An evaluation score of the difficulty of thyroidectomy considering operating time and preservation of recurrent laryngeal nerve.

The purpose of this study was to edit a renovated thyroidectomy difficulty scale (rTDS) in order to identify underlying thyroid diseases with a longer operative time and higher technical difficulty, also considering preservation of recurrent laryngeal nerve. We developed a renovated scale with a maximum score of 20 points by creating a form in which five variables were considered: vascularity, friability, mobility/fibrosis, gland size and difficulty in preservation of the recurrent laryngeal nerve. Two surgeons separately evaluated each of these. Through a simple linear regression analysis, we have analyzed the relationship between rTDS score and operative times, and between rTDS score and preservation of recurrent nerve. Eventually, Spearman's rank correlation coefficient has been used in order to evaluate our double-blind study. Our cohort included 131 patients undergoing total thyroidectomy. The mean of the rTDS was 9.00 ± 3.67 for Surgeon A and 8.31 ± 3.42 for Surgeon B, with Spearman's rank correlation coefficient between surgeons of 0.85 (p < 0.0001). We have shown that the rTDS score significantly influences the operating times (R2 = 0.44 for surgeon A, R2 = 0.46 for B, p < 0.0001 for both). Moreover, we can say that the rTDS score significantly influences preservation of the recurrent nerve (R2 = 0.37, Beta 0.61, 8.84 t test, p < 0.0001). Our rTDS is a useful tool and, thanks to it, we identified hyperthyroidism and goiter as the hardest underlying disease for surgery. Thus our scale could change operative approach, resulting in better surgeries' scheduling and identification of pathologies that require higher attention.

Minor hepatic resection using heat coagulative necrosis.

Intra- and postoperative bleeding represents an extremely serious and frequent complication of hepatic surgery. In this study, we evaluated the effectiveness of a radiofrequency (RF) device using heat to cause coagulative necrosis of the hepatic parenchyma to control hemostasis in minor hepatic resection. Between December 2005 and November 2007, a study was conducted of 21 patients undergoing 22 hepatic resections with the RF-assisted technique. Sixteen of these were affected by hepatocellular carcinoma and five had liver metastases from colorectal cancer. Intraoperative blood loss, the need for blood transfusion, the complication rates, operating times, and the duration of postoperative hospitalization were evaluated. Four segmentectomies and 18 tumor-ectomies were performed. The average blood loss was of 15.7 mL (range, 0-40 mL); the average operating time was 25.7 minutes (range, 12-43 minutes); the mean postoperative hospital stay was 8.2 days (range, 3-49 days) with a median of 6.0 days. The authors concluded that the RF-assisted technique can be a useful method not only for reducing blood loss and avoiding blood transfusions, but also for reducing operating time and postoperative hospitalization for minor liver resections.

Combined hepatectomy and radiofrequency ablation for multifocal hepatocellular carcinoma: a case report.

INTRODUCTION: At the present time, the best possible choice for the local management of a multifocal hepatocellular carcinoma (HCC) developing on liver cirrhosis is multimodal treatment of the disease. Combined approach based on simultaneous radiofrequency ablation (RFA) together with limited surgical resection represents a valid choice of treatment. CASE PRESENTATION: A 75-year-old white female patient affected of HCV-associated cirrhosis in Child-Pugh's functional class A5, developed a bifocal HCC. The patient had undergone a limited surgical resection together with simultaneous RFA, without intraoperative and postoperative surgical complications. At 36 months after surgery, still shows no sign of disease relapse. CONCLUSION: This strategy directed at the management of multifocal HCC, may prove more useful for the reduction of surgical risk and post-operative progression of the liver cirrhosis than large-scale hepatectomy, since it presents no peri-operative mortality and a complication rate of less than 10%.

Multimodal approaches to the treatment of hepatocellular carcinoma.

The prevalence of hepatocellular carcinoma in Europe and the US is increasing and is currently the leading cause of death in patients with cirrhosis. Surveillance programs for patients with cirrhosis aim to detect tumors at an early stage, when the greatest therapeutic benefits can be achieved. Curative treatments for early-stage tumors include liver transplantation, resection and percutaneous ablation. Transarterial chemoembolization (TACE) and sorafenib can improve survival for patients with intermediate and advanced tumors, respectively. In clinical practice, combination therapies are often used, despite limited evidence to support this approach from randomized controlled trials. Combination therapy with radiofrequency ablation (RFA) plus percutaneous ethanol injection can, however, improve survival for selected patients compared with RFA alone. Combined treatment with TACE and RFA also improves patients' survival compared with TACE or RFA monotherapy. TACE performed before or after surgical resection, however, is not beneficial. Prevention of tumor progression in patients awaiting liver transplantation requires nonsurgical treatments; however, the real advantages of the available treatment modalities are yet to be defined. The role of sorafenib administration in combination with TACE after the use of potentially curative treatments, for the treatment of intermediate hepatocellular carcinoma, or in selective settings after liver transplantation, requires further study.

