A Fatal Case of Metastatic Pulmonary Calcification during the Puerperium.

We present an unusual case of a fatal respiratory failure in a young woman developed two weeks after she gave birth at home. Circumstantial and clinical features of the case were strongly suggestive for a 'classical' septic origin of the respiratory symptoms. Autopsy, together with histopathological and immunohistochemical analyses allowed demonstrating a massive calcium redistribution consisting of an important osteolysis, especially from cranial bones and abnormal accumulation in lungs and other organs. Such physiopathology was driven by a primary hyperparathyroidism secondary to a parathyroid carcinoma as demonstrated by immunohistochemistry. This very rare case is furthermore characterised by a regular pregnancy course, ended with the birth of a healthy new-born. A complex interaction between pregnancy physiology and hyperparathyroidism might be hypothesised, determining the discrepancy between the relative long period of wellness and the tumultuous cascade occurred in the puerperium.

Lethal aorto-oesophageal fistula 16 years after aortic prosthetic reconstruction: Delayed rupture as cause of death.

The development of aorto-oesophageal fistula (AOF) is a rare complication following thoracic aortic repair. Mortality is high, in most cases due to fatal haematemesis. The clinical onset is variable, occurring approximately one year after surgery. We report a case of a lethal AOF in a 58-year-old man. He underwent open vascular surgery 16 years prior to his death due to a rupture of the descending thoracic aorta. In the early 2000s, the open vascular approach was replaced by thoracic endovascular aortic repair. As a result of this approach, the number of surgical complications has reduced, with the exception of AOF.

Pathogenesis and Treatment Options of Cancer Related Anemia: Perspective for a Targeted Mechanism-Based Approach.

Cancer-related anemia (CRA) is a common sign occurring in more than 30% of cancer patients at diagnosis before the initiation of antineoplastic therapy. CRA has a relevant influence on survival, disease progression, treatment efficacy, and the patients' quality of life. It is more often detected in patients with advanced stage disease, where it represents a specific symptom of the neoplastic disease, as a consequence of chronic inflammation. In fact, CRA is characterized by biological and hematologic features that resemble those described in anemia associated to chronic inflammatory disease. Proinflammatory cytokine, mainly IL-6, which are released by both tumor and immune cells, play a pivotal action in CRA etiopathogenesis: they promote alterations in erythroid progenitor proliferation, erythropoietin (EPO) production, survival of circulating erythrocytes, iron balance, redox status, and energy metabolism, all of which can lead to anemia. The discovery of hepcidin allowed a greater knowledge of the relationships between immune cells, iron metabolism, and anemia in chronic inflammatory diseases. Additionally, chronic inflammation influences a compromised nutritional status, which in turn might induce or contribute to CRA. In the present review we examine the multifactorial pathogenesis of CRA discussing the main and novel mechanisms by which immune, nutritional, and metabolic components affect its onset and severity. Moreover, we analyze the status of the art and the perspective for the treatment of CRA. Notably, despite the high incidence and clinical relevance of CRA, controlled clinical studies testing the most appropriate treatment for CRA are scarce, and its management in clinical practice remains challenging. The present review may be useful to indicate the development of an effective approach based on a detailed assessment of all factors potentially involved in the pathogenesis of CRA. This mechanism-based approach is essential for clinicians to plan a safe, targeted, and successful therapy, thereby promoting a relevant amelioration of patients' quality of life.

Feasibility and safety of total laparoscopic hysterectomy for huge uteri without the use of uterine manipulator: description of emblematic cases.

BACKGROUND: Uterine manipulator is a very useful tool in performing total laparoscopic hysterectomy (TLH) for large uteri; however, in some cases, it cannot be used due to unfavorable anatomical conditions. The feasibility and safety of TLH for very large uteri without the use of uterine manipulator has not yet been established. RESULTS: We describe two emblematic cases of TLH for huge fibromatous uteri: the first one for a uterus weighing 5700 g, which is the largest uterus laparoscopically removed to date reported in literature, and the second one for a uterus of 3670 g associated with a severe lymph node neoplastic disease.In both cases, TLH was successfully and safely performed even without the use of uterine manipulator, thus allowing a rapid recovery, especially in the second case, which was essential for a fast start of the most appropriate oncological treatment, the best quality of life and undoubtedly cosmetic advantages. CONCLUSIONS: Although we believe in the great usefulness of the uterine manipulator in performing TLH for huge uteri, in the present paper, we demonstrate the feasibility and safety of such complex surgery also when the use of this tool is not possible due to unfavorable anatomical condition.

Abdominal leiomyosarcomatosis after surgery with external morcellation for occult smooth muscle tumors of uncertain malignant potential: A case report.

