Predictive factors for lymph node involvement in sporadic medullary thyroid microcarcinoma: a systematic review

OBJECTIVE

The aim of the study was to determine the impact of laboratory and imaging tests in predicting central and lateral neck lymph node/LN involvement and in decision making for surgical extent.

MATERIALS AND METHODS

A PubMed, Web of Science and Scopus search was performed according to PRISMA criteria. The relationship between nodule size, diagnostic biomarkers and imaging with LN involvement were evaluated.

RESULTS

The available data analysis did not yield clear indications of the relationship between each of these topics and the presence, number, and location of LN involved. There was no conclusive data for the selective indication of central neck dissection in the preoperative diagnosis of microMTC.

CONCLUSIONS

There is no justification for less invasive interventions than total thyroidectomy with lymph node dissection.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Surgeon volume and hospital volume in endocrine neck surgery: how many procedures are needed for reaching a safety level and acceptable costs? A systematic narrative review

The relationship between quality of care and provider's experience is well known in all fields of surgery. Even in thyroidectomies and parathyroidectomies, the emphasis on positive volume-outcome relationships is believed. It led us to an evaluation of volume activity's impact in terms of quality of care. A systematic narrative review was performed. According to the PRISMA criteria, we selected 87 paper and, after the study selection was performed, 22 studies were finally included in this review. All articles included were unanimous in attributing to activity volume of surgeons as well as centers a substantial importance. Some differences in outcomes between these investigated categories have been found: best results of the high volume surgeon is evident expecially in terms of complications, on the contrary best outcomes of a high volume center are mainly economics, such as hospital stay and general costs of the procedures. A cut-off of 35-40 thyroidectomies per year for single surgeon, and 90-100 thyroidectomies for single center appears reasonable for identifying an adequate activity. Concerning parathyroidectomy, we can consider reasonable a cut off at 10-12 operations/year. More studies are needed in a European or more circumscribed perspective.

Mapping the centers performing endocrine neck surgery in Italy

BACKGROUND

Quality of care and provider's experience seem to be strictly connected in any field of surgery. Aim of this study is to identify a method to classify the centers on the basis of the number of thyroidectomies and parathyroidectomies performed.

METHODS

We listed 666 centers performing endocrine neck surgery in 2015, from the database of the Italian Health Ministry. We performed a descriptive statistic analysis with a dedicated software. We identified the outliers, according to a previous literature review, in those centers performing >1000 and < 10 thyroidectomies, >100 and < 3 parathyroidectomies and we excluded them to our analysis. The remaining centers were grouped in a box-plot. Third quartile, median, procedures performed/3rd quartile value ratio (Standardized Hospitalization Ratio, SHR, superior cut-off), Romamedian/3rd quartile values ratio (inferior cut-off) were calculated. These centers were charted in a bar graph and three zones were identified: "excellence" (SHR>1.1), "SHR", "alert" (between the two cut-offs) and "risk" (under the lower cut-off).

RESULTS

35743 thyroidectomies and 2306 parathyroidectomies were performed in Italy in 2015. After the outliers' exclusion, 407 and 157 centers performing respectively thyroidectomies and parathyroidectomies were analysed. A median value of respectively 37 thyroidectomies and 6 parathyroidectomies, and a 3rd quartile cut-off of respectively 85 and 12 were calculated. Concerning all the 666 centers, we found: 95 excellence centers for thyroidectomy and 33 for parathyroidectomy, respectively 18 and 17 falling into superior cut-off line, 100 and 29 in the alert zone, 453 and 587 in the risk zone.

CONCLUSIONS

Our method, according to the literature data, highlighted a number of thyroidectomies and parathyroidectomies performed in low volume centers. Looking for an optimization in health organization, we can consider some measures such as a net of tutorship of the "alert" hospitals by the excellence ones and a discouragement of the "risk" hospitals in performing endocrine neck surgery.

Deep SSI after mesh-mediated groin hernia repair: management and outcome in an Emergency Surgery Department

AIM

Mesh-mediated groin hernia repair is considered the goldstandard procedure. It has low recurrence rate. Rarely a deep Surgical Site Infection (SSI) is seen when a synthetic prosthesis is used.

