Impact of lymph node ratio in the colorectal cancer staging system.

AIM: Some researchers have proposed the Lymph Node Ratio (LNR) as a prognostic index for post-surgical colorectal cancer follow up. MATERIAL AND METHOD: Two hundred patients with colorectal cancer (ratio F/M of 2:1) were studied. Patients were divided in subgroups according to N-stage and LNR score, subgroups of LNR were made on quartiles. For each subgroup 5 year survival rate was calculated and comparison between groups was carried out. RESULTS: There were 104 patients on N0, 38 on N1 and 58 on N2 stage. Survival rate at 5 years was 61.30% for the NO subgroup, 18.70% for the N1 subgroup, and 12.31% for the N2 subgroup (Fig. 1). The most significant p value, was reported between N0 and N1 as well as between N0 and N2 subgroup (p=0.001). Nodes positive were 44 a LNR ranging from 1% to 25% (1% < LNR < 25%); 24 patients from 26% to 50% (26% < LNR < 50%). In 6 patients LNR was ranging from 51% to 75% (51% < LNR 75%) and in 8 patients from 76% to 100% (76% < LNR 100%); overall survival rate in different quartiles was respectively 27.12%, 9.38%, 16.67% and 1.56%. CONCLUSION: LNR is a reliable prognostic index in post surgical colorectal cancer staging.

Diabetic mastopathy: case report.

UNLABELLED: Diabetic mastopathy is a rare fibro-inflammatory breast disease, which occurs in premenopausal women affected by longstanding type I insulin-dependent diabetes. It is a benign disease and it is often misunderstood for its clinical and radiological features that may mimic a breast cancer. The diagnosis of diabetic mastopathy is based on histological examination and it is characterized by lymphocytic lobulitis with glandular atrophy and perivascular lymphocytic infiltration. The patients do not need to undergo surgery but it is necessary to plan an adequate clinical and radiological monitoring program. KEY WORDS: Diabetic mastopathy, Diagnostic and therapeutic features.

Transcervical video-assisted thymectomy: preliminary results of a modified surgical approach.

PURPOSE: A number of surgical approaches have been reported for thymectomy, including transsternal, transcervical, a combination of complete transsternal and transcervical, and various video-assisted thoracoscopic surgery techniques. A modified video-assisted transcervical approach to thymectomy is here described. METHODS: A video-assisted total thymectomy was performed through a 30-mm cervical incision. No hyperextension of the patient's neck or sternal retractor was used. The surgical instruments utilized for the resection were the ones created for the minimally invasive video-assisted thyroidectomy. RESULTS: Five patients have been operated on so far. The encapsulated gland was removed without any difficulties. No complications occurred. No pain relief was administered after the first 24 h. The patients were discharged within the first two postoperative days. An improvement in clinical symptoms was registered in all patients. CONCLUSIONS: An advantage of this minimally invasive video-assisted transcervical approach to thymectomy is that the entire operation can be performed without neck hyperextension or permanent sternum elevation. Moreover, the surgical instruments created for minimally invasive video-assisted thyroidectomy enabled us to be very precise and to complete the resection without any postoperative morbidity.

Can we define a role for perisentinel lymph-nodes on breast cancer disease?

