The unexpected social cost of inguinal hernioplasty procedures derived from the COVID-19 pandemic: Surgical trend analysis based on an Italian hospital series.

BACKGROUND: The majority of inguinal hernias are usually paucisymptomatic, so are restored electively. The main purpose of this study is to assess the trends in hernia repair surgery before and during the pandemic period, analyzing an Italian hospital series of 390 patients, in an attempt to quantify the negative impact regarding social costs derived from the Covid-19 outbreak. Moreover, we want to focus on the concept of apparently minor pathology as hernioplasty which could represent a life-threatening condition for patients. METHODS: The study population consisted of all patients operated for inguinal hernia in a General Surgery Unit from 2019 to 2021, divided into a pre-pandemic and a pandemic period. RESULTS: The Covid-19 pandemic increased urgent operations in a complicated setting. A statistically significant difference was found regarding the trend of hospitalization length as well as a strong positive correlation between the severity of hernia and the hospitalization length. CONCLUSIONS: During the pandemic, it has been registered a mishandling of inguinal hernias to the detriment of both the healthcare system and patients, due to multifactorial issues and, in particular, to the restrictions imposed by the regional government that erroneously declassed hernia pathology as a minor problem for public health. We do believe that patients, after diagnosis of inguinal hernia, should learn the Taxis maneuver for its feasibility and ease of execution, in order to reduce access to emergencies in many cases and likewise to better pain and discomfort perceived, even in the event of unexpected worldwide healthcare scenario.

Impact of Intermittent Intraoperative Neuromonitoring (IONM) on the Learning Curve for Total Thyroidectomy by Residents in General Surgery.

INTRODUCTION: Recurrent laryngeal nerve (RNL) identification constitutes the standard in thyroidectomy. Intraoperative nerve monitoring (IONM) has been introduced as a complementary tool for RLN functionality evaluation. The aim of this study is to establish how routine use of IONM can affect the learning curve (LC) in thyroidectomy. METHODS: Patients undergoing total thyroidectomy performed by surgery residents in their learning curve course in 2 academic hospitals, were divided into 2 groups: Group A, including 150 thyroidectomies performed without IONM by 3 different residents, and Group B, including 150 procedures with routine use of intermittent IONM, by other 3 different residents. LC was measured by comparing operative time (OT), its stabilization during the development of the LC, perioperative complication rate. RESULTS: As previously demonstrated, the LC was achieved after 30 procedures, in both groups, with no differences due to the use of IONM. Similarly, there were no significant differences among the 2 groups, and between subgroups independently matched, for both OT and complications, even when comparing RLN palsy. Direct nerve visualization and IONM assessment rates were comparable in all groups, and no bilateral RLN palsy (transient or permanent) were reported. No case of interrupted procedure to unilateral lobectomy, due to evidence of RLN injury, was reported. CONCLUSIONS: The study demonstrates that the use of IONM thyroid surgery, despite requiring a specific training with experienced surgeons, does not particularly affect the learning curve of residents approaching this kind of surgery, and for this reason its routine use should be encouraged even for trainees.

The critical view of safety during laparoscopic cholecystectomy: Strasberg Yes or No? An Italian Multicentre study.

BACKGROUND: Laparoscopic cholecystectomy is considered the gold standard for the treatment of gallbladder lithiasis; nevertheless, the incidence of bile duct injuries (BDI) is still high (0.3-0.8%) compared to open cholecystectomy (0.2%). In 1995, Strasberg introduced the "Critical View of Safety" (CVS) to reduce the risk of BDI. Despite its widespread use, the scientific evidence supporting this technique to prevent BDI is controversial. METHODS: Between March 2017 and March 2019, the data of patients submitted to laparoscopic cholecystectomy in 30 Italian surgical departments were collected on a national database. A survey was submitted to all members of Italian Digestive Pathology Society to obtain data on the preoperative workup, the surgical and postoperative management of patients and to judge, at the end of the procedure, if the isolation of the elements was performed according to the CVS. In the case of a declared critical view, iconographic documentation was obtained, finally reviewed by an external auditor. RESULTS: Data from 604 patients were analysed. The study population was divided into two groups according to the evidence (Group A; n = 11) or absence (Group B; N = 593) of BDI and perioperative bleeding. The non-use of CVS was found in 54.6% of procedures in the Group A, and 25.8% in the Group B, and evaluating the operator-related variables the execution of CVS was associated with a significantly lower incidence of BDI and intraoperative bleeding. CONCLUSIONS: The CVS confirmed to be the safest technique to recognize the elements of the Calot triangle and, if correctly performed, it significantly impacted on preventing intraoperative complications. Additional educational programs on the correct application of CVS in clinical practice would be desirable to avoid extreme conditions that may require additional procedures.

