Calcitonin negative Medullary Thyroid Carcinoma: a challenging diagnosis or a medical dilemma?

BACKGROUND: Medullary thyroid carcinoma is a neuroendocrine tumor belonging form a malignant growth of the thyroid parafollicular C-cells, representing from 1 to 10% of all thyroid cancer. The biochemical activity of medullary thyroid carcinoma includes the production of calcitonin and carcinoembryogenic antigen, which are sensitive tumor markers, facilitating the diagnosis, follow-up and prognostication. The diagnosis is reached through the identification of high basal calcitonin serum level or after pentagastrin stimulation test. Medullary thyroid carcinoma is able to produce other relevant biomarkers as procalcitonin, carcinoembryionic antigen and chromogranin A. In Literature are described few cases of medullary thyroid carcinoma without elevation of serum calcitonin, an extremely rare event. The aim of this study was to analyse the presentation, the main features and therapeutic management of medullary thyroid carcinoma associated with negative serum calcitonin levels. METHODS: Using the PubMed database, a systematic review of the current Literature was carried out, up to February 2018. Finally, nineteen articles met our inclusion criteria and were selected according to the modified Newcastle-Ottawa scale. RESULTS: Fourty-nine patients with definitive pathology confirming medullary thyroid carcinoma and with calcitonin serum level in the normal range were identified (24 female, 24 male and not reported gender in 1 case). Mean age was 51.7 years. Serum calcitonin levels were reported for 20 patients with a mean value of 8.66 pg/mL and a range of 0.8-38 pg/mL. Despite the low or undetectable calcitonin serum level, at immunochemistry in almost the half of the cases reported by the Authors, the tumors presented diffuse or focal positivity for calcitonin and carcinoembryionic antigen, while was reported a chromogranin A positivity in 41 of the 43 tested patients. CONCLUSIONS: Calcitonin negative medullary thyroid carcinoma is an extremely rare pathology. The diagnosis and the surveillance is often challenging and delayed, due to the lack of elevation of serum markers as calcitonin and carcinoembryionic antigen. Further studies are needed, to better define options for management of non secretory medullary thyroid carcinoma and to identify new and reliable biomarkers associated to diagnosis and relapse of this medical dilemma.

The impact of the ultrasonic, bipolar and integrated energy devices in the adrenal gland surgery: literature review and our experience.

BACKGROUND: The gold standard approach for surgical treatment of benign and malignant adrenal lesion is considered the laparoscopic one, due to a lot of advantages compared to open approach. The rapid propagation of this surgical technique is due to the diffusion of haemostatic devices in laparoscopic adrenal surgery. The principal aim of this study is to analyze the outcome of LA using each energy modality, evaluating the eventual superiority of an instrument over the others. METHODS: A retrospective study, involving 75 consecutive patients submitted to LA by transperitoneal lateral approach from January 2013 to June 2017, was performed. Age less than 70 years old, adrenal adenomas less than 8 cm in diameter, incidentalomas < 6 cm, myelolipomas < 13 cm, adrenal metastases < 7 cm and ASA score ≤ III were the main surgical inclusion criteria. All involved patients were divided into three group, one for each energy device: group 1 - Harmonic Scalpel, group 2 - Ligasure vessel sealing system and group 3 - Thunderbeat. In each group only one device was applied for dissection and haemostasis during the whole operation. Each group consisted of 25 patients, well matched for histology, tumor size and site, gender and age. The following parameters were collected: age, gender, size of the tumor, side of the affected gland, pathology, operating time, intraoperative blood losses, hospitalization time, complication and conversion rate. RESULTS: There was no significant statistical difference between groups regarding the relationship between male/female, right site/left site, the mean age, hospitalization time and the tumor size (p > 0.05). Significant statistical difference are detectable in operation time and intraoperative blood losses. Thunderbeat, compared respectively with Ligasure and Harmonic Scalpel, is the fastest device (p < 0,001). The second faster device resulted Harmonic Scalpel, which meanly reduced the operation time compared to Ligasure (p = 0.048). intraoperative blood losses are reduced using Thunderbeat (p < 0,001) and HS (p = 0.006) compared to Ligasure, but between Thunderbeat and Harmonic Scalpel there isn't significant statistical difference (p = 0.178). CONCLUSIONS: Analyzing the results, laparoscopic adrenalectomy carried out using Thunderbeat appeared to show a statistically significant decrease in operation time and intraoperative blood losses compared with laparoscopic adrenalectomy performed using Harmonic Scalpel and Ligasure, while hospitalization time was superimposable in all groups. According to our data, a responsible use of advanced energy devices can improve surgical outcomes guarantying a cost savings and patient's satisfaction.