Gastrointestinal stromal tumour of the rectum: report of a case and review of literature.

Gastrointestinal stromal tumour (GIST) is a rare tumour of the gastrointestinal tract which does not generally originate in the rectum. The authors describe a case of a 70-year-old man who underwent an anterior resection of the rectum for a low-risk GIST. The patient was not given adjuvant chemotherapy with imatinib and is still disease-free 30 mo after surgery. The authors conclude that although rectal GIST is extremely uncommon, it should be included in differential diagnosis when a tumour in the rectum is detected. Biopsy of the tumour is essential, since this makes it possible to reach a sure preoperative diagnosis based on the immunohistological features of the CD117 and CD34. Although complete surgical resection with negative tumour margins is the principal curative procedure for primary and non-metastatic tumours, further studies are still needed for the determination of the most effective treatment strategy for patients with rectal GIST.

Treatment of hepatocellular carcinoma in compensated cirrhosis with radio-frequency thermal ablation (RFTA): a prospective study.

BACKGROUND/AIMS: To assess the effectiveness and the safety of radio-frequency thermal ablation (RFTA) in patients with hepatocellular carcinoma (HCC) < or = 5 cm in compensated cirrhosis. METHODS: A cohort of 202 consecutive patients (165 Child-Pugh class A and 37 class B) was prospectively assessed. A single lesion was observed in 160/202 (79.2%), two lesions in 29/202 (14.3%), and three lesions in 13/202 (6.4%) of patients. RESULTS: Sixty-seven patients died. Survival rates were 80% at 12 months, 67% at 24 months and 57% at 30 months (Child-Pugh A 59% and Child-Pugh B 48%). By Cox regression analysis, survival was independently predicted by serum albumin levels > or = 35 g/L, platelet count > or = 100.000/mmc, tumor size < or = 3 cm, complete response at 1 month and Barcelona Clinic Liver Cancer (BCLC) staging classification. Overall recurrence rates were 22, 38, and 44% at 12, 24, and 30 months, respectively. One procedure-related death occurred. The proportion of major complications after treatment was 3.9%. CONCLUSIONS: A complete response after RFTA significantly increases survival. The longest survival is obtained in the presence of HCC < or = 3 cm and of higher baseline albumin levels and platelet counts. BCLC staging classification is able to discriminate patients with good or poor prognosis.

[Laparoscopic Nissen fundoplication and esophageal intestinal metaplasia: preliminary observations]. / Fundoplicatio secondo Nissen videolaparoscopica e metaplasia intestinale in esofago: osservazioni preliminari.

The aim of this preliminary study conducted in a few cases was the retrospective evaluation of the effects of laparoscopic Nissen fundoplication on oesophageal intestinal metaplasia. Seventy-seven patients with hiatal hernia underwent digital videofluorography, endoscopy with biopsies, motility studies and 24-h oesophageal pH-monitoring. On the basis of the results of the diagnostic procedures and considering the patients' ages and response to proton-pump inhibitor treatment, 8 patients underwent laparoscopic Nissen fundoplication; in 5 cases intestinal metaplasia was present at histopathological examination. Two of these had Barrett's oesophagus at endoscopy and intestinal metaplasia was associated with low-grade dysplasia in both at histology; the other 3 did not present a columnar mucosa at endoscopy and 1 had low-grade dysplasia. In all 5 patients, at 1 year postoperative histopathological control, disappearance or decrease of metaplastic epithelium and regression of dysplasia were noted, with excellent results in terms of reflux symptoms at clinical control. On the basis of these preliminary data, it is our opinion that antireflux surgery is not only a suitable treatment in the management of Barrett's oesophagus but also has a favourable effect on intestinal metaplasia regression when a normal oesophageal mucosa is present.

Treatment of hepatitis C: critical appraisal of the evidence.

