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

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.

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

BACKGROUND: 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.

Endometriosis (E) is an estrogen-dependent inflammatory disorder that is observed in approximately 10% of women in childbearing age, and is the most common benign gynecological disorder requiring hospitalization. In 5% of cases, there is an involvement of the gastrointestinal tract, for the most part of the sigmoid colon and rectum (~ 90%). However intestinal obstruction due to severe stenosis of the sigmoid colon, as in the case described by the authors, is rare. The differential diagnosis should include cancer, inflammatory diseases and actinic colitis which has a similar clinical picture to E. Surgical treatment - resection and anastomosis or conservative procedures - provides better results especially when a multidisciplinary approach is used (colorectal surgeon, gynecologist, urologist). The authors report a case of obstruction of the sigmoid colon due to endometriosis and analyze the pathophysiology, diagnosis and surgical management of this disorder.

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

Endometriosis (E) is an estrogen-dependent inflammatory disorder that is observed in approximately 10% of women in childbearing age, and is the most common benign gynecological disorder requiring hospitalization. In 5% of cases, there is an involvement of the gastrointestinal tract, for the most part of the sigmoid colon and rectum (~ 90%). However intestinal obstruction due to severe stenosis of the sigmoid colon, as in the case described by the authors, is rare. The differential diagnosis should include cancer, inflammatory diseases and actinic colitis which has a similar clinical picture to E. Surgical treatment - resection and anastomosis or conservative procedures - provides better results especially when a multidisciplinary approach is used (colorectal surgeon, gynecologist, urologist). The authors report a case of obstruction of the sigmoid colon due to endometriosis and analyze the pathophysiology, diagnosis and surgical management of this disorder.

To date surgical treatment of secondary hyperparathyroidism (HPTs) is still controversial. Subtotal parathyroidectomy with sparing of a part of not-nodular gland and total parathyroidectomy with autotransplantation (subcutaneous or muscular) represent the most common procedures with the aim to warrant a condition of euparathyroidism. Total parathyroidectomy (or so presumed) represent an unusual therapeutic option as the risks arising from aparathyroidism and from the need of a substitutive therapy are largely known. The authors evaluate the surgical results collected from 47 consecutive patients affected by HPTs and Chronic Renal Failure (CRF) and operated on between January 1999 and January 2006. Probably, a proper indication to the type of surgical procedure could be based on the severity of the disease, on the age of the patient and on the expectation of transplant. The significant incidence of recurrence and persistent disease is due to autoimplantation or residual gland hypertrophy after subtotal parathyroidectomy, to the presence of supernumerary or ectopic glands, to cervico-mediastinic hypertrophy of cellular foci. The identification and removal of supernumerary glands, which may cause persisting hyperparathyroidism, is mandatory.

Mechanical cecorectal anastomosis after subtotal colectomy, in the treatment of slow transit constipation, probably represents the most attractive surgical alternative to total colectomy and ileorectal anastomosis. In fact the operation allows better results in terms of postoperative diarrhoea, fecal incontinence and postoperative adherential syndrome. Literature data have demonstrated the feasibility of the laparoscopic approach with tipically advantages of less invasive surgery respect of parietal integrity,less postoperative pain and ileus, fewer postoperative adhesions, a reduced hospitalitation and finally, a better cosmesis. The Authors report a case of mechanical end to end cecorectal anastomosis after laparo-assisted subtotal colectomy (by four trocars) preserving superior rectal and ilecolic vessels, for the treatment of slow transit constipation in a 20 years old male patient .The reported operative approach which links tipical laparoscopic advantages to a more "safety" and "accurate" extracorporeal mechanical anastomosis.

AIM: The Authors analyze the short and long-term results of surgical treatment in 70 consecutive patients operated on from for secondary Hyperparathyroidism (2HPT) of chronic kidney disease (CKD). MATERIAL OF STUDY: Seventy patients affected by 2HPT of CKD, in hemodialytic treatment, were observed from January 1999 to January 2009. Twentyseven patients were submitted to total parathyroidectomy (TP), 36 pts were submitted to total parathyroidectomy plus subcutaneous autoimplantation (TP ai), 7 pts were submitted to subtotal parathyroidectomy (SP). RESULTS: An improvement of the typical clinical symptoms was found in every patient undergoing surgery, and a significant reduction in intact parathyroid hormone (iPTH) serum levels was achieved. TP determined a lower incidence of one year relapse. After TPai 9/36 pts successfully underwent renal transplantation. DISCUSSION: To date surgical treatment of 2HPT is still controversial. SP and TPai are the most commonly adopted surgical interventions while TP had been previously been confined to patients with advanced dialytic vintage or for the treatment of recurrence, for the risks arising from aparathyroidism. TP allows a lower long-term relapse incidence and managing the resulting hypoparathyroidism appears straightforward with medical treatment. CONCLUSIONS: The Authors are in favour of early surgical intervention to prevent cardiovascular complications. TPai may be the operation of choice in patients eligible for kidney transplantation while TP, carachterized by a lower incidence of long term relapse, is reserved to patients not eligible for transplantation and affected by a more "aggressive" forms of 2HPT.

