Early parathyroid hormone (PTH) level as a predictor of post-surgical hypoparathyroidism.

INTRODUCTION: Post-operative hypocalcemia and postoperative persistent hypoparathyroidism remain the most common complications after thyroidectomy. Many approaches have been developed to prevent them, but actually, a common protocol is not yet individuated. MATERIALS AND METHODS: We retrospectively analyzed the results of a prospectively collected database. We dosed PTH preoperatively and 4 h after surgery (PTH_4); calcium was evaluated preoperatively, on the first (I_POD) and on the second postoperative day (II_POD). Hypocalcemia was defined when calcium <8 mg/dl. PTH_4 and I_POD calcium serum levels are identified to predict postoperative hypocalcemia. RESULTS: Three hundred and forty-eight patients were enrolled, 37 patients resulted as hypocalcemic on I_POD and 41 on the II_POD. PTH_4 is related to I_POD (p < 0.001, r = 0.45) and II_POD (p < 0.001, r = 0.44) calcemia. PTH_4-cut-off predicting I_POD hypocalcemia was 10.50 pg/ml (sensitivity: 78.7%, specificity: 72.7%). A PTH_4 value of 11.5 pg/ml is able to predict hypocalcemia during II_POD (sensitivity: 76.5%, specificity: 69.2%). We set up a combined test to predict II_POD hypocalcemia, using PTH_4 and I_POD calcium (sensitivity: 77.8%, specificity: 89.9%). CONCLUSION: This research shows the association between PTH_4 and postoperative hypocalcemia. The PTH_4 cut-off to predict I_POD-hypocalcemia was 10.5 pg/ml. We analyzed the calcemia trend during the postoperative period and we realized a combined test using PTH_4 and I_POD-calcemia. This test improves the accuracy of the previous test. Further studies, in particular multicentric, with a larger sample are necessary to validate the combined model.

Production of Dense Cu-10Sn Part by Laser Powder Bed Fusion with Low Surface Roughness and High Dimensional Accuracy.

Tin-bronze alloys with a tin content of at least 10 wt% have excellent mechanical properties, wear resistance, and corrosion resistance. Among these alloys, Cu-10Sn was investigated in this study for production with the laser powder bed fusion process with a 500W Yb:YAG laser. In particular, a design of experiment (DoE) was developed in order to identify the optimal process parameters to obtain full density, low surface roughness, and high dimensional accuracy. Samples were characterized with Archimedes' method and optical microscopy to determine their final density. It was shown that the first method is fast but not as reliable as the second one. A first mechanical characterization was performed through microhardness tests. Finally, a set of process parameters was identified to produce fully dense samples with low surface roughness and high accuracy. The results showed that the volumetric energy density could represent an approach that is too simplified, therefore limiting the direct correlation with the physical aspects of the process.

Long-Term Outcome of Veno-Occlusive Disease After Liver Transplant: A Retrospective Single-Center Experience.

OBJECTIVES: Veno-occlusive disease after liver transplant has been sporadically reported, and significant uncertainty exists concerning the best treatment and the long-term outcomes. Here, we reviewed our experience to evaluate clinical presentation, treatment, and the long-term outcomes of these patients. MATERIALS AND METHODS: Between 2000 and 2015, 2165 patients underwent liver transplant at our center. The incidence of veno-occlusive disease was 0.3% (7/2165). RESULTS: Timing of veno-occlusive disease onset (median 4.7 mo; interquartile range, 2.5-11.1 mo) varied widely as did clinical presentation, which was characterized by a variable association of liver failure and portal hypertension and different disease pro-gression rates. In all cases, diagnosis of veno-occlusive disease was confirmed by liver biopsy. Six patients (85.7%) presented with veno-occlusive disease after a previous episode of acute cellular rejection. Three patients died due to veno-occlusive disease (n = 2) or due to hepatocellular carcinoma recurrence (n = 1). Two patients were treated by increasing immunosuppression and with interventional procedures (pleurodesis and transjugular intrahepatic portosystemic shunt, respectively), and 2 had successful retransplants. 5-year patient and graft survival rates were 57.1% and 28.6%, respectively. CONCLUSIONS: A tailored approach based on clinical features and including retransplant can achieve acceptable long-term survival in patients with veno-occlusive disease after liver transplant.

