Cancer of the thyroid gland in geriatric age: a single center retrospective study with a 10-year post-operative follow-up.

INTRODUCTION: We evaluated the characteristics of thyroid carcinoma in geriatric patients and outcomes after a 10-years follow-up. METHODS: Comparative retrospective study on a group of 31 geriatric patients and one of 224 non-geriatric, who underwent surgery for thyroid carcinoma in the period 1998-2003. We compared with Fisher's exact test: histology, multifocality, tumor size, lymph-node metastasis, distant metastasis, persistence/recurrence and mortality, including and excluding anaplastic carcinomas, in a subgroup of 26 geriatric patients and another of 223 non-geriatric patients. RESULTS: RESULTS for the geriatric and non-geriatric groups and in the geriatric and non-geriatric subgroups respectively were as follows: multifocality 9/31 vs. 74/224 (p-value 0.8382) and 9/26 vs. 74/223 (p-value 1); tumor size: 16/31 vs. 28/224 T3-T4 (p-value < 0.0001) and 11/26 vs. 27/223 T3-T4 (p-value 0.0004); lymph-node metastases: 17/31 vs. 34/224 (p-value < 0.0001) and 12/26 vs. 33/223 (p-value 0.0004); distant metastases: 8/31 vs. 3/224 (p-value < 0.0001) and 3/26 vs. 2/223 (p-value 0.0088); disease recurrence/persistence: 11/31 vs. 3/224 (p-value < 0.0001) and 6/26 vs. 2/223 (p-value > 0.0001); mortality: 7/31 vs. 2/224 (p-value < 0.0001) and 2/26 vs. 1/223 (p-value 0.0295). Anaplastic carcinomas were predominantly in the geriatric group: 5 vs. 1 (p-value < 0.0001). No statistical differences for other histotypes. DISCUSSION: Thyroid carcinoma is more aggressive in geriatric patients. This may justify a more aggressive surgical strategy with possible prophylactic lymphadenectomy, in addition to ablative therapy with (131)I and suppressive therapy with levothyroxine. CONCLUSION: It would be useful to undertake randomized prospective studies on a large cohort of patients to determine the most effective therapy for geriatric patients suffering from thyroid carcinoma.

Thyroid surgery in the elderly: a comparative experience of 400 patients from an Italian university hospital.

The aim of this study was to compare disease features and surgical complications of patients undergoing surgery under or over 65 years of age. We performed a retrospective review of patients undergoing thyroidectomy or lobectomy from January 1990 through January 2012 in our Institution. Patients aged over 65 years of age were compared with younger patients on a 1:1 ratio. A total of 2012 patients were operated on during the study period. Two-hundred patients aged > 65 years were compared with 200 patients < 65 years old. In this series, no significant differences were observed concerning surgical complications between groups. At multivariate analysis, masses causing compression, extended approaches and malignant lesions were significant predictors of complications, irrespective of age. Due to longer life expectancy, elderly patients are being operated on more frequently. Safety of thyroid surgery in this population is still debated. We observed no difference in surgical outcomes between elderly and younger patients; however, some features of the diseases impair survival in the former. Age did not increase likeliness of worse outcomes in patients receiving thyroid surgery.

Double probe intraoperative neuromonitoring with a standardized method in thyroid surgery.

