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The detection of nodal status is based on examination of lymph nodes (LN) after the tumor surgical resection and the current guidelines recommend to examine atleast 12 regional LN. An inadequate number of examined LN may lead to a lower N stage or to a false-negative nodal disease. To overcome these issues, many authors proposed to consider the metastatic lymph node ratio (mLNR). MLNR is the ratio of the number of metastatic LN to the number of examined LN.241 colon cancer (CC) specimens from patients who had undergone surgical resection between January 2010 and December 2015 at the General Surgery Unit of Parma University Hospital were analyzed. mLNR, which is defined as the ratio of the number of positive LN to the number of examined LN, was calculated in CCs with LN metastasis. In this study we focused on the following mLRN cutoffs:0.15, 0.15-0.3 and3 and we evaluated the prognostic implication of mLNRs.Regarding the impact of examined LN on involved LN in CC, our results showed that the number of involved LN increased with the increasing number of examined LN (p=0.03). We found a significant correlation between OS and RFS rate of patients with CCs and mLNR. Patients with mLNR0.15 were associated with better OS and RFS rate whereas patients with mLNR0.3 were associated with worse OS and RFS rate. OS rate for patients with a mLNR0.15 was 95.24% (89-100%) at 1 year, 83.27% (72.7-95.4%) at 3 years and 68.07% (55.1-84.1%) at 5 years whereas patients with a mLNR0.3 had an OS rate of 51.7% (34.6-77.3%) at 1 year, 36.55% (20.08-64.3%) at 3 years and 31.33% (16.5-59.4%) at 5 years. RFS rate for patients with a mLNR0.15 was 100% (100-100%) at 1 year, 92.2% (84-100%) at 3 years and 85.2% (73.8-98.31%) at 5 years whereas patients with a mLNR0.3 had a RFS of 63.2% (42.8-93.58%) at 1 year and 54.2% (33.1-88.93%) at 3 and 5 years.The prognostic value of pN stage could be more accurate if we consider both the number of LN metastasis and harvested LN. This can be achieved by using the mLNR that can be a useful tool in daily practice to predict the prognosis of patients who undergone surgery for CC.

Breast cancer (BC) is the most common tumor in women, 523.000 cases were estimated in Europe in 2018 and it remains the third cause of cancer related deaths after lung and colorectal cancer. The incidence of thyroid cancer (TC) in females is higher than in males.We have retrospectively collected all female patients undergone to surgery for breast or thyroid cancer in 2010The aim of the study was to value the incidence of BC in patients with a personal history of differentiated thyroid cancer (DTC) and conversely, the incidence of DTC in patients with previous BC within 5 years from the diagnosis of the first tumor in 2010.Among 76 BC patients, 11 were death and 22 didn't answer the phone call or refused to re-submit to thyroid ultrasound so they were excluded from the study and only 43 BC were further considered. Thyroid ultrasound was performed in 2010 and in 2016 and it described nodules in 13 (30%) patients in 2010 and in 21 (49%) patients in 2016. In 2010 no FNA was needed while in 2016 6 (14%) patients underwent to FNA with a benign response (Thyr 2). Among 61 DTC patients, 11 didn't answer the phone or the questions so 50 patients were included in the study. Breast cancer family history was reported in 14 (28%) patients and thyroid cancer family history in 8 (16%) patients. No relapse was reported during follow up.All patients underwent to mammography in 2015 or in 2016 within screening programs and no breast cancer were diagnosed.The female predominance of diseases of the thyroid and breast makes difficult the separation of an expected association with a casual linkageThe relationship between the co-occurrence of breast and thyroid cancer remains controversial and inconclusive.Breast cancer, Breast surgery, Hormone therapy, Thyroid cancer, Thyroidectomy.In considerazione del fatto che il tumore al seno (BC) è il tumore più comune nelle donne, 523.000 casi sono stati stimati in Europa nel 2018 e rimane la terza causa di morte per cancro dopo il cancro del polmone e del colon-retto., e che l’incidenza del carcinoma tiroideo (TC) nelle femmine è più alta che nei maschi, abbiamo raccolto in modo retrospettivo i dati di tutte le pazienti di sesso femminile sottoposte a chirurgia per carcinoma mammario o tiroideo nel 2010. L’obiettivo dello studio è di valutare l’incidenza di BC in pazienti con anamnesi positiva di carcinoma tiroideo differenziato (DTC) e, viceversa, l’incidenza di DTC nei pazienti con precedente BC entro 5 anni dalla diagnosi del primo tumore nel 2010. Tra le 76 pazienti con BC, 11 erano deceduti e 22 non rispondevano alla telefonata o rifiutavano di sottoporsi a ecografia tiroidea, quindi furono escluse dallo studio e solo 43 BC furono ulteriormente considerati. L’ecografia tiroidea è stata eseguita nel 2010 e nel 2016 e ha descritto i noduli in 13 (30%) pazienti nel 2010 e in 21 (49%) pazienti nel 2016. Nel 2010 non è stato necessario procedere a FNA mentre nel 2016 6 (14%) pazienti sono stati sottoposti a FNA con una risposta di benignità. (Thyr 2). Tra le 61 pazienti sottoposte a chirurgia per DTC, 11 non hanno risposto al telefono o alle domande, quindi sono state incluse nello studio 50 pazienti. Una storia familiare di cancro al seno è stata rintracciata in 14 (28%) pazienti e una storia familiare di cancro della tiroide in 8 (16%) pazienti. Durante il followup non è stata segnalata alcuna recidiva. Tutti le pazienti sono state sottoposte a mammografia nel 2015 o nel 2016 nell’ambito di un programmi di screening e non sono stati diagnosticati tumori al seno. In conclusione la predominanza femminile delle malattie della tiroide e della mammella rende difficile la separazione di un’associazione attesa con un legame casuale. La relazione tra la conoccorrenza del cancro della mammella e della tiroide rimane controversa e inconcludente anche nella nostra esperienza.

