Postoperative hypocalcemia: analysis of factors influencing early hypocalcemia development following thyroid surgery.

BACKGROUND: Early Hypocalcemia is the most frequent complication after thyroid surgery. Several studies have tried to identify factors (patient caracteristics or surgical technique variations) affecting hypocalcemia following thyroid surgery. This studiy evaluates the role of several factors in postoperative hypocalcemia development. METHODS: A retrospective study conducted on 2108 patients that underwent thyroid surgery in a single center (1669 women and 439 men). Postoperative early hypocalcemia was defined as serum calcium levels lower than 8,0 mg/dl measured 24 h after surgery. Following factors were evaluated in the study: sex, age, glandular hyperfunction, preoperative diagnosis, preoperative serum calcium levels, preoperative serum PTH levels, type of surgery performed (total thyroidectomy vs. lobectomy); minimally invasive video assisted thyroidectomy (MIVAT); number of parathyroid preserved in situ, postoperative serum calcium levels, changes in perioperative calcium levels (difference between preoperative values ​​and postoperative calcium levels), presence of carcinoma in the surgical specimen, presence of thyroiditis based on histopatology reports. RESULTS: Among evaluated factors only gender and surgical procedure revealed to be significantly correlated to early hypocalcemia development. In fact female patients experienced postoperative hypocalcemia in 42% (701/1669) of cases, which was signicantly higher than the 21.4% (94/439) identified in men. We also noticed a greater hypocalcemia incidence in patient undergoing total thyroidectomy (38.8%) than in patient undergoing lobectomy group (13.8%). Early hypocalcemia development didn't appear to be related to preoperative serum calcium levels but it showed a statistically significant correlation with perioperative serum calcium level drop. CONCLUSION: This findings suggest that sex (female gender is a strong risk factor),surgical procedure and perioperative changes in serum calcium are the only factors (among all variables examined) that influence early hypocalcemia development.

Applicability of laparoscopic approach to the resection of large adrenal tumours: a retrospective cohort study on 200 patients.

BACKGROUND: Controversies exist in the best surgical approach (open vs. laparoscopy) to large adrenal tumours without peri-operative evidence of primary carcinoma, mainly due to possible capsular disruption of an unsuspected malignancy. In addition, intra-operative blood loss, conversion rate, operative time, and hospital stay may be increased with laparoscopy. THE AIMS OF OUR STUDY WERE: (1) to compare clinical outcomes of laparoscopic adrenalectomy for large versus small adrenal tumours and (2) to identify risk factors associated with increased operative time and hospital stay in laparoscopic adrenalectomy. METHODS: This is a multicentre retrospective cohort study in a large patient population (N = 200) who underwent laparoscopic adrenalectomy in 2004-2014 at three Italian academic hospitals. Patients were divided into two cohorts according to tumour size: "large" tumours were defined as ≥5 cm (N = 50) and "small" tumours as <5 cm (N = 150). Further analysis adopting a ≥8 cm (N = 15) cut-off size was performed. RESULTS: The study groups were comparable in age and gender distribution as well as their tumour characteristics. The operative time (p = 0.671), conversion rate (p = 0.488), intra- (p = 0.876) and post-operative (p = 0.639) complications, and hospital stay (p = 0.229) were similar between groups. With a cut-off size ≥5 cm, the early study period (2004-2009), which included operators' learning curve, was associated with increased risk of longer operative time (HR 0.57; 95 % CI 0.40-0.82), while American Society of Anaesthesiology score ≥3 was associated with prolonged hospital stay (HR 0.67; 95 % CI 0.47-0.97). Tumour size ≥8 cm was associated with prolonged operative time (HR 0.47; 95 % CI 0.24-0.94). CONCLUSIONS: Surgeons skilled in advanced laparoscopy and adrenal surgery can perform laparoscopic adrenalectomy safely in patients with ≥5-cm tumours with no increase in hospital stay, or conversion rate, although operative time may be increased for ≥8-cm tumours. Surgeon' experience, size ≥8 cm, and patient comorbidities have the largest impact on operative time and length of hospital stay in laparoscopic large adrenal tumour resection.

Primary Hyperparathyroidism overlapping with Multiple Sclerosis: a catastrophic marriage.