INTRODUCTION: The purpose of this study was to evaluate the effectiveness of intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) and the vagus nerve (VN) with a standardized approach in thyroid surgery. METHODS: Retrospective study with an experimental group with which IONM was used, both with the RLN that the VN, and a control one, each consisting of 300 total thyroidectomies. Each patient underwent a pre-and post-operative videolaryngoscopy. The number of RLNs identified and the number of transient and permanent RNL injuries for each group were assessed, and then compared with χ(2) tests. In the experimental group Sensitivity, Specificity, Positive Predictability, Negative Predictability and Accuracy of IONM were evaluated, depending on the number of true positive results, false negatives, true negatives and false positives obtained by comparing the results of IONM with the post-operative videolaryngoscopies. RESULTS: The results obtained for the experimental group vs. the control group were: RLNs identified 595 (99.1%) vs. 552 (92%) -P Value <0.0001; Permanent RLNs injuries 4 (1.33%) vs. 5 (1.67%) -P Value 1; transient RLNs injuries 1 (0.33%) vs. 8 (2.67%) -P Value 0.044. The IONM system, for the RLN and VN showed respectively: Sensitivity 66.7% vs. 83.3%; specificity 97.6% vs. 99.5%; Positive Predictability 22.2% vs. 62.5%; Negative Predictability 99.6% vs. 99.3%; Accuracy 97.3% vs. 99.3%. CONCLUSIONS: Our study highlights that using IONM with a standardized method in thyroid surgery, improves the ability to identify the RLN and a reduction in the incidence rate of transient RLN injuries.

Verification of the effectiveness of silver dressings to prevent reinfection of skin ulcers after debridement.

OBJECTIVE: To test the usefulness of silver dressings in patients with skin ulcers in the healing phase after debridement. MATERIALS AND METHODS: After randomly selected a group of 30 patients and divided them into three groups (A, B and C) according to the type and severity of the ulcer, we used respectively for each group antiseptics-free dressings, hydrofiber dressings with a low or a high content of silver. Then we performed samples by aspiration from the bottom of the wound three times (zero time, after two weeks, after a month) to prepare bacterial cultures. RESULTS: In group A, 5 ulcers showed signs of critical colonization after two weeks and 2 of these showed evidence of infection without progression to healing after a month. In groups B and C, no ulcer showed signs of infection with negative cultures. In these two groups, wounds evolved towards healing. CONCLUSIONS: Silver dressings seem to be the best option for the prevention of reinfection of skin ulcers; silver concentration should vary according to the degree of ulcer contamination. Dressings with hydrofibers avoid the accumulation of secretions for bacterial growth which would compromise tissue repair.

Abdominal hypertension and venous insufficiency of lower limbs: is there a relationship?

OBJECTIVE: The purpose of our study is to understand the compression, by subcutaneous fat in obese patients, who present a chronic increase in abdominal pressure, and on the sapheno-femoral cross. Such increase would result in a chronic venous insufficiency (CVI) of lower limbs and, if possible, it will be quantified also according to the posture. MATERIAL AND METHODS: We studied two different groups of patients with CVI: obese and non-obese. The severity of CVI was classified with the CEAP classification or by the standards of recent classifications. Abdominal pressure, by means of Kron's method, and anterior-sagittal diameter were measured in some of the non-obese patients (4 males and 4 females) and in all the obese patients. The diameter of the femoral vein of both groups of patients in supine, sitting and standing positions was also measured. RESULTS: We found a higher incidence of CEAP 5-6 classes in the obese group than in the non-obese one; we also saw a higher incidence of classes 1-2 in the non-obese group than in the obese one. Moreover, Kron's method showed a significant difference in abdominal pressure in relation to the BMI and the increase in the femoral vein diameter appears to be related to the weight and to the position. DISCUSSION: It was clear that the clinical manifestations of CVI are more severe in obese than in non-obese patients. Obesity in our study clearly acts with a continuous compressive action on the veins of the abdomen and thereby on the femoral vein, further contributing to a retrograde flow. So we tried to quantify an entity that until now could only be assumed.

NIM vs Neurosign in nerve sparing total thyroidectomy. Multicentric experience.