BACKGROUND: The development of sentinel lymph node biopsy in breast cancer disease and the increasing of using adjuvant systemic therapy provide a rational reduction of axillary dissection in patients with Sentinel Lymph Nodes free from breast cancer cells. The aim of our study was to assess the state of the perisentinel lymph nodes removed and how these nodes can provide further information about the status of the axillary lymph nodes. MATERIALS AND METHODS: We have analysed data about 319 patients undergoing surgery for benign and malignant breast disease from January 2007 to July 2010; 134 cases were subjected to the sentinel lymph node biopsy; 29 cases of these patients had the presence of perisentinel lymph nodes at histological examination. Before the intervention, we have used colloidal albumin marked with 99mtc to select the sentinel lymph node; during the intervention, we identified by probe the ipercaptant lymph node, consequently we removed and sent it to histological extemporaneous definitive examination. RESULTS: In 134 Sentinel Lymph Nodes examined, 15 resulted positive for breast cancer cells at extemporaneous examination. In these cases, we decided to proceed with an axillary dissection in the same operative session, with the discovery of axillary lymph nodes metastases in 3 cases on 15 (20%). The positive predictive value of sentinel lymph node in case of positivity was 0.2. 8 cases (6,7% of the lymph nodes sentinel biopsy made) were negative to extemporaneous examination and positive to definitive histological examination for presence of micrometastasis. In 8 axillary dissection, 3 patients were positive for the presence of metastasis. We have analysed with the test "t-student" these data divided on age and the value of Ki-67. Then we calculated the predictive positive and negative value (patients with negative sentinel lymph node: Mean age (+/- sd) =61.93 +/- 13.8 years, ki-67=10.87 +/- 5.78; patients with positive sentinel lymph node: Age mean (+/- sd) = 64 +/- 12 36 years, ki-67=14.08 +/- 8.005). The study showed no statistically significant differences between the positive and negative sentinel lymphnodes about the age (p=0.58) and the Ki-67 (p=0.184). In the 29 cases in which the sentinel lymph node was negative at extemporaneous histological examination and in which were removed the perisentinel lymph nodes, resulted negative at definitive histological examination, the negative predictive value was equal to 1. CONCLUSIONS: The method of sentinel lymph node has demonstrated to be a reproducible, reliable and safe technique. The positivity of sentinel lymph node at final examination (micrometastasis, cells isolated) in case of extemporaneous examination negative for breast cancer cells, determines specifical considerations on surgical indication to axillary dissection. We think that in selected cases (age, biological characteristic of cancer) in which perisentinel lymph nodes were removed and free from breast cancer cells, may not be indicated in case of sentinel node positivity the axillary dissection.

Choledocholithiasis and endo-laparoscopic rendezvous. Analysis of 59 consecutive cases.

BACKGROUND: Choledocholithiasis is a real problem of major clinical importance. The incidence of cholelithiasis is 10-20%. MATERIALS: We have examined 2907 patients treated with videolaparoscopic cholecystectomy (VLC) between January 2001 and September 2009. 214 cases (7.4%) were affected by choledocolithiasis; among these, 59 consecutive cases were treated by rendezvous, 151 cases by sequential treatment (ERCP-ES before VLC), 3 cases by extraction with Dormia's basket, and 1 case by ERCP-ES after VLC. RESULTS: The complications were one biliary fistula and three hemorrhages (one from the cystic artery, one from the hepatic area and one from trocar's site). The mean hospital stay was 1.38 +/- 0.83 days for the rendezvous group vs 4 53 +/- 0.74 days in the sequential treatment group (p<0.004). The satisfaction scores were 6.6 +/- 1.39 versus 5.7 +/- 0.96 (p<0.004). CONCLUSIONS: The rendezvous procedure reduces hospital stay and has a greater compliance (only one treatment). We can use this option in the management of cases where preoperative ERCP-ES has failed.

Is CD10 a reliable marker of invasive colorectal cancer?

AIM: Previous studies reported that CD10 positive Colorectal Cancer Cells (CRC) characterized by deeply invasive neoplasia. MATERIALS AND METHODS: We have examined 50 pts surgically treated for colorectal cancer on at least 5 years follow up. TNM, grading score and survival have been compared to CD10 expression. RESULTS: Thirty-four out of fifty cases have been analyzed (18 males and 16 female) of whom nineteen were CD10 positive and fifteen were CD10 negative. The remaining 16 cases were droping out. No difference in survival rate between CD10 positive and negative in N0, N1, N2. No difference on survival rate and grading 1, 2, 3. We have then analyzed CD10 positive and CD10 negative cases, according to neoplasia grading, in patients with positive linphonodes N1 and N2. We showed a statistical difference between the CD10 positive/N2 (grading 1.66 +/- 0.5) and the CD10 negative/N2 (grading 3) (p < 0.005). CONCLUSIONS: We can hypothesize that CD10 positive neoplasia display a more invasive behaviour, independently from the N score and the G score, compared to CD10 negative neoplasia.

