Health technology assessment through the six sigma approach in abdominoplasty: Scalpel vs electrosurgery.

Abdominoplasty is a surgical procedure conducted to reduce excess abdominal skin and fat and improve body contouring. Despite being commonly performed, it is associated with a risk of complications such as infection, seroma, haematoma and wound dehiscence. To reduce the incidence of complications, different methods are used to create the abdominal flap, i.e., incision with a scalpel or electrosurgery. In this study, health technology assessment (HTA) using the Six Sigma methodology was conducted to compare these incision techniques in patients undergoing abdominoplasty. Two consecutively enroled groups of patients (33 in the scalpel group and 35 in the electrosurgery group) who underwent surgery at a single institution, the University of Campania "Luigi Vanvitelli", were analysed using the drain output as the main outcome for comparison of the incision techniques. While no difference was found regarding haematoma or seroma formation (no cases in either group), the main results also indicate a greater drain output (p-value<0.001) and a greater incidence of dehiscence (p-value=0.056) in patients whose incisions were made through electrosurgery. The combination of HTA and the Six Sigma methodology was useful to prove the possible advantages of creating skin incisions with a scalpel in full abdominoplasty, particularly a significant reduction in the total drain output and a reduction in wound healing problems, namely, wound dehiscence, when compared with electrosurgery, despite considering two limited and heterogeneous groups.

Update on sutureless thyroidectomy.

INTRODUCTION: The Harmonic scalpel ("Focus" and the new version "Focus+") is one of the first devices for surgical simultaneous cutting and tissue coagulation which allows to obtain dissection and hemostasis by direct application of ultrasound and allows minimally invasive surgical procedures with minimal lateral thermal spread and, thus, minimal adjacent tissue destruction. The aim of the study is to complete the previous study that we made in 2014, based on the TT performed between January 2008 and December 2013, with new data about TT performed in our Surgical Division between January 2014 and December 2016 and compare the outcome using the Ultrasonic scalpel versus the device Ligasure in term of safety, operative time, overall drainage volume, complications, hospital stay. PATIENTS AND METHODS: 250 patients were randomized into two groups: Group A where Ultracision were used and Group B where the Ligasure device was used. RESULTS: The results of the group A and of the Group B 2014-2016 have been compared with the results of the previous study and we found that they are similar, but asymptomatic hypocalcaemia increased in the patients of the new study. CONCLUSIONS: We found that the use of Ultrasonic scalpel and Ligasure is effective both in the hemostasis of all vessels and in dissection of tissues and confirm the results of our first study without significant difference in the rate of post-operative morbidity with these two different energy based devices used.

Laparoscopic pancreatectomy: Did the indications change? A review from literature.

Pancreatic Cancer (PC) is the fourth cause of death for tumors in Western countries. Symptoms are not specific, and can vary according to the tumor size and place. Diagnostic workup includes CA 19-9, CT and MRI. Surgery is the only treatment for PC, associated to radio-chemo therapy. Laparoscopic approaches are actually used for PC treatment in few specialized centers, and could be an alternative to laparotomic surgery. The aim of our study is to evaluate the efficacy of laparoscopy for PC treatment compared to laparotomy. We reviewed 19 articles in literature to assess the feasibility and efficacy of Laparoscopic Distal Pancreatectomy (LDP) and Laparoscopic Pancreaticoduodenectomy (LPD). The results have shown that LDP is nowadays a safe technique, and the outcomes are comparable to laparotomic surgery. Regarding to LPD instead, results are controversial and the data are still not sufficient to consider this technique as a valid alternative to laparotomic surgery.

Acellular bovine pericardium dermal matrix in immediate breast reconstruction after Skin Sparing Mastectomy.

