Incidental papillary thyroid microcarcinoma in consecutive patients undergoing thyroid surgery for benign disease. A single center experience.

BACKGROUND: There has recently been an increase in the incidental histological diagnosis of papillary thyroid microcarcinoma (I-PTMC), that varies from 3.5% in autopsies studies, to 5.2% in thyroid specimens from thyroid surgery, up to 9.4% in patients from areas of endemic goiter. AIM: To evaluate the incidence and the histological characteristics of I-PTMC in patients undergoing thyroidectomy for benign thyroid diseases, and to evaluate sex, age, toxic and non-toxic goiter, Hashimoto's thyroiditis as potential risk factors. MATERIALS AND METHODS: Prospective observational study on 124 patients, median age 56.3±13.25sd range 24-80 years, 93(75%)F, 31(25%)M, with surgical indications for toxic and non-toxic uni/multinodular goiters, in pharmacological euthyroidism. An accurate histological examination (HE) of entirely embedding thyroid samples was performed to identify microscopic foci of I-PTCM. Logistic regression analysis of the abovementioned parameters was performed to identify the risk factors. RESULTS: Total incidence of I-PTMC was 15.3%(19/124), with F/M ratio 2:1. All I-PTMCs were intraparenchymal with an intact thyroid capsule; 68.5% were bilateral-multifocal, 21% unilateral-unifocal, 10.5% unilateral-multifocal; maximum diameter was <5mm in 57.9% and ≥5mm in 42.1%; 63.1% were follicular variant, 36.9% classical variant; intra-thyroid lymphatic invasion and lymph node infiltration of the central compartment and para-tracheal was found in the only patient with "tall-cell" classical variant. No risk factors was found. CONCLUSIONS: The incidence higher than that reported in the literature, is probably due to the accurate HE of entirely embedding thyroid samples, which is the most important tool to identify microscopic foci of I-PTCM. The highest reported rate of bilateral multifocality of the neoplasm recommend the total thyroidectomy as surgical treatment of choice, also in patients undergoing thyroid surgery for "presumptive" benign diseases. KEY WORDS: Benign Thyroid Disease, Incidental Papillary Thyroid Microcarcinoma, I-PTCM, Thyroid Surgery.

A rare case of primary gastric Burkitt's lymphoma associated with malignant pleural mesothelioma.

BACKGROUND: Primary gastric Burkitt lymphoma (PG BL) and malignant pleural mesothelioma (MPM) are rare and aggressive tumors with poor prognosis. HIV and EBV infection have a link in the aetiology of PG BL, while MPM is usually associated with asbestos exposure. Endoluminal bleeding from massive solid tumor, and dyspnea usually due to pleural effusion, are the typical clinical manifestations respectively of PG BL and MPM. In most patients just palliative treatment is indicated. CASE REPORT: A caucasian elderly male, negative for the proven risk factors, presenting respiratory failure due to massive left pleural effusion with severe mediastinal shift. Contrast enhanced - Computed Tomography (CE-CT) showed a large mass causing circumferential thickening of the gastric fundus, infiltrating the left diaphragmatic dome and the ipsilateral crus. Macroscopically, on endoscopy the gastric fundus appeared completely occupied by an ulcerated large mass protunding in the gastric lumen. Histopathological examination from biopsy specimens taken during esophagogastroduodenoscopy and thoracoscopy allowed to make diagnosis of PG BL and MPM. The patient first underwent a placement of a chest tube drainage for the pleural effusion and then a thoracoscopic talc insufflation (TTI) in the left hemithorax. A surgical treatment of the gastric lesion was planned, due to the rapid growth and the high risk of bleeding. The patient died because of fatal cardiac arrhythmia, before undergoig abdominal surgery. CONCLUSIONS: This report presents an unique case of PG BL associated with MPM and highlights the real challenge for the physicians to identify them in early stage, especially in patients without the proved risk factors. The onset symptoms make it a very singular case, characterized by severe dyspnea up to respiratory failure, due to massive left pleural effusion and contralateral mediastinal fluttering, without an active bleeding from the gastric mass, while CE-CT findings were instead negative for pleural thickening and positive for circumferential thickening of the gastric fundus. KEY WORDS: Burkitt Lymphoma, Case Report, Gastric, Pleural Mesothelioma, Pleural Effusion, Respiratory Failure.