Modified "Blumgart-Type" Suture for Wirsung-Pancreaticogastrostomy: Technique and Results of a Pilot Study.

INTRODUCTION: Postoperative pancreatic fistula (POPF) represents the principal determinant of morbidity and mortality after pancreaticoduodenectomy. Since 1994 we have been performing pancreaticogastrostomy with duct-to-mucosa anastomosis (Wirsung-pancreaticogastric anastomosis [WPGA]), but postoperative morbidity, although limited, was still a concern. An original pancreas-transfixing suture technique, named "Blumgart's anastomosis" (BA), has shown efficacy at reducing fistula rates from pancreaticojejunostomy. Few cohort studies have shown that WPGA with pancreas-transfixing stitches may help reduce the rate of POPF. We designed a novel "Blumgart-type" modification of WPGA (B-WPGA) aiming at harnessing the full potential of the Blumgart design. METHODS: A prospective development study was designed around the application of B-WPGA after pancreaticoduodenectomy for primary periampullary tumors. It focused on describing the early iterations of this technique and on assessing the rate of POPF and delayed post-pancreatectomy hemorrhage (DPH) (primary outcomes), along with other perioperative outcomes. Technically, after mobilizing the pancreatic remnant for a few centimeters, the Wirsung duct is cannulated. A lozenge of seromuscular layer is excised from the posterior gastric wall, matching the shape and size of the pancreas's cut surface. Two to four transparenchymal pancreatic-to-gastric submucosa U stitches with 4/0 Gore-Tex are positioned cranially and caudally to the Wirsung duct, respectively, mounted on soft clamps, and tied onto the gastric serosa only after duct-to-mucosa anastomosis. Postoperative follow-up was standardized by protocol and included a pancreatic enzyme check on the drain output. RESULTS: From February 2018 to June 2019, in 15 continuous cases, B-WPGA was performed after pancreaticoduodenectomy. Indications for pancreaticoduodenectomy were mainly ampulla of Vater and pancreatic head adenocarcinomas. There was no operative mortality and no pancreatic anastomosis-related morbidity. Two events (13%) of transiently elevated amylase in the drain fluid, not matching the definition of POPF, were identified in patients with a soft pancreas on postoperative day 2. No DPHs were recorded after a minimum follow-up of 18.6 months. DISCUSSION/CONCLUSION: The principles of BA may be safely applied to the WPGA model. B-WPGA allows (1) gentle compression and closure of the small secondary ducts in the pancreatic remnant; (2) partial invagination of the pancreatic body in the gastric wall, with the pancreatic cut surface protected by the gastric submucosa; and (3) prevention of parenchymal fractures, as the pancreaticogastric stitches are tied onto the gastric serosa. Despite the limited number of cases in this study, the absence of mortality and anastomosis-related complications supports further reproduction of this technical variant. Larger studies are necessary to determine its efficacy.

A Combined Open and Laparoscopic Technique for the Treatment of Umbilical Hernia: Retrospective Review of a Consecutive Series of Patients.

PURPOSE: To investigate the safety and outcomes of laparoscopic control of intraperitoneal mesh positioning in open umbilical hernia repair. METHODS: This study is a retrospective review of a series of adult patients with uncomplicated umbilical hernia who underwent elective open repair with a self-expanding patch with laparoscopic control from March 2011 to December 2018. The adequacy of mesh positioning was inspected with a 5-mm 30° scope in the left flank. The primary endpoint was recurrence. Secondary endpoints were rate of mesh repositioning, intraoperative complications and time, length of stay and postoperative pain. RESULTS: Thirty-five patients underwent open inlay repair of primary umbilical hernia with laparoscopic control. Six patients (17.1%) were obese. The mean operating time was 63.3 min. The mean defect size was 2.6 cm (0.6-5) and the mean mesh overlap was 3.2cm (2.2-4.5). There were no intraoperative complications. Laparoscopic control required mesh repositioning in 5 cases (14.3%). The median length of stay was 2 days. Perioperative complications were recorded in three cases (8.6%): one seroma and two serous wound discharge (Clavien-Dindo I). The recurrence rate was 2.9% (1 case) at a median follow-up of 60 months. BMI>30 was associated with a higher rate of intraoperative mesh repositioning (p=0.001). Non-reabsorbable mesh and COPD were associated with a higher incidence of postoperative complications (p=0.043). Postoperative pain scores were consistently at mild levels, with no statistically significant differences between patients who had their mesh repositioned and those who had not. CONCLUSIONS: Laparoscopic control of mesh positioning is a safe addition to open inlay umbilical hernia repair and enables the accurate verification of correct mesh deployment with low complication and recurrence rates.

