Intraoperative parathyroid hormone (PTH) testing in patients with primary hyperparathyroidism and PTH levels in the normal range.

BACKGROUND: Primary hyperparathyroidism is a common endocrine disorder. Hypercalcemia with normal PTH levels is very unusual and can lead to diagnostic difficulties. There are very few very few studies in the literature and all with limited numerical samples. The goal of the present study was to determine the real incidence and characteristics of primary hyperparathyroidism with normal PTH and to evaluate if intraoperative PTH testing is useful in these patients. METHODS: We performed a retrospective review of 314 patients who had undergone parathyroidectomy to treat primary hyperparathyroidism between January 2002 and December 2016. Patients were divided in two groups according to biochemical preoperative findings: in Group A were included patients with normal serum PTH, in Group B those with increased serum PTH. RESULTS: Nine patients (3.7%) were included in group A and 235 in group B. Patients in group A were younger (51.5 ± 12.9 years vs 59.6 ± 12.5); preoperative serum calcium and the incidence of coexisting thyroid disease were similar between the two groups. Symptomatic patients were more frequent in Group A (77.8% vs 39.1%; p = 0.048). There were no significant differences regarding preoperative localization studies and surgical procedure. Intraoperative PTH determination demonstrated sensitivity of 86% in group A and 97% in group B, specificity and positive predictive value of 100% in both the groups, negative predictive value of 67% in group A and 79% in group B. Histopathological examination demonstrated a single gland disease in 8 (88.9%) patients in group A and a multi gland disease in 1 (11.1%), in group B single gland disease was found in 218 (92.8%) patients and multi gland disease in 17 (7.2%). Unsuccessful surgery with persistent or recurrent hyperparathyroidism occurred in 1 (11.1%) patient in group A and 4 (1.7%) in group B. CONCLUSIONS: Primary hyperparathyroidism with normal PTH is rare but physicians should be aware of this possibility in patients with hypercalcaemia. Patients with normal PTH levels are younger and more frequently symptomatic. Intraoperative PTH testing plays an important role in the operative management even in such patients.

Double Valve Failure Due to Perceval Sutureless Aortic Valve Migration.

A 76-year-old woman was admitted to the authors' hospital with pulmonary edema five months after the successful implantation of a Perceval sutureless aortic valve (Sorin Group Srl, Saluggia, Italy). Both echocardiography and computed tomography scanning demonstrated migration of the aortic valve into the left ventricle, causing severe aortic and mitral (secondary) insufficiency. Following heart team discussions, the sutureless valve was replaced with a standard bioprosthesis (Perimount, Magna Ease; Edwards Lifesciences, Irvine, California, USA) with spontaneous restoration of native mitral valve competence. The present case is the first of a new presentation of early Perceval sutureless aortic valve proximal migration, and highlights the importance of careful preoperative assessment and regular postoperative follow up after sutureless aortic valve implantation.

Parathyroidectomy for primary hyperparathyroidism in the elderly: experience of a single endocrine surgery center.

BACKGROUND: Primary hyperparathyroidism is a common endocrine disease, and its incidence increases with age. AIMS: Our aim was to retrospectively evaluate the impact of age on patient outcomes following parathyroidectomy for primary hyperparathyroidism. METHODS: Two-hundred fifty-six consecutive patients undergoing parathyroidectomy with preoperative diagnosis of primary hyperparathyroidism were divided into three groups according to patient age: group A, ≤64 years; group B, 65-74 years; and group C, ≥75 years. RESULTS: Thyroid disease was associated with the hyperparathyroidism in 44 patients (28.2%) in group A, 34 (44.7%) in B, and 10 (41.7%) in C (p < 0.01). Minimally invasive parathyroidectomy was performed in 104 patients (66.7%) in group A, 35 (46.1%) in B, and 8 (33.3%) in C (p < 0.01). Conversion to bilateral exploration was carried out in five cases in group A (4.6%), three in B (8.3%), and two in C (20%). Multiglandular disease was observed in six patients (3.8%) in group A, seven (9.2%) in B, and five (20.8%) in C (p = 0.012). Mean postoperative stay was similar between groups; no major complications and no cases of mortality occurred. DISCUSSION: Multiglandular disease is more common in older patients than younger individuals, and minimally invasive approaches are less used in this patient group. Increased surgical risk and paucity of symptoms in these patients sometimes result in a delay in surgical treatment. CONCLUSIONS: Parathyroidectomy is a safe and effective procedure to perform in elderly patients. Multiglandular disease was found to be more prevalent in older patients, but minimally invasive parathyroidectomy can be performed safely. Surgeons should consider parathyroidectomy in patients with primary hyperparathyroidism regardless of age.

