Appendectomy versus conservative treatment with antibiotics for patients with uncomplicated acute appendicitis: a propensity score-matched analysis of patient-centered outcomes (the ACTUAA prospective multicenter trial).

PURPOSE: The aim of this prospective multicenter study was to compare antibiotic therapy and appendectomy as treatment for patients with uncomplicated appendicitis confirmed by ultrasound and/or computed tomography. METHODS: The study was conducted from January 2017 to January 2018. Data regarding all patients discharged from the participating centers with a diagnosis of uncomplicated appendicitis were collected prospectively. RESULTS: Of the 318 patients enrolled in the study, 27.4% underwent antibiotic-first therapy, and 72.6% underwent appendectomy. The matched group was composed of 87 patients in both study arms. Of the 87 patients available of 1-year follow-up in the antibiotic-first group, 64 (73.6%) did not require appendectomy. The complication-free treatment success in the antibiotic-first group was 64.4%. A statistically significant higher complication-free treatment success was found in the appendectomy group: 81.8% in the pre-matching sample and 83.9% in the post-matching sample. Patients in the antibiotic-first group reported lower VAS scores compared to those treated with an appendectomy, both at discharge (2.0 ± 1.7 vs 3.6 ± 2.3) and at 30-day follow-up (0.3 ± 0.6 vs 2.1 ± 1.7). The mean of the days of absence from work was higher in the appendectomy group (ß 0.63; 95% CI 0.08-1.18). CONCLUSION: Although laparoscopic appendectomy remains the gold standard of treatment for uncomplicated appendicitis, conservative treatment with antibiotics is a safe option in most cases. Approximately 65% of patients treated with antibiotics are symptom-free at 1 year, without increased risk of adverse events should symptoms recur, and better outcomes in terms of less pain and shorter period of absence from work compared to patients undergoing an appendectomy. TRIAL REGISTRATION: Clinicaltrials.gov identifier (NCT number): NCT03080103.

Can thyroidectomy be considered safe in obese patients? A retrospective cohort study.

BACKGROUND: Obesity is a growing public health concern in most western countries. More and more patients with high body mass index (BMI) are undergoing surgical procedures of all kinds and, in this context, obese patients are undergoing thyroid surgery more than ever before. The aim of the present study was to evaluate whether thyroidectomy can be considered safe in obese patients. METHODS: Patients undergoing thyroidectomy in our Unit between January 2014 and December 2018 were retrospectively analysed. Patients were divided into two groups: those with BMI < 30 kg/m2 were included in Group A, while those with BMI ≥ 30 kg/m2 in Group B. Univariate analysis was performed to compare these two groups. Moreover, multivariate analyses were performed to evaluate whether the BMI value (considered in this case as a continuous variable) had a significant role in the development of each individual postoperative complication. RESULTS: A total of 813 patients were included in this study: 31 (3.81%) were underweight, 361 (44.40%) normal-weight, 286 (35.18%) overweight, 94 (11.57%) obese and 41 (5.04%) morbidly obese. Six hundred and seventy-eight patients were included in Group A and 135 in Group B. At univariate analysis, the comparison between the two groups, in terms of operative time and thyroid weight resulted in statistically significant results (P = 0.001, P = 0.008; respectively). These features were significantly higher in Group B than in Group A. About postoperative stay and complications, no statistically significant difference was found between the two groups. At multivariate analyses, only the development of cervical haematoma was statistically significantly correlated to the BMI value. Patients with high BMI had a lower risk of cervical haematoma (P = 0.045, OR 0.797, 95% CI 0.638-0.995). CONCLUSIONS: This study showed that obesity, in the field of thyroid surgery, is not associated with any increase of postoperative complications. Thus, it is possible to conclude that thyroidectomy can be performed safely in obese patients. Our result about operative times had no clinical significance.

Intraoperative parathyroid hormone (PTH) testing in patients with primary hyperparathyroidism and PTH levels in the normal range.

