Metastatic melanoma causing small bowel perforation: A case report.

INTRODUCTION AND IMPORTANCE: Metastatic localization of melanoma often affects the gastrointestinal tract, with reference to the small intestine. CASE PRESENTATION: In this work we present the clinical course of a patient affected by a surgically treated melanoma of the right conjunctiva, suddenly manifesting abdominal symptomatology. The abdominal computed tomography scan (CT scan) show evidence of free air into the peritoneal cavity, cholecystitis and brain lesions highly suspicious for metastases. Patient underwent emergency surgery, consisting of ileo-cecal resection, cholecystectomy, with the construction of an ileostomy. The histological examination diagnosed multiple ileal and gallbladder localizations of pigmented epithelial melanoma, and localization. CLINICAL DISCUSSION: The treatment of conjunctival melanoma consists in surgical removal. Distant metastases frequently affect the gastrointestinal tract, leading to the necessity to assess patients with abdominal symptoms, in order to avoid emergency scenarios such as the one reported in our study. CONCLUSIONS: Intra-abdominal metastases from melanoma are an event that should not be underestimated, because if detected in time, they can be treated with surgery resulting in a clear improvement in the prognosis. Late diagnosis of intestinal metastases can cause an acute abdomen scenario frequently caused by intestinal obstruction or gastrointestinal bleeding.

Redox-Dependent Modulation of Human Liver Progenitor Cell Line Fate.

Redox homeostasis is determinant in the modulation of quiescence/self-renewal/differentiation of stem cell lines. The aim of this study consisted of defining the impact of redox modifications on cell fate in a human hepatic progenitor line. To achieve this, the HepaRG cell line, which shows oval ductular bipotent characteristics, was used. The impact of redox status on the balance between self-renewal and differentiation of HepaRG cells was investigated using different methodological approaches. A bioinformatic analysis initially proved that the trans-differentiation of HepaRG toward bipotent progenitors is associated with changes in redox metabolism. We then exposed confluent HepaRG (intermediate differentiation phase) to oxidized (H2O2) or reduced (N-acetylcysteine) extracellular environments, observing that oxidation promotes the acquisition of a mature HepaRG phenotype, while a reduced culture medium stimulates de-differentiation. These results were finally confirmed through pharmacological modulation of the nuclear factor (erythroid-derived 2)-like 2 (NRF2), a principal modulator of the antioxidant response, in confluent HepaRG. NRF2 inhibition led to intracellular pro-oxidative status and HepaRG differentiation, while its activation was associated with low levels of reactive species and de-differentiation. In conclusion, this study shows that both intra- and extracellular redox balance are crucial in the determination of HepaRG fate. The impact of redox status in the differentiation potential of HepaRG cells is significant on the utilization of this cell line in pre-clinical studies.

Is Emergency Surgery Back to Pre-Covid-19 Era? Our Cohort Study.

Introduction: The aim of this study is to analyze the progress of hospitalizations and how the emergency operations in our Department of Medical and Surgical Sciences of the Foggia Hospital have changed qualitatively and quantitatively from pre-Covid-19 to today. Methods: Our cohort-study was conducted by analyzing four groups of patients admitted in emergency to our department from 2019 to 2022. Results: We observed a total of 150 patients for the group 1, 25 patients for the group 2, 71 patients for the group 3 and 110 for the group 4, of these 20 were emergency admission during 2019, 16 during 2020, 31 during 2021 and 10 during 2020 (p 0.05); 130 were elective admission during 2019, 9 during 2020, 40 during 2021 and 100 during 2022 (p 0.05). Of the emergency admissions 11 were operated during the no covid period in 2019, 14 during 2020, 29 during 2021, 6 during 2022. Conclusions: The contraction of hospitalizations for urgent and emergency conditions during the first lockdown has been accompanied by positive implications. The measures employed in hospitals to contain the infection determined a reduction in COVID cases, allowing the nearly complete resumption of the surgical activity provided in the pre-COVID era.

Anastomotic leak test using indocyanine green during laparoscopic Roux-en-Y gastric bypass: A cohort study.

