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Sleeve gastrectomy has currently become the most commonly performed bariatric. procedure worldwide according to the last IFSO survey, overtaking gastric bypass with. a share of more than 50% of all primary bariatric-metabolic surgery. Gastric leak, intraluminal bleeding, bleeding from the staple-line and strictures are the most common complications. Portomesenteric vein thrombosis (PMVT)after sleeve gastrectomy is. another complication that has been increasingly reported in case-series in recent.years, although it remains uncommon. In this case report is described an extended portomesenteric vein thrombosis after. sleeve gastrectomy interesting splenic vein too with a favorable course and an. uneventful follow-up. We try to search in this case for pathogenetic factors involved in. this complication. A 42-year old man, with a body mass index (BMI) of 45 kg/m2, with a medical history of Obstructive Sleep Apnea Sindrome (OSAS) underwent laparoscopic sleeve gastrectomy. Early postoperative course was uneventful. Six days after discharge he complained abdominal pain and was admitted at the Emergency Department. A CT scan with intravenous contrast showed an occlusion of the portal vein, of the intrahepatic major branches and an extension to the superior mesenteric vein and the splenic vein. The patient received heparin and oral anticoagulation together with intravenous hydration and proton pump inhibitors. Considering the favourable course the patient was discharged after six days with long-term oral anticoagulation therapy. Anticoagulation with acenocumarol was continued for six months after a CT scan showed resolution of the PMVT without cavernoma. He had no recurrence of symptoms. Porto-mesenteric thrombosis after sleeve gastrectomy is a rare complication but it has been increasingly reported over the last 10 years along with the extensive use of sleeve gastrectomy. Because PMVT is closely associated with sleeve gastrectomy in comparison with other bariatric procedures, we need to investigate what pathogenetic factors are involved in sleeve gastrectomy. Thrombophylic state, prolonged duration of surgery, high levels of pneumoperitoneum, thermal injury of the gastroepiploic vessels during greater curvature dissection, high intragastric pressure, inadequate antithrombotic prophylaxis and delayed mobilization of the patient after surgery have been reported as pathogenetic factors of portmesenteric vein thrombosis. Most of the cases presented in the literature such as our clinical case resolve with medical therapy, although portal vein thrombus extends into the superior mesenteric vein and the splenic vein. Portomesenteric venous thrombosis is a rare but serious complication of bariatric surgery, especially associated with sleeve gastrectomy. Diagnosis is based on CT examination with intravenous contrast, and initial therapy is anticoagulation. Etiologic factors reported in the literature include a long duration of surgery, a high degree of pneumoperitoneum, high intragastric pressure after sleeve gastrectomy and thermal injury to the short gastric vessels and gastroepiploic arcade. Limited operative time, controlled values of pneumoperitoneum, careful dissection with energy device of gastric greater curvature, appropriate prophylaxis with low molecular weight heparin may be useful tools to prevent and limit this complication. Nonetheless we have to search which factors may condition the evolution of an extended PMVT as that described in this case towards resolution or to a further worsening clinical state. Early diagnosis? Correct treatment? Undiscovered patientrelated factors? [ABSTRACT FROM AUTHOR]

Although there are several publications on the new transoral robotic thyroidectomy technique, few have thoroughly reviewed its associated complications. This study analyzed the causes and prevention of transoral robotic thyroidectomy–specific complications and presented preventive measures. The medical records of patients who underwent transoral robotic thyroidectomy performed by a single surgeon between March 1, 2009 and April 30, 2019 were retrospectively analyzed. Patient demographic, clinical, and operative data were analyzed using descriptive statistics. We describe the transoral robotic thyroidectomy–related complications experienced at our institution and how to overcome them. This study included a total of 423 patients who underwent transoral robotic thyroidectomy. The general surgical complications included immediate postoperative bleeding (2 cases) and delayed hematoma (3 cases). Chyle leakage and localized wound infection were found in 1 case each. Transient vocal cord palsy occurred in 4 cases, and 1 case developed transient hypoparathyroidism. The transoral robotic thyroidectomy–specific complications included zygoma bruise (2 cases), flap bruise (3 cases), chin flap perforation (2 cases), and oral commissure tearing (2 cases). The complications occurring when creating the flap included flap burns (4 cases), skin dimpling in the midline of the lower chin (2 cases), and hematomas in the intraoral trocar insertion sites (3 cases). Surgeons familiar with thyroid surgery and experienced in robotic surgery can perform transoral robotic thyroidectomy without causing more complications than those seen with traditional surgery. [ABSTRACT FROM AUTHOR]

