Microwave ablation for large benign thyroid nodules: a proposal for a new approach: "the fluid-motion technique".

INTRODUCTION: Most thyroid nodules are benign, and treatment is primarily indicated for patients with symptoms or cosmetic concerns related to nodular volume. Recently, there has been growing interest in nonsurgical and minimally invasive techniques for the treatment of symptomatic benign thyroid nodules, including microwave ablation (MWA). AIMS: This study aims to evaluate the effectiveness, efficacy, and safety of ultrasound-guided uncooled MWA in the treatment of benign symptomatic thyroid nodules, using a new ablation technique called the "fluid-motion technique." MATERIALS AND METHODS: From April 2021 to February 2023, a total of 150 patients with benign thyroid nodules were treated using MWA at the Endocrine Surgery Unit of Pederzoli Hospital, Peschiera del Garda (Italy), with 102 of them being followed-up for at least 6 months. RESULTS: Before treatment, the mean major diameter was 38.4 ± 10.0 mm, and the mean volume was 13.6 ± 10.5 mL. At 1 month, the mean volume was 6.8 ± 6.2 mL, and at 3 months, it was 4.6 ± 4.1 mL. The mean Volume Reduction Rate (VRR) at 3 months was 61.1 ± 22.0%. Of the nodules, 17 (17%), 65 (66%), and 20 (19%) had volumes ≤ 10, 10.1-20, and ≥ 20.1 mL, respectively. For these nodules, the mean VRR at 3 and 6 months was 55.3 ± 16%, 63.4 ± 24.8%, 72 ± 26.9% and 68.0 ± 11.2%, 73.5 ± 18.3%, and 81.6 ± 15.8%, respectively. CONCLUSION: Our study shows that ultrasound-guided MWA is an effective and safe minimally invasive treatment for benign thyroid nodules. The goal is to achieve a VRR that can reduce symptoms and improve cosmetic appearance.

Reduction of the emergency activity, during the Covid 19 Italian lockdown, what's the lesson to learn?

The COVID 19 pandemic was declared on the 9th of March 2020. The health crisis affected the whole world with a very high and unexpected number of infected people. The situation forced the declaration of lockdown and a worldwide health system reorganization. Surprisingly, the social distancing laws caused a reduction of urgent hospital activities not COVID 19 related. The aim of this manuscript is to analyze the reasons why fewer emergencies were described during the 2020 Italian lockdown. The Data reporting urgent Emergency Room (ER) activity, during the first three weeks of the Italian lockdown (Group 1), were analyzed and compared with the same period in 2019 (Group 2). During the study period in 2020, there was a 46,5% reduction in ER activity compared to that in 2019. Nevertheless, the hospitalization rate was higher in the 2020 then in 2019 (p<0.05). The present data showed that almost half of the basic ER activity araised from mild health problems that could be followed by territorial health services. The strengthening of territorial medical services would allow hospitals to handle critical situations more easily and to focus activity by reducing the waiting list.

Cognitive load in 3d and 2d minimally invasive colorectal surgery.

BACKGROUND: Three-dimensional (3d) laparoscopy has been introduced to enhance depth perception and facilitate surgical operations. The aim of this study was to compare cognitive load during 3d and 2d laparoscopic procedures. METHODS: Two subjective questionnaires (the Simulator Sickness Questionnaire and the NASA task load index) were used to prospectively collect data regarding cognitive load in surgeons performing 2d and 3d laparoscopic colorectal resections. Moreover, the perioperative results of 3d and 2d laparoscopic operations were analyzed. RESULTS: A total of 313 patients were included: 82 in the 2d group and 231 in the 3d group. The NASA TLX results did not reveal significantly major cognitive load differences in the 3d group compared with the 2d group; the SSQ results were better in the 3d group than in the 2d group in terms of general discomfort, whereas difficulty concentrating, difficulty focusing, and fatigue were more frequent in 3d operations than in 2d operations (p = 0.001-0.038). The results of age, sex, and ASA score were comparable between the two groups (p = 0.299-0.374). The median operative time showed no statistically significant difference between the 3d and 2d groups (median, IQR, 2d 150 min [120-180]-3d 160 min [130-190] p = 0.611). There was no statistically significant difference in the risk of severe complications between patients in the 3d group and in the 2d group (2d 7 [8.54%] vs 3d 21 [9.1%], p = 0.271). The median hospitalization time and the reoperation rate showed no difference between the 2d and 3d operations (p = 0.417-0.843). CONCLUSION: The NASA TLX did not reveal a significant difference in cognitive load between the 2d and 3d groups, whereas data reported by the SSQ showed a mild risk of cognitive load in the 3d group. Furthermore, 3d laparoscopic surgery revealed the same postoperative results as 2d standard laparoscopy.