Background: Indocyanine green (ICG) can be injected into the human bloodstream and it allows us to show stomach vascularity in real time. The aim of our study is to observe the preliminary results of the application of indocyanine green fluorescence (IGF) during laparoscopic Roux-en-Y Gastric Bypass (RYGB in our center and how the perfusion of the gastro-jejunal anastomosis affects the onset of fistula. Materials and methods: 30 consecutive patients underwent RYGB with ICG fluorescence angiography at our center from January 2020 to December 2021.5 ml of ICG were then injected intravenously to identify the blood supply of the stomach and the gastro-jejunal anastomosis. The UIN for ClinicalTrial.gov Protocol Registration and Results System is: NCT05476159 for the Organization UFoggia. Results: In the RYGB tested with ICG, we all have adequate perfusion but despite this a methylene blue test was positive and allowed us to reinforce the suture of the gastro-jejunal anastomosis. Conclusion: Intraoperative ICG testing during laparoscopic RYGB may be helpful in determining which patients are at an increased risk for leakage but multiple factors concur to the pathophysiology and the incidence of gastric fistula not only the perfusion.

Tube Duodenostomy to Treat Large Duodenal Perforation: Our Experience and Literature Review.

Background: Duodenal perforation is a life-threatening condition and ideal approaches for the management of duodenal perforations are nowadays unclear, so numerous variables must be considered. Peptic ulcer disease is the most common disease determining a duodenal perforation, however, there may be other less common causes. Methods: We retrospectively analyzed all the patients who presented at our Division of General Surgery for a Duodenal Perforation, from September 2018 to December 2019. We focused on patients requiring a tube duodenostomy. Five patients were included in this study. Results: Five patients suffering from a duodenal perforation were analyzed and their data collected. All patients were treated with tube duodenostomy, pyloric exclusion and omega loop gastro-enteroanastomosis. The duodenostomy was removed four weeks after surgery. All patients suffered postsurgical complications ranging from wound infection to pneumonitis; the incidence of severe complications was greater in the older patients. We did not record any deaths four months after the operation. Conclusions: The tube duodenostomy is an old and dated procedure but simple to implement, which may require an increase in post-operative hospitalization, but which subsists as an effective and safe way to treat patients in critical conditions.

Clinical Usefulness of the Valsalva Manoeuvre to Improve Hemostasis during Thyroidectomy.

Bleeding after total thyroidectomy remains a rare event that affects early postoperative morbidity, occurring in 0.3% to 4.2% of cases. Intraoperative bleeding is an unpleasant complication, and it is often easily manageable, although postoperative bleeding may represent a life-threatening condition for the patient. The purpose of our study was to clarify the role of the Valsalva manoeuvre to reduce postoperative bleeding. Between January 2019 to February 2022, 250 consecutive patients were listed for thyroid surgery at our surgical department. The study cohort consisted of 178 patients, divided into two groups based on the execution of the Valsalva manoeuvre. There was no difference in the duration of surgery between groups. Group B had fewer reinterventions for bleeding. Group A had a significantly greater volume of drainage output than Group B. Cervical haematoma can compromise a patient's life, so bleeding control is crucial. Our results show that using a simple and safe Valsalva manoeuvre can improve the postoperative course with a significant reduction in drainage output, but does not prevent the risk of reoperation for hemorrhage.

Bariatric surgery: to bleed or not to bleed? This is the question.

BACKGROUND: Bariatric surgery procedures are the most successful and durable treatment for morbid obesity. Hemorrhage represents a life-threatening complication, occurring in 1.3-1.7% of bariatric surgeries. MATERIALS AND METHODS: We examined patients undergoing Bariatric Surgery from July 2017 to June 2020 (Group A) and those operated from July 2020 to June 2022 (Group B) in our Department. Starting from July 2020 we have implemented intraoperative measures to prevent postoperative bleeding, increasing mean arterial pressure (MAP) by 30% compared to preoperative and reducing the pneumoperitoneal pressure of CO2 to 8 mmHg in the last 15 min of the operation. RESULTS: The study gathered 200 patients divided into the two described groups. The mean age of Group A is 44 ± 8.49 and 43.73 ± 9.28. The mean preoperative BMI is 45.6 kg/m2 ± 6.71 for Group A and 48.9 ± 7.15 kg/m2 for Group B. Group A recorded a mean MAP of 83.06 ± 18.58 mmHg and group B a value of 111.88 ± 12.46 mmHg (p value < 0.05 and z-score is 4.15226 and the value of U is 13,900). We observed 9 cases of bleeding in group A, most of them being treated with medical therapy and transfusions; only 1 hemodynamically unstable patient underwent re-laparoscopy. We reported only 2 cases of bleeding in group B, one of which required blood transfusions. CONCLUSION: From our study we can conclude that increasing mean arterial pressure (MAP) by 30% compared to preoperative and reducing the pneumoperitoneum pressure of CO2 to 8 mmHg in the last 15 min of the operation led to a decrease in bleeding cases in group B and, most importantly, all the bleedings were easily controllable with medical therapy and/or transfusions. These measures allowed us to reduce postoperative bleeding.

