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INTRODUCTION: Laparoscopic adrenalectomy is a gold standard for the treatment of pheochromocytomas less than 6 cm in diameter. Given the difficulty in dissecting the adrenal glands, the presumed increase in the risk of malignancy, and capsular disruption there is controversy regarding minimally invasive surgery for neoplasms greater than 6 cm. The aim of this study was to report laparoscopic adrenalectomy results in 44 patients with pheochromocytomas either larger or smaller than 6 cm. METHODS: The retrospective clinical study was conducted on 44 patients who underwent surgery in the Campania region in Italy, between January 1998 and January 2008. In 30 cases the lesion measured ≤ 6 cm (group A) in diameter and in 15 > 6 cm (group B). The authors compared cardiovascular instability, operative time, conversion rate, incidence of intra and postoperative complications, length of hospital stay, and medium long term follow-up results in the two groups of patients. RESULTS: By comparing group A vs group B no significant differences were observed in operative time, incidence of intra and postoperative complications lenght of hospital stay or medium long term follow-up results. In patients with pheochromocytomas > 6 cm a higher conversion rate, although not statistically significant, was observed. The same occurred with cardiovascular instability shown by intraoperative sudden bouts of hypertension. One patient underwent "open" reoperation for residual retrocaval glandular tissue, not removed during laparoscopic treatment. CONCLUSIONS: Laparoscopic adrenalectomy for pheochromocytoma by experienced laparoscopic surgeon is safe and probably preferable also in selected cases larger than 6 cm. These patients may have a longer operative time, a greater intraoperative blood loss, a higher conversion rate, more intraoperative hypertensive crises than other patients. Adequate preoperative pharmacological therapy and careful anaesthesia monitoring make possible optimal management of cardiovascular instability.

Splenic abscess is an uncommon but potentially life-threatening disease that generally occurs in patients with neoplasia, immunodeficiency, hemoglobinopathies, trauma, metastatic infection, splenic infarction and diabetes. Splenic abscess should be considered in a patient with fever, left upper abdominal pain, and leukocytosis. Splenectomy has been the gold standard treatment for splenic abscess, however, burdened by high morbidity rate related clinical conditions of the patient. With the recent development of minimally invasive techniques and percutaneous US- or CT-guided procedures, the placement of a drainage has achieved excellent results with resolution of the disease in a high percentage of cases with low morbidity and negligible mortality. Percutaneous drainage is indicated for uniloculated or biloculated abscesses and for high risk surgical patients. It is a reliable technique with a high rate of therapeutical success and low costs compared to surgery. Other advantages include avoiding risks of intra-abdominal spillage and perioperative complications and saving time, along with a better patient compliance and an easier nursing care. The authors describe a case of splenic abscess treated by percutaneous US-guided drainage. Our results suggest that ultrasound-guided percutaneous drainage is a safe and feasible alternative to surgery in the treatment of splenic abscesses. In addition, it allows spleen preservation.

