Autofluorescence of parathyroid glands during endocrine surgery with minimally invasive technique.

PURPOSE: Accidental injury to the parathyroid glands (PTGs) is common during thyroid and parathyroid surgery. To overcome the limitation of naked eye in identifying the PTGs, intraoperative autofluorescence imaging has been embraced by an increasing number of surgeons. The aim of our study was to describe the technique and assess its utility in clinical practice. METHODS: Near-infrared (NIR) autofluorescence imaging was carried out during open parathyroid and thyroid surgery in 25 patients (NIR group), while other 26 patients underwent traditional PTG detection based on naked eye alone (NO-NIR group). Primary variables assessed for correlation between traditional approach and autofluorescence were number of PTGs identified and incidence of postoperative hypoparathyroidism (hypoPT). RESULTS: 81.9% of PTGs were detected by means of fluorescence imaging and 74.5% with visual inspection alone, with an average of 2.72 PTGs visualized per patient using NIR imaging versus approximately 2.4 per patient using naked eye (p = 0.38). Considering only the more complex total thyroidectomies (TTs), the difference was almost statistically significant (p = 0.06). Although not statistically significant, the observed postoperative hypoPT rate was lower in the NIR group. CONCLUSION: Despite the limitations and technical aspects still to be investigated, fluorescence seems to reduce this complication rate by improving the intraoperative detection of the PTGs.

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.

Impact of the Italian Society of Anatomic Pathology and Diagnostic Cytology Classification of Thyroid Nodules in the Treatment of Indeterminate Follicular Lesions: Five-Year Results at a Single Center.

PURPOSE: Aim of the study was to assess the impact of the Italian Society of Anatomic Pathology and Diagnostic Cytology (SIAPEC) classification of 2014, on the treatment of indeterminate thyroid lesions (TIR3). METHODS: We retrospectively analyzed patients undergoing thyroid surgery for TIR3 lesions between 2013 and 2018, at the General Surgery Department of Trieste University Hospital. According to the SIAPEC classification, patients were divided into TIR3A and TIR3B groups. All patients treated before 2014 underwent surgical treatment, and surgical specimens were retrospectively classified after revision of fine-needle aspiration cytology. Starting 2014, TIR3A patients were treated only when symptomatic (i.e., coexistent bilateral thyroid goiter or growing TIR3A nodules), whereas TIR3B patients always received surgical treatment. Hemithyroidectomy (HT) was the procedure of choice. Total thyroidectomy (TT) was performed in case of concurrent bilateral goiter, autoimmune thyroid disease, and/or presence of BRAF and/or RAS mutation. Lastly, we analyzed the malignancy rate in the two groups. RESULTS: 29 TIR3A and 90 TIR3B patients were included in the study. HT was performed in 10 TIR3A patients and 37 TIR3B patients, respectively, with need for reoperation in 4 TIR3B (10.8%) patients due to histological findings of follicular thyroid carcinoma >1 cm. The malignancy rates were 17.2% in TIR3A and 31.1% in TIR3B, (p = 0.16). Predictability of malignancy was almost 89% in BRAF mutation and just 47% in RAS mutation. CONCLUSIONS: The new SIAPEC classification in association with biomolecular markers has improved diagnostic accuracy, patient selection, and clinical management of TIR3 lesions.

Impact of primary cancer features on behaviour of colorectal liver metastases and survival after hepatectomy.

Background: Markers of tumour biology may be valuable prognostic indicators after hepatic resection of colorectal cancer liver metastases (CRLMs). Identification of the aggressiveness of these metastases might inform the appropriateness of hepatic surgery. Methods: Patients undergoing liver resection for CRLMs between January 2001 and July 2013 in four tertiary hospitals were reviewed. A mathematical model to estimate CRLM doubling times was constructed for patients with metachronous metastases. Tumour doubling time was investigated in relation to the features of colorectal cancer, including KRAS status. The hazard rate for recurrence and death following hepatectomy was explored through the Kernel-smoothed estimator. Results: Of 1063 patients undergoing liver resection for CRLMs, 361 with metachronous metastases undergoing single-stage hepatectomy were analysed. The mean doubling time in patients not receiving chemotherapy between surgery for colorectal cancer and CRLM was 71·4 days. Tumour doubling time was shorter in patients with more advanced primary tumour stages, with mutant KRAS and in those who did not receive chemotherapy. For fast-growing CRLMs (doubling time less than 48 days), the risk of recurrence was highest within the first postoperative year, and was about 7 per cent per month. Conclusion: Primary features of colorectal cancer were linked to aggressiveness of CRLMs as measured by doubling time.

