Advanced Localization Technique for Non-Palpable Breast Cancer: Radiofrequency alone VS Combined Technique with Ultrasound.

Breast conservative surgery is the primary therapeutic choice for non-aggressive early breast cancers, and a minimally-invasive approach is strongly recommended. The breast localization represents a modern challenge for surgery. Wire-guided localization is still the gold standard technique, but new wireless systems have been proposed, such as radiofrequency identification with LOCalizerTM (Hologic, Santa Carla, CA, USA), which reports encouraging results. The current study aimed to evaluate the accuracy and efficacy of the combined use of LOCalizerTM and ultrasound compared with the results obtained using LOCalizerTM alone for the detection of non-palpable breast cancer. Ninety-six patients who were candidates for breast localization were enrolled. Group A received a combined localization with LOCalizerTM and US, while group B underwent only LOCalizerTM identification. Oncological radicality was reached in 100% of the patients in Group A and in 89.2% of the patients in Group B, with p = 0.006. The mean specimens' volume was 13.2 ± 0.6 cm3 for Group A and 16.1 ± 1.4 cm3 for Group B, while mean specimen weights were 21.8 ± 2.2 and 24.4 ± 1.8 g, respectively (p = 0.003 and p = 0.004, respectively). LOCalizerTM with ultrasound, in the current series, has resulted in the preferred option for the localization of non-palpable breast cancer, allowing limited resection (in weight and volume), guaranteeing excellent oncological outcomes, and great satisfaction for patients and physicians.

Combined LOCalizer™ and Intraoperative Ultrasound Localization: First Experience in Localization of Non-palpable Breast Cancer.

BACKGROUND: Wire-guided localization is the gold-standard for the detection of non-palpable breast lesions, although with acknowledged limitations. The aim of this study was to evaluate the combined use of LOCalizerr™ (Hologic, Santa Carla, CA, USA), and intraoperative ultrasound (IOUS) for localization and surgery of non-palpable breast cancer. PATIENTS AND METHODS: Patients with non-palpable breast lesions underwent localization procedure with LOCalizer™ and IOUS. After the placement of the marker, eight measures were made to guide the excision. LOCalizerr™ Pencil and IOUS were performed to obtain the distance between the dissection plane and the margins of lesions. RESULTS: The procedure was feasible in the five enrolled patients and associated with clear oncological margins in all cases. Moreover, a high satisfaction according to Likert scale for surgeons, radiologists and patients, performing limited and tailored resections, was reported. CONCLUSION: Combining LOCalizerr™ and IOUS is an effective method for locating non-palpable breast cancer, guarantying excellent oncological and cosmetic results.

Synchronous intrathyroidal parathyroid carcinoma and thyroid carcinoma: case report and review of the literature.

BACKGROUND: Parathyroid carcinoma is a rare endocrine malignancy, rarer when synchronous with a non medullary well differentiated thyroid carcinoma. Parathyroid carcinoma accounts of 0.005% of all malignant tumors and it is responsible for less than 1% of primary hyperparathyroidism. The intrathyroidal localization of a parathyroid gland is not frequent with a reported prevalence of 0.2%. Carcinoma of parathyroids with intrathyroidal localization represents an even rarer finding, reported in only 16 cases described in literature. The rare constellation of synchronous parathyroid and thyroid carcinomas has prompted us to report our experience and perform literature review. CASE PRESENTATION: We herein report a case of a 63-years-old man with multinodular goiter and biochemical diagnosis of hyperparathyroidism. Total thyroidectomy with radio-guide technique using gamma probe after intraoperative sesta-MIBI administration and intraoperative PTH level was performed. The high radiation levels in the posterior thyroid lobe discovered an intrathyroidal parathyroid. Microscopic examination revealed a parathyroid main cell carcinoma at the posterior thyroidal left basal lobe, a classic papillary carcinoma at the same lobe and follicular variant of papillary carcinoma at the thyroidal right lobe. To the best of our knowledge, this is the first case documenting a synchronous multicentric non medullary thyroid carcinomas and intrathyroidal parathyroid carcinoma. CONCLUSIONS: Our experience was reported and literature review underlining challenging difficulties in diagnostic workup and surgical management was carried out.

