A rare and challenging case of intrapericardial hydatidosis.

BACKGROUND: Hydatid cysts are most frequently located in the liver and lungs and very rarely can be found in the pericardium. Diagnosis and treatment are quite challenging, as the disease can present itself in many forms depending to the location and the complications that it might cause. CASE PRESENTATION: A 22-year-old man presented to our hospital with ongoing dry cough for more than 1 month prior to admission. Other symptoms included chest pain, fatigue, low grade fever, and night sweats, which have worsened in the past 2 weeks. Physical examination revealed normal respiratory and heart function. Chest X-ray demonstrated mediastinal enlargement and left pleural effusion. Contrast-enhanced computed tomography images showed a walled cystic mass lesion measuring up to 56 × 50 mm in close proximity to the upper left atrium, ascending aorta and pulmonary artery, potentially localized in the pericardium, with a 10 mm endoatrial filling defect, findings were compatible with hydatid cyst, left pleural effusion and peripheral pulmonary upper left lobe consolidation. Cardiac involvement was excluded on magnetic resonance imaging and trans-esophageal ultrasound. The patient underwent fine needle aspiration of the affected lung and thoracocentesis. No malignancy was found, meanwhile the biopsy confirmed the presence of pulmonary infarction. In view of the imaging findings were highly suspicious of a hydatid cyst, we performed a test of antibody titers that was negative. The patient underwent left anterolateral thoracotomy, and after the opening of the pericardium, a cystic mass of 5 cm in diameter was found next to the left atrium and in close proximity with the left pulmonary veins. The content of the cyst was completely removed after the surgical area was isolated with gauze impregnated with hypertonic solution (NaCl 10%). The mass resulted to be an echinococcal cyst with multiple daughter cysts within it that did not penetrate/involve (perforate) the cardiac wall. CONCLUSION: Pericardial echinococcosis is a very rare pathology in which a high expertise multidisciplinary approach is required. The compression mass effect caused by the cyst can lead to complications, such as in our case where the pulmonary vein was compressed, leading to pulmonary infarction. The value of radiology studies and transoesophageal ultrasound are very important in the diagnosis. Surgery in these cases is always recommended, but preferred surgical approach is questionable. In cases such as ours, we recommend anterolateral thoracotomy.

Second-Degree Type 2 Atrioventricular Block Requiring Permanent Cardiac Pacing in Patients on CDK4/6 Inhibitors: Report of Two Cases.

Introduction: A wide spectrum of cardiovascular (CV) toxicity is associated with anticancer treatment, and nearly all chemotherapeutic agents can elicit CV toxicity. Inhibitors of cyclin-dependent kinases 4/6 (CDK4/6Is) have become standard of care in the treatment of hormone receptor-positive, human epidermal growth factor receptor 2-negative metastatic breast cancer (MBC). CV side effects are uncommon with CDK4/6Is and only include QT prolongation, with a low incidence rate. Case Presentation: This paper describes 2 cases of new-onset second-degree type 2 atrioventricular (AV) blocks requiring permanent cardiac pacing involving 2 women with MBC receiving ribociclib or abemaciclib. Both our patients had no known history or risk factors of cardiac disease and a normal 12-lead resting electrocardiogram (ECG) when diagnosed with breast adenocarcinoma. Both patients have been subjected to surveillance for cardiotoxicity with serial ECG and echocardiography. No left ventricular dysfunction or arrhythmia was found during the follow-up, and cardiac biomarkers were normal. Conclusion: To our knowledge, these are the first cases reported in the literature of new-onset advanced AV blocks in patients under treatment with CDK4/6Is, suggesting the clinical relevance of a more frequent ECG monitoring, besides the QT interval, in these patients.

Extraction of a bullet floating in the pulmonary artery after a gunshot wound.