BACKGROUND: Primary hyperparathyroidism is a common endocrine disorder. Hypercalcemia with normal PTH levels is very unusual and can lead to diagnostic difficulties. There are very few very few studies in the literature and all with limited numerical samples. The goal of the present study was to determine the real incidence and characteristics of primary hyperparathyroidism with normal PTH and to evaluate if intraoperative PTH testing is useful in these patients. METHODS: We performed a retrospective review of 314 patients who had undergone parathyroidectomy to treat primary hyperparathyroidism between January 2002 and December 2016. Patients were divided in two groups according to biochemical preoperative findings: in Group A were included patients with normal serum PTH, in Group B those with increased serum PTH. RESULTS: Nine patients (3.7%) were included in group A and 235 in group B. Patients in group A were younger (51.5 ± 12.9 years vs 59.6 ± 12.5); preoperative serum calcium and the incidence of coexisting thyroid disease were similar between the two groups. Symptomatic patients were more frequent in Group A (77.8% vs 39.1%; p = 0.048). There were no significant differences regarding preoperative localization studies and surgical procedure. Intraoperative PTH determination demonstrated sensitivity of 86% in group A and 97% in group B, specificity and positive predictive value of 100% in both the groups, negative predictive value of 67% in group A and 79% in group B. Histopathological examination demonstrated a single gland disease in 8 (88.9%) patients in group A and a multi gland disease in 1 (11.1%), in group B single gland disease was found in 218 (92.8%) patients and multi gland disease in 17 (7.2%). Unsuccessful surgery with persistent or recurrent hyperparathyroidism occurred in 1 (11.1%) patient in group A and 4 (1.7%) in group B. CONCLUSIONS: Primary hyperparathyroidism with normal PTH is rare but physicians should be aware of this possibility in patients with hypercalcaemia. Patients with normal PTH levels are younger and more frequently symptomatic. Intraoperative PTH testing plays an important role in the operative management even in such patients.

Neomyogenesis in 3D Dynamic Responsive Prosthesis for Inguinal Hernia Repair.

Despite undisputed improvements, prosthetics hernia repair continues to be affected by unacceptable rates of complications. Postoperative adverse events such as discomfort and chronic pain represent a subject of increasing concern among the surgical community. Poor quality biologic response, stiff scar plates, and mesh shrinkage, a typical effect of conventional static meshes and plugs, are all indicated as the main reasons for many of the complications related to inguinal hernia repair. Even the conventional concept of treatment based upon a supposed reinforcement of the groin consequent to the fibrotic incorporation of meshes, would appear to be inadequate in the light of the latest scientific evidence concerning the degenerative genesis of inguinal hernia. Following these recent studies, a newly conceived 3D dynamically responsive implant has been developed. It concerns a multilamellar shaped prosthesis, intended to be placed fixation-free to obliterate the hernia defect. This 3D structure has already demonstrated to induce a probiotic biological response with development of viable tissue, instead of the fibrotic plaque typical of conventional meshes. Newly formed elastic fibers, neo-angiogenesis, and neo-nerve genesis in a surrounding of well perfused connective tissue are the typical elements of the biologic response in the newly conceived implant. In addition to these elements, muscle fibers have also been detected in the implant structure. The aim of this research was to determine the ingrowth of muscle fibers in the implant by assessing the quantity and quality of muscle development in the short, medium, and long term post-implantation. Histological examination of biopsy samples excised from patients who underwent dynamic hernia repair with the 3D dynamic implant showed the presence of muscular elements that in the short term could be described as multiple spots of myocytes in the early stage of development. Over the mid- to long-term, muscle fibers increased in number and level of maturation, assuming the typical aspect of standard muscle bundles in the final phase. Effectively, long term, myocytes histologically evidenced the distinctive arrangement of the muscle structure, with nuclei and striated elements being similar to normal muscle elements. The development of this highly specialized connective tissue in the 3D dynamic responsive implant seems to document the finalization of an enhanced biologic response leading to the ingrowth of typical tissue components of the groin. Reverting degenerative pathogenesis into effective regeneration recognized in the newly conceived 3D prosthesis would appear to represent a significant concept change in the repair of inguinal hernias.