Stapler-less burst pressure in an ex vivo human gastric tissue: a randomized controlled trial.

Stapler-less laparoscopic sleeve gastrectomy (LSG) is emerging as a new potential affordable cost-effective alternative procedure. However, no pre-clinical data are currently available on human tissue. We aimed to evaluate whether traditionally suturing without the use of surgical stapling may produce a comparable bursting pressure on human gastric tissue. A prospective cohort of consecutive patients undergoing LSG was divided in two groups to compare a barbed extra-mucosal running suture (stapler-less) versus a standard stapler line. A burst pressure test was applied to the gastric specimen employing high-resolution manometric catheter. Type, location and features of the leak were described. We enrolled a total of 40 obese patients, 20 patients for each group. Median burst pressures of the stapler-less group resulted statistically significant increased (p < 0.0001) than the one in standard stapler group. In all cases, leak occurred along the surgical closure site independently from the used technique (group 1 vs 2; p = N.S.), more often at the proximal stomach (p < 0.05). In human ex vivo model, traditional surgical suture (i.e. running hand-sewn) produced an effective temporary closure, with superior resistance to increasing volume and pressure. How this may impact on clinical LSG outcomes needs further evaluations and was not the object of this study.

Prolonged iatrogenic thoracic duct chylous fistula in neck surgery: conservative management or surgery? A literature review.

BACKGROUND: Thoracic duct chylous fistula is a rare complication following neck surgery, especially for malignant disease. Despite its low incidence, it can be a life-threatening postoperative complication increasing the risk of infection, bleeding, hypovolemia, electrolyte imbalance, and malnutrition. Currently, the management of thoracic duct fistula is not standardized yet. It can range from conservative to surgical approaches, and even when surgery indication occurs, there is no unanimous agreement on timing and operative steps, so the surgical approach still remains mostly subjective, in accordance with clinical conditions of the patients and with surgeon's experience. AIMS: The aim of the study was to search into Literature a common accepted behaviour in thoracic duct chylous fistula occurring. METHODS: A literature review was carried out. Conservative treatments include fasting associated with total parental nutrition or low-fat diet, compressive dressings, and octreotide administration. If conservative treatment fails, in order to avoid dangerous consequences, functional repair of the thoracic duct injury with lymphovenous microanastomosis should be the preferred solution, rather than an approach that obliterates the thoracic duct or lymphatic-chylous pathways, such as thoracic duct embolization, therapeutic lymphangiography, and thoracic duct ligation. CONCLUSIONS: In our experience, patients undergone thyroidectomy and neck dissection for thyroid-differentiated cancer, who report an unrecognized thoracic duct chylous fistula after surgery, must be treated via integrated conservative and surgical treatment. A literature review about thoracic duct chylous fistula following neck surgery, focusing on the current management and therapeutic approach, was furthermore carried out, in order to delineate the actual therapeutic options in case of thoracic duct chylous fistula occurrence.

The importance of patient selection in bariatric surgery: One not fit for all. Case report of a preventable double severe complication after Laparoscopic gastric banding positioning.

INTRODUCTION: Laparoscopic adjustable gastric banding (LAGB) is a minimal invasive, effective and reversible procedure, even if it is burdened by life threatening complications. PRESENTATION OF THE CASE: A 39 years-old female patient was admitted to our emergency department for abdominal pain and ileus and underwent an explorative laparoscopy. The LAGB was wrapped around the proximal portion of the stomach determining the erosion and ischemia of the great curvature region. It was removed and a large gastric resection of the great curvature was performed. Subsequently, a gastric leak with pleural abscess occurred with the beginning of the oral diet. It was successfully treated with fasting, intravenous antibiotics and a thoracic tube. DISCUSSION: LAGB is a restrictive procedure that compartmentalizes the upper stomach by placing a tight adjustable band around it. However severe and multiple complications can also occur. Slippage is one of the most frequent and dangerous complication. Partial gastric resection (comparable to sleeve gastrectomy) or total/subtotal gastrectomy on the limit of the scarring tissue is use requested in the latter case, with a high risk of postoperative leak. A strict postoperative follow-up is mandatory in order to early recognize any severe complications. CONCLUSION: Strict follow-up in this special subset of patients, the bariatric ones, is mandatory in order to early identify and correct any postoperative complications, avoiding severe sequelae.