Skin-Reducing Mastectomy and Pre-pectoral Breast Reconstruction in Large Ptotic Breasts.

OBJECTIVES: Pre-pectoral breast reconstruction is increasingly offered to breast cancer patients, as the one-stage technique has proved surgical and oncological safety and aesthetic effectiveness. Nevertheless, there are limited data on outcomes after pre-pectoral breast reconstruction in large and ptotic breasts. The aim of the paper is to present the authors' experience in performing Wise pattern mastectomy with pre-pectoral implant and complete acellular dermal matrix (ADM) coverage as a single-stage procedure in patients with large ptotic breasts. MATERIALS AND METHODS: A retrospective review of protective collected data from January 2017 to June 2019 of patients who presented with large and ptotic breasts undergoing skin-reducing mastectomy and immediate pre-pectoral breast reconstruction with complete ADM coverage and inferior dermal sling was performed. Oncological and surgical outcomes were collected. Satisfaction with reconstruction and related quality of life were evaluated through BREAST-Q questionnaire. RESULTS: Nineteen patients met the inclusion criteria. The average patient age was 55.6 years, and the mean body mass index was 31.2. Mean follow-up was 23.2 months from the initial reconstruction. One patient experienced seroma, and two cases of wound dehiscence at the T junction were observed and treated conservatively with no implant loss. All patients were satisfied with the final reconstruction. CONCLUSION: The Wise pattern skin-reducing mastectomy and pre-pectoral breast reconstruction could be offered to patients presenting with large and ptotic breasts. Future studies should better define long-term outcomes. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Current concepts in parathyroid carcinoma: a single Centre experience.

BACKGROUND: Parathyroid carcinoma is a rare neoplasm that may present sporadically or in the context of a genetic syndrome. Diagnosis and management are challenging due to the lack of clinical and pathological features that may reliably distinguish malignant from benign disease. METHODS: From January 2013 to December 2017, from 358 consecutive patients affected by parathyroid diseases, 3 patients with parathyroid carcinoma were treated at our academic Department of General Surgery. We present our experience as illustrative of the different features of clinical presentation of parathyroid carcinoma and review its management considering the recent relevant literature. RESULTS: Case 1: A 62-year-old man was hospitalized for left-sided palpable neck mass, hypercalcemia and elevated PTH. US-guided FNA was suspect for parathyroid carcinoma. A large cystic mass was excised in bloc with total thyroidectomy and central neck dissection. Genetic studies framed a pathologically confirmed parathyroid carcinoma within MEN1 syndrome. Case 2: A 48-year-old woman with hypothyroidism had total thyroidectomy performed for a suspect for right follicular thyroid lesion. Pathology revealed parathyroid carcinoma. Case 3: A 47 year-old man was admitted for hypercalcaemic crisis and renal failure in the context of PHPT. A lesion suggestive on US and MIBI scan for parathyroid adenoma in the right lower position was removed by mini-invasive approach. Pathology revealed parathyroid cancer and patient had completion hemythyroidectomy and central neck dissection. CONCLUSION: Parathyroid cancer is a particularly rare endocrine malignancy, however it should be suspected in patients with primary hyperparathyroidism when severe hypercalcemia is associated to cervical mass, renal and skeletal disease. Parathyroid surgery remains the mainstay of treatment. Radical tumour resection and expedited treatment in a dedicated endocrine Center represent crucial prognostic factors.

Transaxillary robotic-assisted thyroid surgery: technique and results of a preliminary experience on the Da Vinci Xi platform.

