Pre-graduation medical training including virtual reality during COVID-19 pandemic: a report on students' perception.

BACKGROUND: The Coronavirus Disease 19 (COVID-19) pandemic brought significant disruption to in-hospital medical training. Virtual reality simulating the clinical environment has the potential to overcome this issue and can be particularly useful to supplement the traditional in-hospital medical training during the COVID-19 pandemic, when hospital access is banned for medical students. The aim of this study was to assess medical students' perception on fully online training including simulated clinical scenarios during COVID-19 pandemic. METHODS: From May to July 2020 when in-hospital training was not possible, 122 students attending the sixth year of the course of Medicine and Surgery underwent online training sessions including an online platform with simulated clinical scenarios (Body Interact™) of 21 patient-based cases. Each session focused on one case, lasted 2 h and was divided into three different parts: introduction, virtual patient-based training, and debriefing. In the same period, adjunctive online training with formal presentation and discussion of clinical cases was also given. At the completion of training, a survey was performed, and students filled in a 12-item anonymous questionnaire on a voluntary basis to rate the training quality. Results were reported as percentages or with numeric ratings from 1 to 4. Due to the study design, no sample size was calculated. RESULTS: One hundred and fifteen students (94%) completed the questionnaire: 104 (90%) gave positive evaluation to virtual reality training and 107 (93%) appreciated the format in which online training was structured. The majority of participants considered the platform of virtual reality training realistic for the initial clinical assessment (77%), diagnostic activity (94%), and treatment options (81%). Furthermore, 97 (84%) considered the future use of this virtual reality training useful in addition to the apprenticeship at patient's bedside. Finally, 32 (28%) participants found the online access difficult due to technical issues. CONCLUSIONS: During the COVID-19 pandemic, online medical training including simulated clinical scenarios avoided training interruption and the majority of participant students gave a positive response on the perceived quality of this training modality. During this time frame, a non-negligible proportion of students experienced difficulties in online access to this virtual reality platform.

Early Versus Delayed Source Control in Open Abdomen Management for Severe Intra-abdominal Infections: A Retrospective Analysis on 111 Cases.

BACKGROUND: Time to source control plays a determinant prognostic role in patients having severe intra-abdominal infections (IAIs). Open abdomen (OA) management became an effective treatment option for peritonitis. Aim of this study was to analyze the correlation between time to source control and outcome in patients presenting with abdominal sepsis and treated by OA. METHODS: We retrospectively analyzed 111 patients affected by abdominal sepsis and treated with OA from May 2007 to May 2015. Patients were classified according to time interval from first patient evaluation to source control. The end points were intra-hospital mortality and primary fascial closure rate. RESULTS: The in-hospital mortality rate was 21.6% (24/111), and the primary fascial closure rate was 90.9% (101/111). A time to source control ≥6 h resulted significantly associated with a poor prognosis and a lower fascial closure rate (mortality 27.0 vs 9.0%, p = 0.04; primary fascial closure 86 vs 100%, p = 0.02). We observed a direct increase in mortality (and a reduction in closure rate) for each 6-h delay in surgery to source control. CONCLUSION: Early source control using OA management significantly improves outcome of patients with severe IAIs. This damage control approach well fits to the treatment of time-related conditions, particularly in case of critically ill patients.

Right-Sided versus Left-Sided Colectomies for Cancer: Surgical Outcomes and Novel Considerations.

INTRODUCTION: The aim of this study is to compare short-term outcomes of right versus left colectomies performed as a form of cancer treatment. MATERIALS AND METHODS: This study includes 305 consecutive patients with adenocarcinoma treated by laparoscopic or open colectomy. Right colectomy has been compared with left colectomy. The study endpoints were the first flatus day, the first evacuation day, the first day of postoperative solid oral diet intake, and the postoperative hospital stay length. RESULTS: There were 140 (45.9%) right colectomies and 165 (54.1%) left colectomies performed. The cut-off values for the considered (median) endpoints were three, five, four, and eight days, respectively. The first day of postoperative solid oral diet intake and the length of postoperative hospital stay are significantly associated with the type of resection. CONCLUSIONS: The colon cancer patients treated by right-sided colectomy assumed a solid oral diet and presented a longer postoperative hospital stay compared with the patients treated by left-sided colectomy.