Fixation-free incisional hernia repair in the elderly: our experience with a tentacle-shaped implant.

BACKGROUND: Incisional hernia in aged patients represents a challenge even for experienced surgeons. Besides increased risk of complications due to comorbidities, mesh fixation and assuring a sufficient mesh overlap of the defect are the main issues in carrying out the repair. AIMS: In order to assure broader coverage of the abdominal wall and a tension- and fixation-free repair, a specifically designed prosthesis was developed for the surgical treatment of incisional hernias. The results of a fixation-free incisional hernia repair carried out in elderly patients using a tentacle-shaped implant are reported herewith. METHODS: A tentacle-shaped flat mesh with a large central body and integrated arms was used to repair incisional hernia in 23 elderly patients. The mesh was placed fixation-free and secured in place through the friction exerted by the tentacles. All tentacle straps were positioned with a special passer needle. Implant placement was preperitoneal in 18 patients and retromuscular sublay in five. RESULTS: In a follow-up of 18 to 59 months (mean 36 months), four seromas occurred. Postoperative fast track helped avoid the typical complications affecting this patient subset. No infection, hematoma, chronic pain, mesh dislocation or recurrence have been reported to date. DISCUSSION: The tentacle strap system allowed for reduced skin incision thus minimizing surgical trauma and ensuring easier and faster implant placement. CONCLUSION: The tentacle arms of the implant ensured mesh stability and broad defect overlap. Besides a very low complication rate, none of the typical postoperative complications of aged patients occurred.

Parathyroidectomy for primary hyperparathyroidism in the elderly: experience of a single endocrine surgery center.

BACKGROUND: Primary hyperparathyroidism is a common endocrine disease, and its incidence increases with age. AIMS: Our aim was to retrospectively evaluate the impact of age on patient outcomes following parathyroidectomy for primary hyperparathyroidism. METHODS: Two-hundred fifty-six consecutive patients undergoing parathyroidectomy with preoperative diagnosis of primary hyperparathyroidism were divided into three groups according to patient age: group A, ≤64 years; group B, 65-74 years; and group C, ≥75 years. RESULTS: Thyroid disease was associated with the hyperparathyroidism in 44 patients (28.2%) in group A, 34 (44.7%) in B, and 10 (41.7%) in C (p < 0.01). Minimally invasive parathyroidectomy was performed in 104 patients (66.7%) in group A, 35 (46.1%) in B, and 8 (33.3%) in C (p < 0.01). Conversion to bilateral exploration was carried out in five cases in group A (4.6%), three in B (8.3%), and two in C (20%). Multiglandular disease was observed in six patients (3.8%) in group A, seven (9.2%) in B, and five (20.8%) in C (p = 0.012). Mean postoperative stay was similar between groups; no major complications and no cases of mortality occurred. DISCUSSION: Multiglandular disease is more common in older patients than younger individuals, and minimally invasive approaches are less used in this patient group. Increased surgical risk and paucity of symptoms in these patients sometimes result in a delay in surgical treatment. CONCLUSIONS: Parathyroidectomy is a safe and effective procedure to perform in elderly patients. Multiglandular disease was found to be more prevalent in older patients, but minimally invasive parathyroidectomy can be performed safely. Surgeons should consider parathyroidectomy in patients with primary hyperparathyroidism regardless of age.

Long-Term Results of Fixation-Free Incisional Hernia Repair Using a Tentacle-Shaped Implant.

