Prevention of complications during reoperative thyroid surgery.

BACKGROUND: Thyroidectomy performed by an experienced surgeon is associated with a low incidence of recurrent laryngeal nerve injury and permanent hypoparathyroidism. During reoperative thyroid surgery there is a higher technical risk because detection and preservation of the recurrent laryngeal nerves and parathyroid glands are more difficult than in the primary surgery. AIM: Our retrospective cohort study was to assess short- and long-term complications associated with reoperative thyroid surgery in order to suggest a technical approach to lower the morbidity rate. MATERIALS AND METHODS: From January 2005 to September 2013, 745 patients underwent surgery for thyroid disease. Before surgery all patients underwent clinical examination, laboratory blood tests, hormonal assays, neck ultrasound, chest radiography and indirect laryngoscopy. Patients were followed up at 1, 3, 6 months and then annually after operation with hormonal assays, blood tests and neck ultrasound. RESULTS: Eighty (10.7%) out of 745 patients (mean-age= 52.5 years; age-range 18-80) underwent reoperative surgery for recurrent thyroid disease. The primary treatments were enucleoresection (11.2%), thyroid lobectomy(56,3%), thyroid lobectomy with isthmectomy(10%) and subtotal thyroidectomy (22,5%). In the reoperative surgery group (Group Re) the transient RLN complications were 1.3% compared to 0.2% in the primary surgery group (Group P) (p= 0.51). The incidence of temporary hypocalcemia was 45% in the reoperative surgery group vs. 42.7% in the primary surgery group (p=0.72). CONCLUSIONS: Reoperative surgery should be reserved to experienced surgeons. However, even in this case, when surgical maneuvers reserved for primary surgery are applied, then this surgery is associated with a low complications rate.

Gastrointestinal stromal tumors treatment in the Imatinib era. The role of fair indication.

AIM: Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Surgery remains the elective treatment. We retrospectively compared two group of patients, who underwent surgery for GIST before and after Imatinib advent in order to analyze the recurrence and survival rate. METHODS: Two patient groups who underwent surgery for GIST, from January 1997 to December 2002 (Pre-Imatinib group) and from January 2003 to December 2008 (Post-Imatinib group) were compared. Patients were evaluated on the base of gender, age, clinical manifestations, primary location and metastasis positivity, tumor size, mitotic index, immunoreactivity for CD117 and the outcome, including date of death. RESULTS: In the Pre-IM group only one patient died for prostate cancer, 12 months after operation, the other died because of GIST with a 24.6 months of median survival rate (range 15-51). In the remaining 12 patients the median follow up period was 55 months (range 6-152 months). In the Post-IM group the mean follow up was 50.7 months (range 26-74) and they are still being assessed for oncological as well as surgical treatment. CONCLUSION: Early diagnosis and radical resection remain the standard of cure for GISTs. To date, the use of Imatinib lead to its utilization as adjuvant and neo-adjuvant therapy in adults. Our experience suggests that there is a correlation between the mutational status of KIT and clinical outcome. These aspects should be explored for targeted therapy that can effectively combine biological therapy to surgery.

[Open mesh technique versus laparoscopic transabdominal preperitoneal (TAPP) approach in inguinal hernia repair. Our experience]. / Tecnica open versus TAPP nel trattamento dell'ernia inguinale. Nostra esperienza.

BACKGROUND: In the last ten years the introduction of various open mesh and laparoscopic techniques has increased the interest in inguinal hernia surgery. Anyway controversy persists about the most effective inguinal hernia repair. The aim of this study was to compare the results of open mesh technique and laparoscopic transabdominal preperitoneal (TAPP) repair for inguinal hernia. PATIENTS AND METHODS: We considered 584 patients, 532 man and 52 woman, between 19 and 86 years: 332 (56.8%) had open mesh repair and 252 (43.2%) laparoscopic TAPP repair of groin hernia. Operative time, complications, recurrences and time to normal activities were recorded in both groups (range follow-up 1-10 years). RESULTS: The median operative time was 71 min for open group and 92 min for TAPP group. No intraoperative complications were observed. Postoperative complication rate was 4,5% in patients open group and 3% in TAPP group. The recurrence rate was less than 1% in both groups (0,6% for open repair and 0,4% for laparoscopic repair). Significant difference was observed in the median time to return to normal activities: 9,8 days in TAPP group versus 13,4 days in open approach. CONCLUSIONS: Our experience confirmed the safety and effectiveness of laparoscopic transabdominal preperitoneal (TAPP) approach to inguinal hernia repair as excellent alternative to conventional surgery. The reduction of operative time, complications and recurrences is correlated to the surgeon's experience and learning curve.

[Correlation between surgical intervention, adjuvant therapy, and long-term survival in patients operated on for breast neoplasia]. / Correlazione tra intervento chirurgico, terapie adiuvanti e sopravvivenza a distanza in pazienti operate per neoplasia mammaria.

INTRODUCTION: Breast cancer is the most frequent cancer among female sex, above all in rich countries where it occurs ten times more than the others. The most incidence of breast cancer is in female over 45 yrs and over 70 yrs with a plateau during menopause. So it is really very uncommon before 30 yrs. It is well known that breast cancer is related to several risk factors: these have always to be well evaluated before any treatment, especially in surgery. In the last years we can see an improvement of techniques to make diagnosis of breast cancer. Also surgery has improved in that way, so it can ensure better results to patients than before, also from the esthetical point of view. There are lot of discussions on which is the best surgical treatment to do, if lymphoadenectomy of the armpit is always required and if it has to be considered only as a prognostic element or also a therapeutical one. It is also important to plan radio, chemio and hormonal therapy, well chosen on the base of histological exams, and of the grading made either before either during surgery. Last studies moreover evaluate the specificity, the importance and the prognostic value of searching the so called "sentinel lymph node" who is always the first one to be interested in a metastatic process. STUDY AND DISCUSSION: Through a random and retrospective study among all our female patients (Department of Surgical Science in Rome University "La Sapienza") who had surgery for breast cancer in the last ten years (approving all the hystological exams) we have related the kind of surgical treatments to overall survival, to the therapies, and to any possible local recurrence of disease. We analyzed 270 female patients (age between 19 and 83). We considered all surgical treatments used in breast cancer: from the "simple" quadrantectomy up to radical mastectomy with the association of lymphoadenectomy of the armpit (both armpits in case of recurrence to disease). All these patients had then their own therapy (radio, chemo or hormonal one, it depended on each case) and follow up of the length of at least five years. The overall survival was of 82.2%. From these study we made important considerations about all the factors involved in breast cancer. The first step is to consider always all of these to have a well surgical approach, and to get the best compliance and performance from patients in order to have at distance the best results.