Ten-year Audit of Safe Bail-Out Alternatives to the Critical View of Safety in Laparoscopic Cholecystectomy.

BACKGROUND: To prevent vasculobiliary injuries according to the Tokyo Guidelines, Critical View of Safety (CVS) is the recommended method for the identification of the cystic duct and cystic artery. Our aim was to audit laparoscopic cholecystectomies, in order to determine the rate of CVS feasibility and to explore safe bail-out alternatives, when CVS cannot be obtained. METHODS: Patients who underwent either elective or emergent laparoscopic cholecystectomy, between January 2009 and December 2018, in whom the CVS was attempted, were retrospectively identified from the institutional electronic database. Dissection technique was documented in the operative notes. Bile duct injuries (BDI) were classified by the Strasberg classification, and their management and outcome were reported in the patient files. RESULTS: In total, 1226 cases were included in the final analysis. CVS was feasible in 1128 cases (92.0%), whereas 65 patients (5.3%) were managed laparoscopically by a bail-out technique. Of those, 52 (4.3%) underwent a subtotal cholecystectomy, 12 (0.9%) a fundus-first cholecystectomy, and in one patient (0.1%) the operation was concluded by a tube cholecystostomy. Overall conversion rate was 2.7% (33/1226 cases). Male gender, older age, junior surgeons, and acute cholecystitis were significantly associated with higher conversion rates. Post-operatively, 10 patients (0.82%) developed a type A bile leakage. No major BDI (types B-E) were observed, either with CVS or the bail-out techniques. CONCLUSIONS: Our study showed that CVS and the bail-out alternatives complement each other in preventing major BDI and should belong to the armamentarium of every modern surgeon.

Giant sternal metastasis secondary to follicular carcinoma of the thyroid gland: report of a case.

A 70-year-old woman was admitted to our department for investigation and treatment of a progressively enlarging multinodular goiter and a fast growing mass infiltrating the sternum. The patient was euthyroid, but computed tomography (CT) and ultrasonography showed a mass in the anterior mediastinum infiltrating the sternum, with a dominant nodule in the right lobe of the thyroid. Fine needle aspiration biopsy results from both the cervical and the mediastinal masses were suggestive of follicular thyroid carcinoma. The patient underwent total thyroidectomy, thymectomy, and total removal of the mass, along with parts of the sternum, sternocleidomastoid muscle, and attached ribs. The thoracic wall was reconstructed with gortex dual mesh covered by muscle flaps from both pectoralis major muscles. Pathological analysis of both masses confirmed the fine needle aspiration findings and the patient received three cycles of radioactive iodine treatment. She had an uneventful postoperative course, but died of a stroke 8 years later.

Sentinel node biopsy for breast cancer patients: issues for discussion and our practice.

Sentinel node biopsy has been established for several years now as a standard procedure of breast cancer surgery, but there are several variations of the indications and the technique used. This paper provides information regarding several issues of debate for its application as are the selection criteria, the application to patients with multifocal/multicentric breast cancer or DCIS, postneoadjuvant chemotherapy, the necessary number of nodes to be biopsied, the need for lymphoscintigraphy, the technique for frozen section, the factors that may predict nonsentinel nodes (NSNs) involvement, the value of micrometastasis and isolated tumour cells, the internal mammary chain sentinel nodes, and finally the axillary recurrence after SLNB. Our view for these issues is included together with our experience of 430 SLNBs.