INTRODUCTION: Mastectomy for breast cancer may bring the patient to develop long term issues concerning the psychological and physical status. Immediate breast reconstruction (IBR) should be considered and proposed by physicians as an integrated procedure in the surgical approach to breast cancer to reduce further surgery. Acellular dermal matrix (ADM) has been used in revision breast reconstruction for fold malposition, capsular contracture and rippling also, showing good outcomes with low risk of complications. Aim of this study was to verify if the known advantages in using ADM for IBR would led to lower rates of seroma formation, infection, skin flap necrosis and overall complication related to the implant. METHODS: We performed a prospective study, including all consecutive patients undergone to IBR with biological graft with ADM between January 2012 and January 2013 at our Institution. Data on major issues of the patients and complications were recorded. All patients underwent to IBR with ADM (Tutomesh) implant with or without fibrin sealant positioning. RESULTS: A total of 24 patients underwent 28 immediate breast reconstruction with Tutomesh ADM implant. Main postoperative complications included seroma formation in 20.8% (5 pts), infection in 8.3% (2 pts) and hematoma in 4.2% (1 pt). There were any skin flap necrosis in the study. Diabetes was associated in two cases with edema and ecchymosis; hypertension with infection in one case (implant removal) and seroma in one case. First class of obesity (BMI 30-32.7) was associated with seroma in 3 cases, and with infection in one. In patient without fibrin sealant (12 patients - 13 breasts) complications were represented by hematoma (1 pt. 4.2%), infection (1 pt. 4.2%; implant removal) and seroma (4 pts 16.8%). CONCLUSIONS: The use of Tutomesh(®) bovine pericardium for immediate breast is safe and technically useful. Complications rate is not high, except for seroma formation that can be reduced by the contemporary use of fibrin sealant.

Total thyroidectomy without prophylactic central neck dissection combined with routine oral calcium and vitamin D supplements: is it a good option to achieve a low recurrence rate avoiding hypocalcemia? A retrospective study.

AIM: Routine central neck dissection for differentiated thyroid cancer (DTC) to prevent a future recurrence is still a matter of discussion, due to the increased risk of injury to parathyroid glands, without a clear demonstrable benefits in terms of long-term survival. Aim of this study was to investigate if, treating patients with total thyroidectomy (TT) without prophylactic central lymphadenectomy can minimize the risk of hypocalcemia by routine administration of oral calcium and vitamin D supplements, providing at the same time a low recurrence rate. METHODS: In the set of a retrospective study, 221 patients affected by DTC were enrolled. All of them underwent to TT without prophylactic central lymphadenectomy. In the early postoperative period, oral calcium 2g/d taken twice (1 g every 12 hours) and vitamin D 1 g/d taken twice (0.5 g every 12 hours) were administered; changes in serum calcium and hypocalcemia-related symptoms were recorded. Follow-up was based on neck ultrasound and monitoring of serum Tg and Tg-antibodies levels every 6 months during suppressive l-tiroxine treatment. RESULTS: Symptomatic hypocalcemia developed only in 6.3% of patients, whereas laboratory hypocalcemia developed in 10%. Hypocalcemic symptoms were minimal in 4 patients. Intravenous calcium was administered to 6 patients with severe hypocalcemic symptoms. Permanent hypocalcemia developed in two patients. CONCLUSION: Until a conclusive evidence of the actual benefit of prophylactic central lymphadenectomy in the treatment of DTC, it may be avoided. The oral calcium and vitamin D supplements can take a role in the prevention of postoperative hypocalcemia and for increasing the likelihood of a safe and early discharge from the hospital.

Role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy.

AIM: to evaluate the role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy. PATIENTS AND METHODS: 50 consecutive patients, undergoing total thyroidectomy, were enrolled. Oral calcium and vitamin D were administered in the pre and post-operative time. The data concerning symptomatic and laboratoristic hypocalcemia were collected. RESULTS: Incidence of symptomatic hypocalcemia was very low (6%); incidence of laboratoristic hypocalcemia was 10%. No permanent hypocalcemia developed. CONCLUSIONS: Implementing oral calcium and vitamin D both before and after total thyroidectomy can reduce the incidence of hypocalcemia related to surgery.

[Retroperitoneal dedifferentiated liposarcoma (DDLS) with hyperglycemic activity: case report and literature review]. / Liposarcoma dedifferenziato retroperitoneale con attivita ipergligemica: caso clinico e review della letteratura.