We report a rare case of giant retroperitoneal dedifferentiated liposarcoma with osteosarcomatous component. The tumor was removed in a 63-year-old male that not showed any symptom. The histopathological examination highlighted a first differentiated neoplastic component and a second dedifferentiated neoplastic component where prevailed areas of osteosarcoma. To our knowledge only fourteen similar cases have been reported in the literature. KEY WORDS: Dedifferentiated liposarcoma, Osteosarcoma.Si riferisce del caso di un gigantesco liposarcoma retroperitoneale sdifferenziato con componente osteosarcomatosa. Questo tumore è stato asportato da una donna di 63 anni sostanzialmente asintomatica. L’esame istopatologico ha dimostrato una prima componente neoplastica differenziata ed una seconda componente neoplastica sdifferenziata con prevalenti aspetti di osteosarcoma. A nostra conoscenza in letteratura sono stati riportati soltanto altri 14 casi del genere.

Aim: Evaluate impact of lymph node ratio as prognostic factor in gastric cancer. Methods: We studied 463 patients with gastric cancer who underwent curative gastric surgery with D1 or D2 lymphadenectomy, Data were collected from May 1996 through December 2010 at Department of General Surgery of Parma University Hospital. We divided patients in two groups according to number of nodes removed. Results: The results of the present nonrandomized retrospective single center study confirm the promising role of the LNR as an indipendent prognostic factor. Overall survival between LNR categories are statistically significant different between LNR0 and LNR1. Conclusion: The ratio between the number of metastatic and analyzed lymph nodes in patients with gastric cancer can discriminate patients better than the AJCC/UICC staging system: it seems to be related to a more sensitive in the evaluation of overall survival. (www.actabiomedica.it)

Background: Pulmonary metastasectomy is considered a standard procedure in the treatment of metastatic colorectal cancer (CRC). Different prognostic factors including multiple metastatic nodules, the presence of extra-pulmonary metastases and BRAF mutation status have been associated with poor survival. The aim of this study was to evaluate which factors influenced survival in CRC patients undergoing pulmonary metastasectomy by studying primary tumors and pulmonary metastases. Methods: All patients treated for primary CRC who presented pulmonary metastases in a 10-year period were considered (group A). A control group treated for primary CRC who did not develop any pulmonary or extra-pulmonary metastases was taken for comparison (group B). Different prognostic factors including gender, age, tumor location, histological type, inflammatory infiltrate, BRAF, CDX2 and extra-pulmonary metastases were analyzed. Overall survival (OS) and patients’ survival after pulmonary metastasectomy were also considered. Results: Fifty-four patients were evaluated in group A and twenty-three in group B. In group A, BRAF immunohistochemistry did not significantly differ between primary tumors and pulmonary metastases; no difference of BRAF expression was found between group A and B. Even the expression of CDX2 was not significantly different in primary tumors and metastases. Similarly, in group B CDX2 did not significantly differ from primary CRC of group A. The most significant prognostic factor was the presence of extra-pulmonary metastases. Patients with extra-pulmonary metastases experienced a significant shorter survival compared to patients with pulmonary metastases alone (P=0.001 with log-rank test vs. P=0.003 with univariate Cox regression). Interestingly, patients with right pulmonary metastases presented a significant longer survival than those with left pulmonary metastases (P=0.027 with log-rank test vs. 0.04 with univariate Cox regression). Conclusions: The main prognostic factor associated with poor survival after lung resection of CRC metastases is a history of extra-pulmonary metastases. BRAF and CDX2 did not have a significant role in this small series of patients.

