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Background: the case of an oldest-old woman with severe hypercalcemia and hyperparathyroidism due to left parathyroid adenoma. Case presentation: An 85-year-old woman, hospitalized for rapid loss of functional abilities, mental confusion, worsening of depression, anorexia and incontinence. In the medical history, she had depression, hypertension, osteopenia and osteoarthritis. Blood examinations showed high levels of calcium and intact parathyroid hormone (PTHi), severe renal failure with hyperphosphoremia. After hydration and loop diuretic administration, renal function improved and pamidronate and calcimimetic treatments were followed by reduction of calcium levels. The ultrasound of neck identified a possible parathyroid adenoma; 99Tc-sestamibi scintigraphy and CT scan with contrast confirmed the diagnosis. The surgical left hemithyroidectomy was the treatment of choice and the PTHi and calcium reached normal circulating levels immediately post-surgery. At the 3-month clinical follow-up from surgery, the functional, psychological and cognitive functions improved substantially, although mood disorder secondary to disability persisted. Conclusions: Hypercalcemia due to primary hyperparathyroidism is a low prevalence condition among older adults. However, we should keep in mind whenever we find ourselves facing a sudden and unjustified physical, psychological and cognitive deterioration in such a clinical condition old and oldest-old persons.

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

Tracheal varices are a rare condition but they can be an important source of massive or recurrent haemoptysis. Usually they are related to increased pressure in the pulmonary veins. Mediastinal goiter is often associated to compressive effects on the surrounding structures, including mediastinal vessels with potential superior vena cava syndrome.We describe a case, not previously reported in literature, of mediastinal goiter with hemoptysis as first clinical manifestation. Bleeding was attributed to a superior vena cava syndrome associated to a tracheal fragile mucosa with an easily bleeding intramural nodule which was diagnosed as tracheal varices after total thyroidectomy. The nodule in fact disappeared together with the venous hypertensive signs after venous decompression of the mediastinum.Compressive symptoms including tracheal varices, related to mediastinal goiter, can be treated surgically by total thyroidectomy via cervicotomy and when required with associated median sternotomy.

BACKGROUND: In recent years it has seen an increase of incidental thyroid carcinomas (ICs), most of the ICs are any microcarcinoma (MC). The term refers to a CT, predominantly papillary, and smaller than or equal to 1 cm. The MC is characterized by a papillary heterogeneous clinical behavior ranging from small outbreak discovered accidentally after surgery than the cancer that manifests clinically with lymph node metastases in the neck or rarely systemic. METHODS: From January 2007 to June 2009, 1507 patients for benign disease were subjected to surgery. RESULTS: Histological examination confirmed the diagnosis of benignity in 1339 cases. In 168, however, we detected unexpected, incidental carcinoma (CI). In patients with CI receiving total surgery (TT), the next iteration we agree with the endocrinologist. In cases of lobectomia, was run TT and was heading endocrinology. Of the 168 patients with incidental CT, 147 had papillary carcinomas, 12 follicular carcinomas, 5 follicular variant papillary carcinomas, 2 oncocytic carcinomas, 1 uncertain malignancy. CONCLUSION: In our study has highlighted the lack of data (medical history, ultrasound, scintigraphic), they may portend the presence of a tumor in the specimen CI. In all patients with CI, the surgical indication was given for symptomatic disease, for impairment of thyroid function, for failure to respond to medical therapy or unable to continue. The IC is almost always a microcarcinoma, predominantly papillary, and smaller than or equal to 1 cm, has little biological aggressiveness and is susceptible to metabolic radioiodine therapy. On the basis of these data we feel reasonably acceptable to a close follow-up endocrine surgery, particularly in patients with multinodular disease and stress the need for a multi-specialized team. Background. In recent years it has seen an increase of incidental thyroid carcinomas (ICs), most of the ICs are any microcarcinoma (MC). The term refers to a CT, predominantly papillary, and smaller than or equal to 1 cm. The MC is characterized by a papillary heterogeneous clinical behavior ranging fromsmall outbreak discovered accidentally after surgery than the cancer that manifests clinically with lymph node metastases in the neck or rarely systemic.Methods. From January 2007 to June 2009, 1507patients for benign disease were subjected to surgery. Results. Histological examination confirmed the diagnosis of benignity in 1339 cases. In 168, however, we detected unexpected, incidental carcinoma (CI). In patientswith CI receiving total surgery (TT), the next iteration we agree with the endocrinologist. In cases of lobectomia, was run TT and was heading endocrinology. Of the 168 patients with incidental CT, 147 had papillary carcinomas, 12 follicular carcinomas, 5 follicular variant papillary carcinomas, 2 oncocytic carcinomas, 1 uncertain malignancy. Conclusion. In our study has highlighted the lack of data (medical history, ultrasound, scintigraphic), they may portend the presence of a tumor in the specimen CI. In all patients with CI, the surgical indication was given for symptomatic disease, for impairment of thyroid function, for failure to respond tomedical therapy or unable to continue. The IC is almost always a microcarcinoma, predominantly papillary, and smaller than or equal to 1 cm, has little biological aggressiveness and is susceptible to metabolic radioiodine therapy. On the basis of these data we feel reasonably acceptable to a close follow-up endocrine surgery, particularly in patients with multinodular disease and stress the need for amulti-specialized team.