Management of venous ulcers: State of the art.

Venous ulceration is a complex and serious problem that affects 1-2% of the global elderly population (>65 years), and its incidence is constantly increasing. The population group with higher risk of development of venous ulceration is the elderly. These lesions have a significant negative impact on patients' quality of life. Our aim was to analyze the state of the art, starting with the medical literature review. The evidence supports that managing chronic wounds with a multidisciplinary wound care team significantly increases wound healing and reduces the severity of wound-associated pain and the required daily wound treatments compared with persons who are not managed by such a team.

Anal sphincter dysfunction in multiple sclerosis: an observation manometric study.

Constipation, obstructed defecation, and fecal incontinence are frequent complaints in multiple sclerosis. The literature on the pathophysiological mechanisms underlying these disorders is scant. Using anorectal manometry, we compared the anorectal function in patients with and without multiple sclerosis. 136 patients referred from our Center for Multiple Sclerosis to the Coloproctology Outpatient Clinic, between January 2005 and December 2011, were enrolled. The patients were divided into four groups: multiple sclerosis patients with constipation (group A); multiple sclerosis patients with fecal incontinence (group B); non-multiple sclerosis patients with constipation (group C); non-multiple sclerosis patients with fecal incontinence (group D). Anorectal manometry was performed to measure: resting anal pressure; maximum squeeze pressure; rectoanal inhibitory reflex; filling pressure and urge pressure. The difference between resting anal pressure before and after maximum squeeze maneuvers was defined as the change in resting anal pressure calculated for each patient. RESULTS: Group A patients were noted to have greater sphincter hypotonia at rest and during contraction compared with those in group C (p=0.02); the rectal sensitivity threshold was lower in group B than in group D patients (p=0.02). No voluntary postcontraction sphincter relaxation was observed in either group A or group B patients (p=0.891 and p=0.939, respectively). CONCLUSIONS: The decrease in the difference in resting anal pressure before and after maximum squeeze maneuvers suggests post-contraction sphincter spasticity, indicating impaired pelvic floor coordination in multiple sclerosis patients. A knowledge of manometric alterations in such patients may be clinically relevant in the selection of patients for appropriate treatments and for planning targeted rehabilitation therapy.

Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy.

BACKGROUND: Surgical informed consent forms can be complicated for patients to read and understand. We created a consent form with key information presented in bulleted texts and diagrams combined in a graphical format to facilitate the understanding of information during the verbal consent discussion. METHODS: This prospective, randomized study involved 70 adult patients awaiting cholecystectomy for gallstones. Consent was obtained after standard verbal explanation using either a graphically formatted (study group, n=33) or a standard text document (control group, n=37). Comprehension was evaluated with a 9-item multiple-choice questionnaire administered before surgery and factors affecting comprehension were analyzed. RESULTS: Comparison of questionnaire scores showed no effect of age, sex, time between consent and surgery, or document format on understanding of informed consent. Educational level was the only predictor of comprehension. CONCLUSIONS: Simplified surgical consent documents meet the goals of health literacy and informed consent. Educational level appears to be a strong predictor of understanding.

Abdominal compartment syndrome and open abdomen management with negative pressure devices.

BACKGROUND: Abdominal compartment syndrome (ACS) is defined as an increase of intra-abdominal pressure (IAH) to values higher than 20 mmHg, associated with reduced perfusion and organ dysfunction. MATERIALS AND METHODS: There is a classification of open abdomen which stratifies patients according to the natural history of improvement or clinical deterioration. The aim of treatment is to maintain the open abdomen at the lowest level and to prevent progression to a more complex level. DISCUSSION: Surgical treatment essentially consists in abdominal decompression by leaving the abdomen open. Analysis of the literature shows that negative pressure increases the rate of primary fascial closure; entero-cutaneous fistulas are seen in a minority of cases, without seeming consequence of the application of the dressing. Open abdomen management consists of three treatment stages: acute (24-48 hours), intermediate (from 48 hours to 10 days) and late or reconstruction (from 10 days to the final closure). CONCLUSION: It's important to recognize patients at risk of IAH and the first signs of ACS and intervene early with abdominal decompression if this will establish itself. Management of the open abdomen is now facilitated by negative pressure devices, which positively affect the morbidity and mortality of patients with ACS.