Background Early Hypocalcemia is the most frequent complication after thyroid surgery. Several studies have tried to identify factors (patient caracteristics or surgical technique variations) affecting hypocalcemia following thyroid surgery. This studiy evaluates the role of several factors in postoperative hypocalcemia development. Methods A retrospective study conducted on 2108 patients that underwent thyroid surgery in a single center (1669 women and 439 men). Postoperative early hypocalcemia was defined as serum calcium levels lower than 8,0 mg/dl measured 24 h after surgery. Following factors were evaluated in the study: sex, age, glandular hyperfunction, preoperative diagnosis, preoperative serum calcium levels, preoperative serum PTH levels, type of surgery performed (total thyroidectomy vs. lobectomy); minimally invasive video assisted thyroidectomy (MIVAT); number of parathyroid preserved in situ, postoperative serum calcium levels, changes in perioperative calcium levels (difference between preoperative values ​​and postoperative calcium levels), presence of carcinoma in the surgical specimen, presence of thyroiditis based on histopatology reports. Results Among evaluated factors only gender and surgical procedure revealed to be significantly correlated to early hypocalcemia development. In fact female patients experienced postoperative hypocalcemia in 42% (701/1669) of cases, which was signicantly higher than the 21.4% (94/439) identified in men. We also noticed a greater hypocalcemia incidence in patient undergoing total thyroidectomy (38.8%) than in patient undergoing lobectomy group (13.8%). Early hypocalcemia development didn’t appear to be related to preoperative serum calcium levels but it showed a statistically significant correlation with perioperative serum calcium level drop. Conclusion This findings suggest that sex (female gender is a strong risk factor),surgical procedure and perioperative changes in serum calcium are the only factors (among all variables examined) that influence early hypocalcemia development.

Background: The conventional thyroidectomy is the most frequent surgical procedure for thyroidal surgical disease. From several years were introduced minimally invasive approaches to thyroid surgery. These new procedures improved the incidence of postoperative pain, cosmetic results, patient’s quality of life, postoperative morbidity. The minimally invasive video-assisted thyroidectomy (MIVAT) is a minimally invasive procedure that uses a minicervicotomy to treat thyroidal diseases. Methods: We present our experience on 497 consecutively treated patients with MIVAT technique. We analyzed the mean age, sex, mean operative time, rate of bleeding, hypocalcemia, transitory and definitive nerve palsy (6 months after the procedure), postoperative pain scale from 0 to 10 at 1 hour and 24 hours after surgery, mean hospital stay. Results: The indications to treat were related to preoperative diagnosis: 182 THYR 6, 184 THYR 3–4, 27 plummer, 24 basedow, 28 toxic goiter, 52 goiter. On 497 cases we have reported 1 case of bleeding (0,2%), 12 (2,4%) cases of transitory nerve palsy and 4 (0,8%) definitive nerve palsy. The rate of serologic hypocalcemia was 24.9% (124 cases) and clinical in 7.2% (36 cases); 1 case of hypoparathyroidism (0.2%). Conclusions: The MIVAT is a safe approach to surgical thyroid disease, the cost are similar to CT as the adverse events. The minicervicotomy is really a minimally invasive tissue dissection.

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Iatrogenic bile duct injuries are still a diagnostic and therapeutic problem and their incidence increased with the introduction of laparoscopic technique. This case report documents a patient with a biliary fistula from an accessory bile duct - Lushka's duct - after routine laparoscopic cholecystectomy, unresponsive to relaparoscopy, ERCP with papillosphincterotomy, biliary stent and nosobiliary tube placement and finally treated with injection of fibrin glue and balloon tamponade through the external drain. Iatrogenic bile duct injuries remain a challenging problem, in particular when they do not communicate with central biliary tree. The detection of this fistulas is more difficult and their management should be multidisciplinary. This case presentation is to emphasize importance of correct diagnostic evaluation and timely and adequate non-surgical methods of treatment of biliary fistulas. (www.actabiomedica.it).

Background Solitary thyroid nodules are the most common endocrine occurance in general population. With the introduction of Bethesda system for reporting thyroid cytopathology (BSRTC) to fine-needle aspiration (FNA) specimens we found a reliable standard method to evaluate malignancy risk in thyroid neoplasms. This study evaluates the correlation between BSRTC and real results in our center investigating the role of several factors as confounding factors for cytological diagnosis. The study has been designed as a retrospective study conducted on 637 patients that underwent thyroid surgery in a single center (Unit of General Surgery, Parma University Hospital, Italy). Methods We reviewed 637 files of patients who underwent thyroid surgery with a definitive histological finding from surgical specimen. The collected data include: cytological findings from FNA when performed, histological findings after surgery, sex, age, thyroid hyperfunction and the possible presence of thyroiditis. Cytological findings have been evaluated from our institution's pathologists after FNA performed in collaboration with clinical endocrinologists. Thyroid Hyperfunction has been evaluated through a blood test panel for thyroid functionality including reflex TSH, FT3, FT4 and thyreoglobulin. Blood tests' results and patients have been evaluated by clinical endocrinologists before being addressed to surgery. Thyroiditis have been confirmed as an ultrasound scanning (US) finding or as a corollary from histologic results. All patients have been evaluated by the surgeon and underwent different intervention as total, thyroidectomy, near total thyroidectomy or emithyroidectomy depending on cythology, US findings and symptoms in case of benignancy. Histological findings have been evaluated only by our center pathologists. Results In our experience the percentage of malignancy in Thyr 2 Thyr 3 and Thyr 4 Bethesda's classes seeems to be higher then those predicted by BSRTC. We also found a high rate of false positive considered as patients included in categories of suspected malignancy (Thyr 3-4-5-6) and subsequently resulted with benign pathology. This happens specially in those patients affected by thyroiditis. Conclusions These findings suggest that we need more studies to evaluate real BSRTC predictive value in single centers. Meanwhile we found out that thyroiditis may be a confounding factor in cytological examination wich would lead to an overstating of thyroid nodules.