Laparoscopic near-total splenectomy: a single-center experience of a standardized procedure.

Background: Near-total splenectomy (NTS) represents an innovative and effective surgery technique for spleen disease, reducing the risk of severe infections and thromboembolic events after total splenectomy. The authors reported a laparoscopic near-total splenectomy (LNTS) surgical experience following the optimal results of the open approach, describing a standardized and effective minimally invasive technique with the purpose of preserving a minimal residual spleen.Material and methods: From November 2006 to September 2016, 15 patients with splenic and hematologic disease underwent LNTS, according to a laparoscopic procedure developed by the authors. The end criterion was to conserve a remanent spleen of 10-15 cm3 in size.Results: Patient age ranged between 18 and 59 years. Mean operative time was 70 ± 20 min. Mean hospital stay was 3.46 (range 3-7) days. One complication occurred during the surgery for a lesion of the inferior polar artery with need of a total splenectomy. No conversion to open surgery was necessary.Conclusions: LNTS is a safe and effective technique for the management of splenic and hematologic disease with a low intra- and post-operative complication rate, and it can minimize the late sequelae of secondary splenectomy. However, it requires further studies with more cases to evaluate its role.

Intracorporeal versus extracorporeal anastomosis after laparoscopic left colectomy for splenic flexure cancer: results from a multi-institutional audit on 181 consecutive patients.

Although intracorporeal anastomosis has been demonstrated to be safe and effective after right colectomy, limited data are available about its efficacy after left colectomy for colon cancer located in splenic flexure. A multi-institutional audit was designed, including 92 patients who underwent laparoscopic left colectomy with intracorporeal anastomosis (IA) compared with 89 matched patients who underwent a laparoscopic left colectomy with extracorporeal anastomosis (EA). There was no significant difference in terms of age, sex, BMI, and ASA score between the two groups. Post-surgical history and stage of disease according to AJCC/UICC TNM were also similar. IA and EA groups demonstrated similar oncologic radicality in terms of the number of lymph nodes harvested (18.5 ± 9 vs. 17.5 ± 8.4; p = 0.48). Recovery after surgery was also better in patients who underwent IA, as confirmed by the shorter time to flatus in the IA group (2.6 ± 1.1 days vs. 3.4 ± 1.2 days; p < 0.001) and higher post-operative pain expressed in the mean VAS Scale in the EA group (1.7 ± 2.1 vs. 3.5 ± 1.6; p < 0.001). Laparoscopic left colectomy with intracorporeal anastomosis was associated with a lower rate of post-operative complications (OR 6.7, 95% CI 2.2-20; p = 0.001). However, when stratifying according to Clavien classification, the difference was consistently confirmed for less severe (class I and II) complications (OR 7.6, 95% CI 2.5-23, p = 0.001) but not for class III, IV, and V complications (OR 1.8, 95% CI 0.1-16.9; p = 0.59). Our results were consistent to hypothesize that a complete laparoscopic approach could be considered a safe method to perform laparoscopic left colectomy with the advantage of a guaranteed faster recovery after surgery. Further randomized clinical trials are needed to obtain a more definitive conclusion.

Pancreatic stump closure after pancreatoduodenectomy in elderly patients: a retrospective clinical study.

