Goiter in a fresco by i Fiammenghini, 1615 (Abbey of Santa Maria di Rovegnano, Chiaravalle, Italy).

In a large fresco, which narrates brutal episodes of torture against Cirtercian monks, in the right corner of the background an ugly aggressor with a huge goiter, symbol of evil and sin, attacks a monk with a sword.

Goiter in a Fresco by Giovanni Luigi Valesio (1611, Church of Saints Eusebio and Vittore, Peglio, Como).

In the Fresco, "Faith and Its Fight Against Heresy (1611, Church of Saints Eusebio and Vittore, Peglio, Como)" is depicted as an old woman with 'scattered and steep hairs', ugly and physically in poor condition, also due to the presence of a voluminous goiter.

Goiter in a fresco by simone peterzano, master of caravaggio (1578-1582, Garegnano Charterhouse, Milan).

Simone Peterzano mostly known as the master of Caravaggio executed frescoes in the presbytery of Garegnano Charterhouse. One fresco details a shepherd with a goiter.

Goiter drawing in Ulrich Boner's Der Edelstein Codices Palatini Germanici 794.

We provide an example of representation of thyroid swelling in the artwork of Ulrich Boner's Der Edelstein Codices Palatini Germanici 794.

Will the shepherd be able to play the alpine horn with that huge goiter (XVI century)?

PURPOSE: There are many of the representations in iconography of individuals with goiters reported in the literature. METHODS: The article describe a unique representation of goiter, as observed by the authors in a sculpture in Italy. RESULTS: In a Nativity, in the upper part of the altar of the Church of the Annunciata, Boccioleto (Val Sermenza, Piedmont, Italy), a horn player with a huge goiter, gladdens the Holy Family. Wooden work by Francesco Antonio d'Alberto, 1694. CONCLUSION: This is an appropriate example of the iconography of "real goiter," since in this case the sculptor had the aim of showing person with goiter.

Report of four simultaneous pancreas-kidney transplants in HIV-positive recipients with favorable outcomes.

The advent of combined antiretroviral therapy (cART) dramatically changed the view of human immunodeficiency virus (HIV) infection as an exclusion criterion for solid organ transplantation, resulting in worldwide reports of successful transplants in HIV-infected individuals. However, there are few reports on simultaneous pancreas-kidney transplant in HIV-positive recipients detailing poor outcomes. A series of four pancreas-kidney transplant performed on HIV-infected individuals between 2006 and 2009 is presented. All recipients reached stably undetectable HIV-RNA after transplantation. All patients experienced early posttransplant infections (median day 30, range 9-128) with urinary tract infections and bacteremia being most commonly observed. In all cases, surgical complications led to laparotomic revisions (median day 18, range 1-44); two patients underwent cholecystectomy. One steroid-responsive acute renal rejection (day 79) and one pancreatic graft failure (month 64) occurred. Frequent dose adjustments were required due to interference between cART and immunosuppressants. At a median follow-up of 45 months (range, 26-67) we observed 100% patient survival with CD4 cell count >300 cells/mm(3) for all patients. Although limited by its small number, this case series represents the largest reported to date with encouraging long-term outcomes in HIV-positive pancreas-kidney transplant recipients.

Pulmonary tuberculosis in an HIV- and hepatitis C virus-coinfected kidney-pancreas transplant recipient: a case report.

Tuberculosis (TB) is a serious infection in immunocompromised patients, such as solid organ transplant recipients and HIV-infected patients. The diagnosis and treatment in this population present several challenges because of the aspecific clinical manifestations, the difficulty in diagnosis, and the choice of the most appropriate therapeutic regimen. Therapeutic challenges arise from drug-related toxicities, interactions between immunosuppressive, antiretroviral, and antituberculous drugs. We present a case of primary TB infection that occurred 3 years after transplantation in a HIV-and hepatitis C virus-coinfected kidney-pancreas recipient. The infection was successfully treated with no hepatotoxicity or rejection with a non-rifampin-containing regimen.

Surveillance of surgical site infections after thyroidectomy in a one-day surgery setting.

BACKGROUND AND AIM: Different studies underline the importance of hospital stay on the development of infectious complications. We performed an audit of surgical site infections (SSI) after thyroidectomy was performed in a one-day surgery setting. MATERIALS AND METHODS: One hundred and twelve consecutive patients admitted between April 2007 and discharged before May 2008 were studied. Patient selection criteria for one-day surgery were specific medical and social-logistic status. The technique of thyroidectomy was standardized. RESULTS: SSI affect 2.6% of patients undergoing thyroid surgery with short hospitalization. The incidence of SSI was 3.2% following thyroidectomy, 2% for lobectomy. Mean time interval to symptom onset was 3 days (range 2-6). Most likely organism was Staphylococcus aureus. WI was associated with prolonged ambulatory medications. CONCLUSIONS: Rates of SSI are similar to those described in the literature with longer hospitalization. All SSI become evident only after patient discharge. Prevention of SSI is very much the responsibility of the persons working in the operating theater. Effort should be made to improve sterile technique. Appropriate antibiotic coverage is indicated when infection develops postoperatively.

