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Background: Thyroid fine-needle aspiration (FNA) is a reliable and cost-effective diagnostic tool for establishing the nature of thyroid nodules, although up to 30% of FNAs are still classified as "indeterminate." Molecular testing of FNAs could improve preoperative diagnosis, thereby reducing unnecessary surgery. In this multicenter prospective study the authors investigated, using a 7-gene assay, the distribution and diagnostic impact of BRAF, RAS, RET/PTC, and PAX8/PPARg, the most frequent genomic alterations occurring during thyroid oncogenesis., Methods: In total, of 1172 routine FNAs from 7 centers in southern Italy were classified according to the Bethesda System for Reporting Thyroid Cytopathology. Each specimen was tested, and molecular data were compared with available histology or cytologic follow-up., Results: In particular, for atypia of undetermined significance/follicular lesion of undetermined significance cases, the 7-gene test confirmed the high positive predictive value of BRAFV600E and BRAF-like mutations (80%) and the moderate positive predictive value of RAS-like alterations (32.4%), suggesting different surgical management, depending on the type of mutation. The rate of mutation-positive FNAs was strictly related to the risk of malignancy of each diagnostic class, supporting the identification of prognostically relevant diagnostic categories., Conclusions: The 7-gene panel test improves the preoperative risk stratification of indeterminate thyroid FNAs, especially when considering the biologic significance of the different types of mutations. Moreover, the rate of mutation-positive FNAs is related to the risk of malignancy of each diagnostic class., (© 2019 American Cancer Society.)

Background: Medullary thyroid carcinoma is a malignant uncommon and aggressive tumour of the parafollicular C cells. In about 75% of cases it is sporadic while, in case of RET mutation, it is associated to multiple endocrine neoplasia type 2 (25% of cases). The biochemical features of medullary thyroid carcinoma include the production of calcitonin and carcinoembryogenic antigen. The above-mentioned features are useful in the diagnostic process as well as in the follow up and in the prognostication of the disease. Even if calcitonin elevation is strongly associated to MTC, it can also be found increased in many pathological different conditions as pregnancy, lactation, C-cells hyperplasia, autoimmune thyroiditis, end stage renal disease, lung and prostate cancer and several neuroendocrine tumours. Major medullary thyroid tumours are usually connected to high doses of circulating calcitonin, in fact non-secretory variants have hardly been described., Case Presentation: We herein report the case of a 59 years old male, who had undergone total thyroidectomy for multinodular goiter with negative preoperative calcitonin, showing medullary thyroid carcinoma at definitive pathology. To the best of our knowledge, this is the first case documenting a non-secretory medullary thyroid carcinoma, with double negative markers at the time of diagnosis and at the relapse., Conclusion: A Literature review underlining pathological hypothesis, differential diagnosis and alternative and innovative biomarkers to identify non-secretory medullary thyroid carcinoma was carried out.

Permanent hypoparathyroidism is the most common long-term complication after thyroidectomy. We evaluated whether iPTH concentrations on the first postoperative day may be a good predictor of this complication. Patients undergoing thyroidectomy in our Unit between January 2017 and February 2018 who developed postsurgical hypoparathyroidism were analysed. According to iPTH values on the first postoperative day and on the basis of the detection threshold of the iPTH test used, patients were divided into 2 groups: Group A (iPTH < 6.3 pg/mL, undetectable), Group B (iPTH ≥ 6.3 pg/mL). Seventy-five patients were included in this study: 64 in Group A and 11 in Group B. Permanent hypoparathyroidism occurred in 14 (21.88%) patients in Group A, while none developed this complication in Group B. When iPTH was < 6.3 pg/mL, the sensitivity for the prediction of permanent hypoparathyroidism was 100%, the specificity was 18.03%, the positive predictive value was 21.88% and the negative predictive value was 100%. No patient with iPTH ≥ 6.3 pg/mL on the first postoperative day developed permanent hypoparathyroidism. On the other hand, iPTH concentrations < 6.3 pg/mL have not proved to be a strong predictor of this condition. However, this cut-off value can be useful to identify patients at risk of developing this complication., Competing Interests: Conflict of interest: Authors state no conflict of interest.

Background: Medullary thyroid carcinoma is a neuroendocrine tumor belonging form a malignant growth of the thyroid parafollicular C-cells, representing from 1 to 10% of all thyroid cancer. The biochemical activity of medullary thyroid carcinoma includes the production of calcitonin and carcinoembryogenic antigen, which are sensitive tumor markers, facilitating the diagnosis, follow-up and prognostication. The diagnosis is reached through the identification of high basal calcitonin serum level or after pentagastrin stimulation test. Medullary thyroid carcinoma is able to produce other relevant biomarkers as procalcitonin, carcinoembryionic antigen and chromogranin A. In Literature are described few cases of medullary thyroid carcinoma without elevation of serum calcitonin, an extremely rare event. The aim of this study was to analyse the presentation, the main features and therapeutic management of medullary thyroid carcinoma associated with negative serum calcitonin levels., Methods: Using the PubMed database, a systematic review of the current Literature was carried out, up to February 2018. Finally, nineteen articles met our inclusion criteria and were selected according to the modified Newcastle-Ottawa scale., Results: Fourty-nine patients with definitive pathology confirming medullary thyroid carcinoma and with calcitonin serum level in the normal range were identified (24 female, 24 male and not reported gender in 1 case). Mean age was 51.7 years. Serum calcitonin levels were reported for 20 patients with a mean value of 8.66 pg/mL and a range of 0.8-38 pg/mL. Despite the low or undetectable calcitonin serum level, at immunochemistry in almost the half of the cases reported by the Authors, the tumors presented diffuse or focal positivity for calcitonin and carcinoembryionic antigen, while was reported a chromogranin A positivity in 41 of the 43 tested patients., Conclusions: Calcitonin negative medullary thyroid carcinoma is an extremely rare pathology. The diagnosis and the surveillance is often challenging and delayed, due to the lack of elevation of serum markers as calcitonin and carcinoembryionic antigen. Further studies are needed, to better define options for management of non secretory medullary thyroid carcinoma and to identify new and reliable biomarkers associated to diagnosis and relapse of this medical dilemma.

Background: Prophylactic central neck lymph-nodes dissection is still a topic of major debate in Literature. There is a lack of randomized controlled trials proving advantages in its application in terms of overall survival and local recurrence. Due to the recent rapid increase of elderly population, differentiated tumor carcinoma diagnosis increased in patients over 65 years old. The aim of this study was to compare recurrence rate, complications rate and histological features of tumors in elderly population., Methods: A retrospective study was carried out collecting data from 371 patients with differentiated thyroid cancer without clinical evidence of lymph-nodes involvement in three Italian referral centers from 2005 to 2015. All patients were aged ≥ 65 years and were divided in two groups based on the performed surgery (total thyroidectomy alone or associated with central lymph-nodes dissection). Moreover, patients were stratified according to the age between 65 and 74 years old and over 75 years old., Results: Total thyroidectomy alone was performed in 184 patients (group A) and total thyroidectomy with prophylactic central neck dissection was performed in 187 cases (group B). There was a statistically significant difference in complications between the groups in terms of neck hematoma (0.5% group A vs 3.7% group B), temporary hypoparathyroidism (11.4% group A vs 21.4% group B), and temporary unilateral recurrent nerve injury (1.5% group A vs 6.4% group B). Lymph nodes recurrence rate was 9.2% in group A and 8.5% in group B, with no statistically significant difference. There was a statistically significant difference in patients over 75 years old in terms of temporary hypoparathyroidism (24% group A vs 11% group B), permanent hypoparathyroidism (2,7% group A vs 0,3% group B) and recurrent nerve injury (9,5% group A vs 2% group B)., Conclusions: The role of prophylactic central neck dissection is still controversial, especially in elderly patients, and an aggressive surgical approach should be carefully evaluated. The Authors reported a similar low recurrence rate between total thyroidectomy and total thyroidectomy associated with prophylactic central neck dissection, with increased postoperative complications in the lymphadenectomy group and in patients over 75 years old, advocating a tailored surgical approach in elderly population.

