Neuroendocrine response to diclofenac in healthy subjects: a pilot study.

PURPOSE: The precise effects of non-steroidal anti-inflammatory drugs on the neuroendocrine hydro-electrolytic regulation are not precisely understood. The aim of this pilot study was to evaluate, in healthy subjects, the neuroendocrine response of the antidiuretic system to intravenous diclofenac infusion. METHODS: For this single-blinded, cross-over study, we recruited 12 healthy subjects (50% women). Test sessions were divided into three observation times (pre-test; test; 48 h post-test), which were repeated equally on two different occasions, with the administration of diclofenac (75 mg in saline solution 0.9% 100 cc) on 1 day, or placebo (saline solution 0.9% 100 cc) on another day. The night before the test the subjects were asked to collect a salivary cortisol and cortisone sample, which was repeated on the night of the procedure session. Serial urine and blood samples were collected on the test day (for osmolality, electrolytes, ACTH, cortisol, copeptin, MR-proADM, MR-proANP; the last three represent more stable and analytically reliable molecules than their respective active peptides). Moreover, the subjects were evaluated with the bioimpedance vector analysis (BIVA) before and after the test. Forty-eight hours after the end of the procedure urine sodium, urine potassium, urine osmolality, serum sodium and copeptin were revaluated together with BIVA. RESULTS: No significant changes in circulating hormone levels were observed; anyway, 48 h after diclofenac, BIVA showed a significant water retention (p < 0.00001), especially in extracellular fluid (ECF) (16.47 ± 1.65 vs 15.67 ± 1.84, p < 0.001). Salivary cortisol and cortisone tended to increase only the night after placebo administration (p = 0.054 cortisol; p = 0.021 cortisone). CONCLUSION: Diclofenac resulted in an increased ECF at 48 h, but this phenomenon seems to be associated with a greater renal sensibility to the action of vasopressin rather than with an increase in its secretion. Moreover, a partial inhibitory effect on cortisol secretion can be hypothesized.

GHRH + arginine test and body mass index: do we need to review diagnostic criteria for GH deficiency?

INTRODUCTION: The proportion of patients with low GH response to provocative tests increases with the number of other pituitary hormone deficiencies, reason why in panhypopituitary patients GH stimulation tests may be unnecessary to diagnose GH deficiency (GHD) PURPOSE: To re-evaluate the diagnostic cut-offs of GH response to GHRH + arginine (ARG) test related to BMI, considering the patients' pituitary function as the gold standard for the diagnosis of GHD. METHODS: The GH responses to GHRH + ARG were studied in 358 patients with history of hypothalamic-pituitary disease. GHD was defined by the presence of at least 3 other pituitary deficits (n = 223), while a preserved somatotropic function was defined by the lack of other pituitary deficits and an IGF-I SDS ≥ 0 (n = 135). The cut-off with the best sensitivity (SE) and specificity (SP), was identified for each BMI category using the ROC curve analysis. To avoid over-diagnosis of GHD we subsequently searched for the cut-offs with a SP ≥ 95%. RESULTS: The best GH cut-off was 8.0 µg/l (SE 95%, SP 100%) in lean, 7.0 µg/l (SE 97.3%, SP 82.8%) in overweight, and 2.8 µg/l (SE 84.3%, SP 91.7%) in obese subjects. The cut-off with a SP ≥ 95% was 2.6 µg/l (SE 68.5%, SP 96.6%) in overweight and 1.75 µg/l (SE 70.0%, SP 97.2%) in obese subjects. CONCLUSIONS: This is the first study that evaluates the diagnostic cut-offs of GH response to GHRH + ARG related to BMI using a clinical definition of GHD as gold standard. Our results suggest that with this new approach, the GHRH + ARG cut-offs should be revised to avoid GHD over-diagnosis.

Development and internal validation of a predictive score for the diagnosis of central adrenal insufficiency when morning cortisol is in the grey zone.