INTRODUCTION: The fixation and the overlap of the mesh represent an open issue in incisional hernia repair. An exclusively designed prosthesis has been developed to assure a suture-free repair and a broader coverage of the abdominal wall. This study describes the long-term results of incisional hernia procedures carried out positioning a tentacle-shaped implant through a specifically developed surgical technique. MATERIALS AND METHODS: A proprietary symmetrically-shaped flat mesh constituted by a large central body with integrated radiating arms was used to repair incisional hernias in 68 patients. The prosthesis was placed in preperitoneal/retromuscular sublay. The friction of the straps passing through myotendineal structures of the abdomen was intended to assure an adequate grip to firmly hold the device in place with a broad overlap of the hernia defect in a fixation-free fashion. All tentacle straps were positioned through a special needle passer crossing the abdominal wall laterally from the defect borders then cut short in the subcutaneous layer. RESULTS: In a long-term follow-up of 12 to 96 months (mean 58 months), 11 seromas occurred. No infections, hematomas, chronic pain, mesh dislocation, or recurrence have been reported. CONCLUSIONS: The tentacle strap system of the prosthesis effectively ensured reduced skin incision and an easier implant placement avoiding the need for suturing the mesh. Regularly performed computed tomography (CT) and ultrasound (US) investigations proved that the arms of the implant ensured a proper orientation and stabilization of the mesh in association with a broad defect overlap. The specifically developed surgical procedure showed a quick postoperative recovery, a very low complication rate, and no recurrences, even in the long-term.

Total thyroidectomy without prophylactic central neck dissection in clinically node-negative papillary thyroid cancer: is it an adequate treatment?

BACKGROUND: Cervical lymph node metastases in papillary thyroid cancer are common. Although central neck dissection is indicated in clinically nodal-positive disease, it remains controversial in patients with no clinical evidence of nodal metastasis. The aim of this retrospective study was to determine the outcomes of clinically lymph node-negative patients with papillary thyroid cancer who underwent total thyroidectomy without a central neck dissection, in order to determine the rates of recurrence and reoperation in these patients compared with a group of patients submitted to total thyroidectomy with central neck dissection. METHODS: Two-hundred and eighty-five patients undergoing total thyroidectomy with preoperative diagnosis of papillary thyroid cancer, in the absence of suspicious nodes, were divided in two groups: those who underwent a thyroidectomy only (group A; n=220) and those who also received a central neck dissection (group B; n=65). RESULTS: Six cases (2.1%) of nodal recurrence were observed: 4 in group A and 2 in group B. Tumor histology was associated with risk of recurrence: Hürthle cell-variant and tall cell-variant carcinomas were associated with a high risk of recurrence. Multifocality and extrathyroidal invasion also presented a higher risk, while smaller tumors were at lower risk. CONCLUSIONS: The role of prophylactic central lymph node dissection in the management of papillary thyroid cancer remains controversial. Total thyroidectomy appears to be an adequate treatment for clinically node-negative papillary thyroid cancer. Prophylactic central neck dissection could be considered for the more appropriate selection of patients for radioiodine treatment and should be reserved for high-risk patients only. No clinical or pathological factors are able to predict with any certainty the presence of nodal metastasis. In our experience, tumor size, some histological types, multifocality, and locoregional infiltration are related to an increased risk of recurrence. The potential use of molecular markers will hopefully offer a further strategy to stratify the risk of recurrence in patients with papillary thyroid cancer and allow a more tailored approach to offer prophylactic central neck dissection to patients with the greatest benefit. Multi-institutional larger studies with longer follow-up periods are necessary to draw definitive conclusions.

Diagnosis and treatment of symptomatic right paraduodenal hernia: report of a case.

We report a typical case of right paraduodenal hernia (RPH) and review the literature on the pathogenesis, diagnosis and treatment of this uncommon entity. A 32-year-old woman was hospitalized with acute abdominal cramps, nausea, and vomiting. Computed tomography (CT) findings suggested RPH, which was confirmed by explorative laparoscopy. We performed an open repair by suturing the orifice after reducing the hernia. At her 2-year follow-up, the patient reported complete resolution of her symptoms. Because RPH is rare and its clinical signs are nonspecific, radiological examinations are essential for a correct preoperative diagnosis. CT is currently the most accurate diagnostic tool, but laparoscopy may be necessary to confirm the diagnosis. This hernia can be repaired by simple suturing of the hernial orifice, either laparoscopically or via an open procedure, although several authors consider complete intestinal derotation to be the best option.

Follicular nodules (Thy3) of the thyroid: is total thyroidectomy the best option?