The surgical approach to the axilla in breast cancer has been a controversial issue for more than three decades. Data from recently published trials have provided practice-changing recommendations in this scenario. However, further controversies have been triggered in the surgical community, resulting in heterogeneous diffusion of these recommendations. The development of clinical guidelines for the management of the axilla in patients with breast cancer is a work in progress. A multidisciplinary team discussion was held at the research hospital Policlinico San Matteo from the Università degli Studi di Pavia with the aim to update recommendations for the management of the axilla in patients with breast cancer. An evidence-based approach is presented. Our multidisciplinary panel determined that axillary dissection after a positive sentinel lymph node biopsy may be avoided in cN0 patients with micro/macrometastasis to ≤2 sentinel nodes, with age ≥40y, lesions ≤3 cm, who have not received neoadjuvant chemotherapy and have planned breast conservation (BCS) with whole breast radiotherapy (WBRT). Cases with gross (>2 mm) ECE in SLNs are evaluated on individual basis for completion ALND, axillary radiotherapy or omission of both. Patients fulfilling the criteria listed above who undergo mastectomy, may also avoid axillary dissection after multidisciplinary discussion of individual cases for consideration of axillary irradiation. Women 70 years or older with hormone receptors positive invasive lesions ≤3 cm, clinically negative nodes, and serious or multiple comorbidities who undergo BCS with WBRT, may forgo axillary staging/surgery (if mastectomy or larger tumor, comorbidities and life expectancy are taken into account). [ABSTRACT FROM AUTHOR]

Purpose Although a few techniques for lengthening intestine by mechanical stretch have been described, they are relatively complex, and the majority involve placement of an intraluminal device. Ideally, techniques applicable to humans would be easy to perform and extraluminal to avoid the potential for mucosal injury. This study of distraction enterogenesis used an extraluminal, radially self-expanding shape-memory polymer cylinder and a simple operative approach to both elongate intestine and grow new tissue. Methods Young Sprague Dawley rats (250–350 g) underwent Roux-en-Y isolation of a small intestinal limb and were divided in three groups: no further manipulation (Control 1, C1); placement of a nonexpanding device (Control 2, C2); or placement of a radially expanding device by the limb (Experimental, Exp). For C2 and Exp animals, the blind end of the limb was wrapped around the radially expanding cylindrical device with the limb-end sutured back to the limb-side. Bowel length was measured at operation and at necropsy (14 days) both in-situ and ex-vivo under standard tension (6 g weight). Change in length is shown as mean ± standard deviation. A blinded gastrointestinal pathologist reviewed histology and recorded multiple measures of intestinal adaptation. The DNA to protein ratio was quantified as a surrogate for cellular proliferation. Changes in length, histologic measures, and DNA:protein were compared using analysis of variance, with significance set at P < 0.05. Results The length of the Roux limb in situ increased significantly in Exp animals (n = 8, 29.0 ± 5.8 mm) compared with C1 animals (n = 5, − 11.2 ± 9.0 mm, P < 0.01). The length of the Roux limb ex vivo under standard tension increased in the Exp group (25.8 ± 4.2 mm) compared with the C2 group (n = 6, − 4.3 ± 6.0, P < 0.01). There were no differences in histologic measures of bowel adaptation between the groups, namely villous height and width, crypt depth, crypt density, and crypt fission rate (all P ≥ 0.08). Muscularis mucosal thickness was also not different (P = 0.25). There was no difference in DNA:protein between groups (P = 0.47). Conclusion An extraluminally placed, radially expanding shape-memory polymer cylinder successfully lengthened intestine, without damaging mucosa. Lack of difference in muscularis thickness and a constant DNA:protein ratio suggests that this process may be related to actual growth rather than mere stretch. This study demonstrated a simple approach that warrants further study aiming at potential clinical applicability. [ABSTRACT FROM AUTHOR]