An unusual evolution of a case of Klippel-Trenaunay syndrome.

Klippel-Trenaunay syndrome (KTS) is a rare congenital disorder. KTS can be diagnosed on the basis of any 2 of 3 features: cutaneous capillary malformations, soft tissue or bony hypertrophy and varicose veins. We present an unusual case of KTS complicated by an infection of venous ulcers of the lower limb by larvae. The treatment of infection was a complete debridement; however baseline treatment of KTS is still in evaluation.

Abnormal right hepatic artery injury resulting in right hepatic atrophy: diagnosed by laparoscopic cholecystectomy.

An intact hepatic artery is the gateway to successful hepato-biliary surgery. Introduction of laproscopic cholecystectomy (LC) has stimulated a renewed interest in the anatomy of hepatic artery. In this case report we have highlighted importance of variations of right hepatic artery in terms of origin and course We present a rare asymptomatic case of liver atrophy due to an intraoperative lesion of right hepatic artery. We also performed a literature review about surgical vascular lesions and tried to confirm the right concept behind "non trivial procedure" of the LC.

Difficult abdominal access in laparoscopic cholecystectomy in elderly patients: our experience and literature review.

Laparoscopic cholecystectomy (LC) is currently the gold standard treatment for symptomatic cholelithiasis. LC is actually condidered a medium complexity surgical operation. LC could be technically hard, especially if patient underwent previous surgical operation. These difficulties increase in outcome of previous operation in right upper quadrant (RUQ): in this case laparoscopic access is defined as an "hard access". We present two cases in which an unconventional access was performed: laparoscopic cholecistectomy is a safe and feasible procedure, although a careful assessment preoperative is indispensable. In particular, caution is required in both the triangulation of the trocar, which in pneumoperitoneum induction.

Fibrin glue versus stapler fixation in laparoscopic transabdominal inguinal hernia repair: a single center 5-year experience and analysis of the results in the elderly.

INTRODUCTION: Inguinal hernia surgery is one of the most common surgical procedures performed worldwide. Some studies demonstrated clear advantages of laparoscopic approach in terms of chronic pain, recurrence rate and daily life activities Aim of this study was to compare short and long-terms outcome of tacks and fibrin glue used during laparoscopic transabdominal hernioplasty (TAPP). METHODS: This is a retrospective study conducted by our division of General Surgery. From May 2008 to May 2013 we performed 116 hernioplasty with TAPP technique. We compared two groups of patients: a group of 59 patients treated with fibrin glue and a group of 57 patients treated with conventional tacks and the two subgroups of patients over 65 years old. We evaluated: perioperative outcomes, early and late complications. RESULTS: There were no significative difference about length of postoperative stay, time to return to work, recurrence rate and complications. DISCUSSION: This study demonstrates that fibrin glue are same tolerated than tacks by patients and that the glues lead to the same good results during initial follow-up and in long term data also in the elderly. Meticulous preparation of the groin with preservation of spermatic sheet is in our opinion necessary to provide effective pain reduction and a good result in every TAPP procedure.

Percutaneous drainage and sclerosis of mesenteric cysts: literature overview and report of an innovative approach.

We present the case of a 29-years-old male patient, affected by a voluminous post-traumatic mesenteric cyst, a rare abdominal disease; our patient represents a rarely affected age group. Treatment was based on interventional radiology with an US-guided drainage and sclerosis by ethyl alcohol of the lesion. The intervention performed on this patient represents the application of a standardized radiological technique to a new contest, mesenteric cysts, whose gold-standard treatment is represented in literature by surgery. In our case we obtained an optimal result, with complete regression of the treated cyst: it proved to be an effective, feasible, safe and minimally invasive procedure.

Endorectal ultrasound in the diagnosis of rectal cancer: accuracy and criticies.