BACKGROUND: Identification of the best management strategy for nodules with Thy3 cytology presents particular problems for clinicians. This study investigates the ability of clinical, cytological and sonographic data to predict malignancy in indeterminate nodules with the scope of determining the need for total thyroidectomy in these patients. METHODS: The study population consisted of 249 cases presenting indeterminate nodules (Thy3): 198 females (79.5%) and 51 males (20.5%) with a mean age of 52.43 ± 13.68 years. All patients underwent total thyroidectomy. RESULTS: Malignancy was diagnosed in 87/249 patients (34.9%); thyroiditis co-existed in 119/249 cases (47.79%) and was associated with cancer in 40 cases (40/87; 45.98%). Of the sonographic characteristics, only echogenicity and the presence of irregular margins were identified as being statistically significant predictors of malignancy. 52/162 benign lesions (32.1%) and 54/87 malignant were hypoechoic (62.07%); irregular margins were present in 13/162 benign lesions (8.02%), and in 60/87 malignant lesions (68.97%). None of the clinical or cytological features, on the other hand, including age, gender, nodule size, the presence of microcalcifications or type 3 vascularization, were significantly associated with malignancy. CONCLUSIONS: The rate of malignancy in cytologically indeterminate lesions was high in the present study sample compared to other reported rates, and in a significant number of cases Hashimoto's thyroiditis was also detected. Thus, considering the fact that clinical and cytological features were found to be inaccurate predictors of malignancy, it is our opinion that surgery should always be recommended. Moreover, total thyroidectomy is advisable, being the most suitable procedure in cases of multiple lesions, hyperplastic nodular goiter, or thyroiditis; the high incidence of malignancy and the unreliability of intraoperative frozen section examination also support this preference for total over hemi-thyroidectomy.

Effective Surgical Management of a Large Serous Ovarian Cyst in a Morbidly Obese Middle-Aged Woman: A Case Study and Literature Review.

BACKGROUND In contemporary gynecological practice, encountering giant ovarian tumors is a rarity. While most are benign and of the mucinous subtype, the borderline variant only accounts for approximately 10% of these cases. This paper addresses the paucity of information about this specific subtype, emphasizing critical elements of managing borderline tumors that can pose life-threatening complications. Additionally, a review of other documented cases of the borderline variant in the literature is also included to foster a deeper understanding of this uncommon condition. CASE REPORT We present the multidisciplinary management of a 52-year-old symptomatic woman with a giant serous borderline ovarian tumor. Preoperative assessment showed a multiloculated pelvic-abdominal cyst responsible for compression of the bowel and retroperitoneal organs, and dyspnea. All tumor markers were negative. Together with anesthesiologists and interventional cardiologists, we decided to perform a controlled drainage of the cyst of the tumor, to prevent hemodynamic instability. Subsequent total extrafascial hysterectomy, contralateral salpingo-oophorectomy, and abdominal wall reconstruction, followed by admission to the intensive care unit, were also conducted by the multidisciplinary team. During the postoperative period, the patient experienced a cardiopulmonary arrest and acute renal failure, which were managed by dialysis. After discharge, the patient underwent oncologic followup, and after 2 years, she was found to be completely recovered and disease free. CONCLUSIONS Intraoperative controlled drainage of Giant ovarian tumor fluid, planned by a multidisciplinary management team, constitutes a valid and safe alternative to the popular choice of "en bloc" tumor resection. This approach avoids rapid changes in body circulation, which are responsible for intraoperative and postoperative severe complications.

Functioning glucagonoma associated with primary hyperparathyroidism: multiple endocrine neoplasia type 1 or incidental association?

