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OBJECTIVES The aims of this study were to determine the presence of endothelial dysfunction by measuring aortic intima-media thickness (aIMT) and carotid intima-media thickness (cIMT) and to evaluate the role of traditional risk factors for premature atherosclerosis in children with inflammatory bowel disease (IBD). METHODS Thirty-four children with IBD (25 Crohn disease [CD] and 9 ulcerative colitis [UC]; mean age 11.1 years) and 27 healthy subjects matched for sex and age were enrolled. In all of the patients, demographic characteristics and risk factors for atherosclerosis (age, sex, body mass index, blood pressure, dyslipidemia, active and passive smoking, and family history for cardiovascular diseases), CD and UC clinical activity scores, and inflammatory markers were evaluated. aIMT and cIMT were measured by high-resolution B-mode ultrasound. RESULTS aIMT was significantly higher in patients than in controls (P

Background Laparoscopic left colectomy has obtained a large spread in colon surgery for malignant disease despite the need for an adequate learning curve. However few studies reported long term data in comparison with open left colectomy and most of the authors of large series on colorectal surgery don't describe, in subgroup analysis, results obtained in left colonic resections. The aim of this study is to report the short and long term follow-up of laparoscopic left colon resection in comparison with the open approach, from a single centre, performed in the same timeframe. Methods Between January 2005 to January 2007, 55 patients with sigma adenocarcinoma underwent to laparoscopic or open left colectomy at the Department of Digestive Surgery, "S. Maria" hospital in Terni – Italy. Perioperative and histopathological data and results from oncological follow-up, until April 2013, are analyzed. Results 28 patients underwent laparoscopic left colectomy, while 27 patients open left colectomy. Mean hospital stay was 8.44 ± 1.21 in the laparoscopic group versus 6.86 ± 1.01 in the open group. The histopathological analysis shows a mean of 18.13 ± 6.8 lymph nodes removed after laparoscopy and 13.96 ± 5.72 after open surgery ( P = 0.02). Kaplan–Meier analysis does not reveal significative differences in disease free survival (HR = 0.85; 95% CI = 0.21–3.40; P = 0.81). Overall survival up to 5 years shows one death per group. Conclusions Laparoscopy, respect to the open approach, could improve perioperative clinical outcomes, hospital stay and harvested lymph nodes with comparable long term oncological follow-up in patients with sigmoid colon cancer.

PURPOSE To assess the best technique and the diagnostic accuracy of Quasistatic Ultrasound Elastography (QUE) in thyroid nodules. Interobserver agreement was also evaluated. MATERIALS AND METHODS A preliminary study of 50 patients with 54 thyroid nodules was performed with quantitative software in order to define the best cut-off value of different imaging methods. All patients underwent total thyroidectomy and histopathology findings served as the standard of reference. Thereafter, 154 nodules in 137 consecutive patients were prospectively evaluated by three operators. Findings at fine-needle aspiration cytology and histopathology (N = 60) served as the standard of reference. RESULTS The most accurate technique was the axial peri-intranodular measurement method which achieved an area under the ROC curve of 0.961 (95 %CI 0.848 - 1.00) and had an optimal cut-off value of 3.00. QUE in the differentiation of thyroid nodules showed for operator 1: sensitivity 90 % (95 %CI 73.5 - 97.9 %), specificity 92.7 % (95 %CI 86.7 - 96.6 %), LR+ 12.40 (6.54 - 23.50), LR- 0.11 (0.04 - 0.32) and accuracy 91.4 % (95 %CI 85.4 - 97.3 %); for operator 2: sensitivity 86.7 % (95 %CI 69.3 - 96.2 %), specificity 87.1 % (95 %CI 79.9 - 92.4 %), LR+ 6.72 (4.16 - 10.80), LR- 0.15 (0.06 - 0.38) and accuracy 86.9 % (95 %CI 80.0 - 93.7 %); for operator 3: sensitivity 80 % (95 %CI 61.4 - 92.3 %), specificity 83.9 % (95 %CI 76.2 - 89.9 %), LR+ 4.96 (3.20 - 7.70), LR- 0.24 (0.12 - 0.49) and accuracy 81.9 % (95 %CI 74.0 - 89.9 %). Interobserver agreement values between operator 1 and operator 2 (k = 0.79) (p

Thyroid pathology including thyroid nodules and diffuse thyroid diseases represents often a diagnosing challenge for clinicians. US, although highly accurate in identifying thyroid nodules and diffuse thyroid diseases, is still not sufficiently accurate to evaluate them. US-elastography has been introduced in order to further increase US accuracy in many fields and eventually for thyroid disease. The aim of the present paper it to provide an update of the literature on different available techniques and the results reported both for thyroid nodules differentiation and for diffuse thyroid disease evaluation. Advantages and limitations of elastography are also discussed.

Objectives: To verify the prevalence of chronic cerebrospinal venous insufficiency in patients affected by different clinical forms of multiple sclerosis and in healthy subjects using the Zamboni ultrasound protocol combined with M-mode ultrasound examination. Materials and methods: We enrolled 112 patients with multiple sclerosis and 67 healthy subjects from 20 to 67 years of age. All the patients underwent Duplex and color-Doppler sonography of the neck vessels, transcranial colour duplex sonography, M-mode study of the valve system and of venous abnormalities. Subjects were positive for chronic cerebrospinal venous insufficiency when at least two of five hemodynamic criteria of the Zamboni protocol were fulfilled. Chronic cerebrospinal venous insufficiency condition was further analyzed by a multivariate analysis including age, sex, disease duration, subtypes of multiple sclerosis and expanded disability status scale score as independent variables. Results: No healthy subjects was positive for chronic cerebrospinal venous insufficiency, while in the sample of patients affected by multiple sclerosis the diagnosis was made in 59.8% of cases ( p Conclusion: Chronic cerebrospinal venous insufficiency is a haemodynamic condition strongly associated with multiple sclerosis and is not found in normal controls. The addition of M-mode ultrasound to the diagnostic protocol allows improved observation of venous valve abnormalities.

