Achieving the learning curve in total thyroidectomy: a prospective evaluation on resident's training by CUSUM and KPSS analysis.

INTRODUCTION: Total thyroidectomy (TT) is one of the most common procedures among general and endocrine surgeons worldwide. The conventional approach by neck incision is still the most frequently used, despite the growth of mini-invasive approaches. Controversies exist about the optimal learning curve for resident surgeons approaching this procedure. The aim of this study was to compare TT performed by experienced surgeons and residents in two academic hospitals, to define the correct shape of the specific learning curve. METHODS: Between January 2016 and December 2018 patients undergoing TT in two academic departments were prospectively enrolled. In each department patients were divided into four groups: a reference group (A), consisting of 50 consecutive patients operated on by a senior surgeon, and three other groups (B, C, D) of 50 patients each where thyroidectomy was carried out by three different general surgery residents in their last 3 years of residency, respectively. Data were analysed by CUSUM and KPSS tests in order to compare operative time (OT) and its stabilisation during the learning curve. RESULTS: Data from CUSUM test reported that residents could perform TT with OT similar to the senior surgeon after approximately 25-30 procedures, while the KPSS test showed that residents became more stable after 30 procedures, with no increase in perioperative complications. CONCLUSIONS: This prospective study shows how a specific training in thyroid surgery can be reliable thanks to experienced tutors, and confirmed that the effect of dedicated and programmed training may result in positive outcomes for patients requiring thyroidectomy.

Surgical intervention for intestinal typhoid perforation.

AIM: Typhoid perforation is the most fatal complication of typhoid fever in developing countries and is most often caused by the bacteria Salmonella Typhi. There are conflicting views as to which type of surgical intervention gives the best outcome. The aim of this study was to determine the mortality associated with the different types of surgical interventions employed in patients with typhoid perforation. METHOD: This was a retrospective review of the medical records of adult and paediatric surgical patients treated in the general and paediatric surgical units of the Korle Bu Teaching Hospital. Information was obtained from medical records at the Korle Bu Teaching Hospital in Accra, Ghana, between January 2009 and April 2012. The data was analysed using IBM SPSS Statistics version 20 and 22. RESULTS: 133 patients (median age of 21 years, 72.2% males) with typhoid perforation were included in the study. The typhoid perforation specific mortality rate was 12.8%. Males had a significantly lower mortality rate (7.3%) compared to females (27%). Simple bowel closure (85.7% of total) was the most common surgical intervention performed and patients operated upon with this method had a significantly lower mortality rate (9.6%) compared to patients with bowel resection (31.6%). CONCLUSIONS: In this study, patients treated with intestinal resection were more likely to die from typhoid perforation and female gender was a risk factor for death. Simple bowel closure was the predominant surgical procedure.

Recurrent esophageal stricture from previous caustic ingestion treated with 40-year self-dilation: case report and review of literature.

BACKGROUND: Corrosive esophageal strictures are common. The severity of the strictures depends on type, quantity, duration of contact and concentration of the caustic substance ingested. Endoscopic balloon dilation and endoscopic bougienage are a cornerstone in the management of the benign esophageal strictures and are the most widely used treatments, but are expensive and invasive procedures. CASE PRESENTATION: We report the case of an 82-year-old patient with a corrosive esophageal stricture treated for over 40 years by means of home self-bougienage. The procedure has been carried out for the longest lapse of time described in literature, with an excellent control of symptoms. In the case reported, after being carried out for more than 40 years, self-dilation allowed good quality of life and symptoms management, ensuring an excellent nutritional status. CONCLUSIONS: Following an adequate patient training, self-dilatation can be a safe and effective option of treatment, avoiding frequent expensive hospital admissions for endoscopic esophageal dilatation.

Correct information to patients undergoing breast-conserving surgery: the medicolegal significance.

Many of the women newly diagnosed with breast cancer not have access to all the information they need to make the surgical and treatment choices that are most appropriate for them. Research clearly shows that lumpectomy and other breast-conserving surgeries are just as safe as mastectomy for most women with early stage disease, and yet approximately half will undergo the more disfiguring procedures, but many healthy women who have strong family histories of breast cancer consider prophylactic mastectomies, and their decisions are also based on very limited information, because there are few studies showing the effectiveness of that procedure. This paper delineates how to avoid limited information and biased recommendations is important for a conscious and informed choice by the patients.