The identification of prognostic factors in gastric cancer is important for predicting patients' survival and determining therapeutic strategies.A retrospective analysis ofpatients who underwent surgery for gastric cancer between 1996 and 2010. The appropriate cut-off value of tumor size related to survival was determined using receiver-operating characteristic (ROC) curves and it was 2,5 cm. Patients were divided into three groups: a small size group (SSG,2,5 cm), a medium size group (MSG, between 2,5 and 5 cm) and a large size group (LSG, ≥ 5 cm).Depth of invasion and lymph node metastasis resulted significantly related to tumor size (p0.05). Kaplan- Meier survival curves showed that OS rate was significantly higher in SSG patients. The prognosis of patients with tumor size2,5 cm was better than patients with tumors ≥ 2.5 cm in size (p0.01).The tumor size resulted significantly related to OS and it was related to depth of invasion and lymph node metastasis that are themselves prognostic factors. These results confirm and reinforced literature and suggest that at diagnostic pre-operative work-up we can yet define a prognostic value based on tumor size and underline the primary role of complete resection with free surgical margins and D2 lymphadenectomy.In patients with gastric cancer tumor size suggests information about the malignancy of the tumor: it is an important predictor of survival and 2,5 cm may be considered as a valid cut-off to define a better or worse prognosis.Gastric cancer, Prognosis,Survival, Tumor size.L’identificazione di fattori prognostici nei pazienti con cancro gastrico è importante per predire la sopravvivenza e per determinare le successive strategie terapeutiche. Le dimensioni del cancro gastrico sono state a lungo discusse come possibile fattore prognostico indipendente e, anche se il loro ruolo in questa neoplasia non è ancora certo, il loro valore prognostico è risultato essere collegato allo stadio del tumore in molti studi presenti in letteratura. Abbiamo condotto un’analisi retrospettiva su 463 pazienti che sono stati sottoposti a chirurgia per cancro dello stomaco dal 1996 al 2010 presso la Clinica Chirurgica e dei Trapianti d’Organo dell’Azienda Ospedaliero Universitaria di Parma. L’analisi si è poi focalizzata su 346 pazienti che sono stati sottoposti a chirurgia curativa. Abbiamo utilizzato le curva ROC per determinare un appropriato valore cut-off delle dimensioni del cancro gastrico da correlare con la sopravvivenza; questo valore è risultato essere 2,5 cm. I pazienti sono stati quindi suddivisi, anche sulla base della letteratura, in tre gruppi: a small size group (SSG, dimensioni2,5 cm), a medium size group (MSG, dimensioni tra 2,5 e 5 cm) e a large size group (LSG ≥ 5 cm). L’analisi statistica ci ha mostrato correlazione tra le dimensioni del cancro gastrico e l’infiltrazione di parete e la presenza di metastasi linfonodali (p0.05). Le curve di sopravvivenza sec. Kaplan-Meier hanno dimostrato che la sopravvivenza è significativamente più alta nei pazienti con cancro gastrico2,5 cm. La prognosi dei pazienti con cancro gastrico minore di 2,5 cm è migliore di quella dei pazienti con cancro gastrico superiore a 2,5 cm. Le dimensioni sono un importante fattore prognostico indipendente con significatività statistica sulla sopravvivenza (p0.01). Questi risultati confermano i dati presenti in letteratura e suggeriscono che già agli esami preoperatori ed in corso di intervento chirurgico possiamo già avere un ulteriore fattore prognostico sulla neoplasia che ci può aiutare anche nella gestione chirurgica della patologia.