Management of incidental pancreatic neuroendocrine tumor: a case report with literature review.

BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) are rare and accounting for less than 5% of all pancreatic neoplasms. Their management depends on dimension of the lesion, main pancreatic duct (MPD) caliber, tumor malignancy features and evolutive potential. CASE REPORT: Incidental finding of a lesion 1.2 cm wide of the pancreatic body, after contrast enhanced total body CT, in a 71 years old obese Caucasian male (BMI>25), during follow-up for cutaneous melanoma. The lesion was confirmed by MRI and 68-Ga pancreatic scintigraphy. EUS showed a second hypoecogenic and hypovascularized lesion compatible with pancreatic tail PNET. After FNB, Ki-67 was below 3%. DISCUSSION: 68-Gallium PET-CT was the preferred technique for the staging of the neuroendocrine neoplasm, for treatment planning, for the localization of the pancreatic lesion, excluding the presence of unknown extra-pancreatic lesions. EUS-FNB is indicated in patient with suspicion of PNET, although further investigation is needed to include it as a routine diagnostic examination. CONCLUSION: Surgery is mandatory in case of PNETs larger than 2 cm, with MPD dilation, Ki-67>20% and compression symptoms.

Post-traumatic multifocal abdominal splenosis. The role of the clinical history. Case report and review of literature.

BACKGROUND: Splenosis is a benign clinical condition caused by the heterotopic autotransplantation of spleen's tissue tipically occurring after spleen rupture. Splenosis may be asymptomatic and found accidentally. When signs and symptoms occur they are due to mass effect or bleeding of the splenic nodules. CASE REPORT: 74-years-old male presenting with intestinal sub-occlusion and past medical history of post-traumatic splenectomy at 18-years-old. Based on TC findings of multiple hyperenhanced solid lesions located in greater omentum, mesentery and parietal peritoneum of right pelvic walls, the presumptive diagnosis was peritoneal carcinomatosis of unknown primary site. Stenosis of a ileum loop in the right pelvis, with dilatation and faecal stasis of the upstream loops proximal, required surgical procedure. At the opening of the peritoneal cavity the multifocal lesions varied in size, were reddish blu color, sessile, lobulate and with strong adhesions to the visceral peritoneum. Omentectomy and the blunt exicision of 3 extraparietal solid nodules, which had tenacious adhesions with stenotic ileum loop serosa for the lenght of 8 cm, were performed. Histopathological examination of surgical specimens showed splenic tissue with red pulp. CONCLUSION: CT scan usually do not allow to make a certain diagnosis of splenosis, so the clinical history of splenic trauma or splenectomy, positive in all cases reported in literature, represent the key in the diagnostic pathway of splenosis. Management should be conservative as much as possible nonetheless in abdominal splenosis the surgical approach should be chosen for the symptomatic patients who present abdominal pain, occlusion or bleeding. KEY WORDS: Abdominal, Splenosis, Spleen, Surgery.

Solitary Fibrous Tumor of the Seminal Vesicle: A Systematic Literature Review and Case Presentation.

BACKGROUND/AIM: Solitary fibrous tumors (SFTs) are ubiquitous mesenchymal neoplasms that have an unpredictable biological behavior. Histological criteria for this type of malignancy are uncertain. Clinical characteristics, diagnostic and treatment options of SFTs originating in the seminal vesicle are presented in this review article. MATERIALS AND METHODS: A systematic review including the following databases: Scopus, Embase and Medline from 1960 until the end of March 2021 was performed according to the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. RESULTS: We found seven patients affected with SFTs of seminal vesicle, in which we added our own case, making a total of 8 patients. Mean age at presentation was 55±7 years. Mean size of the SFTs was 9±2 cm and the right seminal vesicle was preferentially involved. The majority of patients were symptomatic and presenting symptoms were hematuria, dysuria, hematospermia, urinary increased frequency and urgency. Abdominal ultrasonography, computed tomography (CT) scan, and magnetic resonance (MRI) were the diagnostic tools. Trans-rectal ultrasound-guided core biopsy was also used. Seven (87%) patients had open surgery. Adjuvant radiotherapy after R0 resection was used in 1 patient. CONCLUSION: The treatment of SFTs located in the seminal vesicle necessitates a radical surgical resection to obtain acceptable results in terms of local recurrence and distant metastases.

