Parathyroid Retrospective Analysis of Neoplasms Incidence (pTRANI Study): An Italian Multicenter Study on Parathyroid Carcinoma and Atypical Parathyroid Tumour.

BACKGROUND: Parathyroid cancer (PC) is a rare sporadic or hereditary malignancy whose histologic features were redefined with the 2022 WHO classification. A total of 24 Italian institutions designed this multicenter study to specify PC incidence, describe its clinical, functional, and imaging characteristics and improve its differentiation from the atypical parathyroid tumour (APT). METHODS: All relevant information was collected about PC and APT patients treated between 2009 and 2021. RESULTS: Among 8361 parathyroidectomies, 351 patients (mean age 59.0 ± 14.5; F = 210, 59.8%) were divided into the APT (n = 226, 2.8%) and PC group (n = 125, 1.5%). PC showed significantly higher rates (p < 0.05) of bone involvement, abdominal, and neurological symptoms than APT (48.8% vs. 35.0%, 17.6% vs. 7.1%, 13.6% vs. 5.3%, respectively). Ultrasound (US) diameter >3 cm (30.9% vs. 19.3%, p = 0.049) was significantly more common in the PC. A significantly higher frequency of local recurrences was observed in the PC (8.0% vs. 2.7%, p = 0.022). Mortality due to consequences of cancer or uncontrolled hyperparathyroidism was 3.3%. CONCLUSIONS: Symptomatic hyperparathyroidism, high PTH and albumin-corrected serum calcium values, and a US diameter >3 cm may be considered features differentiating PC from APT. 2022 WHO criteria did not impact the diagnosis.

Mastectomy with one-stage or two-stage reconstruction in breast cancer: analysis of early outcomes and patient's satisfaction.

Aim of this study is to compare early post-operative outcomes and patient's satisfaction after skin-sparing and/or nipple-sparing mastectomy (SSM/SNSM) followed either by breast reconstruction with one-stage prepectoral implantation or two-stage technique for breast cancer (BC) or BRCA1/2 mutation.From January 2018 to December 2021, 96 patients (mean age of 51.12 ± 10.9) underwent SSM/SNSM and were divided into two groups: in group A (65 patients, 67.7%), mastectomy was followed by one-stage reconstruction; in group B (31 patients, 32.3%) by two-stage. Operative time was significantly longer in A vs. B (307.6 ± 95.7 vs. 254.4 ± 90.91; P < 0.05). Previous breast surgery was more common in B vs. A (29.0% vs. 7.7%; P < 0.05), while bilateral surgery was performed more frequently in A vs. B (40% vs. 6.5%; P = 0.001). All SSM/SNSM for BRCA1/2 mutation were followed by immediate prepectoral implantation. No significant differences were found between groups in terms of post-operative complications. At pathology, DCIS and invasive ST forms, such as multicentric/multifocal forms, were detected more frequently in B, while NST type in A (all P < 0.05). A multivariate analysis showed improved post-operative satisfaction at BREAST-Q survey in Group A (P = 0.001). Encouraging oncologic outcomes after SSM/SNSM for BC enabled the improvement of breast reconstructive techniques. One-stage reconstruction is characterized by better aesthetic outcomes and by greater patient's satisfaction. When SSM/SNSM is technically difficult to perform, as in multicentric/multifocal forms or previous breast surgery, mastectomy followed by two-stage reconstruction should be considered to achieve a radical surgery.

Intraabdominal sporadic desmoid tumors and inflammation: an updated literature review and presentation and insights on pathogenesis of synchronous sporadic mesenteric desmoid tumors occurring after surgery for necrotizing pancreatitis.

Sporadic intra-abdominal desmoid tumors are rare and known to potentially occur after trauma including previous surgery, although knowledge of the underlying pathogenetic mechanism is still limited. We reviewed the recent literature on sporadic intraabdominal desmoids and inflammation as we investigated the mutational and epigenetic makeup of a case of multiple synchronous mesenterial desmoids occurring after necrotizing pancreatitis. A 62-year-old man had four mesenteric masses up to 4.8 cm diameter detected on CT eighteen months after laparotomy for peripancreatic collections from necrotizing pancreatitis. All tumors were excised and diagnosed as mesenteric desmoids. DNA from peripheral blood was tested for a multigene panel. The tumour DNA was screened for three most frequent ß-catenin gene mutations T41A, S45F and S45P. Expression levels of miR-21-3p and miR-197-3-p were compared between the desmoid tumors and other wild-type sporadic desmoids. The T41A CTNNB1 mutation was present in all four desmoid tumors. miR-21-3p and miR-197-3p were respectively upregulated and down-regulated in the mutated sporadic mesenteric desmoids, with respect to wild-type lesions. The patient is free from recurrence 34 months post-surgery. The literature review did not show similar studies. To our knowledge, this is the first study to interrogate genetic and epigenetic signature of multiple intraabdominal desmoids to investigate potential association with abdominal inflammation following surgery for necrotizing pancreatitis. We found mutational and epigenetic features that hint at potential activation of inflammation pathways within the desmoid tumor.

