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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.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.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).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.

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.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.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.Use of fibrin glue does not always prevent seroma formation, but does reduce seroma magnitude, duration and necessary evacuative punctures.

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 randomized study to compare the outcome of total thyroidectomy using the ultrasonic scalpel versus standard clamp and tie (CT) procedure in terms of safety, operative time, overall drainage volume, complications, hospital stay.Between January 2008 and December 2010, 200 patients (130 women, 70 men; mean age 46 years) undergoing thyroidectomy were randomized into two groups: group A, where CT technique were used, and group B, where the ultrasonic device was used.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. In group B there is a statistically significant reduction of the operative times (63 ± 9' vs 85 ± 15', P0.001) and overall drainage volume (50 ± 20cc vs 70 ± 25cc, P0.001) .The ultrasonic scalpel is 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. Our study shows that the use of ultrasound in thyroid surgery reduces significantly surgical time and overall drainage volume. Furthermore, we also verified a decrease in hospitalization time, postoperative pain and blood loss, without increasing complication rates, for patients who underwent total thyroidectomy with the ultrasonically activated shear.

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disease among adults in Europe and USA. A recent consensus conference (the Montreal Consensus) defined GERD as "a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications". Symptoms were considered to be " troublesome" if they adversely affected an individual's well-being. GERD can lead to both esophageal and non-esophageal symptoms. The most common typical symptoms of GERD are heartburn and regurgitation. Non-esophageal GERD symptoms include chronic aspiration with cough and laryngitis (Shaheen & Ransohoff, 2002). At its core, GERD is the failure of the antireflux barrier, allowing abnormal amounts of reflux of gastric contents into the esophagus (Dodds et al., 1982). The primary treatment modality for GERD is acid suppression therapy, in particular by use of PPI (Castell et al., 2002). However, consideration should be given for surgery if the following indications exist: complications of GERD (such as peptic stricture or Barrett's esophagus), extraesophageal manifestations (chest pain, pulmonary symptoms), failed medical management, or desire to discontinue medical treatment despite adequate symptomatic control. Minimal invasive anti-reflux surgery can be considered an effective GERD therapy, with its mechanical function both in the short and long term period. Several different ways of fashioning a total fundoplication lead to different outcomes. This chapter addresses the technical details of the antireflux technique we adopted without modifications for all patients with GERD. In particular it

Constipation accounts for 20% in western world population. In absence of any organic aetiology, this disorder may be related to bad alimentary habits based on inadequate introduction of the three components of stool (fibres, probiotics and water) that are essential for the physiologic activity of colon. Chronic constipation may be also associated with either colic or rectal anatomo-functional alterations. Colonic constipation (slow transit constipation) is usually related to a motility disorder (inertia coli) associated with a reduction of propagating contraction waves and decreased Cajal’ cells; on the other hand, rectal outlet dysfunction type constipation may be related to anatomical alterations (e.g. internal mucosal prolapse, rectocele) causing difficult rectal outlet and functional pelviperineal dyssynergia. The physiologic defaecatory act involves not only synchronism between rectum and anus, but even correct thoraco-abdominoperineal dynamics and vertebral position. This has to be carefully assessed by considering patient’s ability to accomplish adequate thoraco-abdominoperineal muscle movements needed for both adequate defaecatory dynamics and urine and stool retention. Therefore, the ideal treatment should not only address anatomical alterations such as mucosal prolapse, rectocele, rectorectal intussusception and sphincter defects, usually requiring a surgical approach, but even functional disorders, often insidious and difficult to detect. Surgery is mandatory to treat pathological findings, that physically represent an obstacle to fecal transit in the rectum. Many surgical techniques have been developed for the treatment of outlet obstruction with conflicting results. STARR (stapled transanal rectal resection) is a new surgical procedure that was launched by Longo in 2001. It is a minimally invasive transanal operation for rectocele and mucosal/rectal prolapse using a double circular stapler. This procedure is indicated when rectal mucosal prolapse is thought to be the cause of difficult defecation, and appears to be a rational treatment. This treatment aims to normalize the anatomical relationship of the anal mucosa with hemorrhoidal piles and anal sphincters by restoring the prolapse and improving venous perfusion. The procedure pulls the anal