This study was done to compare quantitative elastosonography and ultrasound analysis in the characterisation of thyroid nodules. From July 2009 to September 2011, 123 patients with 147 thyroid nodules were included in our study. All patients enrolled had to undergo thyroidectomy because of nodular thyroid disease (goitre or nodules). After preliminary examination with conventional ultrasound (US) and colour Doppler US, the patients were examined with elastosonography, using high-level equipment (Toshiba Aplio XG) and quantitative software (Elasto-Q). Each lesion was characterised using an US score (echogenicity, borders, microcalcifications and colour Doppler pattern), and then by elastosonographic strain ratio. Each patient subsequently underwent thyroidectomy. Histological results were used as the gold standard. Histological examination demonstrated 89 benign and 58 malignant lesions. On average, the strain ratio value was 2.84±2.69 (range, 0.05–14.5; p=0.001). Sensitivity and specificity of the US score were about 56% and 72%, respectively, whereas those of the strain ratio were 93% and 89%, using a cut-off of 2 obtained with receiver operating characteristic (ROC) curve analysis. Elastosonography was more accurate than US and colour Doppler US in characterising thyroid nodules (p=0.002). Quantitative elastosonography is a useful diagnostic tool in the evaluation of thyroid lesions, and can be used to limit fine-needle aspiration cytology and improve the selection of patients for thyroidectomy.

To assess whether ultrasound elastography (USE) with strain ratio increases diagnostic accuracy of Doppler ultrasound in further characterisation of cytologically Thy3 thyroid nodules. In two different university diagnostic centres, 315 patients with indeterminate cytology (Thy3) in thyroid nodules aspirates were prospectively evaluated with Doppler ultrasound and strain ratio USE before surgery. Ultrasonographic features were analysed separately and together as ultrasound score, to assess sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Receiver operating characteristic (ROC) curves to identify optimal cut-off value of the strain ratio were also provided. Diagnosis on a surgical specimen was considered the standard of reference. Higher strain ratio values were found in malignant nodules, with an optimum strain ratio cut-off of 2.09 at ROC analysis. USE with strain ratio showed 90.6 % sensitivity, 93 % specificity, 82.8 % PPV, 96.4 % NPV, while US score yielded a sensitivity of 52.9 %, specificity of 84.3 %, PPV 55.6 % and NPV 82.9 %. The diagnostic gain with strain ratio was statistically significant as proved by ROC areas, which was 0.9182 for strain ratio and 0.6864 for US score. USE with strain ratio should be considered a useful additional tool to colour-Doppler US, since it improves characterisation of thyroid nodules with indeterminate cytology. • Strain ratio measurements improve differentiation of thyroid nodules with indeterminate cytology • Elastography with strain ratio is more reliable than ultrasound features and ultrasound score • Strain ratio may help to better select patients with Thy 3 nodules candidate for surgery

Background Sleeve gastrectomy is indicated for the treatment of obesity and related co-morbidity including diabetes. The dynamic changes in insulin secretion and sensitivity after sleeve gastrectomy are unknown. Methods Whole-body insulin sensitivity was measured by the euglycaemic hyperinsulinaemic clamp technique, and insulin secretion by C-peptide deconvolution after an oral glucose tolerance test (OGTT), before and 3, 6 and 12 months after sleeve gastrectomy in morbidly obese subjects. The time course of glucagon-like peptide (GLP) 1, as a marker of insulin secretion following OGTT, was also assessed. Results Ten patients were included in the study. Median (range) baseline insulin sensitivity (M-value) increased from 84·0 (20·2–131·4) mmol per kg per min at baseline to 122·8 (99·0–179·3) mmol per kg per min at 12 months after surgery (P = 0·015). Fasting insulin sensitivity, measured by homeostatic model assessment of insulin resistance, which represents a surrogate index of hepatic insulin resistance, decreased from 3·3 (1·9–5·5) to 0·7 (0·5–1·1) mg/dl·µunits/ml (P < 0·001). Total insulin secretion, measured as incremental area under the curve (AUC), after OGTT decreased from 360·4 (347·9–548·0) to 190·1 (10·1–252·0) mmol/l·180 min at 12 months (P = 0·011). The AUC for GLP-1 increased from 258·5 (97·5–552·6) to 5531·8 (4143·0–7540·9) pmol/l·180 min at 12 months after sleeve gastrectomy (P < 0·001). In multiple regression analysis, 51 per cent of the M-value variability was explained by GLP-1 secretion. Conclusion Sleeve gastrectomy improved insulin sensitivity and reduced insulin secretion within 6 months after surgery. Although there was a correlation between insulin sensitivity and bodyweight, the major driver of the improvement in insulin sensitivity was GLP-1 secretion.

Background Laparoscopic sleeve gastrectomy (SG) has gained great popularity as a stand-alone bariatric procedure because short- and mid-term outcomes in terms of weight loss and resolution of co-morbidities have been very positive. However, long-term results from large series still are sparse. Objectives To evaluate the long-term clinical outcomes of SG in a large series of patients undergoing SG as a stand-alone procedure. Setting University hospital in Italy. Methods A retrospective analysis of prospectively collected data from 182 patients undergoing SG between 2006 and 2008 in the authors' institution. Long-term outcomes at 6 and 7 years were analyzed in terms of weight loss and co-morbidities resolution. Results Mean initial body mass index (BMI) was 45.9±7.3 kg/m 2 . Major postoperative complications occurred in 8 patients (5.4%): 4 leaks, 2 bleeding, 1 abdominal collection, and 1 dysphagia. All complications were managed conservatively. One hundred forty-eight patients (81.4%) completed the 72-month (6-year) follow-up. Thirty-seven patients (25%) reached a follow-up of 84 months. At year 6 follow-up the mean BMI and the mean percentage of excess weight loss (%EWL) were 30.2 kg/m 2 and 67.3%, respectively. Mean total body weight loss was 44.9 kg, while a %EWL >50 was registered in 123 patients (83.1%). Preoperative BMI did not significantly influence postoperative %EWL. Remission of type 2 diabetes mellitus, arterial hypertension, obstructive sleep apnea syndrome, and gastroesophageal reflux disease symptoms occurred in 83.8%, 59.7%, 75.6%, and 64.7% of patients, respectively. Conclusion %EWL and resolution of co-morbidities appear to be sustained 6 and 7 years after SG. Preoperative BMI is not predictive for weight loss outcomes.

Since the great diffusion of laparoscopic treatment of obesity, there is a growing interest concerning the learning process for those surgeons who undertake the bariatric activity. However, papers analyzing the learning curve (LC) for sleeve gastrectomy (SG) are still scarce. This study aims to investigate whether the LC for SG of a novice bariatric surgeon might be positively influenced by the training in a high-volume bariatric center (HVBC). Between October 2010 and January 2014, 128 patients underwent SG by the same young surgeon who previously attended a 2-year training in a HVBC. His LC has been divided into three consecutive periods: in the first period (1st–47th SGs) he operated in the HVBC, while in the second (48th–88th SGs) and third period (89th–128th SGs) he moved to a novel department where surgical and ancillary staff were initially not confident with bariatric procedures but progressively owned the proper experience. Preoperative characteristics, operative data, complications and postoperative results of the three periods were compared. Mean follow-up was 1 year. Preoperative patients’ characteristics were homogeneous. No significant differences have been registered among the three periods concerning operative data, mortality, intra- and post-operative complications, weight loss outcomes and comorbidities’ resolution. Post-operative follow-up rates at 6 and 12 months were 98.4 and 92.1 %, respectively. Long-lasting fellowship in a HVBC might allow the novel bariatric surgeon to safely and proficiently overcome the LC for SG, even in a new established bariatric setting.