BACKGROUND: Pancreatic fistula (PF) after pancreatoduodenectomy (PD) represents the major source of morbidity. Derivative procedures are preferred by pancreatic surgeons, but the optimal management of remnant pancreatic stump remains controversial. AIMS: The purpose of this retrospective study is to evaluate the efficacy and safety of pancreatic stump closure in selected elderly patients (>65 years). METHODS: Clinical data of 44 PD undergone mechanical closure of the pancreatic stump performed between 2001 and 2014 in two department of general and oncologic surgery were retrospectively collected. Considering the age, patients were divided into two groups: 21 patients of less than 65 years (Group A) and 23 patients of more than 65 years (Group B). RESULTS: A soft pancreatic parenchyma with a not-dilated duct (diameter <3 mm) was reported in all the 44 patients. A grade-A PF, which did not required further treatments, developed in 20 cases (45.4%; 13 in group A and 7 in group B; p < 0.05), grade-B in 5 patients (11.4%; 3 in group A and 2 in group B; statistically not significant) and a grade-C PF was observed only in one patient (2.2%; 1 in group A and 0 in group B). DISCUSSION: In selected "high risk" elderly patients (>65 years) with soft pancreatic texture, the closure of the pancreatic stump can be a useful tool in the surgical armamentarium with the aim to reduce the incidence of age-related complications. CONCLUSIONS: Prospective randomized controlled trial to better evaluate PF risk factors is needed.

Role of prophylactic central compartment lymph node dissection in clinically N0 differentiated thyroid cancer patients: analysis of risk factors and review of modern trends.

In the last years, especially thanks to a large diffusion of ultrasound-guided FNBs, a surprising increased incidence of differentiated thyroid cancer (DTC), "small" tumors and microcarcinomas have been reported in the international series. This led endocrinologists and surgeons to search for "tailored" and "less aggressive" therapeutic protocols avoiding risky morbidity and useless "overtreatment". Considering the most recent guidelines of referral endocrine societies, we analyzed the role of routine or so-called prophylactic central compartment lymph node dissection (RCLD), also considering its benefits and risks. Literature data showed that the debate is still open and the surgeons are divided between proponents and opponents of its use. Even if lymph node metastases are commonly observed, and in up to 90% of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is subject to intensive research and the best indications of lymph node dissection are still controversial. Identification of prognostic factors for central compartment metastases could assist surgeons in determining whether to perform RLCD. Considering available evidence, a general agreement to definitely reserve RCLD to "high-risk" cases was observed. More clinical researches, in order to identify risk factors of meaningful predictive power and prospective long-term randomized trials, should be useful to validate this selective approach.

Clinical significance of prophylactic central compartment neck dissection in the treatment of clinically node-negative papillary thyroid cancer patients.

BACKGROUND: Lymph nodal involvement is very common in differentiated thyroid cancer, and in addition, cervical lymph node micrometastases are observed in up to 80 % of papillary thyroid cancers. During the last decades, the role of routine central lymph node dissection (RCLD) in the treatment of papillary thyroid cancer (PTC) has been an object of research, and it is now still controversial. Nevertheless, many scientific societies and referral authors have definitely stated that even if in expert hands, RCLD is not associated to higher morbidity; it should be indicated only in selected cases. MAIN BODY: In order to better analyze the current role of prophylactic neck dissection in the surgical treatment of papillary thyroid cancers, an analysis of the most recent literature data was performed. Prophylactic or therapeutic lymph node dissection, selective, lateral or central lymph node dissection, modified radical neck dissection, and papillary thyroid cancer were used by the authors as keywords performing a PubMed database research. Literature reviews, PTCs large clinical series and the most recent guidelines of different referral endocrine societies, inhering neck dissection for papillary thyroid cancers, were also specifically evaluated. A higher PTC incidence was nowadays reported in differentiated thyroid cancer (DTC) clinical series. In addition, ultrasound guided fine-needle aspiration citology allowed a more precocious diagnosis in the early phases of disease. The role of prophylactic neck dissection in papillary thyroid cancer management remains controversial especially regarding indications, approach, and surgical extension. Even if morbidity rates seem to be similar to those reported after total thyroidectomy alone, RCLD impact on local recurrence and long-term survival is still a matter of research. Nevertheless, only a selective use in high-risk cases is supported by more and more scientific data. CONCLUSIONS: In the last years, higher papillary thyroid cancer incidence and more precocious diagnoses were worldwide reported. Among endocrine and neck surgeons, there is agreement about indications to prophylactic treatment of node-negative "high-risk" patients. A recent trend toward RCLD avoiding radioactive treatment is still debated, but nevertheless, prophylactic dissections in low-risk cases should be avoided. Prospective randomized trials are needed to evaluate the benefits of different approaches and allow to drawn definitive conclusions.