INTRODUCTION: Although rare, cases of abdominal sarcomatosis (AS) after laparotomy/laparoscopic interventions for uterine smooth muscle tumors of uncertain malignant potential (STUMP) have been reported. PRESENTATION OF CASE: We describe a rare case of diffuse abdominal sarcomatosis in a patient that some year earlier had undergone myomectomy for a suspected uterine myoma, which was histologically proven to be a STUMP. Once the patient was admitted at our Department, she underwent a diagnostic laparoscopy that confirmed a condition of peritoneal sarcomatosis disseminated through the entire abdomen, and then a laparotomic total hysterectomy, bilateral salpingo-oophorectomy, and total omentectomy, achieving a complete cytoreduction. Histological examination showed high-grade uterine leyomiosarcoma (LMS). Since there is no evidence of any clinical benefit of adjuvant treatment, given the risk of disease recurrence, we decided, with the patient's agreement, to conduct close follow-up with a Positron Emission Tomography (PET)/Computed Tomography (CT) scan every 3months and diagnostic laparoscopy every 6months, even in the absence of PET/CT positivity. After 2years PET/CT showed a relapse of LMS in the perigastric region and, therefore the patient underwent a diagnostic/operative laparoscopy with complete removal of the neoplastic recurrence. To date, the patient is disease-free. DISCUSSION AND CONCLUSION: STUMPs should be submitted to a frequent surveillance for their risk of recurrence, dissemination and transformation into LMS, even many years after the first diagnosis. A follow-up including surgical re-exploration with laparoscopy and PET/CT imaging may allow early detection and timely treatment of the relapse with good long-term outcome, as demonstrated by our case.

Reassessing the approach to informed consent: the case of unrelated hematopoietic stem cell transplantation in adult thalassemia patients.

INTRODUCTION: The informed consent process is the legal embodiment of the fundamental right of the individual to make decisions affecting his or her health., and the patient's permission is a crucial form of respect of freedom and dignity, it becomes extremely important to enhance the patient's understanding and recall of the information given by the physician. This statement acquires additional weight when the medical treatment proposed can potentially be detrimental or even fatal. This is the case of thalassemia patients pertaining to class 3 of the Pesaro classification where Allogenic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative treatment. Unfortunately, this kind of intervention is burdened by an elevated transplantation-related mortality risk (TRM: all deaths considered related to transplantation), equal to 30% according to published reports. In thalassemia, the role of the patient in the informed consent process leading up to HSCT has not been fully investigated. This study investigated the hypothesis that information provided by physicians in the medical scenario of HSCT is not fully understood by patients and that misunderstanding and communication biases may affect the clinical decision-making process. METHODS: A questionnaire was either mailed or given personally to 25 patients. A second questionnaire was administered to the 12 physicians attending the patients enrolled in this study. Descriptive statistics were used to evaluate the communication factors. RESULTS: The results pointed out the difference between the risks communicated by physicians and the risks perceived by patients. Besides the study highlighted the mortality risk considered to be acceptable by patients and that considered to be acceptable by physicians. CONCLUSIONS: Several solutions have been suggested to reduce the gap between communicated and perceived data. A multi-disciplinary approach may possibly help to attenuate some aspects of communication bias. Several tools have also been proposed to fill or to attenuate the gap between communicated and perceived data. But the most important tool is the ability of the physician to comprehend the right place of conscious consent in the relationship with the patient.

Identification alone versus intraoperative neuromonitoring of the recurrent laryngeal nerve during thyroid surgery: experience of 2034 consecutive patients.

BACKGROUND: The aim of this study was to evaluate the ability of intraoperative neuromonitoring in reducing the postoperative recurrent laryngeal nerve palsy rate by a comparison between patients submitted to thyroidectomy with intraoperative neuromonitoring and with routine identification alone. METHODS: Between June 2007 and December 2012, 2034 consecutive patients underwent thyroidectomy by a single surgical team. We compared patients who have had neuromonitoring and patients who have undergone surgery with nerve visualization alone. Patients in which neuromonitoring was not utilized (Group A) were 993, patients in which was utilized (group B) were 1041. RESULTS: In group A 28 recurrent laryngeal nerve injuries were observed (2.82%), 21 (2.11%) transient and 7 (0.7%) permanent. In group B 23 recurrent laryngeal nerve injuries were observed (2.21%), in 17 cases (1.63%) transient and in 6 (0.58%) permanent. Differences were not statistically significative. CONCLUSIONS: Visual nerve identification remains the gold standard of recurrent laryngeal nerve management in thyroid surgery. Neuromonitoring helps to identify the nerve, in particular in difficult cases, but it did not decrease nerve injuries compared with visualization alone. Future studies are warranted to evaluate the benefit of intraoperative neuromonitoring in thyroidectomy, especially in conditions in which the recurrent nerve is at high risk of injury.

Role of intraoperative neuromonitoring of recurrent laryngeal nerves in the outcomes of surgery for thyroid cancer.

