Updates on surgical management of advanced gastric cancer: new evidence and trends. Insights from the First International Course on Upper Gastrointestinal Surgery--Varese (Italy), December 2, 2011.

Between the Ninth International Gastric Cancer Congress (IGCC) in South-Korea (Seoul, 2011) and the Tenth IGCC in Italy (Verona, 2013), the Insubria University organized the First International Course on Upper Gastrointestinal Surgery (Varese, December 2, 2011), with the patronage of Italian Research Group for Gastric Cancer (IRGGC) and the International Gastric Cancer Association (IGCA). The Course was intended to be a comprehensive update and review on advanced gastric cancer (GC) staging and treatment from well-known international experts. Clinical, research, and educational aspects of the surgeon's role in the era of stage-adapted therapy were discussed. As highlighted in the meeting, in this final document we summarize and thoroughly analyze (with references only for well-acquired randomized control trials) the new and old open problems in surgical management of advanced GC. Between the Ninth (Seoul, 2011) and the Tenth (Verona,2013) International Gastric Cancer Congress, the First International Course on Upper Gastrointestinal Surgery (Varese, December 2, 2011) was organized by the University of Insubria. This congress received the patronage of the International Gastric Cancer Association and the Italian Research Group for Gastric Cancer. The aim was to discuss open issues in surgical management of advanced gastric malignancies. We considered the opinions of several recognized experts in the field from both the Eastern and Western world, focused on definition problems and oncological and technical issues to define the current principles of advanced gastric cancer (GC) surgery.

Visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy: what about the costs?

BACKGROUND: The objective of the present study was to evaluate costs for thyroidectomy performed with the aid of intraoperative neural monitoring (IONM), which has gained widespread acceptance during thyroid surgery as an adjunct to the gold standard of visual nerve identification. METHODS: Through a micro-costing approach, the thyroidectomy patient-care process (with and without IONM) was analyzed by considering direct costs (staff time, consumables, equipment, drugs, operating room, and general expenses). Unit costs were collected from hospital accounting and standard tariff lists. To assess the impact of the IONM technology on hospital management, three macro-scenarios were considered: (1) traditional thyroidectomy; (2) thyroidectomy with IONM in a high-volume setting (5 procedures per week); and (3) thyroidectomy with IONM in a low-volume setting (1 procedure per week). Energy-based devices (EBD) for hemostasis and dissection in thyroidectomy were also evaluated, as well as the reimbursement made by the Italian Healthcare System on the basis of diagnosis related groups (DRGs), about €2,600. RESULTS: Comparison between costs and the DRG fee shows an underfunding of total hospitalization costs for all thyroidectomies, regardless of IONM use (scenario 1: €3,471). The main cost drivers are consumables and technologies (25%), operating room (16%), and staff (14%). Hospitalization costs for a thyroidectomy with IONM range from €3,713 to €3,770 (scenarios 2 and 3), 5­7% higher than those for traditional thyroidectomy. Major economic differences emerge when an EBD is used (€3,969). CONCLUSIONS: The regional DRG tariff for thyroid surgery is barely sufficient to cover conventional surgery costs. Intraoperative neural monitoring accounts for 5­7% of the hospitalization costs for a thyroidectomy.

Wound morbidity in mini-invasive thyroidectomy.

BACKGROUND: The incidence of wound morbidity (WM) after conventional thyroidectomy (CT) is 2 to 7%. This study evaluated the rate of WM after video-assisted thyroidectomy (VAT), with emphasis on surgical-site infections (SSIs). METHODS: A total of 112 patients were recruited for this prospective, randomized surveillance analysis. The eligibility criteria included nodule smaller than 30 mm, gland volume less than 30 ml, and no previous neck surgery or advanced cancer. The exclusion criteria specified coexistent infection, immunosuppressive treatment, and pathologies requiring antibiotic prophylaxis. The patients were randomized for VAT or CT. Neither antibiotic prophylaxis nor a drain was used. The patients were followed after surgery for WM. RESULTS: Both groups consisted of 56 patients. The rate for WM was significantly lower in the VAT group (n = 1) than in the CT group (n = 8) (p < 0.05). The incidence of SSI was 5.3% after CT and 0% after VAT (p < 0.05), and the most common pathogenic organism was Staphylococcus aureus. All WMs became evident after patient discharge. Wound infection was associated with prolonged ambulatory dressings. CONCLUSIONS: No previous studies have compared the rates for WM associated with endoscopic versus open surgery in the cervical area. Wound morbidity was significantly reduced after VAT relative to CT. The authors underscore the important effect of the minor surgical trauma associated with VAT on the development of SSIs.