BACKGROUND: Robotic thyroidectomy by transaxillary approach (RATS) is regarded as a feasible and safe alternative procedure in selected patients with benign disease or thyroid cancer of low risk, facilitating thyroidectomy with respect to conventional endoscopic approach and offering improved cosmetic results. The Da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) presents technical advantages over its previous generations, including overhead docking, more compact robotic arms, extended range of motion, and ability for camera to be docked in any arm. This construct supports dissection in smaller spaces with less arm interference and improved view. We present an initial experience of RATS on DVSS Xi in an academic Centre in Italy. METHODS: We conducted a prospective observational study, involving patients with thyroid disease and treated between April 2016 and January 2018. A modified thyroidectomy retractor (Modena retractor, CEATEC Medizintechnik, Germany) was used to lift a musculocutaneous flap and operate gasless. Instrument placement was recorded for each procedure. Each procedure description was broken down into three phases, creation of working space, machine docking with instrument positioning and endoscopic operating technique. Duration of cases was recorded. Patients selected were young women, BMI < 30, thyroid nodule < 5 cm, cytology TIR2 to TIR4 (TIR4:only nodules < 1 cm diameter). RESULTS: Twelve RATS were performed within the learning curve for the robotic technique, 10 lobectomies and 2 total thyroidectomies. No patients required reintervention. Mean duration of surgery was 198.9 min for lobectomy and 210 for thyroidectomy. The same surgical team performed all procedures. No patients presented surgery-related complications, mean stay was 3 days. Decrease in operating time was observed after 8 cases along with more precise preparation of working space. Four arms were used in the first 10 procedures then only three. No recurrent laryngeal nerve dysfunction, no seroma or haematoma were recorded. One patient had transient hypocalcaemia after total thyroidectomy. CONCLUSIONS: Since the early phases of a preliminary experience RATS appeared a safe alternative to open thyroidectomy. Uptake of technique was quick on Xi platform with few technical tweaks over techniques described for Si machines. Careful patient selection is crucial. TRIAL REGISTRATION: Retrospectively registered on 20 july 2018 . TRIAL REGISTRATION NUMBER: researchregistry4272. The Research Registry: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5b517f08dbc2045aefd7f9b4/.

Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of elective rectal resection for rectal cancer in adults by robotic surgery compared with conventional laparoscopic surgery. SUMMARY OF BACKGROUND DATA: Technological advantages of robotic surgery favor precise dissection in narrow spaces. However, the evidence base driving recommendations for the use of robotic surgery in rectal cancer primarily hinges on observational data. METHODS: We searched MEDLINE, Embase, and CENTRAL for randomized controlled trials (until August 2016) comparing robotic surgery versus conventional laparoscopic surgery. Data on the following endpoints were evaluated: circumferential margin status, mesorectal grade, number of lymph nodes harvested, rate of conversion to open surgery, postoperative complications, and operative time. Data were summarized as relative risks (RR) or weighted mean differences (WMDs) with 95% confidence intervals (95% CIs). Risk of bias of studies was assessed with standard methods. RESULTS: Five trials were eligible, including 334 robotic and 337 laparoscopic surgery cases. Meta-analysis showed that RS was associated with lower conversion rate (7.3%; 4 studies, 544 participants, RR 0.58; 95% CI 0.35-0.97, P = 0.04, I = 0%) and longer operating time (MD 38.43 minutes, 95% CI 31.84-45.01: P < 0.00001) compared with laparoscopic surgery. Perioperative mortality, rate of circumferential margin involvement (2 studies, 489 participants, RR 0.82, 95% CI 0.39-1.73), and lymph nodes collected (mean 17.4 Lymph Nodes; 5 trials, 674 patients, MD -0.35, 95% CI -1.83 to 1.12) were similar. The quality of the evidence was moderate for most outcomes. CONCLUSION: Evidence of moderate quality supports that robotic surgery for rectal cancer produces similar perioperative outcomes of oncologic procedure adequacy to conventional laparoscopic surgery. Robotic surgery portraits lower rate of conversion to open surgery, while operating time is significantly longer than by laparoscopic approach.

A method to repair the recurrent laryngeal nerve during thyroidectomy.