INTRODUCTION: Injury to cranial nerve represents 5% of negligence litigation against general surgeons and of all malpractice jury verdicts in endocrine surgery 60% accounts for recurrent nerve injuries and 15% for anoxic brain injuries from RLN injuries, unrecognized post-operatively. During Total Thyroidectomy is reported an incidence of failure to find the nerve in 5- 18% of cases and if we think that routine identification of the RLN during thyroid surgery has reduced the injury rate from 10% to less than 4% and that the incidence of nerve paralysis was 3 to 4 times greater in cases where the nerve was not exposed than in cases where was routinely exposed, then we understand the importance of a clear identification during every thyroid dissection MATERIALS AND METHODS: 880 Total Thyroidectomies during the last 4 years, since Jannuary 2007 until December 2010, (610 F, 270 M; mean age 44,5 years old, range 14-83). All patients were examined pre and postoperatively (1-6 months after) by direct laryngoscopy or laryngofibroscopy to check vocal cord mobility (medium follow up 25.5 months range 3-50 months). The Authors reviewed charts from two randomized groups, selected by a double blind, statistically designed study and again compared in a multivariate analysis (Stat 2004 ltd): 1) 480 total sutureless thyroidectomies, performed during the previous year with continuous intra-operative nerve monitoring using dedicated endotracheal tube with a last generation Nerve Integrity Monitor Pulse II (N.I.M. pulse II®) 2) 400 total sutureless thyroidectomies: performed with continuous intra-operative nerve monitoring using dedicated Laryngeal Electrode, a self-adhesive device designed to fit onto standard reinforced endotracheal tubes (Neurosign® 1040 - 4 Channel EMG) RESULTS: There were no statistically significative difference between the two groups for distribution of age, sex, epidemiological characteristics, type of pathology etc. The incidence of major complications in thyroid surgery in the first two groups (total Thyroidectomy performed by NIM and by Neurosign), as well as compared with the data of the literature are absolutely overimposable; only significative difference is a reduction of the costs in the second group (Neurosign). The 1st group (NIM) specificity is 90.2% (433/480). There were 6 cases of temporary RLN paralysis (temporary paralysis rate: 1.25 % of patients), 3 true positive and 3 false negative. Finally there were 3 cases of permanent RLN paralysis (0.75%), 2 truepositive and 1 false-negative developed after 10 days (demyelination by thermal injury). The 2nd group (Neurosign) specificity of 89 % (356/400). There were 6 cases of temporary RLN paralysis (rate: 1.5 %, p > 0.5), 2 true positive, 1 false positive and 4 false negative. Finally 2 cases of permanent RLN paralysis (0.5% p > 0.5), 2 true-positive. DISCUSSION AND CONCLUSION: Our data confirm a useful application of NIM and Neurosign in thyroid dissection nerve prevention. We don't believe that those procedures can be useful for learning thyroid gland surgery, because can't preserve from an accurate dissection and nerve identification technique, but can only support in nerve-at-risk thyroidectomy or during dissection can support expert surgeon's decision, having a clear pre-operative (post-anesthesiologist) and post-operative predictive value. Those procedures are anyway expensive and time consuming (25000-30000 € for the E.M.G. system and almost 200-250 € for each dedicated endotracheal tube in NIM group). So Neurosign group has over-imposable results in terms of complications specificity and accurancy (no statistically significative differences), but it's a much cheaper procedure!

Nerve sparing sutureless total thyroidectomy. Preliminary study.

AIM: In the present study the authors assess the advantages of new technologies in thyroid surgery: to prevent nerve injury by using an intra-operative continuous nerve-monitoring techniques and to compare the real advantages of advanced coagulation devices. MATERIALS AND METHODS: Among a series of 440 thyroidectomies (jan 2004-feb 2006) the Authors reviewed charts from two groups: (1) 240 total thyroidectomies performed using the traditional monopolar electrocautery, non-absorbable stitches for the principal vascular pedicles. (2) 140 total thyroidectomies performed using dedicated small bipolar electro thermal coagulator (ligasure-precise). (3) Since 2006 in a double blind group selection of 70, we've performed sutureless thyroidectomy with continuous intraoperative nerve monitoring using dedicated endotracheal tube. Mean operative time, post-operative bleeding, post-operative stay, incidence of transient or definitive laryngeal nerve lesions, incidence of permanent or transient hypocalcaemia, costs of the procedures were analyzed. RESULTS: Major complications in the first two groups compared with the data of the literature are absolutely over-imposable, except a reduction of incidence of transient hypocalcaemia in the Precise group, but if we compare data of the 3rd group (NIM), we find a significative reduction of transient and permanent laryngeal nerve palsy incidence. DISCUSSION AND CONCLUSION: This new technology offers several advantages: (1) atraumatic; (2) easy to use; (3) continuous monitoring and audio feedback to the surgeon (4) works outside the operation field (5) high sensitiveness. Cost-analysis confirm that NIM + ligasure have same or less cost and time and probably less complications than traditional Total Thyroidectomy.