BACKGROUND: When evaluating a patient for central adrenal insufficiency (CAI), there is a wide range of morning cortisol values for which no definite conclusion on hypothalamus-pituitary-adrenal (HPA) axis function can be drawn; in these cases, a stimulation test is required. Aim of this study was to develop an integrated model for CAI prediction when morning cortisol is in the grey zone, here defined as 40.0-160.0 µg/L. METHODS: Overall, 119 patients with history of sellar tumour which underwent insulin tolerance test (ITT) for the evaluation of HPA axis were enrolled. Supervised regression techniques were used for model development. RESULTS: An integrated predictive model was developed and internally validated, and showed a significantly better diagnostic performance than morning cortisol alone (AUC 0.811 vs 0.699, p = 0.003). A novel predictive score (CAI-score) was retrieved, on a 5.5-point scale, by considering morning cortisol (0 points if 130.1-160.0 µg/L, 1 point if 100.1-130.0 µg/L, 1.5 points if 70.1-100.0 µg/L, 2.5 points if 40.0-70.0 µg/L), other pituitary deficits (2 points if ≥ 3 deficits), and sex (1 point if male). A diagnostic algorithm integrating CAI-score and ITT was finally proposed, with an overall accuracy of 99%, and the possibility to avoid the execution of stimulation tests in 25% of patients. CONCLUSIONS: This was the first study that proposed an integrated score for the prediction of CAI when morning cortisol is in the grey zone. This score might be helpful to reduce the number of patients who need a stimulation test for the assessment of HPA axis function.

Optimal timing of blood samplings to detect GH inhibition during oral glucose tolerance test.

BACKGROUND: In patients with suspected acromegaly, evaluation of IGF-I is recommended as first-line test, while the assessment of GH-nadir during oral glucose tolerance test (OGTT) is advised as confirmatory test. The procedure of this test generally involves GH measurement every 30 min (30') from baseline to +120' or +180'. However, the optimal timing of samplings for the distinction between patients with or without active acromegaly is still a matter of debate. METHODS: Sixty-seven healthy subjects and 46 acromegalic patients who achieved documented and persistent long-term cure were enrolled. A greedy algorithm was used to identify the minimal subset of time-points that sufficed to correctly detect GH suppression. RESULTS: The sampling at 90' was the one in which a GH level < 1 µg/L was most frequently achieved (i.e., in 91.3% of cured acromegalic patients and in 91.0% of healthy subjects). Considering the whole cohort, the best combination of 2 time-points was +90' and +150' and achieved 95.6% accuracy; the best combination of 3 time-points was +60', +90' and +150' and achieved 99.1% accuracy. The minimal subset of GH determinations that demonstrated perfect accuracy (100%) needed the inclusion of 4 time-points, namely +60', +90', +120' and +150'. CONCLUSION: A subset of 4 time-points (60' - 90' - 120' - 150') was identified as the most relevant to detect GH suppression at OGTT, with a perfect classification of 100% of subjects. This supports the possibility to restrict the blood samplings to these time-points when assessing disease cure, with possible advantages in terms of saving time and lowering costs.

Hemithyroidectomy versus total thyroidectomy in the intermediate-risk differentiated thyroid cancer: the Italian Societies of Endocrine Surgeons and Surgical Oncology Multicentric Study.

The surgical treatment of the intermediate-risk DTC (1-4 cm) remains still controversial. We analyzed the current practice in Italy regarding the surgical management of intermediate-risk unilateral DTC to evaluate risk factors for recurrence and to identify a group of patients to whom propose a total thyroidectomy (TT) vs. hemithyroidectomy (HT). Among 1896 patients operated for thyroid cancer between January 2017 and December 2019, we evaluated 564 (29.7%) patients with unilateral intermediate-risk DTC (1-4 cm) without contralateral nodular lesions on the preoperative exams, chronic autoimmune thyroiditis, familiarity or radiance exposure. Data were collected retrospectively from the clinical register from 16 referral centers. The patients were followed for at least 14 months (median time 29.21 months). In our cohort 499 patients (88.4%) underwent total thyroidectomy whereas 65 patients (11.6%) underwent hemithyroidectomy. 151 (26.8%) patients had a multifocal DTC of whom 57 (10.1%) were bilateral. 21/66 (32.3%) patients were reoperated within 2 months from the first intervention (completion thyroidectomy). Three patients (3/564) developed regional lymph node recurrence 2 years after surgery and required a lymph nodal neck dissection. The single factor related to the risk of reoperation was the histological diameter (HR = 1.05 (1.00-1-09), p = 0.026). Risk stratification is the key to differentiating treatment options and achieving better outcomes. According to the present study, tumor diameter is a strong predictive risk factor to proper choose initial surgical management for intermediate-risk DTC.