Differentiated thyroid cancer had an excellent prognosis; the diagnosis of sub-centimetric differentiated cancer (microcarcinoma) is more and more frequently. Clinical evolution of microcarcinoma could be various: microcarcinoma can represent an autoptic finding or can evolve with locoregional lymph node involvement or metastasis. Various clinical and genetic factors have been considered to predict the aggressiveness of this neoplasm. From 2001 to 2004, 74 patients with diagnosis of thyroid microcarcinoma underwent surgical treatment. By a retrospective survey we evaluated risk factors and the choice of surgical treatment. The aggressiveness appear to be related mainly to multifocality and size. Our therapeutic strategy is to perform total thyroidectomy for benign pathologies, total thyroidectomy with lymphadenectomy in cases with preoperative diagnosis of microcarcinoma. Differentiated thyroid cancer had an excellent prognosis; the diagnosis of sub-centimetric differentiated cancer (microcarcinoma) is more and more frequently. Clinical evolution of microcarcinoma could be various: microcarcinoma can represent an autoptic finding or can evolve with locoregional lymph node involvement or metastasis. Various clinical and genetic factors have been considered to predict the aggressiveness of this neoplasm. From 2001 to 2004, 74 patients with diagnosis of thyroid microcarcinoma underwent surgical treatment. By a retrospective survey we evaluated risk factors and the choice of surgical treatment. The aggressiveness appear to be related mainly to multifocality and size. Our therapeutic strategy is to perform total thyroidectomy for benign pathologies, total thyroidectomy with lymphadenectomy in cases with preoperative diagnosis of microcarcinoma.

Massive campaigns of screening of breast pathologies improved early diagnosis of breast cancers. Most of these cancers are small-sized (T1) and seldom show intraoperative nodal involvement. Sentinel node biopsy is the elective choice in the above mentioned cases because, if negative, it avoids axillary dissection. International literature reports rates of false negative sentinel node biopsy ranging among 4.5 and 12%; results in our experience account for almost 6%. As a consequence, there is the definite risk of potentially positive axilla that will not be dissected with subsequent risk of axillary recurrence within 24 months. The reason of that could be related to the fact that in Referral Centers this technique is performed in strictly selected patients, so as to gain a diagnostic accuracy of 98%. The rate of axillary recurrences does not justify the routine axillary dissection, since this is just a staging, not a therapeutic procedure. In case of doubt, it can be recommended a close and careful follow-up of the axilla.

INTRODUCTION: At present we are still debating on which is the most adequate therapeutic strategy concerning the size of the thyroidectomy and the extension of the lymphectomy in differentiated thyroid tumors. PATIENTS AND METHODS: From January 2000 to December 2005, 334 operations for thyroid neoplasms have been performed; 304 (91%) for differentiated tumors. In 124 cases (37%) the latero-cervical and/or the central compartment lymphectomy have been associated with thyroidectomy: 79 monolateral and central compartment lymphectomies (ML and CCL) (64%), 11 bilateral and central compartment lymphectomies (BL and CCL) (8%), and 34 central compartment lymphectomies (CCL) (28%) have been performed. RESULTS: Out of the 124 lymphectomies, in 44 cases (35.5%) we found the presence of metastasis in the lymph nodes of latero-cervical and central compartments, in 10 cases (8%) absence of metastasis in the lymph nodes of the latero-cervical and central compartments, in 25 cases (20%) presence of metastasis in the latero-cervical lymph nodes and absence of metastasis in the lymph nodes of the central compartment. In 11 cases of bilateral and central compartment lymphectomies, 5 of them (4%) had positive lymph nodes of the latero-cervical and central compartments, while the other, only 6 (5%), had positive latero-cervical lymph nodes on the same side as the neoplasia. In 34 central compartment lymphectomies there was absence of metastasis. Mortality rate was zero. There was one case (0.8%) of recurrent laryngeal nerve temporary bilateral palsy (RTBP); 4 cases (3.2%) of recurrent temporary monolateral palsy (RTMP); 2 cases (1.6%) of definitive monolateral palsy (DMP); 29 cases (23.5%) of temporary hypoparathyroidism (TH); 7 cases (5.5%) of definitive hypoparathyroidism (DH). CONCLUSIONS: Latero-cervical lymphectomy should be performed by necessity when clinical tests or pre-diagnostic exams show suspect lymph nodes, whereas central compartment lymphectomy should be performed in any case of thyroid neoplasia.