Artificial intelligence against breast cancer (A.N.N.E.S-B.C.-Project).

INTRODUCTION: Our preliminary study examined the development of an advanced innovative technology with the objectives of--developing methodologies and algorithms for a Artificial Neural Network (ANN) system, improving mammography and ultra-sonography images interpretation;--creating autonomous software as a diagnostic tool for the physicians, allowing the possibility for the advanced application of databases using Artificial Intelligence (Expert System). MATERIALS AND METHODS: Since 2004 550 F patients over 40 yrs old were divided in two groups: 1) 310 pts underwent echo every 6 months and mammography every year by expert radiologists. 2) 240 pts had the same screening program and were also examined by our diagnosis software, developed with ANN-ES technology by the Engineering Aircraft Research Project team. The information was continually updated and returned to the Expert System, defining the principal rules of automatic diagnosis. RESULTS: In the second group we selected: Expert radiologist decision; ANN-ES decision; Expert radiologists with ANN-ES decision. The second group had significantly better diagnosis for cancer and better specificity for breast lesions risk as well as the highest percentage account when the radiologist's decision was helped by the ANN software. The ANN-ES group was able to select, by anamnestic, diagnostic and genetic means, 8 patients for prophylactic surgery, finding 4 cancers in a very early stage. DISCUSSION AND CONCLUSION: Although it is only a preliminary study, this innovative diagnostic tool seems to provide better positive and negative predictive value in cancer diagnosis as well as in breast risk lesion identification.

[Antibiotic prophylaxis in breast surgery. Preliminary resuls of a multicenter randomized study on 1400 cases]. / Antibiotico profilassi in Chirurgia Senologica. Risultati preliminari di uno studio multicentrico randomizzato su 1400 casi trattati.

UNLABELLED: Breast surgery is classified among the procedures performed in clean surgery and is associated with a low incidence of wound infection (3-15%). The objective of this study was to evaluate the advantages antibiotic prophylaxis in patients undergoing breast surgery. A multicenter randomized controlled study was performed between January 2008 and November 2008. One thousand four hundred patients were enrolled in prospective randomized study; surgical wound infection was found in 41 patients (2.93%). In our RCT we have shown that in breast surgery antibiotic prophylaxis does not present significant advantages in patients with potential risk of infection (17 patients, 2.42%, subjected to antibiotic prophylaxis vs 24 patients, 3.43%, without antibiotic prophylaxis) (P = 0.27). In patients with drainage there is a significant minor incidence of wound infections in patients receiving antibiotic prophylaxis (5 patients, 0.92%, subjected to antibiotic prophylaxis vs 14 patients, 3.09%, without antibiotic prophylaxis) (P = 0.02). CONCLUSION: This study is only a preliminary RCT to be followed by a study which should be enrolled more patients in order to get the results as statistically significant.

Percutaneous ethanol injection of hyperfunctioning thyroid nodules: long-term follow-up in 125 patients.