Single incision laparoscopic right colectomy.

OBJECTIVE: This study was designed to describe the surgical technique for single-incision laparoscopic right colectomy and present preliminary short-term results. Laparoscopic surgery has been fully validated as alternative, minimally invasive treatment for different benign and malignant conditions. In the attempt to reduce even more the surgical trauma, natural orifices transluminal endoscopic surgery (NOTES™) and single-incision laparoscopic surgery (SILS) have been proposed. Although the lack of proper instrumentations makes NOTES™ not fully suitable for advanced procedures, SILS might play a significant role, although, to date, only limited series and few case reports of single-incision right colectomy are present in the literature. METHODS: After signed, informed consent was obtained, patients with malignant tumors or large polyps of the right colon underwent single-incision colonic resection through a 3-cm incision using two different single-port devices and articulated or coaxial curved instruments. Preliminary results were analyzed retrospectively. RESULTS: A total of 36 patients were selected for SILS procedure. There were no intraoperative complications or conversions to the standard laparoscopic procedure. One patient had a postoperative urinary tract infection and one prolonged ileum that did not required any surgical intervention. No complications were reported in all the remaining cases. The mean postoperative stay was 5 ± 1.2 days (range, 4-14), and mean lymph node retrieval and tumor-free margins was 24 ± 7 (range, 29-15) and 8 ± 3 (range, 6-12) cm, respectively. CONCLUSIONS: Our preliminary results show that single-incision laparoscopic right colectomies are feasible and safe from the oncological point of view; nevertheless larger, randomized experiences are needed to demonstrate the benefits of SILS compared with standard laparoscopic resections.

Postoperative laryngoscopy in thyroid surgery: proper timing to detect recurrent laryngeal nerve injury.

BACKGROUND: There is currently a lack of consensus to support the proper timing for postoperative laryngoscopy that is reliable to diagnose recurrent laryngeal nerve palsy (RLNP) after thyroid surgery. The purpose of this study was to investigate the impact of different time intervals of fiber-optic nasolaryngoscopy (FNL) on the diagnosis of RLNP. METHOD: FNL was performed postoperatively at day 0 (T1), at second day post-op (T2), and +2 weeks (T3). For patients with RLNP, repeated examinations were performed at +2 (T4), +6 (T5), and +12 months (T6). RESULTS: Four hundred thirty-four patients appear for postoperative FNL, providing 825 nerves at risk. Permanent RLNP occurred in 0.7%, temporary RLNP in 6.7%. RLNP rate was 6.4% at T1, 6.7% at T2, 4.8% at T3, 2.5% at T4, 0.8% at T5, and 0.7% at T6. Full recovery of vocal cord function was confirmed after rehabilitation in 87.5% of cases at T5 and 89% in T6. T2 was significantly superior to T3 in terms of diagnosis of RLNP (P < 0.05). Of patients at T2, 10.7% did not see any reason to FNL because of their normal voice register. CONCLUSION: FNL is essential for the detection of vocal cord paralysis after thyroidectomy. We report different time evaluation criteria of vocal cord motility with great and significant variability of results. Second day post-op inspection of the larynx (T2) is suggested. Symptomatic voice assessment is insufficient.

Predictors of loco-regional recurrence and cancer-related death after breast cancer surgery.

