larger than papillary carcinomas (P<0.001). A statistically significant correlation also emerged between nodule size increase and local/lymphovascular invasion (P<0.05). On the other hand, there was no statistically significant correlation between nodule size and multifocality, and between nodule size and presence of lymph node metastases. Out of the patients where it was possible to find this data, 66% underwent radioiodiometabolic treatment: 59% with papillary carcinoma, and 85% with follicular carcinoma.

Conclusions

In patients with Bethesda IV thyroid nodules, diagnostic lobectomy should be the preferable surgical approach in absence of factors that suggest total thyroidectomy. In our opinion, total thyroidectomy remains the first choice in large nodules (≥4 cm) as these nodules have a high malignancy rate, greater local/lymphovascular invasion and a consequent frequent indication for post-operative radiometabolic treatment.

Biosynthetic meshes in contaminated fields: where are we now? A systematic review and meta-analysis in humans

PURPOSE

Selection of an appropriate mesh reinforcement for hernia repair in contaminated fields is a significant problem for surgeons. To date the proper mesh for contaminated fields has not been found. Biosynthetic meshes have emerged as new treatment option in contaminated fields. This study aims to evaluate the postoperative outcomes of biosynthetic meshes in contaminated fields.

METHODS

Systematic electronic search (PubMed, Medline, Embase, Scopus), according to PRISMA criteria, was performed. A literature search of scientific papers was performed by two reviewers until April 2021. Articles were chosen based on reference to biosynthetic meshes, their use in infected fields, and in human subjects. GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of studies. According to CDC-Centers for Disease Control classes patients were divided into two subgroups, group 1 (CDC class 2) and group 2 (CDC classes 3-4).

RESULTS

The research included 21 articles and 1619 patients were analyzed. Long-term follow-up showed a significant higher recurrence rate than short-term follow-up. P < 0.001. Meta-analysis of these studies showed that the SSI were significantly higher in CDC classes 3-4 than CDC class 2 (P < 0.01). No differences were found in SSO (P = 0.06) and recurrence (P = 0.37) rate among the two groups. Phasix™ was the most common mesh in 15 studies. The mean follow-up was 23.0 months. The surgical site infection (SSI) rate was 17.3%. The surgical site occurrence (SSO) rate was 32.4%. Recurrence rate was 11.5%.

CONCLUSION

This is the first systematic review and meta-analysis on the clinical outcomes of abdominal wall repair using biosynthetic mesh in contaminated-infected settings. The results show good results in patients at high risk of postoperative wound complications. The aim of this study is to add to the growing literature on biosynthetic mesh a picture of current literature evidence to help future researchers performing further studies on this topic.

Serum 25-hydroxyvitamin D level is unreliable as a risk factor and prognostic marker in papillary thyroid cancer

Background

Low levels of vitamin D and altered local vitamin D metabolism have been associated with the prevalence and aggressiveness of several cancers. However, the effect of vitamin D on papillary thyroid cancer (PTC) is controversial. This study aimed to evaluate the impact of preoperative serum vitamin D levels and local vitamin D metabolism on the clinicopathologic characteristics and prognosis of PTC.

Methods

In total, 1,578 patients with PTC and 128 patients with benign thyroid diseases were included. Clinical and pathologic data were analyzed to evaluate the role of vitamin D as a risk factor and prognostic marker in PTC. Moreover, a tissue microarray was used to investigate the role of local vitamin D metabolism in PTC progression.

Results

Participants with PTC were younger compared to those with benign disease. No significant differences in 25-hydroxy vitamin D [25(OH)D] levels were observed between benign and malignant cases. Among patients with PTC, analyses of prognostic features revealed that decreased 25(OH)D levels were not overtly associated with poor prognosis in PTC. Additionally, local vitamin D metabolism was not associated with the aggressiveness of PTC.

Conclusions

Serum 25(OH)D determination may not contribute to risk assessment workup of thyroid nodules. Moreover, decreased preoperative serum vitamin D and local vitamin D metabolism were not associated with poor prognosis of PTC.

Intraoperative Neuromonitoring, Nerves at Risk and Staged Thyroidectomy, our Experience on 377 Consecutive Cases

PURPOSE

The aim of this study was firstly to report the experience of intermittent intraoperative neuromonitoring (I-IONM) and evaluate the impact of loss of signal (LOS) in staged thyroidectomy management.

METHODS

We retrospectively reviewed patients who underwent total thyroidectomy, performed by a single surgeon in two years. All patients have been subjected to I-IONM. In case of intraoperative loss of signal (LOS), planned total thyroidectomy was always aborted. Six-month follow-up was performed. Postoperative dysphonia was evaluated with VHI-10 score in 3 time settings T1, during hospital stay, T2 after 30 days, T3 after 6 months. Dysphonia has been compared to IONM results to evaluate sensitivity and specificity.

RESULTS

377 patients were included. Incidence of dysphonia was calculated based on the number of nerves at risk (NAR). We evaluated a total of 724 NAR. LOS encountered were 43 cases (5.9% of total NAR), of these 14 were LOS 1 while 29 were LOS 2. 27 patients (3.7% of NAR) presented early post-operative dysphonia with VHI-10 score > 13 (T1), among these 16 had presented LOS at IONM (true positives) while11 had no LOS (false negatives). In T2 and T3 we reported a decrease in true positive cases increasing false positives. Sensitivity at T3 reached 85.7% while specificity and odds ratio were respectively 94.8% and 110.

CONCLUSIONS

Given the high sensitivity and specificity, IONM should be considered a useful tool for thyroid surgery and its use should be suggested for patients undergoing planned total thyroidectomy. Its right application may cancel the risk of bilateral paralysis.

How COVID-19 pandemic has changed elective surgery: the experience in a general surgery unit at a COVID-hospital

Objective:

Evaluate the impact of Covid-19 in a critical area and analyze the changes in the daily activities in a General Surgery Unit of a tertiary Covid-Hospital.

Methods:

We report and compared all the surgical procedures performed between two periods (March and April 2019 and March and April 2020) at General Surgery Department of Parma University Hospital, a tertiary Covid-Hospital.

Results:

Between March and April 2019, a total of 232 surgical procedures were performed. Between March and April 2020 only 61 surgical procedures were performed. In 2019 84 patients underwent surgery for cancer and 171 underwent surgery for benign diseases. In 2020 only 37 patients underwent surgery for oncological reasons and 24 underwent surgery for benign diseases.