OBJECTIVE: The purpose of this study was to assess the long-term efficacy of percutaneous ethanol injection (PEI) for the treatment of hyperfunctioning thyroid nodules. MATERIALS AND METHODS: One hundred twenty-five patients (88 women, 37 men; age range, 17-76 years; mean age, 53 years) with 127 hyperfunctioning thyroid nodules (volume, 1.2-90 mL; mean, 10.3 mL) were treated with PEI. There were 1-11 PEI sessions per patient (average, 3.9) performed, with injection of 1-14 mL of ethanol per session (total injected ethanol per patient, 3-108 mL; mean, 14.0 mL). Efficacy of the treatment was assessed with color Doppler sonography; scintigraphy; and free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH) assays. Follow-up (9-144 months; median, 60 months) was performed with TSH and color Doppler sonography every 2 months for 6 months and every 6 months thereafter. RESULTS: Three (2.4%) of 125 patients refused completion of PEI therapy because of pain. Results are reported in 122 patients with 124 nodules. All 122 patients showed posttreatment normal levels of FT3, FT4, and TSH. A complete cure (absent uptake in the nodule and recovery of normal uptake in the thyroid parenchyma) was obtained in 113 (93%) of 122 patients-115 (92.7%) of 124 treated nodules. Residual hyperfunctioning nodular tissue along with decreased thyroid parenchyma uptake (partial cure) was present in nine patients accounting for nine (7.3%) of 124 nodules. Rates of complete cure after PEI were: overall nodules, 115 (92.7%) of 124; nodules < or = 10 mL, 63 (94.0%) of 67; nodules > 10 to < or = 30 mL, 32 (91.4%) of 35; nodules > 30 to < or = 60 mL, 17 (89.5%) of 19; nodules > 60 mL, three (100%) of three. The overall rate of major complications (transient laryngeal nerve damage, two patients; abscess and hematoma, one patient each) was four (3.2%) of 125 patients. Follow-up examinations showed marked shrinkage of 112 treated nodules ranging from 50% to 90% of the pretreatment volume (mean, 66%) and new growth of hyperfunctioning tissue in four patients at color Doppler sonography and scintigraphy at 12, 18, 18, and 48 months' follow-up, respectively. However, all patients remained euthyroid (low or normal TSH and normal FT3 and FT4) during follow-up. CONCLUSION: PEI of hyperfunctioning thyroid nodules seems to be an effective and safe alternative to traditional treatment. It also appears to be effective in patients with hyperfunctioning thyroid nodules larger than 30 mL.

[Locally advanced breast cancer in elderly patients: treatment standardised or tailored to individual needs?]. / Cancro della mammella localmente avanzato nell'età senile: trattamento standardizzabile o modulato?

Breast cancer in elderly patients occurs frequently and is often inadequately managed. Furthermore, for organizational and social reasons, the incidence of locally advanced neoplasms is higher in this age group than in the younger population. The aim of the study was to assess our experience in this specific pathology and review the international literature on this topic. From 2001 to 2005 116 cases of breast cancer in elderly women (70-95 years old) were observed by our surgical units. Of these, 38 were at a locally advanced stage (10--26.3%--stage IIIA, 28--73.7%--stage IIIB). Comorbidity (two or more diseases) existed in 32 patients. A Madden modified radical mastectomy was carried out in all cases. Resection was extended to the chest-wall tissues in cases of local infiltration. Surgical mortality was 10% (4 cases). Eight of the 34 patients discharged died within 24 months (2 of disease progression). Adjuvant chemotherapy was never offered. On the other hand, all patients received hormone therapy (tamoxifen). 10 of the 26 patients (38.4%) surviving over 2 years underwent redo surgery for local relapse of disease. Our conclusions are: 1) breast cancer in elderly patients is often underestimated and undertreated; 2) disease management cannot be standardized, but must be tailored to the single patient; 3) short- and medium-term results are satisfactory; 4) comorbidity must be carefully assessed.

The role of laparoscopy in pancreatic surgery.