Current Developments and Unusual Aspects in Gastrointestinal Surgical Stapling.

Stapling devices are used in gastrointestinal, gynecologic, thoracic, and many other surgeries to resect organs, transect tissues, and anastomose different structures. These devices became widely accepted standard practice in many gastrointestinal operations, especially since the successful advent of minimally invasive surgery. Despite the relevant advantages related to the use of a surgical stapler, we must also consider that these instruments may be at risk of failure. When any component fails, the patient is at risk of operative morbidity. Gastrointestinal surgical stapling technique still needs refinement in order to increase its reliability. Staple line reinforcement has been widely used and seems to effectively reduce anastomotic complications. Literature provides us with examples of studies supporting both bleeding and leakage reduction after staple line reinforcement, but high-quality evidence is not available to date. Semi-absorbable and nonabsorbable materials have been the earliest available. The use of bioabsorbable staple line reinforcement materials has recently become more widespread, and these materials are more widely used these days. Powered staplers were made available to the market some time ago and represent a rather unheard of aspect of endosurgical stapling. Despite powered staples being supposedly convenient compared with manual ones only one relevant article was found when searching the U.S. National Library of Medicine for "powered stapler." New surgical stapling devices are constantly developed and introduced on the market. Results with such devices depend on the stapler features but also surely vary according to the surgeon experience.

A Review on Vacuum-assisted Closure Therapy for Septic Peritonitis Open Abdomen Management.

This article presents a literature review undertaken to identify advantages of vacuum-assisted closure (VAC) methods compared with other temporary abdominal closure (TAC) methods for septic peritonitis open abdomen (OA) management. A literature review was conducted through the U.S. National Library of Medicine at the National Institutes of Health. OA management and septic peritonitis were the main topics considered for this purpose. Online available information from papers discussed at relevant meetings and congresses was also included for review. The search was designed following the Patient Intervention Comparison Outcome Criteria. All shortlisted articles were reviewed by two authors independently. The review resulted in 79 items. Only one randomized study was found and considered for review. A large variety of TAC methods for OA are reported in the available literature to date and are described with a heterogeneous set of names. VAC methods allow the possibility of draining and accounting for fluids collecting in the peritoneal cavity. VAC may offer a solution to fascial closure problems. VAC helps prevent peritoneal contamination. Intra-abdominal hypertension prevention is one factor undoubtedly favoring VAC methods against non-VAC ones for OA management in septic peritonitis.

Neoadjuvant Chemotherapy in Breast Cancer: Evaluation of the Impact on Surgical Outcomes and Prognosis.

The correlation between TNM staging and histology variations in a sample of patients who underwent neoadjuvant chemotherapy demonstrates a positive impact on both increasing conservative surgery and achieving pCR, resulting in better outcomes in terms of disease-free survival (DFS) and the risk of relapse. Benefits have also been highlighted in terms of cosmetic outcomes, postoperative complications, and psychological benefits. However, the overall outcomes must be evaluated according to the subtype and individual characteristics of the patients.

Is routine axillary lymph node dissection needed to tailor systemic treatments for breast cancer patients in the era of molecular oncology? A position paper of the Italian National Association of Breast Surgeons (ANISC).

