Impact of enhanced recovery program on clinical outcomes after elective colorectal surgery in a rural hospital. A single center experience.

Background: The main purpose was to determine the impact on postoperative outcomes of a standardized enhanced recovery program (ERP) for elective colorectal surgery in a rural hospital. Methods: A prospective series of patients (N = 80) undergoing elective colorectal resection completing a standardized ERP protocol in 2018-2020 (ERP group) was compared to patients (N = 80) operated at the same rural hospital in 2013-2015 (pre-ERP group), before the implementation of the program. The exclusion criteria for both groups were: ASA score IV, TNM stage IV, inflammatory bowel disease, emergency surgery, and rectal cancer. The primary outcome was hospital length of stay (LoS) which was used as an estimate of functional recovery. Secondary outcomes included 30-day readmission and mortality rates as well as associated factors with both postoperative complications and prolonged hospital LoS. Results: Baseline characteristics were comparable in both groups. The median adherence to ERP protocol elements was 68 % versus 12 % in the retrospective control group. The median hospital LoS in the ERP-group was significantly lower than in the pre-ERP group (5 vs. 10 days) with no increase in 30-day readmission and mortality rates. The Body Mass Index ≥30 and the traditional peri-operative protocol were the associated factors to postoperative complications, while following a traditional peri-operative protocol was the only factor associated with a prolonged hospital LoS (p < 0.0001). Conclusions: Although limited hospital resources are perceived as a barrier to ERP implementation, the current experience demonstrates how adopting an ERP program in a rural area is feasible and effective, despite it requires greater effort.

Incisional Hernia After Laparoscopic Right Colectomy for Colorectal Cancer: A Prospective Study with Retrospective Control on Intracorporeal Versus Extracorporeal Anastomosis.

Background: Incisional hernias often occur after laparoscopic colorectal surgery, but the precise risk factors are not fully understood. This study's primary aim was to compare the incidence of incisional hernias following laparoscopic right colectomy with intracorporeal anastomotic reconstruction (ICA) versus extracorporeal anastomotic reconstruction (ECA). Materials and Methods: A cohort study compared two groups of patients who underwent elective laparoscopic right colectomy for colon cancer following a standardized perioperative enhanced recovery program (ERP): a prospective group underwent ICA from January 2018 to February 2020 and a retrospective group underwent ECA from January 2013 to December 2016. The presence of incisional hernias was assessed by reviewing patients' follow-up computed tomography scans or evaluating the patients by telephone interview or outpatient office visit and diagnostic imaging. Secondary objectives included the hospital length of stay, postoperative complications, 30-day readmission rate, reoperation, and mortality. Results: The study included 89 patients who had laparoscopic right colectomy for malignant colon neoplasms. Among these, 48 underwent ECA (ECA group), and 41 had ICA (ICA group). At a median follow-up of 36 months, incisional hernia was observed in 1 patient (2.4%) in the ICA group, in contrast to 11 (22.9%) confirmed cases in the ECA group (P = .010). The length of hospital stay was similar between the two groups (5 days versus 4 days; P = .064). The two groups showed similarities in terms of postoperative complications (P = .093), hospital readmission (P = .999), and the rate of reoperation within 30 days (P = .461). Conclusions: The ICA technique was associated with a reduced risk of incisional hernias compared with the ECA technique, with similar outcomes in short-term postoperative complications and overall patient recovery.

Predictive Factors of Recurrence After Laparoscopic Incisional Hernia Repair: A Retrospective Multicentre Cohort Study.

Background: The main purpose of this study was to analyze patient-related factors that may influence the risk of hernia recurrence following laparoscopic incisional hernia repair (LIHR), including the potential role of chosen materials. Materials and Methods: A multicenter, retrospective cohort study was conducted on all patients who were aged >18 years and who underwent elective laparoscopic incisional hernia mesh repair at the Departments of Surgery of the S. Anna University Hospital in Ferrara and Sassuolo Hospital in Modena, Italy. Exclusion criteria were as follows: patients undergoing an open or emergency incisional hernia repair or with primary ventral hernia. All hernia and operative variables that may favor hernia recurrence were collected and analyzed. Follow-up was conducted through a standardized telephone interview, followed by an outpatient visit and diagnostic imaging if needed. Results: From September 2002 to September 2017, 312 consecutive patients underwent elective laparoscopic incisional hernia mesh repair. At a mean 22-month follow-up, 273 patients presented no recurrence of incisional hernia and 39 had relapsed. Intra- and postoperative complications were similar between groups. Unadjusted Cox regression analysis showed a statistically significant association between both the partially absorbable mesh (P < .0001) and absorbable tacks (P = .001) and recurrence, while after adjusting for potential confounders, only the partially absorbable mesh was significantly associated with recurrence (P = .007). Conclusions: The laparoscopic approach may be considered safe for incisional hernia mesh repair. In this multicenter, retrospective cohort study, the use of a partially absorbable mesh in LIHR was the only predictor of hernia recurrence. The partially absorbable mesh that was investigated, however, has been withdrawn from the market.