Chronic hepatitis C virus infection is currently the most common cause of end stage liver disease worldwide. Although the conclusions of the last National Institutes of Health Consensus Development Conferences on Hepatitis C have recently been published, several important issues remain unanswered. This paper reviews the available data using an evidence-based approach. Current evidence is sufficient to recommend IFN treatment for all patients with acute hepatitis. A later initiation of therapy yields the same likelihood of response as early treatment. A daily induction dose during month 1 is the best treatment option. The current gold standard of efficacy for treatment-naive patients with chronic hepatitis C is the combination of pegylated IFN and ribavirin. The overall sustained viral response rate to these regimens is 54 - 56% following a 48-week course of therapy. Patients with genotype 1 infection will have a 42 - 51% likelihood of response to 48weeks of therapy. Those with genotypes 2 or 3 infection will respond to 24weeks in 78 - 82% of cases. Debate continues regarding the optimal dose and duration of peginterferon (PEG-IFN), not only in patients infected with genotype 2 or 3 but also in those infected with genotype 1. The optimal dose of ribavirin has yet to be determined. Available data show the need to give the highest tolerable doses (1000-1200mg/day) to the difficult-to-treat patients (genotype 1, cirrhotics, obese), although there is a greater likelihood of intolerance. Genotypes 2 and 3 may receive 800mg/day, which is also the most appropriate lower dose for those patients who require dosage modification for anaemia or other side effects. Tolerability and compliance to therapy are still a problem, as approximately 15- 20% of patients within trials and > 25% in clinical practice withdraw from therapy. New PEG-IFNs are more effective than conventional IFN in improving liver histology. Monotherapy with PEG-IFN induces a marked reduction in staging in virological sustained responders, and to a lesser degree in relapsers, but provides no benefit to nonresponders after 24-48weeks of treatment. The use of maintenance therapy in virological nonresponders aiming to improve histology should be considered experimental and of unproven benefit. Pooling data from the literature suggests a slight preventive effect of IFN on hepatocellular carcinoma development in patients with HCV-related cirrhosis. The magnitude of this effect is low and the observed benefit may be due to spurious associations. The preventive effect is more evident among sustained responders to IFN.

[Historical aspects of a frequent anal disease: haemorrhoids]. / I momenti storici di una frequente patologia anale: le emorroidi.

In this report the authors outline the main historical aspects of haemorrhoids after a thorough review of the literature. The first texts concerning haemorrhoids are the ancient Egyptian papyruses. The twenty centuries of the history of haemorrhoids are marked by multiple pathogenetic theories, and of these the vascular and the sliding of the anal mucosa are still valid. From an analysis of the historical texts and the most recent publications, we deduce that the principles of therapy are substantially unchanged since the days of Hippocrates. In conclusion, we can say that, as in ancient times, the therapy of haemorrhoids is based on three fundamental approaches: surgical treatment, ambulatorial non-surgical treatment and medical treatment.

[Hiatal hernia, gastro-oesophageal reflux and oesophagitis: videofluorographic, endoscopic and histopathological correlation]. / Ernia iatale, reflusso gastroesofageo ed esofagite: correlazione videofluorografica, endoscopica ed istopatologica.

The aim of the study was to evaluate the correlation between hiatal hernia and gastro-oesophageal reflux and related histological abnormalities in patients without endoscopic oesophagitis. A consecutive series of 78 patients with a history of gastro-oesophageal reflux symptoms and hiatal hernia, as defined by videofluorography combined with a water siphon test, underwent oesophagogastroduodenoscopy and multiple biopsies. Hiatal hernia was confirmed endoscopically in 99% of cases. The water siphon test was positive for reflux in 72% of cases. At endoscopy 42% of patients had oesophagitis and/or Barrett's oesophagus and 58% had no lesions. In the group without endoscopic lesions, at histology oesophagitis-related alterations were found in 98% and intestinal metaplasia in 27%. In conclusion, this study shows that symptomatic gastro-oesophageal reflux patients with radiologically defined hiatal hernia should undergo endoscopy with multiple biopsies above the squamocolumnar junction, even when endoscopy is normal. This is in order to detect histological gastro-oesophageal-reflux-related alterations, above all, when a positive water siphon test is also present, owing to its known correlation with intestinal metaplasia.

[Radiofrequency thermoablation in the treatment of primary and secondary liver tumours]. / La termoablazione nel trattamento delle neoplasie epatiche primitive e secondarie.