Impact of preoperative platelet count on perioperative outcome after laparoscopic splenectomy for idiopathic thrombocytopenic purpura. / Impacto del recuento plaquetario preoperatorio en la evolución perioperatoria tras la esplenectomía laparoscópica por púrpura trombocitopénica idiopática.

INTRODUCTION: Laparoscopic splenectomy (LS) is the preferred treatment of idiopathic thrombocytopenic purpura (ITP) when medical treatment fails. The objective was to evaluate the feasibility and safety of LS according to the preoperative platelet count. METHODS: This study is a retrospective analysis of a series of 199 patients who underwent LS for ITP from 1993 to 2015. The patients were divided into 3 groups according to platelet count: group i (<10×10(9)/L), group ii (10-50×10(9)/L) and group iii (> 50×10(9)/L). RESULTS: Operative time was significantly lower in Group III compared to Group I and II (100±53 and 105±61min, P<.025)). Intraoperative blood loss was statistically higher in group i (263±551ml) with respect to the other 2: group ii (128±352ml) and group iii (24±62ml) (P<.003). Hospital stay was 6.4±5.8 days in group i, significantly higher compared to groups ii and iii (3.8±2.3 and 3.2±1.8 days, respectively (P<.003)). CONCLUSION: Conducting a LS in ITP patients with low platelet counts is effective and safe.

Suprarenal solitary fibrous tumor associated with a NF1 gene mutation mimicking a kidney neoplasm: implications for surgical management.

Solitary fibrous tumor (SFT) is a rare spindle cell neoplasm, usually occurring in the pleura. Pararenal SFT, mimicking an adrenal gland or renal tumor, as here described, is extremely rare. We report a case of a right suprarenal SFT, incidentally discovered by abdominal ultrasound in a 54-year-old woman carrying a point neurofibromatosis 1 (NF1) gene mutation. Preoperative diagnostic work-up was ineffective in evaluating its origin, and an open radical right nephrectomy was therefore undertaken. Immunohistochemical assay showed a positivity for CD34, CD99 and Bcl-2, so suggesting a diagnosis of SFT. According to our knowledge, the association between this type of tumor and NF1 gene mutation has never been described. In cases of pararenal tumors, a more detailed preoperative diagnosis could be useful to better plan the extension of resection, allowing, in selected cases, nephron-sparing surgery. More studies are needed to better analyze the relationship between NF1 gene mutation and SFT.

Predictive value of nodal metastases on local recurrence in the management of differentiated thyroid cancer. Retrospective clinical study.