Retrospective Study of Indications and Outcomes of Open Abdomen with Negative Pressure Wound Therapy Technique for Abdominal Sepsis in a Tertiary Referral Centre.

In patients with advanced sepsis from abdominal disease, the open abdomen (OA) technique as part of a damage control surgery (DCS) approach enables relook surgery to control infection, defer intestinal anastomosis, and prevent intra-abdominal hypertension. Limited evidence is available on key outcomes, such as mortality and rate of definitive fascial closure (DFC), which are needed for surgeons to select patients and adequate therapeutic strategies. Abdominal closure with negative pressure wound therapy (NPWT) has shown rates of DFC around 90%. We conducted a retrospective study to evaluate in-hospital survival and factors associated with mortality in acute, non-trauma patients treated using the OA technique and NPWT for sepsis from abdominal disease. Fifty consecutive patients treated using the OA technique and NPWT between February 2015 and July 2022 were included. Overall mortality was 32%. Among surviving patients, 97.7% of cases reached DFC, and the overall complication rate was 58.8%, with one case of entero-atmospheric fistula. At univariable analysis, age (p = 0.009), ASA IV status (<0.001), Mannheim Peritonitis Index > 30 (p = 0.001) and APACHE II score (p < 0.001) were associated with increased mortality. At multivariable analysis, higher APACHE II was a predictor of in-hospital mortality (OR 2.136, 95% CI 1.08−4.22; p = 0.029). Although very resource-intensive, DCS and the OA technique are valuable tools to manage patients with advanced abdominal sepsis, allowing reduced mortality and high DFC rates.

Effect of Antibiotic Prophylaxis on Surgical Site Infection in Thyroid and Parathyroid Surgery: A Systematic Review and Meta-Analysis.

Thyroid and parathyroid surgery are considered clean procedures, with an incidence of surgical site infection (SSI) after thyroidectomy ranging from 0.09% to 2.9%. International guidelines do not recommend routine antibiotic prophylaxis (AP), while AP seems to be employed commonly in clinical practice. The purpose of this systematic review is analyzing whether the postoperative SSI rate in thyroid and parathyroid surgery is altered by the practice of AP. We searched Pubmed, Scopus, the Cochrane Library, and Web of Science (WOS) for studies comparing AP to no preoperative antibiotics up to October 2021. Data on the SSI rate was evaluated and summarized as relative risks (RR) with 95% confidence intervals (95% CI). Risk of bias of studies were assessed with standard methods. Nine studies (4 RCTs and 5 nRCTs), including 8710 participants, were eligible for quantitative analysis. A meta-analysis showed that the SSI rate was not significantly different between AP and no preoperative antibiotics (SSI rate: 0.6% in AP vs. 2.4% in control group; RR 0.69, 0.43-1.10 95% CI, p = 0.13, I2 = 0%). A sensitivity analysis and subgroup analysis on RCTs were consistent with the main findings. Evidence of low quality supports that AP in thyroid and parathyroid surgery produce similar SSI rates as to the absence of perioperative antibiotics.

Prognostic and Therapeutic Role of Angiogenic Microenvironment in Thyroid Cancer.

Thyroid cancer is the most common endocrine malignancy, with a typically favorable prognosis following standard treatments, such as surgical resection and radioiodine therapy. A subset of thyroid cancers progress to refractory/metastatic disease. Understanding how the tumor microenvironment is transformed into an angiogenic microenvironment has a role of primary importance in the aggressive behavior of these neoplasms. During tumor growth and progression, angiogenesis represents a deregulated biological process, and the angiogenic switch, characterized by the formation of new vessels, induces tumor cell proliferation, local invasion, and hematogenous metastases. This evidence has propelled the scientific community's effort to study a number of molecular pathways (proliferation, cell cycle control, and angiogenic processes), identifying mediators that may represent viable targets for new anticancer treatments. Herein, we sought to review angiogenesis in thyroid cancer and the potential role of proangiogenic cytokines for risk stratification of patients. We also present the current status of treatment of advanced differentiated, medullary, and poorly differentiated thyroid cancers with multiple tyrosine kinase inhibitors, based on the rationale of angiogenesis as a potential therapeutic target.

