Incidence and Clinical Relevance of Incidental Papillary Carcinoma in Thyroidectomy for Multinodular Goiters.

INTRODUCTION: Patients undergoing a total thyroidectomy for multinodular goiter typically have a long clinical history of the disease. They often come to surgery for compression symptoms, with no suspicion of neoplastic disease. For these patients, the incidence of microcarcinomas is high, even though we know that this does not affect subsequent therapies and long-term survival. On the other hand, when a true incidental carcinoma is present, the patient requires specific therapy and long-term follow-up. The purpose of the study was to identify the incidence of incidental carcinomas in the high prevalence region of goiter, the clinical-pathological characteristics of the tumor, and the therapeutic implications. METHOD: This is a retrospective study, from January 2010 to December 2020, on a case series of 1435 total thyroidectomies for goiters. All patients had a preoperative diagnosis of a benign disease. Gender, mean age, and mean duration from the initial diagnosis of goiter were evaluated along with the number and frequency of fine needle aspirations carried out. On the basis of the histological examination, the incidence of incidental carcinoma was then assessed (diameter ≥ 10 mm) as well as the incidence of microcarcinoma (diameter < 10 mm), the pathological characteristics (multifocality, capsular invasion), and the subsequent prescribed therapies. RESULTS: Patients with incidental carcinoma numbered 41 (2.8%%), 34 women and 7 men. The mean age was 53.5 years, while the patients diagnosed with microcarcinoma were 88 (6.1%). The mean duration of the disease from initial diagnosis was 7.8 years. On average, these patients underwent 1.8 fine needle aspirations during the course of the disease, almost exclusively in the first four years. The mean diameter of the tumor was 1.35 cm (±0.3). Multifocality was present in six patients, while only one patient presented capsular invasion. The chi-square test delivered a significant dependence on gender in terms of the incidental diagnosis after Yates correction (chi-stat = 5.064; p = 0.024), highlighting a higher incidence in the female population. All patients underwent subsequent metabolic radiotherapy. The mean follow-up was 6.3 years and in the 35 patients examined, none displayed any recurrence of the disease. CONCLUSIONS: Incidental carcinoma is not uncommon in patients who have undergone total thyroidectomy for goiters. It must be differentiated from microcarcinoma for its therapeutic implications and the follow-up of the patient. Statistical analysis has shown that the only significant variable is gender. In a goiter area, the careful monitoring of patients is required to highlight suspicious clinical-instrumental aspects that may appear even several years after the initial diagnosis.

Pediatric primary spontaneous pneumothorax: a comparison of treatment at pediatric surgery vs. thoracic surgery departments.

Management of pediatric Primary Spontaneous Pneumothorax (PSP) is controversial and based on guidelines on adults. Therapeutic strategies include: observation, needle aspiration, chest drain, or surgery. We aimed to assess: i) differences in the management of PSP in pediatric vs. adult departments; ii) risk of recurrence associated to each therapeutic choice; iii) management of "large" pneumothorax (i.e. >3cm at the apex on chest X-Ray); iv) role of CT scan in addressing the treatment. We reviewed all PSP treated at Pediatric Surgery Unit (PSU) and Thoracic Surgery Unit for adults (TSU) in a 10-year period (2011 to 2020). We included a total of 42 PSP: 30/42 1st episodes and 12/42 recurrences. Among the 30/42 1st episodes, 15/30 were managed in the PSU and 15/30 in the TSU. Observation was significantly most common among PSU patients (9/15, 60%) vs. TSU cases (1/15, 6.7%; p=0.005]. Chest drain placement was reduced in PSU (3/15, 20%) vs. TSU (12/15, 80%; p=0.002). Observational was associated with a reduced risk of recurrence (0/10, 0%) compared to chest drain (7/15, 46.7%; p=0.01). Management of 20/42 "large" pneumothorax was: 4/20 (20%) observation, 10/20 (50%) chest drain, 2/20 (10%) needle aspiration, 4/20 (20%) surgery. Twentythree/ 29 PSP (79.3%) underwent CT-scan after the first episode. Bullae were detected in 17/23 patients and 5/17 (29.4%) had seven episodes of recurrence. PSP patients treated by PSU were more likely to receive clinical observation. Those managed by TSU were mostly treated by chest drain. Observation seems an effective choice for clinically stable PSP, with low risk of recurrence at a mid-term follow-up. CT-scan seems not to detect those patients at higher risk of recurrence.

Congenital growth hormone deficiency associated with hip dysplasia and Legg-Calve-Perthes disease.