Background. Subtotal parathyroidectomy (SP) and total parathyroidectomy (TP) with autotransplantation (TPai) are the most commonly adopted operations for the treatment of secondary hyperparathyroidism (2HPT). TP without autotransplantation had previously been confined to patients with advanced dialytic vintage, not eligible for kidney transplantation. Over the years, the procedure has gained more widespread use, but there is no precise knowledge on the immediate and long-term effects. Methods. The Authors analysed the immediate and long-term results of TP without autotransplantation, that is after the systematic removal of at least four glands in 20 patients operated for 2HPT, which were compared with results from TPai in an equal number of cases. Results. An improvement of the typical clinical symptoms was found in every patient undergoing surgery, and a significant reduction in intact parathyroid hormone (iPTH) serum levels was achieved. Immediate normalisation of iPTH level was observed in 11/20 TP cases, hypoparathyroidism in 4/20 and persistent HPT in five cases. One year of follow-up showed a slight increase in hypoparathyroidism, with 1/20 (5 %) recurrence of the disease. One year TPai results showed a similar percentage of euparathyroidism, as well as a higher long-term recurrence rate (4/20, 20 %), although values do not reach statistical significance. Conclusions. TP may still be considered the operation of choice in patients with aggressive forms of 2HPT or of advanced dialytic vintage, with no access to renal transplantation, because of its low recurrence rate (5%). Postoperative aparathyroidism is rare, while hypoparathyroidism and hypocalcaemia can be well controlled by medical treatment. Background: Subtotal parathyroidectomy (SP) and total parathyroidectomy (TP) with autotransplantation (TPai) are the most commonly adopted operations for the treatment of secondary hyperparathyroidism (2HPT). TP without autotransplantation had previously been confined to patients with advanced dialytic vintage, not eligible for kidney transplantation. Over the years, the procedure has gained more widespread use, but there is no precise knowledge on the immediate and long-term effects. Methods: The authors analyzed the immediate and long-term results of TP without autotransplantation, that is after the systematic removal of at least four glands in 20 patients operated for 2HPT, which were compared with results from TPai in an equal number of cases. Results: An improvement of the typical clinical symptoms was found in every patient undergoing surgery, and a significant reduction in intact PTH (iPTH) serum levels was achieved. Immediate normalization of iPTH level was observed in 11/20 TP cases, hypoparathyroidism in 4/20 and persistent HPT in 5/20 cases. One year of follow-up showed a slight increase in hypoparathyroidism, with 1/20 (5%) recurrence of the disease. One-year TPai results showed a similar percentage of euparathyroidism, as well as a higher longterm recurrence rate (4/20, 20%), although values do not reach statistical significance. Conclusions: TP may still be considered the operation of choice in patients with aggressive forms of 2HPT or of advanced dialytic vintage, with no access to renal transplantation, because of its low recurrence rate (5%). Post-operative aparathyroidism is rare, while hypoparathyroidism and hypocalcemia can be well controled by medical treatment. ©2012, Editrice Kurtis.

Authors evaluated the effects of selective adrenergic blockade by means of doxazosin on blood pressure in 48 patients operated on for pheochromocytoma by a multicenter retrospective study. Age, tumor size, surgical approach, and operative time were analyzed as predictive factors of intraoperative hypertensive crises. Forty-eight patients underwent adrenalectomy—four open surgery and 44 laparoscopic surgery—for pheochromocytoma of adrenal glands from 1998 to 2008 after preoperative administration of doxazosin. Perioperative cardiovascular status modifications and surgical medium- and long-term outcomes were analyzed. There was no mortality, conversion rate was 4.5 per cent, and morbidity rate was 8.3 per cent. Intraoperative hypertensive crises (180/ 90 mmHg or higher) were observed in 14.5 per cent (seven of 48) of patients and were treated pharmacologically with no aftermath. None of the examined variables influenced the occurrence of intraoperative hypertensive episodes. Postoperative hypotension (lower than 90/60 mmHg) was observed in four of 48 patients (8.3%) and was treated by crystalloids and hydrocortisone. In the surgical treatment of pheochromocytoma, the preoperative adrenergic blockade by doxazosin does not prevent intraoperative hypertensive crises. Nevertheless, in our series, they were of short duration and were not associated with major cardiovascular complications. Perioperative hemodynamic instability was managed bypreoperative pharmacological treatment, allowing low morbidity.

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions, is still controversial. Analysing and comparing the experience of two units for endocrine surgery, we retrospectively evaluated 721 patients, surgically treated after a follicular neoplasm diagnosis. Total thyroidectomy was routinely performed in one Institution, while in the other one it was selectively carried out. The main criteria leading to hemythyroidectomy were a single nodule, the age ≤45 years, the absence of thyroiditis or clinical/intraoperative suspicion of malignancy. Total thyroidectomy was performed in 402/721 patients (55.7%), hemythyroidectomy in 319/721 cases (44.2%) and a completion thyroidectomy in 51/319 cases (15.9%). The overall malignancy rate was 24% (176/721 patients), respectively 16% (51/319 patients) following hemythyroidectomy, and 31% (125/402 patients) following total thyroidectomy. Definitive recurrent laryngeal nerve paralysis and permanent hypoparathyroidism were not reported in hemythyroidectomy patients in which lower mean hospitalization and costs were observed. Considering the low-risk of follicular neoplasm solitary lesions, hemythyroidectomy is still the safest standard of care with lower hospitalization and costs. In case of multiglandular disease or thyroiditis, that might be associated with a higher risk of cancer, total thyroidectomy should be recommended. Further investigation is warranted to achieve a better preoperative follicular neoplasm diagnostic accuracy in order to reduce the amount of unnecessary surgical operations with a diagnostic aim.