BACKGROUND: Patients with thoracic trauma caused by gunshots face a high risk of death, and medical staff often encounter technical difficulties in resolving these cases. Most gunshot wounds result in an entrance and exit wound. In cases with no exit wound, missiles are seen in other areas with screening radiographs. The bullet may migrate depending on gravity, coughing, swallowing, blood flow, or local erosion. CASE PRESENTATION: We present the case of a teenager who was hospitalized in critical condition owing to a left hemithorax injury caused by an improvised explosive device. The patient underwent two surgeries: an anterior left thoracotomy during which a hole in the myocardium was sutured, and after radiography, anterolateral right thoracotomy was performed, in which a deformed projectile was found at the level of the intermediate right pulmonary artery. CONCLUSIONS: This case highlights the crucial importance of repeated imaging to assess the possibility of projectile migration within the cardiovascular system in similar cases of penetrating injury. Immediate surgery was necessary and very important for the survival of our patient, despite the difficulties presented by this complicated case.

Intrapericardial gossypiboma found 14 years after coronary artery bypass grafting.

BACKGROUND: Foreign body left after surgery surrounded by a foreign body reaction otherwise known as gossypiboma, have been first described in 1884. Although it occurs rarely, it can lead to various complications which include adhesions, abscess formation and related complications. Intrathoracic gossypiboma is a rare but serious consequence of negligence, mainly during abdominal and cardiothoracic surgery that can lead to severe medical consequences. This paper aims to raise awareness among surgeons and nurses in the operating room to prevent such errors and future complications. CASE PRESENTATION: A patient with a history of coronary arterial bypass grafting performed 14 years ago, presented with shortness of breath and dry cough. A chest X-ray revealed a large mass in the left hemithorax. The chest CT demonstrated the presence of a heterogeneous density mass of 11 cm and smooth edges in the middle mediastinum, next to the heart and partially intrapericardial. Because clinical and radiologic evidence revealed presence of a mass, we did proceed with CT guided FNA of the mass. The cytology findings confirmed an inflammatory lesion. Based on patient symptomatology and the evidence of a mass, allegedly compressing the cardiopulmonary structures in vicinity, we performed surgical exploration. An old and degraded piece of surgical swap was found and removed through an anterolateral left thoracotomy. The post-operative course was excellent. CONCLUSIONS: Forgetting surgical swaps during surgery is a medical fault. To avoid them, surgical units should design and implement a surgical inventory process to account for surgical instruments or surgical swaps. Failure to make a proper diagnosis of cases such as these can lead to further health complications in these patients. The iatrogenic foreign material seen as a mass in the radiologic films had not been previously noticed by other health professionals although the patient had undergone X-ray and cardiac ultrasound examinations in the 14 years following coronary bypass surgery. Once the causative agent was identified and removed the patient returned to normal activity.

Anastomotic leakage following laparoscopic resection of low and mid rectal cancer.

PURPOSE: Anastomotic leakage is considered the commonest major complication after surgery for rectal cancer. MATERIALS AND METHODS: Patients who underwent laparoscopic LAR or ULAR for rectal cancer were recruited. The primary outcome was the incidence of the AL during 30 days postoperative. RESULTS: Fifty-nine consecutive patients were included in the study. Fifty-three patients underwent LAR with stapled colorectal anastomoses, while the remaining 6 patients underwent ULAR with hand-sewn coloanal anastomoses. The median duration of operation was 195 minutes (range; 120-315). The defunctioning ileostomy was created in 24 (7%) patients. Overall, there was no recorded mortality. Only 10 (17%) patients developed complications. There were only 4 patients who developed AL. Three patients had a subclinical AL as they had defunctioning ileostomy at the time of the initial procedure, the diagnosis was made by CT with rectal contrast. They were treated conservatively with transanal anastomotic drainage under endoscopic guidance. One patient had a clinically significant AL, demonstrated as a peritonitis. This patient required reoperation during which pelvic abscess was drained, resection of the previous anastomosis, and hartmann's colostomy was performed. CONCLUSION: Standardization of a definition, as well as, criteria for the diagnosis of AL, will help in comparison of the results and the surgical techniques in order to optimize the required care offered to rectal cancer patients. On expert hands, it is feasible to perform a laparoscopic sphincter-saving total mesorectal excision, additionally, it provides the advantages of a clear view of the deep pelvis and facilitates a precise sharp dissection. KEY WORDS: Anastomosis, Anastomotic Leakage, Rectal cancer, Total mesorectal excision.