INTRODUCTION: Endorectal ultrasound (ERU) is used for locoregional staging of rectal cancer. Our work compares the data in the literature regarding diagnostic accuracy of the technique and results of routine use of the technique in two centers in Piedmont. MATERIAL AND METHODS: 77 reports ultrasound with the final diagnosis of rectal cancer from the period 2008-2012 were examined. The echographies were performed by two experienced operators, using two ultrasound device with the same technical characteristics. RESULTS: Sensitivity levels are high, with the exception of stage T3. Specificity is always high. The relationships of verisimilitude, both negative and positive, showing that the accuracy of the test is still high. The risk of overstaging is higher for pT1, while most important the risk of understaging concerns the stage T3 (23.5%); on the contrary the ERU is able to exclude infiltration of perirectal organs with a good accuracy (NPV of 99.3%). CONCLUSION: Although our study was a retrospective study, likewise some literature's reports, the interpretation of our analysis results shows a significant risk of downstaging T3 and N+ tumors. ERU represents in our experience a very important radiological staging methods to evaluate T1 and T2 rectal cancer.

Perioperative and postoperative outcomes of perforated diverticulitis Hinchey II and III: open Hartmann's procedure vs. laparoscopic lavage and drainage in the elderly.

Hartmann's procedure (HP) is the most performed technique for acute diverticulitis. Laparoscopic lavage and drainage (LLD) is an option evaluated as definitive treatment for diverticulitis Hinchey grade II-III. Aim of the study is to analyze and compare LLD vs HP outcomes. From January 1st 2009 and December 31st 2012 we prospectively enrolled 30 patients with diagnosis of acute diverticulitis Hinchey grade II-III. Fourteen patients underwent to LLD (LLD group, LLDG) and 16 patients to HP (Hartmann group, HG). We evaluated: demographic variables, comorbidities, admission clinical status, radiological imaging, intraoperative outcomes (operative time), postoperative outcomes (admission to ICU, timing of drainage removal, restore of bowel functions, timing of oral solid intake), mortality rate (perioperative and after 12 months) and morbidity rate (surgical, infectious, cardiovascular, renal and systemic complications). Exclusion criteria were: other diseases, colon cancer's suspect or diagnosis, conversion to HP. Patients' mean age was 64.8 years in HG and 62.6 in LLDG. M:F ratio was 6:10 in HG, 8:6 in LLDG. Data showed improved outcomes in LLDG for: total operative time (p < 0.0001), admission to ICU (p 0.0447), restoration of bowel functions (p 0.0035 for gases, p 0.0152 for feces), mobilization (p 0.0087) and length of hospital stay (p 0.0132). According to literature, LLD is related to operative risk, morbidity and mortality rate and length of stay lower than HP. LLD also gives the possibility to avoid stoma. Despite limits of our study, we consider LLD as a "safe and effective" treatment for Hinchey grade II-III acute diverticulitis.

ACTH-secreting neuroendocrine pancreatic tumor: a case report.

INTRODUCTION: Incidence of neuroendocrine tumor (NET) is increased in the last thirty years from 1.1 to 5.2 cases per 100,000 people in the United States. They can originate from the pancreatic gland and for the majority of cases are not functioning (80%). A small percentage of functioning may produce adrenocorticotropic hormone (ACTH) and lead to ectopic ACTH Syndrome (EAS), responsible of Cushing-Syndrome. RESULTS: We present a case of a 30 year-old woman suffering from EAS due to a neoformation of the pancreatic tail of the maximum diameter of 4 cm. The lesion was resectable at preoperatory imaging. The patient was subjected to distal splenopancreasectomy. Histological examination showed a well-differentiated neuroendocrine carcinoma pT3N0. The postoperative course was regular. At two years of follow-up patient is almost completely asymptomatic for Cushing's but she has developed multiple liver metastases, for which she began chemotherapy. DISCUSSION: p-NET responsible for EAS is usually malignant and the radical treatment of excision of the lesion is not possible because they occur at the time of diagnosis with liver metastases or unresectable. Our patient had a mass at the time of diagnosis resectable but despite radical surgery, she has developed multiple liver metastases at two years and she was undergoing chemotherapy. CONCLUSIONS: In agreement with previous literature we confirm the aggressive nature of pancreatic tumors secreting ACTH, despite radical surgery. Conversely, surgical treatment is effective on the resolution of clinical symptoms.