BACKGROUND: De-escalation of axillary surgery in breast cancer (BC) management began when sentinel lymph node biopsy (SLNB) replaced axillary lymph node dissection (ALND) as standard of care in patients with node-negative BC. The second step consolidated ALND omission in selected subgroups of BC patients with up to two macrometastases and recognized BC molecular and genomic implication in predicting prognosis and planning adjuvant treatment. Outcomes from the recent RxPONDER and monarchE trials have come to challenge the previous cut-off of two SLN in order to inform decisions on systemic therapies for hormone receptor-positive (HR+), human epidermal growth factor receptor type-2 (HER2) negative BC, as the criteria included a cut-off of respectively three and four SLNs. In view of the controversy that this may lift in surgical practice, the Italian National Association of Breast Surgeons (Associazione Nazionale Italiana Senologi Chirurghi, ANISC) reviewed data regarding the latest trials on this topic and proposes an implementation in clinical practice. MATERIAL AND METHODS: We reviewed the available literature offering data on the pathological nodal status of cN0 breast cancer patients. RESULTS: The rates of pN2 status in cN0 patients ranges from 3.5 % to 16 %; pre-surgical diagnostic definition of axillary lymph node status in cN0 patients by ultrasound could be useful to inform about a possible involvement of ≥4 lymph nodes in this specific sub-groups of women. CONCLUSIONS: The Italian National Association of Breast Surgeons (ANISC) considers that for HR + HER2-/cN0-pN1(sn) BC patients undergoing breast conserving treatment the preoperative workup should be optimized for a more detailed assessment of the axilla and the technique of SLNB should be optimized, if considered appropriate by the surgeon, not considering routine ALND always indicated to determine treatment recommendations according to criteria of eligibility to RxPONDER and monarch-E trials.

Updates on surgical management of advanced gastric cancer: new evidence and trends. Insights from the First International Course on Upper Gastrointestinal Surgery--Varese (Italy), December 2, 2011.

Between the Ninth International Gastric Cancer Congress (IGCC) in South-Korea (Seoul, 2011) and the Tenth IGCC in Italy (Verona, 2013), the Insubria University organized the First International Course on Upper Gastrointestinal Surgery (Varese, December 2, 2011), with the patronage of Italian Research Group for Gastric Cancer (IRGGC) and the International Gastric Cancer Association (IGCA). The Course was intended to be a comprehensive update and review on advanced gastric cancer (GC) staging and treatment from well-known international experts. Clinical, research, and educational aspects of the surgeon's role in the era of stage-adapted therapy were discussed. As highlighted in the meeting, in this final document we summarize and thoroughly analyze (with references only for well-acquired randomized control trials) the new and old open problems in surgical management of advanced GC. Between the Ninth (Seoul, 2011) and the Tenth (Verona,2013) International Gastric Cancer Congress, the First International Course on Upper Gastrointestinal Surgery (Varese, December 2, 2011) was organized by the University of Insubria. This congress received the patronage of the International Gastric Cancer Association and the Italian Research Group for Gastric Cancer. The aim was to discuss open issues in surgical management of advanced gastric malignancies. We considered the opinions of several recognized experts in the field from both the Eastern and Western world, focused on definition problems and oncological and technical issues to define the current principles of advanced gastric cancer (GC) surgery.

Gastric plication: how to decrease the size of the stomach without transection.

Gastric plication is an emerging bariatric procedure with the potential for providing safe and significant weight loss and improvement of metabolic parameters without resection, bypass, or implantable device. Laparoscopic plication consists of infolding the greater gastric curvature to reduce stomach volume using running sutures. As a new procedure in bariatric/metabolic surgery very few clinical studies are available. Herein we present technical notes about and evidence from literature.

Vagus nerve stimulation for standardized monitoring: technical notes for conventional and endoscopic thyroidectomy.

Standardization of the intraoperative neuromonitoring (IONM) technique is an essential aspect of modern monitored thyroid surgery. The standardized technique involves vagal nerve stimulation. VN stimulation is useful for technical problem solving, detecting non-recurrent laryngeal nerve (non-RLN), recognizing any recurrent laryngeal nerve (RLN) lesions, and precisely predicting RLN postoperative function. Herein, we present technical notes for the VN identification to achieve the critical view of safety of the VN stimulation with or without dissection.

Low neutrophil-to-lymphocyte ratio and pan-immune-inflammation-value predict nodal pathologic complete response in 1274 breast cancer patients treated with neoadjuvant chemotherapy: a multicenter analysis.

