Genetic characterization of an almond germplasm collection and volatilome profiling of raw and roasted kernels.

Almond is appreciated for its nutraceutical value and for the aromatic profile of the kernels. In this work, an almond collection composed of 96 Sicilian accessions complemented with 10 widely cultivated cultivars was phenotyped for the production of volatile organic compounds using a proton-transfer time-of-flight mass spectrometer and genotyped using the Illumina Infinium®18 K Peach SNP array. The profiling of the aroma was carried out on fresh and roasted kernels enabling the detection of 150 mass peaks. Sixty eight, for the most related with sulfur compounds, furan containing compounds, and aldehydes formed by Strecker degradation, significantly increased during roasting, while the concentration of fifty-four mass peaks, for the most belonging to alcohols and terpenes, significantly decreased. Four hundred and seventy-one robust SNPs were selected and employed for population genetic studies. Structure analysis detected three subpopulations with the Sicilian accessions characterized by a different genetic stratification compared to those collected in Apulia (South Italy) and the International cultivars. The linkage-disequilibrium (LD) decay across the genome was equal to r2 = 0.083. Furthermore, a high level of collinearity (r2 = 0.96) between almond and peach was registered confirming the high synteny between the two genomes. A preliminary application of a genome-wide association analysis allowed the detection of significant marker-trait associations for 31 fresh and 33 roasted almond mass peaks respectively. An accurate genetic and phenotypic characterization of novel germplasm can represent a valuable tool for the set-up of marker-assisted selection of novel cultivars with an enhanced aromatic profile.

A rare clinical entity: stump appendicitis. Case report and complete review of literature.

BACKGROUND: Stump appendicitis is a rare delayed complication post-appendectomy and it represents a diagnostic problem as clinicians are often not very familiar with this pathology. MATERIALS AND METHODS: One case of stump appendicitis has been reported in a 54 year old woman, whose acute phase was conservatively treated in our Department. A review of Medline literature was also carried out, from 1945 to 2015, showing 111 cases of stump appendicitis. RESULTS: Stump appendicitis has been reported after either open or laparoscopic appendectomy, in a range between days to several years from the first procedure. Nowadays, it is not considered yet as a possible differential diagnosis in patients with pain in the right iliac fossa previously undergone appendectomy. For this reason, the diagnosis can be delayed and complications such as acute abdomen, perforation, sepsis can occur. Completion appendectomy is the treatment of choice for stump appendicitis. CONCLUSIONS: The aim of this article is to underline the importance of stump appendicitis. Clinicians should be aware of the possibility of SA and they should confirm any clinical suspicion throughout radiologic images, in order to promptly recognize this entity and to avoid the related complications.

Videolaparoscopic cholecystectomy in patients with previous abdominal surgery. Personal experience and literature review.

OBJECTIVES: Laparoscopic cholecystectomy (LC) is today the "gold standard" treatment of gallbladder stones. Role of LC is still debated in the presence of abdominal scars due to the frequent post-operative adhesions which make access to the peritoneal cavity difficult. This study aim to assess role and outcomes of LC on a previous abdominal surgery on the scarred abdomen. MATERIALS AND METHODS: We have carried out a retrospective study on 499 consecutive patients who had undergone LC from 2009 to 2015; 21 of these (4.2%) undergone previous abdominal surgery. In all 21 cases the pneumoperitoneum was established with Veress needle at the Palmer's point and the procedure was carried out after adhesiolysis in 62% of cases. RESULTS: The mean operative time was 79±12 minutes; none of the patients with previous abdominal surgery required conversion to open cholecystectomy and there were no postoperative complications related to Veress introduction or to the adhesiolysis. The difficult dissection and adhesiolysis were more frequent in the patients with upper abdomen scar (62%) respect to lower abdomen scar (38%). CONCLUSIONS: Patients with scarred abdomen for previous abdominal surgery had obviously more adhesions in the abdomen than patients without preceding surgery, but today previous abdominal surgery should not constitutes absolute contraindications to LC. Moreover, patients with previous lower abdominal incisions had fewer adhesions in the upper abdomen than did patients with upper incision and, probably, in these cases adhesiolysis is unnecessary, if the surgical field is well exposed whereas adhesiolysis is mandatory when the adhesions are thick and widespread, to the anterior and posterior abdominal wall.