To determine which tumor-related factors might predispose the patient to loco-regional recurrence or death and the impact of these factors on the different types of events. We retrospectively analyzed the data of 1991 women between January 1998 and March 2010 for a first primary nonmetastatic breast cancer and treated with surgery and neo-adjuvant/adjuvant therapy. The overall survival distribution was estimated using the Kaplan-Meier method. The prognostic impact of several factors on cumulative overall and loco-regional recurrence free survival was evaluated by univariate (log-rank test) and multivariate analysis (Cox regression). At log-rank test, pT, nodal status, histotype, grading, lymphangioinvasive growth, tumor diameter, estrogen receptors (ER) status, progesterone receptors (PR) status, expression of Ki67, and expression of Her2/neu had a prognostic value on loco-regional recurrence or overall survival. In the multivariate analysis grading remained the only independent predictor of loco-regional recurrences. With regard to overall survival, the Cox model selected grading along with nodal status and PR status. Loco-regional recurrences after breast cancer surgery are not frequent events. They are markers of tumor aggressiveness and predictor of an increased likelihood of cancer-related death. However, loco-regional recurrence and systemic tumor progression are partially independent events, since some prognostic factors differ.

Breast cancer in pregnancy.

Pregnancy-related breast cancer (PBC) is one of the most common malignancies during pregnancy (approx. one in 3,000 pregnancies); up to 3% of breast cancers are diagnosed in pregnancy. As maternal age at the time of pregnancy continues to increase as the incidence of breast cancer, the incidence of PBC is expected to increase. A review of the literature was performed in order to identify optimal treatment strategies. Most of the data surrounding the diagnosis and treatment PBC is small cohort studies, and there are no randomized controlled trials. Diagnostic delays are common. Preoperative histologic confirmation is required. Conservative surgery can be proposed at the end of second and third trimester, and radiotherapy is delayed after childbirth. The safety of sentinel lymph node biopsy has yet to be confirmed, and the axillary dissection is the traditional treatment of choice. The chemotherapeutic agents utilized are the same as those used in non-pregnant patients, but they should not be administered in the first trimester. Radiotherapy and endocrine therapy are recommended to be avoided during pregnancy. The treatment of PBC is multidisciplinary and necessitates active communication among the patient, obstetrician, medical, surgical, and radiation oncologists. Diagnosis is often delayed because of physiologic changes of the breast; obstetricians should perform a thorough breast examination at the first prenatal visit and maintain a high index of suspicion for cancer. Other therapies may need to be considered, although their usage now is not currently recommended owing to the paucity of safety data.

The role of micrometastatic disease in sentinel lymph node in breast cancer.

Sentinel lymph node (SLN) biopsy is the standard procedure for axillary node staging in breast cancer. Improvements in histopathological analysis and immunohistochemistry have recently increased the rate of detection of lymph nodal micrometastases. The clinical implications and prognostic significance of micrometastases in SLN still remain a controversial issue. Literature review was analyzed by searches of Medline and PubMed data bases. Whereas most studies carried on small groups of patients did not show differences in survival, recently some studies with longer follow-up and with larger populations demonstrated that prognosis of patients with micrometastases is worse compared to that of patients with SLN free of disease. To date, completion axillary dissection remains the standard option when a macro or micrometastasis (0.2-2 mm) in the SLN is found. However, in absence of level-1 evidence guidelines, each case requires discussion in the context of a multi-disciplinary team.

The technique of intraoperative neuromonitoring in thyroid surgery.

Recurrent laryngeal nerve (RLN) palsy during thyroidectomy is associated with multiple risk factors as patient- and surgeon-related bailiff. The risk is greater for thyroid cancer, Graves' disease, re-operation, and mediastinal goiter in less experienced centers and in patients in whom the RLN could not be identified during operation. Anatomical landmarks exist to identify RLN. Nevertheless, transient and permanent RLN injuries still exist. Intraoperative neuromonitoring (IONM) has been introduced to facilitate identification and verify functional integrity of the RLN in thyroid surgery. In this chapter, we present relevant medical literature and personal experience on thyroid surgery with IONM. Technical, medical, and legal aspects of monitoring are discussed.

Neuromonitoring and video-assisted thyroidectomy: a prospective, randomized case-control evaluation.