Conclusions:

During pandemic Covid-19 the access to health services was limited and poor. Limited access to health services and the fear of Covid-19 infection can explain the lower number of elective surgical procedures for cancer in 2020 compared to the same period in the 2019. (www.actabiomedica.it)

Multifocality in patients treated for papillary Thyroid Carcinoma: a preliminary analysis of related risk factors

Background:

Multifocality is usually detected afterwards surgery for papillary thyroid cancer (PTC) and has been reported in 18-87% of PTC.

Methods:

This is a retrospective single-center study involving a series of 238 patients that underwent thyroidectomy or lobectomy after preoperative fine needle aspiration (FNA) diagnosis of Thyr 5 or Thyr 6, according to Bethesda classification, from January 2015 to December 2019 at the General Surgery Unit of the University - Hospital of Parma. We divided patients into two main groups: patients with multifocal papillary thyroid cancer at postoperative diagnosis and patients with unifocal papillary thyroid cancer. The aim of the study is to identify demographic or preoperative radiological risk factors for the presence of multifocal PTC and to verify the presence of cyto-histological features of greater aggressiveness in multifocal tumors than in unifocal ones.

Results:

Out of our sample, 176 patients were females (73,9%) and 62 males (26,1%) with a mean age of 50,45 ±14,41. Preoperative cytological diagnosis resulted Thyr 5 in 47 cases (19,7%) and Thyr 6 in 191 cases (80,3%). Multifocal cancer was reported in 35,8% of the females and in 32,3% of the males. Older age was significatively related to the presence of multifocal papillary carcinoma (p<0.05). Preoperative bilateral thyroid nodules were associated with a higher finding of multifocal disease at histological examination (p<0.05). The presence of multifocal disease was related with a higher soft tissue invasion at the histological specimen (p<0.05). Tumor size was not related to multifocal PTC in our study.

Conclusions:

Older age of patient and preoperative bilateral thyroid nodules are significantly associated to multifocal thyroid cancer. In add to this, multifocal disease is related to higher finding of perithyroidal tissue invasion at histological exam. In case of predictive factors for multifocal PTC, surgeons should take total/near-total thyroidectomy always into consideration. (www.actabiomedica.it)

Wounds morphologic assessment: application and reproducibility of a virtual measuring system, pilot study

BACKGROUND AND AIMS

Assessment of wounds morphology can be considered, in the everyday medical activity, the first step for the correct pathway of diagnosis. Authors present a pilot study focused on the statistical analysis of 32 cases of wounds measurements conducted by both the traditional method (paper ruler) both the digital smartphone analysis.

MATERIALS AND METHODS

32 lesions were morphologically evaluated. All the enrolled patients were evaluated by both the traditional method (paper ruler) both a digital smartphone analysis based on the app imitoMeasure. The extracted data were compared to the traditional measurements and a statistical analysis was based on intraclass correlation coefficients (ICC).

RESULTS

Three morphological parameters were evaluated: width (expressed in cm), length (expressed in cm) and area (expressed in cm2). The area (expressed in cm2) was found to be the less comparable, but the data were close in this case, too.

CONCLUSION

The present study shows that the digital measuring systems should be easily addressed as versatile tools that could be applied in daily clinical practice in the future.

Relationship between surgeon experience and adverse events in thyroid surgery

In scientific literature there are numerous authors that have highlighted how the outcome of patients undergoing surgical treatment, such as intraoperative or postoperative complications, surgical time, mean hospital stay, is related to the surgeon’s experience based on the number of cases treated per year for a specific disease. In our study we decided to verify if, in our clinical practice, there are significant differences in postoperative outcomes between procedures performed by a senior surgeon, a young specialist or a surgical resident, evaluating if surgical experience affects positively either on intraoperative complications such as bleeding, hypocalcemia, dysphonia, or on surgical time, mean hospital stay and postoperative complications. In this retrospective study we examined all cases of patients that underwent surgery for thyroid disease at our Operative Unit, from January 1, 2015 to December 31, 2019. The analysis of our data highlights how the surgeon’s experience affects the surgical outcome of patients undergoing lobectomy or total thyroidectomy. Our conclusion was that a high volume center, like the one we are working in, with a correct selection of the patients, allows to train a surgical resident guaranteeing both the surgical training of the doctor and the patients safety. (www.actabiomedica.it)

Adverse events in thyroid surgery: observational study in three surgical units with high volume/year

Background

Thyroid surgery, performed for benign or malignant pathologies, is one of the most frequently performed procedures and its frequency has even been increasing in recent years. Postoperative bleeding, recurrent laryngeal nerve (RLN) palsy, associated to dysphonia, dysphagia, dyspnea, and hypoparathyroidism represent the most fearful and common complications. We conducted a multicenter, observational study of retrospectively collected data in three high-volume referral centers, enrolling all patients undergone to thyroid surgery between January 2016 and December 2017 in Parma University Hospital, Cagliari University Hospital and Ferrara University Hospital.

Materials

Patients were divided into five groups, differentiated thyroid carcinoma, medullary thyroid carcinoma, non-toxic benign pathology, hyperfunctioning benign pathology and NIFTP (Non-invasive Follicular Thyroid neoplasm with Papillary-like nuclear features). A follow up at 7 and 30 days was executed, evaluating the onset of paresthesia, dysphonia and dysphagia. A 6-month follow-up was conducted in cases of early complications.

Results

Totally, 1252 patients were eligible for the study: 907 female and 345 male, with a female to male ratio of 2.6:1 and an average age of 53.428. Total thyroidectomy was performed in 1022 cases, lobectomy in 230. After 6 months we recorded paresthesia in 0.5%, dysphonia in 1.8% and dysphagia in 0.5%.

Conclusion

Our study confirms once again that a share of morbidity escapes the possibilities of prediction and control by the operator, depending on patient anamnestic, pathological or anatomical factors.

The modified TIME-H scoring system, a versatile tool in wound management practice: a preliminary report

Background and Aims:

The concept of WBP (wound bed preparation) has revolutionized the way to diagnose and correctly identify the best therapeutic path about the widespread clinical problem of difficult wounds. Starting from the modified TIME-H, authors conducted a preliminary study with the aim of assessing the impact of skin lesions and soft tissues for the surgical patient.

Materials and Methods:

38 patients were preliminarily evaluated. The patients were classified according to the lesion examined, in particular among those who had an infectious or vascular etiology (SSTIs), and patients with surgical site lesions (SSI) and assigned to one of three categories prognosis: favorable (with healing expected within 12 weeks) (0-3A, 0-1B), intermediate (with healing expected over 12 weeks) (4-6A, 2-4B) and uncertain healing (7-8A, 5-8B).