Gut microbiota characterisation in obese patients before and after bariatric surgery.

Intestinal microbiota analysis of obese patients after bariatric surgery showed that Proteobacteria decreased after laparoscopic sleeve gastrectomy (SG), while it increased after laparoscopic gastric bypass (LGB). Comparing to normal weight (NW) patients, obese patients that were selected for SG showed an almost equal amount of Firmicutes and Bacteroidetes and the ratio was not affected by the surgery. Obese patients before LGB showed a predominance of Bacteroidetes, whose amount regained a relative abundance similar to NW patients after surgery. Obese patients before LGB showed the predominance of Bacteroides, which decreased after surgery in favour of Prevotella, a bacterium associated with a healthy diet. The bacteria detected at the highest percentages belonged to biofilm forming species. In conclusion, in this study, we found that the characterization of the gut microbial communities and the modality of mucosal colonisation have a central role as markers for the clinical management of obesity and promote the maintenance of good health and the weight loss.

Ileocaecal valve syndrome after surgery in adult patients: myth or reality?

AIM: The onset of symptoms after removal of the ileocaecal valve (ICV) may be perceived as an unwanted effect of surgery and induce patients to bring unnecessary litigation against surgeons. The aim of our study is to assess the real impact on the quality of life of patients whose ICV has been surgically removed, using three validated questionnaires. METHOD: In patients who had their ICV removed surgically, the Gastrointestinal Quality of life (GIQLI) questionnaire and those used by the European Organization for research and Treatment of Cancer (EORTC) were administered before and after surgery. The empirical rule effect size method was used to evaluate the clinical significance of the statistical data. RESULTS: We interviewed 225 patients. Data collected through the three questionnaires highlighted a trend towards postoperative improvement of the selected gastrointestinal symptoms compared with the baseline. The GIQLI questionnaire showed a statistically significant improvement in 'pain', 'nausea' and 'constipation' during the follow-up. Constipation appeared more frequently in patients older than 70 years compared with younger ones. The EORTC-QLQ-C30 questionnaire showed a significant correlation between diarrhoea and extended right colectomy at 3 months after surgery, which was not confirmed at 6 months. The EORTC QLQ-CR29 questionnaire showed a slight deterioration of 'leakage of stools from the anal opening' at 6 months after surgery, but this symptom was not deemed clinically significant. CONCLUSION: We found that bowel functions in most patients after surgical removal of the ICV were satisfactory. Providing patients with a comprehensive and exhaustive informed consent during preoperative consultations could promote patient trust and avoid misunderstandings.

Partial thyroidectomy for papillary thyroid microcarcinoma: Is completion total thyroidectomy indicated?

AIM: Papillary thyroid microcarcinoma (PTMC) is increasing in incidence. Despite its excellent clinical outcomes, there is still debate regarding which surgical approach is more appropriate for PTMC, procedures including hemithyroidectomy (HT), total thyroidectomy (TT), and completion thyroidectomy (CT) after initial HT and histopathologic examination confirming a PTMC. Here we report our experience in the surgical management of PTMC. METHODS: We conducted a retrospective evaluation of all patients who received a postoperative diagnosis of PTMC between January 2001 and January 2016. Every patient was divided according to the type of surgery performed (TT or HT alone). Follow-up consisted of regular clinical and neck ultrasonographic examination. Clinical and histopathological parameters (e.g. age, sex, lesion size, histological features, multifocality, lymph node metastases, BRAF status when available) as well as clinical outcomes (e.g. complications rates, recurrence, overall survival) were analyzed. RESULTS: Group A consisted of 86 patients who underwent TT, whereas Group encompassed 19 patients who underwent HT. Mean follow-up period was 58.5 months. In Group A, one patient (1.2%) experienced recurrence in cervical lymph nodes with need for reoperation. In Group B, eight patients (42%) underwent completion thyroidectomy after histopathological examination confirming PTMC, while one patient (5.3%) developed PTMC in the contralateral lobe with need for reoperation at 2 years after initial surgery. Multifocality was found in 19 patients in Group A (22%). Of these, 14 presented bilobar involvement, whereas in 3 cases multifocality involved only one lobe. 1 patient in Group B (5.3%) presented with unilateral multifocal PTMC (p = 0.11). CONCLUSIONS: Low-risk patients with PTMC may benefit from a more conservative treatment, e.g. HT followed by close follow-up. However, appropriate selection of patients based on risk stratification is the key to differentiate therapy options and gain better results.

Rationality in prophylactic central neck dissection in clinically node-negative (cN0) papillary thyroid carcinoma: Is there anything more to say? A decade experience in a single-center.