Gastric perforation by intragastric balloon: Laparoscopic gastric wedge resection can be a strategy?

INTRODUCTION: IGB (Intragastric Balloon) is acknowledged to be a safe and secure device, whose outcomes in terms of weight loss are widely discussed. Bariatric community has soon noted tolerance and benefit of this tool, considered a first and easy step before bariatric surgery. Nevertheless, some authors have described a series of complications that, although rare, could be life threatening and hard to manage, as a gastric perforation. PRESENTATION OF CASE: We reported a case of a 55-year-old obese woman, undergone placement of IGB device heisting in a gastric perforation. In the same day of surgery, we performed an emergency, applying a combined endoscopic and laparoscopic approach, to remove the balloon and to close perforation by a gastric resection. DISCUSSION: Short term outcome was satisfactory, and the patient had a successful further follow up and weight loss. CONCLUSION: IGB is a valuable tool among bariatric procedure, nevertheless the surgeon has to consider the possible and life-threatening complications and to provide a multidisciplinary equip to face this occurrence.

A Gelatin-Thrombin Matrix Topical Hemostatic Agent (Floseal) in Combination With Harmonic Scalpel Is Effective in Patients Undergoing Total Thyroidectomy: A Prospective, Multicenter, Single-Blind, Randomized Controlled Trial.

BACKGROUND: Hemostasis during thyroidectomy is essential; however, the safest, most efficient, and most cost-effective way to achieve this is unclear. This randomized, multicenter, single-blind, prospective study evaluated the efficacy and safety of using different hemostatic approaches in patients undergoing total thyroidectomy. METHODS: Patients aged ≥18 to 70 years were randomized to Floseal + a harmonic scalpel (HS), Floseal alone, HS alone, or standard total thyroidectomy. Primary endpoint was 24-hour drain output. Secondary endpoints included surgery duration and complications. RESULTS: Two hundred and six patients were randomized to Floseal + HS (n = 52), Floseal alone (n = 54), HS alone (n = 50), and standard total thyroidectomy (n = 50). The 24-hour drain output was lower in the Floseal + HS group compared with standard thyroidectomy. Floseal + HS also had a shorter surgery time (P < .0001) versus the other 3 treatments. CONCLUSION: Floseal + HS can be effective at reducing postsurgical drain output and provides a complementary hemostatic approach in patients undergoing total thyroidectomy.

Effectiveness of an advanced hemostatic pad combined with harmonic scalpel in thyroid surgery. A prospective study.

INTRODUCTION: Hemostasis during thyroidectomy is essential; however the most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with the combination of harmonic scalpel (HS) and an advanced hemostatic pad (Hemopatch). METHODS: Patient undergone TT were divided into two groups: HS + hemopatch and HS + traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates. RESULTS: Between September 2014 and March 2015, 60 patients were enrolled (30 to Hs + Hemopatch, 30 to Hs and standard hemostasis); 71.4% female; mean age 48.5 years. The 24-h drain output was lower in the HS + hemopatch group compared with standard TT. HS and hemopatch also had a shorter mean surgery time (p < 0.0001) vs standard TT. CONCLUSION: combination of hemopatch plus HS is effective and safe for TT with a complementary hemostatic approach.

Total thyroidectomy with harmonic scalpel combined to gelatin-thrombin matrix hemostatic agent: is it safe and effective? A single-center prospective study.