Morbidity following thyroid surgery: acceptable rates and how to manage complicated patients.

PURPOSE: The endocrine surgeon and the endocrinologist should standardize how they deal with patients with an indication for thyroidectomy, as the road to surgery starts well before the operation itself. The patient should be thoroughly informed about where and how surgery will be performed, the postoperative improvements that can be expected, and the possibility and incidence of relevant complications. This short review aims at identifying the most common postoperative issues after thyroidectomy, with the relevant therapeutic suggestions. METHODS: A revision of studies reporting the morbidity of thyroid surgery, involving the largest numbers of patients. RESULTS: It has been clearly demonstrated that the outcome of thyroid surgery is significantly better when the procedure is performed by an experienced surgeon. Thus, the number of thyroidectomies performed by a surgeon should drive the endocrinologist when referring a patient. CONCLUSIONS: Despite the surgeon's experience, thyroidectomy is burdened by a relatively high rate of postoperative issues ranging from less severe ones to others causing significant changes in the patient's quality of life. Minor, non-invalidating symptoms have been described in 40% of patients after thyroidectomy (e.g. hoarseness, mild dysphagia, some degree of voice alteration); however, these symptoms usually resolve within a few months of surgery, with or without early treatment. On the other hand, major postoperative complications are observed in a limited number of patients, but in these cases early diagnosis is important to provide the most appropriate postoperative treatment, and thus hasten full recovery or at least achieve the greatest possible improvement.

Completion thyroidectomy for differentiated thyroid cancer (results in a consecutive series of 68 patients).

INTRODUCTION: Completion thyroidectomy plays an important role in the management of patients with thyroid cancer. The aim of this study is to determine the indications for and timing of a second surgery, as well as surgical complications. MATERIAL AND METHODS: Operative reports, as well as the hospital and outpatient records of 686 consecutive patients, who had undergone surgery for differentiated thyroid cancer, were reviewed. Among these, 68 (9,9%) patient records of a completion thyroidectomy for cancer were analyzed. RESULTS: The mean time interval between the first and second operation was 3.6 months (range: 1-9). Post-operative complications occurred in 9 patients (12,9%). Among three patients with inferior laryngeal nerve palsy (4,4%) one had definitive palsy (1.4%). Hypoparathyroidism occurred in 6 patients (8,8%) being permanent in one of them (1.4%). No significant difference either for definitive inferior laryngeal nerve lesions (p = 0.9) or for definitive hypocalcemia (p = 1) was found between the groups of patients who had a completion thyroidectomy and those who had a one-step total thyroidectomy for cancer. CONCLUSIONS: Correct indications for re-operation, total lobectomy as a primary surgical procedure as well as lateral access to the residual thyroid gland could all reduce the high risks of complications related to this kind of surgery.

[Lymphadenectomy in differentiated thyroid carcinoma]. / La linfectomia nel carcinoma differenziato della tiroide.

Differentiated thyroid carcinoma accounts for 90% of all thyroid cancers and occurs as papillary carcinoma in 90% of cases. It was shown as this is characterized by an excellent long-term prognosis, although in follow-up long series, were described recurrence rates up to 35%. Although in the past has not been attributed prognostic significance to the lymph nodes, in the last decade has shown how these can affect the rate of locoregional recurrence of differentiated thyroid carcinoma. This renewed interest in lymph node metastatic disease has prompted a shift in surgical treatments more aggressive, with a view to achieving a low incidence of locoregional recurrence. Analyzing the more recent guidelines formulated at the international level, we can highlight how we gradually consolidated the role of prophylactic central compartment lymphadenectomy in the surgical treatment of patients with differentiated thyroid carcinoma. The aim of this treatment, in fact, is not only to reduce the mortality of patients, but to obtain an adequate staging, facilitate radiotherapy treatment, obtain undetectable thyroglobulin levels, avoiding the need for repeated reiterventi, made more simple follow-up. All these objectives can be achieved by careful surgery. Total thyroidectomy associated with prophylactic lymphadenectomy of the central compartment was found to achieve these objectives, although in the absence of data from randomized trials, its role remains controversial.

[Artificial nutrition in inflammatory bowel disease]. / La nutrizione artificiale nelle malattie infiammatorie intestinali.