Summary: Vocal cord palsy (VCP) is one of the most frequent complications following thyroidectomy. We evaluated the outcomes of intraoperative reconstruction of the recurrent laryngeal nerve (RLN). Of 917 patients who underwent thyroid surgery in a single high-volume general surgery ward between 2000 and 2015, 12 (1.3%) were diagnosed with RLN injury and were retrospectively categorized into 2 groups: group A (n = 5), with intraoperative evidence of iatrogenic transection or cancer invasion of the RLN, and group B (n = 7), with postoperative confirmation of VCP. In group A, immediate microsurgical primary repair of the RLN was performed. Postoperative assessment included subjective ratings (aspiration and voice quality improvement) and objective ratings (perceptual voice quality according to the grade, roughness, breathiness, asthenia and strain [GRBAS] scale, and direct laryngoscopy). In group A, roughness, breathiness and strain were significantly lower at 9 months than at 3 months (p < 0.05). Although larger, multicentre studies are needed, the results suggest potentially excellent postoperative phonatory function after immediate RLN reconstruction.

Parathyroid Reimplantation in Forearm Subcutaneous Tissue During Thyroidectomy: A Simple and Effective Way to Avoid Hypoparathyroidism.

INTRODUCTION: Parathyroid autotransplantation plays an important role in preventing hypoparathyroidism following thyroidectomy. The preferred reimplantation site is still the sternocleidomastoid muscle, but this approach does not permit to check graft vitality postoperatively. The authors report the first prospective evaluation of normal parathyroid gland reimplantation in forearm subcutaneous tissue (using the same technique proposed during parathyroidectomy for hyperplasia) in case of devascularized or inadvertently removed glands during thyroid surgery. MATERIALS AND METHODS: From January 2013 to August 2014, we performed 348 consecutive thyroidectomies for various disease, both benign and malignant. In 25 cases, due to inadvertent parathyroid removal or evidence of insufficient blood supply, we removed and fragmented the gland into 0.5-1 mm slices (one for frozen section) and reimplanted it into two subcutaneous pockets on the non-dominant forearm. After surgery we checked grafted gland function by evaluation of serum parathormone gradient between reimplanted versus non-reimplanted arm (considering significant a ratio of 1.5 or more), at 1 week, 1 and 3 months after surgery. RESULTS: We observed recovery of reimplanted graft function in 48, 88 and 96% of patients respectively at 1 week, 1 and 3 months after surgery. All patients showed normal parathormone levels in peripheral blood (non-reimplanted arm). In one case we observed post-operative wound hematoma on graft-site. This patient showed no graft functionality in post-operative period (even at 3 months follow-up). CONCLUSIONS: Parathyroid gland reimplantation in forearm subcutaneous tissue during thyroid surgery is a safe, easy and effective procedure; furthermore, it allows a good control of graft functionality and would allow an easy grafted gland removal if needed.

Minimally invasive treatment of Mirizzi's syndrome: is there a safe way? Report of a case series.

Mirizzi's syndrome (MS) is a rare complication of the inveterate biliary lithiasis. Diagnostic and therapeutic standardization is still missing, especially since laparoscopic cholecystectomy has become the gold standard approach for symptomatic cholelithiasis. Our study is a retrospective analysis based on a case-series. It considered 370 cholecystectomies performed from 2006 to 2011. We selected 11 patients affected by MS (2.97%). We divided them according to Csendes' classification. Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was used for biliary drainage when the patient suffered jaundice and/or cholangitis and, preoperatively, to confirm the suspicion of MS obtained through Magnetic Resonance Cholangio-Pancreatography (MRCP). We found it useful to exploit nasobiliary drainage (NBD) for intra-operative check of the biliary tree. In all 5 patients of the type 1 group MS was discovered intraoperatively and treated with Laparoscopic Sub-total Cholecystectomy (LSC). One patient suffered from biliary leakage, solved with NBD positioning. The type 2 group was made up of 2 women and 1 man. All of them were preoperatively submitted to ERCP and NBD positioning. Two underwent LSC and one was converted to laparotomy. The type 3 was represented by a 63-year-old woman suffering from recurrent cholangitis. She was submitted to MRCP, ERCP and then underwent LSC. The 2 patients affected by type 4 underwent open biliary reconstruction. In conclusion, every attempt should be made to identify MS prior to LCS since it will allow NBD insertion by ERCP. Once LCS is initiated, if MS is identified intra-operatively, we can provide the most practical surgical options.

