Long-term results after laparoscopic sleeve gastrectomy in a large monocentric series.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) has gained great popularity as a stand-alone bariatric procedure because short- and mid-term outcomes in terms of weight loss and resolution of co-morbidities have been very positive. However, long-term results from large series still are sparse. OBJECTIVES: To evaluate the long-term clinical outcomes of SG in a large series of patients undergoing SG as a stand-alone procedure. SETTING: University hospital in Italy. METHODS: A retrospective analysis of prospectively collected data from 182 patients undergoing SG between 2006 and 2008 in the authors' institution. Long-term outcomes at 6 and 7 years were analyzed in terms of weight loss and co-morbidities resolution. RESULTS: Mean initial body mass index (BMI) was 45.9±7.3 kg/m(2). Major postoperative complications occurred in 8 patients (5.4%): 4 leaks, 2 bleeding, 1 abdominal collection, and 1 dysphagia. All complications were managed conservatively. One hundred forty-eight patients (81.4%) completed the 72-month (6-year) follow-up. Thirty-seven patients (25%) reached a follow-up of 84 months. At year 6 follow-up the mean BMI and the mean percentage of excess weight loss (%EWL) were 30.2 kg/m(2) and 67.3%, respectively. Mean total body weight loss was 44.9 kg, while a %EWL >50 was registered in 123 patients (83.1%). Preoperative BMI did not significantly influence postoperative %EWL. Remission of type 2 diabetes mellitus, arterial hypertension, obstructive sleep apnea syndrome, and gastroesophageal reflux disease symptoms occurred in 83.8%, 59.7%, 75.6%, and 64.7% of patients, respectively. CONCLUSION: %EWL and resolution of co-morbidities appear to be sustained 6 and 7 years after SG. Preoperative BMI is not predictive for weight loss outcomes.

Learning curve for laparoscopic sleeve gastrectomy: role of training in a high-volume bariatric center.

BACKGROUND: Since the great diffusion of laparoscopic treatment of obesity, there is a growing interest concerning the learning process for those surgeons who undertake the bariatric activity. However, papers analyzing the learning curve (LC) for sleeve gastrectomy (SG) are still scarce. This study aims to investigate whether the LC for SG of a novice bariatric surgeon might be positively influenced by the training in a high-volume bariatric center (HVBC). METHODS: Between October 2010 and January 2014, 128 patients underwent SG by the same young surgeon who previously attended a 2-year training in a HVBC. His LC has been divided into three consecutive periods: in the first period (1st-47th SGs) he operated in the HVBC, while in the second (48th-88th SGs) and third period (89th-128th SGs) he moved to a novel department where surgical and ancillary staff were initially not confident with bariatric procedures but progressively owned the proper experience. Preoperative characteristics, operative data, complications and postoperative results of the three periods were compared. RESULTS: Mean follow-up was 1 year. Preoperative patients' characteristics were homogeneous. No significant differences have been registered among the three periods concerning operative data, mortality, intra- and post-operative complications, weight loss outcomes and comorbidities' resolution. Post-operative follow-up rates at 6 and 12 months were 98.4 and 92.1 %, respectively. CONCLUSIONS: Long-lasting fellowship in a HVBC might allow the novel bariatric surgeon to safely and proficiently overcome the LC for SG, even in a new established bariatric setting.

Strain ratio ultrasound elastography increases the accuracy of colour-Doppler ultrasound in the evaluation of Thy-3 nodules. A bi-centre university experience.