Nasotracheal prolonged safe extubation in acute respiratory failure post-thyroidectomy: An efficacious technique to avoid tracheotomy? A retrospective analysis of a large case series.

BACKGROUND: Acute respiratory failure is a rare life threatening complication following thyroid surgery and its incidence is reported as high as 0.9%. Clinical presentation of severe acute respiratory failure is characterized by dyspnea, inspiratory airways distress, hypoxia and its standard current management is the orotracheal intubation and safe extubation. In case of persistent distress, tracheotomy is mandatory. The Authors, analysing a large acute respiratory failure clinical series, describe an innovative treatment of this severe condition: the nasotracheal prolonged safe extubation. METHODS: Patients treated at our Intensive Care Unit for acute respiratory failure following thyroid surgery from January 2004 to December 2013, were reviewed. Demographic data including gender, age, clinical presentation, laryngoscopic findings, management and outcome during a 24-months follow-up after treatment were collected and evaluated. Moreover, the strategy for prolonged nasotracheal safe extubation was carefully described. RESULTS: Nineteen out of the 2853 patients scheduled for thyroid surgery (0.66%) at our University Hospital, developed post-operative acute respiratory failure. All of them were treated by nasotracheal prolonged safe extubation. The success rate in avoiding highly invasive treatment was of 84.2%, since only 3 patients needed definitive tracheotomy (15.7%). CONCLUSIONS: In our series, the prolonged safe extubation reduced the almost totality of expected tracheotomies in patients with acute respiratory failure following thyroid surgery (84.2%), demonstrating its feasibility and efficacy. It was a well tolerated and minimal invasive procedure that allowed a good respiratory ability and a fast clinical resolution of the laryngeal functional impairment.

Unintentional recurrent laryngeal nerve injuries following thyroidectomy: Is it the surgeon who pays the bill?

BACKGROUND: Thyroidectomy is one of the most common intervention in general surgery and, after the turn of the century, its rate has sharply increased, along with a worldwide increased incidence of differentiated thyroid cancers. Therefore, injuries of the recurrent laryngeal nerve have become one of the most frequent cause of surgical malpractice claims, mostly following surgery for benign pathology. MAIN BODY: Even if the incidence of definitive paralysis is generally lower than 3%, during the last 20 years in Italy, the number of claims for damages has sharply raised. As a consequence, a lot of defensive medicine has been caused by this issue, and a witch-hunt has been accordingly triggered, so determining mostly a painful and lasting frustration for the surgeons, who sometimes are compelled to pay a lot of money for increasing insurance premiums and lawyers fees. Recurrent laryngeal nerve injury should be considered as a potentially catastrophic predictable but not preventable event, rather than the result of a surgical mistake. CONCLUSION: Purposes of the Authors are analyzing incidence, conditions of risk, and mechanisms of recurrent laryngeal nerve injuries, underlining notes of surgical technique and defining medical practice recommendations useful to reduce the risk of malpractice lawsuits and judgments against surgeons.

Radioguided thyroidectomy for follicular tumors: Multicentric experience.