Surgical resection remains the main curative treatment for gastric cancer but is still affected by high postoperative morbidity and mortality rates, especially in Western countries.We've analyzed patients treated for gastric cancer at our Operative Unit of ent, extent of lymphadenectomy and survival. General Surgery and Organ Transplantation of the University Hospital of Parma from January 2006 till December 2010, relating the occurrence of eventual complications to sex, age at diagnosis, definitive histological examination, type and duration of surgical treatment.The surgically treated cases were 152 (30.4 gastrectomies per year on average). 62 patients developed at least one adverse event during the postoperative period, reaching 108 total events. Among these, 71 were minor complications (grade I-II in Clavien-Dindo's classification), while 26 were major ones (grade III). Postoperative mortality affected 8 patients (5.3%). Data analysis did not stress any statistically significant correlation between the valued variables and the global incidence of complications. For severe ones, some risk factors emerged such as the type of gastrectomy, the execution of a multi-visceral resection and the operative time. Five-year overall survival has been 36.7%, lower in patients with severe complications (29%) when compared to patients without severe complications (38%). Radicality of operation, the lymph node involvement and the occurrence of severe complication emerged as significant prognostic factors for five-year overall survival.Surgery is still the mainstay of treatment for gastric cancer and the only one able to grant a curative therapy. When performed in high-volume centres, with more than 20 gastrectomies per year, it represents a safe treatment, affected by low mortality. Attention must be paid to careful preoperative selection, to treatment of pre-existent comorbidities, to plan a therapeutical strategy to minimize surgical stress, to postoperative monitoring and to managing complications', as they're able to impact not only low-term outcomes but also overall and disease-free survival. The poor prognosis for these patients is mainly related to advanced stage at presentation, thus confirming the need to increase early diagnosis in order to detect in larger percentages the tumor in its early stage.Complications, Gastrectomy, Gastric Cancer, Survival.L’intervento chirurgico resettivo rimane il principale trattamento curativo per il cancro gastrico ma risulta ancora gravato da alti tassi di morbilità e mortalità postoperatorie soprattutto in Occidente.Abbiamo analizzato i pazienti trattati per cancro gastrico presso l’Unità operativa di Chirurgia generale e Trapianti d’Organo dell’Azienda Ospedaliera Universitaria di Parma dal 1/1/2006 al 31/12/2010 correlando l’insorgenza di eventuali complicanze al sesso, età, esame istologico definitivo, tipo e durata di intervento chirurgico, estensione della linfadenectomia e sopravvivenza.I casi trattati chirurgicamente sono stati 152 (media 30.4 gastrectomie/anno). 62 pazienti hanno sviluppato almeno un evento avverso nel postoperatorio per un totale di 108 eventi. Di questi 71 erano di grado III secondo la classificazione Clavien-Dindo, 26 di grado III. La mortalità postoperatoria ha riguardato 8 pazienti (5.3%). L’analisi dei dati non ha rilevato nessuna associazione statisticamente significativa fra le variabili considerate e l’incidenza globale di complicanze. Per le complicanze severe si sono rivelati fattori di rischio il tipo di gastrectomia, l’esecuzione di una resezione allargata e la durata prolungata dell’intervento. Il tasso di sopravvivenza globale a 5 anni è stato del 36,7%, più basso nei pazienti con complicanze severe (29%) rispetto ai pazienti senza complicanze severe (38%). La radicalità dell’intervento, l’invasione linfonodale e lo sviluppo di complicanze severe si sono rivelati fattori prognostici significativi per la sopravvivenza globale a 5 anni. CONCLUSIONI: la chirurgia rimane il principale trattamento per cancro gastrico e l’unico in grado di operare una terapia curativa. In centri ad alto volume (con più di 20 gastrectomie per anno) rappresenta un intervento sicuro con bassa incidenza di mortalità. Grande attenzione va posta all’accurata selezione preoperatoria, al trattamento delle comorbilità preesistenti, alla modulazione della strategia terapeutica al fine di minimizzare lo stress chirurgico, al monitoraggio postoperatorio e alla gestione delle eventuali complicanze per il possibile impatto non solo sui risultati a breve termine ma anche sulla sopravvivenza globale e libera da malattia. La prognosi infausta correlata alla presentazione in stadio già avanzato conferma la necessità di aumentare la diagnosi precoce per identificare stadi iniziali in percentuali più elevate.

Iatrogenic diaphragmatic hernia following laparoscopic left colectomy for splenic flexure cancer. An unusual complication Diaphragmatic hernias are a migration of abdominal structures into the thorax via a diaphragmatic defect; they may be classified as congenital or acquired and acquired hernias can be hiatal, traumatic or iatrogenic, generally complications of thoracic or abdominal surgery. We report a case of iatrogenic diaphragmatic hernia after a laparoscopic left colectomy for splenic flexure tumor; to our knowledge, in literature this case is the first reported. A 51-years-old woman was readmitted to our Hospital on 11th post-operative day for bowel occlusion and a CT - scan revealed left diaphragmatic herniation with fluid dilatation of the small bowel that appeared in the left hemithorax. Laparoscopic surgery resolution was decided and after the reduction of the small bowel in the abdomen we closed the defect using two direct absorbable auto-block hemi-continuous sutures that were covered by a synthetic absorbable mesh. Probably we didn't notice a minimal injury of the left diaphragm caused by ultrasonic scalpel and we can suppose that this delay in presentation may be a result of the gradual enlargement of a microscopic lesion. Patient's gas exchanges were good during surgery and during post-operative course.Diaphragmatic hernia, Iatrogenic, Laparoscopy, Left colectomy, Ultrasonic scalpel.Le ernie diaframmatiche sono descritte come una migrazione di alcune strutture addominali in torace attraverso un difetto del diaframma e possono essere classificate come congenite (Bochdalek e Morgagni) o acquisite; tra queste ultime distinguiamo le ernia iatali, quelle posttraumatiche e quelle iatrogene (dopo chirurgia addominale o toracica). In letteratura sono riportati vari esempi di ernia diaframmatica complicante chirurgia (chirurgia dell’esofago e dello stomaco; chirurgia della colecisti e del fegato); in questo lavoro abbiamo descritto il caso clinico di un’ernia dell’emidiaframma sinistro insorta dopo intervento di emicolectomia sinistra laparoscopica per cancro della flessura splenica. Il decorso intra e postoperatorio della paziente è stato del tutto regolare e la paziente è stata dimessa in ottava giornata post-operatoria. In undicesima giornata post-operatoria la paziente è rientrata presso la nostra struttura per quadro occlusivo senza alcun tipo di sintomo respiratorio; abbiamo eseguito una TC torace – addome in urgenza che ha mostrato un difetto dell’emidiaframma sinistro con migrazione si anse ileali distese nell’emitorace omolaterale. È stata decisa risoluzione chirurgica del problema ed è stata eseguita una laparoscopia diagnostica che ha evidenziato un difetto di circa 4 cm dell’emidiaframma sinistro senza alcun danno a carico delle anse erniate che sono quindi state delicatamente ridotte in addome. Il difetto diaframmatico è stato riparato sempre in laparoscopia usando due suture emicontinue in filo autobloccante e la sutura è stata poi ricoperta con una protesi in Vicryl fissata con colla di fribrina. Il decorso post-operatorio è stato regolare e la paziente è stata dimessa in quinta giornata post-operatoria. La patogenesi di questa ernia diaframmatica non è così chiara; noi abbiamo tratto due principali considerazioni. In primo luogo durante la mobilizzazione della flessura splenica abbiamo usato uno strumento ad ultrasuoni che può causare scottatura del diaframma provocando quindi un punto di debolezza che può poi evolvere in un’ernia; considerando che il tumore era a livello della flessura e che questa si presentava molto alta probabilmente durante tali manovre abbiamo causato un piccolo danno al diaframma del quale non ci siamo accorti in corso di intervento. In secondo luogo la ventilazione positiva dell’intubazione ha evitato l’insorgenza di insufficienza respiratoria ed ha continuato a mantenere il polmone ben espanso. Dopo l’estubazione l’incremento della pressione addominale può aver causato l’aumento delle dimensioni del difetto diaframmatico e l’erniazione delle anse in emitorace sinistro. La chirurgia è il trattamento di scelta per la risoluzione di questo tipo di complicanza e la laparoscopia dovrebbe essere considerata l’approccio di scelta se il pregresso intervento era stato condotto con il medesimo approccio, se i parametri del paziente sono tutti stabili e se l’ernia viene diagnosticata a distanza di poco tempo dal pregresso intervento chirurgico.