Results:

At the end of the one-year observation period, authors established the healing prediction rate among the studied lesions: the surgical site lesions presented the highest percentage of predictivity (88%), followed by the mixed etiology (72%) and the infectious/vascular injuries (63%).

Conclusion:

This modified-TIME-H can be considered as a versatile and useful scoring tool that should be used in daily clinical practice for the study and treatment of chronic wound diseases.

Thyroid nodules with indeterminate cytology: association between nodule size, histopathological characteristics and clinical outcome in differentiated thyroid carcinomas - a multicenter retrospective cohort study on 761 patients

A great number of surgical diagnostic procedures are performed every year for thyroid nodules that are included in undetermined cytological classes that reveal to be malignant thyroid carcinomas in one-third of cases. In the most recent guidelines, lobectomy is the most recommended surgical approach for this classes of nodules, but total thyroidectomy is the recommended treatment for undetermined nodules larger than 4 cm. The main study aim is to support or question the dimensional criteria as an independent clinical decision element for undetermined thyroid nodules management. We examined data regarding 761 patients undergoing thyroid surgery for undetermined thyroid nodules at two high-volume endocrine surgery units in Italy. Patients were divided into three groups based on the preoperative size of the nodules (N < 1, 1 < N < 4, N > 4 cm). Among the patients belonging to the different groups, we analyzed: differences in malignancy rate, histological characteristics of invasiveness and neoplastic aggressiveness, rates of recurrence and response to therapy. Nodule size (evaluated as a categorical variable and as a continuous variable) did not show any statistically significant correlation with the rate of malignancy, histopathological characteristics of tumor aggressiveness and the patient’s clinical outcome. Most of the tumors found were included in the low risk class (79.2%) and only one was classified as high risk. Follow up of cancer cases showed excellent results in terms of survival, response to therapy and disease recurrence. Malignant thyroid tumors of any size resulting from a nodule identified as cytologically indeterminate are usually characterized by a low risk follicular pattern, well-differentiated and with an excellent outcome. As a result, preferring an extended surgical attitude for undetermined nodules based on tumor size, in absence of other risk factors, can lead to overtreatment in a significant percentage of cases.

Open abdomen in the management of complicated diaphragmatic hernia: a case report

Diaphragmatic hernia (DH) can be congenital or acquired. DH is a potentially life-threatening condition and the management in emergency setting remain unclear. Nonspecific symptoms can delay the diagnosis. We report a case of a 63-year-old man admitted for abdominal pain and nausea. He was successfully treated with damage control surgery.

Cribiform-morular variant of papillary thyroid carcinoma and familial adenomatous polyposis: Report of a case

Cribiform-morular thyroid carcinoma is a rare variant of papillary thyroid carcinoma. It is usually related to Familial Adenomatous Polyposis (FAP) but rarely it may be sporadic. This variant of PTC occurs in young females and it is rare in the elderly. We report a case of a 20 years old female presenting thyroid carcinoma and personal history of FAP.

A peculiar manifestation and clinical course of occult primary hyperparathyroidism: a case report

We present the clinical case of a patient who developed acute hypercalcemia diagnosed after presenting acute pancreatitis.Male patient, age 67, arrived at the Emergency Department of the University Hospital of Parma for upper abdominal pain, radiated to the back, and associated with nausea. Laboratory tests showed elevation of lipase, serum calcium levels, PTH levels and serum creatinine.  Due to the persistence on hypercalcemia an ultrasound scan of the cervical region was performed and showed a hyperechoic nodule of about 25x26x30 mm at the level of the lower pole of the left thyroid lobe, compatible with hyperplastic parathyroid. In the light of clinical-radiological examinations, acute edematous pancreatitis due to hypercalcemia was diagnosed. Hypercalcemia was attributable to primary hyperparathyroidism, so surgical indication to parathyroidectomy was gave.After medical treatment there was a progressive improvement of the clinical conditions and a few days later the patient underwent surgical operation of lower left parathyroidectomy with progressive normalization of the serum calcium levels. If hypercalcemia persists ​​after the beginning of a specific therapy there is an indication to perform an emergency parathyroidectomy; in our case the surgical procedure was performed some days after the diagnosis because the calcium serum levels ​​had returned to normal values with significant improvement of the clinical conditions, despite persistence of high PTH values.

Jejunal diverticulitis: Things to know to prevent diagnostic mistake

The jejunal diverticula are relatively rare. A female patient was admitted at our emergency department with acute abdominal pain and vomiting. CT-scan of the abdomen showed multiple diverticula in the colon and multiple intra-abdominal fluid collections, also in the left quadrants of the abdomen. Free intraperitoneal extraluminal air was also observed, suggesting bowel perforation. Surgical exploration showed multiple diverticula of the jejunum with a perforated jejunal diverticulum extending approximately 10 cm from ligament of Treitz. Jejunal resection was performed. Jejunal diverticulitis is rare, but it can lead to an acute abdomen increasing mortality especially in elderly patients. Jejunal diverticulitis usually starts with features that mimic colonic diverticulitis. In patients with personal history of colonic diverticulosis and suspected diverticulitis, jejunal or ileal diverticulitis must be excluded occurring with a frequency of 2.3% in patients with known diverticulosis. In absence of pathognomonic colonic diverticulitis CT findings, small intestine acute complicated diverticulitis should be always suspected. In complicated jejunal diverticulitis surgical treatment is mandatory and a laparotomy can be needed for a better management. (www.actabiomedica.it)

Intraoperative neuromonitoring (IONM) in thyroidectomy for carcinoma in an high volume academic Hospital

BACKGROUND

The diagnosis of thyroid carcinoma has changed in last decades, as the surgical technique during thyroidectomy (endoscopic surgery, robotic surgery, new energy device, intraoperative neuromonitoring).

METHODS

We analyzed patients undergone to thyroidectomy or lobectomy for thyroid carcinoma from January 2010 to December 2019 at the General Surgery Unit of the Hospital - University of Parma. We divided patients into two groups, based on the use or not of IONM.

RESULTS

We analyzed data about 638 patients, 486 (76.2%) female and 152 (23.8%) male, with a mean age of 51.8 years. Totally, 574 patients underwent total thyroidectomy and lymphadenectomy was performed in 39 patients. The lobectomy rate was higher in interventions with neuromonitoring (13.93%) than in those without IONM (3.06%). Considering the incidence of postoperative complications and the presence of infiltration of perithyroid tissues or thyroiditis or lymph node metastasis at the histological report, a statistically significant percentage of dysphonia and paraesthesia was recorded only in patients with infiltration of perithyroid tissues (p <0.0001). There was no significant difference in postoperative blood calcium values. The use of intraoperative neuromonitoring has not significantly changed the incidence of postoperative complication.