BACKGROUND: The significance of nodal metastases, very common in papillary thyroid cancer, and the role of lymph node dissection in the neoplasm management, are still controversial. The impact of lymph node involvement on local recurrence and long-term survival remains subject of active research. With the aim to better analyze the predictive value of lymph node involvement on recurrence and survival, we investigated the clinico-pathological patterns of local relapse following total thyroidectomy associated with lymph node dissection, for clinical nodal metastases papillary thyroid cancer, in order to identify the preferred surgical treatment. METHODS: Clinical records, between January 2000 and December 2006, of 69 patients undergoing total thyroidectomy associated with selective lymph node dissection for clinical nodal metastases papillary thyroid cancer, were retrospectively evaluated. Radioiodine ablation, followed by Thyroid Stimulating Hormone suppression therapy was recommended in every case. In patients with loco regional lymph nodal recurrence, a repeated lymph node dissection was carried out. The data were compared with those following total thyroidectomy not associated with lymph node dissection in 210 papillary thyroid cancer patients without lymph node involvement, at preoperative ultrasonography and intra operative inspection. RESULTS: Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and permanent monolateral vocal fold paralysis were respectively 1.4 % (1/69) and 1.4% (1/69), similar to those reported after total thyroidectomy "alone". The rate of loco regional recurrence, with positive cervical lymph nodes, following 8 year follow-up, was 34.7% (24/69), higher than that reported in patients without nodal metastases (4.2%). A repeated lymph node dissection was carried out without significant complications. CONCLUSIONS: Nodal metastases are a predictor of local recurrence, and a higher rate of lymph node involvement is expected after therapeutic lymph node dissection associated with total thyroidectomy. The prognostic significance of nodal metastases on long-term survival remains unclear, and more prospective randomized trials are requested to better evaluate the benefits of different therapeutic approaches.

Surgical treatment of metastases from cutaneous melanoma to the small intestine and the spleen. Case reports and review of the literature.

Cutaneous melanoma is found in the head and neck in 15% of patients, in the limbs in 22%, in the trunk in 40% and in occult sites in 16%. There is usually an interval of at least 3 years between the diagnosis of primary melanoma and the identification of metastases. Primary melanoma metastasizes most frequently to the lymph nodes (73.6% cases) and the lungs (71.3% cases). The small intestine and the spleen are the sites of 36.5% and 30.6% respectively of the gastrointestinal metastases from melanoma. The cases reported provide evidence of the effect radical resection in patients with gastrointestinal metastases can have on survival. The cases and a review of the literature suggest that a careful and multidisciplinary follow-up is of crucial importance since it is the only means of identifying metastases when they can be still cured with surgical treatment.

[Prognostic and curative value of sentinel node in breast cancer. A 377 patients experience]. / Valore prognostico e curativo del linfonodo sentinella nel trattamento chirurgico del cancro della mammella. Analisi di 377 pazienti.

Sentinel node is defined as the first lymphnode receiving limphatic drain from the breast. Several studies show a very low recurrence rate to axillary and locoregional nodes in sentinel node negative patients who did not undergo axillary dissection. Our study aims to verify if complete axillary dissection could be replaced by sentinel node biopsy (SNB) in the staging and treatment of breast cancer. From January 2005 to December 2008, 377 patients (mean age 57.63) underwent SNB in the General Surgery unit of "San Giuseppe Moscati" Hospital in Avellino (Italy). All the patients underwent SNB with local anesthesia. Histologic studies were performed using GIVOM protocol (Veneto Breast cancer interdisciplinary group). Sixty five patients (17.2%) underwent a radical mastectomy with SNB and 312 (82.6%) patients underwent a quadrantectomy with SNB. Of this last group, 178 (47.2%) underwent a superior quadrant excision with SNB, 77 (20.4%) an inferior quadrant excision with SNB and 57 (15.1%) a central quadrant excision with SNB. Ductal carcinoma represented 57.3% of the tumous detected, lobular carcinoma was diagnosed in 16.4% of the cases, intraductal microinvasive carcinoma in 10.3%, ductal carcinoma in situ in 5.8% while the other histotypes were diagnosed in 10% of the tumours. All SNB+ patients (34.5%) underwent a radical axillary dissection in general anesthesia. Sixty nine (53%) patients were diagnosed with axillary node metastasis, after axillary dissection Micrometastasis resulted in 19.6% of the excised patients. The prevalence of axillary node metastasis was 26.4% (581/2198), while the incidence was 34.5% (130/377). The first axillary lymphnodes level was metastasized in 65.8% patients who had undergone an axillary dissection, level I and II in 268% and all the levels in 7.4%. Only one case (0.4%) of nodal metastatic recurrence has been diagnosed in patients who had undergone SNB alone, after a mean follow-up of 28.5 month. Apart from showing a very high diagnostic and staging accuracy, the high level of SN detection associated with a high predictive rate underline a lower complications rate if compared to complete nodal dissection.