[Kidney transplantation from an ABO-incompatible living donor]. / Il trapianto di rene da donatore vivente ABO-incompatibile.

Living donor kidney transplantation is the preferred therapeutic option for patients with end stage renal disease because it provides a superior immunological compatibility, it lessens the preservation-mediated graft injury and it shortens waiting time on dialysis. Unfortunately, about 30-35% of potential living kidney donors are rejected because of incompatible immunological barriers such as ABO-incompatibility or a positive crossmatch. The newest desensitization protocols based on both therapeutic apheresis and perioperative immunosuppressive drugs allowed to overcome antibodies barriers. The aim of those protocols is to wash-out and suppress as much anti-A or anti-B antibodies as possible and to prevent the rebound phenomena after transplantation. Standard plasmapheresis, double-filtration plasmapheresis and selective immunoadsorption are among the most common apheretic modalities applied in ABO-incompatible transplantation. Furthermore, selective immunoadsorption appears to be much safer and to have markedly increased efficacy comparing with plasmapheresis being able to eliminate almost exclusively blood-group antibodies avoiding plasma and coagulation abnormalities. According to literature, long-term patient and graft survival rates are similar to those achieved by ABO-compatible kidney transplants. The comparable outcome seems related to more effective desensitization protocols as well as the protective immune mechanisms of "accommodation". We have been using selective immunoadsorption in the two ABO-incompatible kidney transplants performed in our institution. No acute rejection was experienced at 6 and 26 month follow-up and both grafts are functioning well. Despite the ABO-incompatible kidney transplant widespread use, the best desensitization protocol, the upper baseline and perioperative isoagglutinin titer limit and the most accurate isoagglutinin measurement assay are still to define.

MRI and correlation between TNM and CEA, CA19.9, AFP in rectal cancer Experience of a single academic surgical center.

In our study we examined 75 patients treated for rectal cancer in the period between 01/01/2011 and 31/12/2014. Out of these 75 patients, we considered those 36 staged through MRI. We then compared the TNM stage obtained through MRI with the one emerged from histological examination. The correlation between the two TNM stages was assessed considering all patients staged through MRI and dividing the cases according to the submission or not to a neoadjuvant treatment. Finally, we analyzed serum levels of tumor markers CEA, CA 19.9 and AFP, relating them with the final disease stage. Data analysis showed a statistically significant correlation in the T stages, especially in the population not subjected to neoadjuvant treatment. Instead, for N, we found no statistically significant correlation. Similarly, none of the tumor markers presented a statistically significant correlation with disease stage. However, according to the positivity of tumor markers, we associated the following score: 0, (no positive marker)1 (only one marker positive) 2 (two markers positive) 3 (three markers positive). In presence of three markers positive, meaning the highest score, we found a statistically significant correlation with N + staging of the disease, obtained by postoperative pathologic examination. The conclusion is that MRI is certainly effective in T stage evaluation. Probably, for limph node involvement evaluation, more reliable parameters for establishing possible lymph node malignancy need to be found. The role of the tumor markers CEA, CA 19.9, AFP during preoperative evaluation of rectal tumors remains undefined. KEY WORDS: MRI, Rectal cancer, Tumor markes, Tumor regression, T stage.

Connections between genetics and clinical data: Role of MCP-1, CFTR, and SPINK-1 in the setting of acute, acute recurrent, and chronic pancreatitis.