OBJECTIVE: Growth hormone deficiency (GHD) is usually treated with recombinant human GH (rhGH), and this has been rarely associated with hip disorders. We analysed the clinical data of patients with congenital GHD receiving rhGH who had associated hip dysplasia or Legg-Calve-Perthes disease (LCPD), with a view to determining whether the hip dysplasia was associated with the underlying disease or with rhGH treatment. DESIGN: We performed a retrospective analysis of paediatric and adolescent patients seen between 1992-2018 with congenital GHD and hip disorders. Data were collected through a review of the patients' medical records and included demographics, clinical and imaging data, and the time frame between the onset of the symptoms related to the hip disorders and the onset of GH treatment. RESULTS: Of the 13 patients with hip disorders, hip dysplasia was present in ten patients and LCPD in three. Hip dysplasia was diagnosed before rhGH was initiated in 50% of cases. These patients had bilateral hip dysplasia and isolated GHD. LCPD was diagnosed in one patient before rhGH was commenced and did not progress. In two patients, LCPD was diagnosed after rhGH was started and did temporarily progress in one of them, but rhGH was not discontinued because LCPD did not seem to be related to rhGH treatment. CONCLUSIONS: This study suggests that hip dysplasia could be a manifestation of an underlying GHD. Additionally, rhGH treatment may not necessarily be causative of LCPD.

Intersigmoid Hernia: A Forgotten Diagnosis-A Systematic Review of the Literature over Anatomical, Diagnostic, Surgical, and Medicolegal Aspects.

INTRODUCTION: Intersigmoid hernia is a hernia of the small bowel into the intersigmoid fossa. It is well known to be a rare condition. Recent reports reveal that the preoperative differentiation of intersigmoid hernias is difficult and the diagnosis is often confirmed during the laparotomic exploration. Due to the vague clinical manifestation in most cases, the surgical treatment is frequently delayed. MATERIALS AND METHODS: In this study, we systematically reviewed the literature up to 2019 covering 114 studies and 124 patients with an intersigmoid hernia. The purpose of this work is to improve the understanding of the anatomical aspects, clinical presentation, diagnosis, and treatment of intersigmoid hernia so as to assist the preoperative differentiation of these hernias when presented as acute abdomen in the emergency department. RESULTS: The diameter of the intersigmoid recess was reported with mean 2.65 cm (range 1-10 cm, SD 1.15 cm) and the length of the incarcerated small intestine was between 3 cm (min) and 150 cm (max): mean 25.25 cm, SD 35.04 cm. The diameter of the sigmoid recess was greater in patients who underwent resection due to strangulation (mean 3.31 cm, SD 1.53 cm) compared to those who underwent only reduction of the hernia (mean 2.35 cm, SD 0.74 cm). The time from onset to operation was less in patients undergoing resection surgery due to throttling (mean 3.03 days, SD 3.01 days) compared to those who underwent only a reduction of hernia incarceration (mean 8.49 days, SD 6.83 days). CONCLUSION: Intersigmoid hernia is often a forgotten diagnosis and a clinical challange due to its anatomical characteristics.

Symptoms of obstructive defecation syndrome: functional outcome after stapled haemorrhoidectomy.

BACKGROUND: Patients with haemorrhoids often present obstructive defecation symptoms. Preoperative they can be classified in three groups: slight, severe and mild symptoms. Aim of this study was to postoperatively evaluate functional outcome in patients who underwent stapled haemorrhoidectomy in mild obstructive defecation syndrome. METHODS: We enrolled 98 patients with mild obstructive defecation symptoms using Wexner score preoperatively (range 8-16) from the 332 consecutive patients treated with stapled haemorrhoidectomy between January 2009 and December 2011. All patients were clinically examined 1 month after surgical treatment and every 6 months with a mean followup of 30 months (range 24-42 months). RESULTS: The 98 patients enrolled included 58 men and 40 women. There were no intraoperative complications. Postoperative complications included four patients. A reduction of Wexner score from a mean preoperative score of 12 to a mean postoperative score of 6 just 6 months after surgery was observed. This difference was statistically significant (p<0.001: Mann-Whitney U test). CONCLUSIONS: Careful clinical evaluation of patients with haemorrhoids and obstructive defecation symptom is required to establish the most appropriate treatment. The results of this study indicated that stapled haemorrhoidectomy can improves the functional symptoms for patients with constipation symptoms of moderate degree. KEY WORDS: Functional outcome, Obstructive defecation symptoms, Stapled haemorrhoidectomy.

Human Mesenchymal Stem Cells Reendothelialize Porcine Heart Valve Scaffolds: Novel Perspectives in Heart Valve Tissue Engineering.