The authors describe a Retroperitoneal De Differentiated LipoSarcomas (DDLs), that for its clinical behavior shows peculiar characteristics and original aspects: typical is the recurrence due to local invasiveness, but absolutely original seems to be the surviving time, maybe correlated to its histological evolution (dedifferentiation from leiomyosarcoma to liposarcoma) and an interesting correlation from the tumor recurrence and the glycemic curve first and after the surgical treatments. A 66-year-old woman, presenting typically with very big abdominal masses, treated three times in almost three years, every time with aggressive surgical treatments. Histological response was leiomyo-sarcoma in the first two operations and liposarcoma in the last treatment and in every preoperative phase the patient, normally prediabetic, started to have problem of glycemia balancing, needing an insulin support until the postoperative phases when its glycemia was coming back in normal value without insulin needs, of course until a new tumor recurrence. This last aspect, not depending on pancreas involvement or hormonal activity (immune-histo-chemistry was never conforming a neuro-endocrine activity), seems probably due directly to a mass and metabolic effect of the tumor. Beginning from the description of this case and its interesting biology and reviewing most of the literature on the argument, authors hope to give our support to still debated and partially unknown aspects of these kinds of tumors.

Biliary tract injuries during laparoscopic cholecystectomy: three case reports and literature review.

INTRODUCTION: Biliary tract injuries (BTI) represent the most serious and potentially life-threatening complication of cholecystectomy. During open cholecystectomies (OC), the prevalence of bile duct injuries has been estimated at only 0.1-0.2%. We report 3 cases of BTI during laparoscopic cholecystectomy (LC). CASE 1: Ascalesi Hospital, Naples 2003-2007, 875 LC (BTI 0,11%). During the dissection of triangle of Calot a partial resection of biliary common duct was made. Immediately the lesion was evident and sheltered in laparoscopy, suturing with a spin reabsorbable, without biliar drainage. The post-operative outcome was good, without alteration of the some parameters, and the patient was discharged after three days. At the last follow-up (January 2006) the cholangiography didn't show stricture or leakage. CASE 2: General and Laparoscopic Surgical Unit San Giovanni di Dio Hospital Frattamaggiore 2004-2007, 720 LC (BTI 0,13%). Patient affected by cholecystitis with gallstones. The patient did not present jaundice, but abdominal pain, leucocitosis, fever and US evidence of parietal gallbladder inflammation. LC was performed after 36 h; during operation, common biliar duct was misidentified for subverted anatomy caused by inflammation. The common bile duct was clipped, and the patient presented jaundice after three days after operation. The colangiography was performed showing the stop. Therefore a reoperation was needed and laparotomic Roux-en-Y hepaticojejunostomy was performed. CASE 3: Dpt of Emergency Surgery, Second University of Naples 2000-2007, LC 520 (BTI 0,19%). Patient affected by more than 20 years symptomatic cholelithiasis, with only obesity risk factor; she underwent laparoscopic cholecystectomy and sudden bleeding of the cystic artery, poor vision and probably the long history of symptoms, producing a flogistic alteration of the anatomy, caused a misidentification of the cystic duct and the common bile duct with complete or lateral clipping of the common hepatic duct. The error was unrecognized intra-operatively but after progressive jaundice the postoperative colangiography showed a nearly complete stop by two clips. Roux-en-Y hepaticojejunostomy with intraoperative cholangiographic control was performed. DISCUSSION: The most common cause of BTI is the failure to recognize the anatomy of the triangle of Calot. This is attributed to factors inherent to the laparoscopic approach, to inadequate training of the surgeon and to local anatomical risk factors. The laparoscopic "learning curve" of the surgeon is the most important factor of bile ducts injury. But also local anatomical risk factors are important such as acute cholecystitis, severe chronic scarring of the gallbladder and bleeding or excessive fat in the hepatic hilum. These local risk factors seem to be present in 15% to 35% of BTI. Abnormal biliary anatomy, such as a short cystic duct or a cystic duct entering into the right hepatic duct also may increase the incidence of BTI. Schematic representation of the common mechanisms of BTI during LC are: misidentification of the cystic duct and the common biliary duct, lateral clipping of the common biliary duct, traumatic avulsion the cystic duct junction, diatermic injury of common biliary duct during dissection of the Calot triangle or during the cholecystectomy, injury of anomalous right hepatic duct. CONCLUSION: Conversion to laparotomy, in difficult cases involving inflammatory changes, aberrant anatomy or excessive bleeding, is not to be considered as a failure but rather as good surgical decision in order to ensure the patient's safety.