OBJECTIVES: Acute, acute recurrent, and chronic pancreatitis are inflammatory diseases with multifactorial pathogenic mechanisms. Genetic mutations and polymorphisms have been correlated with pancreatitis. The aim of this study was to investigate the association of cystic fibrosis transmembrane conductance regulator (CFTR) and serine protease inhibitor Kazal type 1 (SPINK-1) gene mutations and monocyte chemoattractant protein 1 (MCP-1) -2518A/G polymorphism with acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic pancreatitis (CP), and to associate genetic backgrounds with clinical phenotype in these three conditions. METHODS: One hundred eighteen AP, 64 ARP, 142 CP patients, and 88 normal controls were enrolled consecutively. We analyzed MCP-1 serum levels using enzyme-linked immunosorbent assay. Polymorphism -2518 of MCP-1 and SPINK-1 N34S gene mutations were determined by PCR-restriction-fragment length polymorphism. Sequence analysis was performed when necessary. Thirty-three CFTR mutations were analyzed in CP and ARP patients using multiplex DNA testing. RESULTS: Serum MCP-1 levels were significantly higher in all patients affected by pancreatic inflammatory diseases. Moreover, we found a significant over-representation of the MCP-1G allele in ARP patients. We found a statistically significant association of CFTR gene mutations with ARP, but not with CP. We did not find a statistically significant association of ARP or CP with the N34S SPINK-1 gene mutation. Interestingly, 39 of 64 ARP patients (61%) carried at least one genetic mutation and/or polymorphism. Five of 64 ARP patients had pancreas divisum and four of these five also carried the G allele. CONCLUSIONS: Analysis of a comprehensive range of potential susceptibility variants is needed to support modeling of the effects of genes and environment in pancreatitis. As such, beyond gene mutations, the context within which those mutations exist must be considered. In pancreatitis the context includes the inflammatory response, clinical features, and exogenous factors.

Minimally invasive video-assisted thyroidectomy (MIVAT): what is the real advantage?

BACKGROUND: The evolution of video-assisted or laparoscopic surgical techniques in the last several years has changed the surgical treatment approach to many diseases, also in endocrine surgery. MATERIALS AND METHODS: From July 2005 to March 2009, we treated 211 patients with minimally invasive video-assisted thyroidectomy (MIVAT). The procedure was performed in accordance with Miccoli's technique using an Ultracision CS 14 (Ethicon Endosurgery) and/or Single Use Automatic Clip Applier S-90 (Autosuture). In all cases, we recorded the incidence of postoperative hypocalcaemia as a serum calcium value lower than 8 mg/dl with or without hypocalcaemic symptoms, postoperative haemorrhage or nerve palsy, mean operative time. All patients were also assessed for postoperative pain and given a visual analogue score from 0 to 10 at 1 and 24 h after surgery. We matched these results with a group of 587 patients treated during the same period with traditional thyroidectomy. RESULTS: The female/male ratio was 4:1; the mean age of the patients was 50.6 years. In the MIVAT group, the mean time of surgical procedure decreased by 52.4 min. We observed 16 hypocalcaemic cases with clinical symptoms (7.58%) (six of these cases were published in a previous article and were among the first 100 cases treated) and 59 cases of serologic hypocalcaemia (27.9%) (serum calcium lower than 8 mg/dl); the mean value of calcium concentration was 7.5 +/- 0.27 mg/dl. We observed six cases of monolateral nerve palsy, and after 6 months, a definitive palsy in two cases (0.9%); these two cases were in the first 25 cases treated. Comparisons with traditional thyroidectomy group showed statistically significant differences in postoperative serologic hypocalcaemia (p < 0.001), no difference in mean calcium value (p = 0.41) and no statistical difference in the incidences of nerve palsy and haemorrhage. CONCLUSIONS: Patients treated with MIVAT showed an improvement in incidence of postoperative hypocalcaemia, postoperative pain, postoperative stay, psychophysical recovery and cosmetic result.

Is it possible to identify a risk factor condition of hypocalcemia in patients candidates to thyroidectomy for benign disease?