Heart valve diseases are usually treated by surgical intervention addressed for the replacement of the damaged valve with a biosynthetic or mechanical prosthesis. Although this approach guarantees a good quality of life for patients, it is not free from drawbacks (structural deterioration, nonstructural dysfunction, and reintervention). To overcome these limitations, the heart valve tissue engineering (HVTE) is developing new strategies to synthesize novel types of valve substitutes, by identifying efficient sources of both ideal scaffolds and cells. In particular, a natural matrix, able to interact with cellular components, appears to be a suitable solution. On the other hand, the well-known Wharton's jelly mesenchymal stem cells (WJ-MSCs) plasticity, regenerative abilities, and their immunomodulatory capacities make them highly promising for HVTE applications. In the present study, we investigated the possibility to use porcine valve matrix to regenerate in vitro the valve endothelium by WJ-MSCs differentiated along the endothelial lineage, paralleled with human umbilical vein endothelial cells (HUVECs), used as positive control. Here, we were able to successfully decellularize porcine heart valves, which were then recellularized with both differentiated-WJ-MSCs and HUVECs. Data demonstrated that both cell types were able to reconstitute a cellular monolayer. Cells were able to positively interact with the natural matrix and demonstrated the surface expression of typical endothelial markers. Altogether, these data suggest that the interaction between a biological scaffold and WJ-MSCs allows the regeneration of a morphologically well-structured endothelium, opening new perspectives in the field of HVTE.

An uncommon association between parathyroid adenoma and Hodgkin disease.

The Authors refer their experience of a patient operated for adenoma of the inferior parathyroid of left lobe associated to a limphoadenopathy fom HD. Diagnostic and therapeutical approach are described. The literature of these last decades reports a single case with similar characteristics, but not with the same association. Numerous neoplasias associated more frequently with parathyroid adenoma are mentioned and the probable causes of this association. Although the associations with other affections of the hemolymphopoietic system are relatively frequent, the causes of the rarity of the association between parathiroid adenoma and HD remain unknown.

Efficacy and safety of ablative techniques in elderly HCC patients.

BACKGROUND: This study was conducted to evaluate the efficacy and safety of ablative techniques in elderly patients with hepatocellular carcinoma (HCC). METHODS: From February 2004 to February 2009, 80 elderly patients (age > or = 70 years) affected by non-resectable HCC were treated with a regional palliative approach, trans-arterial-chemo-embolization and radio-frequency-thermal-ablation (TACE, RFA). Our approach includes a first treatment of TACE and then a control CT plan after a month. A possible following RFA can be performed to ensure a complete necrosis of the lesions, and then a further contrast enhanced CT scan after 2 months. For 60 patients, the first TACE was sufficient to treat the disease at beginning. For 15 patients TACE was followed by RFA, and for 5 patients an RFA was performed directly due to nodule localization. Response to TACE is assessed every 2 to 3 months with serial AFP level and TC scan. RESULTS: Two patients died for related method's causes (2.5%): liver-renal syndrome (1 patients), and portal thrombosis with irreversible postoperative liver failure (1 patients). A total of 15 patients were lost to follow-up (18.7%): 2 (2.5%) patients had died for non-tumor-related causes, 1 due to a liver transplantation, and 12 (15%) due to failure to attend follow-up visits. All patients developed further localisation, medially after 4 months, and underwent TACE treatment for a mean of another two times. A mean follow up is 36.7 months (1-60) with a mean survival rate of 35.1 months (1-60). CONCLUSIONS: We conclude that, even in over 70-year-olds, TACE and RFA treatment should be employed to completely cure HCC, if liver function and tumor stage are acceptable.

Effective treatment of haemorrhoids: early complication and late results after 150 consecutive stapled haemorrhoidectomies.