Innovations in surgical treatment of rectus abdominis diastasis: a review of mini-invasive techniques.

Abdominal rectus diastasis (RD) is characterized by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature. This condition is associated with bulging of abdominal content, and it is mostly acquired during pregnancy or obesity. Symptoms include pain and discomfort in the abdomen, musculoskeletal and uro-gynecological problems in addition to negative body image and impaired quality of life. In this review we present current knowledge on the novel surgical mini-invasive techniques for treatment of RD. The aim of our study is to discuss the use of a standard classification to define pathological RD and possible indications for a minimally invasive repair, considering complications, patients' satisfaction and recurrence rate. A PubMed search of the literature has been conducted in January 2020 including the most recent articles using the following criteria among the interventions for RD: mini-invasive surgery, laparoscopic, endoscopy and robotic procedures. Minimally invasive surgical treatment options for rectus diastasis are poorly investigated and indications for repair are still debated. Guidelines are mandatory to standardize surgical management of RD.

Treatment of postoperative jejunal intussusception in adult with oral gastrografin after laparoscopic low rectal resection. A case report.

INTRODUCTION: Postoperative intussusception is a rare cause of intestinal obstruction in adults. Intussusception refers to a condition in which a segment of the intestine invaginates into the lumen of an adjacent segment of the intestine. PRESENTATION OF CASE: We report a case of postoperative jejunojejunal intussusception in a 42-year-old male following a laparoscopic low anterior resection for rectal cancer. In post-operative day (POD) 2 the patient showed intermittent bowel obstruction and fever. Diagnosis was established with abdominal computed tomography (CT) and enteroclysis, which led to a spontaneous reduction of the invagination. DISCUSSION: The incidence of intussusception in adults is rare condition. It represents less than 5% of all cases. In adults, transient asymptomatic enteric intussusception often resolves spontaneously without any treatment. When bowel obstruction is complete and persistent, surgery is need. Intussusception as cause of intestinal obstruction should be kept in mind in a post operative patient who develops obstructive symptoms. Early diagnosis makes the difference between surgical and others treatment. The pathogenesis and diagnosis of postoperative intussusception in the adult is discussed in the case report. CONCLUSION: The authors presented a rare cause of postoperative small bowel obstruction treated without surgery. The peculiarity of this case report is that the authors have successfully used, in an adult, conservative treatment with gastrografin, which is the treatment of choice used in children. The use of gastrografin was decisive and there were no recurrences in the follow up.

Irreversible electroporation for locally advanced pancreatic cancer through a minimally invasive surgery supported by laparoscopic ultrasound.

INTRODUCTION: Pancreatic cancer is one of the most lethal cancers worldwide, with 5-years survival rate as low as 6%. The majority of pancreatic cancer patients present locally advanced or metastatic disease at diagnosis. Typically, patients affected by locally advanced pancreatic cancer (LAPC) do not undergo radical surgery but are treated with focal ablative therapies. However, a high rate of morbidity due to the heat sink effect has limited the application of ablative techniques on a routine basis in LAPC patients. Irreversible electroporation (IRE) has proved to be a new method of LAPC ablation. PRESENTATION OF THE CASE: A 69-year-old woman affected by LAPC with good response to systemic chemotherapy with FOLFIRINOX and residual 35 mm mass in the neck of the pancreas underwent to IRE through a minimally invasive surgical approach under laparoscopic ultrasound guide. The post-operative course was uneventful and the patient was discharged after 5 days. Six months after surgery she had no evidence of distant or recurrent disease. DISCUSSION: IRE has previously shown promising results in the treatment of LAPC, with relatively acceptable morbidity rates and improvement of survival. We report on the application of IRE through a minimally invasive surgical approach supported by laparoscopic ultrasound. CONCLUSION: In conclusion, we propose a novel technical approach that combines the benefits of IRE on the treatment of patients affected by LAPC with the advantages of laparoscopic surgery.

Intraoperative cholangiography during cholecystectomy in sequential treatment of cholecystocholedocholithiasis: To be, or not to be, that is the question A cohort study.