Pollutants represent potential threats to the human health, being ubiquitous in the environment and exerting toxicity even at low doses. This study aims at investigating the role of fifteen multiclass organic pollutants, assumed as markers of environmental pollution, most of which exerting endocrine-disrupting activity, in thyroid cancer development. The increasing incidence of differentiated thyroid cancer (DTC) may be related to the rising production and environmental dissemination of pollutants. Fifty-five patients, twenty-seven with diagnosis of benign thyroid nodules and twenty-eight suffering from differentiated thyroid cancer, were enrolled and the concentration levels of seven bisphenols, two phthalates (i.e. di(2-ethylhexyl) phthalate (DEHP) and its main metabolite, mono-(2-ethyl-hexyl) phthalate) (MEHP)), two chlorobenzenes, (1,4-dichlorobenzene and 1,2,4,5-tetrachlorobenzene), and 3 phenol derivatives (2-chlorophenol, 4- nonylphenol, and triclosan) were determined in their serum by using a validated analytical method based on high performance liquid chromatography with ultraviolet tandem fluorescence detection. A significant relationship was found between malignancy and the detection in the serum of both bisphenol AF and DEHP. Indeed, their presence confers a more than fourteen times higher risk of developing differentiated thyroid cancer. Relationship between these two pollutants and the risk of malignancy was dose-independent and not mediated by higher thyroid stimulating hormone levels. Even if a conclusive evidence cannot still be drawn and larger prospective studies are needed, the exposure to low doses of environmental endocrine-disrupting contaminants can be considered consistent with the development of thyroid cancer., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: The Harmonic scalpel ("Focus" and the new version "Focus+") is one of the first devices for surgical simultaneous cutting and tissue coagulation which allows to obtain dissection and hemostasis by direct application of ultrasound and allows minimally invasive surgical procedures with minimal lateral thermal spread and, thus, minimal adjacent tissue destruction. The aim of the study is to complete the previous study that we made in 2014, based on the TT performed between January 2008 and December 2013, with new data about TT performed in our Surgical Division between January 2014 and December 2016 and compare the outcome using the Ultrasonic scalpel versus the device Ligasure in term of safety, operative time, overall drainage volume, complications, hospital stay., Patients and Methods: 250 patients were randomized into two groups: Group A where Ultracision were used and Group B where the Ligasure device was used., Results: The results of the group A and of the Group B 2014-2016 have been compared with the results of the previous study and we found that they are similar, but asymptomatic hypocalcaemia increased in the patients of the new study., Conclusions: We found that the use of Ultrasonic scalpel and Ligasure is effective both in the hemostasis of all vessels and in dissection of tissues and confirm the results of our first study without significant difference in the rate of post-operative morbidity with these two different energy based devices used.

No studies have examined scars and quality of life after different treatments of wound dehiscence in patients undergoing post-bariatric abdominoplasty. Scars and quality of life of patients with postoperative wound dehiscence managed with negative pressure wound therapy (group A) and conventional wound therapy (group B) were reviewed 6 months after wound healing. Of 38 patients undergoing treatment for wound dehiscence after 203 abdominoplasty, 35 (group A = 14 versus group B = 21) entered the study. Wound healing in group A was significantly faster than group B (P = 0·001). Patients (P = 0·0001) and observers (P = 0·0001) reported better overall opinions on a scar assessment scale for group A. Better overall quality of life and general health satisfaction were observed in group A (P < 0·05). A significant correlation was observed between the World Health Organization Quality of Life scores and Patient and Observer Scar Assessment Scale scores (r=-0·68, P < 0·0001) in all 35 patients. Negative pressure wound therapy is feasible and effective in patients with wound dehiscence following post-bariatric abdominoplasty. An adequate post-treatment outcome is achieved compared with conventional wound therapy in light of a strong association found between worse patient scar self-assessment and poor overall quality of life, regardless of the received treatment., (© 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Hashimoto's thyroiditis (HT) seems to have favourable prognostic impact on papillary thyroid cancer (PTC), but data were obtained analysing all disease stages. Given that HT-related microenvironment involves solely the thyroid, we aimed to assess the relationship between HT, as detected through pathological assessment, and outcome in intrathyroidal PTC. This was a multicentre, retrospective, observational study including 301 PTC with no evidence of extrathyroidal disease. Primary study endpoint was the rate of clinical remission. Auxiliary endpoint was recurrence-free survival (RFS). HT was detected in 42.5% of the cohort and was associated to female gender, smaller tumour size, lower rate of aggressive PTC variants and less frequent post-surgery radio-iodine administration. HT showed relationship with significantly higher rate of clinical remission ( P  < 0.001, OR 4, 95% CI 1.78-8.94). PTCs with concomitant HT had significantly longer RFS, as compared with non-HT tumours ( P  = 0.004). After adjustment for other parameters affecting disease outcome at univariate analysis (age at diagnosis, histology, tumour size and multifocality), prognostic effect of HT remained significant ( P  = 0.006, OR 3.28, 95% CI 1.39-7.72). To verify whether HT could optimise the identification of PTCs with unfavourable outcome, we assessed the accuracy of 'non-HT status' as negative prognostic marker, demonstrating poor capability of identifying patients not maintaining clinical remission until final follow-up (probability of no clinical remission in PTCs without HT: 21.05%, 95% CI 15.20-27.93). In conclusion, our data show that HT represents an independent prognostic parameter in intrathyroidal PTC, but cannot improve prognostic specificity., (© 2017 Society for Endocrinology.)

Hypocalcaemia is one of the most common complications after thyroidectomy; however, it is still unclear what preoperative factors could predict this event. The aim of this study was to evaluate the role of risk factors for hypocalcaemia after total thyroidectomy (TT). Consecutive patients who underwent total thyroidectomyat our institution between January 2014 and January 2016 were enrolled. The clinical and pathologic characteristics and surgical details of normocalcemic and hypocalcemic patients were compared. Univariate and multivariate analyses to estimate risk ratio were assessed. A total of 328 patients underwent TT; histology revealed benign and malignant disease in 83 and 17% of cases, respectively. Central-compartment neck dissection (CCND) was performed in 36 subjects (10.9%). Parathyroid glands were observed in 23% (76) of specimens. Laboratory asymptomatic hypocalcaemia was observed in 92 (28%) patients; symptomatic hypocalcaemia occurred in 26 (7.9%). Transient hypocalcaemia has been observed in 48 (14.6%) patients; permanent hypocalcaemia occurred in two subjects (0.6%). On univariate analysis, malignant pathology (p < 0.001), CCND (p < 0.05), female gender (p < 0.001), presence of at least two parathyroid glands in specimens (p < 0.002), and operative time longer than 120 min (p < 0.05) were factors that significantly increased the risk of developing asymptomatic and transient hypocalcaemia. After logistic regression analysis, malignant pathology (p < 0.000; p < 0.001) and CCND (p < 0.005; p = 0.013) were the significant factors that affected the development of symptomatic and transient hypocalcaemia. The presence of malignant pathology and CCND was found to be significant risks factors for postoperative hypocalcaemia. In patients in whom this pathological features are present, attention should be paid to rapidly start an adequate therapy.