Primary hyperparathyroidism (PHPT) often leads to neurological or psychiatric disorders, thus mimicking different diseases. Here we present a 77-years old man visited in the Emergency Department complaining for fatigue, multiple falls, nausea, anorexia, and constipation. Symptoms were rapidly worsening, and on admission he appeared sleepy, responsive to verbal stimulus, disoriented, dehydrated, unable to maintain upright position. He suffered from mild, relapsing and remitting Multiple Sclerosis (MS) since the age of 45, at that moment not requiring treatment. The laboratory tests displayed severe hypercalcemia (16.8 mg/dL), slightly decreased level of serum phosphorus (2.8 mg/dL), very high levels of parathyroid hormone (PTH) (508 pg/mL). A parathyroid mass (35x21x32 mm) in left paratracheal position was found with Computed Tomography (CT) of the neck. After correcting hypercalcemia, he was operated on day 18, thus confirming the parathyroid adenoma, that was successfully removed. One month later, the patient was completely well, and able to walk without any help, like three months before. The lab tests' values obtained during the control visit showed complete normalization of calcium-phosphate metabolism. Diabetes, too, was going better, allowing a reduction in metformin dosage. At the best of our knowledge this is the first described case of a clinically significant overlapping between symptoms due to a long-lasting mild MS and an unrecognized, severe, PHPT. This case underlines the importance of a thorough metabolic evaluation of each patient presenting worsening of his neuromuscular and/or neuropsychiatric condition, even when previously known to be affected by a defined neurologic or psychiatric disease.

The prognostic role of metastatic lymph node ratio in colon cancer: a retrospective cohort study on 241 patients in a single center.

BACKGROUND: The detection of nodal status is based on examination of lymph nodes (LN) after the tumor surgical resection and the current guidelines recommend examining at least 12 regional LN. An inadequate number of examined LN may lead to a lower N stage or to a false-negative nodal disease. To overcome these issues, many authors proposed to consider the metastatic lymph node ratio (mLNR). MLNR is the ratio of the number of metastatic LN to the number of examined LN. METHODS: Two hundred forty-one colon cancer (CC) specimens from patients who had undergone surgical resection between January 2010 and December 2015 at the General Surgery Unit of Parma University Hospital were analyzed. mLNR, which is defined as the ratio of the number of positive LN to the number of examined LN, was calculated in CCs with LN metastasis. In this study we focused on the following mLRN cutoffs: <0.15, 0.15-0.3 and >3 and we evaluated the prognostic implication of mLNRs. RESULTS: Regarding the impact of examined LN on involved LN in CC, our results showed that the number of involved LN increased with the increasing number of examined LN (P=0.03). We found a significant correlation between OS and RFS rate of patients with CCs and mLNR. Patients with mLNR<0.15 were associated with better OS and RFS rate whereas patients with mLNR>0.3 were associated with worse OS and RFS rate. OS rate for patients with a mLNR<0.15 was 95.24% (89-100%) at 1 year, 83.27% (72.7-95.4%) at 3 years and 68.07% (55.1-84.1%) at 5 years whereas patients with a mLNR>0.3 had an OS rate of 51.7% (34.6-77.3%) at 1 year, 36.55% (20.08-64.3%) at 3 years and 31.33% (16.5-59.4%) at 5 years. RFS rate for patients with a mLNR<0.15 was 100% (100-100%) at 1 year, 92.2% (84-100%) at 3 years and 85.2% (73.8-98.31%) at 5 years whereas patients with a mLNR>0.3 had a RFS of 63.2% (42.8-93.58%) at 1 year and 54.2% (33.1-88.93%) at 3 and 5 years. CONCLUSIONS: The prognostic value of pN stage could be more accurate if we consider both the number of LN metastasis and harvested LN. This can be achieved by using the mLNR that can be a useful tool in daily practice to predict the prognosis of patients who undergone surgery for CC.

Malignancy risk in Bethesda class IV thyroid nodules in an iodine deficient region.