BACKGROUND: Choledocholithiasis occurs in 10-15% of patients with cholecystolithiasis. Despite the existence of many therapeutic options for the treatment of cholecystocholedocholithiasis, a sequential treatment in which pre-operative ERCP is combined with intraoperative cholangiography (IOC) and laparoscopic cholecystectomy (LC), is the most commonly accepted strategy. However, use of IOC in the "splitting treatment" of cholecystocholedocholithiasis is controversial. The aim of the present study is to investigate the utility of IOC in detecting residual stones in patients undergoing LC in the sequential treatment of common biliary duct or gallbladder stones. METHODS: Patients were recruited retrospectively among those who underwent IOC during LC, performed as second stage in the sequential treatment for cholecystocholedocholithiasis between 2010 and 2016. Demographic and clinical data were obtained from CPT codes at Ospedale Monaldi A.O.R.N dei Colli Naples, Italy. Data obtained from all pre-operative ERCP analyses were recorded, including cholangiogram findings and performance of sphincterotomy. Statistical analysis was carried out using the IBM SPSS Statistic 19.0 software package. RESULTS: Between January 2010 and December 2016 575 patients (343 males, 242 females) underwent IOC during LC for symptomatic cholecystitis due to cholelithiasis. Among patients accrued for the study, 143 underwent preoperative ERCP for suspicion of common biliary duct stones. At the time of pre-operative ERCP, 123 were found to have common biliary duct stones while 20 (15%) presented negative ERCP. Complete removal of stones was accomplished in 119 patients. Among these patients, 13 had residual common biliary duct stones diagnosed by IOC (11%). Two patients underwent laparoscopic bile duct revision and, last, two patients were referred for ERCP at a later point. It is of note that all patients who presented residual stones by IOC had undergone pre-operative sphincterotomy. CONCLUSION: This study demonstrates that IOC is particularly effective in detecting residual stones in patients undergoing LC in sequential treatment of common biliary duct and/or gallbladder stones, and may be used on a routine basis in the sequential treatment of cholecystocholedocholithiasis.

Surgical treatment of thyroid follicular neoplasms: results of a retrospective analysis of a large clinical series.

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions (FN), considering their low definitive malignancy rate and the limited predictive power of preoperative clinic-diagnostic factors, is still controversial. On behalf of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB), we collected and analyzed the experience of 26 endocrine centers by computerized questionnaire. 1379 patients, surgically treated after a FN diagnosis from January 2012 and December 2103, were evaluated. Histological features, surgical complications, and medium-term outcomes were reported. Total thyroidectomy (TT) was performed in 1055/1379 patients (76.5 %), while hemithyroidectomy (HT) was carried out in 324/1379 cases (23.5 %). Malignancy rate was higher in TT than in HT groups (36.4 vs. 26.2 %), whereas the rates of transient and definitive hypoparathyroidism following TT were higher than after HT. Consensual thyroiditis (16.8 vs. 9.9 %) and patient age (50.9 vs. 47.9 %) also differed between groups. A cytological FN diagnosis was associated to a not negligible malignancy rate (469/1379 patients; 34 %), that was higher in TT than in HT groups. However, a lower morbidity rate was observed in HT, which should be considered the standard of care in solitary lesions in absence of specific risk factors. Malignancy could not be preoperatively assessed and clinical decision-making is still controversial. Further efforts should be spent to more accurately preoperatively classify FN thyroid nodules.

Bilateral benign multinodular goiter: What is the adequate surgical therapy? A review of literature.