Patients with an Open Abdomen in Asian, American and European Continents: A Comparative Analysis from the International Register of Open Abdomen (IROA).

BACKGROUND: International register of open abdomen (IROA) enrolls patients from several centers in American, European, and Asiatic continent. The aim of our study is to compare the characteristics, management and clinical outcome of adult patients treated with OA in the three continents. MATERIAL AND METHODS: A prospective analysis of adult patients enrolled in the international register of open abdomen (IROA). TRIAL REGISTRATION: NCT02382770. RESULTS: 1183 patients were enrolled from American, European and Asiatic Continent. Median age was 63 years (IQR 49-74) and was higher in the European continent (65 years, p < 0.001); 57% were male. The main indication for OA was peritonitis (50.6%) followed by trauma (15.4%) and vascular emergency (13.5%) with differences among the continents (p < 0.001). Commercial NPWT was preferred in America and Europe (77.4% and 52.3% of cases) while Barker vacuum pack (48.2%) was the preferred temporary abdominal closure technique in Asia (p < 0.001). Definitive abdominal closure was achieved in 82.3% of cases in America (fascial closure in 90.2% of cases) and in 56.4% of cases in Asia (p < 0.001). Prosthesis were mostly used in Europe (17.3%, p < 0.001). The overall entero-atmospheric fistula rate 2.5%. Median open abdomen duration was 4 days (IQR 2-7). The overall intensive care unit and hospital length-of-stay were, respectively, 8 and 11 days (no differences between continents). The overall morbidity and mortality rates for America, Europe, and Asia were, respectively, 75.8%, 75.3%, 91.8% (p = 0.001) and 31.9%, 51.6%, 56.9% (p < 0.001). CONCLUSION: There is no uniformity in OA management in the different continents. Heterogeneous adherence to international guidelines application is evident. Different temporary abdominal closure techniques in relation to indications led to different outcomes across the continents. Adherence to guidelines, combined with more consistent data, will ultimately allow to improving knowledge and outcome.

Non-traumatic emergency abdominal surgery in nonagenarian patients: a retrospective study.

PURPOSE: The primary aim of this study was to evaluate the 30-day survival of nonagenarian patients who underwent non-traumatic emergency abdominal surgery. Other aims were: 90-day and 12-month survival rates, the postoperative complications rate, the impact of the emergency operation on postoperative functional status, the accuracy of the P-POSSUM in predicting 30-day postoperative mortality and changes in care services after surgery. METHODS: This was a retrospective cohort study of nonagenarian patients who underwent non-traumatic emergency abdominal surgery between January 2010 and June 2017. Patients were divided in two groups according to the 30-day survival status to compare the distribution of patients' characteristics and postoperative outcomes. Overall survival was estimated using the Kaplan-Meier method. To assess the accuracy of P-POSSUM to predict 30-day mortality, a receiver operating characteristic curve and the Hosmer-Lemeshow goodness of fit test were used. RESULTS: 85 nonagenarian patients were enrolled in this study; of these, 27 (31.8%) died within 30 days. The Kaplan-Meier curve showed a rapid decline in survival over the first 30 postoperative days, followed by a more gradual reduction during the rest of the first year. The majority of patients (92.6%) who died within 30 days experienced a medical complication, with a preponderance of respiratory failure (48.2%) and multiple organ failure (33.3%). In the surviving patients, the postoperative functional status had worsened, and 64.2% of patients did not return to their original housing situation or were institutionalized. The accuracy of P-POSSUM in predicting 30-day mortality in nonagenarian patients was poor. CONCLUSIONS: This study may help doctors convey the postoperative risks of morbidity and mortality, and also to adequately inform relatives about the possible adverse discharge destination of surviving nonagenarian patients with a consequent increase in care needs.