Introducing routine intraoperative nerve monitoring in a high-volume endocrine surgery centre: a health technology assessment.

We sought to analyse the effect of the introduction of intraoperative nerve monitoring (IONM) in our routine surgical practice and to provide a circumstantial analysis of direct costs of IONM in total thyroidectomy and of indirect costs associated with vocal fold palsy, as centred in the health care system of Italy. We retrospectively compared outcomes of 232 total thyroidectomies performed between November 2017 and October 2019, respectively, before (109 TT-Group A) and after (123 TT-Group B) adopting IONM technology in November 2018. We analysed the costs of IONM per procedure and rate and costs of vocal fold palsy events (temporary and permanent). Overall, there were 61 thyroid cancers (32 in Group B) and 171 multinodular goitres (91 in Group B). We recorded 5 cases of vocal fold palsy (4.6%-4 transient, 1 permanent) in Group A and none in Group B (p = 0.016). IONM consumables cost 219 eur per case. Healthcare and social cost of Vocal fold palsy ranged between 3200 eur (function recovery < 1 month postoperatively) and over 32,000 eur (permanent event). When only direct costs are considered, IONM can hardly be cost effective. In this study, cost of IONM implementation was offset by the absence of complications attributable to recurrent laryngeal nerve dysfunction.

The Value of Intraoperative Ultrasound in Selective Lateral Cervical Neck Lymphadenectomy for Papillary Thyroid Cancer: A Prospective Pilot Study.

(1) Background: Lymph node metastases from papillary thyroid cancer (PTC) are frequent. Selective neck dissection (SND) is indicated in PTC with clinical or imaging evidence of lateral neck nodal disease. Both preoperative ultrasound (PreUS) and intraoperative palpation or visualization may underestimate actual lateral neck nodal involvement, particularly for lymph-nodes located behind the sternocleidomastoid muscle, where dissection may also potentially increase the risk of postoperative complications. The significance of diagnostic IOUS in metastatic PTC is under-investigated. (2) Methods: We designed a prospective diagnostic study to assess the diagnostic accuracy of IOUS compared to PreUS in detecting metastatic lateral neck lymph nodes from PTC during SND. (3) Results: There were 33 patients with preoperative evidence of lateral neck nodal involvement from PTC based on PreUS and fine-needle cytology. In these patients, IOUS guided the excision of additional nodal compartments that were not predicted by PreUS in nine (27.2%) cases, of which eight (24.2%) proved to harbor positive nodes at pathology. The detection of levels IIb and V increased, respectively, from 9% (PreUS) to 21% (IOUS) (p < 0.0001) and from 15% to 24% (p = 0.006). (4) Conclusions: In the context of this study, IOUS showed higher sensitivity and specificity than PreUS scans in detecting metastatic lateral cervical nodes. This study showed that IOUS may enable precise SND to achieve oncological radicality, limiting postoperative morbidity.

Rare gastrointestinal metastases from primary lung cancer. Two case reports of patients managed with emergency surgery.

BACKGROUND: Lung cancer represents the second leading cause of death in US and the high mortality rate could be related to the diagnosis, usually, performed in an advanced metastatic stage. Gastrointestinal metastases from non-small cell lung cancer, are extremely rare and only few cases complicated by digestive haemorrhage and/or perforation have been reported in literature. MATERIAL AND METHODS: We report two cases of gastrointestinal metastases and their rare clinical onset with haemorrhage and perforation of the digestive tract. Both patients were admitted in an emergency setting. The first case was a 59-year-old man complained of abdominal pain and massive gastrointestinal haemorrhage. An upper gastrointestinal endoscopy revealed an ulcerated gastric mass and an emergency CT-scans showed a right lung mass with biopsy conclusive for a large cell lung cancer. The second case was a 62-year-old man with abdominal pain and shock due to gastrointestinal bleeding. He was submitted to an emergency CT-scan showing two lung nodules (1.0 and 3.5 cm of diameter) as well as widespread metastases, intraperitoneal free air and fluids. RESULTS: Both patients were surgical managed in emergency and pathology revealed the metastatic origin from an unknown large-cell lung cancer and a rare lung adenocarcinoma in the second one. CONCLUSIONS: Despite the rare clinical condition, in patients with a diagnosis of lung cancer managed in emergency for gastrointestinal complication, gastrointestinal metastases should be taken into account, and referred to the primary disease in order to tailor the best approach. KEY WORDS: Gastrointestinal metastases, Lung cancer, Tailored surgery.