BACKGROUND: Benign multinodular goiter (BMNG) is the most common endocrine disease requiring surgery. During the last few years a more aggressive approach has become the trend for bilateral BMNG treatment. METHOD: Randomized clinical trials of any size that compared bilateral subtotal resection, Dunhill procedure and total thyroidectomy for benign multinodular goiter, published between January 2000 and the end of March 2015, were reviewed. DISCUSSION: Total thyroidectomy can be considered the most reliable approach in preventing recurrence. The Dunhill procedure is related to a higher rate of recurrence, but rarely recurrences after Dunhill procedure lead to reoperation. Total thyroidectomy avoid completion thyroidectomy for incidental carcinoma and its related risks. Recurrent laryngeal nerve (RLN) palsy becomes less common as surgical experience increases. Transient and permanent hypoparathyroidism is strictly related to the extent of neck dissection. In the risk-cost analysis we must consider the type of patient candidated to surgery and the impact of the surgical protocol we apply. When thyroid surgery is taken in consideration, specific complication rates of different procedures in each hospital must be analyzed accordingly to patient-specific risk factors and local expertise. CONCLUSION: The Dunhill procedure seems to be a good compromise between radicality and prevention of complications, avoiding reoperation for recurrence or completion thyroidectomy for incidental thyroid carcinoma. More follow-up studies and prospective studies are necessary to better evaluate, definitively, whether to prefer total thyroidectomy or Dunhill procedure in case of benign goiter surgery.

Natural history, diagnosis, treatment and outcome of thyroid microcarcinoma (TMC) A mono-institutional 5 year experience.

Thyroid microcarcinoma (TMC) it's a rare type of differentiated thyroid cancer, which according to the World Health Organization measures 10 mm or less. Accounting 7-16 % of all thyroid carcinomas, it occurs at any age, more frequently in men, with a female to male ratio of 1:3. More frequently histotype is the papillary subset, PTCM. Aim of this study is to retrospectively evaluate the patients diagnosed with TMC in terms of their clinical and histopathological features. In our institution we collected 23 cases of TMC sampled on 338 plongeant being operated. All the tumors, in our study, were found incidentally during the treatment of benign thyroid diseases. All the sample were analyzed and prepared using the same frozen section technique. Surgical pathology identified 11 papillary microcarcinomas, 10 follicular microcarinomas, 1 oncocytary microcarcinomas and in 1 patient was found only a focal tireocitary transformation. TMC's prognosis and treatment is still a subject of controversy We propose our approch consisting in total thyroidectomy (less than 5 gr residual thyroid tissue), being considered the low rate of post-operative complications, and recurrences: all patients are disease-free at the median follow-up of 78 months (range 96 to 30 months). We have considered either the less malignancy habit of this neoplasia either its well prognosis.

Conservative management and parenchyma-sparing resections of pancreatic neuroendocrine tumors: Literature review.

BACKGROUND: Pancreatic neuroendocrine tumors (pNETs) are uncommon entities. pNETs are often small, slow growing, clinically silent neoplasms. However, they have an almost unpredictable biological behaviour with a not negligible malignant potential. Surgery still represents the treatment of choice, but the high morbidity associated to the enucleation or the formal pancreatectomy should be considered in the decision of the proper treatment. Management of these neoplasms is still debated, and indications for a conservative observational approach and for parenchyma sparing resections are not yet standardized. METHOD: We review the state of art on the indications for the conservative management of pNETs. Searches on MEDLINE database were performed to identify articles reporting prognostic systems, biochemical screening, observational management, medical treatment and surgical strategies for pNETs. DISCUSSION: Currently, an accurate 'wait-and-see' policy is recommended by the European Neuroendocrine Tumor Society (ENETS) only for non-functioning pNETs (NF-pNETs) <2 cm. A biochemical screening, based on sampling of serum levels of pancreatic polypeptide (PP) and chromogranin A, can address to early conservative surgery for MEN-1 associated NF-pNETs <2 cm to prevent their malignant transformation. The subtotal (80%) distal pancreatectomy first proposed by Thompson, often with the enucleation of possible pancreatic head tumors, still represents a good compromise between oncological radicality and prevention of pancreatic endocrine/exocrine insufficiency caused by standard radical resections for the treatment of inherited syndromes associated with NF-pNETs >2 cm and symptomatic F-pNETs of any size. CONCLUSION: More studies are needed to further clarify and predict the biologic behaviour of pNETs and increase the indications for conservative observational management and parenchyma sparing pancreas resections.