Malnutrition is often a major clinical problem in patients affected by IBD. Assessment of nutritional status should be routinely carried out in these patients and, in case of severe malnutrition, artificial nutrition should be used. In ulcerative colitis and in Crohn disease localized to colonic segments both Parenteral Nutrition (PN) and Enteral Nutrition (EN) have similar results as support treatments but they have no primary therapeutic effects and then they are indicated only in case of severe malnutrition and/or when a surgical procedure is planned. Some theoretical advantages derived from supplementation of short chain fatty acids and omega3-series is still debated. More evident are the advantages of nutritional support in Crohn enteritis. Both PN and EN have a role as a primary therapy capable to induce remission although these results are not prolonged in time when nutrition is not associated with pharmacological treatments. Experiments of pharmaco-nutrition with glutamine and fish fatty acid have to be validated in the clinical practice. In case of integrity of the small bowel and tolerance of the patient, EN is preferable to PN for its lower costs and reduced related complications. PN is still indicated in more severe cases or in acute phase when the need of restoring rapidly the hydroelectrolitic and nitrogen/caloric balance prevails.

Parathyroid cyst, a case report and review of the literature.

Parathyroid cysts are rare, representing 1% of all neck swellings. A correct preoperative diagnosis is rarely formulated, especially because of the non-specific clinical and ultrasonographic findings; for this reason, patients are often submitted to surgery for thyroid nodules. In the present report we describe a case where the preoperative diagnosis was correctly formulated following the aspiration and PTH assay of clear, colorless, watery fluid from the cyst. While cyst aspiration is considered the elective treatment for these lesions, recurrences being uncommon, surgery was indicated in the present case because of two recurrences after aspiration and the onset of compressive symptoms. Cystic masses of the neck should be accurately diagnosed to recognize their true nature and to allow their correct and non-invasive treatment: surgery is indicated only when recurrences and symptoms are present. Indications for aspiration of all solitary cysts of the neck should be considered to correctly identify their nature.

Doppler evaluation of intrathyroid arterial resistances during preoperative treatment with Lugol's iodide solution in patients with diffuse toxic goiter.

BACKGROUND: The aim of this study was to ascertain the utility of echo-Doppler in the analysis of the low resistance thyroid vascularization in diffuse toxic goiter (DTG), and the effectiveness of Lugol's solution (iodine-iodide solution) in patients undergoing thyroidectomy. STUDY DESIGN: Twenty-five patients with diffuse toxic goiter were evaluated and compared with 19 normal subjects. Patients were treated with increasing doses of Lugol's solution 2% for 7 days until a total dose of 75 mg of iodine was given. Echo-Doppler was performed on the last day of treatment, 12 hours before operation. RESULTS: Mean basal Doppler Resistance Index (RI) of intrathyroid arterial flow was significantly lower in patients with DTG compared with normal controls (0.4718 +/- 0.0625 versus 0.55 +/- 0.05, range: 0.472 to 0.643; p = 0.008). Moreover, the RI was significantly increased in patients with DTG after Lugol's solution (+16.46 +/- 10.22%, range: -2.59 to +39.97; p< 0.0005). CONCLUSIONS: Echo-Doppler RI allowed documenting lower arterial resistances within the thyroid gland in patients with DTG. The use of preoperative Lugol's solution therapy induces normalization of those changes for safer thyroidectomy.

Cervico-mediastinal extension of thyroid cancer.

A surgical series of 30 cervico-mediastinal thyroid cancer patients operated on has been retrospectively reviewed. Results were compared with those obtained in patients operated on for benign cervico-mediastinal goiter and thyroid cancer confined to cervical region. Of 4688 thyroidectomies performed, 30 patients were operated on for thyroid carcinoma with cervico-mediastinal extension. There were 15 males and 15 females. The mean age was 67 years (range, 21-86 years). Patients with cervico-mediastinal cancer were significantly older than patients with benign cervico-mediastinal goiter (P < 0.0001). Time between onset of first symptoms and surgery was significantly longer in patients with cervico-mediastinal cancer than in those with benign cervico-mediastinal goiter (P < 0.0001) and cervical thyroid cancer. Signs and symptoms at the time of surgery were cervical mass in 28 patients (93%), cervical lymphadenopathy in 20 patients (66%), dyspnea in 21 (70%), dysphagia in 9 (30%), dysphonia in 2 (7%), and venous stasis in 1 (3%). None of the patients was asymptomatic. Total thyroidectomy with functional lymphectomy was performed in 16 cases. Seven of these patients were operated on in 2 stages. In 8 cases the operation was a debulking procedure, and in 6 it was a near-total thyroidectomy. Sternotomy was performed in two cases. A differentiated thyroid cancer was found in 21 patients (70%), medullary in 5 (17%) and undifferentiated in 4 (13%). The incidence of medullary carcinoma was significantly higher compared with cervical cancer (P < 0.008). Postoperative complications were higher than those occurring in benign cervico-mediastinal goiter and similar to those occurring in cervical cancer. The actuarial survival was similar to that of cervical cancer matched for age and sex. This analysis shows that the longer clinical history of goiter is related to its endothoracic development and its neoplastic transformation. This finding should further encourage surgeons to treat any cervico-mediastinal goiter as promptly as possible.

