Intraoperative transcystic laparoscopic common bile duct stone clearance with SpyGlass™ discover during emergency and elective cholecystectomy: a single-center case series.

BACKGROUND AND STUDY AIM: The development of a new cholangioscope, the SpyGlass™ Discover (Boston Scientific), has allowed the laparoscopic transcystic common bile duct exploration and stone clearance. The possibility of simultaneous treatment of choledocholithiasis during early laparoscopic cholecystectomy offers the opportunity to enormously reduce the time between acute cholecystitis diagnosis and the execution of cholecystectomy with better outcomes for patients. Furthermore, an altered anatomy of the gastrointestinal tract is not an obstacle to this technique. The aim of the study was to determine whether this new procedure is feasible, safe, and effective. PATIENTS AND METHODS: The investigation employs a retrospective case series study including all consecutive patients with a diagnosis of common bile duct stones undergoing cholecystectomy and intraoperative laparoscopic common bile duct clearance using SpyGlass™ Discover at IRCCS Policlinico San Matteo in Pavia (Italy). Eighteen patients were included from May 2022 to May 2023. RESULTS: A complete clearance of the common bile duct was obtained in 88.9% of patients. The mean postoperative length of stay was 3 days. No major complications occurred. After a median follow-up of 8 months, no recurrence of biliary events or readmissions occurred. CONCLUSION: This procedure has proven to be feasible, safe, and effective.

QUANTITATIVE ASSESSMENT OF AUTOMATED OPTICAL COHERENCE TOMOGRAPHY IMAGE ANALYSIS USING A HOME-BASED DEVICE FOR SELF-MONITORING NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To evaluate a prototype home optical coherence tomography device and automated analysis software for detection and quantification of retinal fluid relative to manual human grading in a cohort of patients with neovascular age-related macular degeneration. METHODS: Patients undergoing anti-vascular endothelial growth factor therapy were enrolled in this prospective observational study. In 136 optical coherence tomography scans from 70 patients using the prototype home optical coherence tomography device, fluid segmentation was performed using automated analysis software and compared with manual gradings across all retinal fluid types using receiver-operating characteristic curves. The Dice similarity coefficient was used to assess the accuracy of segmentations, and correlation of fluid areas quantified end point agreement. RESULTS: Fluid detection per B-scan had area under the receiver-operating characteristic curves of 0.95, 0.97, and 0.98 for intraretinal fluid, subretinal fluid, and subretinal pigment epithelium fluid, respectively. On a per volume basis, the values for intraretinal fluid, subretinal fluid, and subretinal pigment epithelium fluid were 0.997, 0.998, and 0.998, respectively. The average Dice similarity coefficient values across all B-scans were 0.64, 0.73, and 0.74, and the coefficients of determination were 0.81, 0.93, and 0.97 for intraretinal fluid, subretinal fluid, and subretinal pigment epithelium fluid, respectively. CONCLUSION: Home optical coherence tomography device images assessed using the automated analysis software showed excellent agreement to manual human grading.

Regenerative Medicine and Diabetes: Targeting the Extracellular Matrix Beyond the Stem Cell Approach and Encapsulation Technology.

According to the Juvenile Diabetes Research Foundation (JDRF), almost 1. 25 million people in the United States (US) have type 1 diabetes, which makes them dependent on insulin injections. Nationwide, type 2 diabetes rates have nearly doubled in the past 20 years resulting in more than 29 million American adults with diabetes and another 86 million in a pre-diabetic state. The International Diabetes Ferderation (IDF) has estimated that there will be almost 650 million adult diabetic patients worldwide at the end of the next 20 years (excluding patients over the age of 80). At this time, pancreas transplantation is the only available cure for selected patients, but it is offered only to a small percentage of them due to organ shortage and the risks linked to immunosuppressive regimes. Currently, exogenous insulin therapy is still considered to be the gold standard when managing diabetes, though stem cell biology is recognized as one of the most promising strategies for restoring endocrine pancreatic function. However, many issues remain to be solved, and there are currently no recognized treatments for diabetes based on stem cells. In addition to stem cell resesarch, several ß-cell substitutive therapies have been explored in the recent era, including the use of acellular extracellular matrix scaffolding as a template for cellular seeding, thus providing an empty template to be repopulated with ß-cells. Although this bioengineering approach still has to overcome important hurdles in regards to clinical application (including the origin of insulin producing cells as well as immune-related limitations), it could theoretically provide an inexhaustible source of bio-engineered pancreases.

Saving from unnecessary pancreaticoduodenectomy. Brunner's gland hamartoma: Case report on a rare duodenal lesion and exhaustive literature review.