OBJECTIVES: To assess whether ultrasound elastography (USE) with strain ratio increases diagnostic accuracy of Doppler ultrasound in further characterisation of cytologically Thy3 thyroid nodules. METHODS: In two different university diagnostic centres, 315 patients with indeterminate cytology (Thy3) in thyroid nodules aspirates were prospectively evaluated with Doppler ultrasound and strain ratio USE before surgery. Ultrasonographic features were analysed separately and together as ultrasound score, to assess sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Receiver operating characteristic (ROC) curves to identify optimal cut-off value of the strain ratio were also provided. Diagnosis on a surgical specimen was considered the standard of reference. RESULTS: Higher strain ratio values were found in malignant nodules, with an optimum strain ratio cut-off of 2.09 at ROC analysis. USE with strain ratio showed 90.6% sensitivity, 93% specificity, 82.8% PPV, 96.4% NPV, while US score yielded a sensitivity of 52.9%, specificity of 84.3%, PPV 55.6% and NPV 82.9%. The diagnostic gain with strain ratio was statistically significant as proved by ROC areas, which was 0.9182 for strain ratio and 0.6864 for US score. CONCLUSIONS: USE with strain ratio should be considered a useful additional tool to colour-Doppler US, since it improves characterisation of thyroid nodules with indeterminate cytology. KEY POINTS: • Strain ratio measurements improve differentiation of thyroid nodules with indeterminate cytology • Elastography with strain ratio is more reliable than ultrasound features and ultrasound score • Strain ratio may help to better select patients with Thy 3 nodules candidate for surgery.

Aortic Intima-Media Thickness as an Early Marker of Atherosclerosis in Children With Inflammatory Bowel Disease.

OBJECTIVES: The aims of this study were to determine the presence of endothelial dysfunction by measuring aortic intima-media thickness (aIMT) and carotid intima-media thickness (cIMT) and to evaluate the role of traditional risk factors for premature atherosclerosis in children with inflammatory bowel disease (IBD). METHODS: Thirty-four children with IBD (25 Crohn disease [CD] and 9 ulcerative colitis [UC]; mean age 11.1 years) and 27 healthy subjects matched for sex and age were enrolled. In all of the patients, demographic characteristics and risk factors for atherosclerosis (age, sex, body mass index, blood pressure, dyslipidemia, active and passive smoking, and family history for cardiovascular diseases), CD and UC clinical activity scores, and inflammatory markers were evaluated. aIMT and cIMT were measured by high-resolution B-mode ultrasound. RESULTS: aIMT was significantly higher in patients than in controls (P < 0.0005). No significant differences were found for cIMT, although the carotid thickness was higher in patients with IBD than in healthy subjects. At a univariate analysis, inflammatory markers levels and tobacco smoking exposure were significantly related to higher aIMT values, whereas in a multivariate regression model, the inflammatory status was the only independent variable correlated with high aIMT. CONCLUSIONS: aIMT is an earlier marker of preclinical atherosclerosis than cIMT in young children with active IBD. The inflammatory status and the smoking exposure are significantly correlated with the premature endothelial dysfunction. These data emphasize the importance of controlling the chronic intestinal inflammation and endorsing smoke-free environments for children and adolescents with IBD.

Strain US Elastography for the Characterization of Thyroid Nodules: Advantages and Limitation.

Thyroid nodules, with their high prevalence in the general population, represent a diagnostic challenge for clinicians. Ultrasound (US), although absolutely reliable in detecting thyroid nodules, is still not accurate enough to differentiate them into benign and malignant. A promising novel modality, US elastography, has been introduced in order to further increase US accuracy. The purpose of this review article is to assess the thyroid application of US strain elastography, also known as real-time elastography or quasistatic elastography. We provide a presentation of the technique, and of up-to-date literature, analyzing the most prominent results reported for thyroid nodules differentiation. The practical advantages and limitations of strain elastography are extensively discussed herein.

Spider surgical system versus multiport laparoscopic surgery: performance comparison on a surgical simulator.