The Impact of Suprarenal Cross-Clamping on Kidney Function in Patients Undergoing Retroperitoneal Abdominal Aortic Aneurysm Repair following an Enhanced Recovery Protocol.

BACKGROUND: The retroperitoneal approach (RP) is a well-established procedure for juxtarenal and infrarenal (IR) abdominal aortic aneurysm (AAA) repair when an endovascular option is not available. The aim of this study is to compare the effect of suprarenal (SR) and IR aortic clamping on postoperative renal function following an Enhanced Recovery Protocol (ERP). Since there are no defined guidelines within aortic surgery, we focused our attention on the role of fluid and vasopressor administration in the development of postoperative acute kidney injury (AKI). METHODS: This is a single-center retrospective cohort study on 140 RP aortic aneurysm repair patients operated between 2009 and 2019. Patients were divided in 2 groups: 24 had SR clamping and 116 IR clamping. Since 2009, at our institution all patients have followed an Enchanced Recovery Program which has been implemented as standard care for patients undergoing open AAA repair. RESULTS: The 2 groups were well matched for baseline characteristics, preoperative renal function, and comorbidity. There was an increased need for intraoperative fluids (P = 0.015), and vasopressors (P = 0.002) in the SR group compared to the IR group. Patients in the SR group showed a higher trend of postoperative AKI as opposed to the control group (37.5% vs. 19.8%), although this event was not statistically significant (P = 0.106). Acute Kidney Injury Network stage III requiring temporary dialysis occurred in only 3 patients who all belonged to the IR group. Conversely, stage I and II with a 2- or 3-fold increase in postoperative creatinine were more frequent in the SR group. However, these normalized before discharge in all cases. To the best of our knowledge, none of the above required permanent dialysis. CONCLUSIONS: The results from this study show that SR clamping during RP juxtarenal aortic aneurysm repair does not have an adverse effect on postoperative renal function in the short term. However, patients undergoing SR clamping require greater fluid and vasopressor usage, in contrast with the restrictive fluid therapy established by traditional protocols. This could be an important benchmark for future implementation of ERPs in vascular surgery, especially in open procedures requiring visceral clamping.

Enhanced Recovery Program in Laparoscopic Colorectal Surgery: An Observational Controlled Trial.

Background: Most of the evidence for enhanced recovery programs (ERPs) in colorectal surgery relies on nonrandomized studies with control groups either historical or operated on at different facilities. The aim of this study was to investigate ERP in coeval groups admitted in different wards at the same hospital. Materials and Methods: A prospective cohort of consecutive patients (n = 100) undergoing elective laparoscopic colorectal resection completing a standardized ERP (ERP group) was compared with patients (n = 100) operated with traditional perioperative care in the same period at the same institution (non-ERP group). The two groups were located in separate wards and shared the same anesthesiologists. The exclusion criteria were: >80 years old, American Society of Anesthesia (ASA) IV, metastatic disease, and inflammatory bowel disease. The primary outcome was hospital length of stay (LoS), used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, readmission rate, mortality, and protocol adherence. Results: The ERP group protocol adherence was 81%. The LoS was significantly reduced in the ERP group (4 versus 7 days). The number of 30-day postoperative complications was lower in the ERP group (P < .001). No increase was found in 30-day readmission or mortality. Conventional perioperative protocol was the only predictor of any postoperative complication and, together with male sex and age 65-74 years old, was the only factor associated with prolonged LoS. Conclusion: Implementing a colorectal ERP is feasible, safe, and efficient for functional recovery, but high protocol adherence is needed. Following traditional perioperative care is associated with more postoperative complications and prolonged LoS.

The long-term prognostic impact of sentinel lymph node biopsy in patients with primary cutaneous melanoma: a prospective study with 10-year follow-up.