INTRODUCTION: Hemostasis during thyroidectomy is essential; however, the safest, most efficient and cost-effective way to achieve this is unclear. The aim of this study was to evaluate the outcome of total thyroidectomy (TT) performed with combination of harmonic scalpel (HS) and Floseal. METHODS: Patients undergone TT were divided into two groups: HS + Floseal and traditional hemostasis groups. The primary endpoint was 24-h drain output and blood-loss requiring reintervention. Secondary endpoints included surgery duration, postsurgical complications and hypocalcemia rates. RESULTS: Between September 2012 and January 2014, 165 patients were enrolled (100 to HS + Floseal, 65 to standard hemostasis); 80.5% female; mean age 42.3 years. The 24-h drain output was lower in the HS + Floseal group compared with standard TT. HS + Floseal also had a shorter mean surgery time (p < 0.0001) vs standard TT. No differences in post-surgical complications and in hypocalcemiarates between groups. CONCLUSION: combination of Floseal plus the HS is effective and safe for TT and it provides a complementary hemostatic approach.

Intraoperative recurrent laryngeal nerve monitoring in thyroid surgery Evaluation of its use in terms of "spending review".

BACKGROUND: Intra Operative Nerve Monitoring (IONM) has been used in head and neck surgery since the 1970s. Its utilization for monitoring and protecting the recurrent laryngeal nerve, however, is a controversial subject. This paper details the use, value, and cost of this technology within a single institution. METHODS: We conducted a retrospective chart review, analysis of surgery time with and without IONM, analysis of postoperative vocal cord function, and review of the literature RESULTS: IONM did not reduce the operative time during total thyroidectomies in our experience. Use of IONM increased the cost of each surgery by € 450. IONM did not decrease the number of injured nerves (postoperative paresis). CONCLUSIONS: IONM has proven to be highly useful in certain circumstances but has not been definitively proven to protect the nerve any more effectively than the gold standard of nerve visualization. In our study, the use of IONM did not reduce the time of thyroid surgery and did increase the cost. While IONM may, in special clinical circumstances such as revision and malignant thyroid surgery, increase the value of the operation, its use for every thyroid surgery does not appear to be cost effective or valuable to the patient.

Axillary lymphadenectomy for breast cancer in elderly patients and fibrin glue.

BACKGROUND: Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results. METHODS: Thirty patients over 60 years 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 15 patients; the other 15 patients were treated with harmonic scalpel. RESULTS: Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group. CONCLUSIONS: Use of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.

The impact of age and oral calcium and vitamin D supplements on postoperative hypocalcemia after total thyroidectomy. A prospective study.

BACKGROUND: Hypocalcemia caused by transient or definitive hypoparathyroidism is the most frequent complication after total thyroidectomy (TT). We aimed to compare the impact of age and the clinical usefulness of oral calcium and vitamin D supplements on postoperative hypocalcemia after TT, and to determine which risk factors are important for hypocalcemia incidence. METHODS: Two hundred consecutive patients treated by TT were included prospectively in the present study. All patients supplemented oral calcium and vitamin D in the post-operative time. The data concerning symptomatic and laboratoristichypocalcemia were collected. RESULTS: Symptomatic hypocalcemia developed only in 19 patients (9.5%), whereas laboratory hypocalcemia developed in 36 patients (18%). The risk for postoperative hypocalcemia was increate 20-fold for patients older than 50 years. CONCLUSIONS: Age is significantly associated with postoperative hypocalcemia. Implementing oral calcium and vitamin D after total thyroidectomy can reduce the incidence of hypocalcemia related to surgery.

Multifocal thoracic chordoma mimicking a paraganglioma.