Changes in the sensorimotor system and semitendinosus muscle morphometry after arthroscopic anterior cruciate ligament reconstruction: a prospective cohort study with 1-year follow-up.

PURPOSE: To evaluate the time course of sensorimotor integration processes involved in balance capability during 1-year follow-up after arthroscopic anterior cruciate ligament (ACL) reconstruction. To evaluate whether an association exists between balance performance and semitendinosus muscle morphometry features. METHODS: Twenty-seven patients (mean age 29.6 ± 10.8 years) were prospectively followed with stabilometry and ultrasound at 3 months (T0), 6 months (T1), and 1 year (T2) after arthroscopic ACL reconstruction. Body sway and sensorimotor integration processes were evaluated by calculating the percentage difference of sway (PDS) on two surface conditions. RESULTS: A significant difference in PDS was observed over time (p < 0.001). The interaction "Time × Condition" showed significant differences (p = 0.02), with worse performance on the compliant than the firm surface. There was a significant difference in CSA (p < 0.001), MT (p < 0.001), and %HRD (p < 0.001) over time. The interaction "Time*side" was significant for CSA (p = 0.02) and %HRD (p = 0.01). A negative correlation between PDS on compliant surface and CSA was measured at 3- (r = - 0.71, n = 27, p < 0.001) and 6-month post-surgery (r = - 0.47, n = 27, p = 0.013). CONCLUSIONS: Balance was regained within the first 6 months after surgery, while morphometry of the semitendinosus muscle improved mostly between 6 and 12 months in patients who returned to sports activities. Balance capabilities paralleled semitendinosus muscle morphometry improvements. The instrumental assessment of sensorimotor integration processes is relevant in clinical practice as screening tests for primary and secondary prevention of ACL injury. LEVEL OF EVIDENCE: Prospective studies, Level II.

Blunt abdominal trauma following gunshot wound Case report and literature review.

Blunt abdominal trauma following gunshot wound. Case report and literature review Introduction: Similarly to blast weapons, every firearm produces explosion at the moment of shooting, which can cause injuries in every region of the body. The aim of this paper is to present the mechanism of blunt abdominal injury following gunshot wounds, bringing this uncommon disease to the clinicians' attention and to review the literature available. CASE REPORT: A patient developed a delayed bowel perforation following a gunshot injury of the abdomen without breaking of the peritoneum. It was clinically suspected eight hours later and confirmed with contrast-enhanced computed tomography scan. The patient underwent immediate laparotomy. Resection, end-to-end anastomosis, and large lavage of the peritoneal cavity was performed. The patient was discharged ten days after operation in good condition. CONCLUSION: Failure to recognize blunt trauma mechanism following firearm wounds increases the risk of missed injuries. Distant injuries should be suspected in all cases after blast wave and firearms exposure and a follow up should be done for many days to make sure such injuries are excluded. CT scan total body is recommended in all such cases. Key words: Blunt trauma, Distant Injuries, Firearm injuries, Pressure Waves.

HypoparaNet: A Database of Chronic Hypoparathyroidism Based on Expert Medical-Surgical Centers in Italy.

Hypoparathyroidism is a rare disease characterized by low serum calcium levels and absent or deficient parathyroid hormone level. Regarding the epidemiology of chronic hypoparathyroidism, there are limited data in Italy and worldwide. Therefore, the purpose of this study was to build a unique database of patients with chronic hypoparathyroidism, derived from the databases of 16 referral centers for endocrinological diseases, affiliated with the Italian Society of Endocrinology, and four centers for endocrine surgery with expertise in hypoparathyroidism, to conduct an epidemiological analysis of chronic hypoparathyroidism in Italy. The study was approved by the Institutional Review Board. A total of 537 patients with chronic hypoparathyroidism were identified. The leading etiology was represented by postsurgical hypoparathyroidism (67.6%), followed by idiopathic hypoparathyroidism (14.6%), syndromic forms of genetic hypoparathyroidism (11%), forms of defective PTH action (5.2%), non-syndromic forms of genetic hypoparathyroidism (0.9%), and, finally, other forms of acquired hypoparathyroidism, due to infiltrative diseases, copper or iron overload, or ionizing radiation exposure (0.7%). This study represents one of the first large-scale epidemiological assessments of chronic hypoparathyroidism based on data collected at medical and/or surgical centers with expertise in hypoparathyroidism in Italy. Although the study presents some limitations, it introduces the possibility of a large-scale national survey, with the final aim of defining not only the prevalence of chronic hypoparathyroidism in Italy, but also standards for clinical and therapeutic approaches.