PURPOSE: Sentinel lymph node (SLN) biopsy (SLNB) is widely accepted for staging of melanoma patients. It has been shown that clinico-pathological features such as Breslow thickness, ulceration, age, and sex are better predictors of relapse and survival than SLN status alone. The aims of this study were to evaluate the long-term (10-year) prognostic impact of SLNB and to determine predictive factors associated with SLN metastasis, relapse, and melanoma specific mortality (MSM). METHODS: This was a prospective observational study on 289 consecutive patients with primary cutaneous melanoma who underwent SLNB from January 2000 to December 2007, and followed until January 2014, at an Italian academic hospital. RESULTS: SLN was positive in 64 patients (22.1%). The median follow-up was 116 months (79-147 months). Ten-year disease-free survival and melanoma specific survival were poor in patients with positive SLN (58.7% and 66.4%, respectively). Only the increasing Breslow thickness resulted independently associated to an increased risk of SLN metastasis. Cox regression analysis showed that a Breslow thickness >2 mm was an independent predictor of relapse, and male sex and Breslow thickness >2 mm was a predictor of MSM. At 10 years, SLN metastasis was not significantly associated to either relapse or MSM. CONCLUSION: After the fifth year of follow-up, SLN metastasis is not an independent predictive factor of relapse or mortality which are mainly influenced by the characteristics of the primary tumor and of the patient. Patients with a Breslow thickness >2 mm regardless of the SLN status should be considered at high risk for 10-year relapse and mortality.

Staged Thyroidectomy: A Single Institution Perspective.

BACKGROUND: The increasing use of intraoperative neuromonitoring (IONM) in thyroid surgery has revealed the need to develop new strategies for cases in which a loss of signal (LOS) occurs on the first side of a planned total thyroidectomy. OBJECTIVES: This study reviews the experience of the authors in using IONM for planned total thyroidectomy after LOS on the first thyroid lobe. The aims were to estimate the incidence of LOS on the first side of resection and to compare intraoperative strategies applied after this event. MATERIALS AND METHODS: Intermittent IONM was performed with stimulation of both the vagal nerve and the recurrent laryngeal nerve (RLN) (V1, R1, R2, V2). Patients underwent pre- and postoperative laryngoscopy. Before surgery, patients were informed that staged thyroidectomy might be required. RESULTS: This study analyzed 803 consecutive thyroid procedures. Of these, V2 LOS (<100 mcV) occurred after first lobe exeresis in 23 (2.8%) procedures. The surgical procedure was stopped in 20 cases (ie, staged thyroidectomy was performed). In three cases with malignancy and severe comorbidity (ASA score 3-4), total bilateral thyroidectomy was performed as planned. No cases of bilateral RLN palsy occurred. Postoperative laryngoscopy confirmed RLN palsy in 21 of the 23 cases. All true positive patients received speech therapy. Patients who had false positive LOS (n = 2) or malignancy (n = 8) and patients who were symptomatic (n = 7) received completion thyroidectomy within 6 months. One patient received radioactive iodine therapy for hyperthyroidism. Two patients received follow up. CONCLUSIONS: Neuromonitoring changes the surgical decision-making process in a multidisciplinary manner. A shared decision-making process involving the patient, anesthesiologist, and endocrinologist is suggested. In the case of intraoperative LOS on the first-operated side in a planned total thyroidectomy, the thyroid surgeon essentially has three options for surgery on the contralateral side: 1) Perform staged thyroidectomy. This option is recommended in bilateral goiter, Graves' disease, or low-risk thyroid carcinoma (differentiated or medullary thyroid carcinoma). The aim is to avoid bilateral vocal cord palsy. Two-stage completion surgery is delayed until recovery of ipsilateral nerve function. 2) Perform subtotal resection on the contralateral side ventrally to the RLN plane at a safe distance from the nerve. The aim is to avoid further disease recurrence and revision surgery. 3) Perform total thyroidectomy as planned for advanced thyroid carcinoma (including undifferentiated thyroid carcinoma). The aim is to improve disease control through radioactive iodine therapy, radiation therapy, or target therapy immediately after surgery. LEVEL OF EVIDENCE: 4.

Impact of a colorectal enhanced recovery program implementation on clinical outcomes and institutional costs: A prospective cohort study with retrospective control.