BACKGROUND: Haemorrhoidectomy according to Longo potentially reduces post-operative pain and allows an early return to work. The aim of this study was to evaluate the efficacy of the technique, the early and especially late complications, and recurrences, in 150 patients. METHODS: Between January 2005 and December 2006, we performed 150 consecutive haemorrhoidectomies with the Longo technique: 82 for third degree haemorrhoids and 68 for fourth degree haemorrhoids. The mean age of patients was 42 years. Every patient had a pre-operative proctoscopy and endoscopy KIT PPH01 (Ethicon Endo Surgery) was used. We evaluated the length of the operation, the post-operative pain, the early and late complications, and the recurrence of the disease. The mean follow up was 52 months (range 36-72). RESULTS: There was no mortality. The mean length of the operation was 25 minutes with a range of 15 to 45 minutes. Pain, evaluated using the V.A.S. scale, was very light in 114 patients (V.A.S. 2,1) and light in 36 (V.A.S. 3.2). Only 11 (7.5%) patients took painkillers, on demand, for a week after discharge from hospital and 2 patients (1,3%) for more than one month. Early complications (6.6%) were: 5 bleeding (2 after seven days), 4 acute urinary retentions, 1 external haemorrhoid thrombosis and 1 haematoma of the rectus wall. Mean Hospital stay was 2.1 days. Late complications (10%) were: 5 "faecal urgency" which disappeared after six months, 6 moderate asymptomatic strictures, and 4 persistent skin tags. There were 8 recurrences (5.1%), 2 for haemorrhoids of grade 3 e 6 for haemorrhoids of grade 4. All the recurrences appeared within the first 24 months. CONCLUSION: The stapled procedure according to Longo is an effective treatment for haemorrhoids. The results for postoperative pain and early return to work are very good. However, special care for haemostasis is essential in order to avoid bleeding. An effective surgical technique prevents late complications, but results after long term follow up show a not insignificant percentage of recurrences that appeared especially in the fourth degree haemorrhoids. Therefore a careful pre-operative exclusion of those patients with a prominent prolax is necessary

[Ectopic breast tissue and a carcinoma in atypical positions]. / Ectopie mammarie e carcinomi in sede atipica.

AIM: The aim of the study was to considerate neoplams of ectopic breast tissue in particular concerning the diagnostic and surgical related problems, analysing our experience in this extremely rare pathology. MATERIALS AND METHODS: A group of five women affected by neoplasm of ectopic breast tissuehave been examinated, four of them in axillary breast tissue and the other one in parasternal area. They came to our clinical observation (UOC BCG 21, UOC BCG 27-Policlinico Umberto I,-Università "Sapienza" di Roma) between 2006 and 2008. All the patient underwent surgical intervention in our department. DISCUSSION: According to the literature we can assess that this is a rare pathology and so the diagnostic and surgical choices are different from case to case depending on the size, the localization , the local invasion. CONCLUSIONS: This rare pathology can occur in many different forms and areas. This fact makes impossible to create a guideline of diagnosis and treatment. This one must be acted in respect of radicality and when it is possible, of aesthetic criteria.

Minimally invasive approach of the most common complications after laparoscopic cholecystectomy.

AIM OF THE STUDY: LC is now considered the gold standard in the treatment of cholelithiasis with a minimal incidence of complications, typically, bile peritoneum and hemoperitoneum. METHODOLOGY: The Authors wished to verify the possibility of treating complications after LC with a minimally invasive approach. In 1100 LCs over 8 years, they treated 9 bile peritoneum and 4 hemoperitoneum. RESULTS: It was possible to treat all 13 patients with a minimally invasive approach with a complete resolution of the complication and with no further occurrences during the follow up. CONCLUSIONS: The Authors believe that it is possible to treat the majority of complications arising after LC with minimally invasive methods. Nevertheless, a very early diagnosis and the close cooperation of an Endoscopist and an Radiologist is necessary.

99mTc-bombesin detects prostate cancer and invasion of pelvic lymph nodes.

Biopsy is the standard method for the diagnosis of prostate cancer; however, it is inadequate for the assessment of lymph node invasion. Radionuclide imaging might be useful for both diagnosis and N staging, but it requires high uptake of radiotracers in order to overcome difficulties arising from the anatomy of the region. The aim of this study was to assess whether or not technetium-99m labelled bombesin (99mTc-BN) scan is able to detect prostate cancer and invasion of pelvic lymph nodes. Ten patients were studied with 99mTc-BN, transrectal ultrasonography, biopsy, computed tomography and magnetic resonance imaging. All the patients with cancer were operated on. Planar dynamic scintigraphy and single-photon emission tomography (SPET) were performed after administration of 185 MBq 99mTc-BN. Two patients showed benign adenoma and eight showed cancer at biopsy. The average Gleason's score was 7.5+/-1.3. 99mTc-BN dynamic planar scan showed hot spots in the prostatic fossa in two of the eight patients with cancer, both of whom had a prostate-specific antigen level higher than 20 ng/ml. In these patients, high uptake inside the prostatic fossa was detected as early as 1 min after injection, before the arrival of radioactivity in the bladder. True positive SPET scans were obtained in all eight patients with cancer. Invasion of the obturator nodes was detected by SPET in three patients, and in all three was confirmed at surgery. Our preliminary data encourage further studies on the prostate with 99mTc-BN. If the high sensitivity of 99mTc-BN SPET is confirmed, this method may play an important role in diagnosing and staging prostate cancer.