Background: According to the latest guidelines, in patients with high-risk nodules with indeterminate cytology, diagnostic lobectomy should be the preferable surgical approach in the absence of factors that suggest a total thyroidectomy. Methods: This retrospective observational study has as its main aim the evaluation of the cases that underwent surgery, for Bethesda class IV nodules in our iodocarent geographical area. Particular attention was paid to carcinoma incidence, preoperative nodule size, histological characteristics of the neoplasm, surgical approach and eventual need of radiometabolic treatment. A total of 320 patients were included that underwent surgery for Bethesda IV nodules, between January 2010 and December 2020, at the General Surgical Clinic of the University Hospital of Parma, Italy. Results: A total of 230 total thyroidectomies (71.9%) and 90 lobectomies (28.1%) were performed. Our data showed a strong impact of the 2015 ATA Guidelines on the surgical approach choice, with a progressive propensity towards a conservative approach and an increase of lobectomies from 7.2% to 41.5% after the new guidelines introduction. However, in our sample the percentage of lobectomies remains below 50%; this data is certainly influenced by the number of cases of multinodular pathology, often bilateral, in our geographical area. The nodules malignancy rate resulted 28.8%. Our data showed that increasing size correlated with an increasing malignancy rate (P<0.01), and follicular carcinomas were found to be larger than papillary carcinomas (P<0.001). A statistically significant correlation also emerged between nodule size increase and local/lymphovascular invasion (P<0.05). On the other hand, there was no statistically significant correlation between nodule size and multifocality, and between nodule size and presence of lymph node metastases. Out of the patients where it was possible to find this data, 66% underwent radioiodiometabolic treatment: 59% with papillary carcinoma, and 85% with follicular carcinoma. Conclusions: In patients with Bethesda IV thyroid nodules, diagnostic lobectomy should be the preferable surgical approach in absence of factors that suggest total thyroidectomy. In our opinion, total thyroidectomy remains the first choice in large nodules (≥4 cm) as these nodules have a high malignancy rate, greater local/lymphovascular invasion and a consequent frequent indication for post-operative radiometabolic treatment.

The metastatic lymph node ratio is a better prognostic factor than the number of metastatic limph node after curative resection for gastric cancer.

AIM: Evaluate impact of lymph node ratio as prognostic factor in gastric cancer. METHODS: We studied 463 patients with gastric cancer who underwent curative gastric surgery with D1 or D2 lymphadenectomy, Data were collected from May 1996 through December 2010 at Department of General Surgery of Parma University Hospital. We divided patients in two groups according to number of nodes removed Results: The results of the present nonrandomized retrospective single centre study confirm the promising role of the LNR as an independent prognostic factor. Overall survival between LNR categories are statistically significant different between LNR0 and LNR1. CONCLUSION: The ratio between the number of metastatic and analysed lymph nodes in patients with gastric cancer can discriminate patients better than the AJCC/UICC staging system: it seems to be related to a more sensitive in the evaluation of overall survival.

[A video-aided minilaparocholecystectomy]. / Una tecnica di minilaparocolecistectomia video-assistita.

AIM: The main objective is to prospectively evaluate the therapeutic efficacy of minilaparocholecystectomy combined with videolaparoscopic view in cases of complicated gallstones where VLC was risky. MATERIAL OF STUDY: We carried out minilaparotomic video-aided cholecystectomy on 110 patients (32 males and 78 females) with preoperative diagnosis of intraabdominal adhesions or biliary severe inflammation. RESULT: No significant intra or postoperative complications was reported and in all cases pain was never greater than that reported after VLC. In all these cases the anesthetists reported an easier intra-operative management of the vital parameters than with VLC procedures. DISCUSSION: Minilaparocholecystectomy appears a type of alternative procedure able to combine mini-invasiveness with as low a number as possible of intra- and post-operative complications, in cases where VLC have risk. No significant postoperative pain was reported, and in any case pain was never greater than that reported after VLC. Recovery times were similar to those after VLC; patients were able to return to their normal social and working life within a mean 3 days. The procedure carried out by us is a low-cost one: it does not require disposable instruments From the esthetic viewpoint, video-aided minicholecystectomy minimal scars in our cases, wound ranged from 4 to 6 cm. in length. CONCLUSIONS: In patients in whom VLC have risks, video-aided minilaparocholecystectomy represents an easy-to-perform and low-cost alternative. VMC can also be proposed as a procedure of choice in cases of complicated gallstones instead of the traditional open cholecystectomy technique.

Possible association between breast thyroid carcinoma: analysis of risk factors.