INTRODUCTION: Brunner's gland hamartoma (BGH) is an infrequently encountered, benign, polypoid proliferation of Brunner's glands. Usually these lesions are asymptomatic, just only occasionally presenting with duodenal obstruction or bleeding signs and mimicking a tumoral lesion. CASE PRESENTATION: A 72-year-old male, referred for recurrent vomiting and epigastralgia, was investigated and all preoperative findings were suggestive of a tumour of the duodenum. During the scheduled pancreaticoduodenectomy a mass, resultant to a polyp, was palpatory felt inside the duodenum and then successfully and completely resected through a duodenotomy avoiding surgical overtreatment and connected postoperative morbidities. Histological analysis showed hyperplasia of Brunner's glands correspondent to a Brunner's gland hamartoma. BGH was undiagnosed before surgery, due to its particular sub-mucosal growth simulating an expanding process starting from the duodenum, and secondly due to unsuccessful biopsies performed during endoscopic procedure. CONCLUSION: BGH is a rare lesion featuring, when symptomatic, obstructive or bleeding symptoms. Surgical treatment represents the gold standard approach in case of lesions that are technically impossible to remove endoscopically or in case of an undiagnosed lesion. Herein, we report a case of a patient presenting with a duodenal lesion mimicking, in all preoperative findings, a tumour of the duodenum. Duodenotomy and resection of the BGH provided a definitive cure avoiding surgical overtreatment. An intraoperative deep analysis of all surgical cases still remain crucial for a right therapeutic choice even in a new era for surgical technology. For similar intraoperative findings we recommend this technique.

Diabetic retinopathy screening: the first telemedical approach in an Italian hospital.

PURPOSE: To assess the feasibility of a telemedical approach for diabetic retinopathy (DR) screening in the Italian population and to evaluate advantages/disadvantages in comparison to standard slit-lamp funduscopic examination (SFE). METHODS: This 1-year, Italian, single-center, observational study evaluated semiautomatic fundus photography (FP) DR screening, performed during routine type 2 diabetes (T2D) systemic visits and examined remotely. Adults with T2D underwent SFE and 3-field FP. The study was divided into 2 stages (stage 1 validated the screening procedure, stage 2 evaluated the screening impact on the clinical practice). Annual costs of SFE ± FP screening were compared. Patients completed a DR screening questionnaire. RESULTS: Of 1,281 T2D patients enrolled, 61% were male (mean age 65.69 ± 12.64 years). In stage 1, 71% and 15% of patients were considered nongradable when FP was performed before (BPD) versus after pupil dilation (APD). The FP specificity was higher with APD vs BPD (79% vs 25%); therefore, FP APD only was used for stage 2. Of 1,281 patients screened using FP APD, 240 (18.7%) had unreadable images; 64.3% did not have DR, and 17.0% were diagnosed with DR. There was a cost saving of €801.25 when screening was performed using FP. Overall, 98% of patients had a positive opinion of FP screening. CONCLUSIONS: The telemedicine approach provides a convenient, simple test that is well-received by patients and minimizes unnecessary referrals. Telemedicine may also reduce screening costs in our setting.

Modified radical retropubic prostatectomy: personal technical variation "tension free continuum-urethral anastomosis (T.F.C.U.A)" with optical magnification in the preservation of the bladder neck, and estimation of the urinary continence.

OBJECTIVE: To reassess the double continence technique for open retropubic radical prostatectomy, proposed by Malizia and employed by Pagano et al., with the "tension free continuum-urethral anastomosis" (T.F.C.U.A.) personal modification and the use of image magnification optical systems and appropriate and delicate surgical tools. MATERIALS AND METHODS: A total of 173 radical retropubic prostatectomies, performed by the same surgeon, were evaluated in terms of early and late continence. RESULTS: The presence of residual prostate cancer cells within the muscle layer was always excluded by the histopathological examination that also demonstrated that the muscle layer was well represented; satisfactory outcomes were obtained in terms of both early urinary continence (60%) and urinary continence at 6-12 month follow-up (92.4% for the whole series and 97.2% for the last series of patients). CONCLUSIONS: The "tension free" anastomosis obtained by the suspension of the anterior bladder wall to the the pubis along the median line allowed to achieve satisfactory outcomes in terms of urinary continence, even if these data obviously need to be confirmed by other series and comparative trials.

The role of the elastography in the diagnosis of prostate cancer: a retrospective study on 460 patients.