[Non recurrent inferior laryngeal nerve: our surgical experience]. / Il Nervo Laringeo Inferiore Non Ricorrente. Nostra esperienza chirurgica.

AIM: Iatrogenic damage to the recurrent laringeal nerve is the most feared complication in thyroid surgery and the main cause for vocal cord palsy. Prevention of such a lesion is based upon the thorough search for the nerve along its anatomic pathway. In the present study the Authors discuss an important anatomic variation: non-recurrent inferior laryngeal nerve, emphasizing the aspects of surgical anatomy, on the basis of their own experience in neck surgery. MATERIALS AND METHODS: The study takes into conideration 301 surgical interventions on the thyroid gland, in 268 women and 33 men; consisting in 256 total thyroidectomies and 45 loboisthmectomies, as follows: 186 for nodular goiter, 48 for follicular nodule, 34 for papillifer carcinoma, 33 for toxic goiter. The identification and exposure of inferior laryngeal nerve was performed according to the principles and technique by Lahey. RESULTS: The overall prevalence of non recurrent inferior laryngeal nerve was equal to 0.33% (1/301 operations). The anomaly is prevailing on the right side, being due by an anomalous reabsorption of the IV ventral arch. This is the cause of the formation of a subclavian artery that is responsible for dysphagia lusoria. CONCLUSIONS: The rationale for the preservation of recurrent nerve is its systematic identification and exposure along all its course from its laryngeal entry. Diagnosis of non recurrent inferior laryngeal nerve is exclusively intra-operative. The anomaly is clinically asymptomatic and its suspicion can be posed in case of vascular anomalies or dysphagia. In such a circumstance the golden diagnostic tool is the angio Tc-RMN, while both the EGDS and baritate esophagous can be of some diagnostic help.

New trends on fibrin glue in seroma after axillary lymphadenectomy for breast cancer.

BACKGROUND: Axillary lymphadenectomy remains an integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods to reduce seroma magnitude and duration, fibrin glue has been proposed in several studies with controversial results. PATIENTS AND METHODS: Ninety patients underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 45 patients; the other 45 patients were treated conventionally. RESULTS: Suction drainage was removed between post-operative (p.o.) days 3 and 4. Seroma magnitude and duration were significantly reduced (p 0.004 and 0.02, respectively), and there were fewer evacuative punctures, in patients receiving fibrin glue compared with the conventional treatment group. CONCLUSIONS: Use of fibrin glue does not always prevent seroma formation, but does reduce seroma magnitude, duration and evacuative punctures.

Metachronous Paget's disease of the breast: case report.

Paget breast disease is a kind of intraductal carcinoma that through an intracanalicular diffusion invades the basal epidermal layer, reaching the areola and nipple, producing a typical erythematous desquamative eczematous-like lesion. This neoplasia can remain undetected for a long time and inadequately treated as a dermatological affection. Synchronous or metachronous lesions are very uncommon. Surgical choice is conditioned by the presence of a tumor below the epidermal lesion, by its dimensions, and by the possible lymph node involvement. Surgical therapy can be radical or conservative. From our experience we think that lesion biopsy is always necessary to formulate a correct diagnosis and to schedule an appropriate therapeutic approach. In our case, a biopsy was performed first, then on the basis of the frozen section analysis a radical mastectomy with axillary third level lymph nodes dissection, because of the large dimensions of the lesion and the previous history of a methachronous lesion.

Ductal carcinoma in situ of the breast: our experience.

AIM: The ductal carcinoma in situ (DCIS) is a more and more frequent neoplasia, representing over 25% of diagnosed breast cancer in recent surveys.It is particularly interesting as concerns several aspects of which the most important are issues linked to clinical diagnosis and the difficulties of histopathological classification, with evident and important therapeutic implications. PATIENTS AND METHODS: The authors report their experience about 161 ductal carcinoma in situ of the breast. Guidelines for surgical treatment are: radiological or clinical diagnosis, tumor's extension, histological classification, grading and margin status. At the present the authors prefer breast conserving surgery with tumor margin's study. They report their experience in the last seven years about sentinel lymph node biopsy. RESULTS: The most frequent histotype resulted comedocarcinoma (61,8%) followed by non comedo (38,2%). Local recurrence after DCIS therapy is 6,1%. CONCLUSIONS: 80-90% of the patients currently treated for DCIS present non-palpable breast lesions at diagnosis. Breast conserving surgery is the first choice and radiotherapy and endocrine therapy are indicated for selected patients.