Purpose We sought to study the impact of trans-amniotic stem cell therapy (TRASCET) in the Chiari-II malformation in experimental spina bifida. Methods Sprague–Dawley fetuses (n = 62) exposed to retinoic acid were divided into three groups at term (21–22 days gestation): untreated isolated spina bifida (n = 21), isolated spina bifida treated with intra-amniotic injection of concentrated, syngeneic, labeled amniotic fluid mesenchymal stem cells (afMSCs) on gestational day 17 (n = 28), and normal controls (n = 13). Analyses included measurements of brainstem and cerebellar placement on high resolution MRI and histology. Statistical comparisons included ANOVA. Results In parallel to the expected induced coverage of the spina bifida in the afMSC-treated group ( P < 0.001), there were statistically significant differences in brainstem displacement across the groups ( P < 0.001), with the highest caudal displacement in the untreated group. Significant differences in cerebellar displacement were also noted, albeit less pronounced. Pairwise comparisons were statistically significant, with P = 0.014 between treated and normal controls in caudal brainstem displacement and P < 0.001 for all other comparisons. Labeled afMSCs were identified in 71% of treated fetuses. Conclusions Induced coverage of spina bifida by TRASCET minimizes the Chiari-II malformation in the retinoic acid rodent model, further suggesting it as a practical alternative for the prenatal management of spina bifida. [ABSTRACT FROM AUTHOR]

Purpose We sought to determine whether simple intra-amniotic delivery of concentrated amniotic mesenchymal stem cells (afMSCs) may elicit prenatal coverage of experimental spina bifida. Methods Time-dated pregnant Sprague–Dawley dams (n=24) exposed to retinoic acid for the induction of fetal neural tube defects were divided in three groups. Group I had no further manipulations. Groups II and III received volume-matched intra-amniotic injections of either saline (Group II) or a suspension of syngeneic afMSCs labeled with green fluorescent protein (Group III) in all fetuses (n=202) on gestational day 17 (term=21–22 days). Animals were killed before term. Statistical comparisons were by ANOVA ( P < 0.05). Results Of 165 fetuses viable at euthanasia, a spina bifida was present in 58% (96/165), with no significant differences in defect dimension across the groups ( P = 0.19). However, variable degrees of coverage of the defect by a rudimentary skin confirmed histologically were only present in Group III ( P < 0.001), in which donor afMSCs were documented, with no differences between Groups I and II ( P = 0.98). Conclusions Amniotic mesenchymal stem cells can induce partial or complete coverage of experimental spina bifida after concentrated intra-amniotic injection. Trans-amniotic stem cell therapy (TRASCET) may become a practical option in the prenatal management of spina bifida. [ABSTRACT FROM AUTHOR]

Purpose We sought to test a novel, extraluminal method of intestinal lengthening that precludes violation of the intestinal wall. Methods Sprague–Dawley rats (n = 45) with size-matched bowel segments isolated by Roux-en-Y reconstruction were divided into three groups. Group 1 (n = 14) had no further manipulations. In Groups 2 (n = 12) and 3 (n = 19), the isolated segment was wrapped around a length-matched device in a helicoidal fashion. In Group 2, the device consisted of plain polyurethane tubing. In Group 3, it consisted of a gradually expanding hygroscopic hydrogel (12.5 mm final diameter). Euthanasia was performed at 8–21 days. Statistical analysis was by two-way ANOVA ( P < 0.05). Results Overall survival was 87% (39/45). There was a statistically significant increase in bowel length in Group 3 compared to the other two groups ( P < 0.001). This increase correlated with the number of helicoidal coils ( P = 0.018), but not with post-operative time ( P > 0.50). There were no significant differences in total DNA/protein ratio across the groups ( P = 0.65). Histologically, there was an apparent increase in the goblet cell density in Group 3. Conclusions Measured extraluminal helicoidal stretch (Helixtretch) is tolerated by the intestine. Helixtretch induces bowel lengthening in a rodent model. Further analysis of this novel, minimally invasive alternative for intestinal augmentation is warranted. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Mesenchymal stem cells (MSCs) are particularly valuable for structural tissue replacement. We compared the response to hypoxia among human MSCs derived from four different clinically relevant sources as an adjunct to translational developments. Methods: Immunophenotypically indistinguishable human MSC lineages derived from bone marrow (bmMSCs), adipose tissue (adMSCs), amniotic fluid (afMSCs), and umbilical cord blood (cbMSCs) were submitted to either room air or 1% O2, under otherwise standard culture conditions. Cell expansion and quantitative RT-PCR data were obtained at different time points. Statistical analysis was by two-way mixed model and the F-test (P<0.05). Results: The effect of hypoxia on expansion kinetics was dependent on cell source. Only prenatal sources of MSCs – afMSCs (P=0.002) and cbMSCs (P<0.001) – proliferated significantly faster under hypoxia than normoxia. Increased HIF1-alpha expression correlated consistently with increased cell expansion only among afMSCs. There were no significant variabilities in Survivin, Oct-4, and VEGF expressions. Conclusions: Mesenchymal stem cell tolerance to hypoxia in vitro varies with cell source. Prenatal cells, particularly those derived from amniotic fluid, are more robust than their postnatal counterparts. HIF1-alpha may play a role in the amniotic fluid-derived cells’ enhanced response. These findings should inform the choice of mesenchymal stem cells for prospective regenerative strategies. [Copyright &y& Elsevier]

