Is the social status a new prognostic factor in the Fournier's gangrene?

Fournier's gangrene is a life-threatening acute necrotizing fasciitis of perianal, genitourinary and perineal areas. Local symptoms are scrotal swelling, erythema of scrotal skin and pain with generalized constitutional symptoms. The gangrene may extends to abdominal wall, intra-abdominal structures, and even in the retroperitoneal tissues. Urgent surgical debridement is crucial to warrant a good outcome since delayed intervention carries a poor prognosis. We report the case of a not diabetic patient with Fournier's disease presented with severe sepsis and successfully treated with urgent deep debridement and reconstructive surgery. We propose the social status of the patient as a prognostic factor with high impact for survival rate.

MIVAT: the last 2 years experience, tips and techniques after more than 10 years.

BACKGROUND: Minimally invasive video-assisted thyroidectomy (MIVAT) has been introduced into clinical practice by Miccoli in the late 1990s (Miccoli et al., Am J Surg 181(6):567-570, 2001) and it has become a widespread technique used and welcomed worldwide. In this paper, we present our experience of the last 2 years; we also describe tips and techniques derived from over 460 cases performed in the last 10 years by the same surgical team with the same single operator. METHODS: In the last 10 years, we did about 460 MIVAT procedures. In the last 2 years, we performed MIVAT on 156 consecutive patients at Sant'Andrea University Hospital of Rome "Sapienza" University. of 156 cases performed, we were able to monitor the follow-up in 110 patients. RESULTS: On 110 cases, the mean surgical time was 74 ± 7.2 min. In our data, we reported: transitory hypoparathyroidism 11 (10%), definitive hypoparathyroidism 4 (3.60%) (this value is inclusive of patients treated with central neck dissection. The value referred only to MIVAT is 1.05%), 2 (1.81%) transitory monolateral nerve palsy, 16 (14.50%) transitory, and 1 (0.9%) definitive nerve palsy. 4 (3.60%) cases of transitory dysphagia and 0 (0%) cases of definitive dysphagia (Table 4). We also had 1 (0.9%) case of surgical scar infection, 0 (0%) postoperative bleeding, and 2 (1.81%) cases of subcutaneous surgical adhesion. Cosmetic results were: 0 (0%) insufficient, 0 (0%) sufficient, 6 (6.30%) passable, 17 (15.50%) good. and 86 (78.20%) excellent. Conversion rate 0 (0%). CONCLUSION: MIVAT is a good and safe technique, with similar short-term outcomes and similar costs compared to traditional total thyroidectomy. We hope that the tips and techniques reported in this paper as well as the advices in the use of instruments in MIVAT and open surgery will be useful to improve the skills of young surgeons and make thyroid surgery less invasive.

Radioguided surgery with combined use of gamma probe and hand-held gamma camera for treatment of papillary thyroid cancer locoregional recurrences: a preliminary study.

BACKGROUND: Persistent differentiated papillary thyroid cancer (PTC) with metastasis followed by radical locoregional surgery is an indication for limited reoperation. Despite excellent prognosis the major challenge is controlling locoregional recurrences. AIM: To evaluate the efficacy of radioguided excision with combined use of gamma probe and an hand-held gamma camera. PATIENTS AND METHODS: From June 2009 to January 2012, we enrolled twenty-two patients with locoregional PTC recurrences, previously undergone to central and/or lateral neck dissection for PTC. The diagnosis of recurrent PTC was based on thyroglobulin (TG) evaluation [basal and after thyroid stimulating hormone (TSH) stimulation], ultrasound (US), iodine-131 (131I) whole body scan (WBS) and fine needle aspiration cytology (FNAC). In the morning of surgery, radiotracer was injected directly into the lesions by US guide. Careful dissection was carried out using gamma probe and hand held gamma camera. Metastatic lymph nodes were identified and excised. RESULTS: In all the patients recruited, 39 pathologic nodes were injected and 61 nodes were removed. Among the removed nodes, 22 (36.1%) were additional nodes (not injected by radiotracer). Of the additional lymph nodes, 7 (31.8%) were metastatic. Mean radioactive count of the lesion (28.633±9.218 counts/s) was higher than tumor bed (385.73±192.23 counts/s) (p < 0.0001). No complications were observed during radioguided excision, neither on post-operative period. CONCLUSIONS: The use of hand-held gamma camera in addition to gamma probe in our preliminary study allows a minimally invasive procedure and safer identifications of the lesions and ensures the completeness of the excision in a difficult surgical field.

Minimally invasive video-assisted thyroid surgery: how can we improve the learning curve?

OBJECTIVE: Minimally invasive video-assisted thyroidectomy (MIVAT) is a technically demanding procedure and requires a surgical team skilled in both endocrine and endoscopic surgery. A time consuming learning and training period is mandatory at the beginning of the experience. The aim of our report is to focus some aspects of the learning curve of the surgeon who practices video-assisted thyroid procedures for the first time, through the analysis of our preliminary series of 36 cases. PATIENTS AND METHODS: From September 2004 to April 2005 we selected 36 patients for minimally invasive video-assisted surgery of the thyroid. The patients were considered eligible if they presented with a nodule not exceeding 35 mm in maximum diameter; total thyroid volume within normal range; absence of biochemical and echographic signs of thyroiditis. We analyzed surgical results, conversion rate, operating time, post-operative complications, hospital stay, cosmetic outcome of the series. RESULTS: We performed 36 total thyroidectomy. The procedure was successfully carried out in 33/36 cases. Post-operative complications included 3 transient recurrent nerve palsies and 2 transient hypocalcemias; no definitive hypoparathyroidism was registered. All patients were discharged 2 days after operation. The cosmetic result was considered excellent by most patients. CONCLUSIONS: Advances in skills and technology have enabled surgeons to reproduce most open surgical techniques with video-assistance or laparoscopically. Training is essential to acquire any new surgical technique and it should be organized in detail to exploit it completely.

Long-term response to ovariectomy in 35 premenopausal patients with advanced breast cancer, treated in coherence with hormonal tests.

Thirty-five premenopausal patients with metastasized or locally advanced breast cancer underwent ovariectomy. At relapse, after surgery, they were treated with hormone therapy or chemotherapy, according to hormonal tests carried out before the castration. Five-year survival, computed with the actuarial method, confirmed the better prognosis of the hormone-dependent patients and also an improved prognosis in the patients treated with hormone therapy after ovariectomy. Furthermore, chemotherapy proved more efficacious: an increased survival was observed in the non-hormone-dependent patients.