BACKGROUND: Breast cancer (BC) is the most common tumor in women, 523.000 cases were estimated in Europe in 2018 and it remains the third cause of cancer related deaths after lung and colorectal cancer. The incidence of thyroid cancer (TC) in females is higher than in males. METHODS: We have retrospectively collected all female patients undergone to surgery for breast or thyroid cancer in 2010The aim of the study was to value the incidence of BC in patients with a personal history of differentiated thyroid cancer (DTC) and conversely, the incidence of DTC in patients with previous BC within 5 years from the diagnosis of the first tumor in 2010. RESULTS: Among 76 BC patients, 11 were death and 22 didn't answer the phone call or refused to re-submit to thyroid ultrasound so they were excluded from the study and only 43 BC were further considered. Thyroid ultrasound was performed in 2010 and in 2016 and it described nodules in 13 (30%) patients in 2010 and in 21 (49%) patients in 2016. In 2010 no FNA was needed while in 2016 6 (14%) patients underwent to FNA with a benign response (Thyr 2). Among 61 DTC patients, 11 didn't answer the phone or the questions so 50 patients were included in the study. Breast cancer family history was reported in 14 (28%) patients and thyroid cancer family history in 8 (16%) patients. No relapse was reported during follow up.All patients underwent to mammography in 2015 or in 2016 within screening programs and no breast cancer were diagnosed. CONCLUSION: The female predominance of diseases of the thyroid and breast makes difficult the separation of an expected association with a casual linkageThe relationship between the co-occurrence of breast and thyroid cancer remains controversial and inconclusive. KEY WORDS: Breast cancer, Breast surgery, Hormone therapy, Thyroid cancer, Thyroidectomy.

Colorectal cancer screenings: a single center experience.

AIM: evaluating the impact of screening programmes on colorectal cancer (CRC) in Italy. METHODS: we studied 1292 patients with colorectal cancer. Data were collected from January 2004 through December 2015 in Parma University Hospital. We compared clinophatological features to evaluate the real impact of screening programmes on detecting early stage colorectal cancers in target population. RESULTS: screening programmes with fecal occult blood test (FOBT) and colonoscopy covered only patients from 50 to 69. In our study we reported that the 52,3% of patients with CRC were over 70 and out of screen time, while only 47,7% were under 70. Early detection seems to be related to early stage of CRC and to an improved overall survival. CONCLUSION: The importance of early detection in colorectal cancers represents the most important outcome for OS. The risk of colorectal cancer is increased in elderly. Actual screening programmes cover less than 50% of population with colorectal cancer. Screening should be considered for patients over 70, due to the high number of new diagnosis in symptomatic disease and worst prognosis, in accordance with advanced cancer stage and comorbidities in elderly.

Treatment of postoperative accessory bile duct injury by fibrin glue and balloon tamponade: a case report.

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Iatrogenic bile duct injuries are still a diagnostic and therapeutic problem and their incidence increased with the introduction of laparoscopic technique. This case report documents a patient with a biliary fistula from an accessory bile duct - Lushka's duct - after routine laparoscopic cholecystectomy, unresponsive to relaparoscopy, ERCP with papillosphincterotomy, biliary stent and nosobiliary tube placement and finally treated with injection of fibrin glue and balloon tamponade through the external drain. Iatrogenic bile duct injuries remain a challenging problem, in particular when they do not communicate with central biliary tree. The detection of this fistulas is more difficult and their management should be multidisciplinary. This case presentation is to emphasize importance of correct diagnostic evaluation and timely and adequate non-surgical methods of treatment of biliary fistulas. (www.actabiomedica.it).

Correlation between cytological and histological findings in patients who underwent thyroidectomy. Predictive value and confounders.