Chordoma of thoracic vertebras is a very rare locally invasive neoplasm with low grade malignancy arising from embryonic notochordal remnants. Radical surgery remains the cornerstone of the treatment. We describe a case of multifocal T1-T2 chordoma, without bone and disc involvement, incidentally misdiagnosed as a paraganglioma, occurring in a 47-year-old male asymptomatic patient. Neoplasm was radically removed by an endocrine surgeon through a right extended cervicotomy. A preoperative reliable diagnosis of chordoma, as in the reported case, is often difficult. Radical surgery can provide a favorable outcome but, given the high rates of local recurrence of this neoplasm, a strict and careful follow-up is recommended. Although very rare, chordoma should be suggested in the differential diagnosis of the paravertebral cervical masses of unknown origin. Spine surgeon consultation and a FNB should be routinely included in the multidisciplinary preoperative work-up of these neoplasms.

Laparoscopic treatment of pheochromocytomas smaller or larger than 6 cm. A clinical retrospective study on 44 patients. Laparoscopic adrenalectomy for pheochromocytoma.

INTRODUCTION: Laparoscopic adrenalectomy is a gold standard for the treatment of pheochromocytomas less than 6 cm in diameter. Given the difficulty in dissecting the adrenal glands, the presumed increase in the risk of malignancy, and capsular disruption there is controversy regarding minimally invasive surgery for neoplasms greater than 6 cm. The aim of this study was to report laparoscopic adrenalectomy results in 44 patients with pheochromocytomas either larger or smaller than 6 cm. METHODS: The retrospective clinical study was conducted on 44 patients who underwent surgery in the Campania region in Italy, between January 1998 and January 2008. In 30 cases the lesion measured ≤ 6 cm (group A) in diameter and in 15 > 6 cm (group B). The authors compared cardiovascular instability, operative time, conversion rate, incidence of intra and postoperative complications, length of hospital stay, and medium long term follow-up results in the two groups of patients. RESULTS: By comparing group A vs group B no significant differences were observed in operative time, incidence of intra and postoperative complications length of hospital stay or medium long term follow-up results. In patients with pheochromocytomas > 6 cm a higher conversion rate, although not statistically significant, was observed. The same occurred with cardiovascular instability shown by intraoperative sudden bouts of hypertension. One patient underwent "open" reoperation for residual retrocaval glandular tissue, not removed during laparoscopic treatment. CONCLUSIONS: Laparoscopic adrenalectomy for pheochromocytoma by experienced laparoscopic surgeon is safe and probably preferable also in selected cases larger than 6 cm. These patients may have a longer operative time, a greater intraoperative blood loss, a higher conversion rate, more intraoperative hypertensive crises than other patients. Adequate preoperative pharmacological therapy and careful anaesthesia monitoring make possible optimal management of cardiovascular instability.

Verification of the effectiveness of silver dressings to prevent reinfection of skin ulcers after debridement.

OBJECTIVE: To test the usefulness of silver dressings in patients with skin ulcers in the healing phase after debridement. MATERIALS AND METHODS: After randomly selected a group of 30 patients and divided them into three groups (A, B and C) according to the type and severity of the ulcer, we used respectively for each group antiseptics-free dressings, hydrofiber dressings with a low or a high content of silver. Then we performed samples by aspiration from the bottom of the wound three times (zero time, after two weeks, after a month) to prepare bacterial cultures. RESULTS: In group A, 5 ulcers showed signs of critical colonization after two weeks and 2 of these showed evidence of infection without progression to healing after a month. In groups B and C, no ulcer showed signs of infection with negative cultures. In these two groups, wounds evolved towards healing. CONCLUSIONS: Silver dressings seem to be the best option for the prevention of reinfection of skin ulcers; silver concentration should vary according to the degree of ulcer contamination. Dressings with hydrofibers avoid the accumulation of secretions for bacterial growth which would compromise tissue repair.

Abdominal hypertension and venous insufficiency of lower limbs: is there a relationship?