BACKGROUND: The rising interest towards minimally invasive surgery has led to the introduction of laparo-endoscopic single site (LESS) surgery as the natural evolution of conventional multiport laparoscopy. However, this new surgical approach is hampered with peculiar technical difficulties. The SPIDER surgical system has been developed in the attempt to overcome some of these challenges. Our study aimed to compare standard laparoscopy and SPIDER technical performance on a surgical simulator, using standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS). METHODS: Twenty participants were divided into two groups based on their surgical laparoscopic experience: 10 PGY1 residents were included in the inexperienced group and 10 laparoscopists in the experienced group. Participants performed the FLS pegboard transfers task and pattern cutting task on a laparoscopic box trainer. Objective task scores and subjective questionnaire rating scales were used to compare conventional laparoscopy and SPIDER surgical system. RESULTS: Both groups performed significantly better in the FLS scores on the standard laparoscopic simulator compared to the SPIDER. Inexperienced group: Task 1 scores (median 252.5 vs. 228.5; p = 0.007); Task 2 scores (median 270.5 vs. 219.0; p = 0.005). Experienced group: Task 1 scores (median 411.5 vs. 309.5; p = 0.005); Task 2 scores (median 418.0 vs. 331.5; p = 0.007). Same aspects were highlighted for the subjective evaluations, except for the inexperienced surgeons who found both devices equivalent in terms of ease of use only in the peg transfer task. CONCLUSIONS: Even though the SPIDER is an innovative and promising device, our study proved that it is more challenging than conventional laparoscopy in a population with different degrees of surgical experience. We presume that a possible way to overcome such challenges could be the development of tailored training programs through simulation methods. This may represent an effective way to deliver training, achieve mastery and skills and prepare surgeons for their future clinical experience.

Perivascular epithelioid cell neoplasm (PEComa) of the uterus: A systematic review.

BACKGROUND: Perivascular epithelioid cell neoplasm (PEComa) is a rare mesenchymal tumor. Gynecological PEComas account for just over one-fourth of the overall PEComa cases reported in the literature. Surgery is the most recommended primary treatment while adjuvant therapy is generally reserved for high-risk cases. However, the best management of this neoplasia has not been well established, primarily because of the paucity of cases described to date. OBJECTIVES: The aim of this systematic review is to summarize what is known thus far regarding the etiopathogenesis, clinical and pathologic features of PEComas, focusing also on the most valid treatment options for uterine cases. DATA SOURCES: Pubmed articles on PEComas published in various journals over the past 70 years were analyzed. CONCLUSIONS AND KEY FINDINGS: Although the optimal treatment of gynecological PEComas is controversial, surgical resection remains the cornerstone. The use of adjuvant treatment is warranted in high risk patients to increase disease control. A multidisciplinary approach should be key in treatment decision-making regarding gynecological PEComas.

Use of platelet-rich plasma to reinforce the staple line during laparoscopic sleeve gastrectomy: feasibility study and preliminary outcome.

AIMS: Reinforcement of the staple line is one of the most debated technical aspects concerning laparoscopic sleeve gastrectomy (LSG). Different buttressing methods have been proposed and demonstrated to be effective in reducing the incidence of staple line bleeding, although data concerning their effort on staple line leakage are not consistent. The aim of this study was to ascertain the technical feasibility and to report the preliminary outcomes of laparoscopic use of platelet-rich plasma (PRP) to reinforce the staple line during sleeve gastrectomy. PATIENTS AND METHODS: From March 2012 to May 2012, 20 patients were prospectively enrolled (10 females; mean age, 44.6 ± 11 years; mean body mass index, 42.3 ± 5.45 kg/m(2)). Type 2 diabetes mellitus was present in 4 patients, obstructive sleep apnea syndrome in 3, and hypertension in 6. LSG was performed using a 48-French bougie and gold cartridges; reinforcement of the staple lines with buttressed materials or oversewing the suture was performed excluding the last cranial cartridge. PRP was prepared by separating the platelets from autologous blood withdrawn on the same day of surgery, in order to obtain a membrane with cylindrical shape (2×5 cm) formed by fibrin and active platelets. The membrane is introduced through the 10-mm trocar and placed at the upper portion of the staple line. The overall cost for the preparation of PRP is about €15. RESULTS: No intraoperative complications and conversions have been recorded during the surgical procedures. No deaths occurred. The mean operative time was 85 ± 31 minutes, which was not significantly increased compared with the operative time of the surgeon's overall personal series (750 cases). At 12 months of follow-up the abdominal ultrasound was negative for collections, and upper contrast showed no images indicating gastric leaks. In no case did PRP induce symptoms of rejection, infection, or adverse events. CONCLUSIONS: The use of PRP during LSG is feasible, does not increase significantly the operative time, does not require any special devices, and is cost effective. A larger cohort of patients is needed to ascertain the potential effectiveness of PRP in the prevention of postoperative staple line complications.