Surgical treatment of thymoma: personal experience.

INTRODUCTION: Thymomas (THs) are rare epithelial tumors of the thymus gland. In this study we report our personal experience in the management and surgical treatment of THs. CASE REPORTS: We report two clinical cases treated with combined therapy (surgery followed by adjuvant therapy). RESULTS: Total transternal thymectomy was performed in both patients. The post-operative course was uneventful. The patients received adjuvant radiotherapy and chemotherapy. No relapse has been observed during follow-up. DISCUSSION: THs are usually slowly growing tumors with similar incidence in both sexes. They occur through a wide age range, with a peak in the fifth and sixth decades. Distinctive features reminiscent of the normal thymus make the pathologic diagnosis of THs easy in most cases. Malignant behaviour is indicated by microscopic or macroscopic invasion of the tumor capsule or surrounding organs or by the presence of metastases. Although there is no standardized staging system for thymoma, the one proposed by Masaoka is commonly employed. Total thymectomy is the procedure of choice, even for encapsulated tumors, with carefully exploration of the mediastinum for evidence of ectopic thymic tissue or local invasion. CONCLUSIONS: Despite an indolent course and a cytologically bland appearance, all thymic tumors can manifest a malignant behavior. Surgery continues to be the mainstay of treatment, and the ability to achieve complete resection seems to be the most important prognostic factor. Multimodality treatment involving postoperative chemotherapy and radiotherapy appears to increase the rate of complete resection and improves survival in advanced THs.

Bilateral lung and liver hydatid cysts. Case report.

Introduction. Synchronous occurrence of pulmonary and hepatic hydatid cysts is an uncommon manifestation of hydatid disease that is observed in less than 10% of cases. We report a rare case of bilateral lung (with bronchial fistula) and liver cyst, surgically treated after medical therapy. Case report. A 44-year-old housewife reporting fever, anorexia and fatigue that had been present for the previous 20 days received diagnosis of bilateral lung and liver hydatid cyst. Because of the dimensions of right lung cyst and the successive bronchial fistolization, we proceeded to three-stage operation of two thoracotomies and a laparotomy to control the risk of further rupture. After surgery, all post-operatives were uneventful. Complete resolution of the therapy with no evidence of recurrence at 2 years follow-up. Conclusion. We emphasize the need to search for additional hydatids in patients who present with either pulmonary or liver hydatids. The simultaneous treatment of liver and lung should be reserved to patients in good conditions; in all other cases, especially when one cyst is more symptomatic than the others or has more risk of rupture, we prefer to treat single cyst.

Non-recurrent laryngeal nerve coexisting with ipsilateral recurrent nerve: personal experience and literature review.

INTRODUCTION: Non-recurrence and variations in ascending course of the recurrent laryngeal nerve (RLN) represent a risk factor for nerve injuries during thyroid surgery. Non-recurrent laryngeal nerve (NRLN) coexisting to recurrent nerve branch is a rare anatomic anomaly. It could be a cause of nerve injuries during thyroidectomy. A systematic intraoperative nerve identification may allow an effectiveness prevention of iatrogenic injuries. CASE REPORT: We report one case of a young woman underwent to total thyroidectomy (TT) for papillary thyroid carcinoma (PTC) where we found a rare variation of the right inferior laryngeal nerve anatomy. We identified both right laryngeal nerve structures before completing thyroidectomy avoiding possible nerve damage. The postoperative course was without complications. DISCUSSION: Iatrogenic injury of RLN is one of the most serious complication in thyroid surgery. Several risk factors favouring this complication were found as the presence of anatomic variations of the inferior laryngeal nerve. Identification of a normal caliber recurrent nerve can allow the surgeon to complete the thyroid excision; diversely, in case of a smaller caliber nerve in the usual recurrent course, a careful dissection should be continued to demonstrate a possible merger with ipsilateral non-recurrent nerve. CONCLUSIONS: The aim of this paper is to report a rare case of NRLN associated to a smaller caliber branch of RNL. We emphasize that careful dissection and intimate knowledge of normal and anomaly anatomy allow for avoidance of nerve injury during surgery in the neck.