CASE REPORT

We describe a rare case of bilateral deep SSI after mesh-mediated groin hernia repair. Diagnosis was performed through the physical examination and radiological exams. Microbiological samples identified a methicillin-resistant Staphylococcus aureus responsible of the infection. Target therapy was performed and re-operation performed in order to remove the infected prosthesis and to apply a biological one to create the fibrous scaffold. During follow-up time, right side recurrence was observed. Tru-cut biopsy of fascia was obtained in order to identify the responsible of the recurrence.

CONCLUSION

Combination of antibiotic therapy and surgical reoperation seems to be the correct way to approach the deep SSI after mesh-mediated groin hernia repair. The use of biological mesh after synthetic removal seems to improve the final outcome.

The non-surgical management for hemorrhoidal disease. A systematic review

The non-surgical treatments for hemorrhoids are cost and time-saving techniques usually performed in patients suffering early hemorrhoidal disease. The most used are rubber band ligation (RBL), injection sclerotherapy (IS), and infrared coagulation (IRC). We performed a systematic review in order to evaluate: do these procedures really help to avoid further more aggressive treatments? What are the common harms? What are the rare harms? How many recurrences there are? A total of 21 RCTs were included in this review: 12 on RBL, 4 on IRC and 5 on IS. In RBL bleeding stops in up to 90% and III degree hemorrhoids improves in 78%-83.8%. IV degree prolapse should have a more invasive treatment. The commonest complications are bleeding and pain (8-80%). IRC related improvement is 78%, 51% and 22% for I, II and III degree. Post-operative pain occurs in 15-100% and post-operative bleeding ranges from 15% to 44%. Recurrence rate is 13% at a three months follow-up. IS brings to the resolution of prolapse in 90%-100% of II degree and allows good results for III degree even if reported only by case series. The post-procedural pain is 36%-49%. Bleeding is a very rare harm. Even if not definitive, these treatments could be an alternative for mild symptomatic patients after a clear explanation of recurrence rates and possible complications.

Routinary use of fibrin sealants to prevent prolonged air leak in thoracic surgery: our experience

INTRODUCTION

Prolonged air leak (PAL) is one of the most common postoperative complications after lung surgery. It is associated with increased significant morbidity, lower quality of life, longer hospital stay and higher hospital costs. Since its great clinical and economic burden, it is important to establish the feasibility and the effectiveness of the routinary preventive use of a fibrin sealant in order to reduce the incidence of prolonged air leaks.

PATIENTS AND METHODS

This is a randomized study on 189 adult patients - 118 men (62.4%) and 71 women (37.6%) aged from 39 to 87 y.o. (mean age 68.3 y.o.) - who underwent lung surgery (lobectomy or bilobectomy) with intraoperatory detection of air leakage, from January 2013 to December 2017, at Department of Thoracic Surgery in "Ospedale Maggiore Carlo Alberto Pizzardi" (Bologna, Italy) and Department of Thoracic Surgery in "Paolo Giaccone" Teaching Hospital (Palermo, Italy). Patients were randomly assigned to the "Glue" arm (90 patients) or the "Control" group (99 patients). We only used stapler or manual suture to achieve aerostasis. In addition, we used a fibrin sealant ("glue") to cover the suture line on patients in the "Glue" arm. The primary endpoints were incidence of prolonged air leaks, days with chest tube and mean hospital stay.

RESULTS

In the "Glue" arm we experienced only 1 prolonged air leak (1.1%), while in the "Control" group there were 8 leaks (8.1%). Patients kept chest tube for average 4.15 days in the "Glue" arm and 4.45 days in the "Control" group. The mean hospital stay was average 7.4 days for the "Glue" arm, while 9.1 days in the "Control" group.

CONCLUSIONS

According to our experience it seems that the routinary preventive use of a fibrin sealant results in a lower incidence of prolonged air leaks, a shorter hospital stay with lower hospital costs, representing a cost-effective, feasible and effective system to decrease morbility and mortality among surgical patients.

Outpatient management of proctologic disease. Which techniques for local anesthesia? The experience of a single center

INTRODUCTION

Since 1899 outpatient management of surgical patients had been increasing, becoming the best option when possible. In 1988 was described the first experience of outpatient management of proctologic disease. Advances in local anesthesia techniques have improved the outpatient approach to surgical disease, particularly in patients with proctological diseases.