Laparoscopic surgery developed continuously over the past years becoming the gold standard for some surgical interventions. Laparoscopic colorectal surgery is well established as a safe and feasible procedure to treat benign and malignant pathologies. In this paper we studied in deep the role of laparoscopic right colectomy analysing the indications to this surgical procedure and the factors related to the conversion from laparoscopy to open surgery. We described the different surgical techniques of laparoscopic right colectomy comparing extra to intracorporeal anastomosis and we pointed out the different ways to access to the abdomen (multiport VS single incision). The indications for laparoscopic right colectomy are benign (inflammatory bowel disease and rare right colonic diverticulitis) and malignant diseases (right colon cancer and appendiceal neuroendocrine neoplasm): we described the good outcomes of laparoscopic right colectomy in all these illnesses. Laparoscopic conversion rates in right colectomy are reported as 12-16%; we described the different type of risk factors related to open conversion: patient-related, disease-related and surgeon-related factors, procedural factors and intraoperative complications. We conclude that laparoscopic right colectomy is considered superior to open surgery in the shortterm outcomes without difference in long-term outcomes.Conversion risks, Indication to treatment, Laparoscopy, Post-operative pain, Right colectomy.

Chronic post-operative inguinodynia occurs in about 10 % of patients undergoing inguinal hernioplasty with prosthesis; it is characterized by a broad pleomorphism of symptoms, including relative to individual variability of algic perception. Its intensity can also potentially jeopardize patient’s work and social activities. The most notorious cause of inguinodynia is neuropathy, resulting from the involvement of one or more inguinal nerves (iliohypogastric, ilioinguinal and genitofemoral nerves) in fibroblastic processes, or from nervous stimulation, caused by prosthetic material on adjacent nervous trunks. The aim of our study was to provide a comparative analysis between outcomes of wide nerve resection vs. nerve sparing. In our hospital, between 2000 and 2010, 600 patients underwent monolateral prosthetic inguinal hernia repair, using the original Trabucco technique. In 345 cases, to avoid chronic post-operative pain, we carried out intentional neurectomy, between 3 and 8 cm in length of either the main and/or peripheral branches of the iliohypogastric nerve, ilioinguinal nerve and the genital branch of the genitofemoral nerve, deemed at risk of entrapment because of the prosthetic material. In the control group, which included the other 255 patients, nerves were identified and spared. Follow-up was scheduled at 1 week, 1 month and 1 year after surgery. Case: 1 week after the operation, 135 patients (39.1 %) did not show pain, 201 (58.3 %) reported moderate pain and 9 (2.6 %) showed intense pain; 1 month after the procedure, 300 patients (87 %) did not have pain, 39 (11.3 %) complained of moderate pain and 6 (1.7 %) demonstrated severe pain; 1 year after surgery, only two patients (0.6 %) complained of persistent pain. Control: At the 1-week follow-up, 114 patients (44.7 %) did not show pain, 111 (43.5 %) reported moderate pain and 30 (11.8 %) intense pain; 1 month after the procedure, 183 patients (71.8 %) did not have pain, 45 (17.6 %) complained of moderate pain and 27 (10.6%) showed severe pain; 1 year after surgery, 11 patients (4.3 %) had persistent pain, and two of them were re-submitted to surgery. The lower incidence of chronic pain after nerve resection is statistically significant (0.6 vs. 4.3 % p = 0.0048); the incidence of moderate pain 1 month after the operation is also lower (11.3 vs. 17.6 % p = 0.0097). In addition, among patients subjected to nerve resection there is a faster resolution of algetic symptomatology, over the course of a month; also noteworthy is the lower incidence of intense pain in the short-and medium-term (after 1 week, 11.8 vs. 2.6 % p = 0.0006 ; after 1 month, 10.6 vs. 1.7 % p