CONCLUSIONS

Our study did not show a protective impact of the use of intraoperative neuromonitoring during thyroidectomy on the incidence of postoperative complications but confirmed that it increases the surgeon's feel safety during surgery and facilitates the identification of any undetected nerve lesion with visually intact nerve, inducing the interruption of the thyroidectomy after lobectomy alone, reducing the risk of bilateral recurrent paralysis.

Can we still consider thyroid hyperfunction a protective condition for the onset of thyroid cancer?

Background

Thyroid cancer is the ninth most commonly diagnosed cancer in the world, and the most common endocrine carcinoma. It was originally believed to be a rare event in patients with thyroid hyperfunction and it was reported that hyperthyroidism had a protective role against thyroid neoplasms. However, in recent years, several studies have hypothesized that differentiated thyroid carcinomas and hyperthyroidism may coexist. Our study aims therefore to evaluate the incidence of differentiated thyroid carcinomas on definitive histological examination, in patients undergoing total thyroidectomy or hemithyroidectomy with coexisting hyperfunctioning thyroid disease, to understand whether hyperthyroidism can be considered a protective condition against the onset of thyroid neoplasms.

Methods

The study involved 1,449 patients underwent to thyroid surgery from 2010 to 2018 at the General Surgery Unit, Department of Surgery, University Hospital of Parma, Parma, Italy, presenting thyroid cancer at postoperative histological exam. Patients were divided in two groups based on the presence (Group A) or absence (Group B) of hyperfunction. All data were collected in a dedicated database and include demographic data, such as age and sex, preoperative cytology, date and type of surgery, postoperative diagnosis, characteristics of aggressiveness of the neoplasm and postoperative complications. For data analysis, a P value of less than 0.05 was considered statistically significant.

Results

The incidence of thyroid carcinomas was lower in patients suffering from hyperfunction compared to the incidence found in non-hyperthyroid patients, both in preoperative cytological examination and in postoperative diagnosis through histological examination. Furthermore, the tumors that have developed in patients with hyperfunction had a comparable degree of aggression and invasiveness in the two groups studied. However, we have found an equal incidence of microcarcinomas and occult carcinomas on postoperative histological examination. Postoperative complications in patients with cancer were similar, regardless of the presence or absence of hyperfunctioning thyroid disease.

Conclusions

Our study confirms that hyperthyroidism is a protective condition against thyroid carcinoma, but the finding of an equivalent incidence of occult carcinomas in the two groups stresses the need to perform a cytological examination in case of a nodular pathology in a hyperthyroid patient before performing a treatment.

Preoperatory imaging evaluation in primary hyperparathyroidism and associated thyroid disease

BACKGROUND

Primary hyperparathyroidism (pHPT) is an endocrinological disorder characterized by excessive secretion of parathormone. Minimally invasive approach has become a widespread surgical method for pHPT treatment due to the improvement of preoperative gland localization imaging techniques and the use of intraoperative PTH dosage (IOPTH). We discuss the results of different imaging technique.

MATERIALS AND METHODS

We have conducted a retrospective analysis of 80 patients that underwent surgery for primary hyperparathyroidism in the period between 01/01/2012 and 28/02/2018 and we have focused our data collection on preoperative study, intraoperative findings and follow-up data. We have evaluated the concordance between the findings of the most used imaging techniques, copresence of thyroid disease and IOPTH.

RESULTS

SPECT-CT showed the best results in terms of positivity (93.1%), sensitivity (88.9%) and accuracy (82.8%). Neck ultrasound resulted to have the best positive predictive value (94.4%). IOPTH decrease was correlated with patients' healing (p <0.05). Age lower than 70 years, post-operative calcium and PTH serum levels were related to a higher chance of healing (p <0.05).

CONCLUSION

US-scintigraphy combination is suitable for preoperative evaluation and SPECT/CT confirms to be the best additional examination; the presence of thyroid disease decrease the sensitivity. IOPTH is an important predictor of healing KEY WORDS: Intraoperative PTH, Hyperparathyroidism, Parathyroidectomy, SPECT/CT, Thyroid disease.

Surgeon case volume and 5 years survival rate for colorectal cancer

AIM

Many factors that influence patient outcome in colorectal surgery are not editable, and these are related either the tumor, the patient and the treatment. The surgeon- and hospital-related factors are independent predictors of outcome for colorectal cancer surgery and these are supervision, teaching/training, specialization in colorectal surgery, high caseload, high hospital caseload.

MATERIALS OF STUDY

We evaluated the impact of the experience of 4 surgeons on the 5 years survival rate of patients with colon and rectal cancer and we valued if the surgeons' experience plays an equal role in both.

RESULTS

Four experienced surgeons operated 384 patients with colorectal cancer. Surgeon with the major experience and colorectal-dedicated presented a slightly better total 5 years survival rate, comparing to other surgeons, although he had a considerably better 5 years survival rate in rectal operations.

CONCLUSIONS

We concluded that surgeon- and hospital-related factors directly influence the surgeon learning curve and are therefore rightly considered predictors of outcome in colorectal cancer surgery. A low surgeon or hospital caseload may be compensated by intensified supervision or by improved training and teaching.

KEY WORDS

Colon cancer, Colectomy, Surgeon volume.

How COVID-19 pandemic has changed elective surgery: the experience in a general surgery unit at a COVID-hospital

Objective:

Evaluate the impact of Covid-19 in a critical area and analyze the changes in the daily activities in a General Surgery Unit of a tertiary Covid-Hospital.

Methods:

We report and compared all the surgical procedures performed between two periods (March and April 2019 and March and April 2020) at General Surgery Department of Parma University Hospital, a tertiary Covid-Hospital.

Results:

Between March and April 2019, a total of 232 surgical procedures were performed. Between March and April 2020 only 61 surgical procedures were performed. In 2019 84 patients underwent surgery for cancer and 171 underwent surgery for benign diseases. In 2020 only 37 patients underwent surgery for oncological reasons and 24 underwent surgery for benign diseases.