METHODS

From 2010 to 2016, 1160 patients who needed surgery for proctologic disease have been recruited: 239 hemorrhoidectomies using the variant of Milligan Morgan technique described by Phillips, 45 trans-anal hemorrhoidal DE-arterialization (THD), 315 sphincterotomies, 12 anal polypectomies, 230 loop seton positions, 65 cone-like fistulectomies and 254 fistulotomies for perianal fistulas. In 329 cases, we used the posterior perineal block, 603 local perineal blocks, and 228 tumescent anesthesia.

RESULTS

On a total of 1160 procedure failure rate was of 4.7% (55 cases). Urinary retention (69% 38 cases); bleeding 18% (10 cases), uncontrolled pain 12% of cases (7 cases). The chi-square test demonstrates (p<0.01) that the failure rate of the three types of anesthesia is very different with high statistical significance. The failure rate in patient underwent Posterior Perineal Block was 27/329 cases (8.2%), 8/228 (3.5%) in patients who underwent Tumescent Anesthesia and 20/603 (3.3%) in who underwent Local Perineal Block.

CONCLUSIONS

Outpatient protocols represent the most common approach to minor proctologic disease that needs a good local block, with a good analgesic and sedative assistance, the different local block seems to be the same concerning the pain control, but presents some little, not relevant difference concerning urinary retention rate.

Resection of a giant mediastinal leiomyosarcoma

Primary leiomyosarcomas of the lung are tumors. We report a case of 49-year old female with history of cough, breathless at rest, right sided chest pain. Chest CT showed a huge (16 cm) mediastinal mass located on the right mediastinum encasing the right main pulmonary artery and infiltrating the main right bronchus and pericardium. The tumor was resected with combined pericardiectomy and pnemonectomy via hemiclamshell incision. This surgical access provided an adequate exposure of the chest "blind zones" and it allowed a radical and safe surgical resection of lung, pleura, pericardium and diaphragm. The final diagnosis showed a low grade differentiation leiomyosarcoma.

Postoperative complications, pain and quality of life after thoracoscopic or thoracotomic lobectomy for lung cancer

AIM

Thoracoscopic lobectomy is superior to thoracotomy, but the evidence for this assumption is low. We present a comparison between thoracotomy and thoracoscopy in term of postoperative complications, mortality, postoperative pain, hospital stay and quality of life.

PATIENTS AND METHODS

This is a retrospective analysis of 224 lobectomies in 24-months. 128 patients (57.1%) were operated by thoracotomy; 96 patients (42.9%) by videothoracoscopy.

RESULTS

Major complications were observed in 4/128 (3.1%) in thoracotomy group and in 1/96 (1%) in thoracoscopy. Minor complications were observed in 38/128 patients (29.7%) in the thoracotomy, and in 16/96 (16.7%) thoracoscopy. Thoracoscopy patients had a shorter hospital stay.

CONCLUSION

Our study shows an advantage of thoracoscopy over thoracotomy but further studies are needed.

Choroidal metastasis from lung adenocarcinoma: a rare case report

The choroid is the most common site for intraocular metastatic di sease. Orbital metastasis as metastatic site of lung adenocarcinoma is very rare and in literature a very exiguous number of cases is present. This is a case report of a woman with history of lung adenocarcinoma and, after surgery, detection of a choroidal mass described as lung metastasis, responding to Gefinitib therapy. However a biopsy was not performed. After two years there was a great dimension decrement of the lung metastasis but she is still suffering from recurrent pleural effusion, with pleural thickenings biopsied and diagnosed as recurrences of disease.

Fibrin sealant agents: clinical application of TachoSil® in abdominal surgery. Six years experience in an emergency surgery department and review of the literature

BACKGROUND

The success of every surgical procedure depends on an appropriate hemostatis. Topical haemostatic agents, like fibrin sealants, are an option for providing haemostasis and may be particularly useful for complex injuries.

AIM

The aim of the study is to evaluate the use of TachoSil® in abdominal surgery and its benefits to prevent bleedings, and to establish its fields of use.

METHODS

A retrospective observational study was performed on 308 patients underwent to emergency surgery with TachoSil®'s application into our department between January 2012 and March 2018.

RESULTS

After the application of the hemostatic device there have been no haemorrhagic complications that have needed a second surgical intervention. Most frequently use of TachoSil® was in the gallbladder bed after cholecystectomy for an acute cholecystitis.