Introduction Parathyroidectomy (PTx) is recommended in patients affected by secondary hyperparathyroidism (2HPT) of chronic kidney disease-mineral bone disorders (CKD-MBD), resistant to medical treatment. Analyzing total parathyroidectomy with muscular or subcutaneous autoimplantation (TPai) outcomes in hemodialysis (HD) 2HPT patients, and monitoring intact parathyroid hormone (iPTH) levels, we evaluated long-term functional results of subcutaneous parathyroid glandular tissue autoimplantation. Methods 40 HD 2HPT patients, resistant to medical treatment, and awaiting for renal transplantation, underwent total parathyroidectomy with subcutaneous autoimplantation of 9-12 fragments of not nodular hyperplasia parathyroid tissue in not dominant forearm. iPTH were analyzed 24 hours, and 3-6-12-24 months after surgery. The 1.08-6.99 pmol/L range was taken as reference of normal iPTH level based on which eu- (1.08-6.99), hypo- (< 1.08), aparathyroidism (0) and persistence or relapse ( > 6.99) of disease were determined. Results In every case PTai determined an extraordinary improvement of quality of life, associated with a notable reduction of iPTH serum level. Immediate normalization of iPTH was achieved in 50% of cases; hypoparathyroidism in 25% of cases and persistence of disease in 25% were observed. Long term follow-up showed a reduction of hypoparathyroidism and an increase of relapse rate up to 20%. Grafting resection was never performed. Discussion Subcutaneous autotrasplantation is a very simple and fast surgical technique. Nevertheless, similar success and recurrence rates were reported following muscular or subcutaneous grafting, as confirmed in our experience. Conclusions Subcutaneous grafting was effective as muscular implantation, with comparable functional results, but avoiding its potential complications. Introduction: Parathyroidectomy (PTx) is recommended in patients affected by secondary hyperparathyroidism (2HPT) of chronic kidney disease-mineral bone disorders (CKD-MBD), resistant to medical treatment. Analyzing total parathyroidectomy with muscular or subcutaneous autoimplantation (TPai) outcomes in hemodialysis (HD) 2HPT patients, and monitoring intact parathyroid hormone (iPTH) levels, we evaluated long-term functional results of subcutaneous parathyroid glandular tissue autoimplantation.Methods: 40 HD 2HPT patients, resistant to medical treatment, and awaiting for renal transplantation, underwent total parathyroidectomy with subcutaneous autoimplantation of 9-12 fragments of not nodular hyperplasia parathyroid tissue in notdominant forearm. iPTH were analyzed 24 h, and 3-6-12-24 months after surgery. The 1.08-6.99 pmol/L range was taken as reference of normal iPTH level based on which eu- (1.08-6.99), hypo-(< 1.08), aparathyroidism (0) and persistence or relapse (>6.99) of disease were determined.Results: In every case PTai determined an extraordinary improvement of quality of life, associated with a notable reduction of iPTH serum level. Immediate normalization of iPTH was achieved in 50% of cases; hypoparathyroidism in 25% of cases and persistence of disease in 25% were observed. Long term follow-up showed a reduction of hypoparathyroidism and an increase of relapse rate up to 20%. Grafting resection was never performed.Discussion: Subcutaneous autotrasplantation is a very simple and fast surgical technique. Nevertheless, similar success and recurrence rates were reported following muscular or subcutaneous grafting, as confirmed in our experience.Conclusions: Subcutaneous grafting was effective as muscular implantation, with comparable functional results, but avoiding its potential complications. (C) 2014 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

Introduction: In the surgical management of the patients with Cushing syndrome (CS), minimal invasive adrenalectomy (MA) has become the procedure of choice to treat adrenal tumors with a benign appearance � 6 cm in diameter. Authors evaluated medium- and long-term outcomes of laparoscopic adrenalectomy (LA) for CS or subclinical CS (sCS), performed for ten years in an endocrine surgery unit. Methods: We retrospectively reviewed 21 consecutive patients undergone LA for CS or sCS from 2003 to 2013. Postoperative clinical and cardiovascular status modifications and surgical medium and long-term outcomes were analyzed. Results: In each patient surgery determined a normalization of the hormonal profile. There was no mortality neither major post-operative complications. Mean operative time was higher during the learning curve, there was no conversion, and morbidity rate was 6.3%. Regression of the main clinical symptoms occurred slowly in twelve months. Conclusions: LA is a safe, effective and well-tolerated procedure for the treatment of CS and sCS reducing arterial blood pressure, body weight and fasting glucose levels. Following the learning curve a morbidity rate similar to that reported in the MA series for other adrenal diseases is observed. © 2014 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

Background: The significance of nodal metastases, very common in papillary thyroid cancer, and the role of lymph node dissection in the neoplasm management, are still controversial. The impact of lymph node involvement on local recurrence and long-term survival remains subject of active research. With the aim to better analyze the predictive value of lymph node involvement on recurrence and survival, we investigated the clinico-pathological patterns of local relapse following total thyroidectomy associated with lymph node dissection, for clinical nodal metastases papillary thyroid cancer, in order to identify the preferred surgical treatment. Methods. Clinical records, between January 2000 and December 2006, of 69 patients undergoing total thyroidectomy associated with selective lymph node dissection for clinical nodal metastases papillary thyroid cancer, were retrospectively evaluated. Radioiodine ablation, followed by Thyroid Stimulating Hormone suppression therapy was recommended in every case. In patients with loco regional lymph nodal recurrence, a repeated lymph node dissection was carried out. The data were compared with those following total thyroidectomy not associated with lymph node dissection in 210 papillary thyroid cancer patients without lymph node involvement, at preoperative ultrasonography and intra operative inspection. Results: Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and permanent monolateral vocal fold paralysis were respectively 1.4 % (1/69) and 1.4% (1/69), similar to those reported after total thyroidectomy "alone". The rate of loco regional recurrence, with positive cervical lymph nodes, following 8 year follow-up, was 34.7% (24/69), higher than that reported in patients without nodal metastases (4.2%). A repeated lymph node dissection was carried out without significant complications. Conclusions: Nodal metastases are a predictor of local recurrence, and a higher rate of lymph node involvement is expected after therapeutic lymph node dissection associated with total thyroidectomy. The prognostic significance of nodal metastases on long-term survival remains unclear, and more prospective randomized trials are requested to better evaluate the benefits of different therapeutic approaches.

BACKGROUND: Thyroidectomy is considered a low-risk operation. The authors report a case of tracheal necrosis after total thyroidectomy for multinodular goiter with bilateral adenomas, and a case of oesophageal fistula after total thyroidectomy for papillary cancer. METHODS AND RESULTS: The patient with tracheal perforation was treated by a non operative management after clinical stabilization. The patient with oesophageal perforation underwent surgical treatment consisting of neck drain placement. Both patients are alive after 12 months of follow-up, although the patient who had surgery for papillary cancer of the thyroid gland was found to have multiple diffuse liver and lung metastases. CONCLUSIONS: Thyroidectomy is a safe surgical procedure, but in some patients major complications may arise. In cases of iatrogenic tracheal or oesophageal perforation, conservative non-surgical or conservative surgical treatment, in specialized centers, results in a favourable outcome. The authors discuss the risk factors and management of these two rare complications.