OBJECTIVE: Prostate cancer is one of the most common cancer among men in industrialized total Prostatic Specific Antigen (PSA) and PSA ratio, Trans Rectal Ultrasound Scan (TRUS) and prostate biopsy, which is the gold standard for tumoral diagnosis. The poor sensibility of TRUS, when DRE and/or PSA are abnormal, requires prostate biopsy for diagnostic confirmation. The aim of this study was to evaluate the sensibility and the specificity of real time elastography (SE) with and without the association of TRUS for cancer diagnosis. MATERIAL AND METHODS: We retrospectively evaluated 460 patients who underwent TRUS-guided prostate biopsy. The mean age of patients was 66.4 years, the mean PSA was 7.96 ng/ml and the mean PSA ratio was 17.19%. We compared histopathological findings of prostate biopsies with the results of TRUS and elastography. RESULTS: 32.17% of all patients were positive for prostate cancer.TRUS showed a sensitivity of 76.35% with a low specificity (43.59%), a Positive Predictive Value (PPV) of 39.1% and a Negative Predictive Value (NPV) of 79.53%. SE showed a lower sensitivity (61.49%), but better specificity (75%), PPV (53.85%) and NPV (80.41%). The association of TRUS + SE showed an increase in the sensitivity (79.79%) and in the NPV (86.71%). We separately evaluated the results of the two urologists with a greater experience in the use of these diagnostic methods who got an excellent sensitivity (91.42%) and an high NPV (92.68%). CONCLUSIONS: SE is certainly an useful diagnostic method for the detection of prostate cancer, especially in association with TRUS. A great experience of the sonographist and an adequate training are indispensable to make, in the future, elastography a "structural marker".

Impact of intravesical hyaluronic acid and chondroitin sulfate on bladder pain syndrome/interstitial cystitis.

INTRODUCTION AND HYPOTHESIS: Intravesical instillations of hyaluronic acid (HA) and chondroitin sulfate (CS) may lead to regeneration of the damaged glycosaminoglycan layer in interstitial cystitis/bladder pain syndrome (IC/BPS). METHODS: Twenty-two patients with IC/BPS received intravesical instillations (40 ml) of sodium HA 1.6% and CS 2.0% in 0.9% saline solution (IALURIL, IBSA) once weekly for 8 weeks, then once every 2 weeks for the next 6 months. RESULTS: The score for urgency was reduced from 6.5 to 3.6 (p = 0.0001), with a reduction in pain scores from an average of 5.6 to 3.2 (p = 0.0001). The average urine volume increased from 129.7 to 162 ml (p < 0.0001), with a reduction in the number of voids in 24 h, from 14 to 11.6 (p < 0.0001). The IC Symptom and Problem Index decreased from 25.7 to 20.3 (p < 0.0001), and the Pain Urgency Frequency score, from 18.7 to 12.8 (p < 0.0001). CONCLUSION: The treatment appeared to be effective and well tolerated in IC/BPS in this initial experience.

[Real-time elastography in the diagnosis of prostate cancer: personal experience]. / Ruolo dell'elastosonografia prostatica transrettale nella diagnostica per immagini del carcinoma prostatico: esperienza personale.

INTRODUCTION: Prostate cancer is the most common cancer in men. In the future, a significant further increase in the incidence of prostate cancer is expected. The indication to perform a prostate biopsy is digital rectal examination suspicious for prostate cancer, total prostate specific antigen (PSA) value, free PSA/total PSA ratio, PSA density and PSA velocity, and an evidence of hypoechoic area at transrectal ultrasound scan. Unfortunately the specificity and sensibility are still poor. The aim of this retrospective study is to evaluate the specificity and sensibility of real time elastography versus ultrasound transrectal B-mode scan. METHODS: We retrospectively evaluated 108 pts. having undergone TRUS-guided transrectal prostate biopsy (10 samples). The indication for biopsy is: digital rectal examination, total prostate specific antigen (PSA) value, PSA ratio, PSA density and PSA velocity suspicious for prostate cancer, and/or an evidence of hypoechoic area at transrectal ultrasound scan, and/or hard area at real-time elastography. The mean age of patients is 66.8 years, mean PSA 6.5 ng/mL, and mean ratio 16.5%. We compared the histopathological findings of needle prostate biopsies with the results of transrectal ultrasound and transrectal real-time elastography. RESULTS: 32/108 (29.6%) pts. were positive for prostate cancer (mean Gleason score 7.08), mean PSA 14 ng/mL and mean ratio 9.5%. Transrectal ultrasound scan shows a sensibility of 69% and specificity of 68%. Transrectal ultrasound scan shows a VPP of 51.4%. Transrectal ultrasound scan shows a VPN of 80.9%. Real-time elastography shows a sensibility of 56% and specificity of 85.7%. Real-time elastography shows a VPP of 60.1%. Real-time elastography shows a VPN of 83%. CONCLUSIONS: Elastography has a significantly higher specificity for the detection of prostate cancer than the conventionally used examinations including DRE and TRUS. It is a useful real-time diagnostic method because it is not invasive, and simultaneous evaluation is possible while performing TRUS.