Background: Operative traction of the thyroid lobe is a necessary component of thyroid surgery. This surgical maneuver can cause traction injury of the recurrent laryngeal nerve (RLN), and this complication has been reported to be the most common mechanism of nerve injury. The goal of this study was to investigate the electromyographic (EMG) signal pattern during an acute RLN traction injury and establish reliable strategies to prevent the injury using intraoperative neuromonitoring (IONM). Methods: Fifteen piglets (30 RLNs) underwent IONM via automated periodic vagal nerve stimulation and had their EMG tracings recorded and correlated with various models of nerve injury. Results: In the pilot study, a progressive, partial EMG loss was observed under RLN tractions with different tension (n = 8). The changes in amplitudes were more marked and consistent than were the changes in latency. The EMG gradually gained partial recovery after the traction was relieved. Among the nerves injured with electrothermal (n = 4), clamping (n = 1), and transection (n = 1) models, the EMG showed immediate partial or complete loss, and no gradual EMG recovery was observed. Another 16 RLNs were used to investigate the potential of EMG recovery after different extents of RLN traction. We noted the EMG showed nearly full recovery if the traction stress was relieved before the loss of signal (LOS), but the recovery was worse if prolonged or repeated traction was applied. The mean restored amplitudes after the traction was relieved before, during, and after the LOS were 98 ± 3% (n = 6), 36 ± 4% (n = 4), and 15 ± 2% (n = 6), respectively. Conclusion: RLN traction injury showed graded, partial EMG changes; early release of the traction before the EMG has degraded to LOS offers a good chance of EMG recovery. IONM can be used as a tool for the early detection of adverse EMG changes that may alert surgeons to correct certain maneuvers immediately to prevent irreversible nerve injury during the thyroid operation. [Copyright &y& Elsevier]

Abstract: Purpose: To evaluate the safety and efficacy of percutaneous microwave (MW) ablation treatment in locally advanced, nonresectable, nonmetastatic pancreatic head cancer. Materials and Methods: Ten patients with pancreatic head cancer treated with percutaneous (n = 5) or laparotomic (n = 5) MW ablation were retrospectively reviewed. The MW generator used (45 W at 915 MHz) was connected by coaxial cable to 14-gauge straight MW antennas with a 3.7- or 2-cm radiating section. One or two antennae were used, with an ablation time of 10 minutes. Ultrasonographic (US) and combined US/cone-beam computed tomographic (CT) guidance were used in five patients each. Follow-up was performed by CT after 1, 3, 6, and, when possible, 12 months. Tumor response was assessed per Response Evaluation Criteria In Solid Tumors (version 1.1) and Choi criteria. The feasibility, safety, and major and minor complications associated with quality of life (QOL) were recorded prospectively. Results: The procedure was feasible in all patients (100%). One late major complication was observed in one patient, and no visceral injury was detected. No patient had further surgery, and all minor complications resolved during the hospital stay. An improvement in QOL was observed in all patients despite a tendency to return to preoperative levels in the months following the procedure, without the influence of minor complications. No repeat treatment was performed. Conclusions: Despite the small number of patients, the present results can be considered encouraging, showing that MW ablation is a feasible approach in the palliative treatment of pancreatic tumors. [Copyright &y& Elsevier]