In situ preservation of the partathyroid glands in total thyroidectomy: a propensity score matched analysis.

AIM: Severe hypocalcemia due to parathyroid gland damage may be a serious complication after thyroidectomy. In order to save parathyroid integrity we developed a no-touch parathyroid (NTP) thyroidectomy technique. METHODS: We performed a total extracapsular thyroidectomy with NTP technique in consecutive 50 cases of benign goiter between July 2014 and June 2015. Parathyroid glands were firstly indentified, then they were separated from the thyroid avoiding manipulation or trauma and preserving their vascularization. Traditional scissors were preferentially used for dissection around the glands. Patients operated with NTP technique were matched by a propensity score to a control group. RESULTS: NTP was feasible in all foreseen patients except one. Propensity score selected a group of 23 patients/group for matching. No mortality has been observed in either group. Operative time were comparable between groups. Blood loss were significantly less abundant in the NTP group. No laryngeal permanent paralysis was experienced. Hospital stay was shorter yet not significantly in NTP group. Neither hypocalcemic crisis nor permanent hypoparathyroidism were described in either group. Serum calcium levels (NTP Vs control) were significantly higher in NTP group at day 1 (p=0.03) and day 2 (p=0.002), respectively. Similarly, intact parathormone dosages were significantly higher at day 1 (p=0.004) and day 7 (p=0.001), respectively. CONCLUSIONS: We conclude that NTP thyroidectomy is a feasible in the majority of the patientsand, allows a significant reduction of blood loss without prolonging the operative time. After the procedureboth values of calcemia and intact parathormonewere stable and no hypocalcemic crisis was experienced. KEY WORDS: Parathyroid, Hypoparathyroidism, Hypocalcemia, Total thyroidectomy.

Intraoperative continuous intestinal loop warming technique A prospective randomised trial.

AIM: The aim of this study is to evaluate if the Intraoperative Continuous Intestinal Loop Warming (ICLW) is a valid trick to decrease the postoperative paralytic ileus. METHODS: The subjects were patients who underwent emergency open abdominal surgery for either benign or malignant diseases. Patients were divided into two groups; group A patients who was secluded for ICLW, and a control group B who was not secluded for ICLW. The primary outcomes were the time of recovery of bowel movement, 30 days postoperative mortality and morbidity, morbidity was graded by the Clavien-Dindo classification of surgical complications. Secondary outcomes were operative time, and length of hospital stay. RESULTS: A total numbers of 100 patients were randomly assigned in this prospective study. The mean time of bowel function recovery in the group A was 41.52 hours, whereas for group B was 67.20 hours, these differences were statistically significant with a P value < 0.05. In group B the bowel function recovery for 64% of the patients took between 72-96 hours furthermore, the longest time for peristaltic recovery was 96 hours which was only observed in patients of group B. There were no intra-operative complication in both groups. There is no difference in the two groups in term of 30 day postoperative morbidity. CONCLUSIONS: Intra-operative continuous intestinal loop warming technique is a simple, safe and low cost technique. It seems that intra-operative continuous intestinal loop warming technique maintain tissues hydration and conserve the body temperature limiting the stress response and help in decreasing the incidence of postoperative paralytic ileus. KEY WORDS: Paralytic Ileus, Postoperative Care, Warming.

Delayed diagnosis and treatment of high grade blunt pancreatic trauma. Case report and review of literature.