Acute pancreatitis secondary to non-functioning pancreatic neuroendocrine tumor: uncommon clinical presentation. Clinical case and review of literature.

BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) are uncommon, representing <5% of all pancreatic neoplasms, divided into functioning PNETs with secreted hormone cause of specific symptoms, and non-functioning PNETs (nf- PNETs) characterized by delayed diagnosis with metastases and clinical manifestations of compressive effects. Surgical approach is recommended for functioning and nf-PNETs >2 cm in diameter. CASE REPORT: A 76-year-old woman was admitted to the UOC-University-Surgery Hospital "A. Fiorini" in Terracina for nausea and pain in the upper abdominal quadrants with dorso-lumbar irradiation, arising after the evening meal. After the haematochemistry tests and the instrumental investigations, the diagnosis of acute, severe halitiasic pancreatitis was made. Conventional US, CCT, CE-MRI and EUS showed a 2.8cm diameter lesion in the head-body junction of the pancreas. FNA-cytological examination did not found the presence of atypical pancreatic cells. Total-body scintigraphy with Octreoscan® documented a pathological hypercaptation area located in correspondence with the neoformation. The patient underwent a body-tail spleno-pancreatectomy. The histological examination showed an intermediate grade (G2) nf-PNET infiltrating the lienal vein and stenosing the Wirsung duct, with perilesional pancreatitis. Immunohistochemistry showed CAM 5.2, Synaptophysin (>95%) and Chromogranin (60%) positive immunophenotype, with negative intratumoral Somatostatin expression. CONCLUSION: Although rarely, nf-PNETS may be the cause of severe non-biliary acute pancreatitis from pancreatic ductal system compression. In cases where PET/CT68Ga cannot be performed, total-body scintigraphy with Octreoscan® remains the most widely used method for the diagnosis of PNETs and the identification of extra-pancreatic lesions. Chromogranin and Synaptophysin are confirmed as specific markers of neuroendocrine differentiation. KEY WORDS: Acute pancreatitis, Chromogranin, Pancreatic neuroendocrine tumor, Synaptophysin, Somatostatin.

An uncommon clinical presentation of primary pancreatic lymphoma: Bleeding. Case report and literature review.

BACKGROUND: Primary pancreatic lymphoma (PPL) represents less than 0.5% of all pancreatic neoplasms. Clinical manifestations are non-specific and diagnosis is delayed in the majority of patients. CASE REPORT: 85-year-old woman reporting accidental fall at home 20-days earlier, was admitted with diagnosed of acute abdomen from suspected two-stage rupture of the spleen. The patient complained of pain in the upper abdomen. Blood-chemical tests did not show anemia and leukocytosis, but showed increased CA19.9, CA125, LDH and beta2- microglobulin. Contrast-enhanced CT showed left pleural, perisplenic, perihepatic, and Douglas blood effusion, a neoformation of the body-tail of the pancreas with peri-pancreatic blood layer, splenomegaly due to the presence of a hypodense area as from intraparenchymal hematoma, with an apparently undamaged splenic capsule. The patient underwent emergency exploratory laparotomy, that revealed the presence of modest free serohematic effusion from oozing of the pancreatic neoformation. The local spread of the disease prevented any attempt at surgical resection. Bleeding was checked with the addition of topical hemostats (Tabotamp®) and biopsy sampling of the pancreatic mass was performed. A final histological diagnosis of large cell NHL of centro-follicular origin, double expressor for the CMYC and BCL2 protein, was achieved. The age of the patient, the poor general conditions, the associated pathologies, the locally advanced spread of the disease and the histological aggressiveness, were contraindications to chemo-radiotherapy treatments. CONCLUSION: The initial misdiagnosis was due to the history of recent trauma, the uncommon clinical presentation, the underestimation of the serum increase in markers and the interpretation of the CT. KEY WORDS: Acute Abdomen, Hemoperitoneum, Primary Pancreatic Lymphoma.