Goiter recurrence in patients submitted to thyroid-stimulating hormone suppression: possible role of insulin-like growth factors and insulin-like growth factor-binding proteins.

BACKGROUND: It is known that factors other than thyroid-stimulating hormone, such as insulin-like growth factor-I (IGF-I) and epidermal growth factor, have a goitrogenic effect. It has been established that insulin-like growth factor-binding proteins (IGFBPs) may play a role as autocrine/paracrine factors in regulating the local actions of IGFs. Both an inhibitory and a stimulatory effect for different IGFBPs have been shown in several cell systems. The aim of this study was to assess the involvement of IGFBPs in the goitrogenic process in patients with goiter recurrence. METHODS: The IGFBP-1 and -3 content in normal and nodular tissues obtained at the time of thyroidectomy from 10 patients with recurrent goiters, unresponsive to thyroid-stimulating hormone suppressive therapy, was studied. In all patients, a fragment of normal tissue was also obtained. The IGF-I, IGFBP-1, and -3 content was evaluated by specific immunoassays and/or immunoblotting with anti-IGFBP specific antiserum. RESULTS: The IGF-I content was significantly higher (P < .05) in nodular tissues (8.0 +/- 1.6 ng/g of tissue) than what was found in normal tissue (4.8 +/- 0.9 ng/g). Radioimmunoassay IGFBP-3 concentration in nodular tissue was 111.5 +/- 18.2 ng/g significantly higher (P < .001) than values found in normal tissue (77.5 +/- 18.6 ng/g). By immunoblot, IGFBP-1 appeared higher in all but 1 nodular tissue. CONCLUSIONS: These data raise the possibility that IGFBPs are important in the proliferative activities entailed in the goitrogenic process. Three mechanisms are potentially involved: (1) reduction of the potency of locally produced IGF peptide to downregulate type I receptors (potentiating effect on the autocrine/paracrine mitogenic action of IGFs); (2) increase of the IGF-I tissue concentration restraining its passage to circulation; and (3) protection of IGF-I from degradation. Further studies are needed to define a more precise link between these factors and the recurrence of goiter.

[Laparoscopic cholecystectomy. An analysis of the reasons for a conversion to conventional surgery in an elective surgery department]. / La colecistectomia laparoscopica. Analisi delle cause di conversione in chirurgia tradizionale in un reparto di chirurgia di elezione.

BACKGROUND: To assess which factors determined conversion to laparotomy in patients undergoing laparoscopic elective cholecystectomy. SETTING: department of General Surgery. University of Genoa. Italy. METHODS: Two hundred sixty-four consecutive laparoscopic cholecystectomies were performed in our Department. INTERVENTIONS: laparoscopic cholecystectomy was performed according to Dubois's technique. Duration of the procedure was not considered a reason for conversion. RESULTS: 121 patients showed "difficult intraoperative situations" with further conversion risk factor. Conversion to laparotomy was necessary in 11 patients (4.16%). Five patients underwent conversion in the first 50 cases (10%), while six in the last 214 (2.8%). We had to convert to open cholecystectomy only in eleven patients, despite the high rate of technical difficulties and anatomic anomalies even in cases which, in the past, represented a contraindication to this kind of technique. The use of new instruments and new surgical techniques has reduced to only factors of increased risk in those situations that in the past were considered as contraindications to laparoscopic cholecystectomy. CONCLUSIONS: Conversion to open cholecystectomy is based on the surgeon's decision and the safety should be the main consideration in performing laparoscopic cholecystectomy. The use of a careful dissection could avoid the conversion in many patients.

