How to Manage Advanced Differentiated Thyroid Cancer: Step-by-Step Analysis from Two Italian Tertiary Referral Centers.

BACKGROUND: Differentiated thyroid carcinoma (DTC) has an excellent prognosis; however, advanced disease is associated with a worse prognosis and is relatively common. Surgery followed by RAI treatment remains the mainstream treatment for a large majority of patients with high- and intermediate-risk DTC, but its benefits should be carefully weighed against the potential for harm. The aim of this paper is to critically review the experience in treating advanced DTC at two tertiary referral centers in Italy. METHODS: Retrospective analysis of 300 patients who underwent surgery for ADTC over 30 years. RESULTS: The complication rate was 50.33%. A total of 135 patients (45%) remained at regular follow-up, 118 (87.4%) were alive, while 17 (12.6%) were deceased. The mean overall survival at 12 years was 84.8% with a mean of 238 months. Eleven patients (8.1%) experienced a relapse after a median of 13 months. CONCLUSIONS: ADTC patients adequately treated can achieve prolonged survival even in the case of metastasis or disease relapse. Patients with ADTC should be referred to high-volume centers with the availability of an extended multidisciplinary team to receive tailored treatment.

Postoperative risk of pancreatic fistula after distal pancreatectomy with or without spleen preservation.

INTRODUCTION: Outcomes after distal pancreatectomy with or without splenectomy are controversial. The present study aims to investigate differences in short-term and long-term outcomes between spleen-preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (DPS). METHODS: In this retrospective review of consecutive patients undergoing distal pancreatectomy with or without splenectomy from January 2011 until December 2017 for benign disease, the primary endpoint was to compare postoperative pancreatic fistula (POPF). The secondary endpoint was to compare duration of surgery, intraoperative blood loss, postoperative complications, length of hospital stay, and long-term outcomes. RESULTS: Patients undergoing SPDP had a lower rate of POPF (13.6% vs 46.1%; p = 0.02). Patients undergoing SPDP (n = 22) were discharged earlier than patients undergoing DPS (n = 26) (8 [4-29] vs 12 [6.48] days; p = 0.003). No differences in other intraoperative and postoperative outcomes were found between groups. CONCLUSION: Patients undergoing SPDP developed fewer POPF and were discharged earlier compared to patients undergoing DPS.

Autotransplantation of pancreatic islets. A single-center first experience.

INTRODUCTION: Islets auto-transplantation (IAT) is a well-known procedure that may improve glycemic control after total or completion pancreatectomy compared to insulin therapy alone. CASE REPORT: We herein report our experience in IAT with the case of a sixty years old woman underwent completion pancreatectomy for recurrent pancreatitis. She received IAT by percutaneous trans-hepatic intra-portal injection. The patient recovered well, except for a surgical wound infection that was treated with vacuum therapy. She was discharged on p.o.d. 27th in good general conditions and tolerating a diet. DISCUSSION: Data in literature demonstrate that IAT is cost-effective on the long-run compared to insulin therapy in patients with diabetes. 30-days mortality rate for islets auto-transplantation (IAT) following total pancreatectomy is 5%, which is comparable with previous reports on total pancreatectomy without IAT. Our report may expand the literature on this procedure in order to further develop and improve both technique and outcomes, and clarify the correct indication to surgery. KEY WORDS: Auto-transplantation, Chronic pancreatitis, IAT, Pancreatic islets, Total pancreatectomy.

[The model of the Niguarda Hospital Trauma Team in Milan]. / Il modello organizzativo del Trauma Team dell'Ospedale Niguarda di Milano.

The aim of this work was to describe the model and clinical results obtained by the Niguarda Trauma Team referral center for major trauma, in Milan. The Trauma Team is organized as a trauma service, where general surgeons, anesthesiologists, orthopedic surgeons and neurosurgeons work on a 24 hour rotation. When not in duty in the rotations, specialists work in their specific elective activities. The director of the Trauma Team has the responsibility for discussion and application of protocols, clinical assistance, quality assessment and training. The results of 1334 consecutive cases of major trauma during a 51 month period were reviewed using the trauma registry. 39% overtriage, which increased over the years, and 1.12% undertriage were recorded. Mortality of patients with injury severity scores > 15 was 21%, with a progressive decrease over the years. Blunt trauma accounted for 91.75% and were road-related in most cases. Skeletal injuries were the most frequent findings, but brain and thoraco-abdominal injuries were associated with a higher risk of death. 1476 surgical procedures (16.93% general surgery and 111 interventional angiographic studies) were performed. Quality assessment revealed a significant decrease in preventable deaths within the first 72 hours, after excluding patients admitted in extremis. The results presented in this study demonstrate the possibility of realising a model of organized trauma care in an emergency department in Italy, with patient outcomes comparable to those obtained in Trauma Center in other countries.

[An unusual cause of small bowel obstruction in the elderly]. / Una rara causa di occlusione intestinale nell'anziano.

Paraduodenal hernia is an unusual form of internal hernia that results from a congenital midgut malrotation. It is classified as either right or left, depending on anatomic features, and embryologic origin. Left hernias are three times more common than right. Clinical symptoms may be intermittent and non-specific, as nausea, distension and abdominal pain or sometimes acute small bowel obstruction or ischemia. The average age at diagnosis is usually 38 years. We report a case of right paraduodenal hernia in a 79 years old man admitted to the emergency department with an acute small bowel obstruction.

[Hashimoto's thyroiditis and medullary carcinoma in the same gland: a purely random occurrence?]. / Tiroidite di Hashimoto e carcinoma midollare della tiroide coesistenti nella medesima ghiandola: una coincidenza?

In this paper the authors describe the case of 64-year-old woman who had been suffering from poorly defined thyroid disease for 30 years and Hashimoto's thyroiditis for 3 years, with recent detection of high serum calcitonin and CEA. Her family history was negative for endocrinological diseases and her general medical history was not significant for any diseases, except for mild hypertension. There were no pathological findings at physical examination. Cervical ultrasound showed 2 nodular lesions of the right lobe of the thyroid and the isthmus. FNABs of these nodules were performed under ultrasound control and proved non-diagnostic. The patient underwent total thyroidectomy. Intra-operative frozen sections were negative for cancer. Definitive histological examination was positive for medullary carcinoma of the right thyroid lobe (diameter 0.6 cm) in Hashimoto's thyroiditis. The association between thyroid cancers deriving from follicular cells and Hashimoto's thyroiditis is documented in the literature and would appear to determine a better prognosis. Cases such as the one presented in this paper, however, are rare and it is debated whether lymphocyte infiltration may predispose to the onset of medullary carcinoma or whether it is a defence against the tumour.