Background: Systemic inflammatory markers draw great interest as potential blood-based prognostic factors in several oncological settings. Objectives: The aim of this study is to evaluate whether neutrophil-to-lymphocyte ratio (NLR) and pan-immune-inflammation value (PIV) predict nodal pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in node-positive (cN+) breast cancer (BC) patients. Design: Clinically, cN+ BC patients undergoing NAC followed by breast and axillary surgery were enrolled in a multicentric study from 11 Breast Units. Methods: Pretreatment blood counts were collected for the analysis and used to calculate NLR and PIV. Logistic regression analyses were performed to evaluate independent predictors of nodal pCR. Results: A total of 1274 cN+ BC patients were included. Nodal pCR was achieved in 586 (46%) patients. At multivariate analysis, low NLR [odds ratio (OR) = 0.71; 95% CI, 0.51-0.98; p = 0.04] and low PIV (OR = 0.63; 95% CI, 0.44-0.90; p = 0.01) were independently predictive of increased likelihood of nodal pCR. A sub-analysis on cN1 patients (n = 1075) confirmed the statistical significance of these variables. PIV was significantly associated with axillary pCR in estrogen receptor (ER)-/human epidermal growth factor receptor 2 (HER2)+ (OR = 0.31; 95% CI, 0.12-0.83; p = 0.02) and ER-/HER2- (OR = 0.41; 95% CI, 0.17-0.97; p = 0.04) BC patients. Conclusion: This study found that low NLR and PIV levels predict axillary pCR in patients with BC undergoing NAC. Registration: Eudract number NCT05798806.

Visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy: what about the costs?

BACKGROUND: The objective of the present study was to evaluate costs for thyroidectomy performed with the aid of intraoperative neural monitoring (IONM), which has gained widespread acceptance during thyroid surgery as an adjunct to the gold standard of visual nerve identification. METHODS: Through a micro-costing approach, the thyroidectomy patient-care process (with and without IONM) was analyzed by considering direct costs (staff time, consumables, equipment, drugs, operating room, and general expenses). Unit costs were collected from hospital accounting and standard tariff lists. To assess the impact of the IONM technology on hospital management, three macro-scenarios were considered: (1) traditional thyroidectomy; (2) thyroidectomy with IONM in a high-volume setting (5 procedures per week); and (3) thyroidectomy with IONM in a low-volume setting (1 procedure per week). Energy-based devices (EBD) for hemostasis and dissection in thyroidectomy were also evaluated, as well as the reimbursement made by the Italian Healthcare System on the basis of diagnosis related groups (DRGs), about €2,600. RESULTS: Comparison between costs and the DRG fee shows an underfunding of total hospitalization costs for all thyroidectomies, regardless of IONM use (scenario 1: €3,471). The main cost drivers are consumables and technologies (25%), operating room (16%), and staff (14%). Hospitalization costs for a thyroidectomy with IONM range from €3,713 to €3,770 (scenarios 2 and 3), 5­7% higher than those for traditional thyroidectomy. Major economic differences emerge when an EBD is used (€3,969). CONCLUSIONS: The regional DRG tariff for thyroid surgery is barely sufficient to cover conventional surgery costs. Intraoperative neural monitoring accounts for 5­7% of the hospitalization costs for a thyroidectomy.

Case Report: Male Lobular Breast Cancer in Hereditary Cancer Syndromes.