BACKGROUND: The enhanced recovery program for perioperative care of the surgical patient reduces postoperative metabolic response and organ dysfunction, accelerating functional recovery. The aim of this study was to determine the impact on postoperative recovery and cost-effectiveness of implementing a colorectal enhanced recovery program in an Italian academic centre. MATERIALS AND METHODS: A prospective series of consecutive patients (N = 100) undergoing elective colorectal resection completing a standardized enhanced recovery program in 2013-2015 (ERP group) was compared to patients (N = 100) operated at the same institution in 2010-2011 (Pre-ERP group) before introducing the program. The exclusion criteria were: >80 years old, ASA score of IV, a stage IV TNM, and diagnosis of inflammatory bowel disease. The primary outcome was hospital length of stay which was used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, 30-day readmission and mortality, protocol adherence, nursing workload, cost-effectiveness, and factors predicting prolonged hospital stay. The ERP group patient satisfaction was also evaluated. RESULTS: Hospital stay was significantly reduced in the ERP versus the Pre-ERP group (4 versus 8 days) as well as nursing workload, with no increase in postoperative complications, 30-day readmission or mortality. ERP group protocol adherence (81%) and patient satisfaction were high. Conventional perioperative protocol was the only independent predictor of prolonged hospital stay. Total mean direct costs per patient were significantly higher in the Pre-ERP versus the ERP group (6796.76 versus 5339.05 euros). CONCLUSIONS: Implementing a colorectal enhanced recovery program is feasible, efficient for functional recovery and hospital stay reduction, safe, and cost-effective. High patient satisfaction and nursing workload reduction may also be expected, but high protocol adherence is necessary.

Do I Need to Operate on That in the Middle of the Night? Development of a Nomogram for the Diagnosis of Severe Acute Cholecystitis.

BACKGROUND: Some authors have proposed different predictive factors of severe acute cholecystitis, but generally, the results of risk analyses are expressed as odds ratios, which makes it difficult to apply in the clinical practice of the acute care surgeon. The severe form of acute cholecystitis should include both gangrenous and phlegmonous cholecystitis, due to their severe clinical course, and cholecystectomy should not be delayed. The aim of this study was to create a nomogram to obtain a graphical tool to compute the probability of having a severe acute cholecystitis. METHODS: This is a retrospective study on 393 patients who underwent emergency cholecystectomy between January 2010 and December 2015 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara, Italy. Patients were classified as having a non-severe acute cholecystitis or a severe acute cholecystitis (i.e., gangrenous and phlegmonous) based on the final pathology report. The baseline characteristics, pre-operative signs, and abdominal ultrasound (US) findings were assessed with a stepwise multivariate logistic regression analysis to predict the risk of severe acute cholecystitis, and a nomogram was created. RESULTS: Age as a continuous variable, WBC count ≥ 12.4 × 103/µl, CRP ≥9.9 mg/dl, and presence of US thickening of the gallbladder wall were significantly associated with severe acute cholecystitis at final pathology report. A significant interaction between the effect of age and CRP was found. Four risk classes were identified based on the nomogram total points. CONCLUSIONS: Patients with a nomogram total point ≥ 74 should be considered at high risk of severe acute cholecystitis (at 74 total point, sensitivity = 78.5%; specificity = 78.2%; accuracy = 78.3%) and this finding could be useful for surgical planning once confirmed in a prospective study comparing the risk score stratification and clinical outcomes.

Monitored transoral endoscopic thyroidectomy via long monopolar stimulation probe.

This video aimed to describe the role of intraoperative neuromonitoring (IONM) during transoral endoscopic thyroidectomy vestibular approach (TOETVA) with emphasis given to IONM technical and technological notes, the identification of recurrent laryngeal nerve (RLN). Standardized technique of IONM consist in identifying and monitoring both the vagus nerve and the RLNs before and after resection (V1, V2, R1, R2). According to this report, IONM during TOETVA is feasible and safe in providing identification and function of laryngeal nerves. IONM enable surgeons to feel more comfortable with their initial approach to TOETVA or extended indications. Larger series are needed for appropriated evaluation of IONM in reduction of the rates for RLN complications.

The application of drains in thyroid surgery.