The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study.

BACKGROUND: Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3-0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial. METHODS: Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor. RESULTS: Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding. CONCLUSIONS: The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

Open necrosectomy is feasible as a last resort in selected cases with infected pancreatic necrosis: a case series and systematic literature review.

BACKGROUND: Acute pancreatitis is a common inflammatory pancreatic disorder, often caused by gallstone disease and frequently requiring hospitalization. In 80% of cases, a rapid and favourable outcome is described, while a necrosis of pancreatic parenchyma or extra-pancreatic tissues is reported in 10-20% of patients. The onset of pancreatic necrosis determines a significant increase of early organ failure rate and death that has higher incidence if infection of pancreatic necrosis (IPN) or extra-pancreatic collections occur. IPN always requires an invasive intervention, and, in the last decade, the advent of minimally invasive techniques has gradually replaced the employment of the open traditional approach. We report a series of three severe cases of IPN managed with primary open necrosectomy (ON) and a systematic review of the literature, in order to understand if emergency surgery still has a role in the current clinical practice. METHODS: From January 2010 to January 2020, 3 cases of IPN were treated in our Academic Department of General and Emergency Surgery. We performed a PubMed MEDLINE search on the ON of IPN, selecting 20 from 654 articles for review. RESULTS: The 3 cases were male patients with a mean age of 61.3 years. All patients referred to our service complaining an evolving severe clinical condition evocating a sepsis due to IPN. CT scan was the main diagnostic tool. Patients were initially conservatively managed. In consideration of clinical worsening conditions, and at the failure of conservative and minimal invasive treatment, they were, finally, managed with emergency ON. Patients reported no complications nor procedure-related sequelae in the follow-up period. CONCLUSION: The ON is confirmed to be the last resort, useful in selected severe cases, with a defined timing and in case of proven non-feasibility and no advantage of other minimally invasive approaches.

A Combined Open and Laparoscopic Technique for the Treatment of Umbilical Hernia: Retrospective Review of a Consecutive Series of Patients.

PURPOSE: To investigate the safety and outcomes of laparoscopic control of intraperitoneal mesh positioning in open umbilical hernia repair. METHODS: This study is a retrospective review of a series of adult patients with uncomplicated umbilical hernia who underwent elective open repair with a self-expanding patch with laparoscopic control from March 2011 to December 2018. The adequacy of mesh positioning was inspected with a 5-mm 30° scope in the left flank. The primary endpoint was recurrence. Secondary endpoints were rate of mesh repositioning, intraoperative complications and time, length of stay and postoperative pain. RESULTS: Thirty-five patients underwent open inlay repair of primary umbilical hernia with laparoscopic control. Six patients (17.1%) were obese. The mean operating time was 63.3 min. The mean defect size was 2.6 cm (0.6-5) and the mean mesh overlap was 3.2cm (2.2-4.5). There were no intraoperative complications. Laparoscopic control required mesh repositioning in 5 cases (14.3%). The median length of stay was 2 days. Perioperative complications were recorded in three cases (8.6%): one seroma and two serous wound discharge (Clavien-Dindo I). The recurrence rate was 2.9% (1 case) at a median follow-up of 60 months. BMI>30 was associated with a higher rate of intraoperative mesh repositioning (p=0.001). Non-reabsorbable mesh and COPD were associated with a higher incidence of postoperative complications (p=0.043). Postoperative pain scores were consistently at mild levels, with no statistically significant differences between patients who had their mesh repositioned and those who had not. CONCLUSIONS: Laparoscopic control of mesh positioning is a safe addition to open inlay umbilical hernia repair and enables the accurate verification of correct mesh deployment with low complication and recurrence rates.

Current concepts in parathyroid carcinoma: a single Centre experience.