Non-antibiotic prophylaxis in thyroid surgery. Experience of a single Institution and revision of literature.

AIM: To evaluate the incidence of SSI and systemic infectious complications in a consecutive series of patients undergoing thyroid surgery in the absence of prophylactic antibiotic (NO-AP). METHODS: Prospective observational study including 77 patients who underwent total thyroidectomy and completion of previous hemithyroidectomy in NO-AP. The surgical intervention was performed by surgeons who were experienced in the procedure, and involved the use of Ligasure Harmonic Ethicon®, absorbable hemostat in oxidized regenerated cellulose (Tabotamp®), and skin incision suture device Skin Stapler®. The following risk factors were assessed: gender, age, BMI, alcohol consumption, habitual smoking, co-morbidities, ASA score, indication to surgery, duration of anesthesia and procedure lenght, type of surgical procedure, fever, white blood cells count, dosage of the pre-operative C Reactive Protein in the five first post-operative day, and histological diagnosis. The data were collected and processed using IBM SPSS software v.23.0. RESULTS: No factors of increased infectious risk have been identified. No infectious surgical and systemic complications have been reported causes of prolongation of the length of the hospital stay. CONCLUSIONS: Fever, neutrophilic leukocytosis and increased PCR cannot be assessed as predictive factors of infectious complication in thyroid surgery. The cutaneous antisepsis of the operative field with chlorhexidine gluconate, the improvement of the surgical technique, the protection of the cutaneous margins of incision, the use of new devices, the accurate hemostasis and the reduction of surgery time lead to a lack of SSIs and systemic infection complications in all patients undergoing thyroid surgery in NO-AP. KEY WORDS: Antibiotic prophylaxis, Surgical site infections, Thyroid surgery, Thyroidectomy.

Polypoid lesions of the gallbladder in a consecutive series of 2631 patients. A single-center experience.

BACKGROUND: Challenges in the diagnosis of polypoid gallbladder lesion (PLG) is due to the low sensibility (SE) of ultrasound scan (US), and the selection criteria of patients with PLG to be addressed to surgical treatment or followup are not yet fully defined. MATERIALS AND METHODS: Retrospective observational study was conducted on 2631 patients, 1175(44.6%) M, mean age 56 years, 1456(55.4%) F, mean age 46 years, who underwent laparoscopic and open cholecystectomy. RESULTS: The US diagnosis for PLG was placed in 38/2631(1.4%) patients. On histological examination (HE) the polyps were identified in 68/2631(2.6%) patients and it was associated with biliary lithiasis in 28/2631 (1.1%) cases. From the US and HE comparison, the ultrasound diagnosis was burdened by false positives (8/38; 21%) and false negatives (38/2631;1.45%), with SE 44% (95% c.i.:32.2-55.7). The histological incidence of gall bladder cancer (GBC) was 0.38%(10/2631). DISCUSSION: US survey underestimated the incidence of PLG compared to the histological finding (p=0.021). Female gender has been shown to be a specific risk factor for benign and malignant PLG and non-polypoid mucosal lesions (p=0.041). The parietal lesion size <0.5cm does not exclude the neoplastic nature. Currently the prevention and diagnosis of GBC is based on the early detection and treatment of potentially evolutionary polypoid lesions over a period of about 15 years. CONCLUSIONS: It is probably that early cholecystectomy in all the patients with PLG of diameter <1cm, isolated or associated with lithiasis, symptomatic and asymptomatic, can contribute to the reduction of the incidence of GBC. KEY WORDS: Cholecystectomy, Gallbladder polyps, Gallbladder cancer, Ultrasound scan.

Prophylactic drainage after laparoscopic cholecystectomy for acute cholecystitis: a systematic review and meta-analysis.