Pseudotumor of the liver: a challenging diagnosis.

Inflammatory pseudotumors of the liver are rare, and their natural history is mostly unknown. Making the diagnosis is often difficult, and these masses are often confused with other lesions, generally either primary or secondary neoplasms. The case of a patient who had an exhaustive preoperative work-up, including ultrasonography, CT scan and MRI, is herein presented. The characteristics of each exam, particularly those of the MRI, in which the pattern is poorly described in the literature, are reported. A fine needle biopsy was not contributive, as it was performed too centrally within the nodule. Only a high degree of suspicion and the existence of this tumor might lead to a preoperative diagnosis, thus avoiding major surgery. However, as is evident from the experiences of most authors and from our own, doubt may persist even after an exhaustive work-up. Since the morbidity and mortality of liver resection of noncirrhotic livers is low, surgery should be considered the treatment of choice.

Is euthyroidism the goal of surgical treatment of diffuse toxic goitre?

OBJECTIVE: To find out by studying a homogeneous group of patients whether euthyroidism is achievable by surgical treatment of diffuse toxic goitre. DESIGN: Retrospective study. SETTING: Teaching hospital, Italy. SUBJECTS: 128 of the 152 patients operated on for diffuse toxic goitre during the period January 1971-December 1994 and followed up for a median of 83 months (range 6-289). INTERVENTION. Standard subtotal thyroidectomy. MAIN OUTCOME MEASURES: Operative mortality, recurrence, hypothyroidism and late complications. RESULTS: There were no operative deaths. After 10 years follow up, 11 patients (9%) had developed recurrences and 61 (48%) were euthyroid. In the univariate analysis the risk of hypothyroidism was significantly associated with the year of operation (p = 0.04), the duration of symptoms (p < 0.01), and the degree of lymphocytic infiltration (p < 0.01). The last two were confirmed by multivariate analysis. CONCLUSION: Subtotal thyroidectomy seems to be an effective treatment of diffuse toxic goitre as a stable euthyroid state can be achieved in nearly half the patients after a prolonged follow up.

[An application of mini-invasive surface surgery: the thyroid]. / Un'applicazione della chirurgia mini-invasiva di superficie: la tiroide.

Since its introduction, minimally-invasive surgery has been applied to structures contained in natural cavities such as abdomen, thorax and articulations. At present, its application to surface zones (plastic surgery) gives good results. For this reason, we tried to examine thyroid area through a video-assisted access in a 32 years old woman presenting a nodule with a diameter of about 1 cm, localized in the left parahistmic thyroid area. This approach allowed a good vision of the operative field. In our opinion, this technique could be useful especially to formulate the histological diagnosis of small thyroid nodules for whom the standard surgical biopsy should be considered too invasive.

Large granular lymphocyte leukemia associated with hepatocellular carcinoma: a case report.

The association of large granular lymphocyte leukemia (LGL-L) with hepatocellular carcinoma in a 55-year-old patient is described. An increased number of LGL was seen on peripheral blood smears. The immunophenotype was CD3+, CD4-, CD8+, and a study of the TCR gene rearrangement indicated the monoclonal nature of the proliferation. A liver mass was detected on CT scan and an ultrasound-guided fine needle biopsy revealed the presence of hepatocholangiocellular elements. A right hepatectomy was performed. Major neutropenia persisted despite corticosteroids and granulocyte colony-stimulating growth factor (G-CSF) therapy. Methotrexate at 20 mg/week failed to control lymphocytosis after three months of treatment. A new nodule of hepatocarcinoma reappeared twelve months after surgery and a liver resection was performed.

[A case of traditional appendectomy changed to laparoscopic surgery]. / Su un caso di appendicectomia tradizionale convertita a chirurgia laparoscopica.

The utility of appendectomy performed with laparoscopic procedure is at the present accepted by many surgeons, especially when there is uncertain diagnosis of appendicitis or when an ectopic position is suspected. The authors describe the case report of a 17 years old woman with a diagnosis of subacute appendicitis, in which the unsuccessful finding of the appendix made necessary conversion of traditional laparotomy approach to laparoscopic technique. This choice avoided the execution of an enlargement of laparotomy access, and allowed an easy finding of appendix. Aesthetic results at a distance are very satisfying.