CONCLUSIONS

Our experience, supported by other reports in the literature, suggests the use of TachoSil® may provide an effective option in helping to control bleedings.

P-POSSUM score: a prognostic instrument for postoperative complications in Crohn's disease

AIM

The purpose of this work is to demonstrate the correlation between the p-POSSUM score and the severity of Crohn's Disease (CD) postoperative complications, evaluated by using the Clavien-Dindo score.

PATIENTS AND METHODS

We have selected data of 22 patients (11 males, 11 females) that had been recovered in the Operative Unit of General Surgery of the University of Palermo General Hospital and undergone surgery for CD from 2010 to 2017.

RESULTS

Patients who underwent surgery for complicated CD was divided in three different group on the base of Clavien Dindo score, C1 (Clavien-Dindo ≤ 1), C2 (Clavien Dindo = 2), and C3 (Clavien Dindo ≥ 3). ANOVA one way statistic analysis was used to investigate the presence of statistic difference in the mean of p-POSSUM operative score between the three groups of patients who underwent surgery for complicated CD. Results show that the severity of postoperative complication after surgery for complicated CD is related to the value of p-POSSUM score (p = 0,004965).

CONCLUSIONS

This study clearly demonstrates a statistic correlation between p-POSSUM operative score and the risk of occurrence of severe postoperative complications in patients with Crohn's disease that had been undergone to surgical procedures of resection with ileostomy and percutaneous drainage.

Thyroid neoplasms: surgical and cyto-histopathological connections on a six year cases study

OBJECTIVE

This study aims to evaluate the percentage of cyto-histologic correlation in patients with a thyroid disease documented through clinical-instrumental, cytological (FNAB), histological and surgical examinations. The purpose of this study is also to determine the percentage of disease incidence and evaluating any surgical indication in relation to biological behavior (benign, malignant or indeterminate lesions, occult carcinomas), sex, and age.

BACKGROUND

Almost all of thyroid neoplasms is manifested through thyroid nodule. Therefore, clinical evidence of the thyroid nodule analysis is primarily related to the need to exclude malignant pathology or carcinoma of the thyroid, present in 4-6.5% of cases.

PATIENTS AND METHODS

The trial was conducted analyzing the data including cytological and histology thyroid reports recorded from 1 March 2010 to 1 March 2016, for a total of 5,956 reports. To determine the cyto-histological correlations, have been considered eligible all patients of both sexes, that have performed at least one cytologic exam followed by an histologic exam. Thus, the total number of the cases studied is 554 cases.

RESULTS

Cyto-histologic compliance was 93% with a diagnostic accuracy of 4% higher than the literature examined.

CONCLUSIONS

The results thus obtained show, furthermore, that there is a non-negligible percentage of thyroid disease with malignant biological behavior and involvement of male individuals. Therefore, the execution of the FNAB is of utmost importance for the purpose of a correct surgical indication.

Non-functioning parathyroid cystic tumour: malignant or not? Report of a case

Parathyroid carcinoma (PC) is a very rare endocrine tumour, usually characterized by symptoms such as a neck mass, dysphonia, severe hypercalcemia exceeding 140 mg/L and elevated serum parathyroid hormone levels, even more than 5 times the upper limit of normal. Non-functioning parathyroid cancer is extremely rare and, in this case, its pre-operative diagnosis is often difficult. A 54-year old female patient, referring dysphagia and dysphonia, underwent neck ultrasound and neck CT. A left thyroid nodule, probably cystic, was found. It presented caudal extent on anterior mediastinum causing compression of the left lateral wall of the trachea. The preoperative calcemia was into the normal range. The patient underwent left thyroid lobectomy. Histological exam showed a cystic lesion, immunohistochemically originating from parathyroid that oriented for carcinoma. The 18 months follow-up did not show a residual-recurrent disease. The parathyroid origin of a neck lesion could not be suspected before surgery when specific laboratory tests are not available and clinical effects of hyperparathyroidism syndrome are not present. Histological features are not always sufficient for the differential diagnosis between the parathyroid adenoma and carcinoma. The immunohistochemistry is an useful tool that can aid to reach the definite diagnosis.