Robotic distal pancreatectomy with or without preservation of spleen: a technical note.

BACKGROUND: Distal pancreatectomy (DP) is a surgical procedure performed to remove the pancreatic tail jointly with a variable part of the pancreatic body and including a spleen resection in the case of conventional distal pancreatectomy or not in the spleen-preserving distal pancreatectomy. METHODS: In this article, we describe a standardized operative technique for fully robotic distal pancreatectomy. RESULTS: In the last decade, the use of robotic systems has become increasingly common as an approach for benign and malignant pancreatic disease treatment. Robotic Distal Pancreatectomy (RDP) is an emerging technology for which sufficient data to draw definitive conclusions in surgical oncology are still not available because the follow-up period after surgery is too short (less than 2 years). CONCLUSIONS: RDP is an emerging technology for which sufficient data to draw definitive conclusions of value in surgical oncology are still not available, however this techniques is safe and reproducible by surgeons that possess adequate skills.

Merkel-cell carcinoma: preoperative clinical diagnosis and therapeutic implications.

The authors report the personal experience of some patients undergoing surgery for carcinoma of Merkel and discuss the diagnosis and therapeutic approach guided by literature and international guidelines. Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine tumour, which prefers the Caucasian race in adulthood. Approximately 78% of patients are over than 59 years, the most common location is at the level of the head and neck (50.8%) and less frequently in the limbs (33.7%). The literature is discordant about the causes and risk factors for this cancer. In fact, some authors describe major risk factor the immunosoppression, still others see prolonged exposition to UV radiation increases the risk for the onset of this tumor. Metastasizes early to the skin (28%), the lymph nodes (27%), liver (13%), lung (10%), bone (10%) and encephalon (6%), and may recur both locally (30-60%) and both locoregional (40-73%). Our experience confirms the difficulty of preoperative clinical diagnosis and a correct therapeutic approach to Merkel cell carcinoma for the lack of specific characteristics as first clinical assessment, which may keep the suspect nature. International guidelines provide a wide excision (3 cm in largeness and 2 cm in depth) to reduce the risk of disease recurrence, preferring adjuvant chemotherapy not radiotherapy. For lesions of stage I-II over the wide excision also regional lymphadenectomy is performed or, more rarely, the technique of sentinel lymph node.

Giant cardiac hydatid cyst in children: case report and review of the literature.

Cardiac echinococcus is a rare affliction of the heart caused by the tapeworm Echinococcus granulosus. Primary echinococcosis of the heart represents 0.5-2% of all hydatid disease cases in endemic regions. It evolves slowly, explaining its rarity in children. We report the case of a 11-year-old child affected by a giant cardiac cyst of the left ventricle (LV). The patient underwent cardiac surgery and medical treatment. A retrospective review of the current literature was realized. We found 18 cases: the mean age was 11-years old. Nine cysts were localized in the LV, four in the interventricular septum, three in the right ventricle, and two in the right atrium. All underwent surgery except six patients. Routine echocardiographic screening may be useful in endemic regions where infestation is common. Cardiac echinococcus should be diagnosed in the early and uncomplicated stages and be removed surgically even in asymptomatic patients.

Liver metastases: Contrast-enhanced ultrasound compared with computed tomography and magnetic resonance.