AIM: Hypocalcaemia is the most frequent complication after total thyroidectomy. The incidence of postoperative hypocalcaemia is reported with different percentages in literature. METHODS: We report 227 patients undergoing surgery for benign thyroid disease. After obtaining patient's informed consent, we collected and analyzed prospectively the following data: calcium serum levels pre and postoperative in the first 24 hours after surgery according to sex, age, duration of surgery, number of parathyroids identified by the surgeon, surgical technique (open and minimally invasive video-assisted thyroidectomy, i.e., MIVAT). We have considered cases treated consecutively from the same two experienced endocrine surgeons. Hypocalcaemia is assumed when the value of serum calcium is below 7.5 mg/dL. RESULTS: Pre-and post-operative mean serum calcium, with confidence intervals at 99% divided by sex, revealed a statistically significant difference in the ANOVA test (p < 0.01) in terms of incidence. Female sex has higher incidence of hypocalcemia. The evaluation of the mean serum calcium in pre-and post-operative period, with confidence intervals at 95%, depending on the number of identified parathyroid glands by surgeon, showed that the result is not correlated with values of postoperative serum calcium. Age and pre-and postoperative serum calcium values with confidence intervals at 99% based on sex of patients, didn't show statistically significant differences. We haven't highlighted a significant difference in postoperative hypocalcemia in patients treated with conventional thyroidectomy versus MIVAT. CONCLUSION: A difference in pre- and postoperative mean serum calcium occurs in all patients surgically treated. The only statistical meaningful risk factor for hypocalcemia has been the female sex.

[A video-aided minilaparocholecystectomy]. / Una tecnica di minilaparocolecistectomia video-assistita.

AIM: 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. MATERIAL OF STUDY: 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. RESULT: 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. DISCUSSION: 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. CONCLUSIONS: 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.

Evaluation of CD10 positivity in colorectal polyps in neoplastic transformation.

BACKGROUND: CD10 is a metalloprotein that is potentially associated with greater tumour growth. MATERIALS AND METHOD: We have correlated CD10 positive in carcinomatous polyps with tumour size, grade, patient age and sex, postoperative TNM staging and Asler-Coller classification. We have matched these cases with a control group that showed presence of polypoid adenomatous tissue with mild to moderate dysplasia. RESULTS: We have divided these in a group of 39 cases, characterised by the presence of carcinoma arising in adenomatous polyps, and a control group of 16 cases, characterised by the presence of colorectal polyps with mild to moderate dysplasia. In the first group, we have discarded three cases for incomplete data. In the remaining 36 cases we have identified 28 patients testing positive for CD10 with positivity values and 8 cases negative for CD10. In CD10 positive cases, we have confirmed the presence of increased incidence of lymph node involvement compared to CD10 negative cases, with high specificity and high predictive value and a higher incidence of cases attributable to group C (Asler-Coller) and grading 3. CONCLUSIONS: CD10 positivity should be assessed in terms of increased progression.

Gastric metastasis from breast carcinoma. Report of three cases, diagnostic-therapeutic critical close examination and literature review.

Gastric metastases of breast cancer represent a not so rare event in patients affected. In fact, it occurs in 0.3% of cases. Although the introduction of new adjuvant therapies has given rise to an increase in disease free survival and overall survival rates, it has also led to more frequent occurrences of breast cancer metastatic lesions localized in bone, lung/pleura and liver, but above all in the stomach. The authors present three cases of patients suffering from breast cancer with secondary gastric neoplastic lesions from lobular and infiltrating ductal breast cancer. Lobular breast cancer is the histological type mostly involved in disseminated disease, with an incidence of 85% of cases. A review of the literature reveals that authors address the clinical and diagnostic problems of differentiating between a breast cancer metastasis to the stomach and a primary gastric cancer using recent diagnostic strategies to make an early diagnosis. Today practitioners have specific tests to detect early gastric cancer metastases of breast cancer such as endoscopic ultrasound, which provides a better endoscopic definition of the lesions, and immunohistochemical markers, able to distinguish the primary lobular histological type from ductal cancer. Besides, an early diagnosis associated with the latest adjuvant systemic therapies and hormonal treatment, alone or in combination, may grant affected patients a remission with a survival rate of 10-28 months, and a reasonable quality of life. At present the surgical approach should be reserved for selected cases and/or complications.

Analysis of risk factors for complications in 262 cases of laparoscopic colectomy.