BACKGROUND: The diagnosis of thyroid nodular diseases requires an integrated approach that has been widely established over the past years. This strategy includes: ultrasonography (US) with; implemented Color-Power-Doppler, conventional scintigraphy also with positive indicators, specific pathological studies targeted by immunohistochemically-assays, and the fine needle; aspiration biopsy (FNAB), which, usually, in case of "Follicular Lesions" (10-20%) findings is; unable to distinguish carcinoma from follicular adenoma, then indicating the necessity of surgery to; obtain a correct diagnosis. The aim of this study was to evaluate the role of the scintigraphy with; positive indicators, both preoperatively in diagnostic approach of the thyroid nodules and; intraoperatively as a guide to the extension of the surgical excision. METHODS: On 4482 Thyroidectomy performed, we selected 360 cases of follicular neoplasms (192; females and 168 males). In the preoperative phase, these patients underwent 99 m Tc-sestaMIBI; scintigraphy with both early (10 min) and late (2 h) image acquisition, which were later; compared to the ones obtained by image subtraction of means 99 m Tc-pertechnetate. Following the; sestamibi administration before intervention, we selected the most up-taking nodularity with the; assistance of a specific surgical probe (Neoprobe), quantifying uptake with relation to the surgical pathology, for an amount of 324 total thyroidectomies and 36 hemi thyroidectomies. RESULTS: In all cases of multinodular goiter the benign nodules showed an intraoperative low sestamibi uptake whereas follicular carcinomas showed both a high preoperative uptake and, as a; percentage, the highest values of intraoperative uptake; on the other hand, follicular adenomas had; both pre-and intraoperative mean values of uptake. On the contrary, papillary carcinomas only; showed a mild uptake. CONCLUSIONS: Preoperative sestamibi scintigraphy confirmed its importance in improving the information obtained through different diagnostic investigations. Also intraoperatively, it pointed; out high-risk nodules more accurately. Therefore, radio (Sestamibi) guided surgery could have an; interesting rule in the thyroid follicular lesion treatment.

Cost-effectiveness analysis of the temporary percutaneous ileostomy for faecal diversion after colorectal resection in elderly.

BACKGROUND: Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery. AIMS: We analyse the outcomes and the costs of the TPI in protecting low colorectal anastomosis in elderly, compared to the CLI. METHODS: Data of patients underwent elective anterior rectal resection for rectal cancer with extra-peritoneal colorectal anastomosis protected by ileostomy from January 2011 to December 2015 were reviewed. Sixty-one out of 132 patients were older than 70; 35 underwent faecal diversion by TPI and 26 by CLI. RESULTS: The two groups resulted homogenous about age, sex, operative time, short-term post-operative complications. None of the patients reported anastomotic leakage. The hospital stay and the cost for the first surgical procedure did not show statistically significant differences between TPI and CLI. When comparing the overall hospital stay and costs the differences are statistically significant: the TPI showed a shorter hospital stay (12.4 vs 19.3 days, -35.7%) and a lower cost of hospitalization (7954.0 vs 14,372.1€, -44.7%), compared to CLI. DISCUSSION: The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of TPI, especially in elderly. CONCLUSION: The TPI not only improved the post-operative outcome of the patients, but also allowed a remarkable saving for the National Health System.

Diagnostic, therapeutic and health-care management protocol in thyroid surgery: a position statement of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB).

PURPOSE: The diagnostic, therapeutic and health-care management protocol (Protocollo Gestionale Diagnostico-Terapeutico-Assistenziale, PDTA) by the Association of the Italian Endocrine Surgery Units (U.E.C. CLUB) aims to help treat the patient in a topical, rational way that can be shared by health-care professionals. METHODS: This fourth consensus conference involved: a selected group of experts in the preliminary phase; all members, via e-mail, in the elaboration phase; all the participants of the XI National Congress of the U.E.C. CLUB held in Naples in the final phase. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up. RESULTS: A clear and concise style was adopted to illustrate the reasons and scientific rationales behind behaviors and to provide health-care professionals with a guide as complete as possible on who, when, how and why to act. The protocol is meant to help the surgeon to treat the patient in a topical, rational way that can be shared by health-care professionals, but without influencing in any way the physician-patient relationship, which is based on trust and clinical judgment in each individual case. CONCLUSIONS: The PDTA in thyroid surgery approved by the fourth consensus conference (June 2015) is the official PDTA of U.E.C. CLUB.

Myoblastoma of the breast: Our experience and review of literature.

INTRODUCTION: Breast myoblastoma or granular cell tumor involving the breast parenchyma has been described in detail for the first time since Abrikossoff in 1931. The location of this injury to the breast is very rare, accounting for between 5% and 15% of all cases of cancer of the granular cells. We present our experience regarding the identification of two cases because of the relative rarity of this tumor. It is often confused with breast cancer on clinical and radiological, and its diagnosis can then be difficult for physicians, radiologists and pathologists. PRESENTATION OF CASES: We report the cases of two young women who came to our attention because of the presence of mass shoveled breast, mobile and accompanied by pain cycle independent. In both cases, mammography and ultrasound revealed the presence of heterogeneous mass and irregular, but in one of two such mass located at the Union of external quadrants of the left breast and was in contact with his serratus anterior and suspicion for malignancy. In both cases the 'histology combined with immunohistochemical study proved to be a granular cell tumor. CONCLUSION: Although a granular cell tumor of the breast is a rare tumor breast, should be considered in the differential diagnosis of benign and malignant lesions. Surgeons and pathologists should keep in mind when considering a granular cell tumor cells with abundant granular cytoplasm containing materials to avoid misdiagnosing breast cancer, which could lead to unnecessary surgery.