Highlights: [•] Maternal immunization provides a path to early infant protection against RSV. [•] Structure-based engineering overcomes the biochemical challenges of the RSV F antigen. [•] Improved animal models for RSV vaccine-mediated disease enhancement are needed. [•] A self-amplifying RNA vaccine platform has been designed for safe infant immunization. [•] Infant RSV vaccines aim for high neutralizing titers and a non-Th2-biased response. [Copyright &y& Elsevier]

Background: The purpose of this study was to evaluate the patterns and clinical importance of calcifications in thyroid nodules identified on preoperative computed tomography (CT). Methods: CT of 383 patients undergoing thyroid operations were reevaluated to identify thyroid calcification. A novel classification for thyroid calcifications on CT images was applied. The prevalence and patterns of calcification were classified, analyzed, and correlated with clinical and histopathologic findings. Results: Of the 383 patients, 135 (35.2%) had intrathyroidal calcifications identified on CT. Among these 135 patients, 65 (48%) were found to have thyroid cancer on definitive histopathology. The incidence of cancer was greater in calcified nodules (48%) than in noncalcified nodules (20%; P < .001). According to the calcification patterns, 2 of 9 (22%) nodules with peripheral calcification, 11 of 52 (21%) nodules with coarse calcification, 18 of 31 (58%) nodules with a single punctate calcification, and 34 of 43 (79%) nodules with multiple punctate calcifications were malignant. In the subset of 42 patients who presented with a solitary calcified nodule, 35 (83%) were found to have cancer. In addition, the incidence of lymph node metastases is greater in malignant nodules with calcification than in those without (48% vs 25%; P = .01). Conclusion: Thyroid calcification found on preoperative CT may represent an increased risk for thyroid malignancy. When the pattern shows multiple punctate calcification or the calcification is noted within a solitary nodule, the risk of malignancy is high in this study. [ABSTRACT FROM AUTHOR]

Abstract: In recent years, interest in tissue engineering and its solutions has increased considerably. In particular, scaffolds have become fundamental tools in bone graft substitution and are used in combination with a variety of bio-agents. However, a long-standing problem in the use of these conventional scaffolds lies in the impossibility of re-loading the scaffold with the bio-agents after implantation. This work introduces the magnetic scaffold as a conceptually new solution. The magnetic scaffold is able, via magnetic driving, to attract and take up in vivo growth factors, stem cells or other bio-agents bound to magnetic particles. The authors succeeded in developing a simple and inexpensive technique able to transform standard commercial scaffolds made of hydroxyapatite and collagen in magnetic scaffolds. This innovative process involves dip-coating of the scaffolds in aqueous ferrofluids containing iron oxide nanoparticles coated with various biopolymers. After dip-coating, the nanoparticles are integrated into the structure of the scaffolds, providing the latter with magnetization values as high as 15emug − 1 at 10kOe. These values are suitable for generating magnetic gradients, enabling magnetic guiding in the vicinity and inside the scaffold. The magnetic scaffolds do not suffer from any structural damage during the process, maintaining their specific porosity and shape. Moreover, they do not release magnetic particles under a constant flow of simulated body fluids over a period of 8days. Finally, preliminary studies indicate the ability of the magnetic scaffolds to support adhesion and proliferation of human bone marrow stem cells in vitro. Hence, this new type of scaffold is a valuable candidate for tissue engineering applications, featuring a novel magnetic guiding option. [Copyright &y& Elsevier]