Male breast cancer is an uncommon disease and its aetiology, clinical behaviour and treatment is not well-known . Retrospective studies show that age and stage-matched breast cancer in men and women are compared. Nevertheless, the poor mammary tissue in man allow a rapid local infiltration, late diagnosis and poor survival rate. The Authors report their five years experience and with a short literature review they summarise what is currently known about this uncommon neoplasm in terms of prognostic factors, therapy and survival.

Interstitial lasertherapy (ILT) is one of the percutaneous thermal procedures allowing the ablation of primary or secondary hepatic lesions. This technique can be performed without general anaesthesia, since the patient is completely painless, in spite of the high temperatures reached, because there are no sensitive fibers around the lesion. This study includes patients with small hepatocarcinomas (< 2 cm) non peripherically sited, far from the gallbladder and the hepatic hilum. Twenty patients suffering from 24 cirrhotic hepatocarcinomas (two patients showed two nodules) have been enrolled for the present study. Mean diameter of lesions was 1.8 cm (1.3-2 cm). One or more 21 G (length 20 cm) Chiba's needles were inserted under sonographic view into the lesions. The laser energy was switched on at 4 Watts for 4-6 minutes, until an amount of energy of 900-1800 Joule was reached. All the patients were discharged 48 hours after the procedure. Triphasic CT-scan with contrast were performed 7 to 14 days after ILT, in order to check its efficacy. CT-scan showed complete necrosis in all the nodules ranging from 1.5 to 3 cm. All the patients received only one IL T session, whose longest duration was 20 minutes. No major complications occurred. ILT of small hepatocarcinomas is a safe, efficient procedure, also feasible without anaesthesia. Differently from percutaneous radiofrequency, in fact, it shows the advantage of less pain, that can avoid the need for general anaesthesia. Interstitial lasertherapy (ILT) is one of the percutaneous thermal procedures allowing the ablation of primary or secondary hepatic lesions. This technique can be performed without general anaesthesia, since the patient is completely painless, in spite of the high temperatures reached, because there are no sensitive fibers around the lesion. This study includes patients with small hepatocarcinomas (< 2 cm) non peripherically sited, far from the gallbladder and the hepatic hilum. Twenty patients suffering from 24 cirrhotic hepatocarcinomas (two patients showed two nodules) have been enrolled for the present study. Mean diameter of lesions was 1.8 cm (1.3-2 cm). One or more 21 G (length 20 cm) Chiba's needles were inserted under sonographic view into the lesions. The laser energy was switched on at 4 Watts for 4-6 minutes, until an amount of energy of 900-1800 Joule was reached. All the patients were discharged 48 hours after the procedure. Triphasic CT-scan with contrast were performed 7 to 14 days after ILT, in order to check its efficacy. CT-scan showed complete necrosis in all the nodules ranging from 1.5 to 3 cm. All the patients received only one IL T session, whose longest duration was 20 minutes. No major complications occurred. ILT of small hepatocarcinomas is a safe, efficient procedure, also feasible without anaesthesia. Differently from percutaneous radiofrequency, in fact, it shows the advantage of less pain, that can avoid the need for general anaesthesia.

Laparoscopic cholecystectomy (LC) is associated with an higher incidence of bile duct injury than open cholecystectomy. There has been concern and the reason why bile leakages are more frequent with LC is yet unclear. Bile collections can occurr because of major about (75%) or minor (about 25%) injuries. Anyway, external biliary decompression is a key factor in the treatment, in order to avoid an emergency intervention. The Authors report their experience concerning 3 cases of bile leakages among a series of 458 LC. Only in one of the three cases the subhepatic space was not drained and an emergency laparotomy was performed. The Authors, on the basis of their own experience and of the data reported in literature, suggest the routinary intraoperative placement of a drainage into the subhepatic space, to be removed, if no complications occur, one day after surgery. Laparoscopic cholecystectomy (LC) is associated with an higher incidence of bile duct injury than open cholecystectomy. There has been concern and the reason why bile leakages are more frequent with LC is yet unclear. Bile collections can occurr because of major about (75%) or minor (about 25%) injuries. Anyway, external biliary decompression is a key factor in the treatment, in order to avoid an emergency intervention. The Authors report their experience concerning 3 cases of bile leakages among a series of 458 LC. Only in one of the three cases the subhepatic space was not drained and an emergency laparotomy was performed. The Authors, on the basis of their own experience and of the data reported in literature, suggest the routinary intraoperative placement of a drainage into the subhepatic space, to be removed, if no complications occur, one day after surgery.