Total thyroidectomy without prophylactic central neck dissection in clinically node-negative papillary thyroid cancer: is it an adequate treatment?

BACKGROUND: Cervical lymph node metastases in papillary thyroid cancer are common. Although central neck dissection is indicated in clinically nodal-positive disease, it remains controversial in patients with no clinical evidence of nodal metastasis. The aim of this retrospective study was to determine the outcomes of clinically lymph node-negative patients with papillary thyroid cancer who underwent total thyroidectomy without a central neck dissection, in order to determine the rates of recurrence and reoperation in these patients compared with a group of patients submitted to total thyroidectomy with central neck dissection. METHODS: Two-hundred and eighty-five patients undergoing total thyroidectomy with preoperative diagnosis of papillary thyroid cancer, in the absence of suspicious nodes, were divided in two groups: those who underwent a thyroidectomy only (group A; n=220) and those who also received a central neck dissection (group B; n=65). RESULTS: Six cases (2.1%) of nodal recurrence were observed: 4 in group A and 2 in group B. Tumor histology was associated with risk of recurrence: Hürthle cell-variant and tall cell-variant carcinomas were associated with a high risk of recurrence. Multifocality and extrathyroidal invasion also presented a higher risk, while smaller tumors were at lower risk. CONCLUSIONS: The role of prophylactic central lymph node dissection in the management of papillary thyroid cancer remains controversial. Total thyroidectomy appears to be an adequate treatment for clinically node-negative papillary thyroid cancer. Prophylactic central neck dissection could be considered for the more appropriate selection of patients for radioiodine treatment and should be reserved for high-risk patients only. No clinical or pathological factors are able to predict with any certainty the presence of nodal metastasis. In our experience, tumor size, some histological types, multifocality, and locoregional infiltration are related to an increased risk of recurrence. The potential use of molecular markers will hopefully offer a further strategy to stratify the risk of recurrence in patients with papillary thyroid cancer and allow a more tailored approach to offer prophylactic central neck dissection to patients with the greatest benefit. Multi-institutional larger studies with longer follow-up periods are necessary to draw definitive conclusions.

Follicular nodules (Thy3) of the thyroid: is total thyroidectomy the best option?

BACKGROUND: Identification of the best management strategy for nodules with Thy3 cytology presents particular problems for clinicians. This study investigates the ability of clinical, cytological and sonographic data to predict malignancy in indeterminate nodules with the scope of determining the need for total thyroidectomy in these patients. METHODS: The study population consisted of 249 cases presenting indeterminate nodules (Thy3): 198 females (79.5%) and 51 males (20.5%) with a mean age of 52.43 ± 13.68 years. All patients underwent total thyroidectomy. RESULTS: Malignancy was diagnosed in 87/249 patients (34.9%); thyroiditis co-existed in 119/249 cases (47.79%) and was associated with cancer in 40 cases (40/87; 45.98%). Of the sonographic characteristics, only echogenicity and the presence of irregular margins were identified as being statistically significant predictors of malignancy. 52/162 benign lesions (32.1%) and 54/87 malignant were hypoechoic (62.07%); irregular margins were present in 13/162 benign lesions (8.02%), and in 60/87 malignant lesions (68.97%). None of the clinical or cytological features, on the other hand, including age, gender, nodule size, the presence of microcalcifications or type 3 vascularization, were significantly associated with malignancy. CONCLUSIONS: The rate of malignancy in cytologically indeterminate lesions was high in the present study sample compared to other reported rates, and in a significant number of cases Hashimoto's thyroiditis was also detected. Thus, considering the fact that clinical and cytological features were found to be inaccurate predictors of malignancy, it is our opinion that surgery should always be recommended. Moreover, total thyroidectomy is advisable, being the most suitable procedure in cases of multiple lesions, hyperplastic nodular goiter, or thyroiditis; the high incidence of malignancy and the unreliability of intraoperative frozen section examination also support this preference for total over hemi-thyroidectomy.