[Endoscopic rubber band ligation in treatment of esophageal varices bleeding. Personal experience]. / La legatura elastica nel trattamento endoscopico della emorragia da rottura di varici esofagee. Esperienza di un singolo centro.

INTRODUCTION: Bleeding esophageal varices is the most serious complication of the portal hypertension, and the greater cause of dead (25% of the patients). The survival after esophageal varices bleeding depends in wide part from the swiftness and effectiveness of hemostasis and from the degree of functional liver reserve. Aim of our manuscript is to report our experience about hemostasis bleeding esophageal varices with endoscopic rubber band ligation. PATIENTS AND METHODS: From January 1999 to January 2008 we performed 302 esofagogastroduodenoscopy (EGDS) for esophageal varices bleeding (M: F ratio = 1.4:1, mean age 56.4 years, 62% of cases with HCV-related cirrhosis, 29% alcoholic cirrhosis and 9% cryptogenic cirrhosis; 20% suffered from chronic renal failure, 15% diabetes mellitus, 10% hepatocellular carcinoma on cirrhosis, 5% systemic encephalopathy and 1% AIDS). RESULTS; All patients were treated within 6 hours after the first reported episode of haematemesis and all received beta-blocker therapy after the episode. In the first phase of our experience were used rechargeable elastic ligator and then multibyte, even in combination with polidocanol sclerotherapy (8%) or injection of cyanoacrylate (5%). The best results were achieved with band ligation, in terms of primitive haemostasis, rebleeding, (3%), intraoperative mortality (1%) and 6 weeks mortality (1%). CONCLUSION: To date, no single method applicable to all patients with bleeding esophageal varices, but endoscopic rubber band ligation is currently considered the first-line treatment of proper multidisciplinary approach to the patient, both during the acute event than prevention of rebleeding, because it is an effective, safe and repeatable, in experienced hands.

Hsp10, Hsp70, and Hsp90 immunohistochemical levels change in ulcerative colitis after therapy.

Ulcerative colitis (UC) is a form of inflammatory bowel disease (IBD) characterized by damage of large bowel mucosa and frequent extra-intestinal autoimmune comorbidities. The role played in IBD pathogenesis by molecular chaperones known to interact with components of the immune system involved in inflammation is unclear. We previously demonstrated that mucosal Hsp60 decreases in UC patients treated with conventional therapies (mesalazine, probiotics), suggesting that this chaperonin could be a reliable biomarker useful for monitoring response to treatment, and that it might play a role in pathogenesis. In the present work we investigated three other heat shock protein/molecular chaperones: Hsp10, Hsp70, and Hsp90. We found that the levels of these proteins are increased in UC patients at the time of diagnosis and decrease after therapy, supporting the notion that these proteins deserve attention in the study of the mechanisms that promote the development and maintenance of IBD, and as biomarkers of this disease (e.g., to monitor response to treatment at the histological level).

Neck node dissection in thyroid cancer. A review.