BACKGROUND: Solitary thyroid nodules are the most common endocrine occurance in general population. With the introduction of Bethesda system for reporting thyroid cytopathology (BSRTC) to fine-needle aspiration (FNA) specimens we found a reliable standard method to evaluate malignancy risk in thyroid neoplasms. This study evaluates the correlation between BSRTC and real results in our center investigating the role of several factors as confounding factors for cytological diagnosis. The study has been designed as a retrospective study conducted on 637 patients that underwent thyroid surgery in a single center (Unit of General Surgery, Parma University Hospital, Italy). METHODS: We reviewed 637 files of patients who underwent thyroid surgery with a definitive histological finding from surgical specimen. The collected data include: cytological findings from FNA when performed, histological findings after surgery, sex, age, thyroid hyperfunction and the possible presence of thyroiditis. Cytological findings have been evaluated from our institution's pathologists after FNA performed in collaboration with clinical endocrinologists. Thyroid Hyperfunction has been evaluated through a blood test panel for thyroid functionality including reflex TSH, FT3, FT4 and thyreoglobulin. Blood tests' results and patients have been evaluated by clinical endocrinologists before being addressed to surgery. Thyroiditis have been confirmed as an ultrasound scanning (US) finding or as a corollary from histologic results. All patients have been evaluated by the surgeon and underwent different intervention as total, thyroidectomy, near total thyroidectomy or emithyroidectomy depending on cythology, US findings and symptoms in case of benignancy. Histological findings have been evaluated only by our center pathologists. RESULTS: In our experience the percentage of malignancy in Thyr 2 Thyr 3 and Thyr 4 Bethesda's classes seeems to be higher then those predicted by BSRTC. We also found a high rate of false positive considered as patients included in categories of suspected malignancy (Thyr 3-4-5-6) and subsequently resulted with benign pathology. This happens specially in those patients affected by thyroiditis. CONCLUSIONS: These findings suggest that we need more studies to evaluate real BSRTC predictive value in single centers. Meanwhile we found out that thyroiditis may be a confounding factor in cytological examination wich would lead to an overstating of thyroid nodules.

Relationship between postoperative complications and survival after gastrectomy for cancer.

BACKGROUND: Surgical resection remains the main curative treatment for gastric cancer but is still affected by high postoperative morbidity and mortality rates, especially in Western countries. MATERIALS AND METHODS: We've analyzed patients treated for gastric cancer at our Operative Unit of ent, extent of lymphadenectomy and survival. General Surgery and Organ Transplantation of the University Hospital of Parma from January 2006 till December 2010, relating the occurrence of eventual complications to sex, age at diagnosis, definitive histological examination, type and duration of surgical treatment. RESULTS: The surgically treated cases were 152 (30.4 gastrectomies per year on average). 62 patients developed at least one adverse event during the postoperative period, reaching 108 total events. Among these, 71 were minor complications (grade I-II in Clavien-Dindo's classification), while 26 were major ones (grade III). Postoperative mortality affected 8 patients (5.3%). Data analysis did not stress any statistically significant correlation between the valued variables and the global incidence of complications. For severe ones, some risk factors emerged such as the type of gastrectomy, the execution of a multi-visceral resection and the operative time. Five-year overall survival has been 36.7%, lower in patients with severe complications (29%) when compared to patients without severe complications (38%). Radicality of operation, the lymph node involvement and the occurrence of severe complication emerged as significant prognostic factors for five-year overall survival. CONCLUSIONS: Surgery is still the mainstay of treatment for gastric cancer and the only one able to grant a curative therapy. When performed in high-volume centres, with more than 20 gastrectomies per year, it represents a safe treatment, affected by low mortality. Attention must be paid to careful preoperative selection, to treatment of pre-existent comorbidities, to plan a therapeutical strategy to minimize surgical stress, to postoperative monitoring and to managing complications', as they're able to impact not only low-term outcomes but also overall and disease-free survival. The poor prognosis for these patients is mainly related to advanced stage at presentation, thus confirming the need to increase early diagnosis in order to detect in larger percentages the tumor in its early stage. KEY WORDS: Complications, Gastrectomy, Gastric Cancer, Survival.

The prognostic role of tumor size in patients with gastric cancer.

AIM: The identification of prognostic factors in gastric cancer is important for predicting patients' survival and determining therapeutic strategies. MATERIALS OF STUDY: A retrospective analysis ofpatients who underwent surgery for gastric cancer between 1996 and 2010. The appropriate cut-off value of tumor size related to survival was determined using receiver-operating characteristic (ROC) curves and it was 2,5 cm. Patients were divided into three groups: a small size group (SSG, < 2,5 cm), a medium size group (MSG, between 2,5 and 5 cm) and a large size group (LSG, ≥ 5 cm). RESULTS: Depth of invasion and lymph node metastasis resulted significantly related to tumor size (p < 0.05). Kaplan- Meier survival curves showed that OS rate was significantly higher in SSG patients. The prognosis of patients with tumor size < 2,5 cm was better than patients with tumors ≥ 2.5 cm in size (p < 0.01). DISCUSSION: The tumor size resulted significantly related to OS and it was related to depth of invasion and lymph node metastasis that are themselves prognostic factors. These results confirm and reinforced literature and suggest that at diagnostic pre-operative work-up we can yet define a prognostic value based on tumor size and underline the primary role of complete resection with free surgical margins and D2 lymphadenectomy. CONCLUSION: In patients with gastric cancer tumor size suggests information about the malignancy of the tumor: it is an important predictor of survival and 2,5 cm may be considered as a valid cut-off to define a better or worse prognosis. KEY WORDS: Gastric cancer, Prognosis,Survival, Tumor size.

