Special Use of Intraoperative Endoscopy in Sleeve Gastrectomy: A Case Report.

Sleeve gastrectomy is the most frequently performed operation for the treatment of morbid obesity. Even though sleeve gastrectomy is now widely standardized, it may still benefit from the use of certain devices and procedures such as intraoperative endoscopy. The use of an endoscope offers numerous advantages that can considerably reduce the morbidity and mortality of patients who undergo laparoscopic sleeve gastrectomy. This paper describes our experience with a case in which the information obtained by endoscopy allowed us to perform a real-time assessment of the location of two large gastric polyps to control the staple-line.

Metachronous bilateral ectopic breast carcinoma: a case report.

An incomplete regression of the mammary line during embryogenesis occurs in 0.2-6% of the population, which may result in the presence of ectopic breast tissue (EBT). The development of a carcinoma in the EBT is a rare event. The authors present a case report of a 76-year-old female patient, with a lobular carcinoma in an abdominal wall EBT submitted to surgery and adjuvant chemotherapy.

Right-Sided versus Left-Sided Colectomies for Cancer: Surgical Outcomes and Novel Considerations.

INTRODUCTION: The aim of this study is to compare short-term outcomes of right versus left colectomies performed as a form of cancer treatment. MATERIALS AND METHODS: This study includes 305 consecutive patients with adenocarcinoma treated by laparoscopic or open colectomy. Right colectomy has been compared with left colectomy. The study endpoints were the first flatus day, the first evacuation day, the first day of postoperative solid oral diet intake, and the postoperative hospital stay length. RESULTS: There were 140 (45.9%) right colectomies and 165 (54.1%) left colectomies performed. The cut-off values for the considered (median) endpoints were three, five, four, and eight days, respectively. The first day of postoperative solid oral diet intake and the length of postoperative hospital stay are significantly associated with the type of resection. CONCLUSIONS: The colon cancer patients treated by right-sided colectomy assumed a solid oral diet and presented a longer postoperative hospital stay compared with the patients treated by left-sided colectomy.

Topographical Variations between Splenic Flexure and Spleen: A Study with CT Image-Based Reconstruction.

INTRODUCTION: An issue that is seldom seen in the literature relates the detailed relationship of the splenic flexure (SF) and the spleen-both carefully examined-with a prospective approach in patients undergoing computer tomography (CT) scan. MATERIALS AND METHODS: SF localization has been searched and examined in 120 consecutive CT scans. Several different variables (age, gender, BMI, indication of CT scan, etc.) have been considered. In cooperation with the Radiology Division, we brought to completion a dedicated topographic outline, with the purpose of providing a detailed classification for SF localization. RESULTS: The SF lies, in 52% of cases, in what we called the inferior (I) position, below the spleen. Other categories of our classification were anterior (A) and posterior (P) positions, which were found respectively in 42% and 8% of analyzed cases. Considering all the variables given, we did not find any significant statistical correlation (p > 0.05). CONCLUSIONS: This study was carried out to classify types of SF in terms of its positional relationship with the spleen. We investigated 120 CT scans and classified the SF into three types, according to its localization: inferior (I), anterior (A), and posterior (P) types. A better understanding of the anatomic variability in SF may be useful for minimizing complications and performing an accurate surgical dissection.

Transoral thyroidectomy: why is it needed?

Transoral thyroidectomy (TOT) represents reasonably the desirable minimally invasive approach to the gland due to the scarless non-visible incisions, the limited distance between the gland and the access that minimize tissue dissection and respect of the surgical anatomical planes. Patients are routinely selected according to an extensive inclusion criteria: (I) ultrasonographically (US) estimated thyroid diameter not larger than 10 cm; (II) US gland volume ≤45 mL; (III) nodule size ≤50 mm; (IV) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (V) follicular neoplasm; (VI) papillary microcarcinoma without lymph node metastasis. The operation is realized through median, central approach which allows bilateral exploration of the thyroid gland and central compartment. TOT is succeed both endoscopically adopting ordinary endoscopic equipments or robotically. In detail three ports are placed at the inferior oral vestibule: one 10-mm port for 30° endoscope and two 5-mm ports for dissecting, coagulating and neuromonitoring instruments. Low CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sterncleidomuscles similar to that of conventional thyroidectomy. TOT is now reproducible in selective high volume endocrine centers.

Neuromonitoring in endoscopic and robotic thyroidectomy.