The RET gene codes for a tyrosine kinase receptor, expressed in neural crest derived cells playing a central role during embryogenesis. The RET proto-oncogene is responsible for medullary thyroid cancer and multiple endocrine neoplasia type 2. To date, more than 50 germline point mutations have been described. A specific correlation between genotype and phenotype is well recognized. Genetic testing is predictive of cancer onset, age at onset and biological aggressiveness. In recent years, the concept of codon-oriented prophylactic surgery has been introduced and three levels of risk have been identified on the basis of specific mutations. A review of the literature shows the excellent results of laboratory, genetic and clinical research that have made it possible to reduce medullary thyroid cancer-related mortality.

Papillary and follicular thyroid carcinoma are still characterised by unclear biological and clinical behaviour with an autoptic incidence higher than the clinical incidence. Lymph-node involvement represents a prognostic factor that may increase the rate of local relapse, reducing long-term survival only in high risk patients--age > 45 years, M+, T > 3 cm, extra thyroidal extension, follicular histotype. The authors analyse the role of lymph-node cervical dissection. Routine or selective, extended or conservative lymphectomy are described in the literature. Prognostic factors are useful to determine the most appropriate surgical procedure. An elective cervical central dissection may be indicated in patients at high risk, while in cases of monolateral lymph-node metastases, in patients at low risk, a selective lymph node dissection of levels VI-III-IV is associated with lower morbidity. Modified radical neck dissection is reserved for patients at high risk or in cases of multiple lymph-node metastases (> 5) to reduce the incidence of local relapse. In the treatment of differentiated thyroid carcinoma an elective total thyroidectomy must be performed in combination with adjuvant radioiodine ablation.

BACKGROUND: Parathyroidectomy (Ptx) ameliorates anemia (A) and reduces postoperative erythropoiesis-stimulating agent (ESA) requirement. The authors retrospectively evaluated the effects of successful Ptx on chronic A and ESA need in 30 2HPT patients. METHODS: From 2004 to 2009,30 anemic hemodialysis (HD) patients, affected by severe 2HPT, underwent Ptx -15 total parathyroidectomy (TP) and 15 TP + subcutaneous autoimplantation (TPai). Patients were evaluated for iPTH, hemoglobin (Hb) levels, erythrocyte count, hematocrit and erythropoietin dosing before and at 6, and 12 months after surgery. RESULTS: In every case, Ptx achieved a dramatic reduction of iPTH levels. In 26/30 cases(86.6%) an improvement of Hb levels was observed,and 27/30 (90%) patients did not need postoperative ESA treatment,irrespective of the type of surgical procedure carried out (TP or TPai). CONCLUSIONS: Successful Ptx for 2HPT of CKD determined a considerable improvement of A,reducing exogenous ESA need.In 2HPT of HD patients A is a secondary indication to surgical treatment,but we propose that this condition should be taken into more careful account, given the high costs of ESA therapy. Background: Parathyroidectomy (Ptx) ameliorates anemia (A) and reduces postoperative erythropoiesis-stimulating agent (ESA) requirement. The authors retrospectively evaluated the effects of successful Ptx on chronic A and ESA need in 30 2HPT patients. Methods: From 2004 to 2009,30 anemic hemodialysis (HD) patients, affected by severe 2HPT, underwent Ptx -15 total parathyroidectomy (TP) and 15 TP + subcutaneous autoimplantation (TPai). Patients were evaluated for iPTH, hemoglobin (Hb) levels, erythrocyte count, hematocrit and erythropoietin dosing before and at 6, and 12 months after surgery. Results: In every case, Ptx achieved a dramatic reduction of iPTH levels. In 26/30 cases(86.6%) an improvement of Hb levels was observed,and 27/30 (90%) patients did not need postoperative ESA treatment,irrespective of the type of surgical procedure carried out (TP or TPai). Conclusions: Successful Ptx for 2HPT of CKD determined a considerable improvement of A,reducing exogenous ESA need.In 2HPT of HD patients A is a secondary indication to surgical treatment,but we propose that this condition should be taken into more careful account, given the high costs of ESA therapy.