Resistance to secondary thrombosis of the On-X mitral prosthesis.

A 60-year-old man underwent aortic and mitral valve replacement with mechanical On-X prostheses, plus tricuspid annuloplasty ring and maze radiofrequency ablation. Two years later, he was admitted to hospital with severe orthopnea and hemolysis. Echocardiography revealed a blocked prosthetic mitral leaflet due to interference of the preserved subvalvular apparatus. Intraoperatively, one leaflet was found to be blocked by the native mitral apparatus, but no thrombus and/or pannus was present. Although, despite an abnormal blood flow, the On-X prosthesis is resistant to secondary thrombosis, even under adverse hemodynamic conditions, interference of the valve with cardiac structures remains a possibility.

Intraoperative parathyroid hormone assay during focused parathyroidectomy: the importance of 20 minutes measurement.

BACKGROUND: Parathyroid hormone (PTH) monitoring during the surgical procedure can confirm the removal of all hyperfunctioning parathyroid tissue, as the half-life of PTH is approximately 5 min. The commonly applied Irvin criterion is reported to correctly predict post-operative calcium levels in 96-98% of patients. However, the PTH baseline reference concentration is markedly influenced by surgical manipulations during preparation of the affected glands, interindividual variability of the PTH half-life and modifications in the physiological state of the patient during surgery. The aim of this study was to evaluate the possible impact of the measurement of intraoperative PTH 20 minutes after surgery. METHODS: Between 2003 and 2012, 188 patients underwent a focused parathyroidectomy associated to rapid intraoperative PTH assay monitoring. Blood samples were collected: 1) at pre-incision time, 2) at 10 min after gland excision and 3) at 20 min after excision, if a sufficient reduction of PTH value was not observed. On the bases of the Irvin criterion, an intra-operative PTH drop>50% from the highest either pre-incision or pre-excision level after parathyroid excision was considered a surgical success. RESULTS: A >50% decrease of PTH after gland excision compared to the highest pre-excision value occurred in 156/188 patients (83%) within 10 min and in further 12/188 after 20 minutes (6.4%). In the remaining 20 patients (10.6%) values of PTH remained substantially unchanged or decreased less than 50% and for this reason bilateral neck exploration was performed. An additional pathologic parathyroid was removed in 9 cases, a third in one. In the other 10 cases further neck exploration by a standard cervical approach was negative and in four of these persistent postoperative hypercalcemia was demonstrated. The overall operative success was 97.3%. Intraoperative PTH monitoring was accurate in predicting operative success or failure in 96.3% of patients. CONCLUSIONS: The 20 minutes PTH measurement appears very useful, avoiding unnecessary bilateral exploration and the related risk of complications with only a slight increase of the duration of surgery and of the costs. PTH values decreasing appeared to be influenced by surgical manipulations during minimally invasive parathyroidectomy.

The Nanostructured Self-Assembly and Thermoresponsiveness in Water of Amphiphilic Copolymers Carrying Oligoethylene Glycol and Polysiloxane Side Chains.

Amphiphilic copolymer self-assembly is a straightforward approach to obtain responsive micelles, nanoparticles, and vesicles that are particularly attractive for biomedicine, i.e., for the delivery of functional molecules. Here, amphiphilic copolymers of hydrophobic polysiloxane methacrylate and hydrophilic oligo (ethylene glycol) methyl ether methacrylate with different lengths of oxyethylenic side chains were synthesized via controlled RAFT radical polymerization and characterized both thermally and in solution. In particular, the thermoresponsive and self-assembling behavior of the water-soluble copolymers in water was investigated via complementary techniques such as light transmittance, dynamic light scattering (DLS), and small-angle X-ray scattering (SAXS) measurements. All the copolymers synthesized were thermoresponsive, displaying a cloud point temperature (Tcp) strongly dependent on macromolecular parameters such as the length of the oligo(ethylene glycol) side chains and the content of the SiMA counits, as well as the concentration of the copolymer in water, which is consistent with a lower critical solution temperature (LCST)-type behavior. SAXS analysis revealed that the copolymers formed nanostructures in water below Tcp, whose dimension and shape depended on the content of the hydrophobic components in the copolymer. The hydrodynamic diameter (Dh) determined by DLS increased with the amount of SiMA and the associated morphology at higher SiMA contents was found to be pearl-necklace-micelle-like, composed of connected hydrophobic cores. These novel amphiphilic copolymers were able to modulate thermoresponsiveness in water in a wide range of temperatures, including the physiological temperature, as well as the dimension and shape of their nanostructured assemblies, simply by varying their chemical composition and the length of the hydrophilic side chains.