The development of ultrasound contrast agents with excellent tolerance and safety profiles has notably improved liver evaluation with ultrasound (US) for several applications, especially for the detection of metastases. In particular, contrast enhanced ultrasonography (CEUS) allows the display of the parenchymal microvasculature, enabling the study and visualization of the enhancement patterns of liver lesions in real time and in a continuous manner in all vascular phases, which is similar to contrast-enhanced computed tomography (CT) and contrast-enhanced magnetic resonance imaging. Clinical studies have reported that the use of a contrast agent enables the visualization of more metastases with significantly improved sensitivity and specificity compared to baseline-US. Furthermore, studies have shown that CEUS yields sensitivities comparable to CT. In this review, we describe the state of the art of CEUS for detecting colorectal liver metastases, the imaging features, the literature reports of metastases in CEUS as well as its technique, its clinical role and its potential applications. Additionally, the updated international consensus panel guidelines are reported in this review with the inherent limitations of this technique and best practice experiences.

Laparoscopic versus open left colectomy in patients with sigmoid colon cancer: prospective cohort study with long-term follow-up.

BACKGROUND: Laparoscopic left colectomy has obtained a large spread in colon surgery for malignant disease despite the need for an adequate learning curve. However few studies reported long term data in comparison with open left colectomy and most of the authors of large series on colorectal surgery don't describe, in subgroup analysis, results obtained in left colonic resections. The aim of this study is to report the short and long term follow-up of laparoscopic left colon resection in comparison with the open approach, from a single centre, performed in the same timeframe. METHODS: Between January 2005 to January 2007, 55 patients with sigma adenocarcinoma underwent to laparoscopic or open left colectomy at the Department of Digestive Surgery, "S. Maria" hospital in Terni - Italy. Perioperative and histopathological data and results from oncological follow-up, until April 2013, are analyzed. RESULTS: 28 patients underwent laparoscopic left colectomy, while 27 patients open left colectomy. Mean hospital stay was 8.44 ± 1.21 in the laparoscopic group versus 6.86 ± 1.01 in the open group. The histopathological analysis shows a mean of 18.13 ± 6.8 lymph nodes removed after laparoscopy and 13.96 ± 5.72 after open surgery (P = 0.02). Kaplan-Meier analysis does not reveal significative differences in disease free survival (HR = 0.85; 95% CI = 0.21-3.40; P = 0.81). Overall survival up to 5 years shows one death per group. CONCLUSIONS: Laparoscopy, respect to the open approach, could improve perioperative clinical outcomes, hospital stay and harvested lymph nodes with comparable long term oncological follow-up in patients with sigmoid colon cancer.

Potential prognostic and diagnostic application of a novel monoclonal antibody against keratinocyte growth factor receptor.

KGFR is involved in the pathogenesis of several human cancers. In this study, we generated and characterized a monoclonal antibody specific to KGFR (SC-101 mAb) and evaluated its potential use in basic research and as a diagnostic and prognostic tool. The specificity and biological activity of the SC-101 mAb were evaluated by Western blotting, immunofluorescence, and immunoprecipitation analyses on various cell lines. KGFR expression in breast, pancreatic, and thyroid carcinoma was assessed by immunohistochemistry (IHC) with SC-101 mAb. KGFR expression levels revealed by SC-101 mAb resulted to increase proportionally with tumor grade in breast and pancreatic cancer. In addition, SC-101 mAb was able to detect KGFR down-modulation in thyroid cancer. SC-101 mAb might represent a useful tool for basic research applications, and it could also contribute to improve the accuracy of diagnosis and prognosis of epithelial tumors.

Epigenetic-related gene expression profile in medullary thyroid cancer revealed the overexpression of the histone methyltransferases EZH2 and SMYD3 in aggressive tumours.

Epigenetic control of gene expression plays a major influence in the development and progression of many cancer types. Aim of the present study was to investigate the expression of epigenetic regulators in a large cohort of medullary thyroid carcinomas (MTC), correlating the data with the clinical outcome and mutational status of the patients. Taqman Low Density Arrays (TLDAs) were used to analyze expression levels of several genes involved in the epigenetic control of transcription in a series of 54 MTCs. The patients cohort included 13 familial MTCs and 41 sporadic forms; 33 hosted a RET mutation and 13 a RAS somatic mutation. The expression profiling revealed in the more aggressive diseases (i.e. occurrence of metastases; persistent disease; disease-related death) a significant increase of EZH2 and SMYD3 gene expression. The increased levels of EZH2 and SMYD3 did not correlate significantly with mutational status of RET or RAS genes. Thus, the histone methyltransferases EZH2 and SMYD3 mRNA expression may represent useful prognostic biomarkers tailoring the most appropriate follow-up and timing of therapeutic approaches.