It has been shown that the use of drain in thyroid surgery does not reduce the reoperation rate for hemorrhage. The aim of this systematic review was to update the knowledge of the role of drain in thyroid surgery in term of postoperative complications, pain and hospital length of stay (LOS). A systematic search was performed in the PubMed and Embase database to identify all randomized controlled trials (RCTs) comparing clinical outcomes in patients who underwent thyroidectomy or lobectomy with or without drainage. The primary outcome was reoperation rate for bleeding; the secondary outcomes were development of hematoma, seroma, and wound infection; postoperative pain evaluated by Visual Analogue Scale (VAS) at the postoperative day (POD) 1, and hospital LOS. Risk ratios (RRs) and 95% confident intervals (95% CI) were used for dichotomous variables; mean differences (MDs) and 95% CI for continuous variables. Statistical heterogeneity was evaluated and its degree was quantified by the I2 statistic. Twenty RCTs were included, with 2,204 patients enrolled. No difference was found between the two groups in term of reoperation [RR 1.13 (0.43, 2.95); I2 =0%], hematoma [RR 1.18 (0.71, 1.95); I2 =0%], and seroma [RR 0.82 (0.44, 1.53); I2 =0%]. Patients with drain had higher postoperative pain [MD 1.91 (1.30, 2.53); I2 =97%], prolonged hospital LOS [MD 1.34 (0.91, 1.76) days; I2 =98%], and increased wound infection rate [RR 2.82 (1.36, 5.86); I2 =0%], even though the latter was not confirmed in the sensitivity analysis including only studies with ≥100 patients per trial. The use of drain after thyroid surgery increase postoperative pain and hospital LOS, with no decrease of reoperation rate, hematoma and seroma formation. An increased wound infection rate in patients with drain is suggested, but a large RCT should be performed to confirm this correlation.

Thyroidectomy in elderly patients aged ≥70 years.

Worldwide, the indications for thyroid surgery have been continuously extended among elderly patients in the last 20 years. The balance between treatment indication and surgical risk is certainly an interesting topic for every thyroid surgeon. This paper is a review of recent literature from January 2005 up to April 2017. We analyzed three principal subjects: indications for surgical treatment, medical complications and surgical complications. We can summarize the conclusions of our analysis, stating that age could not be considered as an absolute factor, but in relation to the comorbidities and the general clinical condition of the patient. Special risk indices dedicated to geriatric patients could be very useful in order to facilitate the decision-making process; however, relying on the current knowledge, we could state that there is value in providing surgery to geriatric patients in highly specialized and high-volume centers, where access to technology and its systematic use, coupled with surgeons' experience, could certainly avail the geriatric patient management.

The effect of an Enhanced Recovery Program in elective retroperitoneal abdominal aortic aneurysm repair.

OBJECTIVE: Enhanced Recovery Programs (ERPs) have been introduced to accelerate postoperative recovery and are mainly focused on decreasing the surgical stress response. Limited data are available regarding the implementation of ERPs in patients who undergo abdominal aortic aneurysm (AAA) repair using the retroperitoneal approach. The aims of this study were: (1) to evaluate the implementation of an ERP in patients who underwent elective retroperitoneal AAA repair; and (2) to define independent predictors of prolonged hospital length of stay (LOS) in these patients. METHODS: This was a retrospective cohort study on 221 patients who underwent elective AAA repair via a retroperitoneal approach from 2005 through 2013 at an Italian university hospital. Patients who received surgery from 2008 through 2013 and enrolled in an ERP (n = 130) were compared with those who received surgery from 2005 through 2007 and managed with traditional perioperative care (n = 91). RESULTS: Patient characteristics were comparable between groups. Intensive care unit admissions were prevalent among patients who received traditional care vs patients in the ERP (P < .01). ERP patients had fewer major (P < .01) and minor (P = .019) complications, and mortality was similar between groups. Complete functional recovery was achieved earlier in ERP patients vs controls (P < .01). Patients in the ERP group left the hospital earlier than controls (P < .01). No readmission ≤30 days were reported in the ERP group. Age ≥65 years and being in a conventional care protocol were found to be independent predictors of prolonged hospital LOS. CONCLUSIONS: The implementation of an ERP after elective AAA repair using a retroperitoneal approach reduced postoperative intensive care unit admission, accelerated functional recovery, and decreased morbidity and LOS with no readmission ≤30 days. Age ≥65 years and conventional perioperative care were the only independent predictors of prolonged LOS.

Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients.