Background: Lobular breast carcinoma (LBC) is considered an exceptionally rare disease in men, including only 1% of all male breast malignancies. The majority of LBCs have negative immunohistochemical staining for E-cadherin (CDH1) expression, and the loss of CDH1 function was traditionally implicated in the tumorigenesis of diffuse gastric cancer as well as LBC. It is well recognized that LBC in women could be involved in both hereditary breast and ovarian cancer (HBOC) and hereditary diffuse gastric cancer (HDGC) syndromes; however, there are no data present in literature about the involvement of male LBC in these inherited conditions. Methods: BRCA1, BRCA2, and CDH1 genes were performed on DNA from peripheral blood using next-generation sequencing (NGS), Sanger sequencing, and multiplex ligation-dependent probe amplification analyses. BRCA2 and CDH1 somatic gene analyses were performed on breast tumoral DNA using the NGS sequencing approach. Results and conclusions: Here, we describe two men affected by LBC, the carriers of a pathogenic variant of BRCA2 and CDH1 genes, respectively. Our data, including somatic and germline results, demonstrate a strong relationship between male LBC and HBOC/HDGC syndromes, excluding a sporadic origin of LBC in these two patients. Male LBC could represent a sentinel cancer for inherited syndrome identification, and early identification of cancer susceptibility could improve cancer prevention both for men and women in these families. The history of the LBC patient carrier of the CDH1 variant suggests to include male LBC genetic testing criteria and male breast surveillance in HDGC guidelines.

Wound morbidity in mini-invasive thyroidectomy.

BACKGROUND: The incidence of wound morbidity (WM) after conventional thyroidectomy (CT) is 2 to 7%. This study evaluated the rate of WM after video-assisted thyroidectomy (VAT), with emphasis on surgical-site infections (SSIs). METHODS: A total of 112 patients were recruited for this prospective, randomized surveillance analysis. The eligibility criteria included nodule smaller than 30 mm, gland volume less than 30 ml, and no previous neck surgery or advanced cancer. The exclusion criteria specified coexistent infection, immunosuppressive treatment, and pathologies requiring antibiotic prophylaxis. The patients were randomized for VAT or CT. Neither antibiotic prophylaxis nor a drain was used. The patients were followed after surgery for WM. RESULTS: Both groups consisted of 56 patients. The rate for WM was significantly lower in the VAT group (n = 1) than in the CT group (n = 8) (p < 0.05). The incidence of SSI was 5.3% after CT and 0% after VAT (p < 0.05), and the most common pathogenic organism was Staphylococcus aureus. All WMs became evident after patient discharge. Wound infection was associated with prolonged ambulatory dressings. CONCLUSIONS: No previous studies have compared the rates for WM associated with endoscopic versus open surgery in the cervical area. Wound morbidity was significantly reduced after VAT relative to CT. The authors underscore the important effect of the minor surgical trauma associated with VAT on the development of SSIs.

Pure Ductal Carcinoma In Situ of the Breast: Analysis of 270 Consecutive Patients Treated in a 9-Year Period.

INTRODUCTION: Ductal carcinoma in situ (DCIS) is an intraductal neoplastic proliferation of epithelial cells that are confined within the basement membrane of the breast ductal system. This retrospective observational analysis aims at reviewing the issues of this histological type of cancer. MATERIALS AND METHODS: Patients treated for DCIS between 1 January 2009 and 31 December 2018 were identified from a retrospective database. The patients were divided into two groups of 5 years each, the first group including patients treated from 2009 to 2013, and the second group including patients treated from 2014 to 2018. Once the database was completed, we performed a statistical analysis to see if there were significant differences among the 2 periods. Statistical analyses were performed using GraphPad Prism software for Windows, and the level of significance was set at p < 0.05. RESULTS: 3586 female patients were treated for breast cancer over the 9-year study period (1469 patients from 2009 to 2013 and 2117 from 2014 to 2018), of which 270 (7.53%) had pure DCIS in the final pathology. The median age of diagnosis was 59-year-old (range 36-86). In the first period, 81 (5.5%) women out of 1469 had DCIS in the final pathology, in the second, 189 (8.9%) out of 2117 had DCIS in the final pathology with a statistically significant increase (p = 0.0001). From 2009 to 2013, only 38 (46.9%) were in stage 0 (correct DCIS diagnosis) while in the second period, 125 (66.1%) were included in this stage. The number of patients included in clinical stage 0 increased significantly (p = 0.004). In the first period, 48 (59.3%) specimen margins were at a greater or equal distance than 2 mm (negative margins), between 2014 and 2018; 137 (72.5%) had negative margins. Between 2014 and 2018 the number of DCIS patients with positive margins decreased significantly (p = 0.02) compared to the first period examined. The mastectomies number increased significantly (p = 0.008) between the 2 periods, while the sentinel lymph node biopsy (SLNB) numbers had no differences (p = 0.29). For both periods analysed all the 253 patients who underwent the follow up are currently living and free of disease. We have conventionally excluded the 17 patients whose data were lost. Conclusion: The choice of the newest imaging techniques and the most suitable biopsy method allows a better pre-operative diagnosis of the DCIS. Surgical treatment must be targeted to the patient and a multidisciplinary approach discussed in the Breast Unit centres.