BACKGROUND: Parathyroid carcinoma is a rare neoplasm that may present sporadically or in the context of a genetic syndrome. Diagnosis and management are challenging due to the lack of clinical and pathological features that may reliably distinguish malignant from benign disease. METHODS: From January 2013 to December 2017, from 358 consecutive patients affected by parathyroid diseases, 3 patients with parathyroid carcinoma were treated at our academic Department of General Surgery. We present our experience as illustrative of the different features of clinical presentation of parathyroid carcinoma and review its management considering the recent relevant literature. RESULTS: Case 1: A 62-year-old man was hospitalized for left-sided palpable neck mass, hypercalcemia and elevated PTH. US-guided FNA was suspect for parathyroid carcinoma. A large cystic mass was excised in bloc with total thyroidectomy and central neck dissection. Genetic studies framed a pathologically confirmed parathyroid carcinoma within MEN1 syndrome. Case 2: A 48-year-old woman with hypothyroidism had total thyroidectomy performed for a suspect for right follicular thyroid lesion. Pathology revealed parathyroid carcinoma. Case 3: A 47 year-old man was admitted for hypercalcaemic crisis and renal failure in the context of PHPT. A lesion suggestive on US and MIBI scan for parathyroid adenoma in the right lower position was removed by mini-invasive approach. Pathology revealed parathyroid cancer and patient had completion hemythyroidectomy and central neck dissection. CONCLUSION: Parathyroid cancer is a particularly rare endocrine malignancy, however it should be suspected in patients with primary hyperparathyroidism when severe hypercalcemia is associated to cervical mass, renal and skeletal disease. Parathyroid surgery remains the mainstay of treatment. Radical tumour resection and expedited treatment in a dedicated endocrine Center represent crucial prognostic factors.

Parathyroid carcinoma in multiple endocrine neoplasm type 1 syndrome: case report and systematic literature review.

The aim of this report was to illustrate a case of parathyroid carcinoma (PC) in a patient with multiple endocrine neoplasia type 1 (MEN1) along with a comprehensive literature review. A 61-year-old man presented with 9-cm PC causing primary hyperparathyroidism (PHPT). His pre-operative corrected calcium and intact PTH serum levels were 2.92 mmol/L and 391.7 pg/mL, respectively. The neoplastic gland was removed in bloc with thyroid and central compartment lymph nodes. A literature review was run by searching PubMed MEDLINE from 1977 to 2018 for studies of all types, in the English language only, using the terms "Parathyroid, carcinoma, Multiple endocrine neoplasia, type 1, (MEN1)." Pathology confirmed PC. Post-operative calcium and PTH levels were normal. A diagnosis of MEN1 was established post-operatively. Seventeen cases of PC in patients with MEN1 have been reported in the literature. 59% of patients were men, and median age at diagnosis was 50 years, with median serum PTH of 379 pg/mL and median serum calcium level of 3.2 mmol/L. The occurrence of PC in the context of MEN1 is extremely rare. Diagnosis and treatment may represent a challenge, so opportune identification or suspicion of malignancy and adoption of correct surgical approach may offer affected patients the best outcome.

Management of Mirizzi Syndrome in Emergency.

INTRODUCTION: Mirizzi syndrome (MS) is a rare complication of cholelithiasis. Despite the success of laparoscopic cholecystectomy as a minimally invasive approach to gallstone disease, MS remains a challenge, also for open and robotic approaches, due to the subverted anatomy of the hepatocystic triangle. Moreover, when emergency surgery is needed, the optimal preoperative diagnostic assessment could not be always achievable. We aim to analyze our experience of MS treated in emergency and to assess the feasibility of a diagnostic and therapeutic decisional algorithm. METHODS: From March 2006 to February 2016, all patients with a preoperative diagnosis, or an intraoperative evidence of MS, were retrospectively analyzed at our Academic Hospital, including patients operated on in emergency or in deferred urgency. Eighteen patients were included in the study using exclusion criteria and were treated in elective surgery. RESULTS: The patients were distributed according to modified Csendes' classification: type I in 15 cases, type II in 2, type III in 0, type IV in 1, and type V in 0. In the type I group, diagnosis was intraoperatively performed. Laparoscopic approach was performed with cholecystectomy or subtotal cholecystectomy, when the hepatocystic triangle dissection was hazardous. Patients with preoperative diagnosis of acute abdomen and MS type IV were directly managed by open approach. CONCLUSIONS: Diagnosis of MS and the therapeutic management of MS are still a challenge, mostly in an emergency setting. Waiting for standardized guidelines, we propose a decisional algorithm in emergency, especially in nonspecialized centeres of hepatobiliary surgery.