Intraoperative neuromonitoring (IONM) has proven effective for intraoperative verification of RLN function in the conventional thyroid surgery. However, no studies have performed a systematic evidence-based assessment of this novel health technology in endoscopic and robotic thyroidectomy. Evidence-based criteria were used in a systematic review of relevant literature for years 2000-2015. Four electronic databases (CENTRAL, MEDLINE, Cochrane and EMBASE) were used to retrieve relevant reports published from January 1, 2000 to September 1, 2016. The search terms included "endoscopic thyroidectomy", "robotic thyroidectomy", "IONM", "continuous IONM (CIONM)", "neural monitoring", "recurrent laryngeal nerve monitoring", and "superior laryngeal monitoring". The following data were retrieved from eligible studies of patients undergoing endoscopic or robotic thyroidectomy: objective of study, design and setting of study, population, intervention examined, quality of data, follow-up and dropout rate, risk of bias, and outcomes assessed. Of 160 studies retrieved, only 9 (5%) studies used IONM. Eight studies reported 522 nerve at risk (NAR) with IONM. Only three were prospective randomized studies. Reports of IONM endoscopic and robotic procedures included their use for re-surgery and use in both benign and malignant cases. None of the IONM endoscopic procedures involved bilateral palsy. Two studies reported the use of a staged strategy. The rates of recurrent laryngeal palsy were 0-3.6% for transient and 0-0.4% for permanent. Only 30% of the studies performed vagus nerve stimulation, and only 25% performed superior laryngeal nerve monitoring. In addition to the use of IONM as an assistive technology for navigating the anatomy in challenging procedures such as endoscopic and robotic thyroidectomy, IONM has potential use as a routine adjunct to the conventional video-assisted nerve identification in thyroidectomy.

Transoral endoscopic thyroidectomy: preliminary experience in Italy.

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a feasible novel surgical procedure that does not need visible incisions. We describe our initial experience with TOETVA. We recruited 15 patients who were willing to undergo TOETVA. Inclusion criteria were (a) patients who had a neck ultrasound (US) with a estimated thyroid diameter not larger than 10 cm; (b) US estimated gland volume ≤45 mL; (c) nodule size ≤50 mm; (d) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (e) follicular neoplasm; (f) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through a three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscle. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and intraoperative neuromonitoring. There were 34% total thyroidectomies and 66% hemithyroidectomies. All TOETVA procedures were performed successfully with no conversions. The mean operative time was 87.6 (59-118) min for lobectomy and 107.6 (99-135) min for bilateral procedure. We observed one case of transient postoperative hypocalcemia. There was no recurrent laryngeal nerve palsy. The cosmetic result was excellent in all patients. This is the first case series of TOETVA in Italy. TOETVA may provide a method for ideal cosmetic results. The results are encouraging, and we are optimistic about the future expansion of its applicability.

N staging system: tumor-node-metastasis and future perspectives.

The correct staging of disease, with an exact definition of the extent of cancer at the diagnosis, is crucial in the planning of a specific treatment and in the assessment of real chances of cure. Cancer staging systems are expected to be accurate in the description of the severity of a patient's tumor on the basis of the extent of the primary neoplasm and of its spread, thus giving clinician tools to estimate prognosis and providing objective parameters to compare groups of patients in clinical studies. This last point is of wide importance in evaluating successful treatment strategies in oncology, and this is one of the issues that contributed to the development of stage-adapted therapies.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA): From A to Z.

We depict the transoral endoscopic thyroidectomy vestibular approach (TOETVA). Patient selection criteria are (1) ultrasonographically (US) estimated thyroid diameter no larger than 10cm, (2) US estimated gland volume ≥45mL, (3) nodule size ≥5mm, (4) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter, (5) follicular neoplasm, and (6) papillary microcarcinoma without evidence of metastasis. TOETVA is carried out through a three-port technique placed at the oral vestibule, one 10mm port for 30° endoscope and two additional 5mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sternocleidomastoid muscles bilaterally. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments. Intraoperative neuromonitoring is used for identification and dissecting and monitoring both the superior and inferior laryngeal nerves.

Gastric acid secretion and gastrin release during continuous vagal neuromonitoring in thyroid surgery.