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions (FN), considering their low definitive malignancy rate and the limited predictive power of preoperative clinic-diagnostic factors, is still controversial. On behalf of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB), we collected and analyzed the experience of 26 endocrine centers by computerized questionnaire. 1379 patients, surgically treated after a FN diagnosis from January 2012 and December 2103, were evaluated. Histological features, surgical complications, and medium-term outcomes were reported. Total thyroidectomy (TT) was performed in 1055/1379 patients (76.5 %), while hemithyroidectomy (HT) was carried out in 324/1379 cases (23.5 %). Malignancy rate was higher in TT than in HT groups (36.4 vs. 26.2 %), whereas the rates of transient and definitive hypoparathyroidism following TT were higher than after HT. Consensual thyroiditis (16.8 vs. 9.9 %) and patient age (50.9 vs. 47.9 %) also differed between groups. A cytological FN diagnosis was associated to a not negligible malignancy rate (469/1379 patients; 34 %), that was higher in TT than in HT groups. However, a lower morbidity rate was observed in HT, which should be considered the standard of care in solitary lesions in absence of specific risk factors. Malignancy could not be preoperatively assessed and clinical decision-making is still controversial. Further efforts should be spent to more accurately preoperatively classify FN thyroid nodules.

Background: Thyroid nodules are usually benign; however, 5 to 15% prove to be malignant. Fine-needle aspiration (FNA) has become the gold standard in the evaluation of thyroid nodules, especially in single nodule more than a centimeter and / or in smaller nodule with ultrasound characters of malignancy., Methods: We evaluated retrospectively 179 patients with "undetermined" thyroid fine needle aspiration, undergoing surgery. We compared cytology and histology and we evaluated sex, age, the presence of thyroiditis and dimension of the indeterminate nodule as predictors of malignancy., Results: In 48 patients (26.8%) histological examination confirmed the indeterminate cytological diagnosis and this means that the nodule underwent FNA was diagnosed in effects such as cancer. In 29 patients, on histological examination, the nodule underwent FNA was not diagnosed as cancer, but one or more carcinomas were diagnosed in the same lobe of indeterminate nodule, but in different location and / or in the contralateral lobe. In 102 patients, the definitive histological examination did not confirm the suspected diagnosis and we found a significant positive association only between male sex and histological malignancy., Conclusions: The indeterminate FNA still remains a challenge for the surgeon because it is not yet possible to discriminate patients who really need surgery from those that can be followed in follow-up. The potential of molecular diagnostics for thyroid nodules with indeterminate cytology is promising, but many of these markers are too complex or expensive for routine clinical use or are still poorly standardized., Key Words: Indeterminate FNA, Thyroid, Thyroid fine needle aspiration.

Introduction: Thyroid disease is common in elderly population. The incidence of hypothyroidism and multinodular goiter increases with age. Surgery in elderly patients has been considered to be more hazardous than in a youthful population. Besides the traditional surgical hemostatic techniques, different hemostatic approaches, which further minimize the risk of bleeding and complications during thyroidectomy, have become available. Aim of this study was to review and compare the outcomes of total thyroidectomy (TT) in elderly performed with different energy system., Methods: A total of 255 patients were eligible for the study and enrolled. One hundred and five patients with age >70 years (median age 76, range 70-90) constituted the elderly group (EG), whereas the young group (YG) was composed by 150 patients (median age 36, range 18-69). Each group was further divided into three subgroups, on the basis of the device used (none, Ligasure Precise/Small Jaw or Harmonic Focus) for performing TT as follows: conventional thyroidectomy in EG (CTE) and YG (CTY), Ligasure thyroidectomy (LTE and LTY) and Harmonic thyroidectomy (THE and HTY). Intra-operative and post-operative data, as well as complications rate, were collected., Results: There was no significant difference between the elderly and the young patients treated with total thyroidectomy. Using of Harmonic Focus or Ligasure Precise/Small Jaw allowed a reduction of the duration of surgery (p < 0.05) than conventional approach; complication rate for hemorrhage, hypocalcemia and vocal cord paralysis was similar in all sub-groups., Conclusions: Total thyroidectomy in elderly patients is as safe as in the younger population. Moreover, using the Harmonic Focus and the Ligasure Precise/Small Jaw is a safe, effective, and time-saving alternative to the traditional suture ligation technique for thyroid surgery., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Hemostasis during thyroidectomy is essential; however the most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with the combination of harmonic scalpel (HS) and an advanced hemostatic pad (Hemopatch)., Methods: Patient undergone TT were divided into two groups: HS + hemopatch and HS + traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates., Results: Between September 2014 and March 2015, 60 patients were enrolled (30 to Hs + Hemopatch, 30 to Hs and standard hemostasis); 71.4% female; mean age 48.5 years. The 24-h drain output was lower in the HS + hemopatch group compared with standard TT. HS and hemopatch also had a shorter mean surgery time (p < 0.0001) vs standard TT., Conclusion: combination of hemopatch plus HS is effective and safe for TT with a complementary hemostatic approach., (Copyright © 2015. Published by Elsevier Ltd.)

Introduction: Obesity is a strong independent risk factor of gastroesophageal reflux disease (GERD) symptoms and hiatal hernia development. Pure restrictive bariatric surgery should not be indicated in case of hiatal hernia and GERD. However it is unclear what is the real incidence of disruption of esophagogastric junction (EGJ) in patients candidate to bariatric surgery. Actually, high resolution manometry (HRM) can provide accurate information about EGJ morphology. Aim of this study was to describe the EGJ morphology determined by HRM in obese patients candidate to bariatric surgery and to verify if different EGJ morphologies are associated to GERD-related symptoms presence., Methods: All patients underwent a standardized questionnaire for symptom presence and severity, upper endoscopy, high resolution manometry (HRM). EGJ was classified as: Type I, no separation between the lower esophageal sphincter (LES) and crural diaphragm (CD); Type II, minimal separation (>1 and < 2 cm); Type III, >2 cm separation., Results: One hundred thirty-eight obese (BMI>35) subjects were studied. Ninety-eight obese patients referred at least one GERD-related symptom, whereas 40 subjects were symptom-free. According to HRM features, EGJ Type I morphology was documented in 51 (36.9%) patients, Type II in 48 (34.8%) and Type III in 39 (28.3%). EGJ Type III subjects were more frequently associated to Symptoms than EGJ Type I (38/39, 97.4%, vs. 21/59, 41.1% p < 0.001)., Conclusions: Obese subjects candidate to bariatric surgery have a high risk of disruption of EGJ morphology. In particular, obese patients with hiatal hernia often refer pre-operative presence of GERD symptoms. Testing obese patients with HRM before undergoing bariatric surgery, especially for restrictive procedures, can be useful for assessing presence of hiatal hernia., (Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.)

