Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project.

BACKGROUND AND AIMS: Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients. METHODS: The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations. CONCLUSIONS: The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.

Hypoparathyroidism after total thyroidectomy: prospective evaluation and relation with early hypocalcemia.

AIM: Definitive hypoparathyrodism (hypo-PTH) represents one of the most dangerous complication after total thyroidectomy. Partial or total lesion or accidental removal of parathyroid glands is an unpredictable adverse event, although real incidence is not well defined, such as management of this deficit. We started a prospective evaluation of patients treated with total thyroidectomy in our centre, to identify incidence of hypo-PTH, symptomatic or not, in relation to incidence of early postoperative hypocalcemia in our experience. METHODS: We prospectively evaluated 177 patients treated for benign and malign pathology, measuring calcium before surgery and calcium and PTH at least three months after surgery. Postoperative hypocalcemia was observed in 37.3% of cases. Eight patients (4.5% of cohort) presented low level of PTH, at mean follow-up of 9.1 months. Positive predictive value for postoperative hypocalcemia was 12.1%, while negative predictive was 95.4%; confirming high sensitivity (100%) and low specificity (65.4%) for detecting hypo-PTH. DISCUSSION: All patients with late hypo-PTH presented hypocalcemia on early analysis, while no case with normal postoperative calcemia accounted with hypo-PTH: this may indicate calcemia as valid prognostic factor of good gland production, when is in the range. Moreover, isolated analysis is too limited to determine real predictability. CONCLUSION: Technical standardization represents the best method for prevention of hypo-PTH. Early hypocalcemia is a prognostic factor, even with a low specificity, of deficit of PTH-production. This observation must be related to other known prognostic factors. Postoperative normal calcemia should be a positive prognostic factor of an acceptable PTHfunction, supported by large cohorts. KEY WORDS: Hypocalcemia, Parathormone, Thyroidectomy.

Surgical approach to TIR3 cytology class A prospective evaluation.

AIM: Fine-needle aspiration (FNA) has proven to be a safe and reliable method of investigation of thyroid lesions. Referencing to European classification, the associated risk of malignancy for TIR3, category reserved for aspirates that contain architectural and/or nuclear atypia, is variable in such studies. Aims of study were evaluating safety of surgical approach, assessing perioperative parameters surgically related, and estimating neoplastic rate for TIR3 group. MATERIAL AND METHODS: A prospective evaluation of all TIR3 submitted to thyroidectomy was conducted by assessing histopatohologic results between January 2005 and December 2012, considering two categories, positive (neoplastic) and negative (not neoplastic) group. Intraoperative and complication rate was analyzed on TIR3 population. RESULTS: A total of 1514 total thyroidectomy was performed from 2005 to 2012: a total of 148 cases was considered on TIR3 group. Positive cases amounted to 64 (43.2%), 29 of which were carcinoma (19.6% of total population) and 35 of which were adenoma, while negative cases amounted to 84 (56.8%). Sensitivity and specificity of TIR3 as neoplastic screening was 43.2% and 82.1%. A total of 32 linfectomies was performed (21.6% of group). Positive group presented a significant lower mean age than negative group (42.1 vs 56.2 years) CONCLUSIONS: TIR3 group represents a various category, with probably different malignancy risk. Our results and neoplasms rate confirmed that surgical option should be gold standard, in order to define atypical pattern and reduce delayed diagnoses. Choice of a second FNA or a imaging monitoring should be adopted for specific condition. KEY WORDS: Fine-needle aspiration, Thyroidectomy, TIR3, Thyroid cancer.

[Single incision laparoscopic cholecystectomy: preliminary experience]. / Colecistectomia laparoscopica con singola incisione (S.I.L.S.). Esperienza preliminare.

INTRODUCTION: The Authors describe our preliminary experience with the cholecistectomy with the S.I.L.S. (Single Incision Laparoscopic Surgery), with a multilumen trocar and dedicated laparoscopic instruments. MATERIALS AND METHODS: Five operations of laparoscopic cholecistectomy with S.I.L.S. technique (3 men and 2 women), of age between 26 and 52 years are reported. RESULTS: In one case was applied an additional 5 mm trocar in the right ipocondrium; in two cases a transparietal suture to suspend the gallbladder was used. Operative time was 98 minutes for the first operation, and 45-65 minutes for the following. The operators have been some difficulties to moving the instruments because both the operating instruments and laparoscope are introduced through the same incision and on the same axis, the operator and assistant often impede the movements of each other. Any post-operative complications was registered. All the patients was very satisfied with post-operative pain and aesthetic results. CONCLUSIONS: The S.I.L.S. is a new technique already used in general surgery, urology and ginecology with good results; this surgey is probably destinated to improve his tecnique and instruments, but certainly it going to offer a further push of the mini-invasive "philosophy".

Laparoscopic resection of duodenal gangliocytic paraganglioma. A case report.

Paraganglioma is an exceedingly rare tumour of the duodenum that arises in close proximity to the ampulla of Vater. To date a total of 133 cases of duodenal paraganglioma have been reported in the literature; of these, 27 (20%) were histologically gangliocytic paragangliomas. This neoplasm generally behaves in a benign fashion, although instances of recurrence and/or lymph node metastasis have been described. The treatment consists in endoscopic polypectomy or surgical resection in relation to the histological features and the macroscopic extent of the neoplasm. We present a case of a benign duodenal gangliocytic paraganglioma treated by a laparo-endoscopic approach. We report a case of gangliocytic paraganglioma in a 75-year-old woman admitted to the General Surgery Division of Aosta Regional Hospital (Aosta-Italy), complaining of melaena and anaemia. Upper gastrointestinal endoscopy followed by enteroscopy with a video-capsula, revealed a pedunculated neoplasm in the second portion of the duodenum, with ulceration of the overlying mucosa. Multiple biopsies were performed during the endoscopic examination and showed the cellular pattern of benign paraganglioma. After stabilisation of the patient's clinical status, we performed a resection of the neoplasm via a laparoscopic transduodenal approach and a concomitant intraoperative duodenoscopy. The histological features showed a gangliocytic paraganglioma without a malignant cell pattern. The size of the neoplasm was 4 cm. The resection margins were free of neoplastic infiltration. The postoperative stay was 9 days and there were no intraoperative or postoperative complications. The patient is currently in good health without any tumour recurrence. Transduodenal laparoscopic resection with intraoperative duodenoscopy is a valuable treatment for benign gangliocytic paraganglioma of the duodenum which is unresectable by upper gastrointestinal endoscopy. This approach affords the advantages of the minimally invasive technique and fulfils the surgical tenets of the open transduodenal approach, if en bloc resection of the neoplasm with the adjacent duodenal wall is performed.