BACKGROUND: The aim of the study was to critically review the experience of our unit to identify all the risk factors that can predict the intra-operative and post-operative complications, early and late, that are related to the procedure. MATERIALS AND METHODS: We retrospectively reviewed 293 patients who had undergone laparoscopic colectomy at the General Surgery and Organ Transplantation Unit of the University Hospital of Parma between January 2001 and September 2009. Preoperative tumour staging was performed for all patients by pancolonoscopic examination, performed preferably by the operating surgeon, thoracic-abdominal-pelvic CT, and, for rectal neoplasia, with further input from endoscopic ultrasound and/or pelvic magnetic resonance (MR) imaging. The parameters evaluated for each patient included age, sex, body mass index (BMI), ASA score, preoperative blood tests, associated comorbidities, cancer, others surgical procedures, operative time, laparotomy conversion rate, intra- and post-operative complications, any returns to the operating theatre, length of hospital stay and mortality. RESULTS: A total of 293 laparoscopic colectomy procedures were performed in our unit between January 2001 and September 2009; we analysed 262 of the 293 cases treated, since the data were incomplete and not correctly stored for 31 cases. The overall rate of intra- and post-operative complications was 22.9% (60/262). In 40 cases (40/262, 15.26%), the complications were surgical, and in the other 20 cases (7.63%) they were medical; mortality rate of 0.38% (1/262). CONCLUSIONS: Rectal resection is significantly associated with a greater number of intra- and post-operative complications than the other surgical procedures examined. The laparoscopic approach maintains its benefits even in patients with known preoperative comorbidities and constitutes a feasible procedure even in patients who are obese and/or with ASA status > or = III.

Thyroidectomy for differentiated carcinoma in older patients on a short stay basis.

BACKGROUND: Total thyroidectomy is the treatment of choice for thyroid cancer and for selected benign thyroid conditions. The aging of the general population and the improvements in surgical technique induced an extension of the surgical indications to major thyroid surgery to older patients also on a short stay basis. METHODS: From January 2004 to December 2006, 152 patients affected by thyroid carcinoma underwent total thyroidectomy on a short stay basis. We divided our series in 2 groups of patients according to the age (> or < of 65 yrs) and considered the outcome analysing several factors including: ASA score, mean operative time, mean hospital stay, tumour size, and post-operative complications. RESULTS: The groups consisted of: 115 pts with a mean age of 46.81 +/- 11.63 years and 37 pts with a mean age of 74.53 +/- 3.71 years for the younger and older group respectively. The differences in ASA score and hospital stay were statistically significant between the groups (P < 0.007 and P < 0.004); neither postoperative haemorrage nor permanent hypocalcemia was observed. One permanent paralysis of the recurrent laryngeal nerve was noted at 12 months follow up; transient hypocalcemia, which resolved in all cases within 30 days from surgery, was reported in 23 and in 7 patients in the younger and older group respectively. CONCLUSIONS: Although a longer length of stay was noted in the older group and possibly related to a higher ASA score and a worse preoperative airways condition, total thyroidectomy for differentiated thyroid carcinoma may be safely carried out in older patients on a short stay basis if performed by an expert staff and in the setting of a multidisciplinary and exhaustive preoperative assessment.

Defunctioning stoma in high-risk rectal anastomosis.

BACKGROUND: Ileostomy in rectal surgery is not always indicated for protecting the anastomosis. METHODS: We examined patients who underwent low rectal resection surgery for carcinoma between June 2005 and December 2007. We categorized the patient's characteristics according to the American Society of Anesthesiologists (ASA). We estimated hospital stay, and postoperative Dukes stage. RESULTS: 68 patients, 47 males and 21 females (mean age 67.8 years, range 40-85 years) treated with low rectal resection for carcinoma. An ileostomy was performed in 29 out of 68 patients (42.6%). Six postoperative ileostomy cases led to the appearance of peritonitis from anastomotic fistula. Among the patients with ileostomy 19 pts. (65.5%) belonged to ASA II and 10 pts.(34.5%) to ASA III; among those patients without ileostomy, 32 (82.05%) ASA II and 7 (17.95%) ASA III (p = n.s.). Of patients who underwent the first protective surgical procedure, 4 belonged to ASA II (66.6%) and 2 to ASA III (33.3%). The mean hospital stay for the non ileostomy group was 7.64 +/- 0.7 days, while it was 7.36 +/- 0.49 (p = n.s.) for the ileostomy group. The mean stay of postoperative ileostomy for leakage was 10.83 +/- 1.16 days. CONCLUSIONS: Ileostomy cannot completely prevent the onset of leakage, but may reduce overall hospitalization time.