PURPOSE: The vagus nerve (VN) has essential regulatory roles in the gastric acid secretion and gastrin release. Continuous intraoperative neuromonitoring (CIONM) via VN stimulation is a promising technique in thyroid surgery because it potentially avoids injury to the recurrent laryngeal nerve. However, no studies have investigated changes in gastric acid secretion and gastrin release during CIONM. METHOD: This prospective study of 58 thyroid surgery patients compared gastric acid and serum gastrin at five time points: (1) before skin incision, (2) after baseline calibration of CIONM probe, (3) +20 min from baseline, (4) before probe removal, and (5) after extubation. Patients were excluded if they had any history of using tobacco, acid suppression medications, or drugs that affect gastric motility. Patients were also excluded if they had any history of gastroesophageal reflux symptoms, gastroesophageal reflux disease, peptic ulcer disease, helicobacter pylori infection, or chronic kidney disease. RESULTS: Non significant differences in mean gastric pH values were observed at all time points, i.e., (1) before skin incision (2.2 ± 0.2; p = 0.50), (2) after baseline calibration of CIONM probe (2.0 ± 0.8; p = 0.62), (3) +20 min from baseline (2.5 ± 0.5; p = 0.24), (4) before probe removal (2.9 ± 0.9; p = 0.52), and (5) after extubation (2.6 ± 1.0; p = 0.60). Comparisons of pH monitoring parameters revealed no significant differences in age, gender, side of CIONM (left vs. right), sequence of CIONM, or duration of CIONM. Gastrin values were normal in sequential determinations and did not significantly differ at any time points. CONCLUSIONS: CIONM performed via VN stimulation during total thyroidectomy in healthy patients does not influence gastrin secretion and gastric pH.

New endoscopic procedures for diabetes mellitus type 2 and obesity treatment.

BACKGROUND: Obesity continues to be a growing epidemic worldwide. Obese patients have severe comorbidities that make risky and technically demanding the execution of bariatric surgery from both surgical and anesthetic point of view; therefore, the focus of bariatric surgeons is increasingly moving towards minimally invasive, endoscopic techniques. METHODS: The present review presents and discusses recent endoscopic techniques employed in obesity treatment, their features and results. RESULTS: Endoscopic treatment can be primary or revisional; we can mainly divide the endoscopic devices into five categories: space-occupying devices, restrictive procedures, bypass liner, aspiration therapy and endoscopic revision of gastric bypass for dilated gastric pouch. CONCLUSIONS: Endoscopic treatments for obesity are promising techniques for selected patients but each procedure should be tailored on the patient in a multimodal approach.

Indocyanine green-enhanced fluorescence for assessing parathyroid perfusion during thyroidectomy.

Identification of the parathyroid glands during thyroid surgery may prevent their inadvertent surgical removal and thus provide a better postoperative quality of life. Nevertheless, the most common "technique" for intraoperative evaluation of perfusion of parathyroid gland tissues during thyroid surgery is visual inspection of the physical condition of tissues, e.g., their color and bleeding edges. Another technique is measurement of intact parathyroid hormone. Recently, indocyanine green-enhanced fluorescence has been used in various surgical techniques, particularly laparoscopic surgery, to improve visualization and to provide detailed anatomical information. Fluorescent optical guidance helps surgeons to avoid inadvertent tissue injury while enhancing procedural efficiency. This technique has potential use for evaluating perfusion of the parathyroid gland in real-time intraoperative angiography.

Recurrent laryngeal nerve management in thyroid surgery: consequences of routine visualization, application of intermittent, standardized and continuous nerve monitoring.

The objective is to compare the consequences of routine visualization (RV) and the application of intermitted (I-IONM), standardized (S-IONM), and continuous monitoring (C-IONM) of recurrent laryngeal nerve (RLN) management. RV includes that 698 RLNs managed solely with visual identification. In a second period 777, RLNs were handled by the I-IONM. The third period 768 RLNs monitoring was performed according to the standards. C-IONM via VN stimulation included 626 RLNs. The following issues were analyzed and compared per each period study: RLN identification rate, branching detection, assessment of NRLN, intraoperative recognizable nerve damage, stage thyroidectomy rate, transient or definitive lesions, bilateral nerve palsy, and recovery time. Significance for nerve identification rate was achieved (p = 0.03) when the statistical analysis was applied between RV vs. S-IONM and C-IONM. Extralaryngeal bifurcation was identified in 21, 44, 43, and 46 of RLN dissected, respectively, per period (p = 0.005). The incidence of paralysis in identified and unidentified RLN was 3.8 % (107/2806) and 82 % (52/63), respectively. Rates of temporary/permanent RLNP were 16.7/1.7, 5/1.1, 4.5/1, and 3.1/0 % per period study, respectively (p = 0.07). Recognizable intraoperatively nerve damage was, respectively, 15, 45, 100, and 100 % for period study (p = 0.03). The recovery of injured nerves was significantly faster in C-IONM group. S-IONM and C-IONM cumulate 40-stage procedures. The standardized technique, guidelines adherences, and C-IONM allowed to (1) increase RLN identification; (2) reduce the severity of injuries in terms of (a) reset bilateral RLNP, (b) faster recovery time, and

Transoral endoscopic thyroidectomy via vestibular approach: operative steps and video.