What is the learning curve for intraoperative neuromonitoring in thyroid surgery?

BACKGROUND: The study describes the initial experience and learning curve of intraoperative neuromonitoring (IONM) during thyroidectomy. We describe the prevalence and patterns of IONM technical problems. METHODS: Prospective series of 152 consecutive thyroid operations (304 nerves at risk) were analyzed. Standard technique consists of monitoring vagal and RLNs before, during and after resection. Personal gain of experience was defined by the preceding number of thyroid operations. To establish the number of thyroidectomies required before achieving an effective and safe IONM technique, all of the procedures were divided into three chronological groups of about 50 cases (groups 1, 2, and 3). RESULTS: Patients (90%) had successful IONM with initial endotracheal tube position. Fifteen patients (10%) needed further tube adjustment. Out of 15 patients 14 (93%) were due to non-optimal contact of endotracheal surface electrodes to vocal cords. Tube malrotation was the main reason for initial failure (53%). The success rates of prompt IONM technique were 80% in group 1, 92% in group 2, and 98% in group 3 (p<0.05). Mean operating time was low in group 3 (p<0.03). Vagus and RLNs were localized and monitored in all the cases (100%). The incidence of temporary RLN injury was 2.6%. No permanent complications occurred. Negative EMG response indicated an altered function of RLN and stage thyroidectomies were scheduled. Transient RLN palsies were seen without changes during the entire study period. CONCLUSIONS: This is the first series of thyroidectomies with standardized IONM technique performed in Italy. Neuromonitoring was effective in providing identification and function of laryngeal nerves. IONM successful rates were affected considerably by the extent of surgical and anaesthesiological experiences, starting with relatively low rates in the beginner group and then increasing. We assessed the learning curve: improved operative variables and safe technique were seen in about 50 patients.

Video-assisted thyroidectomy performed in a one-day surgery setting.

BACKGROUND AND AIM: Evidence base data have demonstrated that video-assisted thyroidectomy (VAT) has good results regarding safety, morbidity, patient cure rate, pain and cosmesis. Aim of this study was to evaluate the performance of VAT in an ambulatory setting (i.e. one-day surgery, <24-h stay). MATERIALS AND METHODS: Between September 2007 and July 2008, 43 patients underwent VAT in a one-day surgery division. Patient selection criteria for VAT were: thyroid nodules <30 mm, gland volume <20 ml, no history of thyroiditis or neck surgery or irradiation, "low risk" papillary carcinoma and absence of enlarged lymph nodes. One-day surgery patient selection criteria were medical and social logistic (Materazzi G, et al. Eur Surg Res 2007;39:182-8). Intraoperative neuromonitoring (IONM) was used for RLN identification. Intact parathyroid hormone (iPTH) levels were determined early postoperatively at +6-h. Postoperative complications, conversion rate were analyzed. RESULTS: No cases required conversion to open surgery or ordinary recovery (i.e. >24h). Incidence of temporary hypoparathyroidism was 11.6% (5/43) with no case of symptomatic hypocalcemia. Incidence of temporary RLN injury was 2.3% (1 patient) with no case of permanent or bilateral RLN injury. All patients were satisfied with the type of recovery. CONCLUSIONS: This preliminary report is an example of the safe incorporation between new technologies (IONM, early iPTH measurement) with improvement of the quality and safety of VAT performed in a one-day surgery setting.

Ambulatory thyroid surgery: need for stricter patient selection criteria.

The number of outpatient surgical procedures performed in hospitals increases daily. In some countries, outpatient operations outnumber inpatient operations. The incidence of thyroid disorders and in particular, the cancer forms, has been increasing sharply for many years in several countries. Even if thyroid surgery is performed with low morbidity, no mortality, and short operation time, some potentially lethal complications are strong arguments against shortening of hospital stay. The purpose of this review is to examine the relevant updated published results on selection criteria measures that can be used to assess patients referred to short-stay surgery for thyroid disease.

New technologies in ambulatory thyroid surgery.

Thyroid operations are increasingly performed in the outpatient setting. In general the essential objectives for thyroidectomy are: sparing the parathyroid glands, avoidance of injury to the laryngeal nerves, an accurate hemostasis and an excellent cosmesis. In the last 10 years major improvements and new technologies have been proposed and applied in thyroid surgery; among these mini-invasive thyroidectomy, new devices for achieving hemostasis and dissection, intraoperative neuromonitoring, and PTH assay technology. This paper reviews relevant medical literature published on the influence of these new technologies on quality of thyroid surgery as well as prevention of postoperative morbidity and mortality. Searches were last updated April 2008.

