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Recurrent or persistent primary hyperparathyroidism (HPT) is a rare occurrence requiring generally a careful reoperation. From 1980 to 1992 a total of 192 patients underwent bilateral cervical exploration following a diagnosis of primary hyperparathyroidism. Persistent of recurrent HPT was found in 6 (3.04%) of our cases. In two patients a subtotal parathyroidectomy was performed (parathyroid hyperplasia) and hyperfunctioning parathyroid tissue was found at neck exploration. In one case an ectopic adenomatous fifth gland was found in mediastinum at reoperation. Three patients with recurrent HPT had a parathyroid carcinoma but in only two cases it was possible to identify and remove the pathologic tissue preoperatively localised in mediastinum by double-tracer scintigraphy and CT scan 6 and 15 months after first operation respectively. The third patient with parathyroid carcinoma was inoperable on account of multiple metastases both cervical and thoracic.

The incidence of unsuspected adrenal masses (incidentalomas) based on CT-scan results to be higher than in the past. The aim for our study was to establish some guidelines for an appropriate management.From 1986 to 1995, 61 patients with no history or clinical findings suggestive of adrenal mass or adrenal hyperfunction were discovered by radiologic examination to have an incidentaloma larger than 1 cm. In each patient basal biochemical evaluations were obtained to exclude the presence of adrenal cortical or medullary dysfunction. There were 28 men and 33 (54.1%) women, with a mean age of 53 years (range 16-74). 19 patients underwent CT-guided fine-needle biopsy to exclude metastatic tumors. Furthermore in 29 patients 75-Se-selenomethyl-norcholesterol was performed and 17 were studied by MRI.At CT-scan mean lesion diameter was 5.48 +/- 3.76 cm (range 2-23); 32 adrenal masses were right sided and 3 (4.9%) were bilateral. 17 patients had concordant scintigraphic imaging pattern, 6 bilateral uptake and 6 had discordant imaging. CT-guided FNAB showed malignancy in 9. Adrenalectomy was performed in 45 patients according to a score calculated by 4 parameters: age of the patients, size of the mass, scintigraphic pattern, MR imaging. Twenty-four had a score greater than 9 and in the remaining 21 patients in spite of a score lower than 10 adrenalectomy was performed based on: 1) increased size at CT scan follow-up (15 pts); 2) either suspected primitive malignant neoplasm at CT-guided FNAB or history of malignancy (6 pts); 3) elevated 24-hour dopamine (4 pts). In 12 (26.7%) patients a malignant tumor was found. There were not any statistically significant differences (p0.05) between the age of the patients with malignant neoplasms and those with benign masses, and between the size of the masses, which were 7.58 +/- 5.93 cm (range 2-23) and 5.03 +/- 2.81 cm (range 3-17) respectively. The difference in scores between the patients with malignant masses (12.17 +/- 2.95) and those with benign ones (9.09 +/- 1.33) was statistically significant (p0.01).Since adrenal incidentaloma have a malignancy rate higher than the other adrenal tumors, it is crucial to outlinesome criteria to sort out the patients at risk for whom adrenalectomy is to be warranted. Based on our results we believe that patients with a score9 should undergo adrenalectomy.

Liver transplantation, considered today as the most effective treatment for end-stage liver diseases, can not always be performed on every patient affected with a liver disease. Patients with end-stage liver diseases, usually have high bilirubin, encephalopathy and renal failure. In these situations cytokines play an important role in different processes, from apoptosis to regeneration. The aim of this clinical study has been to analyse the action of new artificial liver system, called Molecular Adsorbent Recycling System (MARS) on cytokines metabolism in patients affected with acute on chronic liver failure. The results are intriguing because an increase of IL-6 and a decrease of TNF-alpha observed during MARS treatment. The study confirms the efficacy of MARS therapy in terms of homeostasis of the cytokines network and suggests an usefulness of monitoring their level during liver failure.

There are few studies evaluating the prognostic impact on survival of treatment strategy in patients with hepatocellular carcinoma (HCC). The aim of this study was to analyse whether a multimodal approach, that represents a synergic association of different therapeutic procedures, may improve survival of patients with HCC.Two hundred and fourteen patients with HCC were enrolled in the study. The multimodal approach was chosen for 27 out of 106 (25%) non surgical patients, 42 out of 81 (52%) patients who underwent liver resection and 19 out of 27 (70%) patients who underwent liver transplantation.The long-term survival of patients who underwent the multimodal approach improved significantly with respect to patients treated by both resection and other therapies alone. The 5-year survival rates were 52% vs. 11% (p0.05) in the non surgical group and 40% vs. 24% (p0.05) in the resection group when a multimodal approach was used for the treatment of recurrences. In patients with advanced HCC undergoing liver transplantation, multimodal treatment resulted in long-term survival comparable to that of patients with early HCC.A multimodal approach should be suggested in all patients with HCC, since a careful integration of surgical and non surgical treatments may improve long-term survival in such patients.