Male breast cancer, clinical presentation, diagnosis and treatment: Twenty years of experience in our Breast Unit.

BACKGROUND: The male breast cancer (MBC) is a rare and represents less than 1% of all malignancies in men and only 1% of all breast cancers incident. We illustrate the experience of our team about the clinico-pathological characteristics, treatment and prognostic factors of patients treated over a period of twenty years . RESULTS: Forty-seven patients were collected 1995-2014 at the Breast Unit of the Hospital of Terni, Italy. The average age was 67 years and the median time to diagnosis from the onset of symptoms was 16 months. The main clinical complaint was sub areolar swelling in 36, 76% of cases. Most patients have come to our attention with advanced disease. The histology of about ninety percent of the tumors were invasive ductal carcinoma. Management consisted mainly of radical mastectomy; followed by adjuvant radiotherapy and hormonal therapy with or without chemotherapy. The median follow-up was 38 months. The evolution has been characterized by local recurrences; in eight cases (17% of all patients). Metastasis occurred in 15 cases (32% of all patients). The site of bone metastases was in eight cases; lung in four cases; liver in three cases; liver and skin in one case and pleura and skin in one case. CONCLUSION: The male breast cancer has many similarities to breast cancer in women, but there are distinct functions that need to be appreciated. Future research for a better understanding of the disease should provide a better account of genetic and epigenetic characteristics of these forms; but, above all, epidemiological and biological cohorts numerically more consistent.

Tracheal varices caused by mediastinal compression of a large intrathoracic goiter: report of a case.

INTRODUCTION: Tracheal varices are a rare condition but they can be an important source of massive or recurrent haemoptysis. Usually they are related to increased pressure in the pulmonary veins. Mediastinal goiter is often associated to compressive effects on the surrounding structures, including mediastinal vessels with potential superior vena cava syndrome. CASE REPORT: We describe a case, not previously reported in literature, of mediastinal goiter with hemoptysis as first clinical manifestation. Bleeding was attributed to a superior vena cava syndrome associated to a tracheal fragile mucosa with an easily bleeding intramural nodule which was diagnosed as tracheal varices after total thyroidectomy. The nodule in fact disappeared together with the venous hypertensive signs after venous decompression of the mediastinum. CONCLUSIONS: Compressive symptoms including tracheal varices, related to mediastinal goiter, can be treated surgically by total thyroidectomy via cervicotomy and when required with associated median sternotomy.

Robot-assisted or conventional laparoscoic rectopexy for rectal prolapse? Systematic review and meta-analysis.

AIM: The use of robotic technology has proved to be safe and effective, arising as a helpful alternative to standard laparoscopy in a variety of surgical procedures. However the role of robotic assistance in laparoscopic rectopexy is still not demonstrated. METHODS: A systematic review of the literature was carried out performing an unrestricted search in MEDLINE, EMBASE, the Cochrane Library, and Google Scholar up to 30th June 2014. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. We meta-analyzed the data currently available regarding the incidence of recurrence rate of rectal prolapse, conversion rate, operative time, intra-operative blood loss, post-operative complications, re-operation rate and hospital stay in robot-assisted rectopexy (RC) compared to conventional laparoscopic rectopexy (LR). RESULTS: Six studies were included resulting in 340 patients. The meta-analysis showed that the RR does not influence the recurrence rate of rectal prolapse, the conversion rate and the re-operation rate, whereas it decreases the intra-operative blood loss, the post-operative complications and the hospital stay. Yet, the RR resulted to be longer than the LR. Post-operative ano-rectal and the sexual functionality and procedural costs could not meta-analyzed because the data from included studies about these issues were heterogeneous and incomplete. CONCLUSION: The meta-analysis showed that the RR may ensure limited improvements in post-operative outcomes if compared to the LR. However, RCTs are needed to compare RR to LR in terms of short-term and long-term outcomes, specially investigating the functional outcomes that may confirm the cost-effectiveness of the robotic assisted rectopexy.