Defining the learning curve for video-assisted thyroidectomy.

BACKGROUND AND AIM: Several studies have demonstrated that endoscopic thyroidectomy is a safe technique. Aim of the study is to evaluate the feasibility of video-assisted thyroidectomy (VAT) performed by a junior surgeon. MATERIALS AND METHODS: We consider 67 consecutive standard VAT gasless approaches. VAT was performed by an under 35-years-old surgeon trained in basic laparoscopy tutored by an experienced surgeon. Outcome measures were operative and hospitalization times, incision length, and complications. Conversion to open surgery was defined as the need to perform a longer incision. To establish the number of procedures required before achieving a safe VAT technique, procedures were divided into three chronological groups of about 30 lobectomies (Groups 1, 2, and 3). RESULTS: Success rates of VAT were 90% in group 1, 97% group 2, 100% group 3 respectively (P<0.05). Most conversions were due to bleeding. In group 1, the overall mean operative time was 111 min, group 2, 93 min, group 3, 86 min (P<0.03). Mean length of incision significantly increased from the initial incision: group 1, +1.3 cm, group 2, +0.9, group 3, +0.5 cm (P>0.05). Group 3 had a faster recovery after surgery. The incidences of temporary hypoparathyroidism were 8.9%. The incidences of temporary RLN injury were 2.9%. CONCLUSIONS: To date there are no recommendations regarding the amount of endoscopic training required to safely perform VAT, but our experience demonstrated that surgeon's age cannot be considered having a negative effects on results. Success of VAT technique was considerably associated with experience: improved operative variables and safe technique were seen after 30 lobectomies.

Treatment of high output entero-cutaneous fistulae associated with large abdominal wall defects: single center experience.

BACKGROUND AND AIM: Enteric fistulas are defined by their sites of origin, communication and flow. We evaluate the treatment of complex patients with entero-cutaneous fistulae with large abdominal wall defects. MATERIALS AND METHODS: Retrospective case note review of 19 patients (15 males, median age 46 years) treated at the Department of Surgical Sciences, University of Insubria, Varese, Italy. These were distinguished by multiple/wide gastrointestinal fistula orifices, with total discontinuity of bowel. Fistulas were not covered by abdominal wall thus presenting with a giant abdominal wall defects. Surgery was planned once adequate nutritional status was present. RESULTS: All fistulas resulted from previous surgery for IBD in 7 cases (37%), abdominal trauma 4 (21%), acute necrotic infected pancreatitis 3 (16%), intra-abdominal malignancy 3 (16%), and diverticular disease 2 (10%). The most common site of presentation was ileum (80%). Median fistula output was 800ml/day (range 400-1600ml/day). Seltzer's prognostic index identified malnutrition in 70% of patients at the time of presentation. The elapsed mean time from onset of fistula and elective time of surgical management were 184 days (range 20-2190 days). The VAC system was used in the last 7 patients preoperatively and in 6 patients with postoperative abdominal wound dehiscences that could not be closed immediately and who were at high risk for healing complications. There were no complications from the VAC therapy. Surgery was successful in 69% of cases. Mortality rate was 21%. Factors related to mortality were persistent malignancy, malnutrition and sepsis. CONCLUSIONS: After optimization of nutritional status surgery with en bloc resection of fistula offers best results. In this series, cancer and sepsis were unfavourable factors for outcome. These fistulas may be successfully managed with a multidisciplinary approach.

Colorectal cancer: the role of laparoscopy.

Since the first report in 1991 the laparoscopic resection of colon cancer is progressing slowly and just in the last 2-3 years is becoming more popular. The resistance to its use by some general and colo-rectal surgeons is receding. The explanations are that technology is evolving quickly and there is a worldwide diffusion of more sophisticated surgical instruments. Moreover several randomized trials have been published showing that the outcomes of laparoscopic colon surgery are similar or better than those of conventional surgery and the early reports suggesting the tumour dissemination were not confirmed. The revolution in oncological surgery that we are observing in these last decades with the introduction and diffusion of mini-invasive approach is comparable to that regarding conventional surgery during the period of Halsted. Therefore the principles of surgery accepted during the years must not be forgotten.

Colonic stenting for malignant disease: review of literature.

Colonic stents potentially offer effective palliation for patients with bowel obstruction attributable to incurable malignancy, and a "bridge to surgery" for those in whom emergency surgery would necessitate a stoma. Literature search of the Medline, Scopus and Cochrane Library was performed to identify comparative studies reporting outcomes on colonic stenting and surgery for large bowel obstruction; and to identify the use of stents as a "bridge to the elective surgery". Colorectal stenting can be considered a safe and effective procedure with a low mortality and morbidity for both preoperative and palliative decompression of colonic obstruction.