INTRODUCTION: This study evaluates the role of intraoperative neuromonitoring (IONM) in video-assisted thyroidectomy (VAT) with emphasis given to the identification of recurrent laryngeal nerve (RLN) and external branch of superior laryngeal nerve (EBSLN). METHODS: The study was based on a prospectively randomized series comprising 72 standard VAT gasless approaches. In the control group (N = 36), the laryngeal nerves were identified by 30 degrees 5-mm endoscope magnification solely. The standard technique of the IONM group (N = 36) consisted of localizing and monitoring EBSLN, both vagus and RLNs, before and after thyroid resection to prove nerve integrity. Surgical outcomes were mean operative time, nerve representation, incision length, and morbidity. RESULTS: All procedures were performed successfully. There were no instances of equipment malfunction or interference. No permanent complications occurred in either group. The incidences of temporary RLN injury were 2.7% (1 patient) and 8.3% (3 patients) in the IONM and control group, respectively. The EBSLN was identified better in the IONM group: 83.6% versus 42% (p < 0.05). In the IONM group, a negative electromyography (EMG) response indicated an altered function of RLN and stage thyroidectomy was scheduled. CONCLUSIONS: This is the first VAT series with a standardized IONM technique. The technical feasibility and safety of IONM in selected patients seem acceptable. Neuromonitoring during VAT is effective in providing identification and function of laryngeal nerves. IONM enables surgeons to feel more comfortable with their approach to VAT. A reduction of rates for postoperative complications could not be demonstrated in the present study. Larger series are needed for further evaluation.

Solitary fibrous tumor of the male breast: a case report and review of the literature.

Extrapleural solitary fibrous tumors are very rare and occasionally they appear in extraserosal soft tissues or parenchymatous organs. In such cases the right preoperative diagnosis is often difficult and challenging, because both radiological and cytological examinations are not exhaustive. For these reasons, surgical excision is frequently the only way to reach the correct diagnosis and to achieve definitive treatment. A few cases of solitary fibrous tumors have been also described in the breast. Although rare, this lesion opens difficulties in preoperative diagnosis entering in differential diagnosis with other benign lesions as well as with breast cancer. In this article we describe a case of a solitary fibrous tumor of the breast in a 49-year-old man. Problems related to differential diagnosis and the possible pitfalls that can be encountered in the diagnostic iter of such rare tumor are discussed.

Prospectives and surgical usefulness of perioperative parathyroid hormone assay in thyroid surgery.

Hypocalcemia is the most frequent complication after thyroid surgery. The incidence varies and has been reported as ranging from 1.2 to 40%. Permanent hypoparathyroidism occurs in less than 3% of patients, whereas transient postoperative hypocalcemia is much more common. Postoperative hypoparathyroidism is traditionally detected by serial measurement of serum calcium concentrations and requires multiple venepunctures and, potentially, several days of hospitalization following the procedure. The parathyroid hormone (PTH) molecule is a polypeptide composed of an 84-amino acid sequence with an active amino terminal on one end and an inactive carboxyl unit on the other. Measurement of the intact PTH (iPTH) is an accurate representation of the true parathyroid state. In recent years, iPTH assay has been under investigation for thyroid surgery in many centers as an early iPTH measurement may be of value for prediction of postoperative symptomatic hypocalcemia, guiding the surgeon for parathyroid autotransplatation, and selection of patients requiring onset of calcium substitution or safe discharge home. This paper reviews the relevant medical literature published regarding the influence of PTH assay technology on the quality of thyroid surgery, as well as on the prevention of postoperative symptomatic hypocalcemia. Searches were last updated in April 2008.

Safe incorporation of new technologies in thyroid surgery.

The history of thyroid surgery starts with Billroth, Kocher and Halsted, who developed the technique for thyroidectomy between the years of 1873 and 1910. In general the essential objectives for thyroidectomy are: sparing the parathyroid glands, avoidance of injury to the laryngeal nerves, an accurate hemostasis and an excellent cosmesis. In the last 10 years, major improvements and new technologies have been proposed and applied in thyroid surgery. These include mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, regional anesthesia, intraoperative neuromonitoring, parathyroid hormone assay technology and genetic screening. This paper reviews the relevant medical literature published on the influence of these new technologies on the quality of thyroid surgery, as well as prevention of postoperative morbidity and mortality. Searches were last updated in April 2008.