5-year Follow-up of Reimplanted Parathyroid Glands in Forearm Subcutaneous Tissue During Thyroidectomy. A Confirmation of Graft Vitality in a Large Series of Patients.

INTRODUCTION: The aim of this study is to assess the outcomes of parathyroid gland reimplantation with PR-FaST technique in patients undergoing thyroid surgery, focusing on graft functionality over a 5-year follow-up period. MATERIALS AND METHODS: We analyzed data from 131 patients who underwent parathyroid reimplantation using the PR-FaST technique during thyroid surgery due to inadvertent parathyroid removal or evident vascular damage. Postoperative evaluations included serum calcium (Ca), magnesium (Mg), and phosphorus (P) analyses on the 1st and 2nd postoperative days, at 10 days, and at 1, 3, 6 months, 1 year, and 5 years of follow-up. Additionally, the mean values of serum intact parathyroid hormone (iPTH) concentration were measured from blood samples collected from both the reimplanted arm (iPTH RA) and non-reimplanted arm (iPTH NRA) within the same period. RESULTS: Among 131 patients, at 10 days post-surgery, only 46 patients (35.1%) out of 131 exhibited graft viability (iPTH ratio >1.5). This percentage increased to 72.8% (94 patients) after 1 month and further to 87.8% (108 patients) after 3 months post-surgery. At 1 year, 84.7% of patients showed good graft functionality. After 5 years, the percentage remained stable, with graft viability observed in 81.3% of patients. Only 91 of the initial 131 patients completed follow-up up to 5 years, with a dropout rate of 30.5 %. CONCLUSIONS: Parathyroid reimplantation using the PR-FaST technique is a viable option for patients undergoing thyroidectomy and has been shown to be a reproducible and effective technique in most patients, with sustained graft functionality and parathyroid hormone production over a 5-year follow-up period.

Retrospective comparison of Traditional vs. LigaSure impact dissection during pancreatoduodenectomy: how to save money by using an expensive device.

Pancreatoduodenectomy is an exceptional procedure that requires an extensive dissection of the supramesocolic region extended to the first jejunal limb. Lymphadenectomy, required for cancer, increases the dissection surface. The extensive preparation of the area is traditionally conducted with bipolar ormonopolar instruments, while clips, ligatures, and sutures are used for haemostasis. LigaSure™ vessel sealing(LSVS; Valleylab, Boulder, CO) is a technology that obtains vessel closure by using the body's own collagen and elastin to create a permanent fusion zone. This is obtained by a combination of forceps pressure and radio frequency. This effect has been improved by the introduction of the Force Triad™ (Valleylab, Boulder,CO) energy platform, controlled by TissueFect™ (Valleylab, Boulder, CO) sensing technology. With this device, the surgeon is able to fuse vessels up to 7 mm, lymphatics, tissue bundles, and pulmonary vasculature in a fast-seal cycle of almost 4 seconds. In our daily practice of open surgery we observe a rapid improvement of abdominal drainage output with a drastic reduction of protein loss. Its practical significance is, in our opinion, that we obtain a rapid recovery of normal serum protein levels with a low number of blood/plasmasac transfusions and a real improvement of anastomosis healing. Moreover, the efficacy and the speed of work of the device allow us to reduce the operating time significantly but safely. We performed a retrospective analysis of the data of 20 pancreatic resections conducted both with traditional dissection and with the Liga-Sure Impact device with Force Triad platform in order to verify whether observed data were real. Our clinical results show that the use of the LigaSure Impact device with Force Triad energy platform is really useful in open surgery to save operating time, number of postoperative days, and hemoderivate administration.

Intraabdominal sporadic desmoid tumors and inflammation: an updated literature review and presentation and insights on pathogenesis of synchronous sporadic mesenteric desmoid tumors occurring after surgery for necrotizing pancreatitis.

