Unlocking the Long-Term Effectiveness of Benralizumab in Severe Eosinophilic Asthma: A Three-Year Real-Life Study.

Background: Benralizumab has been shown to restore good control of severe eosinophilic asthma (SEA). Robust data on benralizumab effectiveness over periods longer than 2 years are scarce. Methods: This retrospective multicentric study was conducted on 108 Italian SEA patients treated with benralizumab for up to 36 months. Partial and complete clinical remission (CR) were assessed. Data were analyzed with descriptive statistics or using linear, logistic, and negative binomial mixed-effect regression models. Results: At 36 months, benralizumab reduced the exacerbation rate by 89% and increased the forced expiratory volume in 1 second (FEV1) (+440 mL at 36 months, p < 0.0001). Benralizumab improved asthma control as well as sinonasal symptoms in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP). Up to 93.33% of patients either reduced or discontinued OCS; benralizumab also decreased ICS use and other asthma medications. Overall, 84.31% of patients achieved partial or complete CR. Conclusions: Benralizumab improved asthma and sinonasal outcomes up to 36 months. These findings support the potential of benralizumab to induce CR, emphasizing its role as a disease-modifying anti-asthmatic drug for the management of SEA. Further research is warranted to expand these findings by minimizing data loss and assessing benralizumab's long-term safety.

A mini-invasive approach is feasible in patients with primary hyperparathyroidism and discordant or negative localisation studies.

Preoperative localisation of pathological glands in patients with primary hyperparathyroidism (PHP) is the mainstay for mini-invasive parathyroidectomy. Nevertheless, a not negligible number of patients presents discordant or negative neck ultrasound (US) and 99mTc-Sestamibi (MIBI) scan. The aim of this study was to assess if a mini-invasive approach is feasible in this kind of patients. In this retrospective study were included patients that underwent parathyroidectomy for PHP. Patients were divided into two groups according to concordance of US and MIBI scan results. 242 patients were included: 183 had concordant preoperative studies, and 59 had discordant or negative studies. A mini-invasive approach was possible in 42 (72.9%) patients with unclear preoperative studies, whereas 12 (20.3%) additional patients required conversion to BNE. The incidence of persistent PHP was higher in patients with unclear preoperative studies (8.5% vs 2.7%), but this difference did not reach a statistical significance (p = 0.121). In patients with unclear preoperative studies, a negative result of intraoperative PTH allowed to avoid a persistent disease in 12 patients, while in 3 cases led to an unnecessary additional exploration. In patients with discordant preoperative studies a mini-invasive approach is feasible; in this setting, the use of intraoperative PTH is mandatory to reduce the incidence of persistent PHP.

Is extensive surgery really necessary in patients with parathyroid carcinoma? Single-centre experience and a brief review of the literature.

AIM: Parathyroid carcinoma (PC) represents a rare cause of primary hyperparathyroidism (PHPT). In this paper, among patients who underwent surgery for PHPT, we compared those with benign parathyroid disease with those affected by PC in terms of demographic and preoperative biochemical features. Moreover, we singularly described all 10 cases of PC treated at our Institution (including a case that occurred in a patient with tertiary hyperparathyroidism) and a brief review of the literature. MATERIAL AND METHODS: Patients undergoing surgery for PHPT in our Unit between 2003 and 2018 were retrospectively analysed. They were divided into two groups: Group A (benign parathyroid disease), Group B (PC). The case of PC that occurred in the patient with tertiary hyperparathyroidism was not included into the two groups. RESULTS: Three hundred and eight patients were included: 299 in Group A and 9 in Group B. The mean preoperative serum PTH value and mean preoperative serum calcium level were significantly higher in Group B than in Group A (P = 0.018, P = 0.027; respectively). Including the case of PC that occurred in the patient with tertiary hyperparathyroidism, 10 patients with PC were treated at our Institution. Among these, 3 underwent a re-exploration. Disease recurrence occurred in 1 (10%) patient, who developed a local recurrence and distant metastases. CONCLUSIONS: In the presence of PHPT characterized by particularly high preoperative levels of serum PTH and calcium this malignancy should be suspected. On the basis of our experience, we believe that extensive surgery is not always necessary. KEY WORDS: Hyperparathyroidism, Parathyroid carcinoma, Parathyroid surgery.

Adrenal incidentalomas and subclinical Cushing syndrome: indications to surgery and results in a series of 26 laparoscopic adrenalectomies.

BACKGROUND: Casual detection of an adrenal mass, the so called incidentaloma (AI) requires an in-depth analysis of imaging phenotype together with hormonal investigation, in order to evaluate both its potential malignancy and the occurrence of a preclinical condition of hypercortisolism (Subclinical Cushing Syndrome, SCS). Aim of the present work is to evaluate surgical indications and results of surgery in patients harbouring an AI with inapparent hypercortisolism. METHODS: The study has been carried on in a series of 26 Laparoscopic Adrenalectomies (LA) performed from January 2009 and January 2015. Indications to surgery included AI (11 cases), Cushing's syndrome (7 cases), suspected metastases (5 cases) and Conn's disease (3 cases). Six patients with AI had a SCS associated with variable forms of a metabolic syndrome: they were evaluated in detail analysing cortisol secretion and values of Arterial Hypertension, Diabetes Mellitus and BMI before and after surgery. RESULTS: As far as SCS is concerned, LA was completed in 5 patients (one case converted). Pathology revealed 5 adenomas and one nodular hyperplasia. Four cases required oral cortisone administration at the discharge. At a mean follow- up of 33 months cortisol secretion returned to normal range in all patients; an improvement of metabolic condition was observed in 60, 25, and 50 per cent of hypertensive, diabetic and obese patients respectively. CONCLUSION: Indications to LA in case of AI and SCS is strongly supported by the presence of an associated metabolic syndrome. In spite of a limited number, our experience confirms the favourable results of surgery in such patients. KEY WORDS: Adrenal incidentaloma, Laparoscopic adrenalectomies, Subclinical Cushing syndrome.

Surgery for primary hyperparathyroidism in patients with preoperatively negative sestamibi scan and discordant imaging studies: the usefulness of intraoperative parathyroid hormone monitoring.

The aim of this study was to evaluate the impact of intraoperative parathyroid hormone (PTH) monitoring on surgical strategy, intraoperative findings, and outcome in patients with negative sestamibi scintigraphy and with discordant imaging studies. We divided our 175 patients into 3 groups: group A was methoxyisobutylisonitrile (MIBI)-positive and ultrasonography positive and was concordant (114 patients), group B was MIBI-positive and ultrasonography-negative (50 patients), and group C was MIBI-and ultrasonography-negative (11 patients). The overall operative success was 99.12% in group A, 98% in group B, and 90.91% in group C, with an incidence of multiglandular disease of 3.5% in group A, 12% in group B, and 9.09% in group C. Intraoperative PTH monitoring changed the operative management in 2.63% of patients in group A and 14% in group B. The use of intraoperative PTH achieves to obtain excellent results in the treatment of primary hyperparathyroidism in high-volume centers, even in the most difficult cases, during MIBI-negative and discordant preoperative imaging studies.

Laparoscopic adrenalectomy in a case of congenital duplication of the inferior vena cava. Case report.

INTRODUCTION: Congenital duplication of the inferior vena cava is frequently associated with other vascular anomalies of its venous tributaries. Awareness of such occurrence facilitates laparoscopic surgery and avoids inadvertent vascular injuries. CASE REPORT: An adrenal mass of increasing size was discovered in a 39 years old lady previously submitted to restorative proctocolectomy for Familial Polyposis Coli. Since the first preoperative work up, Computerized Tomography showed a duplicated inferior vena cava as well as other visceral and vascular anomalies. During laparoscopic adrenalectomy a double adrenal vein was discovered: the first one draining normally into the vena cava and the second one into the righ renal vein. Both of them were clipped and divided and surgical outcome was succesful. DISCUSSION: The progress in cross-sectional imaging made easily recognisable congenital anomalies of the inferior vena cava in patients otherwise asymptomatic. Its occurrence has been evaluated through previous reports on venous anomalies during adrenal and renal surgery as well as through angiographic studies. Knowledge of these anomalies is very important for interventional radiologists, urologists and for general surgeons. However when facing adrenal surgery the operator should be aware that a double vein can be found in up to 10% of the cases and such occurrence is more predictable in case of pheochromocytoma and of large adrenal mass. Surgeons should rely both on preoperative dignostic imaging and careful dissection through laparoscopic magnified view to avoid harmful bleeding complications.

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.

Comparison between different femoral fixation devices for ACL reconstruction with doubled hamstring tendon graft: a biomechanical analysis.

PURPOSE: The aim of the present study was to compare the mechanical behavior of some devices used for femoral fixation of doubled hamstring tendon graft in anterior cruciate ligament (ACL) reconstruction when included in a graft fixation complex (GFC). METHODS: An ACL reconstruction was performed on 90 porcine knees. The graft used was the doubled lateral extensor of toes (DLET). Nine different femoral fixation devices were tested and classified according to their fixation mechanism: compression (Bioscrew and RCI screw); expansion (Rigidfix); cortical suspension (Ligament Anchor, EndoButton-CL, and Swing Bridge); cancellous suspension (Linx-HT); and cortical-cancellous suspension (Transfix and Bio-Transfix). All GFC were subjected to a cyclic loading test, then to a load-to-failure test. Graft elongation after 1,000 load cycles, failure load, and stiffness were calculated for each device. RESULTS: Regarding graft elongation, Bioscrew and RCI screws showed the highest mean values. All the other GFC showed no significant differences between them when delta elongation (elongation(1,000 cycles) - elongation(20 cycles)) was considered. For failure load, the highest mean values were observed for Bio-Transfix, Transfix, and Swing Bridge; a homogeneous subset with the lowest mean values was formed by Ligament Anchor, RCI screw, Bioscrew, and Linx-HT. For stiffness, the greatest values were observed for Bio-Transfix, Transfix, and Swing Bridge; all other groups showed no significant differences between them. CONCLUSIONS: Cortical-cancellous suspension fixation seemed to offer the best and most predictable results in terms of elongation, fixation strength, and stiffness. For both compression and suspension, the weakest fixation was attained with cancellous fixation devices. Cortical suspension devices showed a greatly variable mechanical behavior, according to their design. CLINICAL RELEVANCE: Transcondylar devices offer the best structural properties for femoral fixation of doubled hamstring tendon graft in ACL reconstruction.