This retrospective comparative multicenter study aims to analyze the impact on patient outcomes of total thyroidectomy (TT) performed by resident surgeons (RS) with close supervision and assistance of attending surgeons (AS).All patients who underwent TT between 2009 and 2013 in 10 Units of endocrine surgery (8 in Italy, 1 in France, and 1 in UK) were evaluated. Demographic data, preoperative diagnosis, extension of goiter, type of surgical access, surgical approach, operative time, use and duration of drain, length of hospitalization, histology, and postoperative complications were recorded. Patients were divided into 3 groups: A, when treated by an AS assisted by an RS; B and C, when treated by a junior and a senior RS, respectively, assisted by an AS.The 8908 patients (mean age 51.1 ± 13.6 years), with 6602 (74.1%) females were enrolled. Group A counted 7092 (79.6%) patients, Group B 261 (2.9%) and Group C 1555 (17.5%). Operative time was significantly greater (P < 0.001) in B (101.3 ± 43.0 min) vs A (71.8 ± 27.6 min) and C (81.2 ± 29.9 min). Duration of drain was significantly lower (P < 0.001) in A (47.4 ± 13.2 h) vs C (56.4 ± 16.5 h), and in B (42.8 ± 14.9 h) vs A and C. Length of hospitalization was significantly longer (P < 0.001) in C (3.8 ± 1.8 days) vs B (2.4 ± 1.0 days) and A (2.6 ± 1.5 days). No mortality occurred. Overall postoperative morbidity was 22.3%: it was significantly higher in B vs A (29.5% vs 22.3%; odds ratio [OR] 1.46, 95% confidence interval [CI] 1.11-1.92, P = 0.006) and C (21.3%; OR 1.55, 95% CI 1.15-2.07, P = 0.003). No differences were found for recurrent laryngeal nerve palsy, hypoparathyroidism, hemorrhage, and wound infection. The adjusted ORs in multivariate analysis showed that overall morbidity remained significantly associated with Group B vs A (OR 1.48, 95% CI 1.12-1.96, P = 0.005) and vs C (OR 1.60, 95% CI 1.19-2.17, P = 0.002), while no difference was observed in Group A vs B + C.TT can be safely performed by residents correctly supervised. Innovative gradual training in dedicated high-volume hospitals should be proposed in order to allow adequate autonomy for the RS and safeguard patient outcome., Competing Interests: The authors have no funding and conflicts of interest to disclose.

Background: Hemostasis during thyroidectomy is essential; however, the safest, most efficient, and most cost-effective way to achieve this is unclear. This randomized, multicenter, single-blind, prospective study evaluated the efficacy and safety of using different hemostatic approaches in patients undergoing total thyroidectomy., Methods: Patients aged ≥18 to 70 years were randomized to Floseal + a harmonic scalpel (HS), Floseal alone, HS alone, or standard total thyroidectomy. Primary endpoint was 24-hour drain output. Secondary endpoints included surgery duration and complications., Results: Two hundred and six patients were randomized to Floseal + HS (n = 52), Floseal alone (n = 54), HS alone (n = 50), and standard total thyroidectomy (n = 50). The 24-hour drain output was lower in the Floseal + HS group compared with standard thyroidectomy. Floseal + HS also had a shorter surgery time (P < .0001) versus the other 3 treatments., Conclusion: Floseal + HS can be effective at reducing postsurgical drain output and provides a complementary hemostatic approach in patients undergoing total thyroidectomy., (© The Author(s) 2015.)

Background: To evaluate the use of a double loop reconstruction following pylorus preserving proximal pancreaticoduodenectomy (PPPPD)., Methods: Morbidity and mortality were evaluated in 55 patients undergoing PPPPD for malignant tumors, followed by a double loop reconstruction., Results: The mean intra-operative blood loss was 908mL±531. In-hospital mortality was 5.4% (3/55 pts). The mean length of hospital stay was 17±5 days (range 12-45 days). Postoperative complications occurred in 25 patients (46.2%). Five patients developed an anastomotic leak, one biliary and four pancreatic (4/55; 7%). Delayed gastric emptying occurred in 8 patients (14.5%). Reoperation was required in two patients for hemorrhage., Conclusions: A double loop alimentary reconstruction following PPPPD led to a low incidence of DGE and pancreatic fistula. Although mortality rate was higher than that reported by referral centres, this technique has been performed in a not specialized unit attaining acceptable results., (Copyright © 2016. Published by Elsevier Ltd.)

Background: Few studies have reported long-term recurrence rates after asymmetric excision with primary closure in the treatment of sacrococcygeal pilonidal disease., Methods: A retrospective analysis of a prospectively maintained database of 550 surgical excisions performed for sacrococcygeal pilonidal disease between 1988 and 2005 was performed., Results: A total of 550 patients with a diagnosis of pilonidal sinus underwent surgical excision over a period of 17 years. Thirty-eight out of the 550 patients (3.5%) were lost at follow-up. At a mean follow up of 11.2 ± 5.3 years, median 11 years (range = 3-22), the recurrence rate was 8.9%. Actuarial 1-, 5-, 10-, and 20-year disease-free survival rates were 98%, 94%, 92%, and 83%, respectively, with a median overall disease-free survival of 10 years (95% confidence interval [CI] = 3-15). When patients were stratified according to several variables known to influence recurrence, an age of less or ≥22 years (odds ratio [OR] = 1.5, 95% CI = 0.3-7.5, P = .001), a family history of sinus (OR = 5.9, 95% CI = 2.7-12, P = .0001), and intraoperative methylene blue use (OR = 6.3, 95% CI = 1.2-31, P = .024) were indicated as independent predictors of disease-free survival rates., Conclusions: D-shape asymmetric excision and scar lateralization, with primary multilayer subcuticular closure, suction drain insertion, and skin closure in patients with sacrococcygeal pilonidal disease is a safe and adequate surgical treatment offering an effective healing rate as well as low recurrence. Several features are likely to predict a better or a worse long-term recurrence rate in patients undergoing surgery for sinus pilonidalis., (© The Author(s) 2014.)

Background: To date, therapeutic guidelines and pattern of reflux for patients with no-dysplasia (ND) or low-grade dysplasia (LGD) Barrett's esophagus (BE) remain unclear. We aimed to analyze pattern of reflux and regression of ND- or LGD-BE after medical and surgical treatment., Methods: We studied a cohort of ND- and LGD-BE patients who underwent laparoscopic total fundoplication and a cohort of ND- and LGD-BE patients managed medically. Patients were matched for age, sex, and disease duration. After 1 year of follow-up at least, all patients underwent upper endoscopy with esophageal biopsies to evaluate any histological changes, as well as manometry and impedance-pH-metry to re-assess reflux patterns., Results: Thirty-seven patients (20 LGD, 17 ND) undergoing laparoscopic fundoplication were enrolled and compared with 25 patients (13 LGD, 12 ND) managed with proton pump inhibitors (PPI). Laparoscopic fundoplication resulted in a better control of both acidic and weakly acidic reflux (P < 0.001) and was associated with a higher probability of reversion for LGD (P < 0.01). Esophageal motility did not differ between surgically and medically treated patients., Conclusions: In patients with ND- or LGD-BE, laparoscopic fundoplication seems to warrant a better control of all kinds of refluxate and it is associated with a higher likelihood of reversion of both LGD- and ND-BE, compared with PPI therapy.

