Combined pancreatojejunal and hepatojejunal anastomotic stent placement in total laparoscopic pancreaticoduodenectomy.

INTRODUCTION: Laparoscopic pancreaticoduodenectomy (LPD) is a technically demanding procedure that is considered safe and feasible if performed in a high-volume institution, where surgeons and medical staff is appropriately trained. For this advanced abdominal procedure only few studies described a reproducible stepwise technique and a standard approach is still lacking. METHODS: The attached video reports all steps of our standardized LPD with pancreatojejunal and hepatojejunal anastomotic stent placement performed with a double approach. The laparoscopic demolitive phase, exactly as the laparotomic one, begins with the surgeon placed on the patient's right side, while for the reconstructive one he moves between the patient's legs. The main characteristic of this technique is an easy realization of the end-to-side biliary anastomosis with a Kehr's "T" tube segment placement as internal biliary stent. This easy technical tip can facilitate the anastomosis realization that remains the most challenging step of this laparoscopic technique, especially in case of small common bile duct. RESULTS: We consider that our standardized technique can be safely performed and it can facilitate the anastomosis execution, especially the hepatic-jejunal. DISCUSSION: Despite our reproducible stepwise technique could help to minimize the learning curve for LPD, further randomized controlled trials are needed to validate the superiority of minimally invasive approach.

Impact of the Italian Society of Anatomic Pathology and Diagnostic Cytology Classification of Thyroid Nodules in the Treatment of Indeterminate Follicular Lesions: Five-Year Results at a Single Center.

PURPOSE: Aim of the study was to assess the impact of the Italian Society of Anatomic Pathology and Diagnostic Cytology (SIAPEC) classification of 2014, on the treatment of indeterminate thyroid lesions (TIR3). METHODS: We retrospectively analyzed patients undergoing thyroid surgery for TIR3 lesions between 2013 and 2018, at the General Surgery Department of Trieste University Hospital. According to the SIAPEC classification, patients were divided into TIR3A and TIR3B groups. All patients treated before 2014 underwent surgical treatment, and surgical specimens were retrospectively classified after revision of fine-needle aspiration cytology. Starting 2014, TIR3A patients were treated only when symptomatic (i.e., coexistent bilateral thyroid goiter or growing TIR3A nodules), whereas TIR3B patients always received surgical treatment. Hemithyroidectomy (HT) was the procedure of choice. Total thyroidectomy (TT) was performed in case of concurrent bilateral goiter, autoimmune thyroid disease, and/or presence of BRAF and/or RAS mutation. Lastly, we analyzed the malignancy rate in the two groups. RESULTS: 29 TIR3A and 90 TIR3B patients were included in the study. HT was performed in 10 TIR3A patients and 37 TIR3B patients, respectively, with need for reoperation in 4 TIR3B (10.8%) patients due to histological findings of follicular thyroid carcinoma >1 cm. The malignancy rates were 17.2% in TIR3A and 31.1% in TIR3B, (p = 0.16). Predictability of malignancy was almost 89% in BRAF mutation and just 47% in RAS mutation. CONCLUSIONS: The new SIAPEC classification in association with biomolecular markers has improved diagnostic accuracy, patient selection, and clinical management of TIR3 lesions.