INTRODUCTION: thyroid cancer recurs most commonly in one or more cervical lymph nodes. Surgical treatment for differentiated or medullary thyroid carcinoma consists of total thyroidectomy (TT). The aim is to elucidate the potential benefits and drawbacks of neck dissection TT related. MATERIALS AND METHODS: differences between therapeutic and prophylactic neck dissection were analysed to prevent post-operative morbidity, neck recurrences and improve survival. DISCUSSION: there is considerable controversy regarding the treatment of patients with cervical node metastases specially in differentiated thyroid cancer. Considering that a neck dissection might help to reduce local recurrence, especially in medullary carcinoma, controversial remains regarding the modality and extension of cervical dissection. There are several surgical strategies to cervical lymphadenectomy as a prophylactic node dissection or a dissection only in symptomatic patients or the "node-picking" technique for selective lymphadenectomy or sentinel node biopsy. So it is possible to employ several kind of neck-node compartment related dissection. The risk of iatrogenic lesion during neck dissection is relatively high specially for nerve structures (i.e.: recurrent laryngeal nerve or spinal accessory nerve), so an experienced surgeon must mind the risk is higher during a re-operation in an anatomical subverted region. CONCLUSIONS: the extent of dissection and the experience of the surgeon both play important roles in determining the risk of surgical complications and recurrence. The decision to add neck dissection to total thyroidectomy weighed against documented benefits and risks. Injuries may also occur as a result of inadequate technique or as a result of poor expertise of the surgeon. We believe that deep knowledge of the thyroid region's surgical anatomy is necessary to realize a skilled and careful surgery of the neck.

[Role of ERCP in the era of videolaparoscopic cholecystectomy. Personal experience]. / Il ruolo della CPRE nell'era della colecistectomia videolaparoscopica. Nostra esperienza.

INTRODUCTION: In subjects operated by videolaparoscopic cholecystectomy (VLC) incidence of synchronous cholecysto-choledochal stones is 7-20%. Aim of the study is to report our experience in endoscopic treatment of common bile duct (CBD) stones before VLC (sequential treatment). PATIENTS AND METHODS: From January 2001 to May 2007, 189 ERCP for synchronous cholecysto-choledochal stones were performed with analgo-sedation. In selected cases antibiotics and protease inhibitors were used. RESULTS: CBD clearance was 100%. The incidence of complications (mild, moderate and severe) was 8.2%, mortality 0.53% (1 patient). We observed 31 cases of transient asymptomatic hyperamilasemia (16.4%). A total of 186 subjects were operated by VLC, with only 3 conversion, without procedure-related mortality. CONCLUSIONS: In our opinion, the best treatment of syncronous cholecisto-choledochal stones is related to available tools and human experience, but for an experienced surgical and endoscopic team the sequential approach is feasible, safe and effective.

[Endoscopic surveillance of colon-rectum in the narrow band imaging era]. / Sorveglianza endoscopica del colon-retto. Ruolo del Narrow Band Imaging (NBI).

BACKGROUND AND AIMS: Colonoscopic surveillance is an established method of colorectal cancer (CRC) screening that reduces death rates, but has an adenoma miss rate of 10-20%. Narrow band imaging (NBI), a novel endoscopic technology, highlights superficial mucosal capillaries and improves contrast for small adenomas. This study evaluated the role of NBI in the improving colon adenoma detection. PATIENTS AND METHODS: White light colonoscope was compared with NBI for adenoma detection during colonoscopy. 120 patients presenting for diagnostic colonoscopy were randomly assigned to undergo colonoscopy using either conventional white light or NBI colonscope during instrument withdrawal. The outcome parameter was the difference in the adenoma detection rate between the two techniques. All polyps detected were removed for histopathological analysis. RESULTS: Adenomas were detected more frequently in the NBI group (51) than in the control group (49); however, the difference was not statistically significant (p = 0.128). The extubation time was significatively longer in the NBI group (p = 0.003). CONCLUSIONS: In our experience, the NBI did not increased the adenomas detection rate compared to white light by an endoscopist with a known high detection rate using white light.

Herpes simplex esophagitis in immunocompetent host: a case report.

Introduction. Herpes simplex esophagitis is well recognized in immunosuppressed subjects, but it is infrequent in immunocompetent patients. We present a case of HSE in a 53-year-old healthy man. Materials and Methods. The patient was admitted with dysphagia, odynophagia, and retrosternal chest pain. An esophagogastroduodenoscopy revealed minute erosive area in distal esophagus and biopsies confirmed esophagitis and findings characteristic of Herpes Simplex Virus infection. Results. The patients was treated with high dose of protonpump inhibitor, sucralfate, and acyclovir, orally, with rapid resolution of symptoms. Discussion. HSV type I is the second most common cause of infectious esophagitis. The majority of symptomatic immunocompetent patients with HSE will present with an acute onset of esophagitis. Endoscopic biopsies from the ulcer edges should be obtained for both histopathology and viral culture. In immunocompetent host, HSE is generally a self-limited condition. Conclusions. HSE should be suspected in case of esophagitis without evident cause, even if the patient is immunocompetent. When the diagnosis of HSE is confirmed, careful history and assessment for an immune disorder such as HIV infection is crucial, to look for underlying immune deficiency.

Acute onset of esophageal duplication cyst in adult. Case report.

INTRODUCTION: Esophageal duplication (ED) cyst is unusual congenital disorder of the foregut, accounting for 10% to 15% of duplications of all foregut cysts. We report a case of esophageal duplication with acute clinical presentation, treated successfully with surgical resection. CASE REPORT: 46-year-old man with acute dysphagia and gastroesophageal reflux of 2 weeks duration, showed submucosal bulging mass in the posterior wall of the middle third of oesophagus, fluid-filled cystic structure, dyshomogeneous, low-attenuation mass with smooth borders compatible with an hemorrhagic esophageal duplication cyst. With the suspect of acute presentation of a complicated esophageal cyst, the patient underwent surgery by right posterolateral thoracotomy. A gastrografin esophagogram was performed on third postoperative day and showed no leaks. DISCUSSION: Up to 80% of the esophageal duplication cysts are diagnosed in childhood and the majority of young patients develop symptoms, while symptomatic cyst into adult life is very rare (<7%). Acute onset is generally due to complications, i.e. intracystic hemorrhage, perforation, and infection, especially of the cyst with esophageal communication. Complete surgical excision by thoracotomy or thoracoscopy is the therapy of choice even if the patient is asymptomatic because of the risk of complications such as aspiration and bleeding. CONCLUSIONS: The diagnosis and treatment of esophageal cysts is still evolving. The pathological diagnosis of oesophageal duplication requires the presence of the Ladd and Gross criteria. The infrequent acute onset doesn't modify the management and the surgical resection is the procedure of choice. The future of the treatment of esophageal cysts lies in the advancement of minimally invasive operative techniques.

[Complications of elective esophago-gastro-duodenoscopy (EGDS). Personal experience and literature review]. / Le complicanze della esofagogastroduodenoscopia (egds) in elezione. Esperienza personale e revisione della letteratura.

INTRODUCTION: Although upper gastrointestinal (GI) endoscopy is reasonably safe, it is not perfectly so. The complication rate is about 0.1% for EGDS. Aim of this study is to schedule and evaluate all possible complications, starting from personal experience in Operative Unit of Surgical Endoscopy. PATIENTS AND METHODS: We evaluated all EGDS performed at the Operative Unit of Surgical Endoscopy of Policlinico in Palermo between January 2000 and January 2008. A single staff of endoscopists performed diagnostic and therapeutic exam. All complications were tabulated and scheduled to identify possible risk factors or indicators procedure- or patient-related. RESULTS: 5.258 patients (43.6 %) experienced temporary and self-limiting hypoxia (SaO2 < 85%); we report totally 18 complications (0.15%), according to literature data: 2 hypopharinx perforations (0.016%), 2 middle esophagus perforation (either with death of patients = 0.016%), 3 post-biopsy hematomas of the gastric wall (0.02%) and 2 duodenal wall (0.016%) 6 (0.04%) post-polypectomy bleeding, 1 abscess post-percutaneous endoscopic gastrostomy (PEG) (0.008%) and 1 accidentally PEG remove (0.008%). DISCUSSION: EGDS-related complications may occur and cannot be prevented completely even in expert hands however, early recognition and proper management will lead to better outcome. Because of the complexity of endoscopic procedures has increased, endoscopists need to be aware of all possible procedure-related complications and should use strategies to minimize it. CONCLUSIONS: Endoscopic complications will inevitably occur if an endoscopist does many procedures. The knowledge of potential complications and their expected frequency can lead to improved risk-benefit analysis by physicians and patients as well as true informed consent by patients. Early recognition of complications and prompt intervention may minimize patient morbidity.

[Mechanical versus manual anastomoses in colorectal surgery. Personal experience]. / Anastomosi meccaniche versus anastomosi manuali nella chirurgia del retto. Esperienza personale

BACKGROUND: The diffusion in the years '80 of the stapler has modified the habits of the surgeons, determining the reduction of the operative time in colorectal surgery and the possibility to operate cancer of lower rectum, but leaving unchanged the rates of postoperative complications and bringing to the footlights some new complications. Aim of paper is to report our experience about of mechanical sutures in the colorectal anastomoses, with particular attention to the risk factors and complications procedure-related. PATIENTS AND METHOD: From January 2000 to January 2006 in the Section of General and Thoracic Surgery of the University in Palermo, 26 stapled colorectal anastomosis and 11 mechanical terminal colostomies after Miles' amputation have been performed; 12 patients have been submitted to low colorectal termino-terminal anastomosis, 6 to termino-terminal ultralow anastomosis, 1 to coloanal anastomosis and 7 to Knight-Griffen technique. RESULTS: We registered 2 anastomotic dehiscences (8%), 3 (12%) anastomotic bleeding and one anastomotic stenosis (4%) 12 months after surgery. No mortality procedure-related took place. DISCUSSION: From the literature review emerges the absence of statistically differences between manual and mechanical suture in the colorectal anastomosis in terms of mortality, morbidity (clinical and radiological incidence of the anastomotic gaps, anastomotic stenosis, redo, bleeding, infection of the wound) of employed time to make the anastomosis and of staying in hospital. These data are from American Schools, while greater incidence of radiological leakage is recorded in the European schools is for the manual suture. CONCLUSIONS: At present does not exist clinical trial that shows the superiority of mechanical stapling versus manual suture in the colorectal anastomosis. Stapler makes possible the lower colo-rectal anastomosis often avoiding abdomino-perineal amputation of the rectum, with better quality of life and oncological radicality, but increasing however the incidence of complications as anastomotic dehiscence and stenosis, even if not statistically significant.

The importance of pyramidal lobe in thyroid surgery.

INTRODUCTION: Pyramidal lobe (PL) is an embryological remnant of the thyro-glossal duct; its incidence varies from 15% to 75% but data concerning its size are lacking and limited to autoptic and radiologic evidences. Aim of our study is to elucidate the intraoperative frequency, location and surgical management of the PL. PATIENTS AND METHODS: 604 total thyroidectomy were performed between 1999 and 2007 in Unit of General and Thoracic Surgery of the University Policlinico of Palermo. The intraoperative incidence of PL was 12% (57% male, 43% female, mean age 42.5 years), but only about 50% were identified preoperatively with ultrasonography (US) (4% false positive) or with Tc-99m pertechnetate scintigraphy (8% false positive). RESULTS: In 77% of cases the lobe was affected by nodular pathology in multinodular goiter, in 1.3% by papillary cancer; in the rest of cases was normal. PL branched off more frequently from the left part of the isthmus (96%) than from the right part (4%) and in 25% of cases was associated with delphian lymph node. No PL exceeded 2 cm in length in pathologic specimen. There was no difference in thyroidectomy operative time with or without PL. At US, scintigraphic and laboratory follow-up (2 months-8 years), no incomplete resection of the gland due to the presence of PL were recorded. DISCUSSION: In anatomical studies the frequency of the PL is between 15% and 75%; PL is in 10-17% of normal subject and in 43% of patients with multinodular goiter. The PL is of great importance to the thyroid surgeon during thyroidectomy: it is crucial to look for, identify, and remove the PL, as this can be a cause of incomplete resection of the gland. If left behind in a patient who will require postoperative radioactive iodine, its presence will virtually nullify the anticipated benefit of I131 by absorbing most of the radioactive material; may exist relapse of cancer from PL left in situ. CONCLUSIONS: The intraoperative frequence of PL is 12%, and it is considered a normal component of the thyroid. Scintigraphic visualization of the PL depends on the kind of thyroid disorder and on the experience of radiologist, so the PL can often not be diagnosed by scintigraphic imaging. Finally, the whole anterior cervical region has to be investigated very carefully during thyropidectomy not to overlook a long or thin pyramidal lobe or other ectopic thyroid tissue because actually doesn't exist the goldstandard preoperative method to diagnoses PL.

Endoscopic cytology in biliary strictures. Personal experience.

INTRODUCTION: The differential diagnosis between malignant and benign biliary strictures is the cornerstone of the management of jaundiced patients. The aim of our study is to define the role of cytology of the bile withdrawn during endoscopic retrograde cholangiopancreatography (ERCP), to reach a diagnosis of the nature of biliary stricture. PATIENTS AND METHODS: This retrospective study was conducted on 67 consecutive patients affected of ingravescent obstructive jaundice who underwent ERCP+/-PTE (percutaneous transhepatic endoscopic)+bile withdrawn+stenting. We founded hilar stricture in 21 patients (31.3%), middle third the common duct stricture in 17 (25.3%), and lower third stricture in 28 patients (41.4%). In one patient (2%) the cholangiography did not show any stricture, but we continued with the withdrawn of bile after positioning a naso-biliary drainage. RESULTS: Diagnosis was made in only 40 of 65 patients (61.5%) and no epithelial lining cells of the biliary tree was found in the remaining 25 patients (38.5%). The presence of neoplasm in the pancreato-biliary tract was excluded (absence of malignant cells) in 25 of 40 diagnostic exams (62.5%). During follow-up only 7 of these 25 patients resulted in having a benign disease (true negatives 28%) while the remaining 18 cases were diagnosed with malignant neoplasm of the pancreato-biliary tract (false negatives 72%). Nine of 14 with positive cytology for carcinoma were diagnosed with cholangiocarcinoma (65%), 4 with pancreatic (28%) and 1 with ampullary carcinoma. Of 25 non-diagnostic samples, 5 (20%) resulted as benign, 20 (80%) as malignant. The statistical analysis by chi-square test allowed us to conclude that bile cytology, if diagnostic, is significantly valid in identifying carcinoma of the pancreato-biliary tract (p<0.05) instead, considering the high rate of non diagnostic samples, its meaning is limited (p=0.09). DISCUSSION: Exfoliative cytology of bile samples obtained during ERCP is easier and less invasive method to determine the diagnosis of biliary strictures, but due to its low sensibility, varying from 6 to 63%, it doesn't appear accurate to establish a definite diagnosis; the stricture dilatation before the withdrawal increases the diagnostic sensibility and accuracy of the cytological exam. CONCLUSION: Bile withdrawn for cytology during ERCP is a safe method with no increasing in patient's morbidity. It allows a diagnostic orientation in 75% of the patients. Bile withdrawn after dilatation of stricture allows improves sensibility and accuracy. Negative results does not exclude malignant disease, however, if positive, it is considered diagnostic (positive predictive value 100%).

[Thoracentesis and pleurodesis in the treatment of pleural effusion. Personal experience]. / Toracentesi e pleurodesi nel trattamento dei versamenti pleurici. Esperienza personale.

AIM: The pleural effusion is a sign of pulmonary, pleural or extrapulmonary, benign or malignant pathology. Our aim is to bring our experience on the treatment of the malignant pleural effusion through thoracentesis and successive pleurodesis. PATIENTS AND METHODS: From January 2000 to January 2007 we performed 217 thoracentesis of which 123 (57%) in subjects with malignant pleural effusion. In 92 of 123 subjects (75%) we performed a drainage with small size thoracic tube to realize directly the pleurodesis with sterile des-asbestos talc. RESULTS: None complication was registered during and after thoracentesis and pleurodesis and no mortality was recorded. We usually used talc slurry technique. Relapse rate after first treatment was of 12.2%. CONCLUSIONS: The pleural effusion is a pathological condition that usually needs repeated operative procedures with serious danger for the patient, however without definitive results. On the basis of our experience and considering the characteristics of sclerosing agents, we conclude that the sure, effective and economic agent for the pleurodesis is the des-asbestos talc.

What to do when endoscopic retrograde cholangio-pancreatography fails? Personal experience.

BACKGROUND: Endoscopic retrograde cholangio pancreatography failure is a rare and some dramatic reality too for the management of bilio-pancreatic tract disorders and in these cases it needs to utilize others operative technique. PATIENTS AND METHODS: Over a 6-year period, a total of 757 ERCPs were performed. In seventeen of these ERCPs the standard endoscopic technique failed and we employed alternative techniques such as interventional radiology or surgical management or double endoscopic approach. RESULTS: In all 17 failed ERCPs the alternative procedures allowed us to success in bilio-pancreatic disease. CONCLUSION: ERCP is an operator-dependent procedure. Even in expert hands failure occurs in 3% to 10% of cases. ERCP failure doesn't be considerated a dramatic situation in the management of the bilio-pancreatic disease for a multidisciplinary team (endoscopist, surgeon and interventional radiologist) whose cooperation allows to success.

[Surgical management of medullary thyroid carcinoma. Personal experience]. / Trattamento chirurgico del carcinoma midollare della tiroide. Esperienza personale.

INTRODUCTION: Medullary Thyroid Carcinoma (MTC) is a rare malignancy of the parafollicular C cells of the thyroid gland. Aim of our study is reporting retrospective analysis of our experience about the surgical treatment of MTC, especially pointing on lymphadenectomy. PATIENTS AND METHODS: from January 2000 to March 2006, were performed 546 thyroidectomy, 6 of them for MTC (1.09%): 5 sporadic and 1 familiar. All the patients were operated with standard technique (total thyroidectomy) and submitted to endocrinologic and instrumental follow-up. RESULTS: in our experience, we do not registered early or late complications as bleeding, laryngeal nerves lesions and parathyroid lesions or intra-postoperative deaths. DISCUSSION: MTC occurs sporadically or as part of the multiple endocrine neoplasia type 2 (MEN 2 a/b) syndromes in patients who have inherited a mutation in the RET proto-oncogene. The diagnosis is made by fine needle aspiration biopsy (FNAB) and by measuring calcitonin levels in the blood. Primary treatment consists of surgical resection including a total thyroidectomy, central neck nodal dissection and functional lateral neck nodal dissections. Most patients with a palpable primary tumour have nodal disease at the time of operation, and nodal involvement is often bilateral. CONCLUSIONS: adequate resection of the primary tumour and cervical lymph nodes is important to optimize outcome and minimize the risk of recurrent disease. Following primary surgical resection, more than 50% of the patients will have recurrent disease with persistent elevation of calcitonin levels. Currently, there is no adequate systemic therapy for recurrent disease. Surgical reoperation or conservative observation are the best available options.