Laparoscopic lymph node biopsy in the diagnosis of lymphoma. Indications and results.

BACKGROUND: Exclusive abdominal nodal involvement due to Hodgkin or non Hodgkin lymphoma (HL,NHL) is a rare condition, but its occurrence requires a good enough specimen for diagnosis and therapy. Aim of this work is to evaluate the results of laparoscopic lymph node biopsy (LLNB) in a series of patients where a primitive or relapsing lymphoma was suspected. METHODS: This study has been carried on the patients submitted to LLNB from 2007 to 2011. Cases records were retrospectively reviewed for age, sex, diagnostic work up, previous biopsy, conversion to laparotomy, pathologic diagnosis and perioperative complications. RESULTS: Eleven cases were evaluated including 4 males and 7 females; mean age was 56.5 years. All patients underwent Ultrasound (US) and CT scan. A previous US or CT guided biopsy was performed in 5 cases, but in all of them failed to obtain a diagnosis. LLNB was successfully performed in 8 cases and required a conversion in three. Causes of conversion were obesity in one case and previous surgery in two. Results of pathology were NHL 5 cases, HL 2, follicular hyperplasia 2, sarcoidosis and tuberculosis 1 case respectively. No mortality nor morbidity occurred. Mean hospital stay was of 2.7 days. CONCLUSION: LLNB proved to be a safe procedure with no perioperative complications. Laparoscopy however should not be undertaken if superficial lymphadenopathy is present. A thorough CT evaluation of abdominal nodal involvement by the surgical team is mandatory prior to laparoscopy in order to plan the surgical approach and the route to reach the node.

Forgotten goiter. Our experience and a review of the literature.

"Forgotten" goiter is an extremely rare disease which is defined as a mediastinal thyroid mass found after total thyroidectomy. The authors report their experience of 7 cases of residual mediastinal goiter after total thyroidectomy for substernal goiter. Six patients were female and one male with a median age of 56 years (range: 25-70 years). Four patients were asymptomatic, 2 patients showed signs of mediastinal compression, and one patient had persistent hyperthyroidism. A sternal splitting incision associated with a cervical incision was required in 3 patients while an exclusively cervical incision was sufficient in 4 patients. Histology did not show neoplasia. Postoperative outcome was uncomplicated in 6 patients and in one patient a transient recurrent laryngeal nerve paralysis occurred. In the majority of cases forgotten goiter is the consequence of the incomplete removal of a plunging goiter, although sometimes it may be attributed to a concomitant, unrecognized mediastinal goiter which is not connected to the thyroid. The residual goiter has the same clinical presentation as an ordinary intrathoracic goiter. Our experience confirms that surgical treatment of forgotten goiter is associated with only minimal morbidity although a sternal split is sometimes required. Forgotten goiter is a rare pathology which can be prevented if particular attention is paid to preoperative imaging and intraoperative management during the first operation. However surgical treatment for forgotten goiter, when performed in specialized centers, is associated with low morbidity.

The use of the harmonic scalpel in thyroid surgery. Our experience.

The aim of this study was to evaluate the potential advantages of the use of Harmonic Scalpel in thyroidectomies in terms of operative time and complications. Between May 2007 and June 2010 1151 patients were submitted to total thyroidectomy. In 681 thyroidectomies were performed using harmonic scalpel FOCUS (group A), in 470 without it (group B). Mean operative time was 97 minutes in group A and 114 in group B with a mean difference of 17 minutes (14.9%). 554 patients in group A (81.35%) and 345 in group B (73.4%) were discharged in second postoperative day. In group A, hypoparathyroidism was present in 348 patients at discharge (48%), in 23 at 6 months (3.38%) and in 10 at 12 months (2.13%), in group B, in 255 at discharge (54.26%), in 61 at 6 months (12.98%) and in 28 at 12 months (5.96%). The major benefit of Harmonic Scalpel used during thyroidectomy is the reduction in the time of operation. All studies but one to date have reported reductions in operative time, ranging from 6 to 78 minutes with a 10% to 35% savings in operative time and this was confirmed in our study. A reduction of hypoparathyroidism, particularly transitory, and in length of hospital stay was reported in some studies and confirmed in our experience. The use of Harmonic Scalpel in thyroid surgery is safe and effective and is associated with a significant reduction in operative time, postoperative hypocalcaemia and hospital stay, without increasing complications rate.