Laparoscopic versus open donor nephrectomy. An appraisal on surgical outcome and post-operative course.

INTRODUCTION: Laparoscopic living donor nephrectomy (LLDN) is supposed to be safe and effective and it ensures an excellent allograft function in the recipient. The use of laparoscopic technique is rapidly spreading in most transplant programs since it offers advantages over the open procedure. Aim of our study is to evaluate both surgical outcome and post-operative course in the LLDN group comparing with an historical series of open donor nephrectomies (ODN). MATERIALS AND METHODS: From January 1992 to August 2008, 37 living donor nephrectomies were performed in our center. 23 nephrectomies were carried out, laparoscopically and 14 by open technique. Donors characteristics were comparable in both groups. RESULTS: All laparoscopic nephrectomies were performed successfully without conversion. No significant differences were observed between the two groups for both surgical complication and graft and patient survival rates. Mean warm ischemia time (p < 0.04), resumption of oral intake (p < 0.03) and length of hospital stay (p < 0.0001) were shorter in the LLDN group. Mean operative time (p < 0.036) was longer in the LLDN group, whereas time to return to work and daily activities were similar (p < 0.52). CONCLUSION: Laparoscopic nephrectomy provides some post-operative advantages over the open technique without additional surgical risk ensuring comparable graft and patient outcomes. Therefore, LLDN has become the standard approach in our transplant center. However, the laparoscopic procedure should be performed only by experienced surgical staff in order to prevent serious complications in the donors.

Association between primary hyperparathyroidism and thyroid disease. Role of preoperative PTH.

BACKGROUND: The association between patients with surgically treatable thyroid disease and patients affected by PHPT is not just accidental. MATERIALS: We report 591 patients who underwent total thyroidectomy in our center. Data, collected during the preoperative period according to our protocol for candidates to total thyroidectomy, included: type of thyroid disease, sex, age, type of surgical procedure, preoperative PTH and plasmatic calcium level. Calcium plasmatic level has been monitored at 24 hours after surgery on day 6 and monthly for 6 months. RESULTS: On 591 cases, PTH above the normal range were present in 19.1% (113 patients), all asymptomatic for PHPT 30 were males (26.6%) and 83 females (73.4%), with a mean age of 62.97 +/- 12.51 years and 57.38 +/- 15.09 years ( p = 0.19). The mean preoperative PTH and calcium plasmatic level were 104.4 +/- 21.96 pg/ml and 119.7 +/- 37.93 pg/ml (p = 0.39) and 9.21 +/- 0.59 mg/dL e 9.37 +/- 0.87 mg/dl (p = 0.45) respectively. Intraoperative exploration proved a pathological parathyroid gland in 12 on 113 cases. In 9 of the 12 patients with parathyroid adenoma, hypocalcaemia developed. It resolved in 7 days for 4 patients and within 30 days for the others. No hypocalcaemia has been recorded at a 6 months follow up for the 97 considered (4 were lost at follow up). CONCLUSION: Preoperative PTH measurement for all patients undergoing total thyroidectomy may offer a concrete tool to screen and identify the above-described category of patients, with no additional cost for further radiological investigations, because this class of patients will be submitted to bilateral cervical exploration associated with a total thyroidectomy.

Giant Merkel cell carcinoma of the left arm. Case report.

Merkel cell carcinoma is a rare tumor of dermal origin generally found in sun exposed skin. We report the case of a woman of 76 years old presenting a large vascularized Merkel cell carcinoma (MCC) of the left arm lateral to the elbow joint, infiltrating the muscolo-fascial plane who was treated with surgical therapy and post operative radiotherapy.