Klinefelter syndrome (KS) is a hypergonadotropic hypogonadism characterized by a 47, XXY karyotype. The risk of testicular cancer in KS is of interest in relation to theories about testicular cancer etiology generally; nevertheless it seems to be low. We evaluated the need for imaging and serum tumor markers for testicular cancer screening in KS. Participants were 40 consecutive KS patients, enrolled from December 2009 to January 2013. Lactate dehydrogenase (LDH), alpha-fetoprotein (AFP), and beta-human chorionic gonadotrophin subunit (β-HCG) serum levels assays and testicular ultrasound (US) with color Doppler, were carried out at study entry, after 6 months and every year for 3 years. Abdominal magnetic resonance (MR) was performed in KS when testicular US showed micro-calcifications, testicular nodules and cysts. Nearly 62% of the KS had regular testicular echotexture, 37.5% showed an irregular echotexture and 17.5% had micro-calcifications and cysts. Eighty seven percent of KS had a regular vascular pattern, 12.5% varicocele, 12.5% nodules <1 cm, but none had nodules >1 cm. MR ruled out the diagnosis of cancer in all KS with testicular micro calcifications, nodules and cysts. No significant variations in LDH, AFP, and β-HCG levels and in US pattern have been detected during follow-up. We compared serum tumor markers and US pattern between KS with and without cryptorchidism and no statistical differences were found. We did not find testicular cancer in KS, and testicular US, tumor markers and MR were, in selected cases, useful tools for correctly discriminating benign from malignant lesions.

Aim: To study costs of laparoscopic and open liver and pancreatic resections, all the compiled data from available observational studies were systematically reviewed., Methods: A systematic review of the literature was performed using the Medline, Embase, PubMed, and Cochrane databases to identify all studies published up to 2013 that compared laparoscopic and open liver [laparoscopic hepatic resection (LLR) vs open liver resection (OLR)] and pancreatic [laparoscopic pancreatic resection (LPR) vs open pancreatic resection] resection. The last search was conducted on October 30, 2013., Results: Four studies reported that LLR was associated with lower ward stay cost than OLR (2972 USD vs 5291 USD). The costs related to equipment (3345 USD vs 2207 USD) and theatre (14538 vs 11406) were reported higher for LLR. The total cost was lower in patients managed by LLR (19269 USD) compared to OLR (23419 USD). Four studies reported that LPR was associated with lower ward stay cost than OLR (6755 vs 9826 USD). The costs related to equipment (2496 USD vs 1630 USD) and theatre (5563 vs 4444) were reported higher for LPR. The total cost was lower in the LPR (8825 USD) compared to OLR (13380 USD)., Conclusion: This systematic review support the economic advantage of laparoscopic over open approach to liver and pancreatic resection.

Esophageal achalasia is a chronic and progressive motility disorder characterized by absence of esophageal body peristalsis associated with an impaired relaxation of lower esophageal sphincter (LES) and usually with an elevated LES pressure, leading to an altered passage of bolus through the esophago-gastric junction. A definitive cure for achalasia is currently unavailable. Palliative treatment options provide only food and liquid bolus intake and relief of symptoms. Endoscopic therapy for achalasia aims to disrupt or weaken the lower esophageal sphincter. Intra-sphincteric injection of botulinum toxin is reserved for elderly or severely ill patients. Pneumatic dilation provides superior results than botulinum toxin injection and a similar medium-term efficacy almost comparable to that attained after surgery. Per oral endoscopic myotomy is a promising option for treating achalasia, but it requires increased experience and further objective and long-term follow up. This article will review different endoscopic treatments in achalasia, and summarize the short-term and long-term outcomes.

Background: Off-midline closure after excision and primary closure in the treatment of sacrococcygeal pilonidal disease has been suggested to improve surgical outcomes and reduce median recurrence rate. The aim of this study was to investigate several features known to be related to recurrence, allowing adequate comparison of recurrence between D-shaped asymmetric and symmetric excision in the treatment of sacrococcygeal pilonidal disease., Methods: An analysis of a prospectively maintained database of 569 surgical excisions performed for sacrococcygeal pilonidal disease between 1988 and 2007 was performed., Results: The recurrence rate was lower in the asymmetric (n = 423) than in the symmetric (n = 101) group (9% vs 22.0%, P = .0001). After a median follow-up period of 11 years, 5-year 10-year, and 20-year disease-free survival rates were higher in the asymmetric group (94%, 92%, and 89% vs 84%, 79%, and 71%, respectively, P = .005)., Conclusions: D-shaped asymmetric excision is an effective treatment of sacrococcygeal pilonidal sinus. Better long-term recurrence rates are achieved compared with symmetric excision, when stratified for several features known to be related to recurrence., (Copyright © 2014 Elsevier Inc. All rights reserved.)

In consideration of the use of fibrin glue in a general surgery department, authors analyze their last two years series. Operations on liver and biliary ducts, bowel and proctologic surgery, thyroid and breast surgery, abdominal wall hernias, fistulas and difficult wounds are considered with a literary review on fibrin sealant.

Background: Sleeve gastrectomy (SG) is currently gaining popularity due to an excellent efficacy combined to minimal anatomic changes. However, some concerns have been raised on increased risk of postoperative gastroesophageal reflux disease (GERD) due to gastric fundus removal, section of the sling muscular fibers of gastroesophageal junction, reduced antral pump function, and gastric volume. We undertook the current study to evaluate by means of high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) the impact of SG on esophageal physiology., Methods: In this study, 25 consecutive patients had HRiM and MII-pH before and after laparoscopic SG. The following parameters were calculated at HRiM: lower esophageal sphincter (LES) pressure and relaxation, peristalsis, number of complete esophageal bolus transit, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH with the patient in both upright and recumbent positions., Results: At a median follow-up of 13 months, HRiM showed an unchanged LES function, increased ineffective peristalsis, and incomplete bolus transit. MII-pH showed an increase of both acid exposure of the esophagus and number of non-acid reflux events in postprandial periods., Conclusions: Laparoscopic SG is an effective restrictive procedure that creates delayed esophageal emptying without impairing LES function. A correctly fashioned sleeve does not induce de novo GERD. Retrograde movements and increased acid exposure are probably due to stasis and postprandial regurgitation.