Laparoscopic total fundoplication is considered the most effective surgical option for gastroesophageal reflux (GER) disease. Some authors assume that total fundoplication may expose the patient to delayed transit of the swallowed bolus and increased risk of dysphagia, particularly when peristaltic dysfunction is present. We undertook this study to evaluate by means of combined multichannel intraluminal impedance and esophageal manometry (MII-EM) the impact of fundoplication on esophageal physiology. An objective measurement of the influence of the total wrap on bolus transit may be helpful in refining the optimal antireflux wrap (ie, partial vs. total).In this study, 25 consecutive patients who underwent laparoscopic Nissen-Rossetti fundoplication had MII-EM and combined 24-hour pH and multichannel intraluminal impedance (MII-pH) before and after the surgical procedure. All patients completed preoperative and postoperative symptom questionnaires. The following were calculated for liquid and viscous deglutition lower esophageal sphincter pressure and relaxation, distal esophageal amplitude, the number of complete esophageal bolus transits and the mean total bolus transit time. The acid and nonacid GER episodes were calculated by MII-pH with the patient in both upright and recumbent positions.The postoperative MII-EM showed an increased lower esophageal sphincter pressure (P0.05), whereas lower esophageal sphincter relaxation and distal esophageal amplitude did not change after surgery (P = NS). Complete esophageal bolus transits and bolus transit time did not change for liquid swallows (P = NS), but was more rapid for viscous after surgery (P0.05). Twenty-four hour pH monitoring confirmed the postoperative reduction of both acid and nonacid reflux (P0.05).Laparoscopic Nissen-Rossetti is effective in controlling both acid and nonacid GER without impairment of esophageal function. Appropriate preoperative investigation, meticulous patient selection and correct surgical technique are extremely important in securing good results.

Identifying and treating patients with extra-esophageal symptoms is a challenge. When the patient is unable to control his symptoms with pharmacological therapy alone, anti-reflux surgery may be indicated. This study aims to evaluate the outcomes of total fundoplication in the resolution of extra-esophageal manifestations and verify changes in 24-h MII-pH monitoring before and after surgery. From October 2005 to October 2010, patients who reported respiratory symptoms, possibly related to GERD, have been sent to our Institute. All patients were practiced ambulatory 24-h MII-pH before and after surgery. Thirty-five patients selected for the antireflux surgery have undergone all the same surgical procedures. Data were collected prospectively at 6 and 12 months after laparoscopic fundoplication. After laparoscopic fundoplication, the total percentage of exposure time with esophageal pH < 4, and both in upright and supine position was very low. A statistically significant difference (p < 0.05) was found in the number of detected refluxes at MII and detected refluxes at MII 15-cm segment in pre and post-operative period. Symptom relief was obtained in all patients. Laparoscopic fundoplication is a safe and effective procedure to protect from refractory GERD and extra-esophageal symptoms, when evaluated with a thorough pre-operative selection.

OBJECTIVE We evaluated the efficacy of malabsorptive bariatric surgery on daily blood glucose fluctuations and oxidative stress in type 2 diabetic obese patients. RESEARCH DESIGN AND METHODS The 48-h continuous subcutaneous glucose monitoring was assessed in type 2 diabetic patients before and 1 month after biliopancreatic diversion (BPD) (n = 36), or after diet-induced equivalent weight loss (n = 20). The mean amplitude of glycemic excursions and oxidative stress (nitrotyrosine) were evaluated during continuous subcutaneous glucose monitoring. During a standardized meal, glucagon-like peptide (GLP)-1, glucagon, and insulin were measured. RESULTS Fasting and postprandial glucose decreased equally in surgical and diet groups. A marked increase in GLP-1 occurred during the interprandial period in surgical patients toward the diet group (P < 0.01). Glucagon was more suppressed during the interprandial period in surgical patients compared with the diet group (P < 0.01). Mean amplitude of glycemic excursions and nitrotyrosine levels decreased more after BPD than after diet (P < 0.01). CONCLUSIONS Oxidative stress reduction after biliopancreatic diversion seems to be related to the regulation of glucose fluctuations resulting from intestinal bypass.