BACKGROUND: Diagnosis of multiple endocrine neoplasia type 1 (MEN1) is commonly based on clinical criteria, and confirmed by genetic testing. In patients without known MEN1-related germline mutations, the possibility of a casual association between two or more endocrine tumors cannot be excluded and subsequent management may be difficult to plan. We describe a very uncommon case of functioning glucagonoma associated with primary hyperparathyroidism (pHPT) in which genetic testing failed to detect germline mutations of MEN-1 and other known genes responsible for MEN1. CASE PRESENTATION: The patient, a 65-year old woman, had been suffering for more than 1 year from weakness, progressive weight loss, angular cheilitis, glossitis and, more recently, skin rashes on the perineum, perioral skin and groin folds. After multidisciplinary investigations, functioning glucagonoma and asymptomatic pHPT were diagnosed and, since family history was negative, sporadic MEN1 was suspected. However, genetic testing revealed neither MEN-1 nor other gene mutations responsible for rarer cases of MEN1 (CDKN1B/p27 and other cyclin-dependent kinase inhibitor genes CDKN1A/p15, CDKN2C/p18, CDKN2B/p21). The patient underwent distal splenopancreatectomy and at the 4-month follow-up she showed complete remission of symptoms. Six months later, a thyroid nodule, suspected to be a malignant neoplasia, and two hyperfunctioning parathyroid glands were detected respectively by ultrasound with fine needle aspiration cytology and 99mTc-sestamibi scan with SPECT acquisition. Total thyroidectomy was performed, whereas selective parathyroidectomy was preferred to a more extensive procedure because the diagnosis of MEN1 was not supported by genetic analysis and intraoperative intact parathyroid hormone had revealed "adenoma-like" kinetics after the second parathyroid resection. Thirty-nine and 25 months after respectively the first and the second operation, the patient is well and shows no signs or symptoms of recurrence. CONCLUSIONS: Despite well-defined diagnostic criteria and guidelines, diagnosis of MEN1 can still be challenging. When diagnosis is doubtful, appropriate management may be difficult to establish.

The Use of Harmonic Focus and Thunderbeat Open Fine Jaw in Thyroid Surgery: Experience of a High-Volume Center.

Background: In thyroid surgery, achieving accurate haemostasis is fundamental in order to avoid the occurrence of complications. Energy-based devices are currently extensively utilized in this field of surgery. This study aims to compare Harmonic Focus and Thunderbeat Open Fine Jaw with regard to surgical outcomes and complications. Methods: Patients submitted to total thyroidectomy in our center, between January 2017 and June 2020, were retrospectively analysed. Based on the energy-based device utilized, two groups were identified: Group A (Harmonic Focus) and Group B (Thunderbeat Open Fine Jaw). Results: A total of 527 patients were included: 409 in Group A and 118 in Group B. About surgical outcomes, the mean operative time was significantly shorter in Group B than in Group A (p < 0.001), while as regards complications, the occurrence of transient recurrent laryngeal nerve injury was significantly greater in Group B than in Group A (p = 0.019). Conclusions. Both Harmonic Focus and Thunderbeat Open Fine Jaw have proven to be effective devices. Operative times were significantly shorter in thyroidectomies performed with Thunderbeat Open Fine Jaw; however, the occurrence of transient recurrent laryngeal nerve injury was significantly greater in patients operated on with this device.

Intact parathyroid hormone value on the first postoperative day following total thyroidectomy as a predictor of permanent hypoparathyroidism: a retrospective analysis on 426 consecutive patients.

INTRODUCTION: Hypoparathyroidism represents a common complication following total thyroidectomy. To date, there is still no reliable and immediate postoperative parameter to establish which patients with postsurgical hypoparathyroidism will develop permanent hypoparathyroidism. The main purpose of the present study was to assess whether the intact parathyroid hormone (iPTH) value on the first postoperative day is a good predictor of permanent hypoparathyroidism. MATERIAL AND METHODS: Patients undergoing thyroidectomy in our unit between March 2018 and January 2020 were analysed. According to the iPTH value on the first postoperative day and on the basis of the detection threshold of the iPTH test used, patients were divided into two groups: Group A (iPTH ≥ 4.6 pg/mL) and Group B (iPTH < 4.6 pg/mL, undetectable). RESULTS: In total 426 patients were included: 364 in Group A and 62 in Group B. Permanent hypoparathyroidism occurred in 3 (0.82%) patients from Group A and in 26 (41.94%) from Group B (p < 0.001). When iPTH levels were < 4.6 pg/mL on the first postoperative day the sensitivity for the prediction of permanent hypoparathyroidism was 89.66%, the specificity was 90.93%, the positive predictive value (PPV) was 41.94%, the negative predicitive value (NPV) was 99.18% and the accuracy was 90.85%. CONCLUSIONS: An iPTH value < 4.6 pg/mL on the first postoperative day following total thyroidectomy has proven to be a good parameter for early identification of patients at high risk for permanent hypoparathyroidism. Moreover, we want to underline that in our experience no patient with an iPTH level > 6.5 pg/mL developed this complication.