Introduction: Aim of this study is to determine whether quality of life (QoL) assessment in association with instrumental evaluation can help to identify factors predictive of outcome both in surgically and medically treated GERD patients., Methods: Between January 2005 and June 2010, 301 patients affected with GERD were included in the study. QoL was evaluated by means of GERD-HRQL and SF-36 questionnaires administered before treatment, at 6 months, at 1 year follow-up and at the end of the study. The multivariate analysis was used to detect if variables such as sex, age, heartburn, acid regurgitation, dysphagia, presence of esophagitis, percentage of total time at pH < 4, symptom index score (SI), the SF-36 and HRQL scores before treatment, at 6 months and 1 year could affect the QoL questionnaires scores at the end of the study., Results: One hundred forty-seven patients were included in the surgical group and 154 in the medical group. No differences with regard to gender, age, mean SF-36 and HRQL scores before treatment were documented. At the end of the study, quality of life was significantly improved for SF-36 and HRQL scores, either for surgical or medical group. The multivariate analysis showed no factors individually affected the SF-36 and the HRQL scores, but symptom index score (SI) and QoL questionnaires scores at 6 months and 1 year follow-up., Conclusions: The combined use of pHmetry with evaluation of SI and QoL questionnaires can predict the outcome of GERD patients managed either by medical or surgical therapy., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Lymph nodal involvement in papillary thyroid cancers is very common, but the role of lymph node dissection is still controversial. Surgeons are consequently divided between opposed to and in favor of routine central neck dissection associated with total thyroidectomy., Methods: Clinical records of 210 patients undergoing from January 2000 to December 2006 total thyroidectomy without routine lymph node dissection were retrospectively evaluated. One hundred and ninety eight patients (94.2%) underwent radioiodine ablation as well, followed by Thyroid Stimulating Hormone suppression therapy. In patients with loco regional lymph nodal recurrence, central (VI) and ipsilateral (III-IV) lymph node dissection was performed., Results: Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and permanent vocal fold paralysis were respectively 1.4% and 1.9%. After an 8-year mean follow-up, the rate of loco regional recurrence was 4.2%-9/210 patients. In these cases selective lymph node dissection was carried out without complications., Discussion: The role of neck dissection in papillary thyroid cancer management, is still subject of research and controversial regarding routine or therapeutic indications, surgical extension, its impact on local recurrence and survival., Conclusion: A low loco regional recurrence rate may be observed after total thyroidectomy without prophylactic lymph node dissection. Lymph nodal recurrences were more frequent in young male patients, sometime affected by follicular variant, in each case less than 2 cm. There is a general agreement about the extension of therapeutic lymph node dissection, while routine central neck dissection is still controversial and may be indicated in high risk patients., (Copyright © 2014. Published by Elsevier Ltd.)

Background: Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results., Methods: Eighty patients underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 40 patients; the other 40 patients were treated conventionally., Results: Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were significantly reduced (p=0.004 and 0.02, respectively), and there were fewer evacuative punctures, in patients receiving fibrin glue compared with the conventional treatment group., Conclusions: Use of fibrin glue does not always prevent seroma formation, but does reduce seroma magnitude, duration and necessary evacuative punctures.

Objective: The ultrasonic scalpel is a surgical shear that uses high-frequency mechanical energy to enable simultaneous vessel sealing and tissue coagulation at the same time. We conducted a prospective study to compare the outcome of total thyroidectomy using the ultrasonic scalpel versus the device Ligasure in terms of safety, operative time, overall drainage volume, complications, hospital stay., Methods: Between January 2008 and December 2013,400 patients (260 women, 140 men; mean age 46 years) undergoing thyroidectomy were randomized into two groups: group A, where Ultracision were used, and group B, where the Ligasure device was used., Results: There was no significant differences between the two groups in terms of age, gender, indication for thyroidectomy, thyroid gland weight and diameter, histopathologic diagnosis, preoperative and postoperative serum calcium levels, postoperative complications and reoperative thyroid surgery, time of operation and amount of drainage., Conclusions: The ultrasonic scalpel and the Ligasure ares safe, effective, useful, and time-saving alternative to the traditional suture ligation technique for thyroid surgery. They simplified total thyroidectomy, eliminating the need for clamp-and-tie maneuvers while achieving efficient hemostasis., (Copyright © 2014. Published by Elsevier Ltd.)

Introduction: Hemostasis during thyroidectomy is essential; however, the safest, most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with combination of harmonic scalpel (HS) and Floseal., Methods: Patients undergone TT were divided into two groups: HS + Floseal and traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates., Results: Between September 2012 and January 2014, 165 patients were enrolled (100 to HS + Floseal, 65 to standard hemostasis); 80.5% female; mean age 42.3 years. The 24-h drain output was lower in the HS + Floseal group compared with standard TT. HS + Floseal also had a shorter mean surgery time (p < 0.0001) vs standard TT. No differences in post-surgical complications and in hypocalcemiarates between groups., Conclusion: combination of Floseal plus the HS is effective and safe for TT and it provides a complementary hemostatic approach., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: The aim of the present study was to critically review the incidence of venous thromboembolism and postoperative hemorrhage in patients undergoing total thyroidectomy without preoperative prophylaxis., Methods: A prospective electronic database of all patients undergoing total thyroidectomy over a six-year period within August 2013 in our medical unit was analyzed. The incidence of postoperative bleeding and Venous thromboembolism (VTE) was reviewed by subgrouping all patients according to a risk factor score (RFS) for VTE as outlined in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Best Practice Guidelines., Results: An overall 1018 consecutive patients [244 men (24%, mean age 46 ± 13 years), 778 women (76%, mean age 44 ± 17 years)] underwent total thyroidectomy. Postoperative bleeding occurred in 8/1018 patients (0.8%). One out of 1018 (0.1%) patients also subcategorized according to the RFS had VTE. The incidence of VTE complication in the entire population was lower than the risk of postoperative bleeding (P < .0001)., Conclusion: The risk of developing VTE in patients who undergo total thyroidectomy for benign and malignant diseases without preoperative prophylaxis is roughly 8-fold less than developing a potentially life threatening complication as postoperative bleeding. Until large well conducted prospective studies on the impact of preoperative prophylaxis on postoperative VTE and bleeding will clarify the issue, it is conceivable to propose the use of stockings and/or anticoagulants according to the individual patient risk factors., (Copyright © 2014. Published by Elsevier Ltd.)

Introduction: Among the surgical procedures for treatment of morbid obesity, laparoscopic sleeve gastrectomy has known widespread diffusion in the last years, although it is not free from significant morbidity rates. Aim of this work is to evaluate the incidence of Helicobacter pylori (HP) infection on the postoperative outcome of patients undergoing laparoscopic sleeve gastrectomy., Methods: Between January 2008 and December 2013, 184 patients (65 males, 119 females), mean age 35.8 ± 5.7 years, affected with morbid obesity, mean BMI 46.6 ± 6.7, underwent laparoscopic sleeve gastrectomy. All the specimens at the end of the operation were analysed by the same pathologist. Histological grading was based on the Sidney classification., Results: Seventy-two of the patients (39.1%) were HP positive, while 112 (60.9%) were negative. No significant differences were observed between the HP+ and HP- group in terms of age, sex, weight, BMI, incidence of comorbidities and duration of follow-up. All the operations were completed via laparoscopic approach. No mortality was observed. Postoperative complications occurred in 5 patients (2.7%): three leaks (1.6%), all in the HP- group and two bleedings (1.1%), one in the HP+ and one in the HP- group. In two cases a reintervention was necessary. No significant differences were observed in the morbidity rates between the two groups. Overall mean excess weight loss at 6 months, 12 months and 24 months was respectively 47.4 ± 11.3%, 61.1 ± 12.4% and 68.4 ± 13.5%, with no significant differences between the HP+ and HP- groups., Conclusions: HP infection seems not to influence postoperative outcome of patients operated of laparoscopic sleeve gastrectomy., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