Conclusions:

During pandemic Covid-19 the access to health services was limited and poor. Limited access to health services and the fear of Covid-19 infection can explain the lower number of elective surgical procedures for cancer in 2020 compared to the same period in the 2019. (www.actabiomedica.it)

Operating Room Setup: How to Improve Health Care Professionals Safety During Pandemic COVID-19-A Quality Improvement Study

Background: COVID-19 is a terrific pandemic and a potential risk for every health care professional (HCP), especially during emergency conditions where the right timing is essential for the correct treatment. During surgery the correct setting of operative room (OR) is mandatory to reduce the risk of contamination. Personal protection equipment (PPE), specific devices, and planned OR setting are essential during surgery in pandemic COVID-19. Methods: Medline, PubMed, Scientific societies recommendations, and guidelines were consulted to identify articles reporting the setup of OR during pandemic COVID-19. Results: OR must have a high-efficiency particulate air (HEPA) filter with negative pressure and a high air exchange cycle rate. Every supply kit should be packed and placed in the OR before patient arrival. A detailed checklist of equipment and devices is necessary. Personal PPE at the highest level should be provided to every HCP (Association of the Advancement of Medical Instrumentation [AAMI]-Level-III surgical gowns; double latex-free gloves with Acceptable Quality Level <1.0; FFP3 or powered air-purifying respirator masks with face shield). Anesthesia should be performed with a rapid sequence intubation. During surgery energy devices should be settled to the lower level in combination with a smoke evacuation switch pen with disposable smoke evacuation HEPA filter to minimize surgical smoke spread. During laparoscopy low pneumoperitoneum pressures and aspiration systems must be provided. Conclusions: Emergency surgery during pandemic COVID-19 increases the risk for every HCP in the OR. A theoretical risk of transmission from the surgical field exists. It is mandatory the adoption of strong strategies to reduce the risk of contamination in the OR.

Management of intra-abdominal-infections: 2017 World Society of Emergency Surgery guidelines summary focused on remote areas and low-income nations

BACKGROUND

Most remote areas have restricted access to healthcare services and are too small and remote to sustain specialist services. In 2017, the World Society of Emergency Surgery (WSES) published guidelines for the management of intra-abdominal infections. Many hospitals, especially those in remote areas, continue to face logistical barriers, leading to an overall poorer adherence to international guidelines.

METHODS

The aim of this paper is to report and amend the 2017 WSES guidelines for the management of intra-abdominal infections, extending these recommendations for remote areas and low-income countries. A literature search of the PubMed/MEDLINE databases was conducted covering the period up until June 2020.

RESULTS

The critical shortages of healthcare workers and material resources in remote areas require the use of a robust triage system. A combination of abdominal signs and symptoms with early warning signs may be used to screen patients needing immediate acute care surgery. A tailored diagnostic step-up approach based on the hospital's resources is recommended. Ultrasound and plain X-ray may be useful diagnostic tools in remote areas. The source of infection should be totally controlled as soon as possible.

CONCLUSIONS

The cornerstones of effective treatment for intra-abdominal infections in remote areas include early diagnosis, prompt resuscitation, early source control, and appropriate antimicrobial therapy. Standardization in applying the guidelines is mandatory to adequately manage intra-abdominal infections.

Emergency Surgery in A Tertiary Hospital: The Covid-19 Experience

Objective: Evaluate the impact of Covid-19 in a critical area and analyze the changes in the daily activities in an Emergency Department of a tertiary COVID-Hospital. Methods: We reported and compared the surgical procedures performed for acute appendicitis and acute cholecystitis between two periods (March and April 2019 and March and April 2020) at Emergency Surgery Department of Parma University Hospital, a tertiary COVID-Hospital. Results: A total of 72 patients underwent surgery between March and April 2019 and 36 between March and April 2020 for acute appendicitis and cholecystitis. The average length of stay was comparable in the two considered years for LA (4.23±1.69 days in 2019 versus 4.5±2.33 days in 2020). The average length of stay in patients with acute cholecystitis was 5.9±3.8 days in 2019 and 8.23±5.5 days in 2020(P=0.038). The average hospitalization was comparable with 2019 data (5.62±3.77 days)n March 2020;whereas, April 2020 was statistically significantly longer 10.5±6 days (P= 0.023). Conclusions: Half of the emergency centers reported a drop in the overall number of urgent cases as confirmed in our department, where the number of total appendicectomy and cholecystectomy was halved comparing the two months in 2019 and 2020, 72 operations in 2019 versus 36 operations in 2020.During the pandemic, the confidence of the population to the healthcare systems was poor, and this can explain the delayed access to the emergency department of patients who suffered from an acute illness. Bangladesh Journal of Medical Science Vol.19(0) 2020 p. S 66-S 68

Mini-invasive thyroidectomy and intraoperative neuromonitoring: a high-volume single-center experience in 215 consecutive cases

BACKGROUND

Endocrine surgery recent evolution has been characterized by introduction of mini-invasive video-assisted technique. When a new technique is introduced in surgical use the rate of adverse events must be the same of previous standardized technique. In MIVAT procedure complication rate and in particular nerve injury risk is associated surgeon's experience. The new approach is the intraoperative neuro-monitoring (IONM) use in MIVAT in order to reduce the laryngeal nerve injury rate in a more technically difficult surgical procedure.

METHODS

We analyzed clinical and surgical data regarding 215 patients treated with MIVAT technique and simultaneous IONM utilization from September 2014 to December 2019 in a single high-volume surgical center. We recorded data regarding age, gender, preoperative diagnosis, surgical time, early postoperative hypocalcemia, hematoma and vocal cord palsy. We compared these data to our first 211 cases of MIVAT (July 2005 to June 2009) at the beginning of the learning curve, performed without using IONM. We tried to highlight the impact of MIVAT and IONM simultaneous use on surgical outcome comparing results to our previous studies, also highlighting the learning curve effect.

RESULTS

We detected a postoperative transitory clinical hypocalcemia in 14 patients (6.5%). No postoperative hematoma was recorded. Using I-IONM during thyroidectomy, we recorded in five cases a loss of signal; in three cases (1.4%) we experienced a temporary postoperative vocal cord palsy, only one case of definitive palsy. We did not observe any significant differences in surgical complications rate between the first 211 cases and these last 215 cases. We have not found any statistically significative difference regarding IONM use during MIVAT procedure related to MIVAT performed without IONM. In our previous experience cases series of MIVAT the percentage of transitory nerve palsy reported was 2.4% (non-significant P value). Surgical indication has changed.

CONCLUSIONS

In our experience we report that the use of IONM in MIVAT is as helpful to improve the safe of procedure. The risk of nerve palsy in literature associated to MIVAT is the same of the related one to classic technique (CT). We have not found statistical positivity to use IONM in MIVAT related to MIVAT without IONM. In our previous experience cases series of MIVAT the percentage of transitory nerve palsy reported was 2.4% (non-significant P value). The most important IONM effect, in our opinion is the "safety feeling" experienced by the surgeon using IONM in a more challenging procedure. As a University Hospital, training surgery residents, we also identified the IONM as a very useful teaching support.

Mini-invasive thyroidectomy and intraoperative neuromonitoring: a high-volume single-center experience in 215 consecutive cases

BACKGROUND

Endocrine surgery recent evolution has been characterized by introduction of mini-invasive video-assisted technique. When a new technique is introduced in surgical use the rate of adverse events must be the same of previous standardized technique. In MIVAT procedure complication rate and in particular nerve injury risk is associated surgeon's experience. The new approach is the intraoperative neuro-monitoring (IONM) use in MIVAT in order to reduce the laryngeal nerve injury rate in a more technically difficult surgical procedure.

METHODS

We analyzed clinical and surgical data regarding 215 patients treated with MIVAT technique and simultaneous IONM utilization from September 2014 to December 2019 in a single high-volume surgical center. We recorded data regarding age, gender, preoperative diagnosis, surgical time, early postoperative hypocalcemia, hematoma and vocal cord palsy. We compared these data to our first 211 cases of MIVAT (July 2005 to June 2009) at the beginning of the learning curve, performed without using IONM. We tried to highlight the impact of MIVAT and IONM simultaneous use on surgical outcome comparing results to our previous studies, also highlighting the learning curve effect.

RESULTS

We detected a postoperative transitory clinical hypocalcemia in 14 patients (6.5%). No postoperative hematoma was recorded. Using I-IONM during thyroidectomy, we recorded in five cases a loss of signal; in three cases (1.4%) we experienced a temporary postoperative vocal cord palsy, only one case of definitive palsy. We did not observe any significant differences in surgical complications rate between the first 211 cases and these last 215 cases. We have not found any statistically significative difference regarding IONM use during MIVAT procedure related to MIVAT performed without IONM. In our previous experience cases series of MIVAT the percentage of transitory nerve palsy reported was 2.4% (non-significant P value). Surgical indication has changed.

CONCLUSIONS

In our experience we report that the use of IONM in MIVAT is as helpful to improve the safe of procedure. The risk of nerve palsy in literature associated to MIVAT is the same of the related one to classic technique (CT). We have not found statistical positivity to use IONM in MIVAT related to MIVAT without IONM. In our previous experience cases series of MIVAT the percentage of transitory nerve palsy reported was 2.4% (non-significant P value). The most important IONM effect, in our opinion is the "safety feeling" experienced by the surgeon using IONM in a more challenging procedure. As a University Hospital, training surgery residents, we also identified the IONM as a very useful teaching support.

Surgery in COVID-19 patients: operational directives

The current COVID-19 pandemic underlines the importance of a mindful utilization of financial and human resources. Preserving resources and manpower is paramount in healthcare. It is important to ensure the ability of surgeons and specialized professionals to function through the pandemic. A conscious effort should be made to minimize infection in this sector. A high mortality rate within this group would be detrimental.This manuscript is the result of a collaboration between the major Italian surgical and anesthesiologic societies: ACOI, SIC, SICUT, SICO, SICG, SIFIPAC, SICE, and SIAARTI. We aim to describe recommended clinical pathways for COVID-19-positive patients requiring acute non-deferrable surgical care. All hospitals should organize dedicated protocols and workforce training as part of the effort to face the current pandemic.

Intraoperative neuromonitoring in traditional and miniinvasive thyroidectomy. A single center experience in 1652 nerve at risk

Background:

The world is rapidly urbanizing, causing alarming health problems to their citizens. The Cities Changing Diabetes program aims to address the social factors and cultural determinants that can increase type 2 diabetes (T2D) vulnerability among people living in cities.

Methods:

Public data of Italian Institute for Statistics (ISTAT) and available scientific reports were reviewed and findings integrated. The prevalence of T2D in the 8 health districts of Rome was mapped and the correlation between prevalence and social and cultural determinants was assessed.

Results:

The metropolitan area of Rome has 4.3 million inhabitants. People over 65 has increased by 136,000 units in the last decade, reaching 631,000 citizens in 2015. Elderly people living alone are 28.4%. The obesity prevalence is 9.3%, as compared to 8.2% in the year 2000. The prevalence of T2D is 6.6%, varying in the different 8 health districts between 5.9% and 7.3%. A linear correlation exists between the prevalence of diabetes in the districts, unemployment rate and use of private transportation rate (Pearson R 0.52 and 0.60, respectively), while an inverse correlation is present with aging index, school education level, and slow mobility rate (Person R -0.57, -0.52, and -0.52, respectively).

Conclusions:

Important socio-demographic changes have occurred in Rome during the last decades with a raise in the prevalence of obesity and diabetes. A wide variation exists in the prevalence of T2D among the districts of Rome, associated with social and cultural determinants. This study model can help rethinking diabetes in an urban setting. (www.actabiomedica.it)

Possible association between breast thyroid carcinoma: analysis of risk factors

BACKGROUND

Breast cancer (BC) is the most common tumor in women, 523.000 cases were estimated in Europe in 2018 and it remains the third cause of cancer related deaths after lung and colorectal cancer. The incidence of thyroid cancer (TC) in females is higher than in males.

METHODS

We have retrospectively collected all female patients undergone to surgery for breast or thyroid cancer in 2010The aim of the study was to value the incidence of BC in patients with a personal history of differentiated thyroid cancer (DTC) and conversely, the incidence of DTC in patients with previous BC within 5 years from the diagnosis of the first tumor in 2010.

RESULTS

Among 76 BC patients, 11 were death and 22 didn't answer the phone call or refused to re-submit to thyroid ultrasound so they were excluded from the study and only 43 BC were further considered. Thyroid ultrasound was performed in 2010 and in 2016 and it described nodules in 13 (30%) patients in 2010 and in 21 (49%) patients in 2016. In 2010 no FNA was needed while in 2016 6 (14%) patients underwent to FNA with a benign response (Thyr 2). Among 61 DTC patients, 11 didn't answer the phone or the questions so 50 patients were included in the study. Breast cancer family history was reported in 14 (28%) patients and thyroid cancer family history in 8 (16%) patients. No relapse was reported during follow up.All patients underwent to mammography in 2015 or in 2016 within screening programs and no breast cancer were diagnosed.

CONCLUSION

The female predominance of diseases of the thyroid and breast makes difficult the separation of an expected association with a casual linkageThe relationship between the co-occurrence of breast and thyroid cancer remains controversial and inconclusive.

KEY WORDS

Breast cancer, Breast surgery, Hormone therapy, Thyroid cancer, Thyroidectomy.

Treatment of postoperative accessory bile duct injury by fibrin glue and balloon tamponade: a case report

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Iatrogenic bile duct injuries are still a diagnostic and therapeutic problem and their incidence increased with the introduction of laparoscopic technique. This case report documents a patient with a biliary fistula from an accessory bile duct - Lushka's duct - after routine laparoscopic cholecystectomy, unresponsive to relaparoscopy, ERCP with papillosphincterotomy, biliary stent and nosobiliary tube placement and finally treated with injection of fibrin glue and balloon tamponade through the external drain. Iatrogenic bile duct injuries remain a challenging problem, in particular when they do not communicate with central biliary tree. The detection of this fistulas is more difficult and their management should be multidisciplinary. This case presentation is to emphasize importance of correct diagnostic evaluation and timely and adequate non-surgical methods of treatment of biliary fistulas. (www.actabiomedica.it).

Hemobilia due to cystic artery pseudoaneurysm following cholecystectomy: diagnosis and management, a case report

Hemobilia is an unusal cause of upper gastrointestinal bleeding and may be the result of the formation of an hepatic vessel pseudoaneurysm. This is a rare occurence after laparoscopic or open cholecistectomy. The most importants factor for pathogenesis are direct or indirect iatrogenic injuries during intervention and hepatic trauma. Clinical presentation may also be late and includes more frequently upper gastrointestinal bleeding due to pseudoaneurysm rupture, abdominal pain and jaundice secondary to bile duct compression. Therapies includes trans arterial embolization of feeding artery and percutaneous ingjection of embolic devices into the aneurysm. Surgery must be reserved for cathether based therapy failure. We report a case of a 66 year old man, presenting a month after cholecystectomy, complaining abdominal pain in the upper right quadrant and hematemesis. An EGDS exam showed hemobilia and computed tomography (CT) revealed a cistic artery pseudoaneurysm (PSA) wich have been successfully treated with hyperselective arterial embolization. Although this is a rare complication the surgeon must be aware of related symptoms and signs in order to sospect pseudoaneurysm as prompt recognition and treatment are essential. Untreated haemobilia may determine an immediate threat to life leading to acute haemodynamic instability We describe both diagnostic features and therapeutic strategies in comparison to the most recent literature. (www.actabiomedica.it)

IONM and thyroidectomy in benign thyroid disease. Analysis of adverse events

OBJECTIVES

The aim of this study is to identify statistically significant differences in the onset of postoperative complications in patients undergoing thyroid surgery for benign pathology, following the systematic introduction of intraoperative neuromonitoring (IONM) of the laryngeal nerves.

MATERIALS AND METHODS

In this study we have retrospectively analysed data of 604 consecutive patients underwent to thyroidectomy in the Unit of General Surgery - University Hospital of Parma between January 2011 and December 2017. All patients were divided in two groups: the first group of patients was operated without the use of IONM (Group A) the second group was operated after the introduction of the systematic use of IONM (Group B). We have compared the incidence of adverse events in these two groups, analysing the impact of IONM on the onset of the most frequent complications after thyroid surgery. We have considered the impact of other variables in both groups, such as thyroiditis, hyperfunction and gland sinking in mediastinum.

RESULTS

No statistically significant differences in the incidence between Group A (patients operated without the use of IONM) and Group B (patients operated with the use of IONM) were detected, though a decreasing trend after the introduction of IONM was observed. No statistically significant differences were reported even analysing the influence of other patient's variables such as thyroiditis, hyperfunction and glandular sinking in mediastinum.

CONCLUSION

Even if the number of patients considered is not sufficient to value statistically significant differences, the decreasing trend of the incidence of postoperative complications after introduction of IONM encourage us. The surgeon expertise is still the most relevant variable influencing the decreasing of postoperative complications, underlining the importance of the centralization of this kind of surgery in the high volume centres.

Non-surgical complications in oncological colorectal surgery: a comparison between open and laparoscopic techniques

BACKGROUND

Most of the studies on laparoscopic surgery in the treatment of colorectal cancer analyzed the oncological or surgical outcome. It remains to be clarified, if laparoscopic surgery leads to a significant reduction in the incidence of systemic complications in the postoperative period.

MATERIALS AND METHODS

We undertook a quantitative and qualitative assessment of non-surgical complications arising in our patients during the postoperative stay ,in relation to laparoscopic surgery compared to open surgery for colorectal cancer. In the study, 426 patients were recruited. The interventions were performed by an open technique for 225 patients, in VL for 145 patients and 56 patients were subjected to intraoperative conversion.

RESULTS

The correlation between surgical technique and onset cardiac complications showed a higher rate of onset of these in open (11.7%) than the VL technique (5.5%). Same result for pulmonary complications (open 13.2%, VL 3.4%) and renal (open 5.7%, VL 1.4%). Average age of patients treated with open surgery 75 years, average operating time duration 169 minutes. Average age patients treated in VL 69 years, average operating time duration 175 minutes. A possible benefit of videolaparoscopic rectal surgery on non-surgical complications has also been investigated, but a significant conclusion has not been reached due to the small number of adverse events found in the reference sample. The evaluation of the duration of the operating session in relation to non-surgical complications showed an increase in the occurrence of pulmonary, renal and systemic adverse events. There was also a significantly greater risk of pulmonary complications in male patients (M 12.7%, F 6.8%). Finally, by stratifying patients by age, a significant positive correlation emerged in the onset of pulmonary complications in the subgroup of patients aged ≥ 70 years, operated with open technique (open 14.6%, vl 3.8).

CONCLUSIONS

The data analysed shows a reduction of pulmonary and renal cardiac adverse events after laparoscopic oncological surgery, it has not come to a conclusion for rectal cancer. There is also an increase in adverse events related to the duration of the operating session, the male sex and the age ≥ 70 years, thus enhancing the hypothesis that elderly patients are actually the population who can ultimately benefit more of minimally invasive surgical techniques.

KEY WORDS

Adverse eventColectomy, Colorectal cancer, Laparoscopy, Open surgery.

IONM and minimally invasive videoassisted thyroidectomy

BACKGROUND

We know that benefits of MIVAT are related to a better cosmetic result and lower post-operative pain in comparison to CT. The incidence of nerve cold palsy is related to a correct identification of the recurrent laringeal nerve (RLN) as standard procedure in thyroid surgery. From September 2014 we have introduced the use of intraoperative neural monitoring(I-IONM) in all thyroidectomies in the Unit of General Surgery of University Hospital of Parma, including in MIVAT.