[Conservative anal fistula treatment with collagenic plug and human fibrin sealant. Preliminary results]. / Trattamento conservativo delle fistole perianali con plug in matrice extracellulare biologica e colla di fibrina umana: esperienza preliminare.

The authors, on the basis of a long clinical experience with human fibrin glue in general surgery, compared two different extracellular matrix (collagen), Surgisis and TissueDura, with human fibrin glue, applied during the operation, and sometimes in postoperative, to obtain the healing of perianal fistulas. The collagenic extracellular matrix provides, according to the rationale suggested, an optimal three-dimensional structure for the fibroblastic implant and neoangiogenesis, hence for the fistula "fibrotizzation" and closure. The encouraging results for transphincteric fistulas and a simple and easy technique push to researchers on samples statistically significant.

Plurifocal breast cancer and double lymphatic spread.

BACKGROUND: Sentinel node (SN) has been proved to be a reliable technique in predicting the lymph nodes state of the axilla in breast cancer. For the majority of the authors the intradermal and peritumoral injection is the best way. PATIENTS AND METHODS: Our experience, from 1997, includes 587 cases of SN in women with resectable breast cancer less than 3 cm of diameter. We performed the lymphoscintigraphy after a peritumoral injection of radioactive tracer and, if the lesion was superficial, we associated an intradermal injection on the skin above the lesion itself. Two patients had multifocal right breast cancer. We did two separate injections around each tumor. RESULTS: The radioactive tracer spread towards the internal mammary chain and homolateral axillary nodes. CONCLUSIONS: We consider the peritumoral injection as essential in tumors located deeply in the breast (under ultrasound guide if not palpable) together with intradermal injection in superficial ones. Using this technique the possibility of a mis-identification of the SN is reduced.

Fibrin glue to reduce seroma after axillary lymphadenectomy for breast cancer.

UNLABELLED: Axillary lymphadenectomy remains an integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among the methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial RESULTS: Sixty patients underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray was applied to the axillary fossa in 30 patients; the other 30 patients were treated conventionally. Suction drainage was removed between postoperative days III and IV. Seroma magnitude and duration were significantly reduced (P=0.004 and 0.02, respectively), and there were fewer evacuative punctures, in patients receiving fibrin glue compared with the conventional treatment group. The authors conclude that the use of fibrin glue does not always prevent seroma formation, but does reduce seroma magnitude, duration and necessary evacuative punctures.

[Carcinoma of the cervical esophagus. Problems of surgical technique]. / Carcinoma dell'esofago cervicale. Problemi di technica chirurgica.

The tape shows the surgical technique used by the Authors for the alimentary tract reconstruction after total esophagectomy for cancer of the upper esophagus. A review of the main reconstructive techniques used for this disease is reported.

Esterification of retinol in rat liver. Possible participation by cellular retinol-binding protein and cellular retinol-binding protein II.

Retinol bound to cellular retinol-binding protein (CRBP) was available for esterification by liver microsomes in the absence of exogenous acyl donors. Moreover, exogenous acyl-CoA gave little or no stimulation of ester production over what was observed with the endogenous acyl donor. In contrast, unbound retinol was esterified in an acyl-CoA-dependent reaction. The presence of two different enzyme activities, acyl-CoA-dependent and -independent, was demonstrated by differential sensitivities to several enzyme inhibitors. The enzyme reaction with retinol-CRBP and endogenous acyl donor produced retinyl esters normally found in vivo in liver. In addition, rates of esterification with this system were sufficient to maintain liver stores. Liver also contains cellular retinol-binding protein, type II (CRBP(II] during the perinatal period. Radioimmunoassay revealed highest levels of CRBP(II) in liver 3-4 days after birth. Examination of retinol esterification by microsomes from the liver of 3-day-old rats revealed a retinyl ester synthase activity with lower Km and higher Vmax than that found in the adult. The activity could use either retinol-CRBP or retinol-CRBP(II) and an endogenous acyl donor. The microsomes from 3-day-old liver had greater esterifying ability than microsomes from adult liver, perhaps due to the presence of two retinyl ester synthase enzymes.