Do facial nerve displacement pattern and tumor adhesion influence the facial nerve outcome in vestibular schwannoma surgery?

OBJECTIVE: To assess the nerve facial displacement by a vestibular schwannoma and nerve adhesion to tumor as predictive factors of facial function outcome. STUDY DESIGN: A prospective cohort study. SETTING: Tertiary referral center. PATIENTS: Ninety-six patients undergoing a solitary vestibular schwannoma surgery during 2005 were included. Data concerning tumor size (Stage 1, intracanalicular; Stage 2, < or =15 mm in the cerebellopontine angle [CPA]; Stage 3, 15-30 mm in the CPA; and Stage 4, >30 mm in the CPA), intraoperative facial nerve displacement (Type 1, anterior to the tumor; Type 2, anterior and superior to the tumor and separated from the cochlear nerve; Type 3, superior to the tumor; and Type 4, posterior to the tumor), degree of tumor adhesion (weak, intermediate, and strong) and postoperative facial function according to the House and Brackmann classification at days 10, 30, 90 and 180 were collected. RESULTS: A good facial function (Grade 1 or 2) was reported in 73% at postoperative Day 180. Univariate analysis showed that facial outcome was better in small tumors, in displacement Types 1 and 2 (Type 1, 46%; Type 2, 34%; and Type 3, 20%), and in tumors with weak and intermediate adhesion (weak, 10%; intermediate, 38%; and strong, 52%). Facial nerve displacement and adhesion were related to tumor stage. The combination of tumor stage, adhesion, and nerve displacement in a logistic regression model was highly predictive of postoperative facial function. CONCLUSION: Facial nerve displacement and nerve adhesion to tumor are significant predictive factors of facial function outcome after vestibular schwannoma surgery in addition to tumor size.

[Ovarian cyst in a case of female pseudohermaphroditism in a patient with male phenotype]. / Cisti ovarica in paziente a fenotipo maschile e pseudoermafroditismo femminile. Caso clinico.

Female pseudohermaphroditism is an intersexual state distinguished by virilized external genitals and secondary sex characters in a XX subject. We report a case of female pseudohermaphroditism diagnosed later on the discovery of an abdominal mass, then revealed to be an enormous ovarian cyst. Hormonal dosages suggested the presence of partial surrenalic b-hydroxylase deficiency. For this reason the clinical picture was considered expression of an adreno-genital syndrome, displayed as female pseudohermaphroditism with Prader stage V virilization.

[Synchronous and metachronous tumours of colon cancer. A review of 5 years of experience (1999-2004)]. / I tumori sincroni e metacroni del colon-retto. Revisione di 5 anni di attività (1999-2004).

The authors report on 30 synchronous cancer (19%) and 9 metachronous cancer (5.7%) observed in 5 years (1999-2004) in 158 patient operated for colon cancer, defining metachronous cancer a tumor arisen at least 6 months after the first one or further then 5 cm from the anastomosis of the first colon resection. International case records report an incidence of 0.6-14% for synchronous cancer and 1-8% for metachronous cancer. The incidence of synchronous cancer is increasing for the presence of more oncogenic factors in the environment, for the improvement in radiology and endoscopy, for the raise of medium life. In accord with other authors, they show that the main risk factor for the developing of metachronous cancer is the coexistence of colon adenomas at the moment of the diagnosis of the tumor. The various incidence percentages can be explained by different way of diagnosis and classification.

A case of bilateral breast cancer and Graves' disease.

We report a case of bilateral breast cancer associated with Graves' disease characterized by a large goiter and complicated by a severe ophthalmopathy. The hyperthyroidism was treated initially with methimazole and then with thyroidectomy, the ophthalmopathy with intravenous steroids combined with orbital radiotherapy. The breast tumors underwent surgical resection followed by chemotherapy. We describe this case because of the well-known association between breast cancer and thyroid disease, particularly of the autoimmune type, the causes of this being still unclear. Recent literature on this topic is reviewed, discussing the possible role of the Na(+)-I(-) symporter and anti-TPO antibodies.