Temporary percutaneous ileostomy for faecal diversion after intestinal resection for acute abdomen in elderly: how to avoid the conventional loop ileostomy.

Conventional loop ileostomy (CLI) is a suitable procedure for transitory faecal diversion after colocolic or colorectal anastomosis, but it causes relevant morbidities (dehydration, discomfort, peristomal infections) and requires a second operation to be closed. We already described an alternative technique of temporary percutaneous ileostomy (TPI), which can be removed without surgery, as faecal diversion in low colorectal anastomosis. Now we report our experience with the TPI in protecting colocolic and colorectal anastomosis in urgency in elderly. From January 2012 to June 2014, 45 patients underwent urgent surgical procedures for acute abdomen with colonic and/or rectal resections and colocolic or colorectal anastomosis with faecal diversion by TPI. Nineteen out of 45 patients were older than 70. Four low colorectal anastomoses, 10 intra-peritoneal colorectal anastomosis and 4 colocolic anastomosis were performed. Neither intra-operative complications nor post-operative deaths were observed. None of the 19 patients treated had evidence of clinical or radiological leakage of the anastomosis. Post-operative complications occurred in 7 patients and nobody required re-intervention. No intestinal obstruction was reported in the early (30 days) post-operative period. The TPI seems to be a valid alternative to standard ileostomy, ensuring an optimal faecal diversion both in elective surgery and in urgency. The TPI also ensures less patient discomfort and it can be easily removed without surgery, unlike the CLI. The limited duration of the faecal diversion and the uselessness of a second surgical procedure to remove the TPI are the most important advantages of this new technique, especially in elderly.

Thyroid anaplastic carcinoma: the impact of multimodality treatment on survival. The experience of a referral center for endocrine surgery.

AIM: Anaplastic thyroid carcinoma (ATC) is characterized by local invasiveness, risk of recurrence and very poor prognosis. METHODS: We retrospectively reviewed 79 consecutive patients treated between 1996 and 2012. We analysed the multimodality treatment of ATC considering the impact of surgery and radiotherapy on survival. RESULTS: Patients were divided in groups A and B (tumor less and larger than 5 cm). Surgery was carried out in 44 patients, radiotherapy in 48 patients. Tracheostomy and endoprosthesis were used respectively in 48.1% and in 25.3% of patients. The mean survival was 5.35 (± 3.2) months with no significant difference in group A vs. group B. Considering patients undergone surgery, significant impact on survival was observed comparing A vs. B (P=0.013). Combination of surgery and radiotherapy significantly improves outcome comparing A vs. B (P=0.017). Improvement in survival compared to no treatment at all was observed in both groups respectively for surgery (P=0.001 and P=0.0001) and radiotherapy (P=0.047 and P=0.0001). CONCLUSION: Although the severity of prognosis of ATC, multimodality treatment still significantly improves local control of the disease achieving acceptable survival in selected patients and adequate palliation of symptoms for the others. Surgery is still a fundamental treatment.

Total thyroidectomy and central lymph node dissection. Experience of a referral centre for endocrine surgery.