Reinforcement of the staple line is one of the most debated technical aspects concerning laparoscopic sleeve gastrectomy (LSG). Different buttressing methods have been proposed and demonstrated to be effective in reducing the incidence of staple line bleeding, although data concerning their effort on staple line leakage are not consistent. The aim of this study was to ascertain the technical feasibility and to report the preliminary outcomes of laparoscopic use of platelet-rich plasma (PRP) to reinforce the staple line during sleeve gastrectomy.From March 2012 to May 2012, 20 patients were prospectively enrolled (10 females; mean age, 44.6 ± 11 years; mean body mass index, 42.3 ± 5.45 kg/m(2)). Type 2 diabetes mellitus was present in 4 patients, obstructive sleep apnea syndrome in 3, and hypertension in 6. LSG was performed using a 48-French bougie and gold cartridges; reinforcement of the staple lines with buttressed materials or oversewing the suture was performed excluding the last cranial cartridge. PRP was prepared by separating the platelets from autologous blood withdrawn on the same day of surgery, in order to obtain a membrane with cylindrical shape (2×5 cm) formed by fibrin and active platelets. The membrane is introduced through the 10-mm trocar and placed at the upper portion of the staple line. The overall cost for the preparation of PRP is about €15.No intraoperative complications and conversions have been recorded during the surgical procedures. No deaths occurred. The mean operative time was 85 ± 31 minutes, which was not significantly increased compared with the operative time of the surgeon's overall personal series (750 cases). At 12 months of follow-up the abdominal ultrasound was negative for collections, and upper contrast showed no images indicating gastric leaks. In no case did PRP induce symptoms of rejection, infection, or adverse events.The use of PRP during LSG is feasible, does not increase significantly the operative time, does not require any special devices, and is cost effective. A larger cohort of patients is needed to ascertain the potential effectiveness of PRP in the prevention of postoperative staple line complications.

Background Perivascular epithelioid cell neoplasm (PEComa) is a rare mesenchymal tumor. Gynecological PEComas account for just over one-fourth of the overall PEComa cases reported in the literature. Surgery is the most recommended primary treatment while adjuvant therapy is generally reserved for high-risk cases. However, the best management of this neoplasia has not been well established, primarily because of the paucity of cases described to date. Objectives The aim of this systematic review is to summarize what is known thus far regarding the etiopathogenesis, clinical and pathologic features of PEComas, focusing also on the most valid treatment options for uterine cases. Data sources Pubmed articles on PEComas published in various journals over the past 70 years were analyzed. Conclusions and key findings Although the optimal treatment of gynecological PEComas is controversial, surgical resection remains the cornerstone. The use of adjuvant treatment is warranted in high risk patients to increase disease control. A multidisciplinary approach should be key in treatment decision-making regarding gynecological PEComas.

Wanting to find a way of identifying patients suitable for early discharge after thyroidectomy, we set out to establish whether ionized calcium concentration is a better predictor of post-surgical hypocalcemia than total serum calcium. Data were analyzed to establish whether serum ionized calcium concentrations are correlated with total serum calcium levels and symptomatic hypocalcemia after thyroidectomy. Sixty-two patients undergoing total thyroidectomy at the Department of Surgical Sciences of the "Sapienza" University of Rome, Italy, in 2010. Ionized calcium was measured before (day 0) and after surgery (days 1, 2 and 60) in all the patients. These measurements were compared with preoperative (day 0) and postoperative total serum calcium levels (days 1, 2 and 60). The preoperative ionized calcium levels differed from the ionized calcium levels recorded on days 1 and 2; this pattern was not observed for the total calcium concentrations. Conversely, total calcium on days I and II correlated significantly with the various ionized calcium measurements. The presence of parathyroid glands in the surgical specimen did not seem to affect suitability for discharge. The statistical analysis showed that ionized calcium measurements are more reliable than total calcium measurements in the immediate and long-term follow-up of total thyroidectomy patients. Applying a 95% confidence interval we established reference values for both total serum calcium and ionized calcium, below which all patients develop postoperative symptomatic hypocalcemia. In conclusion, measurement of ionized calcium, as opposed to total calcium, should be strongly recommended in the immediate and longterm follow-up of total thyroidectomy patients.

Radiographic mammography (MM) is routinely used to diagnose breast cancer. MM has a number of well-known limitations, especially in cases of a dense or dysplastic breast. Scintimammography (SM) with Tc-99m MIBI has been successfully used as a useful complement to MM. The authors report a case of a 57-year-old woman with MM with tiny calcifications in the left breast, which were classified by the radiologist as probably benign lesions. SM with Tc-99m MIBI showed a focal area of increased uptake in the upper outer quadrant of the left breast. On the basis of SM results, an excisional biopsy was performed and pathologic examination revealed infiltrating ductal carcinoma.

The contralateral axillary lymph node metastasis (CAM) from breast cancer are very rare, and pose a number of classification problems and therefore also on the surgery attitude to be adopted and the subsequent surgical oncological approach, making a distinction between synchronous and metachronous cases. You must always wait for a reasonable period of time to exclude the presence of an occult cancer in the contralateral breast. You make assumptions about the lymphatic pathways that determine this metastasis underlining that in the literature (rare) cases are reported in which the lymphoscintigraphic sentinel lymph node search has shown an uptake of contralateral axillary lymph nodes.Breast cancer, Controlateral axillary lymph node metastasis, Lymph node metastasis.