Is it really useful the Harmonic scalpel in axillary dissection for locally advanced breast cancer? A case series

BACKGROUND

The seroma is one of the most common complications in the axillary lymph nodal dissection (different surgical approaches have been tried to reduce the seroma incidence). In our study we evaluate the outcome of patients using or not the ultrasonic scalpel (Harmonic scalpel) according to a standardized surgical technique.

PATIENTS AND METHODS

From January 2011 to December 2015 120 patients underwent axillary dissection for breast cancer. Patients were divided in two groups: patients belonging to the first group underwent Harmonic scalpel dissection and patients belonging to the second group underwent classical dissection. Each group consisted of 60 patients. Quadrantectomy (QUAD) was performed in 54 patients, 66 women underwent mastectomy. In all patients axillary dissection included the I, II and III level. We compared two groups in terms of: time of surgery, hematoma, drainage volume, days of sealing drainage, seroma formation, number of post-seroma aspirations, upper limb lymphedema, wound infections, post-operative pain.

RESULTS

Statistically significant results were obtained in terms of the total volume of the breast and axillary drainage in the two techniques. There were no significant differences in the two samples in terms of operative time incidence of seroma, post-operative hematoma, wound infection, and lymphedema of the upper limb.

CONCLUSION

The small number of cases did not allow us to reach definitive conclusions. The use of Harmonic scalpel seems to show smaller incidence of seroma and reduction of the amount of both breast and axillary drainages. Further studies are needed to define the real advantage in terms of cost benefit of using these devices in the axillary surgery.

Laparoscopic ileocecal resection in acute and chronic presentations of Crohn's disease. A single center experience

INTRODUCTION

The terminal ileum is the most involved tract in Crohn's disease. The obstruction in this location is the most frequent complication. Acute or chronic presentations can occur. Surgery finds a role in the management of chronic strictures and in acute clinical presentations with complications not improving with conservative therapy.

PATIENTS AND METHODS

We investigate the outcome of patients with obstruction of the ileo-cecal bowel tract laparoscopically managed. It was analyzed the average operative time (OT), the conversion rate and the occurrence of re-operation due to surgical complications.

RESULTS

21 patients underwent an ileocecal resection for complicated Crohn's disease between January 2013 and December 2014. The admissions were performed in emergency in 42% of patients. The preintervention hospital stay was 5.8 (Sd 6.23). The mean operative time was 154 min (Sd 41). 28% of the procedures were converted to open surgery. The average hospital stay was 10 days (Sd 5) in uncomplicated patients. The morbidity rate was 28%. In 19% of cases a re-intervention was needed due to anastomotic leakage (3pts) and one hemoperitoneum for bleeding from the suture line.

DISCUSSION

Laparoscopy seems an affordable technique in the management of obstructive pattern of Crohn's disease. It should be the preferable approach in young patients that probably will be submitted to subsequent surgery for the same disease; in fact, the reduced adhesions formation provided by the less bowel manipulation make easy the subsequent access. Older patients had usually more post-operative morbidity and mortality mostly due to pre-existing conditions; if possible in these patients the treatment should be medical.

Uncommon localizations of hydatid cyst. Review of the literature

INTRODUCTION

Hydatid disease is an endemic anthropozoonosis with usual localization in liver and lungs. Rarely it localizes in uncommon sites as spleen, skeleton, kidney, brain, cardiac muscle, peritoneum, sub cutis. Complications of uncommon localizations are the same that for usual ones.

MATERIAL AND METHODS

Review of the literature on rare and atypical localization of hydatid cysts in soft tissues. Key-words used on Pub-Med [(echinococ OR hydatid) AND (soft tissue OR subcutaneous OR cutaneous)] without time limit. There were found 282 articles; 242 were excluded because of muscular or bone localizations. 40 were coherent.

RESULTS

Different variables are taken into account: age, sex, geographic area, anatomic localization of the cyst, dimension, symptoms, signs, mobility, blood exams and specific serological tests, imaging techniques for diagnosis, existing of septa in the structure, treatment, anaesthesia, spillage, neo-adjuvant and adjuvant treatment, follow-up period, recurrent lesions.

CONCLUSION

It would be useful create an homogeneous and standardized collection of data of these rare and potentially life-threatening conditions in order to create guide-line of diagnostic and therapeutic process and create (or adopt) unique classification of the lesions.