Pulmonary metastasectomy for colorectal cancer: analysis of prognostic factors affecting survival.

BACKGROUND: Pulmonary metastasectomy is considered a standard procedure in the treatment of metastatic colorectal cancer (CRC). Different prognostic factors including multiple metastatic nodules, the presence of extra-pulmonary metastases and BRAF mutation status have been associated with poor survival. The aim of this study was to evaluate which factors influenced survival in CRC patients undergoing pulmonary metastasectomy by studying primary tumors and pulmonary metastases. METHODS: All patients treated for primary CRC who presented pulmonary metastases in a 10-year period were considered (group A). A control group treated for primary CRC who did not develop any pulmonary or extra-pulmonary metastases was taken for comparison (group B). Different prognostic factors including gender, age, tumor location, histological type, inflammatory infiltrate, BRAF, CDX2 and extra-pulmonary metastases were analyzed. Overall survival (OS) and patients' survival after pulmonary metastasectomy were also considered. RESULTS: Fifty-four patients were evaluated in group A and twenty-three in group B. In group A, BRAF immunohistochemistry did not significantly differ between primary tumors and pulmonary metastases; no difference of BRAF expression was found between group A and B. Even the expression of CDX2 was not significantly different in primary tumors and metastases. Similarly, in group B CDX2 did not significantly differ from primary CRC of group A. The most significant prognostic factor was the presence of extra-pulmonary metastases. Patients with extra-pulmonary metastases experienced a significant shorter survival compared to patients with pulmonary metastases alone (P=0.001 with log-rank test vs. P=0.003 with univariate Cox regression). Interestingly, patients with right pulmonary metastases presented a significant longer survival than those with left pulmonary metastases (P=0.027 with log-rank test vs. 0.04 with univariate Cox regression). CONCLUSIONS: The main prognostic factor associated with poor survival after lung resection of CRC metastases is a history of extra-pulmonary metastases. BRAF and CDX2 did not have a significant role in this small series of patients.

Minimally invasive thyroidectomy: a ten years experience.

BACKGROUND: The conventional thyroidectomy is the most frequent surgical procedure for thyroidal surgical disease. From several years were introduced minimally invasive approaches to thyroid surgery. These new procedures improved the incidence of postoperative pain, cosmetic results, patient's quality of life, postoperative morbidity. The mini invasive video-assisted thyroidectomy (MIVAT) is a minimally invasive procedure that uses a minicervicotomy to treat thyroidal diseases. METHODS: We present our experience on 497 consecutively treated patients with MIVAT technique. We analyzed the mean age, sex, mean operative time, rate of bleeding, hypocalcemia, transitory and definitive nerve palsy (6 months after the procedure), postoperative pain scale from 0 to 10 at 1 hour and 24 hours after surgery, mean hospital stay. RESULTS: The indications to treat were related to preoperative diagnosis: 182 THYR 6, 184 THYR 3-4, 27 plummer, 24 basedow, 28 toxic goiter, 52 goiter. On 497 cases we have reported 1 case of bleeding (0,2%), 12 (2,4%) cases of transitory nerve palsy and 4 (0,8%) definitive nerve palsy. The rate of serologic hypocalcemia was 24.9% (124 cases) and clinical in 7.2% (36 cases); 1 case of hypoparathyroidism (0.2%). CONCLUSIONS: The MIVAT is a safe approach to surgical thyroid disease, the cost are similar to CT as the adverse events. The minicervicotomy is really a minimally invasive tissue dissection.

Analysis of indication for laparoscopic right colectomy and conversion risks.