Radiofrequency thermoablation is a locoregional procedure based on the use of electromagnetic waves that induce movement and consequently the production of heat. This is the basis for the coagulative necrosis produced in the tissues. The method, experimented with and developed in the '90s, is today extensively used in the treatment of focal hepatic lesions, both primary and secondary. The factors that condition the procedure are related essentially to the characteristics of the tumours and to the possibility of obtaining a predictable area of necrosis that guarantees the radicality of the treatment. As regards primary neoplasms, it should be stressed that the treatment for hepatocellular carcinoma is implemented only in a small percentage of cases due to both the stage of the cirrhosis and because a wide resection is not justified for small-sized lesions or for recurrences after resection. As far as liver metastases are concerned, particularly those from the colon-rectum, surgery is becoming increasingly indicated. Obviously the conditions are decidedly less demanding than those of surgery in liver parenchyma with cirrhosis. Radiofrequency thermal ablation, even in this condition, has a place as an alternative or in combination with liver resection, particularly during recurrences or in cases of multiple metastases that require extensive extirpative operations. The authors present their experience over the period from February 1999 to December 2002 in 82 patients, 71 with hepatocellular carcinoma and 11 with metastases, treated with radiofrequency thermoablation. Depending upon the site, the number of lesions and the Child-Pugh functional classes in patients with cirrhosis, 117 treatments were carried out: the percutaneous approach was used in 77 cases and the open procedure in 36, while the thermoablation was combined with surgical resection in 4 cases. The results are examined on the basis of perioperative morbidity and mortality and local recurrence, and the time of hospitalisation is compared in the different patient groups. The authors conclude favourably for this procedure, which is associated with an extremely low percentage of complications and with an almost total lack of perioperative mortality, and in some cases may be a valid alternative and in other cases a useful complement to resection treatment.

[Benign diseases of the thyroid: indications for surgical treatment and the current role of total thyroidectomy]. / Affezioni benigne della tiroide: indicazioni al trattamento chirurgico ed attuale ruolo della tiroidectomia totale.

Total thyroidectomy is the most popular surgical option in a wide range of indications for the treatment of benign disease of the thyroid. The preference for the procedure derives from a long period of observation and clinical experience dating as far back as the early 'seventies and confirms its safety and efficiency. Nevertheless, many doubts still exist as to the indications in the context of benign thyroid disease, as well as the incidence and seriousness of the complications which, though not frequent, are often invalidating. On the basis of the experience gained over the period from January 1994 to November 2002 in 697 patients undergoing surgery for benign disease of the thyroid, the authors analyse the indications for the various different therapeutic options and evaluate the results of total thyroidectomy in terms of therapeutic efficiency, relapse rates and complications. The latter are analysed on the basis of dividing the patients into 2 groups, one comprising 545 patients treated with total thyroidectomy as first-line treatment and the second consisting of 34 patients treated with total thyroidectomy for relapsing goitre after subtotal thyroidectomy. Comparison of the respective incidences of complications reveals a significant difference between the two groups of patients. Total thyroidectomy after subtotal thyroidectomy presented a significantly higher percentage of complications than initial total thyroidectomy. The authors come out in favour of total thyroidectomy with its low incidence of complications and the radical control of the disease it affords, reserving lobectomy-isthmectomy for selected cases of patients with monolateral disease which does not expose the patient to any risk of relapse.

[Supra-esophageal manifestations of gastroesophageal reflux, a different diagnostic approach and an indication for laparoscopic Nissen fundoplication: our experience]. / Manifestazioni sopraesofagee della GERD, un diverso approccio diagnostico ed un'indicazione alla Nissen laparoscopica: nostra esperienza.

24-hour oesophageal pH monitoring with a dual pH probe is considered to be the most sensitive test for diagnosing GORD-related otolaryngological manifestations. In this study we evaluate an initial diagnostic approach with digital videofluorography associated to the water siphon test and primary "ex juvantibus" therapy with proton pump inhibitors for patients with supra-oesophageal symptoms of GORD. The results of Nissen fundoplication surgical treatment are also assessed in some of these patients. Two hundred and thirty patients with suspected GORD-related supra-oesophageal symptoms were referred for videofluorography and the water siphon test. When hiatal hernia and/or reflux were found, patients were referred for medical therapy with proton pump inhibitors. Five patients, who had had a good or excellent response to the medical therapy, but had a recurrence underwent laparoscopic Nissen fundoplication and videofluorography 6 months after surgery. Within 6 months, more than 80% of patients had an excellent or good response to medical therapy. In patients undergoing laparoscopic Nissen fundoplication, hoarseness and chronic cough disappeared within 3 months and videofluorography showed good morphofunctional results of the surgery. In patients with GORD-related supra-oesophageal manifestations, videofluorography plus the water siphon test is useful initial investigation, and laparoscopic Nissen fundoplication can be a valid alternative therapeutic option.