Paget Breast disease i a kind of intraductal carcinoma that through an intracanalicular diffusion invades the basal epidermical layer, reaching the areola and nipple, producing a typical erythematous desquamative eczematous-like lesion this neoplasia can remain undetected for a long time and inadeguately trated as a dermatological affection. Synchronous or metachronous lesions are very uncommon. From our experience we think that lesion biopsy is always necessary to formulate a correct diagnosis and to schedule an appropriate therapeutic approach. In our case a biopsy was performed first, than on the basis of the frozen sction analysis a radical mastectomy with axillary third level lynphonodes dissection, because of the large dimension of the lesion and the previous history of metachronous lesion

Loss of circadian patterning of metabolism-related functions seems to play a role in the pathogenesis of obesity; therefore, it is reasonable to hypothesize that the functional 3111T/C single nucleotide polymorphism (SNP) of the (Circadian locomotor output cycles kaput) CLOCK gene may have a part in the genetic susceptibility to obesity. The aim of this study was to assess the frequencies of 3111T/C CLOCK gene SNP in overweight/obese subjects with or without binge eating disorder (BED) as compared to normal weight healthy controls. A total of 284 Caucasian subjects, including 92 normal weight healthy subjects and 192 overweight/obese patients (107 with BED) participated into the study. Genotype and allele frequencies did not significantly differ between normal weight controls and overweight/obese patients with and/or without BED. However, overweight/obese patients carrying the CC genotype had significantly higher values of body mass index (BMI) as compared to those carrying the CT and/or TT genotypes. Moreover, obese class III individuals had a significantly higher frequency of both the CC genotype and the C allele as compared to individuals with BMI

Squamous papilloma of the esophagus is a rare benign lesion of the esophagus. Radiofrequency ablation is an established endoscopic technique for the eradication of Barrett esophagus. No cases of endoscopic ablation of esophageal papilloma by radiofrequency ablation (RFA) have been reported. We report a case of esophageal papilloma successfully treated with a single session of radiofrequency ablation. Endoscopic ablation of the lesion was achieved by radiofrequency using a new catheter inserted through the working channel of endoscope. The esophageal ablated tissue was removed by a specifically designed cup. Complete ablation was confirmed at 3 mo by endoscopy with biopsies. This case supports feasibility and safety of as a new potential indication for Barrx(TM) RFA in patients with esophageal papilloma.

The Authors analyzed the results of 120 central venous catheterisms of internal jugular vein performed by eco-color-Doppler from January 2000 to December 2004 in obese patients candidated to bariatric surgery.As the considerable adiposity and post-operation necessities, this procedure has been very useful. The average performing time was 10 minutes, 95.8% of success and 4.2% of impossibility (thrombosis internal jugular vein bilateral).The eco-color-Doppler guide CVC is a safe procedure with short performing time, low rate of failures and complications, and high rate success. It was very helpful in obese patients candidated to bariatric operation, allowing a comfortable and easy venous access, as well as the administration of liquids otherwise administered with difficulty by peripheral way, correlated to corporal weight in qualitative and quantitative terms, such at improve the process of post-operative recovery.

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.

Background Hypocalcemia caused by transient or definitive hypoparathyroidism is the most frequent complication after total thyroidectomy (TT). We aimed to compare the impact of age and the clinical usefulness of oral calcium and vitamin D supplements on postoperative hypocalcemia after TT, and to determine which risk factors are important for hypocalcemia incidence. Methods Two hundred consecutive patients treated by TT were included prospectively in the present study. All patients supplemented oral calcium and vitamin D in the post-operative time. The data concerning symptomatic and laboratoristichypocalcemia were collected. Patients were evaluated according to age, sex, postoperative serum calcium levels, and preoperative serum alkaline phosphatasis levels. Results Symptomatic hypocalcemia developed only in 19 patients (9.5%), whereas laboratory hypocalcemia developed in 36 patients (18%). The risk for postoperative hypocalcemia was increate 20-fold for patients older than 50 years. Conclusions Age is significantly associated with postoperative hypocalcemia. Implementing oral calcium and vitamin D after total thyroidectomy can reduce the incidence of hypocalcemia related to surgery.

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 Thirty patients over 60 years 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 15 patients; the other 15 patients were treated with harmonic scalpel. Results Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group. Conclusions Use of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.

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.

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). There were 114 (36.6%) patients who filled out the SF36 questionnaire (98 in the younger group, rate: 37.4%; 16 in the elderly group, rate: 32.6%) pre- and post-operatively. There was no significant difference between the two age groups regarding preoperative PCS ( 45.6 ± 7.8 in YG vs. 44.2 ± 8.2 in EG; P = 0.51) and MCS ( 48.1 ± 10.7 in YG vs. 46.9 ± 9.2 in EG; P = 0.67). There was no significant difference between the two age groups regarding postoperative PCS (49.8 ± 11.9 in YG and 48.2 ± 9.5 in EG ; P = 0.61 and MCS (48.4 ± 10.7 in YG vs. 50.1 ± 6.9 in EG; P = 0.54). 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.

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.