In the literature, there is a large evidence against the use of drains in laparoscopic cholecystectomy (LC) in elective surgery. However, evidence is lacking in the setting of acute cholecystitis (AC). The present meta-analysis was performed to assess the role of drains to reduce complications and improve recovery in LC for AC. An electronic search of the MEDLINE, Science Citation Index Expanded, SpringerLink, Scopus, and Cochrane Library database from January 1990 to July 2018 was performed to identify randomized clinical trials (RCTs) that compare prophylactic drainage with no drainage in LC for AC. Odds ratio (OR) with confidence interval (CI) for qualitative variables and mean difference (MD) with CI for continuous variables were calculated. Three RCTs were included in the meta-analysis, involving 382 patients randomized to drain (188) versus no drain (194). Morbidity was similar in both the study groups (OR 1.23; 95% CI 0.55-2.76; p = 0.61) as well as wound infection rate (OR 1.98; 95% CI 0.53-7.40; p = 0.31) and abdominal abscess rate (OR 0.62; 95% CI 0.08-4.71; p = 0.31). Abdominal pain 24 h after surgery was less severe in the no drain group (MD 0.80; 95% CI 0.46-1.14; p < 0.000). A significant difference in favor of the no drain group was found in the postoperative hospital stay (MD 1.05; 95% CI 0.87-1.22; p < 0.000). No significant difference was present with respect to postoperative fluid collection in the subhepatic area and operative time. The present study shows that prophylactic drain placement is useless to reduce complications in LC performed to treat AC. Postoperative recovery is improved if drain is not present.

Pre-Operative Skin Antisepsis with Chlorhexidine Gluconate and Povidone-Iodine to Prevent Port-Site Infection in Laparoscopic Cholecystectomy: A Prospective Study.

BACKGROUND: Skin preparation with antiseptic agents is commonly recommended for incisional site cleansing before surgery. We present the result of a prospective case series submitted to a scheduled pre-operative antiseptic procedure combining chlorhexidine gluconate and povidone-iodine before elective laparoscopic cholecystectomy. PATIENTS AND METHODS: Consecutive patients underwent pre-operative standardized cleansing of the operation site combining chlorhexidine gluconate and povidone-iodine. Patients were reviewed one week and four weeks post-operatively. RESULTS: Post-operative infection was observed in seven patients (4.3%). All observed infections were port-site infections, always located at the level of the umbilical incision. In all cases infections involved skin and subcutaneous tissue. Staphylococcus aureus was isolated in five patients (71.4%) and miscellaneous aerobic gram-positive bacteria in two subjects (28.6%). Post-operative hospital stay was the only factor significantly associated with the development of port-site infections. CONCLUSIONS: Port-site infections are a common complication after elective laparoscopic cholecystectomy. The proposed pre-operative disinfection procedure is effective in reducing port-site infections. Reducing hospital stay may contribute to limiting the occurrence of this complication.

Subhepatic mass occurrence after using oxidized and regenerated cellulose polymer in laparoscopic cholecystectomy: a case series.

BACKGROUND: Oxidized regenerated cellulose (ORC) is a bioabsorbable surgical hemostatic. We present the first prospective case series of circumscribed mass occurrence after using ORC in laparoscopic cholecystectomy. METHODS: Tabotamp (Ethicon, Inc., Somerville, NJ) in the form of tightly woven knitted patches was used to achieve hemostasis in 83 patients submitted to LC. RESULTS: A subhepatic mass was detected in five patients and radiologic characteristics were described. Abdominal contrast enhanced CT showed a heterogeneous soft-tissue mass. NMR was performed in one patient and showed a T2-weighted hyperintense mass. CONCLUSION: ORC retention after surgery is not uncommon at long-term follow-up. The radiologic characteristics of a suspected ORC retention mass can differentiate it from a neoplastic lesion, so that surgery can be avoided.

Review of a non-epithelial tumour of the small bowel after c-kit revolution.