Carcinoma of the pancreas is extremely common, with a five-year mortality rate of about 95-99%. Radical surgery requires good technical skill and can cause complications and operative mortality, but should be avoided in patients with extrapancreatic involvement. Advances in dynamic spiral CT-scan have decreased the number of unnecessary laparotomies. VLS is indicated in cases of pancreatic mass deemed resectable or "doubtful" by CT-scan. Direct laparoscopic visualization can be combined with intraoperative laparoscopic ultrasonography (LUS), which has shown a positive predictive value of resectability of 91%. Laparoscopic pancreatoduodenectomy (LPD) shows a high rate of complications and should be performed by very well-trained surgeons. Laparoscopic distal pancreatectomy (LDP) with an "en bloc" splenectomy and spleen preservation should be performed.

Surgical treatment of differentiated thyroid carcinoma: a retrospective study.

A retrospective study was carried out to assessed reliability of the prognostic factors (histology, age, sex, and stage), and standard procedures for the surgical treatment of differentiated thyroid cancers (DTC). From the 144 DTC cases reviewed with follow-up ranging from 1 to 25 years (m = 6.33 years), total mortality for cancer was found to be 55% (8 patients), with a predictive positive value for recurrence of 95.4% and 91.8% at 12 and 24 months, respectively. Median survival was 8.8 years (range 1 to 25 years). The multivariate analysis showed that factors such as age > 45 years, histology of intermediate malignancy, size up to 1.5 cm, and presence of metastases, significantly worsened the prognosis, regardless of the intervention that was carried out. We suggest total thyroidectomy for the treatment of benign pathologies and confirmed or suspected cases of cancer. We reserve loboisthmectomy for the treatment of benign pathologies confined to one lobe or those with FNAB suggesting a follicular neoplasm.

Efficacy of magnetic resonance cholangiopancreatography in detecting common bile duct lithiasis: our experience.

It has been shown that magnetic resonance cholangiopancreatography (MRCP) has a diagnostic accuracy comparable to that of ERCP. The aim of this study was to compare the diagnostic accuracy of MRCP in patients with suspected choledocholithiasis, but with negative ultrasonography findings. Among 404 patients undergoing videolaparocholecystectomy for cholelithiasis, 48 with risk factors for coledocholithiasis were evaluated. All the patients with risk factors underwent preoperative hepatobiliary ultrasonography and MRCP. Patients were assigned to one of 2 main groups: A) patients with common bile duct stones at ultrasonography (15/48: 31%) and B) patients without evidence of common bile duct stones on ultrasonography (33/48: 69%), with B comprising two subgroups: B1) MRCP-positive for stones (7/33:21%) and B2) negative US and MRCP (26/33:79%). MRCP showed 100% sensitivity and 100% specificity. The high sensitivity of MRCP allows us to recommend a greater use of the procedure with avoidance of unnecessary ERCP, which should be reserved for therapeutic purposes only.

Laparoscopic cholecystectomy in the morbidly obese.

In the early days of video-assisted laparoscopic cholecystectomy (VLC), obesity was considered a contraindication for the procedure. We reviewed charts from 304 patients undergoing VLC; 90 patients were obese, and among these, according to a classification currently used by medical nutritionists and based on BMI, 45 were overweight (BMI > or = 25 < or = 29.9), 27 were considered conventionally obese (BMI > or = 30 and < 40) and 18 morbidly obese (BMI > or = 40). In this study we considered only the morbidly obese patients (5 males and 13 females). The average age was 42.3 years (range: 21-65) and the average weight 275 Ib (range: 186-331 Ib). Six patients had previously undergone abdominal surgery. All patients were symptomatic for gallstones, and 5 of them were suffering from acute cholecystitis. Mean operative time was 20 minutes (range: 10-45 minutes) longer than that of non-obese patients. No open conversion was necessary. No major postoperative morbidity and no cases of mortality occurred. The mean hospital stay and resumption of normal diet were similar to those of non-obese patients. Regardless of the higher postoperative risks after open cholecystectomy in obese patients (pulmonary complications, thromboembolism, wound infections and cardiovascular complications), we suggest VLC as the procedure of choice for cholecystectomy in these patients.