Shortening hospital stay for thyroid surgery.

The number of outpatient surgical procedures performed in hospitals, increases daily. In some countries, such as Italy, outpatient operations outnumber inpatient operations. The incidence of thyroid disorders and, in particular, the cancer forms, has been increasing sharply for many years in several countries. Even if thyroid surgery is performed with low morbidity, no mortality and short operation time, some potentially lethal complications are strong arguments against shortening of hospital stay. The purpose of this review is to examine the relevant updated published results on the outcome measures that can be used to assess the quality of shortstay surgery for thyroid disease with well-controlled trials. We discuss the special ethical and legal issues that this thyroid surgery raises. Searches were last updated in May 2007.

The Iconography of Goiter: Five Sculptures in the Sacred Mountains of Varallo, Orta, and Varese in Italy.

Many of the representations of individuals with goiters reported in the literature actually refer to occasional swelling of the anterior neck, or "pseudogoiter," the artists not having any plan to expose this pathology. The article describes five representations of goiters, as observed by the authors in the sculptures of the Sacred Mountains of Varallo, Orta, and Varese, Italy. They are classical and appropriate examples of the iconography of "real goiter," since in these cases the sculptors had the definite aim of showing persons with goiter.

A rationale multidisciplinary approach for treatment of esophageal and gastroesophageal junction cancer: Accurate review of management and perspectives.

Cancer of the esophagus and of gastroesophageal junction can be cured, even if with lacking cure rate. Different approaches have been developed, mostly when carcinoma has loco-regional pattern. Multimodality therapy showed a survival rate superior than 10% if compared to a single approach. This is a systematic review, carried to assess the following matters: Which therapeutic opportunities are available? Who could benefit of them? Which adverse reactions could possibly verify? How can physicians definitely choose the proper strategy? Which is the role of surgery? We mean to give either General Practitioner or specialists clear and efficient updates about current treatment of this tumour, starting from physical examination. Four eminent guidelines were consulted for our study: Cancer Care Ontario's Program in Evidence-Based Care, NCCN, Belgian Health Care Knowledge Centre and Esmo.

Preoperative assessment of rectal cancer stage: state of the art.

Rectal cancer is one of the most common tumors worldwide; it accounts for approximately 25-30% of cancers arising in the large bowel. Owing to greater distribution of screening programs and better attention from both patients and General Practitioners to this disease, in recent years we have observed an increasing number of cases diagnosed in the early stages, with a consequent better prognosis. The improved 5-year survival is also partially due to better, and more accurate, diagnostic techniques and to more curative treatments. In this review, the authors analyze and discuss the more recent diagnostic techniques for an accurate preoperative staging of rectal cancer, highlighting each method's advantages and limits for their routine use in clinical practice.

Postoperative fever.

BACKGROUND: Fever is common in surgical patients. The list of potential causes is long and includes many noninfective etiologies. CAUSES: Only about 40% of fever episodes in hospitalized patients are caused by infection. Any fever in a surgical patient is a cause for concern. New or continuing fever more than three days after surgery should raise a strong suspicion of persistent illness or a new complication. On rare occasions, these fevers can be attributed to potentially life-threatening occult infections, including acute cholecystitis, antibiotic-related pseudomembranous colitis, systemic candidiasis, or transfusion-related cytomegalovirus disease. A change in the microbiology of postoperative infections has also been noticed, characterized by a greater incidence of infections caused by methicillin-resistant Staphylococcus aureus, by polymicrobial flora, and by fungi. TREATMENT: Control of nosocomial infections has become more challenging recently because of widespread bacterial resistance to antibiotics and to more frequent surgical indications in elderly patients at higher risk. Early recognition and appropriate treatment of these infections relieves anxiety, reduces hospital costs, and increases patient survival rates. CONCLUSIONS: The workup and therapy for the individual patient may differ, depending on the underlying disease and clinical appearance and the clinician's suspicion for infection. Subsequent testing should be based on the clinical findings. Perhaps more money is wasted in the evaluation of early postoperative fever than on any other aspect of postoperative care.