INTRODUCTION: The aim of this retrospective study was to evaluate the ability of intraoperative neuromonitoring to predict the postoperative functional outcome and its role in reducing the postoperative recurrent laryngeal nerve palsy rate during thyroidectomy for thyroid malignancy. METHODS: Between June 2007 and March 2013, 656 consecutive patients with thyroid cancer underwent thyroidectomy by a single surgical team. We compared 357 patients who have had neuromonitoring (Group A) to 299 patients who have undergone surgery with nerve visualization alone (group B). RESULTS: In group A 7 recurrent laryngeal nerve paralysis were observed (1.96%), 6 (1.68%) transient and 1 (0.28%) permanent; a bilateral recurrent laryngeal palsy was observed in 1 of the 7 cases (0.28%). In group B 6 recurrent laryngeal nerve paralysis were observed (2.01%), 5 (2.01%) transient and 1 permanent (0.33%); bilateral palsy was observed in 1 of the 6 cases (0.33%). Differences were not statistically significative. CONCLUSIONS: Routine visual nerve identification remains the gold standard of recurrent laryngeal nerve management in surgery for thyroid cancer. Intraoperative neuromonitoring is safe, effective, reliable, and easy to perform in excluding postoperative recurrent laryngeal palsy. It helps to identify the nerve in thyroid cancer, but it did not decrease the injuries compared with visualization alone in this study; however, its use can change the operative strategy in order to prevent the risk of bilateral damage in case of signal loss. Future studies are needed to evaluate the benefit of intraoperative neuromonitoring in thyroidectomy for thyroid cancer.

Chronic pain following inguinal hernia repair: assessment of quality of life and medico-legal aspects.

The aim of our study was to evaluate the quality of life (QoL) of a group of patients who underwent tension-free inguinal hernia repair in light of the possible medicolegal implications. We conducted a retrospective study on the QoL of patients who underwent inguinal hernioplasty. One hundred and fifty patients who answered the SF-36 questionnaire were included in the study. Twenty-six (17.3%) had chronic pain, 18 (12%), sensory deficits, and 106 (70.6%) did not complain of any symptoms. There was no a significant deterioration in QoL compared to the reference population. In the group with chronic pain, 10 patients (38.4%) reported being very limited in performing "physically demanding activities"; 18 (69.2%) reported a deficit of performance in activities of daily living; 8 (30.7%) complained of a reduction of time spent at work because of emotional disorders. In one case the pain was particularly severe and required surgical treatment. The answers obtained through the questionnaire show that tension-free hernioplasty does not degrade patients'QoL. However in the group of patients with chronic pain examined one year after surgery, QoL had deteriorated so much that it affected the employment sphere and the social and relational sphere. Although there is a relatively low incidence and frequency of problems relating to chronic pain following inguinal hernioplasty, chronic pain can sometimes have serious effects on QoL and socio-economic and legal implications.

Ethical issues of unrelated hematopoietic stem cell transplantation in adult thalassemia patients.

BACKGROUND: Beta thalassemia major is a severe inherited form of hemolytic anemia that results from ineffective erythropoiesis. Allogenic hematopoietic stem cell transplantation (HSCT) remains the only potentially curative therapy. Unfortunately, the subgroup of adult thalassemia patients with hepatomegaly, portal fibrosis and a history of irregular iron chelation have an elevated risk for transplantation-related mortality that is currently estimated to be about 29 percent. DISCUSSION: Thalassemia patients may be faced with a difficult choice: they can either continue conventional transfusion and iron chelation therapy or accept the high mortality risk of HSCT in the hope of obtaining complete recovery.Throughout the decision making process, every effort should be made to sustain and enhance autonomous choice. The concept of conscious consent becomes particularly important. The patient must be made fully aware of the favourable and adverse outcomes of HSCT. Although it is the physician's duty to illustrate the possibility of completely restoring health, considerable emphasis should be put on the adverse effects of the procedure. The physician also needs to decide whether the patient is eligible for HSCT according to the "rule of descending order". The patient must be given full details on self-care and fundamental lifestyle changes and be fully aware that he/she will be partly responsible for the outcome. SUMMARY: Only if all the aforesaid conditions are satisfied can it be considered reasonable to propose unrelated HSCT as a potential cure for high risk thalassemia patients.

[Iatrogenic lesions of the common bile duct in laparoscopic cholecystectomy: three fundamental requirements for their prevention]. / Le lesioni iatrogene della via biliare principale in churgia videoassistita: tre esigenze in tema di prevenzione.

Laparoscopic cholecystectomy has become the gold standard in the treatment of benign biliary disease. Common bile duct injuries are the most serious and feared complications of laparoscopic cholecystectomy, since they cause substantial morbidity and increased hospital stay, and increasingly often are the subject of legal disputes. The causes of these kinds of lesions, according to the international literature, are usually inadequate normal and pathological anatomical knowledge, an incomplete learning curve, inadequate surgical technique, and lastly insufficient compliance of the surgeon. Another important, though underestimated, role in the aetiology of these lesions is played by the human factor, and particularly by a peculiar preconceived attitude. The latter manifests itself as a lack of realism, reasonableness and morality. These three basic requirements are part of universal human experience in the dynamics of knowing and, although not statistically quantifiable, may play a role comparable to that of the technical quality of the surgical performance. In our study we have tried to show, with regard to the prevention of biliary lesions during laparoscopic cholecystectomy, the extent of the importance of these three requirements in the dynamics of knowing, particularly in laparoscopic surgery, where they are not adequately taken into consideration. The analysis of the profound interaction between these requisites and surgical practice may allow correct identification of this preconceived attitude on the part of the operator, which can be avoided or minimized only through appropriate surgical training.