Major postoperative complications after pancreatic resection for P-NETS are not associated to earlier recurrence.

BACKGROUND: The oncological impact of surgical complications has been studied in visceral and pancreatic cancer. AIM: To investigate the impact of complications on tumour recurrence after resections for pancreatic neuroendocrine tumours. METHODS: We have retrospectively analysed 105 consecutive resections performed at the Royal Free London Hospital from 1998 to 2014, and studied the long-term outcome of nil-minor (<3) versus major (≥3) Clavien-Dindo complications (CD) on disease-free (DFS) and overall survival (OS). RESULTS: The series accounted for 41 (39%) pancreaticoduodenectomies, two (1.9%) central, 48 (45.7%) distal pancreatectomies, eight (7.6%) enucleations, four (3.8%) total pancreatectomies. Sixteen (15.2%) were extended to adjacent organs, 13 (12.3%) to minor liver resections. Postoperative complications presented in 43 (40.1%) patients; CD grade 1 or 2 in 23 (21.9%), grades ≥3 in 20 (19%). Among 25 (23.8%) pancreatic fistulas, 14 (13.3%) were grades B or C. Thirty-four (32.4%) patients developed exocrine, and 31 (29.5%) endocrine insufficiency. Seven patients died during a median 27 (0-175) months follow up. Thirty-day mortality was 0.9%. OS was 94.1% at 5 years. Thirty tumours recurred within 11.7 (0.8-141.5) months. DFS was 44% at 5 years. At univariate analysis, high-grade complications were not associated with shorter DFS (p = 0.744). At multivariate analysis, no parameter was independent predictor for DFS or OS. The comparison of nil-minor versus major complications showed no DFS difference (p = 0.253). CONCLUSION: From our series, major complications after P-NETs resection are not associated to different disease recurrence; hence do not require different follow up or adjuvant regimens.

Use of biological mesh in trans-anal treatment for recurrent recto-urethral fistula.

PURPOSE: To report the author's experience on a mini-invasive technique using bioprosthetic plug and a rectal wall flap advancement in the treatment of recurrent recto-urethral fistula. MATERIALS AND METHODS: Between 2013 and 2015, seven patients with recurrent recto-urethral fistula were referred to the Pederzoli Hospital, Peschiera del Garda, Verona, Italy. Intraoperatively all patients were found to have a rectal wall lesion and were treated with urinary and fecal diversion. For the persistence of the fistula, all the patients underwent a mini-invasive treatment consisting on placement of a bioprosthetic plug in the fistula covered by an endorectal advancement flap through a trans-anal and trans-urethral combined technique. RESULTS: Median operative time was 48 min with a median blood loss of 30 ml. Median hospital stay was 3 days (IQR 1-3). No case of fistula recurrence or plug migration was described. None of the patients experienced fecal or urinary incontinence. All patients obtained complete fistula healing. CONCLUSIONS: Recurrent recto-urethral fistula is a challenging postsurgical complication for surgeons and urologists, and its best treatment is still unknown. Our method seems to be feasible and effective for the treatment of complex recto-urethral fistula.