AIM: Thyroid cancer prognosis is determined by several variables, even with extremely elevated survival rate. The most debated issues are the type of thyroidectomy and extension of lymphadenectomy. Aim of the study is the analysis of benefits of level VI lymphadenectomy associated to total thyroidectomy in the treatment of thyroid cancer. PATIENTS AND METHODS: 316 total thyroidectomy with central node dissection were carried out in the Unit of Endocrine Surgery, University of Perugia. Direct parathyroid auto-implantation was carried out if damage or accidental excision occurred. High risk patients received radioiodine treatment. RESULTS: Lymph node metastases in the VI level were observed in 42% of cases with a significant difference (p 0.0042) of positive lymph node in level VI comparing tumor larger than 1 cm vs smaller than 1 cm. No significant differences were observed when considering difference of sex, and age. Significant difference (p 0.005) was shown when considering over 45 years old male patients with tumor larger than 1 cm vs smaller ones. The 78% of patients underwent iodine ablation after surgery. Recurrence rate in these patients was 3.2%, with no significant difference compared to not treated patients. Bilateral temporary recurrent nerves palsy were observed in 0.6% of cases, unilateral temporary recurrent nerves palsy in 3.4%, unilateral permanent palsy in 1.5%, temporary hypoparathyroidism in 17%, permanent hypoparathyroidism in 4.4%. CONCLUSIONS: Total thyroidectomy combined to central node dissection, even in absence of risk factors and without clinical evident nodes, is the treatment of choice offering clear indications to radioiodine ablation.

Fournier's gangrene: early diagnosis. How to diagnose, how to manage it.

Fournier's gangrene (FG) is a rare surgical emergency and a life-threatening condition with a rapidly progressive gangrene defined as a necrotizing fasciitis of the perineal or genital areas leading to septic shock and death if untreated. Risk factors are diabetes, immune compromise, obesity, drug use, or genital trauma. Patients are treated by incision and drainage. Aim of the study is to analyze cases of early manifestations of FG and consider aspect of diagnosis based on clinical presentation and the importance of precocious surgical treatment. We had experience of early lesions of FG in 22 cases. We report three cases in which the initial clinical presentation was typical of precocious signs referable to FG. Foley catheter was used in all cases, no diverting colostomy was performed. The patients were treated by artificial i.v. feeding. No extensive demolition of perineal tissues were operated, neither plastic surgery was required. Antibiotic therapy combined to surgical treatment with incision and drainage were performed in all cases. Admission in the intensive care unit was effective when indicated. No mortality was registered in all 22 cases of the series. FG is rare, severe condition requiring a multidisciplinary approach. An early diagnosis and an aggressive surgical treatment, improved by antibiotic therapy, hyperbaric oxygen therapy and proper wound care are the key points of FG management. In selected patients, colostomy or cystostomy must be considered when simple catheterization is not sufficient. Severe cases must be therefore referred to high-volume and specialized centres with specialist professional and intensive care facilities.

Urologic surgery in gynecologic oncology: a large single-institution experience.

OBJECTIVE: The increasing tendency to a tailored treatment in gynecologic oncology has required the extension of the intervention to other non-gynecological structures, as the urinary district. Moreover the role of the urological surgery in gynecologic oncology is still not completely explored. The objective of the study is to evaluate the occurrence of urological procedures in gynecologic oncology surgery. METHODS: Patients admitted to the Division of Gynecologic Oncology, Catholic University of Sacred Hearth, Rome, Italy, between January 2009 and December 2012, were retrospectively analyzed. Clinical charts identified the occurrence of urological procedures in major gynecological surgery. RESULTS: A total of 728 patients were analyzed for the study. A total of 204 urologic procedures were carried out in 83 patients. In all patients, preoperative hydronephrosis appears to be the only statistically significant predisposing factor to urological procedures. At multivariate analysis, stratifying data for different neoplasm, recurrence was the only adjunctive significant variable for ovarian cancer, as well as neo-adjuvant treatment and recurrence for cervical cancer. CONCLUSIONS: This study has identified preoperative factors influencing the needing of urological procedures in different gynecologic neoplasms, allowing a proper planning of surgical treatment, tailored on each patient.

Diagnostic, therapeutic and healthcare management protocols in parathyroid surgery: II Consensus Conference of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB).

AIM: To update the Diagnostic-Therapeutic-Healthcare Protocol (Protocollo Diagnostico-Terapeutico-Assistenziale, PDTA) created by the U.E.C. CLUB (Association of the Italian Endocrine Surgery Units) during the I Consensus Conference in 2008. METHODS: In the preliminary phase, the II Consensus involved a selected group of experts; the elaboration phase was conducted via e-mail among all members; the conclusion phase took place during the X National Congress of the U.E.C. CLUB. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up. CONCLUSIONS: The PDTA for parathyroid surgery approved by the II Consensus Conference (June 2013) is the official PDTA of the U.E.C. CLUB.