In this video we describe transoral endoscopic thyroidectomy vestibular approach (TOETVA). Inclusion criteria are (I) patients who had a ultrasonographically (US) estimated thyroid diameter not larger than 10 cm; (II) US estimated gland volume ≤45 mL; (III) nodule size ≤50 mm; (IV) a benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter; (V) follicular neoplasm; (VI) papillary microcarcinoma without evidence of metastasis. The procedure is carried out through three-port technique placed at the oral vestibule, one 10-mm port for 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments. CO2 insufflation pressure is set at 6 mmHg. An anterior cervical subplatysmal space is created from the oral vestibule down to the sternal notch, laterally to the sterncleidomuscles. Thyroidectomy is done fully endoscopically using conventional endoscopic instruments and intraoperative neuromonitoring (IONM).

Usefulness of CBCT and guidance software for percutaneous embolization of a lymphatic leakage after thyroidectomy for cancer.

Lymphatic leakage can develop as an iatrogenic complication of thoracic, cardiac, and neck surgery. The management of this complication may be challenging and involves more specialists. Percutaneous, image-guided techniques may offer two advantages: mini-invasivity and ability to image and identify the anatomy and the site of the leakage. We report a case of refractory cervical chylous leakage after thyroidectomy and lymphadenectomy for cancer that was successfully treated with an ultrasound-guided intranodal lymphangiography and a percutaneous puncture of the leak performed using CBCT as imaging guidance.

Self-Retaining Retractor Widox® for Thyroid Surgeries: Technical Note.

During a thyroidectomy, perfect exposure of the vascular nerve structures, parathyroid gland, trachea, larynx, esophagus, and lymphnodes is crucial to facilitate the surgeon in the meticulous dissection. WIDOX® (MOSS Spa, Lesa, Italy) is an atraumatic self-retaining thyroidectomy retractor specifically designed for thyroid surgeries with an octagonal shape and six retractors (Fig. 1). It is a sterile, single-use device which keeps the surgical wound and the neck muscles retracted allowing the proper exposure of the operatory field. The device substitutes the manual retractors held by the surgeon's assistants. In our institute, we started using the self-retaining retractor WIDOX® from May 2015 for a total of 50 patients. From our preliminary experience, the self-retaining retractor WIDOX® is simple and practical and can be adapted to each patient. The use of energy-based devices and the neuromonitoring is not prevented by the presence of this retractor.

Continuous Intraoperative Neuromonitoring (C-IONM) Technique with the Automatic Periodic Stimulating (APS) Accessory for Conventional and Endoscopic Thyroid Surgery.

One of the most important trends in intraoperative neural monitoring (IONM) in thyroid surgery is currently the real-time monitoring of the vagus nerve (VN) in order to prevent recurrent laryngeal nerve (RLN) iatrogenic damages. Notably, continuous intraoperative neuromonitoring (C-IONM) seems to be superior to intermitted intraoperative neural monitoring (I-IONM) because it enhances standardization by permanent vagus nerve (VN) stimulation, and it provides entire and constant RLN function monitoring as the surgeon dissects and removes the thyroid gland. It also has to be highlighted that the surgical maneuvers for the automatic periodic stimulating (APS) placement must be accurate and standardized in order to avoid a potential iatrogenic morbidity on the VN function. We recommend the experienced surgeon be very careful in each step, with cautious dissection. With this review article we provide a comprehensive analyses of C-IONM technique with the APS accessory for conventional and endoscopic thyroid surgery.

Indocyanine green-enhanced fluorescence in laparoscopic sleeve gastrectomy.

The aim of this study is to present our preliminary experience with indocyanine green fluorescence (IGF) imaging in laparoscopic sleeve gastrectomy. After dissection of the greater curve sleeve, gastrectomy is performed using a linear articulated stapler. Once the stomach is resected, an indocyanine green solution is prepared and injected in a periferic vein. A laparoscopic system with a high-definition camera system connected to a laparoscope equipped with a specific filter for optimal detection of the near-infrared fluorescence was used at all times as previously reported in a paper of Boni et al. A methylene blue test is routinely performed after near-infrared fluorescence, and a routine gastrografin upper gastrointestinal study is performed on postoperative day 2. We retrospectively identified 15 patients undergoing laparoscopic sleeve gastrectomy between April and October 2014. IGF imaging was used for all patients. A regular and homogeneous perfusion was observed along the entire gastric sleeve including the esophago-gastric junction. On the contrary, the excised specimen appeared devascularized at IGF imaging as expected. Intraoperative methylene blue test was negative in all cases. The contrast swallow did not document any leak. Neither clinical leak nor other complications occurred postoperatively (minimum follow-up of 2 months). IGF is a recent development in minimally invasive surgery. In this preliminary experience, IGF results resemble to intraoperative methylene blue test and postoperative contrast swallow ones. IGF allows a real-time assessment and gives a direct image of tissue perfusion and vascularization. Moreover, IGF may be helpful to explain the exact pathogenesis of gastric leak.