Gastro Intestinal Stromal Tumors (GISTs) are defined as mesenchymal tumours that develop within the wall of the gastrointestinal tract. Surgery is the treatment of choice and may be indicated for locally advanced or previously non resectable disease after a favorable response to preoperative therapy with tyrosine kinase inhibitors.A retrospective analysis was conducted for all patients with a confirmed or suspected diagnosis of GIST who were admitted to the University Hospital of Parma from January 2000 to January 2015.The following parameters were reviewed and analyzed: age, sex, blood type, symptoms on presentation, tumor site, tumor size, mitotic rate, risk grade, histopathology and immunohistochemistry assays, type of cells.All patients underwent elective surgery. Between January 2000 and January 2015, 61 patients were admitted to the OU General Surgery and Organ Transplantation, University Hospital of Parma and received surgical treatment for GISTs. Thirty-five were male (57.4%) and 26 female (42.6%). The mean age at diagnosis was 69.03 ± 10.07 years (range 29 - 89 years); males 69.6 ± 9.3 years (range 49 - 89 years) and females 68 ± 12.4 years (range 29 - 86 years). Larger tumor size, higher mitotic rate, higher risk rate, margin status contributed to poorer outcome (lower OS and DFS) as independent factors.Radical surgery is the treatment of choice for resectable GISTs. Very low and low-risk tumor can be treated with surgery alone.Gastrointestinal Stromal Tumor, Margin Status, Overall Survival, Tumor size.Tumori Stromali Gastrointestinali (GIST) sono definiti come tumori di origine mesenchimale mesenchimale che si sviluppano all’interno della parete del tratto gastrointestinale. La chirurgia è il trattamento di scelta e può essere indicata per patologia localmente avanzata o giudicata non resecabile prima di un ariposta positiva al trattamento con inibitori della tyrosine kinase.Abbiamo condotto una analisi retrospettiva su tutti i pazienti con diagnosi sospetta o confermata di GIST che sono stati ricoverati presso l’ospedale universitario di Parma dal gennaio 2000 al gennaio 2015. Abbiamo analizzato i seguenti parametri: sesso, età, gruppo sanguigno, sintomatologia, dimensioni del tumore, sede del tumore, indice mitotico, grading, risuslttao istologico e immunoistochimico, tipo di cellularità.Tutti i pazienti sono stati sottoposti a chirurgia in elezione. Tra genaio 2000 e gennaio 2015, 61 pazienti sono stati ricoverati presso il reparto di Chirurgia generale e Trapianti d’Organo, dell’Azienda Ospedaliera Universitaria di Parma con trattamento chirurgico. 35 erano di sesso maschile (57,4%) e 26 di sesso femminile (42,6%). L’età media alla diagnosi era di 69.03+/-10.07 anni (range 29-89 anni); maschi 69.6+/-9.3 anni(range 49- 89 anni) e femmine 68+/-12.4 anni (range 29-86 anni) I tumori che presentavano come fattori indipendenti un diametro maggiore, un più alto indice mitotico, un rischio più alto, l’interessamento dei margini di resezione presentavano un outcome peggiore (più basso OS e DFS).La chirurgia radicale è il miglior trattamento per i GIST resecabili. I tumori a basso rischio possono essere trattati con la sola chirurgia.