Clinical aggressiveness and long-term outcome in patients with papillary thyroid cancer and circulating anti-thyroglobulin autoantibodies.

OBJECTIVE: The association between papillary thyroid cancer (PTC) and Hashimoto's thyroiditis is widely recognized, but less is known about the possible link between circulating anti-thyroglobulin antibody (TgAb) titers and PTC aggressiveness. To shed light on this issue, we retrospectively examined a large series of PTC patients with and without positive TgAb. METHODS: Data on 220 TgAb-positive PTC patients (study cohort) were retrospectively collected in 10 hospital-based referral centers. All the patients had undergone near-total thyroidectomy with or without radioiodine remnant ablation. Tumor characteristics and long-term outcomes (follow-up range: 2.5-24.8 years) were compared with those recently reported in 1020 TgAb-negative PTC patients with similar demographic characteristics. We also assessed the impact on clinical outcome of early titer disappearance in the TgAb-positive group. RESULTS: At baseline, the study cohort (mean age 45.9 years, range 12.5-84.1 years; 85% female) had a significantly higher prevalence of high-risk patients (6.9% vs. 3.2%, p<0.05) and extrathyroidal tumor extension (28.2% vs. 24%; p<0.0001) than TgAb-negative controls. Study cohort patients were also more likely than controls to have persistent disease at the 1-year visit (13.6% vs. 7.0%, p=0.001) or recurrence during subsequent follow-up (5.8% vs. 1.4%, p=0.0001). At the final follow-up visit, the percentage of patients with either persistent or recurrent disease in the two cohorts was significantly different (6.4% of TgAb-positive patients vs. 1.7% in the TgAb-negative group, p<0.0001). At the 1-year visit, titer normalization was observed in 85 of the 220 TgAb-positive individuals. These patients had a significantly lower rate of persistent disease than those who were still TgAb positive (8.2% vs. 17.3%. p=0.05), and no relapses were observed among patients with no evidence of disease during subsequent follow-up. CONCLUSIONS: PTC patients with positive serum TgAb titer during the first year after primary treatment were more likely to have persistent/recurrent disease than those who were consistently TgAb-negative. Negative titers at 1 year may be associated with more favorable outcomes.

Second-generation colon capsule endoscopy vs. colonoscopy in pediatric ulcerative colitis: a pilot study.

BACKGROUND AND STUDY AIMS: Second-generation colon capsule endoscopy (CCE-2) may overcome the invasiveness of colonoscopy in the evaluation of mucosal inflammation, especially in pediatric ulcerative colitis. The aim of this pilot study was to determine the diagnostic accuracy of CCE-2 in evaluating disease activity, using colonoscopy as a gold standard. Disease extent, tolerability, interobserver agreement, and safety were also evaluated. METHODS: A total of 30 consecutive pediatric patients with ulcerative colitis were prospectively enrolled (mean age 14.1 ±â€Š3.2 years). Patients underwent CCE-2 followed by colonoscopy in the late afternoon or the following day. The blinded procedures were performed, and the diagnostic accuracy of CCE-2 to assess disease activity was determined using a modified Matts score, which classified patients as either normal (Matts score ≤ 6) or with active inflammation (Matts score > 6). Interobserver agreement was assessed using the kappa statistic. RESULTS: One patient was excluded from the analysis because they were unable to swallow the capsule, leaving 29 patients available for analysis. The sensitivity of CCE-2 for disease activity was 96 % (95 % confidence interval [CI] 79 - 99) and specificity was 100 % (95 %CI 61 - 100). The positive and negative predictive values of CCE-2 were 100 % (95 %CI 85 - 100) and 85 % (95 %CI 49 - 97), respectively. No serious adverse events were reported. CCE-2 had a higher overall tolerability than colonoscopy (P < 0.05). Interobserver agreement was excellent in all cases (κ > 0.86). CONCLUSIONS: Using a modified Matts score, CCE-2 was accurate in evaluating significant mucosal inflammation in children with ulcerative colitis. TRIAL REGISTRATION: ClinicalTrials.gov -- NCT01740349.