Granular cell tumor (GCT) is a rare neurogenic neoplasm originating from Schwann cells that predominantly affects women and can involve skin and mucousae. In the respiratory system it most frequently involves bronchi and larynx, while it is rare in the trachea. A 26-year old female smoker was hospitalized for a suspected hypoechoic nodule in the right thyroid lobe closely adherent to the trachea. At preoperative computed tomography tracheal lumen was totally clear. The patient underwent a total thyroidectomy with lymph node dissection and tracheal shaving. The postoperative course was complicated by an extensive subcutaneous bilatreral emphysema associated with respiratory distress appeared on the fifth day. Bronchoscopy revealed a right anterolateral subcentimeter lesion near the second tracheal ring. Histologically, the diagnosis was consistent with a tracheal GCT developing into the thyroid parenchyma. The patient was discharged on the twentieth postoperative day. At the follow-up bronchoscopy the lesion was completely healed and at the last 12 month follow-up the patient is doing well. Tracheal tumors are uncommon neoplasms accounting for about 2% of the total respiratory tree tumors. In literature we found <50 papers concerning tracheal GCT and in almost all of the cases patients complained about respiratory symptoms. We report here a rare case of benign GCT of the trachea with extraluminal development, in a young patient who did not complain about preoperative respiratory symptoms, presented on ultrasound as a thyroid nodule with suspected cytology. • Granular cell tumor is a rare neurogenic neoplasm involving unfrequently the trachea. • In literature less than 50 papers concern these tracheal tumors. • Respiratory symptoms are frequently complained by these patients. • In this case we report a rare benign granular cell tumor of the trachea. • The extraluminal development can simulate a thyroid tumor. • Our patient underwent surgery on suspicion of neoplastic thyroid disease. • The patient was not complaining of any respiratory symptoms. • This occurrence has been described in less than 10 similar cases. [ABSTRACT FROM AUTHOR]

Subcutaneous implantation of thyroid tissue is a rare clinical condition that involves the head and neck region and occurs after surgery, diagnostic procedures or cervical trauma. A 90-year old woman with two skin nodules on her thyroidectomy scar was hospitalized and treated by two surgical excisions. Histologically, these lesions were two aggregates of cutaneous oncocytic thyroid cells. In the patient's clinical history there was a total thyroidectomy for multinodular goiter, performed 9 years previously and at which a well-encapsulated subcapsular oncocytic adenoma of the left lobe was also incidentally discovered. At 12 months of follow-up, the patient is showed well and her wounds healed. Subcutaneous colonization or seeding of thyroid tissue is a rare occurrence reported in the literature for both benign and malignant pathologies; among the malignant ones, the implantation of follicular carcinoma cells is the most frequent. Only in one previous case, to our knowledge, subcutaneous colonization originating from oncocytic thyroid (or Hurthle) cell neoplasms has been described. We report an unusual case of double subcutaneous implantation of oncocytic thyroid cells on the cervical scar of an elderly woman, nine years after total thyroidectomy. • Subcutaneous implantation thyroid tissue is a rare event. • It can occur as a result of after surgical or diagnostic procedures or cervical trauma. • There are reports regarding the implantation of both benign/malignant pathologies. • This is the second case of subcutaneous implantation of Hurthle thyroid cells. • It is occurred on the cervical scar, nine years after thyroidectomy. [ABSTRACT FROM AUTHOR]

Abstract Commentary on the paper published Ito Y, Miyauchi A, Oda H. Low-risk papillary microcarcinoma of the thyroid: A review of active surveillance trials. Eur J Surg Oncol. 2018 Mar; 44(3):307–315. doi: 10.1016/j.ejso.2017.03.004. Epub 2017 Mar 16. Review. PubMed PMID: 28343733. [ABSTRACT FROM AUTHOR]

We read with interest the paper by Périé S. et al. entitled "International consensus (ICON) on comprehensive management of the laryngeal nerves risks during thyroid surgery" [1]. The manuscript rises significant additions for recurrent laryngeal nerve (RLN) management and intraoperative neural monitoring (IONM) in thyroid surgery [1]. The more substantial the change in surgeons' practice and the higher the risk for the patient, more important is that surgeons complete relevant IONM didactic course, and have their performance objectively assessed [[4]]. [Extracted from the article]

The advancement of minimally invasive surgery in the field of endocrine surgery over the last 2 decades has fostered the attempt of natural orifice transluminal endoscopic surgery (NOTES) for thyroidectomy and parathyroidectomy via oral incisions. This technically demanding surgery is currently being evaluated in a number of specialised centres. The procedure has gained popularity worldwide and is performed in more than 50 centres. By retrieving information from published or presented articles and direct personal communications, this study reports several issues to enable and optimise correct patient and surgeon candidacy, present the advantages and prevent novel complications under the standards of open thyroid surgery. Not all patients are eligible for the transoral approach. Transoral endoscopic and robotic procedures were described and critically analysed in this study. [ABSTRACT FROM AUTHOR]