The diagnosis of incidental thyroid carcinoma in patients submitted to thyroidectomy for a benign disease is quite frequent. A retrospective analysis was performed on 455 patients submitted to surgical intervention in order to establish the incidence of this kind of carcinoma. Two hundred fifty-six patients (56%) were affected by benign disease (176 multinodular goiter, 12 uninodular goiter, 1 Plummer disease and 67 Basedow disease) and 202 (44%) by carcinoma. In 28 of 256 patients (11%), affected by benign disease, occurred a histological diagnosis of thyroid carcinoma, (10 papillary carcinoma, 1 follicular carcinoma, 29 papillary carcinoma follicular variant). In this study it's considered incidental thyroid carcinoma the one occurred in patients who never underwent Fine Needle Aspiration (FNA) and there were no suspicious features in all exams that may suggest the presence of carcinoma. Twenty-three of the 40 incidental carcinoma (57.5%) were microcarcinomas. Ten patients had a sincronous carcinoma. Actually, these patients are still in a follow up program and no recurrency of disease is occasionally observed. This study shows that the only way to put doubts on the real benignity of the disease is the fine needle aspiration; there are no other instruments that could identify the occurrence of the carcinoma. Moreover in the majority of cases the incidental carcinoma is a microcarcinoma, it doesn't reach significant volume, may be not centered by a FNA, but in most cases it's not really biologically aggressive., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Aim: To establish if the indication for different approaches for thyroidectomy and the incision length provided by means of pre-operative assessment of gland volume and size of nodules resulted in safe and effective outcomes and in any notable aesthetic or quality-of-life impact on patients., Materials and Methods: Ninehundred eightytwo consecutive patients, undergoing total thyroidectomy, were enrolled. The thyroid volume and maximal nodule diameter were measured by means of ultrasounds. Based on ultrasounds findings, patients were divided into three groups: minimally invasive video assisted thyroidectomy (MIVAT), minimally invasive thyroidectomy (MIT) and conventional thyroidectomy (CT) groups. The data concerning the following parameters were collected: operative time, postoperative complications, postoperative pain and cosmetic results., Results: The MIVAT group included 179 patients, MIT group included 592 patients and CT group included 211 patients. Incidence of complications did not differ significantly in each group. In MIVAT and MIT group, the perception of postoperative pain was less intense than CT group. The patients in the MIVAT (7±1.5) and MIT (8±2) groups were more satisfied with the cosmetic results than those in CT group (5±1.3) (p= <0.05)., Conclusions: The MIT is a technique totally reproducible, and easily convertible to perform surgical procedures in respect of the patient, without additional complications, increased costs, and with better aesthetic results.

Total thyroidectomy (TT) is the standard of care for differentiated thyroid cancer (DTC), but still there is no consensus about the role of routine use of prophylactic central lymph node dissection. The aim of this study was to analyze our results of TT without prophylactic central lymphadenectomy in the treatment of DTC. Clinical records, between January 1998 and December 2005, of 221 patients undergoing TT, without prophylactic central lymph node dissection, were retrospectively evaluated. Two hundred and eleven patients (95.47 %) also underwent radioiodine (RAI) ablation followed by thyroid stimulating hormone (TSH) suppression therapy. In patients with loco-regional lymph nodal recurrence, lateral and central lymph node dissection was performed. The incidence of permanent hypoparathyroidism (iPTH <10 pg/ml) and permanent vocal fold paralysis were, respectively, 0.91 and 0.91 %. After a 9.6 ± 3.5 years mean follow-up, the rate of loco-regional recurrence, with positive cervical lymph nodes, was 3.16 % (7/221 patients). In these cases a lateral and central lymphadenectomy was carried out without significant complications. Our results showed that TT without prophylactic central lymph node dissection, followed by RAI ablation, was associated with low morbidity and low loco-regional recurrence rate, even if the lack of a control group treated with TT plus prophylactic central lymphadenectomy suggests caution against generalization of our assumption. Such last combined procedure could be indicated in high-risk patients, in whom loco-regional recurrence is more frequent. However, given the trend in the literature toward prophylactic lymphadenectomy and the avoidance of RAI treatment, prospective randomized trials should be conducted to better clarify this issue.

Aim: Laparoscopic adrenalectomy is considered the standard technique for the surgical removal of the adrenal gland. This report is about a 4-year single experience in our Endocrine and General Surgery Unit with laparoscopic adrenalectomy., Methods: A total of 24 lateral transperitoneal laparoscopic adrenalectomies were performed. The indications for laparoscopic surgery were: aldosteronoma in 3 patients, pheochromocytoma in 6 patients, nonfunctioning adenoma in 6 patients, adenoma causing Cushing's syndrome in 3 patients, 1 lymphangioma-like adenomatoid tumor, 1 myelolipoma, 1 complicated adrenal cyst, 2 adrenocortical carcinomas, 1 lung metastasis., Results: All except two had successful laparoscopic adrenalectomy. Complication occurred in one patient. 3 patients underwent other associated laparoscopic procedures. Operative time ranged from 100 to 240 minutes for laparoscopic adrenalectomy, from 180 to 210 minutes in the cases with two associated laparoscopic procedures, 5 hours for bilateral adrenalectomy; the postoperative hospital stay for laparoscopic adrenalectomy ranged from 4 to 8 days (6,79 days) and from 7 to 13 days (9,12 days) for patients undergoing the open or converted procedure., Conclusions: Laparoscopic adrenalectomy is technically feasible and reproducible. We evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders except in the case of invasive carcinoma or large masses. Antonio Cardarelli Endocrine and General Surgery Unit in Naples is known as a specialized center for thyroid and parathyroid surgery; in future, we could also become a high-volume laparoscopic referral center for adrenal gland pathologies.

Aim: The use of synthetic mesh in transplant patients is still under debate. In this paper the authors report their preliminary experience on biological prosthesis for surgical treatment of incisional hernias in transplant patients., Material of Study: Between 2009-2010, 10 patients with incisional hernia underwent surgery using a biological prosthesis (porcine dermis collagen). All patients were transplanted: 9 kidney transplants and 1 liver transplant., Results: In all patients postoperative course was uneventful and were not observed complications related to surgery, kind of prosthesis or transplanted organs. At follow up, laparoplasty was associated with good functional outcome., Discussion: Transplant patients are at risk for use of synthetic prostheses, as immunosuppressed. In our preliminary experience biological prostheses compared to synthetic ones showed a greater ability to integrate into tissues, to resist bacterial colonization and to reduce cytotoxic or allergenic reactions, providing similar functional results. Moreover it must be added that biological prostheses did not require reductions/suspensions of immunosuppressive therapy and resulted to be versatile. All these features are particularly sought in incisional hernias surgery of transplanted patients., Conclusions: Surgery of incisional hernias in transplanted patients requires a prosthesis with characteristics as close as possible to the ideal one and, in this sense, biological prostheses would seem to outweigh synthetic ones. In our experience, biological prostheses have shown to be safe, effective and reliable; therefore they seem to be able to open new horizons in the treatment of wall defects in this group of patients.