Postoperative hematomas after thyroid surgery. Incidence and risk factors in our experience.

AIM: The aim of our study was to evaluate the incidence and timing of postoperative bleeding and to identify the potential aetiological factors of cervical hematomas complicating thyroid surgery. MATERIAL: Between September 2002 and December 2009, 2559 patients were operated on in Department of Surgery, University Hospital of Cagliari. 2257 total thyroidectomies, 191 total thyroidectomies associated to lymphadenectomy, 83 total thyroidectomies associated to parathyroidectomy, 24 thyroid lobectomies and 4 lobectomies associated to parathyroidectomy were performed. RESULTS: 35 Patients (1.36%) developed a postoperative hematoma, 32 of whom (1.25%) needed a surgical revision. Male sex seemed to have a greater risk: 13 men (2.79% of all males) vs. 19 women (0.90% of all female cases) had to undergo haemostasis revision (p = 0.00204). 16 of 32 patients (50%) who underwent surgical revision had hypertension; incidence of hematoma was 2.09% in patients with hypertension and 0.89% in patients without it (p = 0.02112). DISCUSSION: It is generally difficult to predict which patients are at risk for the development of a hematoma after thyroid surgery. The most intense postoperative monitoring is necessary during the first six hours but hematomas occurring after are not rare. CONCLUSIONS: Postoperative hematoma remains a rare but potentially life-threatening complication. Early recognition with immediate intervention is the key to the management of this complication. Because of the possibly long interval between the initial operation and the hematoma development, ambulatory and one-day thyroid surgery is not advisable.

Thyroidectomy with energy-based devices: surgical outcomes and complications-comparison between Harmonic Focus, LigaSure Small Jaw and Thunderbeat Open Fine Jaw.

BACKGROUND: Being the thyroid gland a highly vascularized organ, achieving a meticulous hemostasis is essential to avoid serious complications. Currently, energy-based devices are widely used in thyroid surgery. The aim of this study was to compare Harmonic Focus (HF), LigaSure Small Jaw (LSJ) and Thunderbeat Open Fine Jaw (TB) in terms of surgical outcomes and complications. METHODS: Patients undergoing thyroidectomy in our Unit between January 2012 and June 2018 were retrospectively analyzed. According to the type of energy-device used, patients were divided into three groups: Group A (HF), Group B (LSJ) and Group C (TB). RESULTS: A total of 1,165 patients were included in this study: 1,012 in Group A, 96 in Group B and 57 in Group C. Demographic data and histopathological findings were comparable between the three groups. About the postoperative stay and complications, no statistically significant difference was found. The mean operative time was 89.41±20.60 minutes in Group A, 85.57±15.91 minutes in Group B and 78.07±17.67 minutes in Group C (P<0.01). However, the post-hoc test for all pairwise comparisons showed a statistically significant difference only between Group A and Group C. CONCLUSIONS: HF, LSJ and TB have proved to be safe and effective. The postoperative stay and complications were comparable between the three groups. Considering the limits of our investigation, further studies are needed to investigate the effect of TB on operative times.

Adult idiopathic intussusception: a case report and review of the literature.

