Bariatric Surgery for Patients with Overweight/Obesity. A Comprehensive Grading Methodology and Network Metanalysis of Randomized Controlled Trials on Weight Loss Outcomes and Adverse Events.

This study aims to compare different types of metabolic bariatric surgery (MBS) with lifestyle intervention/medical therapy (LSI/MT) for the treatment of overweight/obesity. The present and network meta-analysis (NMA) includes randomized trials. MBS was associated with a reduction of BMI, body weight, and percent weight loss, when compared to LSI/MT, and also with a significant reduction of HbA1c and a higher remission of diabetes. Meta-regression analyses revealed that BMI, a higher proportion of women, and a longer duration of trial were associated with greater effects of MBS. The NMA showed that all surgical procedures included (except greater curvature plication) were associated with a reduction of BMI. MBS is an effective option for the treatment of obesity. The choice of BMI thresholds for eligibility for surgery of patients with different complications should be performed making an evaluation of risks and benefits in each BMI category.

Thyroid nodules with indeterminate cytology: association between nodule size, histopathological characteristics and clinical outcome in differentiated thyroid carcinomas - a multicenter retrospective cohort study on 761 patients.

A great number of surgical diagnostic procedures are performed every year for thyroid nodules that are included in undetermined cytological classes that reveal to be malignant thyroid carcinomas in one-third of cases. In the most recent guidelines, lobectomy is the most recommended surgical approach for this classes of nodules, but total thyroidectomy is the recommended treatment for undetermined nodules larger than 4 cm. The main study aim is to support or question the dimensional criteria as an independent clinical decision element for undetermined thyroid nodules management. We examined data regarding 761 patients undergoing thyroid surgery for undetermined thyroid nodules at two high-volume endocrine surgery units in Italy. Patients were divided into three groups based on the preoperative size of the nodules (N < 1, 1 < N < 4, N > 4 cm). Among the patients belonging to the different groups, we analyzed: differences in malignancy rate, histological characteristics of invasiveness and neoplastic aggressiveness, rates of recurrence and response to therapy. Nodule size (evaluated as a categorical variable and as a continuous variable) did not show any statistically significant correlation with the rate of malignancy, histopathological characteristics of tumor aggressiveness and the patient's clinical outcome. Most of the tumors found were included in the low risk class (79.2%) and only one was classified as high risk. Follow up of cancer cases showed excellent results in terms of survival, response to therapy and disease recurrence. Malignant thyroid tumors of any size resulting from a nodule identified as cytologically indeterminate are usually characterized by a low risk follicular pattern, well-differentiated and with an excellent outcome. As a result, preferring an extended surgical attitude for undetermined nodules based on tumor size, in absence of other risk factors, can lead to overtreatment in a significant percentage of cases.

Preoperative localization of parathyroid adenoma in video-assisted era: is cervical ultrasound or 99mTc Sesta MIBI scintigraphy better?

BACKGROUND: Endocrine surgeon localizes solitary adenoma (SA) in preoperative time by cervical ultrasound (c-US) and/or 99mTc Sesta MIBI scintigraphy (MIBI-S), but in clinical practice they often show discordant results. The aim of our study is to verify if c-US and MIBI-S have different sensitivity in preoperative localization of SA, depending on its localization, in planning minimally invasive video-assisted parathyroidectomy (MIVAP). METHODS: This is a retrospective analysis of data (demographics data, preoperative localization of SA by US and MIBI-S, presence of associated thyroid disease, preoperative calcemia, preoperative serum PTH, surgical time, intraoperative PTH values, day 1 postoperative calcemia, definitive histological report) about patients consecutively submitted to MIVAP because of SA between January 2011 and January 2014 in the department of endocrine and general surgery of the University Hospital of Parma (Italy). The data, expressed as percentages (%) and means (±SD), were analyzed with SPSS Statistics 22.0 program. RESULTS: The c-US detected 56.25% of the superior SA (9/16 patients) and it failed to identify 7 superior adenomas (43.75%); MIBI-S identified 6/16 superior SA (37.5%) and failed in the identification of 10 superior adenomas (62.5%). For inferior SA, c-US was positive in 39/45 patients (86.66%) and falsely negative in 6/45 patients (13.33%); MIBI-S correctly showed 31/45 inferior adenomas (68.88%) and it was falsely negative in 14/45 patients (31.11%). MIBI-S showed decreased sensitivity in the identification of superior SA (P=0.0383). C-US had a high sensitivity in the identification of the inferior SA (P=0.0280). CONCLUSIONS: C-US and MIBI-S are the best diagnostic tools for preoperative localization of SA, but both have decreased sensitivity in the presence of a concomitant thyroid diseases. In our experience c-US showed high sensitivity in the identification of inferior SA and MIBI-S showed a decreased sensitivity in the identification of superior SA. Discordant results in the identification of SA did not contraindicate MIVAP. Intraoperative parathormone dosage is fundamental to guide the endocrine surgeon and to verify the completeness of surgical resection.

Metronomic capecitabine in gastroenteropancreatic neuroendrocrine tumors: a suitable regimen and review of the literature.

BACKGROUND: We present a retrospective analysis of metronomic capecitabine in metastatic gastroenteropancreatic neuroendrocrine tumors (GEP-NETs). A review of the literature is also presented. METHODS: From January 2007 to December 2013, ten patients with metastatic GEP-NETs (four pancreatic and six ileal) who progressed after treatment with somatostatin analogs and other cytotoxic agents received oral capecitabine 1,500 mg/day continuously. The median patient age was 68 (range 29-82) years. The median treatment duration was 8 months. RESULTS: Five (50%) patients achieved a partial radiographic response, four (40%) showed stable disease, and one (10%) progressed. Median overall survival was 56 months. Three of the four pancreatic patients achieved a partial radiographic response that lasted for a median of 15.5 months; overall survival and progression-free survival in this subgroup was 58 and 6 months, respectively. CONCLUSION: Data in the literature show that capecitabine has only occasionally been used as a single agent, with increased toxicity. Only one study using single-agent capecitabine reported a progression-free survival of 9.9 months and overall survival of 36.5 months, without an objective response or major toxicity. In our experience, metronomic capecitabine was well tolerated, although minor side effects may have been underestimated due to the retrospective nature of our study. This regimen also seems to be feasible in elderly people. Although high response rates and prolonged response duration indicate the potential efficacy of this treatment, our results should be interpreted cautiously because of the small number of patients involved. Capecitabine was most effective in the pancreatic subgroup, which would seem to be more sensitive to chemotherapy.

Lymph node micrometastases in early gastric cancer and their impact on prognosis.

While the presence of lymph node metastases in early gastric cancer (EGC) is the most significant prognostic factor, the relevance of lymph node micrometastases remains uncertain. The authors studied 5400 lymph nodes dissected from 300 patients treated surgically for EGC between 1976 and 1999, all of whom were histologically pN0. Micrometastases were defined as single or small clusters of neoplastic cells identifiable only by immunohistochemical methods. Lymph node micrometastases were observed in 30 of the 300 patients (10%). No significant correlation was observed between micrometastases and other clinicopathological characteristics. Analysis of overall survival showed no significant difference between positive or negative micrometastasis groups. The results of our study show that the presence of lymph node micrometastases in EGC does not influence patient prognosis.