Can indocyanine green during laparoscopic sleeve gastrectomy be considered a new intraoperative modality for leak testing?

BACKGROUND: Indocyanine green (ICG) when injected intravenously into the bloodstream allows us to show stomach vascularity in real time. The aim of our study was to observe the preliminary results of the application of indocyanine green fluorescence (IGF) during laparoscopic sleeve gastrectomy (LSG) in our center and how the perfusion of the staple line of the stomach affects the onset of fistula. MATERIALS AND METHODS: 82 patients underwent LSG with ICG fluorescence angiography at our center from January 2020 to December 2021. 5 ml of ICG was injected intravenously to identify the blood supply of the stomach, carefully assessing the angle of His. RESULTS: In the ICG-tested LSG, we recorded adequate perfusion in all patients but one: the leakage rate was 1.2%. This data is inferior to the non-tested patients' group. CONCLUSION: Intraoperative ICG testing may be helpful in determining which patients are at an increased risk for leakage but there are multiple factors contribute to the pathophysiology and the incidence of gastric fistula not only the perfusion. Trial registration Retrospectively registrated.

Emergency Surgery for Colon Diseases in Elderly Patients-Analysis of Complications, and Postoperative Course.

Background and Objectives: Colon diseases can turn in a clinical emergency with the onset of some important complications. Some critical conditions are more common in aged patients because they are frailer. The aim of this study is to examine patients over 80 years of age who are undergoing emergency colorectal surgery, and evaluating the aspects associated with post-operative complications and other problems in the short term. Methods: From November 2020 to February 2022, we included 32 consecutive patients older than 80 undergoing emergency surgery due to colon diseases. We collected and analysed all demographic and operative data, and then applied CR-POSSUM score and correlated this with postoperative hospital stay and the onset of postoperative complications according to the Clavien Dindo classification. Results: Postoperative factors were selectively evaluated based on the clinical scenario and different colic pathologies. There were no statistically significant differences, in terms of postoperative hospital stay, postoperative complications, reoperation rate and 30-day mortality. The number of cases of blood transfusions was significant and was more numerous in cases of intestinal perforation and bleeding cases. The value of the Operative Severity Score in bowel perforations was significantly higher. Conclusions: The use of a score to stratify the risk is a useful tool, especially in elderly patients undergoing emergency surgery. The CR-POSSUM score was important for predicting morbidity in our study. Emergency manifestations of colon diseases in the elderly show higher morbidity and mortality rates. The effect of age on outcome is a concept that needs to be emphasized, so further investigation is needed.

Indocyanine green fluorescence angiography in parathyroidectomy for primary hyperparathyroidism.