Adult intussusception is a rare condition. Most of the cases are due to an organic lesion and unlike the incidence in children idiopathic forms are really exceptional, occurring at a rate of 5% of all cases. Whereas in children a main cause is seldom found, adult intussusception is usually characterised by the presence of a leading intraluminal benign or malignant lesion. The authors report their experience with a clinical case of ileocolic intussusception occurring in an 28-year-old white male. In spite of the patient's age, the clinical presentation was very typical with the classic triad of abdominal pain, blood per rectum and a palpable mass. Diagnostic tools, namely US and TC scan, together with colonoscopy confirmed the physical examination, so that surgery was initiated with a definite diagnosis of intussusception. A large polyp or a lymphoma were considered the possible leading causes. After right hemicolectomy, pathology revealed that there was no organic lesion and the bulging mass was caused only by oedema and haemorrhagic infiltration of the invaginated loop. The patient had been on antipsychotic drugs for several months and the possible explanation of the pathology was linked to altered peristalsis induced by the pharmacological agents he was taking. The authors compare their experience with the data reported in the literature, evaluating in particular the incidence, pathology, clinical presentation, diagnosis and treatment of adult intussusception.

[Recurrent goitre: our experience]. / Il gozzo recidivo. Nostra esperienza.

Recurrence after conservative thyroid surgery ranges from 7 to 40%. Risk factors for recurrence are female sex, multiple nodules in the resected lobe and lack of postoperative LT4 therapy. Indications for reoperation are suspected malignancy, recurrent thyrotoxicosis and recurrent uninodular or multinodulare goitre. From 2002 to 2008, 2149 total thyroidectomies were performed. Ninety-two patients had a completion thyroidectomy. The indication was recurrent multinodular goitre in 81, recurrent thyrotoxicosis in 3, and suspected malignancy in 8. Bilateral completion thyroidectomy was performed in 63 cases, lobectomy in 27 cases, removal of a mediastinal recurrence in 1 case and removal of a pyramidal remnant in 1 case. Histological examination revealed papillary cancer in 18 patients and follicular cancer in 1. Mean operative time was 140 minutes (range: 60-260). All patients were submitted to a minimum follow-up of 6 months. Temporary hypoparathyroidism occurred in 36 patients (39.1%) and definitive hypoparathyroidism in 7 patients (7.6%). Transient recurrent laryngeal nerve palsy occurred in 3 cases (3.2%) and permanent nerve palsy in 1 (1.1%). In 3 cases (3.2%) surgical revision of haemostasis was necessary for postoperative haemorrhage. Total thyroidectomy is the treatment of choice in multinodular goitre. In the cases in which reoperation is necessary, the intervention must be performed by an experienced surgeon.

[Fournier's gangrene in an HIV-positive patient. Therapeutic options]. / Gangrena di Fournier in paziente HIV positivo: considerazioni terapeutiche.

Fournier's gangrene is a life-threatening necrotising infection of the perineal and genital regions. The case presented here refers to an HIV-positive 42-year-old man, admitted in emergency to our department with clinical signs and symptoms of sepsis related to gangrene of the perineum and scrotum. An early wide surgical necrosectomy was performed under epidural anaesthesia. Treatment was completed by intensive care, broad-spectrum antibiotics and hyperbaric oxygen therapy. The wound was managed with advanced dressing (AQUACEL Hydrofiber) until complete healing was obtained, and the scrotum was reconstructed with skin flaps. The disease did not involve the testes, spermatic cord or anorectal canal. The satisfactory aesthetic and functional outcome prompts the authors to stress a number of features of the therapeutic approach adopted: (i) the advantages of epidural anaesthesia with an indwelling catheter that allows further necrosectomy and wound dressing to be performed totally painlessly; (ii) the possibility of avoiding faecal diversion by means of synthetic opioid drugs which are useful to reduce the frequency of defecation; and (iii) the positive impact of advanced dressing on the wound healing process in relation to patient satisfaction and cost management.

Surgical gastrostomy when percutaneous endoscopic gastrostomy is not feasible: indications, results and comparison between the two procedures.

Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice in patients unable to eat owing to neoplastic or neurological diseases. In a few cases, however, PEG is not feasible and on such occasions a surgical gastrostomy (SG) proves mandatory to prevent starvation. The aim of the present study was to evaluate the cases submitted to SG when PEG could not be performed and to compare the results of the two procedures. We reviewed the medical records of 52 patients who required clinical nutrition in the years 2000-May 2007: 41 cases underwent PEG and 11 SG. Surgery was adopted when PEG failed or was deemed not to be feasible Analysis of the two series included sex, age, indications, associated diseases, mortality, complications, hospital stay and survival. Head and neck malignancies were the main indication to SG (81.1%), while PEG was adopted mainly for neurological diseases. In two cases, SG was required after failure of PEG due to lack of transillumination. A tracheostomy was present in 54.4% of the SG group and in 17% of the PEG group. Thirty-day mortality was nil in SG and 12% in PEG; morbidity was 9 and 7.3%, respectively. Hospital stay was 7 days in SG and 3 days in the PEG group. Survival at 24 months was poor in both series: 10% in SG and 25% in PEG. In case of PEG failure or contraindication, SG is more than satisfactory in terms of effectiveness, mortality and morbidity.