Laparoscopic appendectomy in the elderly: our experience.

BACKGROUND: Laparoscopic appendectomy for acute appendicitis is one of the most common surgical procedures performed in the world. We aimed to compare laparoscopic and open appendectomy in the elderly in our experience. METHODS: We performed a retrospective review of elderly patients who underwent appendectomy for acute appendicitis from 1st of January 2006 to the 31st of July 2012. We analyzed 39 appendectomies in elderly patients: 20 procedures were performed using open technique (Group O) and 19 using laparoscopic technique (Group L). RESULTS: In the analysis of intraoperative variables there was no statistically significant difference. In this study there was no statistically significant difference also in peri-operative variables. CONCLUSION: Laparoscopic appendectomy is a safe and feasible technique in acute appendicitis also in the elderly.

Laparoscopic repair of wound defects in the elderly: our experience of 5 years.

BACKGROUND: Laparoscopic approach for wound defects is a procedure that aims to reduce surgical aggressiveness against the abdominal wall by using minimal incisions and dedicated instruments. METHODS: We report our experience about clinical outcome of elderly patients undergoing laparoscopic repair for incisional hernias (Group I) and primary inguinal hernias (Group II) from June 2007 to September 2012. RESULTS AND DISCUSSION: In our experience there was no significant difference in laparoscopic procedure between normalweight and overweight patients. CONCLUSIONS: Laparoscopic repair for primary inguinal hernias and incisional ventral hernias with transabdominal placement of composite mesh in the elderly achieves excellent results with lower morbidity in comparison with open surgical approaches.

Transabdominal pre-peritoneal mesh in inguinal hernia repair in elderly: end point of our experience.

BACKGROUND: Aim of this study is to present our standardized laparoscopic transabdominal preperitoneal hernia repair (TAPP) technique, and to study our experience in the elderly as far as concerns preoperative and postoperative variables. METHODS: We described our standardized TAPP technique according with Stuttgart technique 1, and we evalutated our team's experience in TAPP inguinal hernia repair in elderly (> 65 yrs) and in young patients (< 65 yrs). RESULTS: We retrospectively reviewed our Surgery Division's experience about TAPP; we included in our study 185 patients. The sample was subdivided in two groups: TAPP Group (< 65 years patients) and TAPPe Group (> 65 years patients). TAPP Group was composed by 154 patients and TAPPe Group of 31 patients. According with literature, in this subgroup recurrence rate (3,2%), early and delayed complications and mean operative time (86 min). There were no major vascular or intestinal complications. At the moment follow-up is 31 months. There were no incisional hernias on umbilical trocar. Mean satisfaction rate was excellent also in elderly patients. CONCLUSIONS: According with literature, in our experience TAPP technique is a safe and feasible procedure, even in elderly patients.

Diagnosis of incidental gallbladder cancer after laparoscopic cholecystectomy: our experience.

BACKGROUND: Gallbladder carcinoma is a rare high malignancy neoplasm. The incidence of intra or post-operative incidental gallbladder carcinoma diagnosis is estimated between 0,2 and 2,8%. Primary aim of our study is to evaluate incidental gallbladder carcinoma's incidence in our experience. METHODS: We retrospectively reviewed our Surgery Division's experience about the totality of laparoscopic cholecystectomies with post-operative histological evidence of incidental gallbladder cancer. We evaluated patients' characteristics, surgical related variables, histological response, surgivcal radicalization characteristics and surgical outcome. RESULTS: In the considered sample we observed 7 accidental gallbladder adenocarcinomas in post-operative histological examination. Pathological results were:1 pT1b N0 (G1), 2 pT2 N0 (G2), 2 pT2 N1 (G3b), 2 pT3 N1 (G3b) (Table 1). In 5 cases we performed neoplasm radicalization surgery with standard procedure revision. Two patients died before radicalization. Median global survival was 34 months. CONCLUSION: With the increase of laparoscopic cholecystectomies both elective and urgent performed in our centre we observed also an increase of incidentally diagnosed gallbladder neoplasms. Early diagnosis, meticulous peri-operative study and accurate surgical strategy are essential factors to obtain good results in incidental gallbladder cancer.