Sporadic intra-abdominal desmoid tumors are rare and known to potentially occur after trauma including previous surgery, although knowledge of the underlying pathogenetic mechanism is still limited. We reviewed the recent literature on sporadic intraabdominal desmoids and inflammation as we investigated the mutational and epigenetic makeup of a case of multiple synchronous mesenterial desmoids occurring after necrotizing pancreatitis. A 62-year-old man had four mesenteric masses up to 4.8 cm diameter detected on CT eighteen months after laparotomy for peripancreatic collections from necrotizing pancreatitis. All tumors were excised and diagnosed as mesenteric desmoids. DNA from peripheral blood was tested for a multigene panel. The tumour DNA was screened for three most frequent ß-catenin gene mutations T41A, S45F and S45P. Expression levels of miR-21-3p and miR-197-3-p were compared between the desmoid tumors and other wild-type sporadic desmoids. The T41A CTNNB1 mutation was present in all four desmoid tumors. miR-21-3p and miR-197-3p were respectively upregulated and down-regulated in the mutated sporadic mesenteric desmoids, with respect to wild-type lesions. The patient is free from recurrence 34 months post-surgery. The literature review did not show similar studies. To our knowledge, this is the first study to interrogate genetic and epigenetic signature of multiple intraabdominal desmoids to investigate potential association with abdominal inflammation following surgery for necrotizing pancreatitis. We found mutational and epigenetic features that hint at potential activation of inflammation pathways within the desmoid tumor.

Definition of learning curve for thyroidectomy: systematic review on the different approaches.

Background: Thyroidectomy is one of the most common surgical procedures carried out worldwide and it has evolved in recent years with alternative approaches. With the advent of minimally invasive techniques, the learning curve (LC) concept has become a fundamental "dogma". Methods: A literature search, according to the PRISMA guidelines, was performed via PubMed (MEDLINE), Scopus, Cochrane Library, EMBASE, and Web of Science. Only studies assessing the learning process to thyroidectomy (including hemi- and total thyroidectomy), reporting a minimum of 30 procedures and describing clearly the minimum number of performances required to achieve proficiency and the main evaluation items used to establish it, were included. Conventional, endoscopic and robotic approaches were separately analyzed. Only English-language studies were considered. Results: Forty-five relevant studies were selected for the analysis [respectively 16 concerning robotic thyroidectomy (RT), 22 endoscopic thyroidectomy (ET), 6 mini-invasive video assisted thyroidectomy (MIVAT), 1 conventional thyroidectomy (CT)]. The number of procedures required for a single surgeon to achieve competence and the parameters used to define surgical proficiency were fully investigated for each individual technique. Conclusions: Our research shows how the current literature lacks an objective definition of the LC concept. The heterogeneity of analysis methodologies and parameters evaluated, the various surgical techniques and training background of single surgeons, make it impossible to draw univocal results. Future studies should consider confounding factors and establish criteria that should be consensually recognized in the assessment of surgical performances and skills.

Mastectomy with one-stage or two-stage reconstruction in breast cancer: analysis of early outcomes and patient's satisfaction.

Aim of this study is to compare early post-operative outcomes and patient's satisfaction after skin-sparing and/or nipple-sparing mastectomy (SSM/SNSM) followed either by breast reconstruction with one-stage prepectoral implantation or two-stage technique for breast cancer (BC) or BRCA1/2 mutation.From January 2018 to December 2021, 96 patients (mean age of 51.12 ± 10.9) underwent SSM/SNSM and were divided into two groups: in group A (65 patients, 67.7%), mastectomy was followed by one-stage reconstruction; in group B (31 patients, 32.3%) by two-stage. Operative time was significantly longer in A vs. B (307.6 ± 95.7 vs. 254.4 ± 90.91; P < 0.05). Previous breast surgery was more common in B vs. A (29.0% vs. 7.7%; P < 0.05), while bilateral surgery was performed more frequently in A vs. B (40% vs. 6.5%; P = 0.001). All SSM/SNSM for BRCA1/2 mutation were followed by immediate prepectoral implantation. No significant differences were found between groups in terms of post-operative complications. At pathology, DCIS and invasive ST forms, such as multicentric/multifocal forms, were detected more frequently in B, while NST type in A (all P < 0.05). A multivariate analysis showed improved post-operative satisfaction at BREAST-Q survey in Group A (P = 0.001). Encouraging oncologic outcomes after SSM/SNSM for BC enabled the improvement of breast reconstructive techniques. One-stage reconstruction is characterized by better aesthetic outcomes and by greater patient's satisfaction. When SSM/SNSM is technically difficult to perform, as in multicentric/multifocal forms or previous breast surgery, mastectomy followed by two-stage reconstruction should be considered to achieve a radical surgery.

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery.

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs.