Use of loupes magnification and microsurgical technique in thyroid surgery: ten years experience in a single center.

AIM: The use of microsurgical technique and loupes magnification as a support to traditional surgery can help surgical performance and prevent complications in thyroid surgery. PATIENTS AND METHODS: Between January 2004 and December 2014, 782 patients with thyroid diseases were operated by our team with microsurgical technique and loupes magnification 4.5x. All patients had pre and postoperative vocal cords assessment and calcemia and the collected data were analysed. RESULTS: Among the 782 patients, only six patients (0.77%) had unilateral vocal fold immobility treated with medical therapy, phoniatric and neck physiotherapy. All six patients showed complete laryngeal recovery of motility 6/8 weeks after treatment. There were not cases of permanent monolateral or bilateral vocal cord palsy. In 84 patients there were signs and symptoms of hypocalcemia. In 81 patients (10.36%) the restoring of biochemical parameters and the resolution of symptoms occurred between 2 and 6 weeks and in 3 cases (0.38%) there was permanent hypocalcemia more than six months. CONCLUSION: The use of microsurgical technique and loupes magnification in thyroid surgery are safety and effective procedures, that require an appropriate training in reconstructive microsurgery, but may significantly reduce post-operative complications. Here, we report for the first time the largest series of thyroid surgery performed with the use of microsurgical technique and loupes magnification, analysing the postoperative morbidity. In view of our results, we suggest the routine use of 4.5X loupes and microsurgical technique in thyroid surgery.

The natural history of spinal neurofibromatosis: a critical review of clinical and genetic features.

Spinal neurofibromatosis (SNF) is a related form of neurofibromatosis 1 (NF1), characterized by bilateral neurofibromas (histologically proven) of all spinal roots (and, eventually, of all the major peripheral nerve branches) with or without other manifestations of classical NF1. By rigorous application of these criteria to the 98 SNF cases published, we developed: (i) a cohort of 49 SNF patients (21 males and 28 females; aged 4-74 years]: 9 SNF families (21/49), 1 mixed SNF/NF1 family (1/49) and 27 of 49 sporadic SNF patients (including 5 unpublished patients in this report); and (ii) a group of 49 non-SNF patients including: (a) 32 patients with neurofibromas of multiple but not all spinal roots (MNFSR): 4 mixed SNF/MNFSR families (6/32); (b) 14 patients with NF1 manifestations without spinal neurofibromas, belonging to SNF (8/49) or MNFSR families (6/32); (c) 3 patients with neurofibromas in one spinal root. In addition to reduced incidence of café-au-lait spots (67% in SNF vs 56% in MNFSR), other NF1 manifestations were less frequent in either cohort. Molecular testing showed common NF1 gene abnormalities in both groups. The risk of developing SNF vs NF1 was increased for missense mutations [p = 0.0001; odds ratio (OR) = 6.16; confidence interval (CI) = 3.14-13.11], which were more frequent in SNF vs MNFSR (p = 0.0271).

Original technique for preoperative preparation of patients and intraoperative localization of parathyroid adenomas.

Surgical approach of single parathyroid adenoma treatment is turning to a less invasive surgery, allowing us to obtain better aesthetic results, reduction of duration of surgical operation, reduction of post-operative morbidity and hospital stay. Tc99m-sestaMIBI scintigraphy is mainly performed for preoperative localization of parathyroid adenomas. Our technique is instead based on the possibility to inhibit the interference of Tc99m-sestaMIBI uptake of the thyroid gland by means of the administration of Lugol's solution. Indeed, to confirm the identification and removal of the hyperfunctional parathyroid, it is accepted as adequate an ex vivo radioactivity count of the adenoma 20% or 40% greater than the value of the post-excisional background radioactivity, in association or not with intraoperative measurement of PTH. This method allows us to perform surgery with no timetable restriction, and to clearly distinguish the radioactivity of parathyroid adenoma from that of the surrounding tissues and thyroid gland.

Clinical problems in patient with Ehlers-Danlos syndrome and Multiple Chemical Sensitivity undergoing total thyroidectomy.

Clinical practice sometimes brings to face with situations quite peculiar, potentially dangerous for the patient's life. In the great majority of cases, pathologies associated with each other (cardiovascular, respiratory, neurological), while in other cases we can treat rare diseases or syndromes. It's considered exceptional the simultaneous presence of "rare" pathologies in a single patient. This exceptionality has been a push to treat a patient as a "unique" asking for help to deeper studies of pharmacogenetics. Our case reports the management of a patient with Ehlers-Danlos syndrome (EDS) and Multiple Chemical Sensitivity (MCS), undergoing a total thyroidectomy. We found several problems, and we tried to find effective solutions for the management of the patient during the whole peri-operative process, from a clinical, pharmacological and also from a surgical point of view.

Cricothyrotomy performed with the Melker™ set or the QuickTrach™ kit: procedure times, learning curves and operators' preference.

BACKGROUND: Cricothyroidotomy is a surgical airway technique in which an airway device is inserted into the trachea through an incision made at the cricothyroid membrane. It is used for the management of the "difficult airways" and may be a lifesaving procedure in "can't intubate, can't oxygenate" situations. However, many healthcare professionals working in emergency settings have little of no experience with this procedure. Achievement of theoretical and practical knowledge of different cricothyrotomy techniques is therefore a fundamental prerequisite for those healthcare professionals. MATERIALS AND METHODS: In this study, 40 volunteers representative of different categories of healthcare professionals were enrolled for the theoretical and practical 1-day training course on cricothyrotomy. Two commercially available device for cricothyrotomy were used during the course, the Melker™ set, which involves the Seldinger technique, and the QuickTrach™ kit, which does not rely on the use of a guide-wire. Each participant performed a series of 5 attempts on a manikin with each kit. Procedure time was recorded, and satisfaction with the course, preference for each cricothyrotomy kit and self-rating of cricothyrotomy skills were assessed by a self-administered questionnaire. RESULTS: Mean procedure time significantly decreased from the first to the last attempt (48.7±21.9 and 27.8±13.7 seconds, respectively; p<0.0001). The Melker™ set was the most preferred, being rated as "excellent" by 62% of participants. This preference was even more pronounced among anaesthesiologists, that are more familiar with the Seldinger technique. Participants' satisfaction was high: the course was rated as "excellent" by 66.7% of attendees, the theoretical and practical knowledge achieved was rated as "very useful" by 94% of all attendees and by 100% of the anaesthesiologists. CONCLUSIONS: A systematic approach to teach healthcare professionals in the application of various devices for the management of the socalled "difficult airways" may maximize intubation success and minimize complication. The present study provides evidence for the efficacy of training courses in Emergency Departments aimed at improving theoretical and practical cricothyrotomy skills in emergency situations.

Treatment of renal angiomyolipoma: surgery versus angioembolization.

Renal angiomyolipoma (AML) is a benign mesenchymal tumour. AML often leads to haemorrhagic complications such as retroperitoneal haematoma. Treatment varies from case to case, ranging from minimally invasive approaches such as selective embolization of the renal artery to invasive wedge resection, partial nephrectomy or, in more severe cases, radical nephrectomy. Here we report a case of retroperitoneal haematoma secondary to AML, treated with conservative approach by super-selective embolization of the lower-pole segmental renal artery.

[Acquired rectourethral fistula: case report]. / Fistola retto-uretrale acquisita: a proposito di un caso.

Rectourethral fistulas are an uncommon complication of urinary or rectal surgery, trauma, inflammatory disease, radiation therapy for prostate cancer; they represent an unique challenge for the surgeon. Although closure can occure spontaneously, most cases of acquired rectourethral fistula need surgical repair. Despite a century of surgical experience, no single approach has been universally accepted. We report a case of a rectourethral fistula occurred in a 73 year-old man after a radical retropubic prostatectomy and external beam irradiation for prostate cancer, successfully treated with perineal approach.

Extracorporeal shock wave therapy and ultrasound therapy improve pain and function in patients with carpal tunnel syndrome. A randomized controlled trial.

BACKGROUND: Ultrasound (US) therapy improves symptoms in carpal tunnel syndrome (CTS) patients. Extracorporeal shock wave therapy (ESWT) uses acoustic energy to determine its clinical effects, as US-therapy does. AIM: The aim of this study was to compare the short-term efficacy of US and ESWT on mild and moderate CTS. STUDY DESIGN: Randomized controlled trial. SETTING: University outpatient service. POPULATION: Twenty-five patients with mild to moderate CTS, for a total of 42 wrists. METHODS: patients were randomized to receive US, cryo-US or ESWT, and were evaluated for pain and function before treatment started, at the end of treatment, and four and 12 weeks after the end of the treatment. RESULTS: Significant improvement was noted in all groups for pain (P<0.05) and functionality (P<0.05). Patients in ESWT group show greater pain improvement at 12-weeks follow-up when compared with both US and cryo-US groups (P<0.05). CONCLUSION: Patients affected by CTS might benefit from the application of US, cryo-US or ESWT. Benefits persist 3 months after the end of treatment. CLINICAL REHABIL IMPACT: Clinicians might consider the possibility of a short-term non-surgical management for mild-to-moderate CTS.

Validity of the use of a few hand-wrist bones for assessing bone age.

Bone age is widely used as an osseous maturation method to assess biological development in clinical and auxological studies. Numerical methods for calculating bone age have better replicability; however, they require a wide data manipulation. The aim of this study was to evaluate the accuracy of bone age estimation by using just a few ossification centers. In 205 hand and wrist radiographs of children and adolescents, aged 0.9-17.4 years old (111 males and 94 females), bone age was determined by two trained observers employing the five-bone (B5) and the TW2 methods. To compare the results of the two methods, the mean differences by age and sex were tested by the Mann-Whitney test. The relationship of the bone age distribution estimated by B5 and TW2 was calculated and the mean of the bone age determined by the two methods was plotted by age and by differences between bone age calculated by the two methods +/- 2 SD. The bone age determined by B5 was between 1.2 and 16.8, and by TW2 was between 1.2 and 18.0 years. The mean differences between B5 and TW2 (-0.06 +/- 0.6) were not significant (p > 0.05). The distribution of mean differences by age and method demonstrated that all deviations were encompassed into +/- 2 SD with no particular bias. In general terms, a good agreement was obtained between these two methods.

[Pseudosarcoma of the urinary bladder. Report of a case]. / Pseudosarcoma della vescica urinaria. Studio di un caso.

A case of myofibroblastic pseudosarcomatous tumor of the bladder occurred in a patient previously submitted to TURB is reported. Aim of this investigation is to demonstrate, on the basis of the literature, the importance of histopathology in the diagnosis of bladder pseudosarcoma, since endoscopical and radiological methods can erroneously show a neoplasm. A 65-year-old male patient with hematuria, submitted to ultrasonography and cystoscopy, revealed a bladder superficial papillary formation. A TURB was performed and the histological study showed a superficial bladder cancer (T1-G1-2). After a second hematuria episode with stranguria a new bladder formation was diagnosed and resected; the histological study revealed a bladder pseudosarcoma. The absolute benignity of the lesion and the slight difference in the symptomatology between urothelial carcinoma and pseudosarcoma are underlined. Furthermore, the importance of histopathology to obtain an accurate diagnosis is stressed. The difficulty of a preoperative diagnosis without histopathological examination is pointed out.

[Treatment of hemorrhoids with circular mechanic stapler]. / Trattamento della patologia emorroidaria con suturatrice meccanica circolare.

In a pilot study undertaken in collaboration with the Department of Surgery of "San Carlo di Nancy" Hospital in Rome, over the period form January 1998 to February 2000, 128 patients with haemorrhoidal disease underwent surgery using a circular stapler to "lift" the mucous-haemorrhoidal prolapse, according to the pathogenetic theory discussed here below. We compared the results of our series with those of a retrospective series of 80 patients that undergoing traditional surgery (Khubchandani 45, Milligan-Morgan 30, Whitehead 5), evaluating length of operation, postoperative pain and complications. Our preliminary data show that the technique requires only a short learning period, reduces the length of the operation, reduces the medium- and long-term pain and allows mables the patient to resume full working activity earlier.

[The Moschkowitz syndrome in emergency department. Case report]. / La sindrome di Moschkowitz nel Dipartimento di Emergenza. Case report.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening multisystem disorder of unknown etiology, first described by Moschkowitz in 1924. TTP is a thrombotic microangiopathy characterized by microvascular lesions with platelet aggregation. TTP is more common in adults and is associated with pregnancy; diseases such as HIV, cancer, bacterial infection, and vasculitis; bone marrow transplantation; and drugs TTP is a hematologic emergency. It is a multisystem disease that can cause rapid deterioration of the patient's neurologic, renal, and hematologic status. TTP is an uncommon disease with a high fatality rate if untreated or misdiagnosed. Rapid diagnosis and aggressive treatment by therapeutic plasma exchange are necessary to reduce the risk of a fatal outcome. Current clinical criteria for initiating therapy are: thrombocytopenia, and absence of other disease entities that could explain the thrombocytopenia. Early recognition and management are essential for patient survival. TTP is difficult to diagnose because the patient's presentation can be nonspecific and the characteristic pentad of symptoms may not occur together. Other disease entities can have some of the same symptoms. We discuss a case report of Moschkowitz syndrome in Emergency Department.

[Reconstructive microsurgery]. / La microchirurgia ricostruttiva.

Since Microsurgery was born, it has been employed in different surgical fields offering more recently good chances even in sterility. Furthermore microsurgical techniques offer a great support to Plastic Surgery. In fact, it is possible to repair wide tissue damages of the skin, muscles or bones using free flaps. The percentage of success of this surgery increased the overall rate of success of surgical procedures. Therefore a close multidisciplinary relation between the different fields is absolutely required for a correct application of microsurgical techniques.

[Gastrointestinal carcinoids and carcinoid syndrome: classification, diagnosis and therapy]. / I carcinoidi gastrointestinali e la sindrome da carcinoide: inquadramento, diagnosi e terapia.

Historically, carcinoids have long been known as a morphologically distinct class of rare intestinal tumors which behave less aggressively than the more common intestinal adenocarcinomas. In recent decades refined methods in pathology improved our knowledge on the diffuse neuroendocrine system, leading to some confusion in classification and nomenclature of carcinoids. The World Health Organization (WHO) classification of endocrine tumors has cleared the definition of carcinoids. The Authors report on 7 cases of midgut carcinoid tumors and 1 case of carcinoid syndrome focusing on the newer approaches to the diagnosis, localization, and role of surgery and peptide therapy.

[Blind-ending branch of bifid ureter: apropos of a case]. / L'uretere bifido a branca cieca: a proposito di un caso.

The Authors report on a case of blind-ending ureter. A young woman (29 years old) underwent surgery because of recurrent urinary tract infections and left loin pain. The operation consisted in a radical resection of the blind branch together with Coen's operation for the coexistence of vesicoureteral reflux. Authors' goal was to review the international Literature on this rare pathology pointing out their opinion on the existing terminology which is still far from being clear and definite.

[Cholecystectomy and colorectal cancer: a retrospective study of a sample of 285 operated patients]. / Colecistectomia e cancro colo-rettale: studio retrospettivo su un campione di 285 pazienti operati.

A review of 285 patients operated for colo-rectal cancer in order to evaluate cholecystectomy rate in their pathologic history is reported. A surprisingly high rate (9.47%) was registered also when compared with Literature data. Although not definitely conclusive for a positive correlation between cholecystectomy and colo-rectal cancer, the Authors believe that this study identifies a subgroup of patients potentially at risk for colo-rectal cancer. In these subjects a prophylactic, periodic colonoscopy could be useful.

Degradation of mutant p53H175 protein by Zn(II) through autophagy.

TP53, one of the most important oncosuppressors, is frequently mutated in cancer. Several p53 mutant proteins escape proteolytic degradation and are highly expressed in an aberrant conformation often acquiring pro-oncogenic activities that promote tumor progression and resistance to therapy. Therefore, it has been vastly proposed that reactivation of wild-type (wt) function(s) from mutant p53 (mutp53) may have therapeutic significance. We have previously reported that Zn(II) restores a folded conformation from mutp53 misfolding, rescuing wild-type (wt) p53/DNA-binding and transcription activities. However, whether Zn(II) affects mutp53 stability has never been investigated. Here we show that a novel Zn(II) compound induced mutp53 (R175H) protein degradation through autophagy, the proteolytic machinery specifically devoted to clearing misfolded proteins. Accordingly, pharmacological or genetic inhibition of autophagy prevented Zn(II)-mediated mutp53H175 degradation as well as the ability of the Zn(II) compound to restore wtp53 DNA-binding and transcription activity from this mutant. By contrast, inhibition of the proteasome failed to do so, suggesting that autophagy is the main route for p53H175 degradation. Mechanistically, Zn(II) restored the wtp53 ability to induce the expression of the p53 target gene DRAM (damage-regulated autophagy modulator), a key regulator of autophagy, leading to autophagic induction. Accordingly, inhibition of wtp53 transactivation by pifithrin-α (PFT-α) impaired both autophagy and mutp53H175 degradation induced by curcumin-based zinc compound (Zn(II)-curc). Viewed together, our results uncover a novel mechanism employed by Zn(II)-curc to reactivate mutp53H175, which involves, at least in part, induction of mutp53 degradation via wtp53-mediated autophagy.

Skeletal maturity of the hand and wrist of healthy Argentinian children aged 4-12 years, assessed by the TWII method.

One previously trained observer assessed skeletal maturity in a representative sample of 388 and 387 healthy girls and boys respectively from La Plata city, a predominantly university and administrative urban centre in Argentina. The staging system used was TWII and the scores were calculated from three sources: British, Spanish and Italian standards. Our sample showed a marked advancement in bone age with regard to chronological age when using British standards and, to a lesser extent, when applying the Spanish standards. Local mean bone ages were very similar to chronological ages when the Italian scores were used. Second-degree polynomials were adjusted to log10 scores for boys and girls, in order to obtain local values for bone age (BA) transformations. The same staging system should be used in clinical work in Argentina, with the corresponding changes in BA transformatons. A marked advancement of carpal BAs with regard to RUS BAs was found, from age 5 onwards, in both sexes. Mean differences and SD of RUS-minus-carpal BA were 1.28, SD 1.08 and 1.18, SD 1.09 years for girls and boys respectively. These differences have not been described before, and require further investigation.