A mini-invasive approach is feasible in patients with primary hyperparathyroidism and discordant or negative localisation studies.

Preoperative localisation of pathological glands in patients with primary hyperparathyroidism (PHP) is the mainstay for mini-invasive parathyroidectomy. Nevertheless, a not negligible number of patients presents discordant or negative neck ultrasound (US) and 99mTc-Sestamibi (MIBI) scan. The aim of this study was to assess if a mini-invasive approach is feasible in this kind of patients. In this retrospective study were included patients that underwent parathyroidectomy for PHP. Patients were divided into two groups according to concordance of US and MIBI scan results. 242 patients were included: 183 had concordant preoperative studies, and 59 had discordant or negative studies. A mini-invasive approach was possible in 42 (72.9%) patients with unclear preoperative studies, whereas 12 (20.3%) additional patients required conversion to BNE. The incidence of persistent PHP was higher in patients with unclear preoperative studies (8.5% vs 2.7%), but this difference did not reach a statistical significance (p = 0.121). In patients with unclear preoperative studies, a negative result of intraoperative PTH allowed to avoid a persistent disease in 12 patients, while in 3 cases led to an unnecessary additional exploration. In patients with discordant preoperative studies a mini-invasive approach is feasible; in this setting, the use of intraoperative PTH is mandatory to reduce the incidence of persistent PHP.

The role of Rapid Intraoperative Parathyroid Hormone (ioPTH) assay in determining outcome of parathyroidectomy in primary hyperparathyroidism: A systematic review and meta-analysis.

BACKGROUND: Primary hyperparathyroidism (PHPT) is a common endocrine disorder. In the last few decades, the introduction of Rapid Intraoperative Parathyroid Hormone (ioPTH) monitoring has allowed to ensurance of the excision of all hyperfunctioning parathyroid tissues, reducing the risks of persistent and recurrent PHPT. However, the use of ioPTH is still debated among endocrine surgeons. MATERIAL AND METHODS: The objective of this systematic review and meta-analysis was to assess if ioPTH monitoring is able to reduce the incidence of persistent or recurrent PHPT. A systematic literature search was performed using PubMed, Scopus, ISI-Web of Science and Cochrane Library Database. Prospective and retrospective studies addressing the efficacy of ioPTH monitoring were included in the systematic review and meta-analysis. The random-effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated. RESULTS: A total of 28 studies with 13,323 patients were included in the quantitative analysis. The incidence of operative failure was 3.2% in the case group and 5.8% in the control group. After excluding three outlier studies, the quantitative analysis revealed that ioPTH reduced significantly the incidence of postoperative persistent or recurrent PHPT. (Risk Difference = -0.02; CI = -0.03, -0.01; p < 0.001). There was no evidence of heterogeneity among the studies (Q = 19.92, p = 0.70; I2 = 0%). The analysis of several continuous moderators revealed that the effectiveness of ioPTH was larger in studies with lower preoperative serum calcium values and higher incidences of multiple gland disease. CONCLUSION: ioPTH monitoring is effective in reducing the incidence of persistent and recurrent PHPT. Its routine use should be suggested in the next guidelines regarding management of PHPT.