AIM: Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy. Despite its extremely favorable prognosis, cervical lymph node metastases are a common feature of PTC and a known independent risk factor for local recurrence. However, the role of prophylactic central neck dissection (PCND) remains a matter of debate in patients with clinically node-negative (cN0) PTC. To better clarify the current role of PCND in the surgical treatment of PTC, evaluating advantages and disadvantages of PCND and outcome of cN0 PTC patients who have been treated with either total thyroidectomy alone or in combination with PCND. A review of recent literature data is performed. METHODS: Between January 2000 and December 2015, 186 consecutive patients with cN0 PTC were identified to be included in the present study. 74 of these underwent total thyroidectomy associated with PCND, while 112 patients underwent total thyroidectomy alone. The epidemiological and clinical-pathological data of all patients included were collected at diagnosis and during follow-up. RESULTS: Overall complication rate was significantly higher in the group of patients undergoing PCND (39.2% vs. 17.8%, p = 0.0006). To be specific, they presented a considerably increased risk of temporary recurrent laryngeal nerve injury (p = 0.009) and of permanent hypothyroidism (p = 0.016). Overall survival and recurrence rates did not differ between those undergoing PCND and those undergoing total thyroidectomy alone (p = 1.000 and p = 0.715, respectively). CONCLUSIONS: The results of the present study do not support the routine use of PCND in the treatment of cN0 PTC patients.

VEGF121 and VEGF165 differentially promote vessel maturation and tumor growth in mice and humans.

Tumor angiogenesis depends on the vascular endothelial growth factor (VEGF), which exists in multiple splicing isoforms, including the most abundant VEGF165 and VEGF121. We have previously shown that the differential capacity of these two VEGF isoforms to bind Neuropilin-1 accounts for their diverse ability to recruit Nrp1-expressing monocytes (NEMs), resulting in a different arteriogenic potential. Here we measure the expression of VEGF165 and VEGF121 in human cancer and their influence on tumor growth and vascularization. We measured the expression levels of VEGF165 and VEGF121 in human colorectal cancer and found that VEGF121 was more expressed than VEGF165, particularly in patients with extensive lymph node infiltration. Overexpressing either VEGF165 or VEGF121 in a cancer mouse model, we observed that the former decreased, whereas the latter increased tumor growth. In both clinical and experimental tumors, VEGF165 expression resulted in the recruitment of NEMs, paralleled by maturation of the tumor vascular network. Finally, hypoxia induced a shift toward the VEGF165 isoform in the central core of human cancers, as well as in various types of cultured cells. These results demonstrate that the two VEGF splicing isoforms are differentially expressed in colorectal cancers, exerting opposite effects on tumor growth and vessel maturation.

Coexistence of chronic lymphocytic thyroiditis and papillary thyroid carcinoma. Impact on presentation, management, and outcome.

BACKGROUND: The association between chronic lymphocytic thyroiditis (CLT) and papillary thyroid carcinoma (PTC) has been investigated for several years from different perspectives. In spite of that, there were only few attempts to design a common frame of references to understand the complex mutual interactions between the various pathways of inflammatory response and of thyroid tumor induction and progression. This study compares two independent groups of patients aiming to determine the frequency and the prognostic significance of CLT in patients with PTC. MATERIAL AND METHODS: From January 2005 to September 2013, we conducted a retrospective study on 160 patients with PTC who underwent thyroidectomy. CLT was diagnosed histopathologically. Age, sex, tumor features (dimensions, angioinvasion, capsular infiltration, mono/multifocality and lymph node metastases) pathologic findings and outcome were considered. Mean follow-up (metastasis, completeness-of-resection, serum thyroglobulin levels, tumor recurrence) period was 61 months (ranged from 18 to 132 months). A p < 0.05 was considered statistically significant. RESULTS: Patients were divided in 2 groups. In group A there were 90 patients affected by PTC alone, and in group B there were 70 patients affected with PTC associated with CLT. Our data showed that the presence of CLT correlate with a lower grade of PTC (p < 0.05). Considering the sex of the patients there were a statistically significant correlation (p < 0.02) and the presence of CLT associated with PTC was most representative in female patients. CONCLUSIONS: The presence of CLT in patients with PTC correlated with a lower grade of PTC, but it does not affect the overall survival of papillary thyroid cancers.

The role of BRAF(V600E) mutation as poor prognostic factor for the outcome of patients with intrathyroid papillary thyroid carcinoma.