Development of a novel nomogram-based online tool to predict axillary status after neoadjuvant chemotherapy in cN+ breast cancer: A multicentre study on 1,950 patients.

BACKGROUND: Type of axillary surgery in breast cancer (BC) patients who convert from cN + to ycN0 after neoadjuvant chemotherapy (NAC) is still debated. The aim of the present study was to develop and validate a preoperative predictive nomogram to select those patients with a low risk of residual axillary disease after NAC, in whom axillary surgery could be minimized. PATIENTS AND METHODS: 1950 clinically node-positive BC patients from 11 Breast Units, treated by NAC and subsequent surgery, were included from 2005 to 2020. Patients were divided in two groups: those who achieved nodal pCR vs. those with residual nodal disease after NAC. The cohort was divided into training and validation set with a geographic separation criterion. The outcome was to identify independent predictors of axillary pathologic complete response (pCR). RESULTS: Independent predictive factors associated to nodal pCR were axillary clinical complete response (cCR) after NAC (OR 3.11, p < 0.0001), ER-/HER2+ (OR 3.26, p < 0.0001) or ER+/HER2+ (OR 2.26, p = 0.0002) or ER-/HER2- (OR 1.89, p = 0.009) BC, breast cCR (OR 2.48, p < 0.0001), Ki67 > 14% (OR 0.52, p = 0.0005), and tumor grading G2 (OR 0.35, p = 0.002) or G3 (OR 0.29, p = 0.0003). The nomogram showed a sensitivity of 71% and a specificity of 73% (AUC 0.77, 95%CI 0.75-0.80). After external validation the accuracy of the nomogram was confirmed. CONCLUSION: The accuracy makes this freely-available, nomogram-based online tool useful to predict nodal pCR after NAC, translating the concept of tailored axillary surgery also in this setting of patients.

The middle thyroid vein: anatomical and surgical aspects.

BACKGROUND: An issue that has been overlooked in medical literature concerns the prevalence and topographic relationships of the middle thyroid vein (MTV), which have been studied, with a prospective approach, in patients with various thyroid diseases. METHODS: MTV prevalence has been investigated in 394 consecutive lobes and a number of different variables (age, gender, thyroid pathology, gland weight) have been considered. Moreover, in cooperation with our Human Morphology Department, we brought to completion a dedicated anatomy report, with the clear objective of providing a detailed anatomic description of MTV. RESULTS: The prevalence of MTV was 38% of the dissected lobes and 62% of operated patients. Most veins arise from the mid region of the thyroid lobe (80%): B, 3, and 2 positions in accordance with our scheme. As far as thyroid pathology is concerned, we found that the presence of MTV was more frequent in hyperthyroidism and large goiters (p < 0.05). CONCLUSIONS: A better understanding of the anatomic variability in MTV may be useful not only to minimize the risk of bleeding, but it also can help to perform a more accurate dissection with the goal of preserving the laryngeal nerves and parathyroid glands, especially because of its location and relationships with other adjacent structures.

Postoperative laryngoscopy in thyroid surgery: proper timing to detect recurrent laryngeal nerve injury.