INTRODUCTION: Despite technological advancement, high grade pancreatic injuries following blunt abdominal trauma continues to remain a disease that is associated with high morbidity and mortality rates, particularly in cases of delayed diagnosis. The aim of this paper was the presentation of delayed diagnosis and treatment peculiarities of high grade pancreatic trauma and a review of literature. CASE REPORT: A 55-years old man, involved in motor vehicle crashes, was referred to our level I trauma center. Hemodynamically stable. Abdominal physical exam, laboratory and focused abdominal sonography for trauma were normal. First total body multidetector CT scan, performed only after 24 hours, showed almost complete left pneumothorax, left third to fifth rib fractures and subcutaneous emphysema. Left chest tube was applied. On the eighth post-traumatic day, the general condition of the patient started to deteriorate. The patient showed abdominal pain, fever, nausea, vomiting, and bilateral flank ecchymosis. Only the third CT scan performed, on twelfth day, after the peritoneal signs, changes in blood and biochemical parameters appear, we revealed linear laceration and hypo-attenuation area of the neck and a part of distal body pancreas. In laparotomy fat necrosis, giant retroperitoneal abscess, necrosis of the neck and distal body of the pancreas, was found. Distal pancreatectomy with splenectomy was performed. Postoperative course with extensive wound infection and necrotic leakage from peripancreatic drain was complicated. The patient was discharged two months after his operation without any events. CONCLUSION: On time diagnosis of pancreatic trauma, especially in polytrauma patients, continues to remain a challenge for trauma surgeons. Main pancreatic duct injury is an important prognostic factor and the major one determining therapeutic approaches. Adequate surgical approaches decrease morbidity and mortality in pancreatic trauma. KEY WORDS: Delayed diagnosis, Distal pancreatectomy, Pancreatic blunt trauma.

Transitional challenges of Medicine and Surgery in Albania.

Data on the State of Art of Medicine and Surgery in Albania, are given in this short survey. From recent epidemiological data, conditioned by high rate of migration and territory problems, to problems arising from lack of technological supports and important changes in medical education. An analysis that we could do from the observatory of our Medical School, and international one, based on a strict collaboration among an international professor staff, mostly coming from Italian Universities, particularly the University of Rome, "Tor Vergata", co-founder of the "Catholic University Our Lady of Good Counsel" (UCNSBC). The integration between academics in UCNSBC and health personnel in health care offers some interesting opportunities in research. The recognized limited technological supports create the possibilities to adjust and ameliorate health care services, with the aim of a more convenient distribution of the available resources. KEY WORDS: Academic education, Albania, Epidemiology, Health education.

Concept design and simulation study on a "phantom" anvil for circular stapler.

INTRODUCTION: Complications and challenges arising from the intraoperative double-stapling technique are seldom reported in colorectal surgery literature. Partial or full-thickness rectal injuries can occur during the introduction and the advancement of the circular stapler along the upper rectum. The aim of this study is to address some of these issues by designing and optimizing a "phantom" anvil manufactured to overcome difficulties throughout the rectal introduction and advancement of the circular stapler for the treatment of benign and malignant colon disease. METHODS: The design of the "phantom" anvil has been performed using computer-aided modeling techniques, finite element investigations, and 2 essential keynotes in mind. The first one is the internal shape of the anvil, which is used for the connection to the gun. The second is the shape of the cap, which makes possible the insertion of the gun through the rectum. The "phantom" anvil has 2 functional requirements, which have been taken into account. The design has been optimized to avoid colorectal injuries, neoplastic dissemination (ie, mechanical seeding) and to reduce the fecal contamination. RESULTS: Numerical simulations show that a right combination of both top and bottom fillet radii of the shape of the anvil can reduce the stress for the considered anatomic configuration of >90%. Both the fillet radii at the top and the bottom of the device influence the local stress of the colon rectum. CONCLUSIONS: A dismountable device, which is used only for the insertion and advancement of the stapler, allows a dedicated design of its shape, keeping the remainder of the stapler unmodified. Computer-aided simulations are useful to perform numerical investigations to optimize the design of this auxiliary part for both the safety of the patient and the ease of the stapler advancement through the rectum.

The "lost anvil": an original technique for laparoscopic colorectal anastomosis.