BACKGROUND: BRAF(V600E) mutation, which represents the most frequent genetic mutation in papillary thyroid carcinoma (PTC), is widely considered to have an adverse outcome on PTC outcome, however its real predictive value is not still well stated. The aim of the present study was to evaluate if BRAF(V600E) mutation could be useful to identify within patients with intrathyroid ultrasound-N0 PTC those who require more aggressive treatment, by central neck node dissection (CLND) or subsequent postoperative (131)I treatment. METHODS: Among the whole series of 931 consecutive PTC patients operated on at 2nd Clinical Surgery of University of Padova and at General Surgery Department of University of Trieste during a period from January 2007 to December 2012, we selected 226 patients with an intrathyroid tumor and no metastases (preoperative staging T1-T2, N0, M0). BRAF(V600E) mutation was evaluated by PCR-single-strand conformation polymorphism analysis and direct genomic sequencing. We analyzed the correlation between the presence/absence of the BRAF(V600E) mutation in the fine-needle aspiration (FNA) and the clinical-pathological features: age, gender, extension of surgery, node dissection, rate of cervical lymph node involvement, tumor size, TNM stage, variant of histotype, mono/plurifocality, association with lymphocitary chronic thyroiditis, radioactive iodine ablation doses, and outcome. RESULTS: The BRAF(V600E) mutation was present in 104 of 226 PTC patients (47.8%). BRAF(V600E) mutation correlated with multifocality, more aggressive variants, infiltration of the tumoral capsule, and greater tumor's diameter. BRAF(V600E) mutation was the only poor prognostic factor in these patients. DISCUSSION: In our series, BRAF(V600E) mutation demonstrated to be an adverse prognostic factor indicating aggressiveness of disease and it could be useful in the management of low-risk PTC patients, as supplementary prognostic factor to assess the preoperative risk stratification with the aim to avoid unnecessary central neck node dissection (BRAF pos.) or to perform complementary (131)I-therapy (BFAF neg.).

Self-adhesive mesh for Lichtenstein inguinal hernia repair. Experience of a single center.

AIM: Lichtenstein tension-free mesh repair is the most frequently performed procedure for inguinal hernioplasty. In the past surgery aimed to control recurrences. Nowadays it is important to avoid postoperative chronic pain and thus several studies have examined the potential role of meshes in causing postoperative pain. The purpose of this study was to retrospectively assess the early and long-term results after Lichtenstein tension-free repair using a self-adhesive mesh (Parietex ProgripTM - Covidien, Germany) in a single center. METHODS: The study enrolled 211 patients, 199 males (94.3%) and 12 females (5.7%), mean age 62 years (28-90 years), between January 2008 and December 2011. Of these, 206 had primary inguinal hernias while 5 were recurrences following previous tension repair. Ten different general surgeons, including residents, performed Lichtenstein hernia repair using a 12 x 8-cm Parietex ProgripTM mesh. In 88.1% of patients no additional fixation was used, while in 11.9% a single 2-0 polypropylene stitch was placed on the pubic bone. A 1-10 visual analog scale (VAS) was used to assess postoperative pain, evaluating it at 1 week, 1 month and 12, 24 and 36 months. Local paresthesia was assessed at same intervals. Any pain sensation lasting longer than 3 months postoperatively, or requiring injection of analgesics was defined as chronic pain. RESULTS: Mean operating time was 64.1 minutes (SD ± 21.14). There were no intraoperative complications. Early postoperative complications included hematoma-seroma (5.7% cases), superficial wound infection (1%), urinary retention (0.5%), and scrotal swelling (1%). The main follow-up period was 3 years, although patients operated between 2009 and 2011 underwent a shorter follow-up. At one-year follow-up, 17 patients reported groin discomfort, but did not require analgesics. Three patients reported moderate pain, requiring occasional use of oral analgesics, and 2 of these described a discontinuous pain mainly during movement. One patient reported severe pain requiring local injection of analgesics. At 2-year follow-up, 3 patients reported groin discomfort. Five of the 17 patients who reported discomfort at 1 year were lost to the 2-year follow-up. One patient kept reporting a high VAS score (6), though slightly reduced from the previously reported at 1-year follow-up. Recurrence was observed in 0.5% at 1 year and in 2.4% at 2 years. At 3 years only half of the patients (102) were still on follow-up. Of these, 1 reported mild discomfort and 3 developed hernia recurrence. Globally a decrease in pain and local discomfort was observed. No cases of seroma, testicular complications or mesh infection were reported at 1-, 2- and 3-year follow-up. CONCLUSION: Self-gripping mesh for inguinal hernia repair is a good and safe option, easy to handle and with a low incidence of chronic pain (<3%). A sutureless fixation seems to prevent the development of postoperative chronic pain, without increasing recurrence rates. Using a self-adhesive mesh also slightly reduce operating times, and costs are lower when compared to biological glue used to fix the mesh. In conclusion, our experience with the self-gripping mesh is limited but positive, randomized clinical trials are warranted to confirm our results.