Antibiotic Prophylaxis for Thyroid and Parathyroid Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: Although thyroid and parathyroid surgery is considered a clean procedure with a low incidence of surgical site infections (SSIs), a great number of endocrine surgeons use antibiotic prophylaxis (AP). The aim of this study was to assess whether AP is significantly effective in reducing the incidence of SSIs in this kind of surgery. DATA SOURCES: A systematic literature search was performed with PubMed, Scopus, and ISI-Web of Science. Studies addressing the efficacy of AP in reducing the incidence of SSIs in thyroid and parathyroid surgery were included in the systematic review and meta-analysis. REVIEW METHODS: The random effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated. RESULTS: A total of 6 studies with 4428 patients were included in the quantitative analysis. The incidence of SSI was 0.6% in the case group and 0.4% in the control group (odds ratio, 1.07; 95% CI, 0.3-3.81; P = .915). There was no evidence of heterogeneity among the studies (Q = 8.36, P = .138; I2 = 40.17). The analysis of several continuous moderators, including age, use of drain, and duration of surgery, did not generate any significant result. CONCLUSION: AP is not effective in reducing the incidence of SSI in thyroid and parathyroid surgery and should be avoided, notwithstanding the negative impact on social costs and the risk of development of antibiotic resistance.

Is extensive surgery really necessary in patients with parathyroid carcinoma? Single-centre experience and a brief review of the literature.

AIM: Parathyroid carcinoma (PC) represents a rare cause of primary hyperparathyroidism (PHPT). In this paper, among patients who underwent surgery for PHPT, we compared those with benign parathyroid disease with those affected by PC in terms of demographic and preoperative biochemical features. Moreover, we singularly described all 10 cases of PC treated at our Institution (including a case that occurred in a patient with tertiary hyperparathyroidism) and a brief review of the literature. MATERIAL AND METHODS: Patients undergoing surgery for PHPT in our Unit between 2003 and 2018 were retrospectively analysed. They were divided into two groups: Group A (benign parathyroid disease), Group B (PC). The case of PC that occurred in the patient with tertiary hyperparathyroidism was not included into the two groups. RESULTS: Three hundred and eight patients were included: 299 in Group A and 9 in Group B. The mean preoperative serum PTH value and mean preoperative serum calcium level were significantly higher in Group B than in Group A (P = 0.018, P = 0.027; respectively). Including the case of PC that occurred in the patient with tertiary hyperparathyroidism, 10 patients with PC were treated at our Institution. Among these, 3 underwent a re-exploration. Disease recurrence occurred in 1 (10%) patient, who developed a local recurrence and distant metastases. CONCLUSIONS: In the presence of PHPT characterized by particularly high preoperative levels of serum PTH and calcium this malignancy should be suspected. On the basis of our experience, we believe that extensive surgery is not always necessary. KEY WORDS: Hyperparathyroidism, Parathyroid carcinoma, Parathyroid surgery.

Risk factors of permanent hypoparathyroidism after total thyroidectomy Retrospective analysis of 285 consecutive patients.

AIM: Permanent hypoparathyroidism is the most common long-term complication after total thyroidectomy. The aim of the present study was to investigate the risk factors of this complication. MATERIAL AND METHODS: Patients undergoing thyroidectomy in our Unit between January 2017 and February 2018 were retrospectively analysed. They were divided into 2 groups: those with normal parathyroid function in the long term were included in Group A, those who developed permanent hypoparathyroidism in Group B. RESULTS: Two hundred and eighty-five patients were included in this study: 271 in Group A and 14 in Group B. No statistically significant difference was found in terms of sex, age, extent of surgery, rate of retrosternal goiter, postoperative stay and histopathological findings between the 2 groups. On the contrary, mean operative time, rate of patients with PTH values < 6.3 pg/mL on postoperative day 1 and mean thyroid weight were significantly greater in Group B than in Group A (P = 0.049, P < 0.001, P = 0.014; respectively). CONCLUSIONS: Long operative times, PTH levels < 6.3 pg/mL on postoperative day 1 and high thyroid weight have proved to be strong risk factors of permanent hypoparathyroidism after total thyroidectomy. Thus, in these cases a careful follow-up is highly recommended. KEY WORDS: Permanent hypoparathyroidism, Risk factors, Total thyroidectomy.