Background and study aims: Second-generation colon capsule endoscopy (CCE-2) may overcome the invasiveness of colonoscopy in the evaluation of mucosal inflammation, especially in pediatric ulcerative colitis. The aim of this pilot study was to determine the diagnostic accuracy of CCE-2 in evaluating disease activity, using colonoscopy as a gold standard. Disease extent, tolerability, interobserver agreement, and safety were also evaluated. Methods: A total of 30 consecutive pediatric patients with ulcerative colitis were prospectively enrolled (mean age 14.1 ± 3.2 years). Patients underwent CCE-2 followed by colonoscopy in the late afternoon or the following day. The blinded procedures were performed, and the diagnostic accuracy of CCE-2 to assess disease activity was determined using a modified Matts score, which classified patients as either normal (Matts score ≤ 6) or with active inflammation (Matts score > 6). Interobserver agreement was assessed using the kappa statistic. Results: One patient was excluded from the analysis because they were unable to swallow the capsule, leaving 29 patients available for analysis. The sensitivity of CCE-2 for disease activity was 96 % (95 % confidence interval [CI] 79 – 99) and specificity was 100 % (95 %CI 61 – 100). The positive and negative predictive values of CCE-2 were 100 % (95 %CI 85 – 100) and 85 % (95 %CI 49 – 97), respectively. No serious adverse events were reported. CCE-2 had a higher overall tolerability than colonoscopy ( P 0.86). Conclusions: Using a modified Matts score, CCE-2 was accurate in evaluating significant mucosal inflammation in children with ulcerative colitis. Trial registration:ClinicalTrials.gov – NCT01740349

Background Distal pancreatectomy (DP) is a surgical procedure performed to remove the pancreatic tail jointly with a variable part of the pancreatic body and including a spleen resection in the case of conventional distal pancreatectomy or not in the spleen-preserving distal pancreatectomy. Methods In this article, we describe a standardized operative technique for fully robotic distal pancreatectomy. Results In the last decade, the use of robotic systems has become increasingly common as an approach for benign and malignant pancreatic disease treatment. Robotic Distal Pancreatectomy (RDP) is an emerging technology for which sufficient data to draw definitive conclusions in surgical oncology are still not available because the follow-up period after surgery is too short (less than 2 years). Conclusions RDP is an emerging technology for which sufficient data to draw definitive conclusions of value in surgical oncology are still not available, however this techniques is safe and reproducible by surgeons that possess adequate skills.

Purpose. The right hemicolectomy may be conducted through laparoscopic or laparotomic surgery, transverse or midline incisions. The transverse laparotomy offers some advantages compared to the midline laparotomy and laparoscopy. A literature review was performed to evaluate the possible advantages of the transverse incision versus midline incision or laparoscopic right hemicolectomy.Methods. A systematic research was performed in Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, and the Science Citation Index.Results. Laparotomic right hemicolectomy with transverse incision is preferable to laparotomic hemicolectomy with midline incision. A transverse incision offers a lessened postoperative pain following physical activity, a lessened need to administer analgesic therapy during the post-operative time, better aesthetic results, and a better post-operative pulmonary function. Open surgery with transverse or midline incision ensured a shorter operative time, lower costs and a greater length of the incision compared to the laparoscopic. However, there are no differences in the oncological outcomes.Conclusions. It was not possible to identify significant differences between the open right hemicolectomy with transverse incision versus the open right hemicolectomy with midline incision or laparoscopic hemicolectomy.

Evaluation of the diagnostic efficacy and interobserver agreement of Q-elastography in the differentiation of benign from malignant thyroid nodules.A total of 344 thyroid nodules in 288 patients were examined with grey-scale and colour Doppler ultrasound (CDUS) and Q-elastography by two independent operators. Nodules with hypoechogenicity, poorly defined margins, microcalcifications, and intralesional vascularity were classified as suspicious. Diagnostic performances of CDUS features and Q-elastography for predicting thyroid malignancy were estimated using ROC analysis. Cytology or histopathology was the reference standard. Interobserver agreement in the evaluation of CDUS and Q-elastography was assessed using Cohen's k-statistic.Q-elastography showed excellent diagnostic performance for the prediction of thyroid malignancy, with sensitivity of 93 % and specificity of 92 % for operator 1 (best cutoff at 2.02), and sensitivity of 84 % and specificity of 79 % for operator 2 (best cutoff at 1.86). Performance of Q-elastography was superior to that of CDUS. Reproducibility of the findings was excellent for both Q-elastography and CDUS features as assessed with Cohen's k, which was highest for strain ratio measurements (0.95) and lowest for the echogenicity score (0.83).Q-elastography showed excellent performance. It is a valid and reproducible diagnostic method as well as a promising tool for identifying suspicious solid thyroid nodules needing cytological assessment and surgery.• Elastography is an additional tool for optimal characterisation of malignant thyroid nodules. • The use of semiquantitative elastographic evaluation increases the diagnostic performance, • The interobserver agreement of quantitative elastography can be considered to be good.

Objective: The association between papillary thyroid cancer (PTC) and Hashimoto's thyroiditis is widely recognized, but less is known about the possible link between circulating anti-thyroglobulin antibody (TgAb) titers and PTC aggressiveness. To shed light on this issue, we retrospectively examined a large series of PTC patients with and without positive TgAb. Methods: Data on 220 TgAb-positive PTC patients (study cohort) were retrospectively collected in 10 hospital-based referral centers. All the patients had undergone near-total thyroidectomy with or without radioiodine remnant ablation. Tumor characteristics and long-term outcomes (follow-up range: 2.5–24.8 years) were compared with those recently reported in 1020 TgAb-negative PTC patients with similar demographic characteristics. We also assessed the impact on clinical outcome of early titer disappearance in the TgAb-positive group. Results: At baseline, the study cohort (mean age 45.9 years, range 12.5–84.1 years; 85% female) had a significantly higher prevalence of high-risk patients (6.9% vs. 3.2%, p

Epigenetic control of gene expression plays a major influence in the development and progression of many cancer types. Aim of the present study was to investigate the expression of epigenetic regulators in a large cohort of medullary thyroid carcinomas (MTC), correlating the data with the clinical outcome and mutational status of the patients. Taqman Low Density Arrays (TLDAs) were used to analyze expression levels of several genes involved in the epigenetic control of transcription in a series of 54 MTCs. The patients cohort included 13 familial MTCs and 41 sporadic forms; 33 hosted a RET mutation and 13 a RAS somatic mutation. The expression profiling revealed in the more aggressive diseases (i.e. occurrence of metastases; persistent disease; disease-related death) a significant increase of EZH2 and SMYD3 gene expression. The increased levels of EZH2 and SMYD3 did not correlate significantly with mutational status of RET or RAS genes. Thus, the histone methyltransferases EZH2 and SMYD3 mRNA expression may represent useful prognostic biomarkers tailoring the most appropriate follow-up and timing of therapeutic approaches.

Introduction. Our interest was to monitor treatment response using ADC value to predict response of rectal tumour to preoperative radiochemotherapy.Materials and Methods. Twenty-two patients were treated with long course of radiochemotherapy, followed by surgery. Patients were examined by diffusion-weighted imaging MRI at three-time points (prior, during, and after radiochemotherapy) and were classified as responders and nonresponders.Results. A statistical significant correlation was found between preradiochemotherapy ADC values and during treatment ADC values, in responders (F=21.50,Pvalue<0.05). An increase in ADC value during treatment was predictive of at least a partial response.Discussion. Response of tumour to neoadjuvant therapy cannot be easily evaluated, and such capability might be of great importance in clinical practice, because the number of irradiated and operated patients may be superior to the number of who will really benefit from this multimodal treatment. A reliable prediction of the final clinical TN stage would allow radiotherapist to adapt multidisciplinary approach to a less invasive management, sparing surgical procedure in responder patients or even allowing an early surgery in nonresponders, which would significantly reduce radiochemotherapy related toxicity.Conclusion. Early evaluation of response during neoadjuvant radiochemotherapy treatment shows great promise to predict tumour response.