PATIENTS AND METHODS

We have considered all patients treated from September 2014 to September 2017 for thyroid diseases using MIVAT and IONM. Intermittent neuromonitoring with NIM-3.0 equipment (Medtronic, Jacksonville, FL, USA) was used during all operations. We have recorded all data about age, sex, diagnosis, surgical time, i-IONM signal, postoperative pain, postoperative hypocalcemia after 24 hours, haematoma and vocal cord palsy. The mean hospital stay was collected from surgical procedure to hospital discharge. We have considered vocal dysfunctions that persist six months after surgery as permanent.

RESULTS

From September 2014 to September 2017 we treated consecutively with both MIVAT and i-IONM 100 patients. Considering the extent of surgery, 26 pts underwent to hemithyroidectomy and 74 pts to total thyroidectomy. The mean surgical time was 61.8 minutes. In 7 cases the patients were affected by preoperative clinical dysphonia. Using I-IONM during thyroidectomy, we recorded in 5 cases (5%) a loss of signal; in two cases (2%) we experienced a temporary postoperative vocal cord palsy.

DISCUSSION

In our experience the use of IONM has improved the safety during thyroidectomy because precision that can be achieved by endoscopic procedures is further improved by complementary use of IONM. The costs associated to a potential reduction of medical litigation have not been investigated.

The use of energy devices for thyroid surgical procedures. Harmonic Focus versus Biclamp 150

BACKGROUND

Thyroidectomy is the most frequently performed endocrine surgery, and in recent years, the surgical instruments and techniques used in this surgery have greatly evolved. New devices are created to facilitate dissection, haemostasis increasing the intraoperative cost.

MATERIAL AND METHOD

We prospectively examined patients undergoing to traditional thyroidectomy using reusable vs disposable devices (BiClamp 150, ERBE ® - group A vs. Harmonic Focus, ETHICON® - group B). The patients were treated for benign and malignant diseases from two experienced surgeons. The two groups were separated based on age, sex, skin-to-skin operative time, the number of parathyroid glands identified by the surgeon during the operation, preand post-operative serum calcium levels evaluated with PTH until 24 hours after surgery, the mean hospital stay, the evaluation of the content of the drainages at 6 hours and 24 hours, and the thyroid gland volume calculated via ultrasound preoperatively. The patients were asked to complete a form at 24 hours post-op to self-evaluate dysphagia to liquids and pain on a scale from 0 to 10.

RESULTS

The patients analysed were 80 pts. Analysis of the data showed no significant differences between the groups with respect to age, (p = 0:48), or gender, 9 males and 31 females in group A and 8 males and 32 females in group B.The thyroid volume (in ml), calculated on the basis of preoperative ultrasonography, was 43.89 ± 37.10 in group A vs. 54.54 ± 51.92 in group B (p = 0.35). The skin-to-skin operative time was equal to 50.16 ± 10.43 min.vs. 52.39 ± 11:54 min.(p = 0.36) in groups A and B, respectively. No statistically significant differences in pre e postoperative calcium levels. The amount of drainage at 6 hours after surgery was 16.63 ± 15.24ml. in group A and 23.72 ± 21.93ml. in group B (p = 0.07). At 24 hours after surgery, the amount was 57.84 ± 32.56ml. in group A and 66.79 ± 39.94ml. in group B (p = 0.28). For group A and group B, we analysed dysphagia for liquids on a scale from 0 to 10 (4.5 ± 2.35 vs. 4.18 ± 2.4, p = 0.48, respectively), alterations in patients' tone of voice (1.97 ± 2.51 vs. 1.43 ± 0:48, p = 0.29, respectively), and postoperative pain at 24 hours after surgery (2.76 ± 1.99 vs. 2.68 ± 2.12, p = 0.87, respectively). The average cost for group A was equal to € 25 × 40 = 1000 vs. € 450 × 40 = 18000 for Group B. The hospital stay in days was equal to 1.70 ± 0.46 (Group A) vs. 1.66 ± 0.53 (Group B) (p = 0.69).

CONCLUSIONS

One limitation of the current study is its small sample size. Both devices are effective and safe for total thyroidectomy because they have similar effects on the operative time, postoperative bleeding and patient outcomes in endocrine experienced surgical team. On the other hand, in a time of the spending review and the standardisation of surgical techniques to ensure the highest quality of services offered, the BiClamp is a viable alternative tool with a high security standard and low cost that offers significant savings to the health care system.

KEY WORDS

Energy devices, Health care, Thyroidectomy.

CD133 is a selective marker of CRC?

AIM

The aim of our study is to evaluate the surface glycoprotein CD133 as marker of cancer stem cells, as independent prognostic pattern of survival and its positive expression ratio to a chemotherapy increased resistance.

METHODS

The study include our patient, affected by colorectal cancer (CRC) and underwent to surgery at University Hospital of Parma, with curative intent, with a follow up of 5 years; 47 cases were considered. All the cancer-case was considered independently by the histological grade. The monoclonal antibody CD133/1 (clone AC133-MAC, Miltenyi Bioetec, Auburn CA 95602, USA) that recognizes the epitope 1 of CD133 was utilized for the immunohistochemical process.

RESULTS

On the total of 47 patients taken in exam, 8 were excluded for lack of date, 13 were lost during the follow-up. The final number of patients included in the study was 26(17 males and 9 females), medium age of 72.2 years. 2 Stage I, 8 Stage II A, 1 II B, 2 III A, 5 III B, 5 IIIC and 3 IV. Despite for 1, 25 on 26 patients were positive to CD133 (96.5 %), with different dye intensity, directly related at the positive cell pull. The CD133 positivity wasn't therefore related at any other clinic-pathological characteristic.

CONCLUSION

The results obtained from our study goes in the same direction with others, that confirm a high representation of CD133 on the colic tumoral epithelium. It will be appropriate to do prospected and randomized studies, with a larger casistic, utilizing similar methods and a patients populations with more uniform characteristics, to verify the real role of CD133 and other molecules potentially marker of tumoral stem cell (TSC).

[Clonidine in the treatment of short stature: preliminary clinical experience]

Fourteen children between 5 and 12 years old at P1 B1 Tanner's pubertal stage were studied. Seven of them were affected by familiarly short height and seven had a constitutional growth delay. All those patients (responders) except two (hyporesponders) turned out positive to GH stimulation tests (GH to I.T.T., GH to clonidine test). We have treated with clonidine (0.100 mg/m2 for six months) all patients and there were significant results: higher values of basal GH and increase in the response to the clonidine test also in patients hyporesponders before treatment.