AIM: During laparoscopic colorectal anastomosis, the rectal introduction of the circular stapler is achieved without hand assistance, increasing the risk of rectal injury. Therefore, we describe a technical adjustment facilitating rectal advancement of the stapler. MATERIALS AND METHODS: Two hundred consecutive patients with benign condition underwent laparoscopic sigmoidectomy. Before any stapling, the complete circular stapler is introduced into the anus. The anvil is released in the lumen of the colon to be resected. After cross-stapling the rectum, the anvil is retrieved in the resected specimen before the final steps of the anastomosis. Feasibility, safety, and long-term results were evaluated. RESULTS: In 194 patients, the anastomosis was successfully performed at upper rectal level. Only, 1 rectal wall injury was observed. At a median follow-up of 44 months, 3 patients presented anastomotic stenosis and 2 small-bowel obstructions. CONCLUSIONS: "Lost anvil" technique allows easy and safe circular stapler rectal advancement for laparoscopic colorectal anastomosis in benign diseases.

Acute right intrathoracic gastric volvulus. A rare surgical emergency.

The acute intrathoracic gastric volvulus is a rare condition, difficult to diagnose and treat. It consist in a abnormal organo-axial rotation over 180°, associated with gastric obstruction or strangulation. More uncommon condition is the gastric volvulus caused by a right sliding diaphragmatic hernia and dislocating the stomach, or part of it, on the right hemithorax. Gastric volvulus classic clinical presentation described by Borchardt, consist on a triad of severe epigastric pain, vomiting followed by retching without ability to vomit and difficulty or inability to pass a nasogastric tube. Imaging, beginning from a simple chest radiograph showing an elevated gastric air-fluid level in lower lung segments, can help to define diagnosis and to determine the immediate necessity to operate trying to avoid fatal complications as gastric ischemia, perforation or haemorrhage. We present the case of a 58 year-old man arrived at our Emergency Department with moderate acute epigastric pain and already vomiting from 4 hours. The patient underwent initially a chest radiograph, Computed Tomography, upper digestive endoscopy, upper digestive contrasted radiology and then was operated. Post operative situation of the patient on recovery and during the 3 months follow up didn't experience any pain or difficulty in feeding.

Continuous monitoring of the recurrent laryngeal nerve in thyroid surgery: a critical appraisal.

BACKGROUND AND PURPOSE: Intraoperative neuromonitoring (IONM) contributes in several ways to recurrent laryngeal nerve (RLN) protection. Notwithstanding these advantages, surgeons must be aware that the current, intermittent, mode of IONM (I-IONM) has relevant limitations. To overcome these I-IONM limitations, a continuous IONM (C-IONM) technology has been proposed. METHODS: A PubMed indexed literature review of the current limitations of I-IONM is presented and a commentary about C-IONM is provided presenting the preliminary results of research on this topic. MAIN FINDINGS: I-IONM, despite the advantages it produces, presents some important limitations; to overcome these drawbacks a C-IONM technology has been introduced. CONCLUSIONS: RLN traction injury is still the most common cause of RLN injury and is difficult to avoid with the application of I-IONM in thyroid surgery. C-IONM is useful to prevent the imminent traction injury by detecting progressive decreases in electromyographic amplitude combined with progressive latency increases. C-IONM seems to be a technological improvement. Likely, C-IONM by vagal nerve stimulation should enhance the standardization process, RLN intraoperative information, documentation, protection, training, and research in modern thyroid surgery. Although C-IONM is a promising technology at the cutting edge of research in thyroid surgery, we need more studies to assess in an evidence-based way all its advantages.

Endoscopic single-port "components separation technique" for postoperative abdominal reconstruction.

BACKGROUND: In 1990, Ramirez introduced a new procedure to close abdominal wall hernia (AWH), called "components separation technique (CST)". Thanks to endoscopy, surgical repair possibilities have risen, reducing the operative trauma and preserving vascular and neuronal anatomical structures. This report aims to describe a single port endoscopic approach for CST to repair the abdominal wall of a patient undergoing surgery for abdominal aneurysm and already subject to placement of a mesh for AWH. METHODS: We performed endoscopic-assisted CST, using a single-port access with a gasless technique. CONCLUSION: CST is a useful procedure to close large abdominal wall incisional hernia avoiding the use of mesh, notably under contamination, when prosthetic material use is contraindicated. The endoscopic-assisted CST produces same results than the conventional open separation technique and also minimised tissue trauma that ensures blood supply and prevents postoperative wounds complications. The described single port method was found to be safe and effective to close large midline abdominal hernias when a primary open or laparoscopic closure is not feasible or when patients have been previously treated with abdominal meshes.