INTRODUCTION: Primary Hyperparathyroidism (PHPT) is a systemic pathology caused by an excessive secretion of parathyroid hormone. Parathyroidectomy is the treatment of choice in PHPT, and the success of surgery is based on precise localization of the abnormal parathyroid gland. Preoperative diagnosis makes use of imaging techniques and functional examinations, however these are insufficient in some cases for the precise location of the pathological gland. Therefore the need arises for an intraoperative localization technique. MATERIALS AND METHODS: We have retrospectively analyzed 20 consecutive patients with PHPT undergoing parathyroidectomy from April 2019 to September 2021, and divided them in two groups, in base of the use of Indocyanine Green (ICG) fluorescence during the surgery. RESULTS: Of the twenty patients considered in the two groups, all received a preoperative ultrasound evaluation, while second level examinations were reserved for the more difficult cases, with small volume parathyroid adenomas. In the group where the fluorescence method was employed, fluorescence was especially useful in doubtful cases, allowing easier identification of the parathyroid adenoma and consequently a reduction of time and operatory risks. In two procedures using Indocyanine green, a fluorescence signal was weak. CONCLUSIONS: ICG represents a convenient and safe way to detect parathyroid adenomas. We found that ICG fluorescence was very useful in all patients with non-localizing preoperative imaging studies. However further investigation is needed, to demonstrate how ICGfluorescence could be a useful localization method during parathyroid surgery. KEY WORDS: Endocrine surgery, Indocyanine green, Parathyroid surgery.

Functional results of surgical treatment of low-ultralow rectal cancer.

INTRODUCTION: The improvement of surgical procedures and oncological outcomes in the treatment of low-ultralow rectal cancer, made important the evaluation of functional results. The aim of this study is to evaluate the functional results after open and laparoscopic approach. PATIENTS AND METHODS: From our global experience, over the period 2000/2018, within the patients surgically treated for rectal cancer, we have gathered and studied 37 patients with low-ultralow site of lesion, submitted to sphincterpreserving surgery, subdivided based on the approach: 20 open, 17 laparoscopic, of which 8 robotic . For each type of procedure, as low and ultralow anterior resection, intersphinteric resection, abdominoperineal resection, were investigated functional outcomes, as bowel continence, urinary functions, male and female sexual functions, based on the following tests: Wexner Incontinence Score, International Prostatic Symptom Score, International Index of Erectile Function- 5, Female Sexual Function Index. The controls were performed before surgery and 3-6-12 months postoperatively. Statistical analisis: X2-test, impaired and paired t-test two tailed, Bonferroni post-hoctest. RESULTS: The immediate surgical results and pathological features of the tumor are reported and evaluated. The evaluation of fecal continence in all patients submitted to rectal resection and primary anastomosis showed function compromission without differences statistically significant between the laparo and open approach. In the comparison between specific surgical procedures, the damage of continence function were more severe after intersphinteric resection mached with low-ultralow rectal resection. The rehabilitation therapies continued for several months after surgery showed clear improvement. The urinary continence, in male and female patients, did not show statistically significant alterations in the pre and postoperative comparison in relation to the approach and the type of resective intervention. The sexual function in male patients has had impairment after all type of surgical resection but the damage was more severe after intersphinteric resection. The female sexual function had not significant changes between pre and postoperative evaluation. CONCLUSION: Bowel continence damage, urinary and sexual dysfunctions after surgical treatment for low-ultralow rectal cancer are frequent and form the low anterior resection syndrome. The severity of the syndrome is connected with the site of anastomosis. The rehabilitation therapies can play an important role in achieving the appreciable improvements of the functional alterations. KEY WORDS: Laparoscopic surgery, Rectal cancer.

Evidence-Based Second-Line Treatment in RAS Wild-Type/Mutated Metastatic Colorectal Cancer in the Precision Medicine Era.

Target-oriented agents improve metastatic colorectal cancer (mCRC) survival in combination with chemotherapy. However, the majority of patients experience disease progression after first-line treatment and are eligible for second-line approaches. In such a context, antiangiogenic and anti-Epidermal Growth Factor Receptor (EGFR) agents as well as immune checkpoint inhibitors have been approved as second-line options, and RAS and BRAF mutations and microsatellite status represent the molecular drivers that guide therapeutic choices. Patients harboring K- and N-RAS mutations are not eligible for anti-EGFR treatments, and bevacizumab is the only antiangiogenic agent that improves survival in combination with chemotherapy in first-line, regardless of RAS mutational status. Thus, the choice of an appropriate therapy after the progression to a bevacizumab or an EGFR-based first-line treatment should be evaluated according to the patient and disease characteristics and treatment aims. The continuation of bevacizumab beyond progression or its substitution with another anti-angiogenic agents has been shown to increase survival, whereas anti-EGFR monoclonals represent an option in RAS wild-type patients. In addition, specific molecular subgroups, such as BRAF-mutated and Microsatellite Instability-High (MSI-H) mCRCs represent aggressive malignancies that are poorly responsive to standard therapies and deserve targeted approaches. This review provides a critical overview about the state of the art in mCRC second-line treatment and discusses sequential strategies according to key molecular biomarkers.