OBJECTIVE: The purpose of our study is to understand the compression, by subcutaneous fat in obese patients, who present a chronic increase in abdominal pressure, and on the sapheno-femoral cross. Such increase would result in a chronic venous insufficiency (CVI) of lower limbs and, if possible, it will be quantified also according to the posture. MATERIAL AND METHODS: We studied two different groups of patients with CVI: obese and non-obese. The severity of CVI was classified with the CEAP classification or by the standards of recent classifications. Abdominal pressure, by means of Kron's method, and anterior-sagittal diameter were measured in some of the non-obese patients (4 males and 4 females) and in all the obese patients. The diameter of the femoral vein of both groups of patients in supine, sitting and standing positions was also measured. RESULTS: We found a higher incidence of CEAP 5-6 classes in the obese group than in the non-obese one; we also saw a higher incidence of classes 1-2 in the non-obese group than in the obese one. Moreover, Kron's method showed a significant difference in abdominal pressure in relation to the BMI and the increase in the femoral vein diameter appears to be related to the weight and to the position. DISCUSSION: It was clear that the clinical manifestations of CVI are more severe in obese than in non-obese patients. Obesity in our study clearly acts with a continuous compressive action on the veins of the abdomen and thereby on the femoral vein, further contributing to a retrograde flow. So we tried to quantify an entity that until now could only be assumed.

Thromboembolic tendency (TE) in IBD (Inflammatory bowel disease) patients.

BACKGROUND: The incidence of TE events in IBD patients is higher then in population control. The main reason of it, is the hypercoaugulable state. Our aim was to detect serum markers related to TE, that can assume preventing and prognostic meanings. MATERIALS AND METHODS: We performed a 3 years study on 71 patients with IBD, evaluating hypercoaugulability, and then we compared the results with a 71 patients non IBD group control. We also investigated patients of both groups concerning TE events occurred already. RESULTS: In IBD group we found out that 16 patients (22.5%) had history of TE versus >1% of group control. Nineteen of them, already had knowledge of their previous hypercoaugulating condition. 48 (67%) had increased markers value versus less then 6% detected in group control. In IBD group 43% ,20% and 4.2% had respectively 1, 1-3 or > 3 markers higher levels then normal range. Among the markers investigated, we detected increased levels of plated in 33%, homocysteine in 26.7%, d-dimero 25.3%, c3 in 15.4%, apcr in 5.6%. CONCLUSIONS: From our study we detected highest incidence of TE events, and hypercoaugulating status in IBD group. In our previous investigations, plated, homocysteine, d-dimero, c3, and apcr, seems to be the TE markers with higher sensibility. It seems reasonable, according our experience, to propose a new TE risk score index for IBD patients: low, mild and high risk respectively for patients with 1, 1-3 and >3 markers with higher serum levels then normal range. KEYWORDS: Inflammatory bowel disease, Thromboembolism risk score.

Ambulatory laser-assisted surgery: a multicenter application and experience.

BACKGROUND: The widespread use of surgical lasers has found place in dermatologic and aesthetic surgery largely because they are well tolerated with a reduced incidence of postoperative haemorrhage and oedema, few associated adverse events and a high rate of patient satisfaction. PATIENTS AND METHODS: A retrospective analysis of 1232 consecutive patients was performed on patients undergoing a range of laser treatments between January 2005 and January 2010. A mixed variety of indications for laser use included dermatologic surgeries for the removal of fibromas, angiomas and naevi, aesthetic surgeries for acne, superficial vascular conditions, facial rejuvenations and remodelling and tattoo removals as well as many miscellaneous conditions. A range of lasers were employed including CO2, Erbium: Yttrium Aluminum Garnet (Er:YAG), diodes, Alexandrite, Ruby and Neodymium:Yttrium Aluminum Garnet (Nd:YAG) lasers with variable use for different indications in combination with a selective protocol of topical anaesthesia and local cooling systems. RESULTS: Patient satisfaction was high overall (92.4%) with most reported failures amongst those treated for general surgical conditions where there were the highest recorded complication rates. The main failures occurred in those with small cutaneous telangiectases (36.2% incomplete treatment response and 31.9% dissatisfaction rate). In those patients where lasers were used for aesthetic reasons,(most notably in those undergoing tattoo or scar removal and in those with hypertrichosis and dermatofolliculitis), incomplete results occurred in 7.2% with an 11.8% dissatisfaction rate and rare complications (0.9%). In this group, the highest reported incomplete results occurred in patients undergoing tattoo removal (13.9%), followed by scar removal (12.5%) and then by those undergoing treatment for hypertrichosis and dermatofolliculitis (8.8%). CONCLUSIONS: Laser use in general surgery is associated with a high success rate for a wide variety of conditions with high patient satisfaction and a low incidence of adverse events in experienced hands. The advantages and disadvantages as well as the specific recommendations for different laser types are presented with clinical advances resulting from the development of non-ablative laser systems designed for dermal remodeling.