Short- and long-term efficacy of intragastric air-filled balloon (Heliosphere® BAG) among obese patients.

BACKGROUND: Obesity is an increasing health problem worldwide. The intragastric balloon as a temporary endoscopic treatment of obesity can play an important role among the aforementioned group of obese individuals. It can also be used as a preoperative test before subjecting patients to restrictive bariatric surgery. Furthermore, the intragastric device may be applied to patients affected by severe obesity as a "bridge treatment" before they undergo major surgery in order to reduce chances of operation-related risks. To date, there are insufficient data in the literature on the long-term results of the intragastric balloon. METHODS: Our study includes an analysis of our experience with Heliosphere® BAG from 2006 through to 2010, concerning early weight loss and weight loss maintenance over at least 18 months since the device's removal. The 32 patients who completed the 6-month treatment had recorded a mean weight loss of 12.66 kg and a mean overweight loss of 24.37 % (SD, 12.74). RESULTS: A total of 16 patients are subjected to an 18-month follow-up. Their pretreatment and long-term body mass index (BMI) were calculated: 6 months later, when devices were removed, they showed a mean weight of 99.75 kg (SD, 17.90; p < 0.001) and a mean weight loss of 13.62 kg and 26.14 % (SD, 12.79). 18 months after removing Heliosphere® BAG, the 16 patients' mean BMI was 37.28 kg/m² (SD, 5.41; p = 0.004), with a mean weight of 103.56 kg (SD 17.25; p = 0.0125), and a mean weight loss of 9.8 kg or 18.2 % (SD, 12.07). CONCLUSIONS: Heliosphere® BAG enables modest short-term weight loss with little side effects, although mid/long-term follow-up may entail partial weight gain. We believe it can be considered a useful bridge treatment in bariatric surgery in order to reduce chances of preoperative risks.

The treatment of inguinal hernia in the elderly: open technique or laparoscopic approach?

Well defined and shared quality standards characterize the ideal treatment of inguinal hernia: it should be the least traumatic as regards both the requested type of anaesthesia and the operative technique and the least expensive; it should have the least per-and post-operative morbidity. The chosen technique should be also the easiest to learn and to perform; and his positive results should be the most reproducible. While there are a lot of studies about the comparison between open and laparoscopic surgery, the number of the studies about the specific evaluation of the problem in the aged is very limited. Aim of the paper is to aid in evaluation of the problem in a group of patients, on the basis of the reports and on an initial departmental experience. In conclusion the laparoscopic repair is a complementary choice and not an alternative to the open surgery in the elderly patients.

[Morbidity after stapled haemorrhoidectomy: long-term results about 140 patients and review of the literature]. / Complications après anopexie circulaire pour cure d'hémorroïdes: résultats à long terme d'une série de 140 malades et analyse de la littérature.

AIM: The aim of this study was to determine the results and the complications of the treatment of hemorrhoids with circular stapler with a follow-up of 18 months, and to review the complications in the literature. METHODS: From April 1998 to August 1999, 140 patients (83 males and 57 females) with an average age of 43.8 years (range: 19-83 years) underwent haemorrhoidectomy using a circular stapler in three university hospital centers. The degree of hemorrhoids has been classified: three cases of degree II, 97 cases of degree III, and 40 cases of degree IV. All the patients were prospectively evaluated at two weeks, two and 18 months after surgery. RESULTS: The average length of the operation was 18 minutes (range: 8-60 minutes). Mean hospital stay was 36 hours (range: 8-72 hours). There was no intraoperative complication. There was no mortality. The postoperative complication rate was 7.8% (N = 11): there were five cases of bleeding that two complicated by a submucosal hematoma (one was infected and needed a rectotomy on day 21), two cases of urinary retention, and two cases of external hemorrhoid thrombosis. The bleeding occurred in the 12 hours after surgery except for one patient with antivitamin K whith presented a secondary bleeding on day 16. At 18 months, five patients presented a moderate asymptomatic stricture dilated on digital examination. Two patients complained of persistent skin tags. Neither functional trouble nor incontinence to gas, liquids, or solids was presented. With a mean follow-up of 40 months, 90% (N = 112) of the patients were fully satisfied. CONCLUSIONS: Treatment of hemorrhoids with circular stapler appears to be effective with 96% of patients fully satisfied at 18 months. The morbidity rate was low, and no higher than the diathermy excision hemorrhoidectomy. The results are directly dependent on the practice that required a learning, and not on the technique itself.