We present our clinical experience in the management of rare surgical complications in Crohn's disease. Two hundred and eight patients affected by Crohn's disease were treated surgically between January 1992 and September 2001, at the Department of Surgical and Gastroenterological Sciences of the University of Padua. Rare surgical complications were identified in 17 patients (6.2%): 4 with small intestine adenocarcinoma, 5 with massive gastrointestinal bleeding, 5 with free peritoneal perforation and 3 with psoas abscesses. The very substantial clinical variability of Crohn's disease is a constant challenge to researchers. In particular, the high incidence of associated pathologies and complications related to Crohn's disease makes this pathology extremely disabling. In addition, this disease quite often appears to occur together with a rare complication which, though in most cases its course tends to remain unknown, at times may be potentially life-threatening. For this reason, it is crucial to suspect the occurrence of these pathologies, especially in patients responding poorly to therapy or in those whose symptoms suddenly become acute. Early diagnosis and treatment are therefore fundamental for the most appropriate treatment to be administered.

From 1970 to 1993, 196 patients with thyroid cancer were treated surgically. In 26 (13.2%) an invasion of local and regional structures was observed. Eighteen patients had papillary or follicular carcinoma and 9 anaplastic carcinoma. Tracheal invasion occurred in 11 cases and 7 patients underwent total thyroidectomy, segmental resection of the trachea (1-5 rings) and reanastomosis, associated preoperatively in 2 cases with Nd:YAG laser photocoagulation. Six of thirteen patients with muscle invasion are alive at 2-16 years follow-up; 3 patients with tracheal invasion died in less than 6 months and the others seem to be free of disease 6-14 years after operation.

In 15-20% of the cases pheochromocytoma (pheo) localizes in extraadrenal sites and in about 15% of all cases it seems to be multiple. We analyze our 20-year experience in surgical treatment of pheos, studying the differences between typical and extraadrenal or multiple tumors. From 1977 to 1996 we operated 55 patients (patients) with pheos, 28 (50.9%) males and 27 females (mean age 41 years, range 10-63). Two groups have been distinguished: classic pheos (Group 1, 45 patients) and extraadrenal or multiple pheos (Group 2, 10 patients). Hypertensive crises were present in 37/45 (82.2%) patients of Group 1 and in 7/10 patients of Group 2. Five (11.1%) masses were nonfunctioning and incidentally discovered (4 in Group 1 and one in Group 2). In 4 cases association with familial syndromes was observed (3 MEN IIb, 1 von Recklinghausen syndrome); no further significant differences in clinical features and laboratory data were found between the two Groups. At immunohistochemical analysis 26/26 patients resulted positive for chromogranin A and NSE and 17/26 (11/20 in Group 1 and 4/6 in Group 2) resulted positive for S 100 protein. Five (11.1%) malignant pheos were discovered and removed (Group 1); average survival of these patients was 54.4 months, two patients underwent radioactive iodine (131-I-MIBG) therapy after surgery and only one patient is still alive at 24-month follow-up. Recurrence for benign sporadic pheo (Group 1) occurred in one patient 183 months after adrenalectomy. Ectopic, associated with familial syndromes and multiple pheos are not uncommon and although recovery in surgically treated patients is excellent, lifelong follow-up is necessary also in benign tumors.

The aim of this study was to evaluate CEA and CA 15-3 changes in patients surgically treated for breast cancer. One hundred and three women (median age 59 years, range 31-83 years) with pT1-2, pN0-1, M0 breast cancer were followed up for at least 5 years. CEA and CA 15-3 serum levels were measured before operation and every 6 months during follow-up. The diagnostic sensitivity of CEA and CA 15-3 was 22.3% and 33.3% respectively. There was a significant difference (p0.01) between pre- and post-operative (6 months and 5 years after surgery) mean CEA serum levels independent of TNM staging. During follow-up, 21 (20.4%) patients showed recurrence of cancer and overall CEA and CA 15-3 sensitivity was 38.1% and 61.1%, with 98.8% and 91.2% specificity, respectively. Tumor marker measurement may be useful in post-surgical follow-up, but at present they are neither sensitive nor specific enough for early diagnosis of malignancy.

The aim of this study was to review our 20-year experience in the treatment of primary hyperparathyroidism (HPT) and to analyze clinical and biochemical findings in patients surgically treated in the nineties and before.From 1978 to 1997, 302 patients with proved HPT underwent primary surgery. There were 95 (31.5%) males and 207 (68.5%) females with a median age of 53 years (range 11-82 years). Two groups of patients were considered: Group 1 (156 patients undergoing surgery between 1978 and 1989) and Group 2 (146 patients undergoing surgery from 1990 to 1997).No differences (p = NS) were found regarding age at operation and preoperative serum creatinine values. The most frequent symptoms in both groups were of rheumatological nature (54.5% and 42.5% in Groups 1 and 2 respectively). Renal stones were described in 60.3% and 42.5% of Group 1 and 2 patients, while peptic ulcerations or gastritis were present in 25.0% and 15.1%. No differences (p = NS) in the number of patients with neurological and neuropsychiatric rate and in the median size of the removed parathyroid glands were observed between the two groups. Asymptomatic HPT was more frequent (20.5% vs 7.7%) in patients who underwent parathyroidectomy from 1990. Average serum calcium preoperative levels and delayed diagnosis were greater (p0.01) in Group 1 (3.10 vs 2.90 mmol/L and 72 vs 24 months respectively).Increase of asymptomatic patients with HPT allowing an earlier surgical treatment may reduce the time of the of neck exploration and morbidity rate.