NIM vs Neurosign in nerve sparing total thyroidectomy. Multicentric experience.

INTRODUCTION: Injury to cranial nerve represents 5% of negligence litigation against general surgeons and of all malpractice jury verdicts in endocrine surgery 60% accounts for recurrent nerve injuries and 15% for anoxic brain injuries from RLN injuries, unrecognized post-operatively. During Total Thyroidectomy is reported an incidence of failure to find the nerve in 5- 18% of cases and if we think that routine identification of the RLN during thyroid surgery has reduced the injury rate from 10% to less than 4% and that the incidence of nerve paralysis was 3 to 4 times greater in cases where the nerve was not exposed than in cases where was routinely exposed, then we understand the importance of a clear identification during every thyroid dissection MATERIALS AND METHODS: 880 Total Thyroidectomies during the last 4 years, since Jannuary 2007 until December 2010, (610 F, 270 M; mean age 44,5 years old, range 14-83). All patients were examined pre and postoperatively (1-6 months after) by direct laryngoscopy or laryngofibroscopy to check vocal cord mobility (medium follow up 25.5 months range 3-50 months). The Authors reviewed charts from two randomized groups, selected by a double blind, statistically designed study and again compared in a multivariate analysis (Stat 2004 ltd): 1) 480 total sutureless thyroidectomies, performed during the previous year with continuous intra-operative nerve monitoring using dedicated endotracheal tube with a last generation Nerve Integrity Monitor Pulse II (N.I.M. pulse II®) 2) 400 total sutureless thyroidectomies: performed with continuous intra-operative nerve monitoring using dedicated Laryngeal Electrode, a self-adhesive device designed to fit onto standard reinforced endotracheal tubes (Neurosign® 1040 - 4 Channel EMG) RESULTS: There were no statistically significative difference between the two groups for distribution of age, sex, epidemiological characteristics, type of pathology etc. The incidence of major complications in thyroid surgery in the first two groups (total Thyroidectomy performed by NIM and by Neurosign), as well as compared with the data of the literature are absolutely overimposable; only significative difference is a reduction of the costs in the second group (Neurosign). The 1st group (NIM) specificity is 90.2% (433/480). There were 6 cases of temporary RLN paralysis (temporary paralysis rate: 1.25 % of patients), 3 true positive and 3 false negative. Finally there were 3 cases of permanent RLN paralysis (0.75%), 2 truepositive and 1 false-negative developed after 10 days (demyelination by thermal injury). The 2nd group (Neurosign) specificity of 89 % (356/400). There were 6 cases of temporary RLN paralysis (rate: 1.5 %, p > 0.5), 2 true positive, 1 false positive and 4 false negative. Finally 2 cases of permanent RLN paralysis (0.5% p > 0.5), 2 true-positive. DISCUSSION AND CONCLUSION: Our data confirm a useful application of NIM and Neurosign in thyroid dissection nerve prevention. We don't believe that those procedures can be useful for learning thyroid gland surgery, because can't preserve from an accurate dissection and nerve identification technique, but can only support in nerve-at-risk thyroidectomy or during dissection can support expert surgeon's decision, having a clear pre-operative (post-anesthesiologist) and post-operative predictive value. Those procedures are anyway expensive and time consuming (25000-30000 € for the E.M.G. system and almost 200-250 € for each dedicated endotracheal tube in NIM group). So Neurosign group has over-imposable results in terms of complications specificity and accurancy (no statistically significative differences), but it's a much cheaper procedure!