Rectal bleeding and prolapse… not always benign diseases rather anal cancer. The importance of a correct decision making since primary care

Rectal bleeding is very common in general population with a prevalence of 10-20 %. Primary care physicians have to stratify patients basing on urgency and on the colo-rectal cancer risk and to conduct a decision making for the correct management. We report a case of a 61-years-old woman, complaining rectal bleeding and an anal mass attended to their family doctor who does a visit but without a digital rectal examination and diagnosed a hemorrhoidal prolapse suggesting medical therapy. For the persistence of symptoms she comes to our service from emergency attention. Inspection and digital rectal examination revealed an anal mass. CT scan was performed showing a large anal mass involving half anal circumference. Histologic samples showed an epithelial proliferation compatible with a squamous carcinoma. Oncological consult was requested and a chemo-radiotherapy treatment was proposed. This case report highlights the difficulty when physicians assess patients with anorectal complaints in differentiating anal cancer from benign disease, presumably because symptoms are similar. Primary care physicians must maintain a high index of suspicion of cancer in high-risk population. Sensitization of these colleagues is required since digital rectal examination is of inestimable value to verify the presence of a rectal or an anal mass.

Open versus laparoscopic approach in the treatment of abdominal emergencies in elderly population

AIM

To evaluate the role of laparoscopy in the treatment of surgical emergency in old population.

PATIENTS AND METHODS

Over-70 years-old patients submitted to emergency abdominal surgery from January 2013 to December 2014 were collected and grouped according to admission diagnoses. These accounted small bowel obstruction, colonic acute disease, appendicitis, ventral hernia, gastro-duodenal perforation, biliary disease. In each group it was analyzed the operation time (OT), the morbidity rate and the mortality rate comparing open and laparoscopic management using T-test and Chi-square test.

RESULTS

159 over 70-years-old patients underwent emergency surgery in the General and Emergency surgery Operative Unit (O.U.) of the Policlinic of Palermo. 75 patients were managed by a laparoscopic approach and 84 underwent traditional open emergency surgery. T-Test for OT and Chi-square test for morbidity rate and mortality rate showed no differences in small bowel emergencies (p=0,4; 0,25<p<0,9; 0,25<p<0,9), in colonic acute diseases (p=0,35; 0,25<p<0,9; 0,25<p<0,9), in appendicitis (p=0,22; 0,05<p<0,1; 0,25<p<0,9), in complicated ventral hernia (p=0,12; p>0,9; p>0,95) and in gastro-duodenal perforation (p=0,9; p>0.9; p>0.95). In cholecystitis, laparoscopy group showed lower OT (T-Test: p= 0,0002) while Chi-square test for morbidity rate (0,1<p<0,25) and mortality rate (0,25<p<0,9) showed no differences.

CONCLUSIONS

The collected data showed the feasibility of laparoscopic management as an alternative to open surgery in surgical emergencies in elderly population.

An investigation of bedside laparoscopy in the ICU for cases of non-occlusive mesenteric ischemia

BACKGROUND

Acute mesenteric ischemia is a rare affection with high related mortality. NOMI presents the most important diagnostic problems and is related with the higher risk of white laparotomy. This study wants to give a contribution for the validation of laparoscopic approach in case of NOMI.

METHODS

Thirty-two consecutive patients were admitted in last 10 years in ICU of Paolo Giaccone University Hospital of Palermo for AMI. Diagnosis was obtained by multislice CT and selective angiography was done if clinical conditions were permissive. If necrosis was already present or suspected, surgical approach was done. Endovascular or surgical embolectomy was performed when necessary. Twenty NOMI patients underwent medical treatment performing laparoscopy 24 h later to verify the evolution of AMI. A three-port technique was used. In all patients we performed a bed side procedure 48-72 h later in both non-resected and resected group.

RESULTS

In 14 up 20 case of NOMI the disease was extended throughout the splanchnic district, in 6 patients it involved the ileum and the colon; after a first look, only 6 patients underwent resection. One patient died 35 h after diagnosis of NOMI. The second look, 48 h later, demonstrated 4 infarction recurrences in the group of resected patients and onset signs of necrosis in 5 patients of non-resected group. A total of 15 resections were performed on 11 patients. Mortality rate was 6/20-30% but it was much higher in resected group (5/11-45,5%). Non-therapeutic laparotomy was avoided in 9/20 patients and in this group mortality rate was 1/9-11%. No morbidity was recorded related to laparoscopic procedure.