Hypocalcemia is one of the most frequent complications after total extracapsular thyroidectomy (TET). In most of cases it is a transient phenomenon. The aim of this study is to evaluate if and how the oral administration of calcium or calcium combined with D-vitamin could effectively prevent post-thyroidectomy hypocalcemia. A randomized prospective study was performed, recruiting 120 patients who underwent total thyroidectomy. The patients in our series were randomly assigned to one of two groups: group A--patients who received calcium lactogluconate/calcium carbonate (mg 300 per day); group B--patients who received calcium carbonate/cholecalciferol therapy (calcium carbonate: 1500 mg per day; cholecalciferol 400 UI per day). The groups were well matched for age, sex and pathologies. Patients of both A and B groups were divided in two subgroups: those operated on for benign thyroid diseases (A1 and B1) and those operated on for malignancy (A2, B2). Serum calcium assays, performed 24, 48 and 72 hours after surgery, showed mean values of calcemia higher in patients of the B1 and B2 group. Statistical analysis was performed using a Student's t test. Mean serum calcium concentrations on post-operative day one, two and three were higher in patients of the group B (p<

BACKGROUND: Intra Operative Nerve Monitoring (IONM) has been used in head and neck surgery since the 1970s. Its utilization for monitoring and protecting the recurrent laryngeal nerve, however, is a controversial subject. This paper details the use, value, and cost of this technology within a single institution. METHODS: We conducted a retrospective chart review, analysis of surgery time with and without IONM, analysis of postoperative vocal cord function, and review of the literature RESULTS: IONM did not reduce the operative time during total thyroidectomies in our experience. Use of IONM increased the cost of each surgery by € 450. IONM did not decrease the number of injured nerves (postoperative paresis). CONCLUSIONS: IONM has proven to be highly useful in certain circumstances but has not been definitively proven to protect the nerve any more effectively than the gold standard of nerve visualization. In our study, the use of IONM did not reduce the time of thyroid surgery and did increase the cost. While IONM may, in special clinical circumstances such as revision and malignant thyroid surgery, increase the value of the operation, its use for every thyroid surgery does not appear to be cost effective or valuable to the patient.

Phyllodes tumors are biphasic fibroepithelial neoplasms of the breast. While the surgical management of these relatively uncommon tumors has been addressed in the literature, few reports have commented on the surgical approach to tumors greater than ten centimeters in diameter - the giant phyllodes tumor.We report a case of a 45-year-old woman who presented with a large lump in her right breast, involvement of multiple ipsilateral axillary lymph nodes and pectoralis major muscle. Clinical findings and cytologic examination (fine-needle aspiration) were suggestive of cystosarcoma phyllodes and we discuss the techniques utilized for pre-operative diagnosis, tumor removal, and breast reconstruction. A review of the literature on the surgical management of phyllodes tumors was performed.Management of the phyllodes tumor presents the surgeon with unique challenges. The majority of these tumors can be managed by simple mastectomy. In our case clinical findings and cytologic examination (fine-needle aspiration) were suggestive of cystosarcoma phyllodes, for which the patient underwent a modified radical mastectomy. Postoperative radio therapy was given to the loco regional area.Immediate reconstruction, Phylloides tumors, Post-operative radio therapy, Radical surgery.

The incidence and possible association of inferior laryngeal nerve and sympathetic anastomotic branch anomalies were evaluated in this study. Non-recurrent inferior laryngeal nerves stem from vascular anomalies involving the right subclavian artery and aortic arches during embryological development. These anomalies usually have no functional consequences (except for occasional dysphagia), but are potentially dangerous during thyroid surgery, occurring in about 1% of cases. Sympathetic-inferior laryngeal anastomotic branches are described in about 1.5% of cases, and may be confused with non-recurrent inferior laryngeal nerves. 1473 patients submitted to total thyroidectomy for benign disease over the period 2001-2006 were evaluated. Four non-recurrent inferior laryngeal nerves (incidence: 0.27%) and 11 sympathetic-inferior laryingeal anastomotic branches (incidence: 0.74%) were observed. Out of a total of 25 definitive inferior laryngeal nerve lesions, 1 occurred in a case of non-recurrent inferior laryngeal nerve. Awareness of the anatomical anomalies described and accurate surgical technique, including a constant search for the inferior laryngeal nerve, are the requirements for identification of non-recurrent inferior laryngeal nerves and sympathetic-inferior laryngeal anastomotic branches. During the pre-operative workup, ultrasonographic study of the right subclavian artery may be advisable in order to rule out alterations of its origin and course.