One-step versus two-step procedure for management procedures for management of concurrent gallbladder and common bile duct stones. Outcomes and cost analysis.

BACKGROUND: The management of cholelithiasis and choledocholithiasis combined is controversial. The more frequent approach is a two-stage procedure, with endoscopic sphincterotomy and stone removal from the bile duct followed by laparoscopic cholecystectomy. This study aims to demonstrate how, on the basis of the personal experience, the Rendez-vous technique, that combines the two techniques in a single-stage operation is better than the sequential treatment. METHODS: Between June 2017 to December 2019, 40 consecutive patients with cholelithiasis and choledocholithiasis combined were enrolled for the study: 20 were treated with the sequential treatment and 20 with the Rendez-vous method. The preoperative diagnostic work-up was similar in the two group. The endpoints of the study included incidence of endoscopic and surgical complications, rate of hospitalization and cost analysis. RESULTS: The study showed no difference in demographic parameters between the two groups, but the success rate of clearance of CBD was significantly smaller for sequential arm, with the need of additional procedures. We found a statistical reduction of postoperative acute pancreatitis, hospital stay and charges in Rendez-vous group, at the expense of a prolonged total operating time. CONCLUSIONS: The data of the study confirm the superiority of the Rendez-vous technique because it resolves cholelithiasis associated with choledocholithiasis in a single surgical act, with greater acceptance of the patient who avoids a second invasive surgical act, and with a reduction in complications; moreover, it requires shorter hospitalization, resulting in reduced costs. We propose this option in the management of cases where preoperative ERCP-ES has failed. KEY WORDS: Common bile duct stones, Cholecysto-choledocholithiasis, Endoscopic retrograde cholangiopancreatography, Endoscopic sphincterotomy, Laparoscopic cholecystectomy, Laparo-endoscopic Rendez-vous.

Hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma in noncirrhotic liver. A case report and systematic review.

INTRODUCTION: Hepatocellular carcinoma (HCC) is the sixth most common cancer. Spontaneous rupture of HCC is an acute complication with a high mortality rate. The HCC principally arises in the background of chronic liver disease and cirrhosis of the liver. In the last few years, the rising incidence of HCC in noncirrhotic liver suggests the presence of other factors that may play a role in liver carcinogenesis. METHODS: We reviewed all cases treated at the University Surgical Department of Ospedali Riuniti of Foggia from 2009 to 2018. Only a single case of hemoperitoneum caused by spontaneous rupture of HCC in noncirrhotic liver was found. An extensive search of the relevant literature was carried out using MEDLINE, and a total of 58 published studies were screened from the sources listed. CONCLUSIONS: The management of this devastating emergency should be carefully analyzed, with stabilization of vital signs as soon as possible. Patient with ruptured HCC and hemoperitoneum without a prior history of cirrhosis and viral infections benefited from the role of transcatheter arterial embolization (TAE) as the preliminary treatment in order to have a more precise diagnosis and an optimal stabilization of the patient. Delayed or staged hepatectomy after TAE represents the definitive treatment.

Energy Based Vessel Sealing Devices in Thyroid Surgery: A Systematic Review to Clarify the Relationship with Recurrent Laryngeal Nerve Injuries.