UNLABELLED: In this article, we reviewed the case of a patient who was object, in 1999, of a published case report of schwannoma of the jejunal wall. Recently, the patient has been referred to our institution for a mass of the stomach identified by upper gastrointestinal endoscopy. The patient underwent a wedge resection of the stomach and a histopathological diagnosis of GIST of the stomach, based on a positive immunohistochemical staining of c-kit and CD34, was made. In consideration of these findings, we performed immunohistochemistry for c-kit and for CD34 on the previous lesion of the jejunal wall, which resulted strongly positive for CD117 and negative for CD34. A new diagnosis of gastrointestinal stromal tumour (GIST) of jejunal wall with moderate risk of progression was made. The lesion was also classified, according to the AJCC Seventh Edition, as a pT3, pN0, Stage II, GIST. This case shows the importance of a reassessment of the diagnosis of mesenchymal neoplasm of the small intestine made before the development of anti-CD117 antibody for a correct prognostic stratification, a better therapeutic management and a close follow-up, if necessary. KEY WORDS: Adjuvant therapy, c-kit, GIST Imatinib.

Good results of surgery for renal cell carcinoma depend on early diagnosis. The need for an extensive screening program.

AIM: The aim of our study was to assess the value of several prognostic factors for patients with clear cell renal carcinoma without distant metastases (M0) who underwent surgery in our Department from 1980 to 2010. MATERIAL OF STUDY: We analyzed131 consecutive patients with clear cell renal carcinoma who had nephrectomy and extended lymph node dissection from 1980 to 2010 were reviewed. Free from cancer survivals were correlated to several prognostic factors including preoperative blood cell count, tumour cellular differentiation and stage of the disease. RESULTS: In our study we confirmed the importance of the stage of the tumour, in particular of the T, as prognostic factor. Survival was strictly correlated to the stage of the disease: 10 year cancer free survival was 100% in patients with T1, 83% in patients with T2 N0 and 34% for patients with T3N0. No improvement of results was noted in the last years, due to unchanged proportion of early diagnosis. DISCUSSION: Long term survival after surgery for clear cell renal carcinoma depends mainly on the histology type of the tumour and on the stage of the disease. Renal carcinoma does not respond to radio and standard chemotherapy and surgery represents the only effective cure. CONCLUSION: Surgery at earlier stages is essential to improve results in patients with renal carcinoma. Earlier diagnosis at the present time is the best possibility to improve results, with the need for extensive use of screening ultrasound test. KEY WORDS: Lymph node dissection in renal carcinoma, Renal carcinoma, Results of surgery for renal carcinoma.

Does the Implantation Technique for Totally Implantable Venous Access Ports (TIVAPs) Influence Long-Term Outcome?

BACKGROUND: Totally implantable venous access ports (TIVAP) are eventually explanted for various reasons, related or unrelated to the implantation technique used. Having more information on long-term explantation would help improve placement techniques. METHODS: From a series of 1572 cancer patients who had TIVAPs implanted in our center with the cutdown technique or Seldinger technique, we studied the 542 patients who returned to us to have their TIVAP explanted after 70 days or more. As outcome measures we distinguished between TIVAPs explanted for long-term complications (infection, catheter-, reservoir-, and patient-related complications) and TIVAPs no longer needed. Univariate and multivariate analyses were run to investigate the reasons for explantation and their possible correlation with implantation techniques. RESULTS: The most common reason for explantation was infection (47.6 %), followed by catheter-related (20.8 %), patient-related (14.7 %), and reservoir-related complications (4.7 %). In the remaining 12.2 % of cases, the TIVAP was explanted complication free after the planned treatments ended. Infection correlated closely with longer TIVAP use. Univariate and multivariate analyses identified the Seldinger technique as a major risk factor for venous thrombosis and catheter dislocation. CONCLUSIONS: The need for long-term TIVAP explantation in about one-third of cancer patients is related to the implantation techniques used.

Endoscopic placement of self-expandable metallic stents for rectovaginal fistula after colorectal resection: a comparison with proximal diverting ileostomy alone.