"Hepatolithiasis is defined as the occurrence of stones proximal to the biliary confluence and represents a prevalent disease in South East Asia being uncommon in Western countries. Biliary sepsis, hepatic abscesses and cholangiocarcinoma are considered potential complications. The Authors describe a case of a 68 years male patient affected by a left massive intrahepatic lithiasis secondary to common duct stones and associated to acute pancreatitis. The patient refused surgery and was submitted to a conservative transhepatic percutaneous treatment. After a complete removal of intrahepatic stones and a positioning of external internal biliary drainage (14F), a laparoscopic cholecistectomy was performed. The MRI control showed a complete resolution of the intrahepatic lithiasis. Conservative transhepatic percutaneous approach to hepatolithiasis represents a safe and effective treatment allowing good medium-long term results. Surgery is recommended in case of severe hepatic fibrosis or atrophy, suspected cholangiocarcinoma or multiple strictures with biliary distorsion. Integrated therapeutical protocols in referral multidisciplinary centers-offers the best long term results."

Tracheal rupture is a rare condition, and its most common cause is head and neck injury. Nontraumatic disruption of the anterolateral fibrocartilaginous trachea is an exceptional complication following thyroidectomy with few cases reported in literature. We report a case of upper tracheal necrosis arising 15 days after uneventful total thyroidectomy and resulted in pneumomediastinum and subcutaneous emphysema. The patient felt a sudden pop in his neck following an episode of vigorous coughing and experienced rapid swelling in his neck. The presence of pneumomediastinum was diagnosed on chest Computed Tomography scan and bronchoscopy visualized a small perforation on the right side of the anterolateral tracheal wall. The first interesting aspect is that several factors (female gender, thyrotoxic goiter, wound infection or excessive use of diathermy) reported as possible cause of anterior tracheal necrosis in the previous reports are unlike for the present case. The second unusual point is the spontaneous healing of the tracheal tear. Considering the no-critical ill condition of the patient and the size of the tear we decide for a conservative treatment rather than surgical repair. Finally, our report underlights that the presence of subcutaneous emphysema following thyroidectomy should alert the possible existence of tracheal rupture. The favourable outcome of our patient shows that small tracheal perforation due to tracheal necrosis may be successfully treated with conservative treatment.

Background: Minimal invasive adrenalectomy has become the procedure of choice to treat adrenal tumors with a benign appearance, ≤ 6 cm in diameter and weighing < 100 g. Authors evaluated medium- and long-term outcomes of laparoscopic adrenalectomy (LA), performed for ten years in a single endocrine surgery unit. Methods: We retrospectively reviewed 88 consecutive patients undergone LA for lesions of adrenal glands from 2003 to 2013. The first 30 operations were considered part of the learning curve. Doxazosin was preoperatively administered in case of pheochromocytoma (PCC), while spironolactone and potassium were employed to treat Conn’s disease. Perioperative cardiovascular status modifications and surgical and medium- and long-term results were analyzed. Results: Forty nine (55.68%) functioning tumors, and one (1.13%) bilateral adrenal disease were identified. In 2 patients (2.27%) a supposed adrenal metastasis was postoperatively confirmed, while in no patients a diagnosis of incidental primitive malignancy was performed. There was no mortality or major post operative complication. The mean operative time was higher during the learning curve. Conversion and morbidity rates were respectively 1.13% and 5.7%. Intraoperative hypertensive crises (≥180/90 mmHg) were observed in 23.5% (4/17) of PCC patients and were treated pharmacologically with no aftermath. There was no influence of age, size and operative time on the occurrence of PCC intraoperative hypertensive episodes. Surgery determined a normalization of the endocrine profile. One single PCC persistence was observed, while in a Conn’s patient, just undergone right LA, a left sparing adrenalectomy was performed for a contralateral metachronous aldosteronoma. Conclusions: LA, a safe, effective and well tolerated procedure for the treatment of adrenal neoplasms ≤ 6 cm, is feasible for larger lesions, with a similar low morbidity rate. Operative time has improved along with the increase of the experience and of the technological development. Preoperative adrenergic blockade did not prevent PCC intraoperative hypertensive crises, but facilitated the control of the hemodynamic stability.