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

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

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

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

Background: In chronic hemodialysis patients with secondary hyperparathyroidism, pathological modifications of bone and mineral metabolism increase the risk of cardiovascular morbidity and mortality. Parathyroidectomy, reducing the incidence of cardiovascular events, may improve outcomes; however, its effects on long-term survival are still subject of active research. We compared, in hemodialysis patients, the results of parathyroidectomy, in terms of cardiovascular outcomes and mortality, with those present in patients following medical treatment only, prior to the diffusion of calcimimetics. Methods. From January 2004 to December 2006, 30 hemodialysis patients, affected by severe and unresponsive secondary hyperparathyroidism, underwent parathyroidectomy - 15 total parathyroidectomy and 15 total parathyroidectomy + subcutaneous autoimplantation. During a 5-year follow-up, patients did not receive a renal transplantation and were evaluated for biochemical modifications and major cardiovascular events - death, cardiovascular accidents, myocardial infarction and peripheral vascular disease. Results were compared with those obtained in a control group of 20 hemodialysis patients, affected by secondary hyperparathyroidism, and refusing surgical treatment, and following medical treatment only. Results: The groups were comparable in terms of age, gender, dialysis vintage, and comorbidities. Postoperative cardiovascular events were observed in 18/30 - 54% - surgical patients and in 4/20 - 20%- medical patients, with a mortality rate respectively of 23.3% in the surgical group vs. 15% in the control group. Parathyroidectomy was not associated with a reduced risk of cardiovascular morbidity and survival rate was unaffected by surgical treatment. Conclusions: In secondary hyperparathyroidism hemodialysis patients affected by severe cardiovascular disease, surgery did not modify cardiovascular morbidity and mortality rates. Therefore, in secondary hyperparathyroidism hemodialysis patients, resistant to medical treatment, only an early indication to calcimimetics, or surgery, in the initial stage of chronic kidney disease - mineral bone disorders, may offer a higher long-term survival. Further studies will be useful to clarify the role of secondary hyperparathyroidism in determining unfavorable cardiovascular outcomes and mortality in hemodialysis population. © 2013 Conzo et al.; licensee BioMed Central Ltd.

Gastric duplication cyst (GDC) with a pseudostratified columnar ciliatedepithelium is an uncommon malformation supposed to originate from a respiratorydiverticulum arising from the ventral foregut. Morphologic appearance of GDCs isvariable, depending on the density of their contents. GDCs are oftenmisdiagnosed as solid masses by imaging techniques, and as a consequence theymay be wrongly overtreated. We report our case of a 56-year-old man with a 5 cmhypoechoic mass of the gastroesophageal junction, incidentally detected bytransabdominal ultrasonography. Neither transabdominal ultrasonography normagnetic resonance clearly outlined the features of the lesion. The patientunderwent endoscopic ultrasound (EUS), which showed a hypoechoic mass arisingfrom the fourth layer of the anterior gastric wall, just below thegastroesophageal junction. According to EUS features, a diagnosis ofgastrointestinal stromal tumor was suggested. EUS-guided fine-needle aspirationcytology revealed a diagnosis of GDC with pseudostratified columnar ciliatedepithelium. We therefore performed an endoscopically-assisted laparoscopicexcision of the cyst. In conclusion, whenever a subepithelial gastric mass is found in the upper partof the gastric wall, a duplication cyst, although rare, should be considered. Inthis case, EUS-guided fine-needle aspiration cytology could provide acytological diagnosis useful to arrange in advance the more adequate surgicaltreatment.

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.

Metanephric adenoma (MA) is a rare benign tumor, diagnosis of which is often carried out after surgical treatment. In case of peripheral lesions, a partial nephrectomy (PN)—either open or laparoscopic may be preferred—and, furthermore, a radiofrequency (RF)-assisted procedure may facilitate adequate hemostasis. In November 2010, the authors performed a RF-assisted PN, according to Habib’s technique, using a 4-needle bipolar device, on a woman affected by a small exophytic MA of the right kidney. Fibrin glue was applied on the cut surface. Postoperative course was uneventful, and discharge was on postoperative day 4. MA is an extremely rare benign tumor with a favorable prognosis. In case of a preoperative cytological diagnosis, a careful follow-up has to be considered. PN represents the standard of care for small exophytic MA, and RF-assisted procedures allow an excellent hemostasis and a rapid conservative resection, with very low morbidity.

In the surgical treatment of secondary hyperparathyroidism (2HPT) of chronic kidney disease (CKD), a parathyroidectomy (PTx) of 4 glands can only be presumed as 'total', and indications for autoimplantation are complex. Intraoperative rapid parathyroid hormone assay could be useful to predict a radical resection. We evaluated iPTH levels 20 min and 24 h after a 4-gland PTx in 35 patients to determine the predictive value of intraoperative iPTH assay. We analysed retrospectively 35 patients affected by 2HPT of CKD, 13 undergoing total parathyroidectomy (TP) and 22 TP + autoimplantation (TPai), after removing 4 glands in 33 cases and 5 glands in 2. Intact PTH assays were acquired after 40 min before induction of anaesthesia, after removing both ipselateral glands, at 20 min after surgery and on postoperative day 1. 20 min after 4-gland PTx, a decrease of iPTH levels >80 % of the preoperative value was observed in 27 of 35 cases (77.1 %) and 80 % of the preoperative value was observed in 27 of 35 cases (77.1 %) and < 80 % in 8 of 35 cases (22.8 %). In 6 of these 8 patients, iPTH levels were within the normal range 24 h after surgery. Although the intraoperative iPTH assays are of interest in the treatment of 2HPT, the predictive value of this method is not entirely satisfactory. In fact, a 4-gland PTx ensures euparathyroidism in most cases, even when intraoperative iPTH assays are not trustworthy; however, intraoperative iPTH assay, although not a perfect 'tool', is a proved aid for the surgeon in making his decision.

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

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

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

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