BACKGROUND: There is currently a lack of consensus to support the proper timing for postoperative laryngoscopy that is reliable to diagnose recurrent laryngeal nerve palsy (RLNP) after thyroid surgery. The purpose of this study was to investigate the impact of different time intervals of fiber-optic nasolaryngoscopy (FNL) on the diagnosis of RLNP. METHOD: FNL was performed postoperatively at day 0 (T1), at second day post-op (T2), and +2 weeks (T3). For patients with RLNP, repeated examinations were performed at +2 (T4), +6 (T5), and +12 months (T6). RESULTS: Four hundred thirty-four patients appear for postoperative FNL, providing 825 nerves at risk. Permanent RLNP occurred in 0.7%, temporary RLNP in 6.7%. RLNP rate was 6.4% at T1, 6.7% at T2, 4.8% at T3, 2.5% at T4, 0.8% at T5, and 0.7% at T6. Full recovery of vocal cord function was confirmed after rehabilitation in 87.5% of cases at T5 and 89% in T6. T2 was significantly superior to T3 in terms of diagnosis of RLNP (P < 0.05). Of patients at T2, 10.7% did not see any reason to FNL because of their normal voice register. CONCLUSION: FNL is essential for the detection of vocal cord paralysis after thyroidectomy. We report different time evaluation criteria of vocal cord motility with great and significant variability of results. Second day post-op inspection of the larynx (T2) is suggested. Symptomatic voice assessment is insufficient.

Surgical anatomy and neurophysiology of the vagus nerve (VN) for standardised intraoperative neuromonitoring (IONM) of the inferior laryngeal nerve (ILN) during thyroidectomy.

BACKGROUND: Standardisation of the intraoperative neuromonitoring (IONM) technique is a fundamental aspect in monitored thyroid surgery. Vagal nerve (VN) stimulation is essential for problem solving, recognition of any inferior laryngeal nerve (ILN) lesions and prediction of ILN post-operative function. Issues that have been overlooked in the literature, particularly in terms of prospective approaches, are the topographic relationship of the VN with the carotid and jugular vessels as well as the neurophysiology of the VN and ILN that have been studied, with a prospective approach, in patients with various thyroid diseases. METHODS: Cooperation with the Human Morphology Department resulted in the completion of a dedicated anatomy report, with the clear objective of providing a detailed anatomic and neurophysiologic description of the VN (n = 263). RESULTS: VN identification and stimulation was feasible in all cases and did not result in increased morbidity or operative time. Most VNs lay on the posterior region of the carotid ship (73%), i.e. the P position in accordance with our model. Mean amplitudes of EMG signals obtained from VN stimulation were 750 ± 279 µV, lower than those obtained with direct INL stimulation (1,086 ± 349 µV). CONCLUSION: A better understanding of the variability in the VN may be useful not only to minimise complications but also to guarantee an accurate IONM.

Predictors of loco-regional recurrence and cancer-related death after breast cancer surgery.

To determine which tumor-related factors might predispose the patient to loco-regional recurrence or death and the impact of these factors on the different types of events. We retrospectively analyzed the data of 1991 women between January 1998 and March 2010 for a first primary nonmetastatic breast cancer and treated with surgery and neo-adjuvant/adjuvant therapy. The overall survival distribution was estimated using the Kaplan-Meier method. The prognostic impact of several factors on cumulative overall and loco-regional recurrence free survival was evaluated by univariate (log-rank test) and multivariate analysis (Cox regression). At log-rank test, pT, nodal status, histotype, grading, lymphangioinvasive growth, tumor diameter, estrogen receptors (ER) status, progesterone receptors (PR) status, expression of Ki67, and expression of Her2/neu had a prognostic value on loco-regional recurrence or overall survival. In the multivariate analysis grading remained the only independent predictor of loco-regional recurrences. With regard to overall survival, the Cox model selected grading along with nodal status and PR status. Loco-regional recurrences after breast cancer surgery are not frequent events. They are markers of tumor aggressiveness and predictor of an increased likelihood of cancer-related death. However, loco-regional recurrence and systemic tumor progression are partially independent events, since some prognostic factors differ.