BACKGROUND: Self-expandable metal stents can be used to treat patients with rectovaginal fistula after colorectal resection for cancer. METHODS: Fifteen patients with rectovaginal fistula, after colorectal resection for cancer, were treated with endoscopic placement of a self-expandable metal stent. In four patients, a diverting proximal stoma had been performed elsewhere. Mean age was 58 years. All patients had preoperative radiotherapy. In ten patients, the stent was placed as initial form of treatment. Four patients were referred after multiple failed operations. The control group consisted of ten patients who had rectovaginal fistula and underwent proximal diverting ileostomy and percutaneous drainage of the surrounding abscess RESULTS: One patient was not able to tolerate the stent, which was removed. At a mean follow-up of 22 months, the rectovaginal fistula healed in 12 patients. In the remaining two patients, the fistula has reduced significantly in size to allow a successful flap transposition. The fistula healed only in five out of the ten patients who had only a proximal ileostomy. CONCLUSIONS: Endoscopic placement of self-expandable metal stents represents a valid adjunctive to treat patients with rectovaginal fistula, after colorectal resection for cancer.

Thyroid swellings in the art of the Italian Renaissance.

BACKGROUND: Thyroid swellings in the art of the Italian Renaissance are sporadically reported in the medical literature. METHODS: Six hundred paintings and sculptures from the Italian Renaissance, randomly selected, were analyzed to determine the prevalence of personages with thyroid swellings and its meaning. RESULTS: The prevalence of personages with thyroid swellings in the art of Italian Renaissance is much higher than previously thought. This phenomenon was probably secondary to iodine deficiency. The presence of personages with thyroid swelling was related to specific meanings the artists wanted to show in their works. CONCLUSIONS: Even if the function and the role of the thyroid were discovered only after thyroidectomy was started to be performed, at the beginning of the 19th century, artists of the Italian Renaissance had the intuition that thyroid swellings were related to specific psychological conditions. Artistic intuition and sensibility often comes before scientific demonstration, and it should be a guide for science development.

Phytobezoar-induced small bowel obstruction associated with a concomitant gastric phytobezoar and ulcer in an elderly woman.

Bezoars are aggregates of indigested foreign material that accumulate in the gastroenteric tract, expecially in the stomach and in the narrowest points of the small bowel. They often occur in subjects who follow a diet rich in fruit and vegetables and in those one who previously underwent gastric resective surgery for peptic ulcer. Bezoar formation has even been observed in case of reduced gastric motility and secretion due to diabetes, hypothyroidism, pernicious anemia, myotonic syndromes, and Guillain-Barré syndrome. As they are an uncommon cause of small bowel obstruction, phytobezoars are often not considered in the differential diagnosis of occlusive intestinal syndromes and so frequently come as an intraoperative finding. A consequence of this missed diagnosis in the preoperative period is an unnecessary diagnostic delay that can significantly increase morbidity and mortality. This case report illustrates the need to include phytobezoars in the preoperative diagnostic workout of intestinal obstruction in order to rule out the presence of multiple bezoars and prevent recurrent obstruction. Now that phytobezoars are becoming a less infrequent cause of small bowel obstruction than previously thought, such a diagnostic possibility should always be considered.

Endoscopic placement of self-expanding stents in patients with symptomatic anastomotic leakage after colorectal resection for cancer: long-term results.

Anastomotic leak after colorectal resection for cancer is a challenging clinical problem. The postoperative quality of life in these situations is significantly impaired. We prospectively analyzed the effect of placing a self-expanding metal stent (SEMS) at the level of the leak, with or without proximal diverting ileostomy, in 22 patients with symptomatic anastomotic leakage after colorectal resection. The stents were placed successfully in all 22 patients. An proximal ileostomy was created in 15 patients under general anesthesia. The anastomotic leak healed, without evidence of residual stricture or major incontinence, in 19 patients (86 %). In 3 patients, the leak did not heal; in 2 patients with recurrent rectovaginal fistula, the size of the leak decreased significantly, allowing successful flap transposition; and only 1 patient required a permanent stoma. SEMS placement is a valid adjunct to the treatment of patients with symptomatic anastomotic leakage after colorectal resection.