Background Video-games have become an integral part of the new multimedia culture. Several studies assessed video-gaming enhancement of spatial attention and eye-hand coordination. Considering the technical difficulty of laparoscopic procedures, legal issues and time limitations, the validation of appropriate training even outside of the operating rooms is ongoing. We investigated the influence of a four-week structured Nintendo® Wii™ training on laparoscopic skills by analyzing performance metrics with a validated simulator (Lap Mentor™, Simbionix™). Methodology/Principal Findings We performed a prospective randomized study on 42 post-graduate I–II year residents in General, Vascular and Endoscopic Surgery. All participants were tested on a validated laparoscopic simulator and then randomized to group 1 (Controls, no training with the Nintendo® Wii™), and group 2 (training with the Nintendo® Wii™) with 21 subjects in each group, according to a computer-generated list. After four weeks, all residents underwent a testing session on the laparoscopic simulator of the same tasks as in the first session. All 42 subjects in both groups improved significantly from session 1 to session 2. Compared to controls, the Wii group showed a significant improvement in performance (p

Autonomously functioning thyroid nodules (AFTN) are known to receive an increased blood influx necessary to sustain their high rate of growth and hormone production. Here, we investigated the expression of hematic and lymphatic vases in a series of 20 AFTN compared with the contralateral non-tumor tissues of the same patients, and the transcript levels of proteins involved in the control of vascular proliferation, including the vascular endothelial growth factor (VEGF) and platelet-derived growth factors (PDGF) and their receptors and the endothelial nitric oxide synthase (eNOS). In parallel, the expression of the differentiation markers sodium/iodide symporter (NIS), thyroperoxidase (TPO), thyroglobulin (Tg), and TSH receptor (TSHR) was also investigated. The data were further analyzed comparing subgroups of tumors with or without mutations in the TSHR gene. Analysis by means of CD31 and D2-40 immunostaining showed in AFTN an increased number of hematic, but not lymphatic, vessels in parallel with an enhanced proliferation rate shown by increased Ki67 staining. Quantitative RT-PCR analysis revealed an increase of VEGF, VEGFR1 and 2, PDGF-A, PDGF-B, and eNOS expression in tumor versus normal tissues. Also, higher transcript levels of NIS, TPO, and Tg were detected. Comparison of the two subgroups of samples revealed only few differences in the expression of the genes examined. In conclusion, these data demonstrate an increased expression of angiogenesis-related factors associated with an enhanced proliferation of hematic, but not lymphatic, vessels in AFTNs. In this context, the presence of TSHR mutations may only slightly influence the expression of pro-angiogenic growth factors.

Fibroblast growth factor receptor-2 (FGFR-2) plays an important role in tumorigenesis. In thyroid cancer it has been observed a FGFR-2 down-modulation, but the role of this receptor has not been yet clarified. Therefore, we decided to examine the expression of both FGFR-2 isoform, FGFR-2-IIIb and FGFR-2-IIIc, in different histological thyroid variants such as hyperplasia, follicular adenoma and papillary carcinoma. Immunohistochemistry and quantitative Real-Time PCR analyses were performed on samples of hyperplasia, follicular adenoma and papillary carcinoma, compared with normal thyroid tissue. Thyroid hyperplasia did not show statistically significant reduction in FGFR-2 protein and mRNA levels. Interestingly, in both follicular adenoma and papillary carcinoma samples we observed a strongly reduced expression of both FGFR-2 isoforms. We speculate that FGFR-2 down-modulation might be an early event in thyroid carcinogenesis. Furthermore, we suggest the potential use of FGFR-2 as an early marker for thyroid cancer diagnosis.

The objective was to compare Carotid Endarterectomy (CEA) with Carotid Artery Stenting (CAS) in terms of efficacy and safety in patients with symptomatic and asymptomatic extracranial carotid stenosis.This study enrolled 285 patients with symptomatic and asymptomatic carotid stenosis that underwent either to CAS or CEA. The primary end-points were death, stroke and myocardial infarction. The secondary end-points were restenosis and nerve injury. The Data emerged from the follow-up at 1,3,6,12,24 months that provided for clinical and EcocolorDoppler monitoring. A separate analyse was performed evaluating the prediction of the Ultrasonographic appearance of the atheroma on the symptomatic nature of the lesion.The percentage of neurological symptomatology in the periprocedural period was higher in CAS than in CEA group (9% vs 3%). We didn't report any case of periprocedural death. The results from the follow-up are: myocardial infarction 5% CAS vs 7% CEA; stroke 5% CAS vs 4% CEA; restenosis 3% CAS vs 6% CEA; nerve injury 0% CAS vs 1% CEA; mortality 0% CAS vs 1% CEA.CEA is the gold standard for treatment of significant carotid stenosis, although endovascular technique is emerging as a less invasive alternative. CAS has presented a less frequence of myocardial infarction, nerve injury and long-term mortality, but it showed an higher percentage of neurological events both in short and long-term. This last aspect is correlated with the plaque structure. Ultrasonographic study of the atheroma has become a defining moment in the choice of the therapeutic strategy.

Presentation of a personal technique for the treatment of perineal fistulas in outpatients.17 patients with complete non-complex linear intersphincteric or trans-sphincteric fistulas were treated with this technique. First we facilitated the cannulation, then we used the same catheters to place the "seton". We had to use a more subtle and smooth, rugged nylon thread, instead of the floss, due to the difference between the large size of the silk thread and the small lumen of the cannula.The elastic traction has determined not only a valid mean of capillary drainage, but also a rapid passage through the tissues without any functional impairment, in times ranging from 2 to 4 weeks.The traditional surgery is burdened by a significant number of relapses . This is due to the anatomical characteristics of the anal canal, to the difficulty to ensure the integrity of the sphincteric structures and to the position of the fistula. It's essential to identify the whole extension of the fistula to avoid it's partial removal and the persistence of granulation tissue therefore. With our technique, we got a good drainage of the fistula, avoiding to leave any residues or to create false paths causing relapses as may happen with the explorers.The discomfort suffered by patients was minimal and the results achieved led us to support a greater diffusion of this technique in outpatients.

To assess the clinical value of quantitative elastosonography compared with multiparametric ultrasound in differentiating the nature of thyroid nodules.Ninety-seven consecutive patients (32 males, 65 females, mean age, 54 years, range 20-81 years) with thyroid nodules previously detected at color-Doppler ultrasound (CDUS), were prospectively examined with elastosonography with dedicated quantitative software (Elasto-Q, Toshiba) before surgery. Ultrasound examination and elastosonography were evaluated by two investigators in consensus. US features, color-Doppler pattern, and strain ratio value were evaluated. Sensitivity and specificity of CDUS and sono-elastography were compared using X(2) test and ROC curves.Sensitivity and specificity of hypoechogenicity, irregular margins or suspicious halo features, CDUS blood flow pattern, and strain ratio in the diagnosis of malignant nodules were 56.8%, 62.2%, 54.1% and 97.3% and 71.7%, 93.3%, 28.3%, and 91.7%, respectively. Elastosonography was more sensitive and specific than all ultrasonographic features in predicting malignancy of the thyroid nodules (p0.0001). According to elastosonographic features the lesions characterized by strain ratio ≥ 2 were highly likely to be of malignant nature (p0.0001, O.R. 396, 95%, CI: 44-3530).The results of the present study suggest that elastosonography with Q system is a valuable tool in the characterization of thyroid nodules and it seems to be far more accurate than CDUS. These findings as well as those of previous studies support its use in selecting patients who are candidates for surgery.

Fitz-Hugh-Curtis syndrome is an inflammatory disease ofthe liver capsule that occurs as a complication of pelvicinflammatory disease in approximately 25% of cases. Themost common etiological agents are Chlamydia trachomatisand Neisseria gonorrhoeae. Classically, it manifests as acuteright upper quadrant pain, which can sometimes beconfused with pyelonephritis or a primitive condition ofhepatobiliary origin or the digestive tract. A correctdiagnosis is often difficult. Ultrasonography and computedtomography (CT) may be helpful in the differentialdiagnosis of other forms of peritonitis localized in the rightabdominal quadrants, and serology, urine cultures andcervical swabs are generally used to isolate the responsibleorganism. The differential diagnosis could include Chilaiditisyndrome (interposition of a colonic segment between theliver and diaphragm with occlusion) or exudative peritoni-tis from salpingitis. We describe the clinical case of a 24-year-old Caucasian woman who presented with acute rightupper quadrant pain, positive Murphy’s sign, neutrophilicleukocytosis, and fever.

Background The use of pneumatic dilation (PD) is well established in adults with achalasia; however, it is less commonly used in children. Objective To evaluate the efficacy of PD in pediatric achalasia and to define predictive factors for its treatment failure. Design Single-center, prospective cohort study. Setting Academic tertiary referral center. Patients Twenty-four patients with achalasia were enrolled from January 2004 to November 2009 and were followed for a median of 6 years. Intervention PD was performed with the patients under general anesthesia. Main Outcome Measurements Efficacy and safety of PD. Follow-up was performed by using the Eckardt score, barium swallow contrast studies, and esophageal manometry at baseline; 1, 3, and 6 months after dilation; and every year thereafter. A Cox regression model was used to identify independent predictors of failure after the first PD. Results The PD success rate was 67%. In 8 patients, the first PD failed, but the parents of one patient refused a second PD and requested surgery. Of the 7 patients who underwent repeated treatment, the second PD failed in 3 (43%). Overall, only 3 of the 24 patients underwent surgery (overall success rate after a maximum of 3 PDs was 87%). Multivariate analysis showed that only older age was independently associated with a higher probability of the procedure success (hazard ratio [HR] 0.66; 95% CI, 0.45-0.97). Limitations Small sample size, single-center study. Conclusions PD is a safe and effective technique in the management of pediatric achalasia. Young age is an independent negative predictive factor for successful clinical outcome.

Quantitative ultrasound (US) elastography (Q-USE), able to evaluate tissue stiffness has been indicated as a new diagnostic tool to differentiate benign from malignant thyroid lesions. Aim of this prospective study, conducted at the Department of Surgical Sciences, of the “Sapienza” University of Rome, was to evaluate the diagnostic accuracy of Q-USE, compared with US parameters, in thyroid nodules with indeterminate cytology (Thy3).The case study included 140 nodules from 140 consecutive patients. Patient’s thyroid nodules were evaluated by Q-USE, measuring the strain ratio (SR) of stiffness between nodular and surrounding normal thyroid tissue, and conventional US parameters prior fine-needle aspiration cytology. Those with Thy3 diagnosis were included in the study. Forty of the nodules analyzed harbored a malignant lesion. Q-USE demonstrated that malignant nodules have a significant higher stiffness with respect to benign one and an optimun SR cut-off value of 2.05 was individuated following ROC analysis. Univariate analysis showed that hypoechogenicity, irregular margins and SR >2.05 associated with malignancy, with an accuracy of 67.2%, 81,0% and 89.8%, respectively. Data were unaffected by nodule size or thyroiditis. These findings were confirmed in multivariate analysis demonstrating a significant association of the SR and the irregular margins with thyroid nodule’s malignancy. In conclusion, we demonstrated the diagnostic utility of Q-USE in the differential diagnosis of thyroid nodules with indeterminate cytology that, if confirmed, could be of major clinical utility in patients’ presurgical selection.

The term “relapse carcinoma” is used improperly to indicate either a local or loco-regional relapse or a systematic metastatsis [1]. Local relapse (LR) after thyroidectomy for cancer is “the repetition of the neoplastic lesion in proximity of the previous intervention of excision” [2]. According to Duren [3] relapses of thyroidal carcinoma need to be classified as: local (LR): that may present itself in the residual thyroid lobe or in the thyroid bed where surgery was performed; loco-regional (RLR): that may present in the cervical lymph nodes of the central compartment or lateral-cervical nodes; and metastasis in distance (MD). The MD are frequently synchronous with LR or RLR; they have haematogenous genesis and concern most frequently the lungs and skeleton. There is controversy over how to catergorize the relapse in the thyroidal bed with infiltrations of neighbouring organs (periodontal structures muscles, thyroidal cartilage, cricoid, laryngeal nerves, etc. and the neighbouring organs oesophagus, trachea, larynx). As per the classification proposed by Duren [3] these should be considered as LR, whereas according to Mozzillo and Pezzullo [1] they are categorised as RLR. The RLR at the level of the cervical lymphnodal stations represents an ulterior problem: are these true relapses, residual cancer, or recurrence in progression? Caraco [4], in his report to the ninety-fourth Congress of the Italian Society of Surgery, specified that local recurrences are only those recurrences that are characterized by the appearance of neoplastic tissue in the thyroidal lodge, in the residual parenchyma, and in the adjacent structures, excluding the lymph nodes [5,6]. In nearly 53% of cases the relapse is reported in RLR, in 28% in LR, and in 13% the MD is present of these 6% of cases have mixed relapses [7]; the prognosis of LR is however, better than that of the others [8]. The differentiated tumors of the thyroid are slow growing and due to this rarely reach notable dimensions or result in metastasis in lymph and/or haematic systems [2]. Only 10% of patients die from differentiated thyroid cancer [9]. Most of the local relapses occur within the first five years of the excision of the primary cancer [5,6,10-12], however, the recurrence can occur as late as 20 years after the initial diagnosis and treatment [13]. An accurate evaluation of incidence of LR is possible solely with a considerable number of treated patients and lengthy follow-up that is not available at most centres and hence this kind of information can be obtained from the date from centres that have high volume of thyroid carcinoma and good follow-up like Mayo Clinic or Lahey Clinic [5,6,13] or through observational studies at several other medical centres [14]. Currently relapses represent a rare event in patients who undergo removal of thyroidal carcinoma (3-13%) [5,6,10-12,15-17]. This is due to the ever increasing frequency of total thyroidectomy for management of cancer [18]. The complete excision of the thyroidal parenchyma prevents local recurrence. Giovanni Razzaboni in “Treatise on Prognostic Surgery” (1938) stated that “The most rational operating method, so long as not free from grave consequences of another kind, remains the total extra-capsular thyroidectomy, so as is used, when possible, for the surgical removal of whatever other tumour” [19]. he further emphasized in his work published after his death in 1956 entitled “Treatise on Clinical Therapeutic Surgery” that “Only an removal of this capacity justifies, in the face of a proven malignant tumour, surgical intervention, any other incomplete or partial demolition does nothing but accelerate the ready reoccurrences, even in a very short time” [20]. * Correspondence: cirocchiroberto@yahoo.it General and Emergency Surgical Unit. Department of Surgical Sciences, Radiology and Dentistry. University of Perugia, Perugia, Italy Full list of author information is available at the end of the article Cirocchi et al. World Journal of Surgical Oncology 2011, 9:89 http://www.wjso.com/content/9/1/89 WORLD JOURNAL OF SURGICAL ONCOLOGY

AIM: To investigate the effectiveness of low-volume plus ascorbic acid [polyethylene glycol plus ascorbic acid (PEG + Asc)] and high-volume plus simethicone [polyethylene glycol plus simethicone (PEG + Sim)] bowel preparations. METHODS: A total of one hundred and forty-four outpatients (76 males), aged from 20 to 84 years (median age 59.5 years), who attended our Department, were divided into two groups, age and sex matched, and underwent colonoscopy. Two questionnaires, one for patients reporting acceptability and the other for endoscopists evaluating bowel cleansing effectiveness according to validated scales, were completed. Indications, timing of examination and endoscopical findings were recorded. Biopsy forceps were used as a measuring tool in order to determine polyp endoscopic size estimation. Difficulty in completing the preparation was rated in a 5-point Likert scale (1 = easy to 5 = unable). Adverse experiences (fullness, cramps, nausea, vomiting, abdominal pain, headache and insomnia), number of evacuations and types of activities performed during preparation (walking or resting in bed) were also investigated. RESULTS: Seventy-two patients were selected for each group. The two groups were age and sex matched as well as being comparable in terms of medical history and drug therapies taken. Fourteen patients dropped out from the trial because they did not complete the preparation procedure. Ratings of global bowel cleansing examinations were considered to be adequate in 91% of PEG + Asc and 88% of PEG + Sim patients. Residual Stool Score indicated similar levels of amount and consistency of residual stool; there was a significant difference in the percentage of bowel wall visualization in favour of PEG + Sim patients. In the PEG + Sim group, 12 adenomas ≤ 10 mm diameter (5/left colon + 7/right colon) vs 9 (8/left colon + 1/right colon) in the PEG + Asc group were diagnosed. Visualization of small lesions seems to be one of the primary advantages of the PEG + Sim preparation. CONCLUSION: PEG + Asc is a good alternative solution as a bowel preparation but more improvements are necessary in order to achieve the target of a perfect preparation.

The literature suggests several techniques to ensure the optimal anesthetic procedure for carotid surgery. The aim of our study is to combine, in the carotid endarterectomy, a model of general anesthesia with the loco-regional anesthesia in order to test the safety of the method, the eventual brain damage and hemodynamic stability. We also wanted to test whether the immediate postoperative analgesia was adequate.Seventy eight (78) patients were enrolled in the study (from 60 to 75 years), ASA II-III, candidates for unilateral carotid endarterectomy in a period from June 2008 to January 2009. During the procedure data about perioperative neurologic and hemodynamic complications were collected. At the end of the surgical treatment the pain at the awakening moment through verbal numerical scale VNS was estimated. Data are presented as mean values +/- sd and validated using the chi2 test, when required. Significance was accepted at a value of Por = 0.05.85% of patients reported a VNS between 1 and 2 and 10% equal to 3-5. In the study 95% of patients (P0.05) appreciated the technique and only 3 patients reported their dissatisfaction. There was no mortality and in 5 patients a postoperative morbidity was registered.The study demonstrated the advantages in combining loco-regional anesthesia (valid monitoring of neurological and hemodynamic stability) with general anesthesia (complete airways control and patient comfort) during carotid surgery.

The study of the Mondor's syndrome as a possible complication of gigantomastia.A 49 year old woman, with gigantomastia, came to our observation for the presence of a large superficial vein of the left breast affected by thrombophlebitis, compatible with Mondor's syndrome.A "Thorek" breast reduction was performed; the patient was discharged on the second postoperative day and the follow up was smooth and fee from any complications.In the case we observed, gigantomastia had a clear role in the pathogenesis of the Mondor's disease; in fact, the excessive weight of the breasts caused stretching of the mammary dorsal vein evolving in phlebitis. In literature, among the causes related to Mondor's disease the pendulous breast is described, probably with the same dynamic we have seen in this patient, but has never reported, so obviously, the correlation between the two events. It's considered as good practice in the pre-operative evaluation, to make differential diagnosis with any cancer, that, in a certain percentage, is associated with Mondor's syndrome, and once established the causes of the pathology, it is imperative to eliminate them to prevent any relapses.Among the various causes recognized as predisposing to Mondor's syndrome, there has never been described gigantomastia so far. The observation and treatment of a patient in whom the gigantomastia certainly led to the onset of Mondor's disease, has led us to consider this as one of the possible complications of gigantomastia, providing an additional cue to the treatment of this condition even at an early stage.

Background We conducted a systematic review to evaluate the role of Ultrasonic dissector (UAS) versus conventional clamp and tie in thyroidectomy. Materials and methods We searched for all published RCT in into electronic databases. To be included in the analysis, the studies had to compare thyroidectomy with UAS versus conventional vessel ligation and tight (conventional technique = CT). The following outcomes were used to compare the total thyroidectomy group with UAS versus CT group: operative duration, operative blood loss, overall drainage volume during the first 24 hours, transiet laryngeal nerve palsy, permanent laryngeal nerve palsy, transiet hypocalcaemia and permanent hypocalcaemia. Results There are currently 7 RCT on this issue to compare thyroidectomy with UAS versus CT. From the analysis of these studies it was possible to confront 608 cases: 303 undergoing to thyroidectomy with UAS versus 305 that were treated with CT. Actually, it was shown a relevant advantage of cost-effectiveness in patients treated with UAS; there is a statistically significant reduction of the operative duration (weighted mean difference [WMD], -18.74 minutes; 95% confidence interval [CI], (-26.97 to -10.52 minutes) (P = 0.00001), intraoperative blood loss (WMD, -60.10 mL; 95% CI, -117.04 to 3.16 mL) (P = 0.04) and overall drainage volume (WMD, -35.30 mL; 95% CI, -49.24 to 21.36 mL) (P = 0.00001) in the patients underwent thyroidectomy with UAS. Although the analysis showed that the patients who were treated with USA presented more favourable results in incidence of post-operative complications (transient laryngeal nerve palsy: P = 0.11; permanent laryngeal nerve palsy: not estimable; transient hypocalcaemia: P = 0.24; permanent hypocalcaemia: P = 0.45), these data didn't present statistical relevance. Conclusion This meta-analysis shown a relevant advantage only in terms of cost-effectiveness in patients treated with UAS; it is subsequent to statistically significant reduction of operation duration, intraoperative blood loss and of overall drainage volume during the first 24 hours. Although the analysis showed that the patients who were treated with UAS presented more favourable results in incidence of post-operative complications (transiet laryngeal nerve palsy; transiet hypocalcaemia and permanent hypocalcaemia), these data didn't present statistical relevance.

A 45-year-old woman was referred to our service because 9 months earlier she had developed a pulsating mass on the right supraclavicular fossa and torticollis. Ultrasounds and computed tomographic arteriography showed the presence of a subclavian collateral artery aneurysm with a diameter of 21 mm. On selective arteriography, an aneurysm of a suprascapular artery arising directly from the right subclavian artery was reported. The presence of thoracic outlet syndrome was excluded. The aneurysm was successfully treated with ethylene-vinyl alcohol polymer, a liquid embolic agent. The patient was discharged on postoperative day 1 in good general condition. After 12 months, control ultrasounds confirmed the complete thrombosis of the aneurysm sac.

A 75-year-old man was referred to our hospital because of sudden thoracic pain. A saccular aneurysm of the aortic arch extending on the anterior surface of the aortic arch was found on computed tomographic arteriography. The patient was hemodynamically stable and he was programmed for a staged surgical and endovascular approach (hybrid approach). As a first stage and in order to prevent major cardiac complications due to the overstenting of the left subclavian artery (LSA) with the occlusion of the aortocoronary bypass, the patient underwent a polytetrafluoroethylene bypass graft (GORE-TEX, W.L. Gore & Associates, Flagstaff, AZ) between the LSA and the left carotid artery. Intraoperative arteriography revealed a good patency of the left carotid-subclavian bypass and of the left internal mammary bypass on the left anterior descending artery. As a second stage the endovascular procedure was accomplished 5 days later in the operating room. A Gore TAG stent graft (W.L. Gore & Associates) was deployed in the aortic arch 20 mm proximally to the aneurysmatic segment covering the ostium of the LSA. The postoperative course was uneventful and the patient was discharged on the fifth postoperative day in good general conditions. Hybrid procedures for treatment of aneurysms of the aortic arch or of the descending thoracic aorta are a promising alternative to open surgery especially in high-risk patients, with lower early morbidity and mortality rates. Long-term effectiveness remains to be fully elucidated.

KGFR is involved in the pathogenesis of several human cancers. In this study, we generated and characterized a monoclonal antibody specific to KGFR (SC-101 mAb) and evaluated its potential use in basic research and as a diagnostic and prognostic tool. The specificity and biological activity of the SC-101 mAb were evaluated by Western blotting, immunofluorescence, and immunoprecipitation analyses on various cell lines. KGFR expression in breast, pancreatic, and thyroid carcinoma was assessed by immunohistochemistry (IHC) with SC-101 mAb. KGFR expression levels revealed by SC-101 mAb resulted to increase proportionally with tumor grade in breast and pancreatic cancer. In addition, SC-101 mAb was able to detect KGFR down-modulation in thyroid cancer. SC-101 mAb might represent a useful tool for basic research applications, and it could also contribute to improve the accuracy of diagnosis and prognosis of epithelial tumors. Electronic supplementary material The online version of this article (doi:10.1007/s12033-014-9773-x) contains supplementary material, which is available to authorized users.

Background The rising interest towards minimally invasive surgery has led to the introduction of laparo-endoscopic single site (LESS) surgery as the natural evolution of conventional multiport laparoscopy. However, this new surgical approach is hampered with peculiar technical difficulties. The SPIDER surgical system has been developed in the attempt to overcome some of these challenges. Our study aimed to compare standard laparoscopy and SPIDER technical performance on a surgical simulator, using standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS). Methods Twenty participants were divided into two groups based on their surgical laparoscopic experience: 10 PGY1 residents were included in the inexperienced group and 10 laparoscopists in the experienced group. Participants performed the FLS pegboard transfers task and pattern cutting task on a laparoscopic box trainer. Objective task scores and subjective questionnaire rating scales were used to compare conventional laparoscopy and SPIDER surgical system. Results Both groups performed significantly better in the FLS scores on the standard laparoscopic simulator compared to the SPIDER. Inexperienced group: Task 1 scores (median 252.5 vs. 228.5; p = 0.007); Task 2 scores (median 270.5 vs. 219.0; p = 0.005). Experienced group: Task 1 scores (median 411.5 vs. 309.5; p = 0.005); Task 2 scores (median 418.0 vs. 331.5; p = 0.007). Same aspects were highlighted for the subjective evaluations, except for the inexperienced surgeons who found both devices equivalent in terms of ease of use only in the peg transfer task. Conclusions Even though the SPIDER is an innovative and promising device, our study proved that it is more challenging than conventional laparoscopy in a population with different degrees of surgical experience. We presume that a possible way to overcome such challenges could be the development of tailored training programs through simulation methods. This may represent an effective way to deliver training, achieve mastery and skills and prepare surgeons for their future clinical experience.