Background and objectives: The principal complications associated with thyroid surgery consist in postoperative recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, intra-operative and post-operative hemorrhage. In this paper, structured as a literature review, we describe the current knowledge and the technical improvements currently employed in the field of thyroid surgery, focusing on the contribution of energy based devices in relation with the reduction of the operating time and the odds of possible complication. Materials and methods: a relevant systematic literature search on Pubmed was carried out including works from 2004 through 2019, selecting studies providing information on the energy based devices employed in surgeries and statistic data concerning RNL (transient and permanent) injury and operative time. Results: Nineteen studies were reviewed, dealing with 4468 patients in total. The operative variables considered in this study are: employed device, number of patients, pathological conditions affecting the patients, surgical treatment, RNL injury percentage and the operating time, offering an insight on different patient conditions and their relative operative outcomes. A total of 1843 patients, accounting to the 41.2% of the total pool, underwent the traditional technique operation, while 2605 patients (58.3%) were treated employing the energy based devices techniques. Thyroidectomy performed by approaches different from traditional (for example robotic, MIVAT (Mini Invasive Video Assisted thyroidectomy)) were excluded from this study. Conclusions: The energy-based vessel sealing devices in study, represent a safe and efficient alternative to the traditional clamp-and-tie hand technique in the thyroidal surgery scenario, granting a reduction in operating time while not increasing RNL injury rates. According to this information, a preference for energy based devices techniques might be expressed, furthermore, a progressively higher usage rate for these devices is expected in the near future.

Pain control after laparoscopic cholecystectomy. A prospective study.

AIM: The purpose of this study is to evaluate three different analgesic procedures after laparoscopic cholecystectomy for pain control. MATERIAL OF STUDY: The study involved 183 patients who underwent laparoscopic cholecystectomy with the same technique for the induction and maintenance of the general anesthesia. They were divided into three different postoperative pain treatment groups: continuous infusion of Tramadol and Ketorolac with elastomeric pump, intraperitoneal topical instillation of Levobupivacaine, and intraperitoneal aerosolization of Levobupivacaine. RESULTS: No differences were found in the demographics. shorter operating time was observed in group 1. Eight hours after surgery in groups 2 and 3, there was an increase in pain compared to patients in the first group. The request for postoperative analgesic assistance was lower in groups 1 and 2. DISCUSSION: Various topical and intravenous ways for analgesic actions have been used to improve the pain control after laparoscopic procedures, individually and in comparison between them. The main result of our research is that the use of levobupivacaine employed in the topical intraperitoneal application anesthesia by instillation and nebulization, do not improve the postoperative pain in the first 24 hours after LC, compared with intravenous analgesic elastomeric pump. CONCLUSIONS: Despite the positive data found in the literature, our observations have not shown a better pain control after laparoscopic cholecystectomy with the use of intraperitoneal analgesia compared to intravenous. KEY WORDS: Gallstone disease, Gallbladder bladder, Laparoscopic cholecystectomy, Postoperative pain, Stones.

Right hemicolectomy: laparoscopic versus robotic approach.

BACKGROUND: Minimally invasive surgery for colorectal cancer has been demonstrated to have the same oncological results as open surgery, with better clinical outcomes. Robotic surgery is an evolution of minimally invasive technique. This study aims to evaluate surgical and oncological short-term outcomes of robotic right colon resection in comparison with the laparoscopic approach. METHODS: Between January 2014 and May 2017, fifteen laparoscopic right hemicolectomies were compared to seven robotic ones. The primary data points included operation time, length of hospital stay, extraction site incision length, complications, and conversions. When malignancy was the indication for surgery, additional data points have been added. RESULTS: The study showed no difference in parameters between the two groups, but estimated blood loss was significantly smaller for Robotic arm. We found a prolonged total operative room time in the robotic arm, while the surgical time is similar in two groups. The data collected about specimen length and number of lymph nodes suggest that robotic procedure is oncologically similar to laparoscopic one. CONCLUSIONS: Robotic approach allows performance of adequate dissection of the right colon with radical lymphadenectomy as in laparoscopic surgery, confirming the safety and oncological efficacy of this technique, with acceptable results and short-term outcomes. KEY WORDS: Da Vinci surgery, XI, Laparoscopic colorectal surgery, Right hemicolectomy, Robot.

Molecular Mechanisms of Premature Aging in Hemodialysis: The Complex Interplay Between Innate and Adaptive Immune Dysfunction.