To evaluate clinical and histopathological changes of gastric cancer (GC) in the last fifteen years and analyze factors influencing overall survival.We have retrospectively categorized patients submitted to surgery for GC from January 1996 to December 2010. The analysis focused on two periods: 1996-2003 (period 1) and 2004-2010 (period 2).There was an increase in age distribution of GC in period 2 (p=0.012). Significant increase of whole GC was observed in period 2 (p=0.01). Slight but significant changes in TNM stage were found: in group 2 there was a decrease in the rate of early GC and in advanced depth of tumor invasion; increase of lymph nodes involvement was also demonstrated. Overall survival (OS) had not changed from the first to the second period. There was a significant difference in OS calculated for Lauren histotype: from ten months to surgery, patients with diffuse histotype showed worse prognosis.The most important findings were an increase in lymph node involvement and a decrease in depth of tumor invasion, an higher percentage of whole type and a decrease in palliative surgery. Overall-survival hasn't change in the last fifteen years. These results confirms the importance of extent of lymph node dissection in the standard surgical approach of GC, the tumor stage and Lauren histotypes as the main prognostic factors in GC.This work confirms the dismal prognosis of GC and the need to increase diagnosis of early gastric cancer.Gastric cancer, Lauren histotype, Overall survivall.Lo scopo di questo studio è stato analizzare i cambiamenti clinici ed istopatologici del cancro gastrico negli ultimi quindici anni ed analizzare i fattori che influenzano la sopravvivenza globale. Abbiamo retrospettivamente analizzato i pazienti sottoposti a chirurgia per il cancro gastrico da gennaio 1996 a dicembre 2010. L’analisi si è focalizzata su due periodi: 1996-2003 (periodo 1) e 2004-2010 (periodo 2). Abbiamo riscontrato un incremento dell’età di distribuzione del cancro gastrico nel secondo periodo (p=0.012). Sono emersi lievi ma significativi cambiamenti nello stadio della neoplasia (Sistema di stadiazione TNM - 7 th edizione). Non sono stati rilevati cambiamenti nella sopravvivenza globale negli ultimi quindici anni; mentre è stata riscontrata una prognosi peggiore per il tipo diffuso secondo Lauren. I risultati confermano l’importanza di una linfoadenectomia estesa nel trattamento standard del cancro gastrico. Questo lavoro conferma la pessima prognosi dei pazienti affetti da cancro gastrico e la necessità di incrementare la diagnosi di questo tumore ad uno stadio precoce.

Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy. The aims of our study were: (1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy. This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004–2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: “large” tumours were defined as ≥5 cm (N = 50) and “small” tumours as

Myeloid sarcoma is a disease that involves first the breast with rapid systemic dissemination. There is no scientific standard consensus on surgical and medical treatment of myeloid sarcoma of the breast and there is no role for radical surgery because chemotherapy and radiotherapy are required for longer survival. Surgery is needful in investigatory work-up to define immunohistochemistry diagnosis. We reported one case of 39-year-old Caucasian female with myeloid sarcoma without systemic involvement that was admitted to our Operative Unit for breast neoplasm. The patient is alive 19 months after surgery she is in good health, without relapse and she never developed neither clinical nor hematologic signs of myelo-proliferative disease. We can deduce that our therapeutic strategy was correct but we can’t consider the disease completely cured because of its aggressiveness.

Hypocalcemia and unintentional parathyroidectomy would be associated as cause of post-thyroidectomy hypocalcemia.We analysed the cases treated with total thyroidectomy by two experienced endocrine surgeons from January 2010 to December 2011 at the Unit of General Surgery and Organ Transplantation of the University Hospital of Parma. These cases were divided in two groups: "Group A" included patients for whom a histological report was made that was negative for a parathyroid avulsion, and "Group B" included patients for whom an inadvertent avulsion of the intracapsular parathyroid glands had occurred.In total, 538 patients were treated with a total thyroidectomy from January 2010 to December 2011. In 26 cases, the histological report highlighted the presence of an intracapsular parathyroid gland. The values of pre-operative calcaemia in group A and group B were 9.204 ± 0.2703 mg/dl versus 9.283 ± 0.401 mg/dl, respectively (p=0.32). The values of post-operative calcaemia were 8.039 ± 0.596 mg/dl for group A versus 7.569 ± 0.618 mg/dl for group B (p=0.0002) In Group A, 91/512 patients were treated with the minimally invasive video-assisted thyroidectomy (MIVAT) technique (17,7%), while 1/26 patients in group B was treated with a MIVAT (3,8%).Unintentional parathyroidectomies can occur with experienced surgeons, but this complication is not related to a substantial difference in the incidence of hypocalcemia. MIVAT can helps the endocrine surgeon in the detection of the parathyroids glands, but when the parathyroid is intracapsular, is difficult to preserve it, during surgical dissection.

The main objective is to prospectively evaluate the therapeutic efficacy of minilaparocholecystectomy combined with videolaparoscopic view in cases of complicated gallstones where VLC was risky.We carried out minilaparotomic video-aided cholecystectomy on 110 patients (32 males and 78 females) with preoperative diagnosis of intraabdominal adhesions or biliary severe inflammation.No significant intra or postoperative complications was reported and in all cases pain was never greater than that reported after VLC. In all these cases the anesthetists reported an easier intra-operative management of the vital parameters than with VLC procedures.Minilaparocholecystectomy appears a type of alternative procedure able to combine mini-invasiveness with as low a number as possible of intra- and post-operative complications, in cases where VLC have risk. No significant postoperative pain was reported, and in any case pain was never greater than that reported after VLC. Recovery times were similar to those after VLC; patients were able to return to their normal social and working life within a mean 3 days. The procedure carried out by us is a low-cost one: it does not require disposable instruments From the esthetic viewpoint, video-aided minicholecystectomy minimal scars in our cases, wound ranged from 4 to 6 cm. in length.In patients in whom VLC have risks, video-aided minilaparocholecystectomy represents an easy-to-perform and low-cost alternative. VMC can also be proposed as a procedure of choice in cases of complicated gallstones instead of the traditional open cholecystectomy technique.

Il saggio tratteggia i caratteri dell'esperienza letteraria di Lorenzo Viani, considerata attraverso gli anni di più intensa collaborazione al Corriere della Sera tra il 1928 e il 1936.