Skin phototype and local trauma in the onset of balanitis xerotica obliterans (BXO) in circumcised patients.

The association between balanitis xerotica obliterans (BXO) and skin disorders is long established, however, the role of skin phototype and local trauma in its onset has never been investigated in detail. Medical records of all Caucasian children circumcised over a 6-year period were reviewed. The excised skin underwent histological examination for BXO. Children with histological diagnosis of BXO were classified as group A, whereas children without histological diagnosis of BXO were classified as group B. The Fitzpatrick phototype (FT) was obtained in all children performing a personal or family interview with regards to their sunburn and suntan experience. According to their FT, both group A and B patients were divided into two subgroups: FT 1-2, with a higher tendency to sunburn due to their low skin melanin content; and FT 3-4 with a higher tendency to tan due to their higher skin melanin content. Maneuvers of mechanical reduction of the foreskin (MRF) performed at least 5-10 times per month during the year preceding circumcision was also considered. Statistical analysis was performed using univariate and multivariate analysis. A total of 297 patients met the inclusion criteria of our study: 78 patients were classified as group A and 219 as group B. The risk of developing BXO was significantly greater in FT 1-2 patients (n=76) (odd ratio=0.232, 95% confidence interval=0.124-0.435, p<0.0001). Furthermore, those undergoing MRF (n=131) had a significantly higher risk of developing BXO (odds ratio= 5.344, 95% confidence interval=2.860-9.987, p<0.0001). Although the foreskin is not directly exposed to sunlight, this study emphasizes the role of skin phototype on the onset of BXO in circumcised individuals. Moreover, the data produced suggest should the advantages of repeated MRF be weighed against the increased risk of developing BXO, which in turn may increase complication rate of circumcision surgery.

Randomized clinical trial on Harmonic Focus shears versus clamp-and-tie technique for total thyroidectomy.

BACKGROUND: The Harmonic Focus is the last ultrasonic device designed for thyroid surgery. The aim is to assess its efficacy and safety compared with traditional dissection in a prospective randomized trial of total thyroidectomy procedures. METHODS: Total thyroidectomy was performed in 34 patients using the Harmonic Focus, and in 34 patients using the clamp-and-tie technique. RESULTS: In the Harmonic Focus group, relative reductions of 29% and 46% were observed in surgical time and blood loss, respectively. The number of intraoperative instrument exchanges also decreased by 70%, and use of specific materials required to achieve hemostasis decreased significantly. Safety was found to be similar in both patient groups. CONCLUSIONS: Our study showed beneficial effects of Harmonic Focus use in thyroid surgery. Further studies therefore are needed to evaluate cost in the light of savings made in surgical time, materials needed for hemostasis, and human resources.

A dry lab for medical engineers?

INTRODUCTION: We describe a teaching and training method with objective evaluation to improve medical engineering students' knowledge and analysis skills about Minimally Invasive Surgery (MIS) instrumentation and techniques through hands-on experience. Training has been scheduled during a three-month course. METHODS: Twenty medical engineering students were trained to perform three times on a pelvic trainer a sequence of standardized drills connected with the selected MIS techniques, in order to improve their dexterity. The time required to perform each dexterity drill was recorded in seconds.Then, the participants were divided into groups and asked to write an essay about an instrument they chose, analyzing and criticizing the instrument itself. RESULTS: All the trainees showed steady improvement in skill acquisition on the laparoscopic simulator and discussed their essays, making proposals in order to improve the instrument they tested. CONCLUSION: Significant improvement in performance with increasing skillness has been measured; during the course and during their discussion the participants showed deep knowledge of the instrument, ability to analyze and criticize it and ability to make improvement proposals.Dry lab experience for medical engineering students is useful for teaching and improving analysis and management of laparoscopic devices, allowing identification of problems and developing better devices.