Prospective evaluation of acoustic radiation force impulse technology in the differentiation of thyroid nodules: accuracy and interobserver variability assessment.

PURPOSE: The aim of this study is to assess the diagnostic efficacy and interobserver agreement of acoustic radiation force impulse (ARFI) elasticity imaging in differentiating thyroid nodules. METHODS: In our study, 74 consecutive patients (52 females, 22 males; age range 27-77 years, mean: 41 years) with 82 thyroid nodules (60 benign nodules, and 22 malignant) were examined by two radiologists with different experience. Patients underwent either cytology using fine needle aspiration cytology or thyroid surgery. The diagnostic performance of the two operators at ARFI with sensitivity, specificity, positive predictive and negative predictive value, and ROC curves was estimated. Inter-reader variability between the two operators was defined using Cohen's k. RESULTS: According to receiver operating characteristics ROC curves (AUROC = 0.86 for observer 1; 0.81 for observer 2) sensitivity, specificity, PPV and NPV of reader 1 and 2 were respectively: 90, 75, 90.91 and 96.55 %; (cut-off value of shear wave: 2.455 m/s); 90, 72, 90 and 96.90 % (cut-off value shear wave: 2.365 m/s). Concordance between the two operators was good (k = 0.755). CONCLUSIONS: This work is a feasibility study evaluating ARFI imaging. Its results suggest that ARFI imaging is a reproducible method which can be utilized with good diagnostic performance in the thyroid for discriminating benign and malignant nodules using the cut-off value of 2.455 m/s. However, larger studies are needed to validate this method.

Transverse skin crease versus vertical midline incision versus laparoscopy for right hemicolectomy: a systematic review--current status of right hemicolectomy.

PURPOSE: The right hemicolectomy may be conducted through laparoscopic or laparotomic surgery, transverse or midline incisions. The transverse laparotomy offers some advantages compared to the midline laparotomy and laparoscopy. A literature review was performed to evaluate the possible advantages of the transverse incision versus midline incision or laparoscopic right hemicolectomy. METHODS: A systematic research was performed in Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, and the Science Citation Index. RESULTS: Laparotomic right hemicolectomy with transverse incision is preferable to laparotomic hemicolectomy with midline incision. A transverse incision offers a lessened postoperative pain following physical activity, a lessened need to administer analgesic therapy during the post-operative time, better aesthetic results, and a better post-operative pulmonary function. Open surgery with transverse or midline incision ensured a shorter operative time, lower costs and a greater length of the incision compared to the laparoscopic. However, there are no differences in the oncological outcomes. CONCLUSIONS: It was not possible to identify significant differences between the open right hemicolectomy with transverse incision versus the open right hemicolectomy with midline incision or laparoscopic hemicolectomy.

Contralateral axillary metastases from breast cancer. Personal experience and review of literature.

UNLABELLED: The contralateral axillary lymph node metastasis (CAM) from breast cancer are very rare, and pose a number of classification problems and therefore also on the surgery attitude to be adopted and the subsequent surgical oncological approach, making a distinction between synchronous and metachronous cases. You must always wait for a reasonable period of time to exclude the presence of an occult cancer in the contralateral breast. You make assumptions about the lymphatic pathways that determine this metastasis underlining that in the literature (rare) cases are reported in which the lymphoscintigraphic sentinel lymph node search has shown an uptake of contralateral axillary lymph nodes. KEY WORDS: Breast cancer, Controlateral axillary lymph node metastasis, Lymph node metastasis.