BACKGROUND: Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy. THE AIMS OF OUR STUDY WERE: (1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy. METHODS: This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004-2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: "large" tumours were defined as ≥5 cm (N = 50) and "small" tumours as <5 cm (N = 150). Further analysis adopting a ≥8 cm (N = 15) cut-off size was performed. RESULTS: The study groups were comparable in age and gender distribution as well as their tumour characteristics. The operative time (p = 0.671), conversion rate (p = 0.488), intra- (p = 0.876) and post-operative (p = 0.639) complications, and hospital stay (p = 0.229) were similar between groups. With a cut-off size ≥5 cm, the early study period (2004-2009), which included operators' learning curve, was associated with increased risk of longer operative time (HR 0.57; 95 % CI 0.40-0.82), while American Society of Anaesthesiology score ≥3 was associated with prolonged hospital stay (HR 0.67; 95 % CI 0.47-0.97). Tumour size ≥8 cm was associated with prolonged operative time (HR 0.47; 95 % CI 0.24-0.94). CONCLUSIONS: Surgeons skilled in advanced laparoscopy and adrenal surgery can perform laparoscopic adrenalectomy safely in patients with ≥5-cm tumours with no increase in hospital stay, or conversion rate, although operative time may be increased for ≥8-cm tumours. Surgeon' experience, size ≥8 cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.

Radioguided sentinel lymph node biopsy in patients with papillary thyroid carcinoma.

BACKGROUND: The ATA guidelines do not recommend prophylactic central compartment neck dissection in patients with T1-T2 papillary thyroid carcinoma (PTC) with no clinical evidence of lymph node metastasis, however patients' staging is recommended. Lymph node metastasis may be present also in small PTC, but preoperative ultrasound identifies suspicious cervical lymphadenopathy in 20-30% of patients. The role of sentinel lymph node biopsy (SLNB) remain open to debate. It has been shown that the identification rate of SLN in PTC patients is improved using a radiotracer compared to a dye technique. The aim of this systematic review was to evaluate the role of radioguided SLNB (rSLNB) in the treatment of PTC patients. METHODS: A systematic search was performed in the PubMed and Embase database to identify all original articles regarding the application of rSLNB in PTC patients. The primary outcome was false negative rate (FNR) of the rSLNB; the secondary outcomes were SLN intraoperative identification rate (IIR), site of lymph node metastasis, and persistent disease during follow up. RESULTS: Twelve studies were included. Most of PTC patients were T1-T2. The overall SLN IIR, SLN metastatic rate, and FNR were 92.1%, 33.6%, and 25.4%, respectively. Overall, lymph node metastasis were found in the central compartment (23.0%) and in the lateral compartments (10.6%). The persistent disease in patients who underwent SLNB associated to lymph node dissection (LND) in the same compartment of the SLN regardless of the SLN status was 0.6%. CONCLUSIONS: In all PTC patients, also in T1-T2 stage, due to the high FNR the SLNB performed alone should be abandoned and converted into a technique to guide the lymphadenectomy in a specific neck compartment (i.e., central or lateral) based on the radioactivity, regardless of the SLN status, for better lymph node staging and selection of patients for postoperative radioiodine ablation.

Management of blunt splenic injuries Retrospective cohort study of early experiences in an Acute Care Surgery Service recently established.

AIM: To identify patients with splenic injuries, who should benefit from a conservative treatment, and to compare inhospital follow-up and hospital length of stay (LOS), in patients treated by non-operative management (NOM) versus immediate-splenectomy (IS). MATERIAL OF STUDY: A retrospective cohort study on consecutive patients, with all grade of splenic injuries, admitted between November 2010 and December 2014 at the Acute Care Surgery Service of the S. Anna University Hospital of Ferrara. Patients were offered NOM or IS. RESULTS: Fifty-four patients were enrolled; 29 (53.7%) underwent IS and 25 (46.3%) were offered NOM. Splenic artery angioembolization was performed in 9 patients (36%) among this latter group. High-grade splenic injuries (IVV) were more represented in IS group (65.5% vs 8%), while low grade (I-II) were more represented in NOM group (64% vs 10.3%). Failure of NOM occurred in 4 patients (16%). Hospital LOS was longer in IS group (p=0.044), while in-hospital and 30-day mortality were not statistically significant different between the two groups. CONCLUSIONS: Hemodynamically stable patients, with grade I to III of splenic injuries, without other severe abdominal organ injuries, could benefit from a NOM; the in-hospital follow-up should be done, after a control CECT scan, with US. Observation and strictly monitoring of splenic injuries treated with NOM do not affect patients' hospital los. KEY WORDS: Non-operative management, Splenic Rupture, Surgery.