Hemodialysis (HD) patient are known to be susceptible to a wide range of early and long-term complication such as chronic inflammation, infections, malnutrition, and cardiovascular disease that significantly affect the incidence of mortality. A large gap between the number of people with end-stage kidney disease (ESKD) and patients who received kidney transplantation has been identified. Therefore, there is a huge need to explore the underlying pathophysiology of HD complications in order to provide treatment guidelines. The immunological dysregulation, involving both the innate and adaptive response, plays a crucial role during the HD sessions and in chronic, maintenance treatments. Innate immune system mediators include the dysfunction of neutrophils, monocytes, and natural killer (NK) cells with signaling mediated by NOD-like receptor P3 (NLRP3) and Toll-like receptor 4 (TLR4); in addition, there is a significant activation of the complement system that is mediated by dialysis membrane-surfaces. These effectors induce a persistent, systemic, pro-inflammatory, and pro-coagulant milieu that has been described as inflammaging. The adaptive response, the imbalance in the CD4+/CD8+ T cell ratio, and the reduction of Th2 and regulatory T cells, together with an altered interaction with B lymphocyte by CD40/CD40L, have been mainly implicated in immune system dysfunction. Altogether, these observations suggest that intervention targeting the immune system in HD patients could improve morbidity and mortality. The purpose of this review is to expand our understanding on the role of immune dysfunction in both innate and adaptive response in patients undergoing hemodialysis treatment.

Bilateral central neck dissection in the treatment of early unifocal papillary thyroid carcinomas with poor risk factors A mono-institutional experience.

INTRODUCTION: Papillary thyroid carcinoma is the most common type of thyroid cancer worldwide. While total thyroidectomy is widely considered the standard surgical approach for papillary thyroid carcinomas, the role of central lymphadenectomy in early stage poor-risk papillary thyroid tumors is still a matter of debate. This study was designed to assess surgical complications and local disease control rates in patients affected by poor-risk early stage papillary thyroid carcinomas. METHODS: We retrospectively analyze three groups of patients affected by poor-risk early stage papillary thyroid carcinomas treated with three alternative surgical strategies: I) routine total thyroidectomy; II) total thyroidectomy and routine central lymphadenectomy; III) total thyroidectomy and central lymphadenectomy upon positive intraoperative histological evaluation of lymph node involvement. RESULTS: Data from patients treated with routine total thyroidectomy showed 32% of persistence of disease in the central compartment with concurrent positivity in laterocervical compartment in 25% of these cases. By contrast, patients receiving total thyroidectomy and routine central lymphadenectomy showed the involvement of central compartment in 40% of cases, while the remaining 60% of patients were free from lymph node metastases. Finally, patients undergoing total thyroidectomy and central lymphadenectomy upon positive intraoperative lymph node biopsy exhibited lack of persistence of lymph node involvement in central compartment after surgery. Of note, postsurgical complications were lower in patients undergoing conservative surgical approaches. CONCLUSIONS: These data suggest that central lymphadenectomy, performed only in case of positive intraoperative lymph node biopsy, ensures reduced incidence of postoperative complications and optimal loco-regional disease control. KEY WORDS: Bilateral central neck dissection, Intraoperative lymph node biopsy, Papillary thyroid carcinoma, Poor risk factors.

Robotic voluminous paraesophageal hernia repair: a case report and review of the literature.

BACKGROUND: The treatment for sliding esophageal hernia with mild gastroesophageal reflux is usually conservative, but surgical treatment is recommended for refractory sliding esophageal hernia, paraesophageal hernia liable to prolapse, or paraesophageal hernia with ulceration and/or stenosis. Robotic surgery overcomes laparoscopic pitfalls by providing steady-state three-dimensional visualization, augmented dexterity with endo-wrist movements, and superior ergonomics for the surgeon. CASE PRESENTATION: To investigate robotic paraesophageal hernia repair, a literature search was conducted using PubMed with the following key words: mini invasive surgery, robotic surgery, hiatal hernia, and Nissen fundoplication. We present the case of a 44-year-old Italian woman with a 20-year history of gastroesophageal reflux disease refractory to medical treatment, who underwent robotic Nissen fundoplication. In our center, we use the da Vinci® Xi™ Surgical System, which is an advanced tool for minimally invasive surgery. CONCLUSIONS: Various reports published in the literature suggested that the robot-assisted approach was effective and was associated with very low postoperative morbidity and was accompanied by satisfactory symptomatic and anatomical radiological outcomes during a follow-up period. The robotic approach to paraesophageal repair is safe and effective with low complication rates. With increased experience, the operative time, length of stay, and complications decrease without compromising surgical principles.