CONCLUSIONS

Laparoscopy could be a feasible and safety surgical approach for management of patient with NOMI. Our retrospective study demonstrates that laparoscopy don't increase morbidity, reduce mortality avoiding non-therapeutic laparotomy.

Comparison of minimally invasive parathyroidectomy under local anaesthesia and minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism: a cost analysis

BACKGROUND

Primary hyperparathyroidism (PHPT) origins from a solitary adenoma in 70- 95% of cases. Moreover, the advances in methods for localizing an abnormal parathyroid gland made minimally invasive techniques more prominent. This study presents a micro-cost analysis of two parathyroidectomy techniques.

PATIENTS AND METHODS

72 consecutive patients who underwent minimally invasive parathyroidectomy, video-assisted (MIVAP, group A, 52 patients) or "open" under local anaesthesia (OMIP, group B, 20 patients) for PHPT were reviewed. Operating room, consumable, anaesthesia, maintenance costs, equipment depreciation and surgeons/anaesthesiologists fees were evaluated. The patient's satisfaction and the rate of conversion to conventional parathyroidectomy were investigated. T-Student's, Kolmogorov-Smirnov tests and Odds Ratio were used for statistical analysis.

RESULTS

1 patient of the group A and 2 of the group B were excluded from the cost analysis because of the conversion to the conventional technique. Concerning the remnant patients, the overall average costs were: for Operative Room, 1186,69 € for the MIVAP group (51 patients) and 836,11 € for the OMIP group (p<0,001); for the Team, 122,93 € (group A) and 90,02 € (group B) (p<0,001); the other operative costs were 1388,32 € (group A) and 928,23 € (group B) (p<0,001). The patient's satisfaction was very strongly in favour of the group B (Odds Ratio 20,5 with a 95% confidence interval).

CONCLUSIONS

MIVAP is more expensive compared to the "open" parathyroidectomy under local anaesthesia due to the costs of general anaesthesia and the longer operative time. Moreover, the patients generally prefer the local anaesthesia. Nevertheless, the rate of conversion to the conventional parathyroidectomy was relevant in the group of the local anaesthesia compared to the MIVAP, since the latter allows a four-gland exploration.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Amorphous silicon waveguides and light modulators for integrated photonics realized by low-temperature plasma-enhanced chemical-vapor deposition

A new amorphous silicon waveguide is realized by use of amorphous silicon carbon as cladding material. The structure is characterized both experimentally and theoretically, and its application for optical interconnections in photonic integrated circuits on silicon motherboards is proposed. The fabrication process is based on low-temperature (220 degrees C) plasma-enhanced chemical-vapor deposition and is compatible with standard microelectronic processes. Propagation losses of 1.8 dB/cm have been measured at the fiber-optic wavelength of 1.3 microm. A strong thermo-optic coefficient has been measured in this material at this wavelength and exploited for the realization of a light-intensity modulator based on a Fabry-Perot interferometer that is tunable by temperature.

[B-cell lymphoma (MALToma) of the stomach and Helicobacter pylori infection]

The authors, after illustrating physiopathologic aspects of gastric MALTomas, examine the H.P. infections and the possible relations between this kind of bacterium and gastric MALTomas. They hypothesize that H.P. infection represents an important predisposition to gastric lymphoma, due to anatomopathological modifications over gastric mucosa. They conclude that a decreasing of gastric lymphoma could be correlatable an opportune eradication of H.P. despite of at moment it's impossible hypothesize a marked decreasing of lymphoma by an eradication of H.P.

All-silicon Fabry-Perot modulator based on the thermo-optic effect

The operation at 1.5 microm of a silicon Fabry-Perot optical modulator is reported. The electrically driven device, which uses the thermo-optic effect to achieve as much as a 55% intensity modulation depth, has been realized by means of standard silicon microelectronic technology. This demonstrates that this new type of optical modulator can easily be integrated with electronic circuits. An accurate three-dimensional thermal analysis of the device has permitted the setup of a reliable numerical code aimed at the design of optimized integrated versions of it. The simulation outputs therefore predict operation frequencies of hundreds of kilohertz, remarkably superior to those previously reported in thermo-optic-effect-based modulators.