Emergency Laparoscopic Repair of Giant Left Diaphragmatic Hernia following Minimally Invasive Esophagectomy: Description of a Case and Review of the Literature.

Postoperative diaphragmatic hernia (PDH) is an increasingly reported complication of esophageal cancer surgery. PDH occurs more frequently when minimally invasive techniques are employed, but very little is known about its pathogenesis. Currently, no consensus exists concerning preventive measures and its management. A 71-year-old man underwent minimally invasive esophagectomy for esophageal cancer. Three months later, he developed a giant PDH, which was repaired by direct suture via laparoscopic approach. A hypertensive pneumothorax occurred during surgery. This complication was managed by the anaesthesiologist through a high fraction of inspired O2 and several recruitment manoeuvres. The patient remained free of hernia recurrence until he died of neoplastic cachexia 5 months later. Laparoscopic repair of PDH may be safe and effective even in the acute setting and in the case of massive herniation. However, surgeons and anaesthesiologists should be aware of the risk of intraoperative pneumothorax and be prepared to treat it promptly.

Does hyperthyroidism worsen prognosis of thyroid carcinoma? A retrospective analysis on 2820 consecutive thyroidectomies.

BACKGROUND: Hyperthyroidism is associated with high incidence of thyroid carcinoma; furthermore, tumors arisen in hyperthyroid tissue show an aggressive behavior. Thyroid Stimulating Hormone (TSH) and Thyroid-stimulating antibodies, present in Graves's disease, seem to play a key role in carcinogenesis and tumoral growth. METHODS: We retrospectively reviewed our series of patients who underwent thyroidectomy for thyroid carcinoma. We compared pathological features and surgical outcomes of hyperthyroid versus euthyroid patients. RESULTS: From 2007 to 2015, 909 thyroidectomies were performed at our institution for thyroid cancer: 87 patients were hyperthyroid and 822 euthyroid. We observed, in hyperthyroid patients, a higher rate of transient hypoparathyroidism (28.1% vs 13.2%; p < 0.01) and of node metastases (12.6% vs 6.1%; p = 0.03); also local recurrence rate was higher (5.7% vs 2.5%) even if not statistically significant (p = 0.17). Five-year disease free survival rate was significant lower in the same group (89.1% vs 96.6%; p = 0.03). CONCLUSION: Thyroid cancers in hyperthyroid patients have an aggressive behavior, with high incidence of local invasion and a worse prognosis than euthyroid patients. All hyperthyroid patients should undergo a careful evaluation with ultrasound and scintigraphy; in case of suspicious nodules, an aggressive approach, including thyroidectomy and lymphectomy, is justified. In patients with toxic adenoma, thyroid cancer is uncommon, thus a loboisthmectomy can be safely performed. TRIAL REGISTRATION NUMBER: Research registry n. 2670 registered 19 June 2017 (retrospectively registered).

Uncommon pathologies discovered during exploratory laparoscopy for malignant diseases.

In spite of the most sophisticated diagnostic tools, the final diagnosis in malignant diseases may require an exploratory laparoscopy for confirmation. The aim of this study was to report our experience with exploratory laparoscopy and to describe two unexpected cases of uncommon pathologies discovered during this procedure. From January 2003 to December 2005, 7 exploratory laparoscopies were performed to confirm and stage carcinoma with peritoneal involvement (4 cases) and to obtain histological evidence of lymphoma (3 cases). Uncommon pathologies were detected in two cases (28%): the first was a black man presenting with multiple tubercular lesions mimicking neoplastic spread, and the second an elderly Caucasian woman with a pre-pancreatic mass suspected of being a lymphoma, which was due to previous subclinical pancreatitis. The effectiveness of laparoscopy was confirmed in the present experience. A tissue specimen is mandatory when the differential diagnosis is hard to achieve.