Background: Fine needle cytology (FNC) of thyroid nodules is not always diagnostic. Most of FNCs undeterminated for malignancy belong to the cytological class of "follicular neoplasm/suspicious for follicular neoplasm" lesions (FN). In this group only 10-30% of cases are malignant and the most appropriate surgical management is still controversial. Here, this issue was addressed and the more reliable predictive criteria of malignancy were also evaluated., Methods: We retrospectively evaluated 472 patients, surgically treated after a FN diagnosis in a tertiary care referral center. In patients affected by bilateral thyroid disease with a cytological diagnosis of FN, or when high-risk clinical features and familiarity for thyroid cancer were present, total thyroidectomy (TT) was performed. Conversely, hemithyroidectomy (HT) was preferred when the nodule was single and when the age was ≤ 45 years. Frozen section examination was not used, and if cancer was diagnosed by definitive pathology of the HT specimen, the remnant thyroid lobe was removed. Histological features, surgical complications, and long-term outcomes of the remnant lobe were reported. Clinical features predictivity was also evaluated., Results: TT was performed in 154/472 pts (32.62%), while HT was carried out in 318/472 cases (67.37%). The overall malignancy rate (MR) was 18.85% (89/472 pts), respectively 16% (51/318pts) following HT, and 24.6% (38/154pts) following TT, with a statistically significant difference. Similarly, the rates of transient and definitive hypoparathyroidism and the mean hospital stay following TT were higher than after HT (and statistically significant). Age < 45years and female gender were more frequently associated to malignancy. The rate of complications following second surgery was comparable to that of primary HT. In the HT group incidence of unexpected contralateral papillary thyroid cancer (PTC) was 9.8% and, after 88.2 ± 30.42 months mean follow-up, completion surgery for benign pathology was carried out in 6.7% of cases., Conclusions: Our data show that histology following a cytological FN diagnosis is malignant only in a low percentage of cases (89/472, 18.85%). Following TT, a MR higher than in HT was observed. Even if some clinical features are cancer associated, malignancy cannot be reliably predicted before surgery. Thus, in solitary low-risk lesions, HT is still the standard of care. Its lower complication rates makes HT the safest procedure. In case of multiglandular disease TT may be recommended. Further investigation is warranted to achieve a better preoperative diagnostic accuracy in order to reduce the amount of surgical operations with diagnostic aim.

Background: Studies have previously shown laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients. The aim of the current study was to evaluate patients receiving laparoscopic antireflux surgery before and after 65 years of age and to assess their surgical outcomes and improvements in long term quality of life., Methods: Patients were given a standardized symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication., Results: Forty-nine patients older than 65 years of age were defined as the elderly group (EG) whereas the remaining 262 younger than 65 years of age were defined as the young group (YG)., Conclusions: In conclusion, laparoscopic total fundoplication is a safe and effective surgical treatment for gastroesophageal reflux disease generally warranting low morbidity and mortality rates and a significant improvement of symptoms comparable. An improved long-term quality of life is warranted even in the elderly.

Introduction: The aim of this study was to verify the effectiveness of hyaluronic acid in preventing adhesion formation after endoperitoneal surgery in which prosthetic polypropylene mesh is placed directly on the viscera., Methods: Forty albino rats were included in this study and the animals were randomized to the following 4 groups each with 10 rats: polypropylene prosthesis (PP), PP+hyaluronic acid (HA), Hertra prosthesis (HP), HP+HA. A large defect was created in the anterior abdominal wall of each rat and repaired in different ways. In the first group a polypropylene mesh was placed intraperitoneally, while, in the second group the peritoneal surface of the mesh was impregnated with HA. In the third group a Hertra 0 polypropylene rigid mesh was placed intraperitoneally and, in the fourth group, the peritoneal surface of the Hertra 0 mesh was impregnated with HA. Clinical controls on the animals were carried out at 1 month. Each group was divided into two subgroups in which the controls and the prosthetic explantation were randomly carried out at 3 and 6 months. Explanted prostheses were subjected to histological and immunohistochemical analysis, and examined for shrinkage. An assessment of adhesion formation was performed, evaluating the quantity and tenacity of the adhesions., Results: We demonstrated higher levels of adhesions in rats with PP than in those with HP and lower levels in rats with a protective layer of hyaluronic acid. The amount of fibronectin in the periprosthetic fibrotic tissue and the histological score confirmed the previous data., Conclusions: Hertra 0 mesh with HA provided the best results in terms of physical stability and resistance to adhesion formation.

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.

Aim: Cervical lymph node micrometastases are observed in up to 90% of papillary thyroid cancers (PTC), showing that lymph nodal involvement is very common. Nevertheless, during the last years, the role of lymph node dissection in the treatment of PTC has been controversial and, at present, the best indications to the routine or therapeutic neck dissection remain subject of research. In order to better analyze the current role of lymph node dissection in the surgical treatment of PTC, an analysis of the most recent literature data was performed., Study Design: By using as keywords lymph node dissection, selective, lateral or central lymph node dissection, modified radical neck dissection, prophylactic or therapeutic lymph node dissection, papillary thyroid cancer, a Pub Med data base research was carried out. The most recent guidelines of different referral endocrine societies, inhering neck dissection for PTC, were also evaluated., Results: The role of neck dissection in PTC management remains controversial regarding routine or therapeutic indications, surgical extension, and its impact on local recurrence and long term survival. Due to inhomogeneous literature data, the current status of node dissection is still subject of research., Conclusions: There is agreement between endocrine and neck surgeons about the extension of therapeutic lymph node dissection in N+ PTC patients , and also in the prophylactic treatment of N0 "high risk" patients. Considering a recent trend toward routine central lymphadenectomy avoiding radioactive treatment, prospective randomized trials are needed to evaluate the benefits of different approaches.

A 62 y.o. male with tight fimosis, swelling, redness, pain on palpating and necrosis of the penis and scrotum was admitted in our clinic, (FGSI = 6) with periferic vasculopathy; and diabetes mellitus type II and he was in dialysis treatment before the hospitalization. The patient was HCV affected. In 24 hours he underwent radical surgical debridement with excision of all necrotic material from penis and scrotum up to the subdermal layer and tissue of doubtful viability for about 75% of the skin and circumcision. In third, fifth and seventh postoperative days he underwent to local infusion of autologous PLT growth factors. The patient was discharged in 9th postoperative day and FGSI was still 6; the skin and subdermal tissue was barely reskined, with low homogeneous granulation, edema was heavely reduced. In our case, deviation from homeostasis status at admission was the main worrying factor. We found that diabetes mellitus and renal dysfunction at admission was also important risk factor for FG. "E.Coli" was the most common organism isolated from patient wound cultures. The FGSI is an objective and easy to apply score method to quantify the metabolic status and can be used to evaluate therapeutic options and assess results.

Background: In this prospective non randomized observational cohort study we have evaluated the influence of age on outcome of laparoscopic total fundoplication for GERD., Methods: Six hundred and twenty consecutive patients underwent total laparoscopic fundoplication for GERD. Five hundred and twenty-four patients were younger than 65 years (YG), and 96 patients were 65 years or older (EG). The following parameters were considered in the preoperative and postoperative evaluation: presence, duration, and severity of GERD symptoms, presence of a hiatal hernia, manometric and 24 hour pH-monitoring data, duration of operation, incidence of complications and length of hospital stay., Results: Elderly patients more often had atypical symptoms of GERD and at manometric evaluation had a higher rate of impaired esophageal peristalsis in comparison with younger patients. The duration of the operation was similar between the two groups. The incidence of intraoperative and postoperative complications was low and the difference was not statistically significant between the two groups. An excellent outcome was observed in 93.0% of young patients and in 88.9% of elderly patients (p = NS)., Conclusions: Laparoscopic antireflux surgery is a safe and effective treatment for GERD even in elderly patients, warranting low morbidity and mortality rates and a significant improvement of symptoms comparable to younger patients.