Laparoscopic surgery developed continuously over the past years becoming the gold standard for some surgical interventions. Laparoscopic colorectal surgery is well established as a safe and feasible procedure to treat benign and malignant pathologies. In this paper we studied in deep the role of laparoscopic right colectomy analysing the indications to this surgical procedure and the factors related to the conversion from laparoscopy to open surgery. We described the different surgical techniques of laparoscopic right colectomy comparing extra to intracorporeal anastomosis and we pointed out the different ways to access to the abdomen (multiport VS single incision). The indications for laparoscopic right colectomy are benign (inflammatory bowel disease and rare right colonic diverticulitis) and malignant diseases (right colon cancer and appendiceal neuroendocrine neoplasm): we described the good outcomes of laparoscopic right colectomy in all these illnesses. Laparoscopic conversion rates in right colectomy are reported as 12-16%; we described the different type of risk factors related to open conversion: patient-related, disease-related and surgeon-related factors, procedural factors and intraoperative complications. We conclude that laparoscopic right colectomy is considered superior to open surgery in the shortterm outcomes without difference in long-term outcomes. KEY WORDS: Conversion risks, Indication to treatment, Laparoscopy, Post-operative pain, Right colectomy.

Iatrogenic diaphragmatic hernia following laparoscopic left colectomy for splenic flexure cancer An unusual complication.

Iatrogenic diaphragmatic hernia following laparoscopic left colectomy for splenic flexure cancer. An unusual complication Diaphragmatic hernias are a migration of abdominal structures into the thorax via a diaphragmatic defect; they may be classified as congenital or acquired and acquired hernias can be hiatal, traumatic or iatrogenic, generally complications of thoracic or abdominal surgery. We report a case of iatrogenic diaphragmatic hernia after a laparoscopic left colectomy for splenic flexure tumor; to our knowledge, in literature this case is the first reported. A 51-years-old woman was readmitted to our Hospital on 11th post-operative day for bowel occlusion and a CT - scan revealed left diaphragmatic herniation with fluid dilatation of the small bowel that appeared in the left hemithorax. Laparoscopic surgery resolution was decided and after the reduction of the small bowel in the abdomen we closed the defect using two direct absorbable auto-block hemi-continuous sutures that were covered by a synthetic absorbable mesh. Probably we didn't notice a minimal injury of the left diaphragm caused by ultrasonic scalpel and we can suppose that this delay in presentation may be a result of the gradual enlargement of a microscopic lesion. Patient's gas exchanges were good during surgery and during post-operative course. KEY WORDS: Diaphragmatic hernia, Iatrogenic, Laparoscopy, Left colectomy, Ultrasonic scalpel.

Gastrointestinal Stromal Tumors: a single Center retrospective 15 years study.

BACKGROUND: Gastro Intestinal Stromal Tumors (GISTs) are defined as mesenchymal tumours that develop within the wall of the gastrointestinal tract. Surgery is the treatment of choice and may be indicated for locally advanced or previously non resectable disease after a favorable response to preoperative therapy with tyrosine kinase inhibitors. METHODS: A retrospective analysis was conducted for all patients with a confirmed or suspected diagnosis of GIST who were admitted to the University Hospital of Parma from January 2000 to January 2015.The following parameters were reviewed and analyzed: age, sex, blood type, symptoms on presentation, tumor site, tumor size, mitotic rate, risk grade, histopathology and immunohistochemistry assays, type of cells. RESULTS: All patients underwent elective surgery. Between January 2000 and January 2015, 61 patients were admitted to the OU General Surgery and Organ Transplantation, University Hospital of Parma and received surgical treatment for GISTs. Thirty-five were male (57.4%) and 26 female (42.6%). The mean age at diagnosis was 69.03 ± 10.07 years (range 29 - 89 years); males 69.6 ± 9.3 years (range 49 - 89 years) and females 68 ± 12.4 years (range 29 - 86 years). Larger tumor size, higher mitotic rate, higher risk rate, margin status contributed to poorer outcome (lower OS and DFS) as independent factors. CONCLUSIONS: Radical surgery is the treatment of choice for resectable GISTs. Very low and low-risk tumor can be treated with surgery alone. KEY WORDS: Gastrointestinal Stromal Tumor, Margin Status, Overall Survival, Tumor size.