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Thyroid surgery, one of the most common interventions in endocrine surgery, is practiced by many specialists who perform this procedure exclusively. It accounts for the bulk of work even in reference centers that treat rare endocrine tumors (e.g. adrenal and gastrointestinal tract cancer). Better results are obtained by experienced and skilled operators. Surgeons who correctly perform thyroid surgery can achieve excellent outcomes even in other areas of endocrine surgery. So it is surprising that not more is being done to teach the procedure, which has always been considered something of an art, perhaps because surgical treatment of rare endocrine tumors is more stimulating to teach than routine surgical procedures. Nonetheless, teaching correct surgical technique is essential for reducing and avoiding postoperative complications caused by inadequate experience and knowledge. Numerous studies have reported that the incidence of complications is high and that the rate is growing: 5% involve permanent injury to the recurrent laryngeal nerve after intervention for a benign tumor, despite repeated reports that the incidence could be reduced to near zero or at least to 1%. Alarmingly high is the 20% incidence of persistent hypoparathyroidism after total thyroidectomy. Here, too, accurate technique could reduce this rate to 1%. An important point is that permanent laryngeal nerve injury and persistent hypoparathyroidism are both sources of considerable discomfort for patients. One of the chief objectives of modern endocrine surgery is, therefore, to reduce the complications rate to acceptable levels by establishing adequate, uniform teaching protocols and universal guidelines that would help improve the practice of surgery.

Experimental models of acute pancreatitis have been developed for more than a century. Although not closely comparable to human disease, they have contributed to our understanding of the physiopathology and cell biology of the disease. The methods used for the induction are subjected to critical examination. In the relevant literature findings, the advantages of each group are underscored, and reference is made to their defects with regard to reproducibility and reliability, with a view to extending the results obtained to human pathology. A proper understanding and standardization of these models may enable us to choose the most suitable model for studying a given aspect of the disease or for evaluating new treatment protocols. The data collected has made it possible to select standardization criteria for a comparative experimental study in the laboratory.

Patients with cancer of the upper digestive tract may present with malnutrition, which may cause immunodepression and an increased rate of postoperative complications. In this study we describe the rationale and the feasibility of immediate postoperative enteral nutrition (NEPI) and evaluate its effectiveness for the nutritional support of patients undergoing surgery of the upper digestive tract. We studied 46 patients undergoing the following procedures: total gastrectomy (n = 22); oesophageal resection (n = 12); duodenocephalopancreasectomy (n = 12). NEPI was started on postoperative day 0 with a polymeric diet (calories: 53% as CHO, 22% as proteins, 25% as lipids) aiming at a calorie intake of 25 Kcal/Kg/day by postoperative day 4. It was possible to administer 24 Kcal/kg/day with the enteral diet from the 4th to the 10th postoperative day. Oral intake was resumed on average on postoperative day 13, and the mean hospital stay was 27 +/- 17 days. Tolerance of NEPI was good in most patients: only 5 patients (11%) interrupted the enteral nutrition. The mean postoperative weight loss was 3.7%. The rate of septic complications was 27%; mortality was nil. The surgical procedures caused a transient and reversible acute-phase decrease of nutritional and immunological parameters in the early postoperative period. However the NEPI preserved the nutritional status postoperatively as shown by the lack of significant changes in the nutritional indices at 10-14 days after surgery, as compared with baseline. In summary, we documented that NEPI can be started from postoperative day 0 with good intestinal tolerance, allowing adequate nutritional support, after extensive surgical procedures on the upper digestive tract.

In a double blind clinical trial 40 female patients, aged between 14 and 65 years, affected by mastodynia associated with benign non neoplastic disease of the breast, underwent oral treatment with nimesulide (200 mg/day) or placebo for a period of 15 consecutive days, during which no other drug therapy was assumed. The administration of nimesulide produced a clinically significant attenuation of mammary tenseness and mastodynia, in most cases up to complete remission of the symptoms. No adverse reaction was observed.

The importance of the preparation of an operative field which will guarantee satisfactory conditions of asepsis during the entire operation is an indispensible premise for controlling the development of postoperative wound infections. This paper compared the efficacy of disposable clothes and gowns in TNT FABRIC 450* in relation to cotton gowns in reducing the incidence of postoperative wound infections. Cotton items were used for 25 subjects out of a group of 50 operated patients and nonwoven fabric (TNT FABRIC 450*) items were used for the other 25. Thorough bacteriological tests were performed in each patient before, during and after the operation. On the basis of the duration of the operation, it was observed that TNF FABRIC 450* was as efficacious as cotton in controlling postoperative infections in those operations with a short or medium duration; it offered greater protection in lengthy operations, with a higher risk of endogenous and exogenous contamination. It was also observed that disposable items were indispensable in patients treated with radioactive materials and offered greater safety in seropositive patients.

Disturbances of potassium homeostasis are frequently iatrogenic: some drugs, especially diuretics, are sometimes taken without proper electrolyte control and replacement; this can lead to more or less severe hypokalemic states. After some physiopathologic remarks, the Authors report their experience with four patients admitted for severe hypokalemia; the clinical picture was always quite typical: severe muscle weakness (even quadriparesis), cardiac rhythm abnormalities, metabolic alkalosis. A reliable diagnostic tool is muscle biopsy that shows aspects of vacuolar myopathy.

The Authors report their clinical experience about the use of atracurium besylate in preventing succinylcholine-induced fasciculations and postoperative myalgias in fifty athletes (ASA class 1), submitted to arthroscopic meniscectomy. The patients were pretreated with atracurium 5 mg i.v. or saline solution in a double-blind fashion. After 2.5 minutes, succinylcholine 1.3 mg/kg was administered, and fasciculations were recorded on a scale ranging from 0 to 3. Twenty-four hours after surgery all subjects were questioned about myalgias occurrence, scored by a 0-3 scale. Fasciculations occurred in all patients who received saline and in 44% of those treated with atracurium. Myalgias on the postoperative day were observed in 80% of patients treated with saline solution, but only in 36% of patients who received atracurium. The difference between atracurium and saline solution was statistically significant (p less than 0.001) either for fasciculations or myalgias incidence. These findings show that atracurium 5 mg i.v. is effective in preventing succinylcholine-induced fasciculations and postoperative myalgias, and suggest atracurium as the drug of choice for this purpose, particularly in muscular subjects.

With the aim of preventing deep vein thrombosis after radical or modified mastectomy, 100 patients were randomly assigned to one of two different groups: the first group was treated with defibrotide (400 mg b.i.d. e.v.) starting from the day before the operation and continuing for the following seven days. The second group was given calcium heparin (5,000 IU b.i.d. by s.c. route) from day 0 to the 7th post-operative day. Neither side effects nor DVT or PE were observed. The quantity of fluids from the drainages rapidly decreased in both groups from the first day to the third one, while the quantity of blood cells was negligible starting from the second post-operative day. On this basis defibrotide may be considered an effective and well tolerated drug for the prevention of DVT.

The authors suggest preventive minitracheotomy as a support technique in difficult endotracheal intubation, and report their experience in a case of surgical operation to remove a bony neoformation of C1 and C2 posterior arcs. Endotracheal intubation, difficult because no part of the glottis could be seen, was made possible by preventive minitracheotomy. In this way sedation, myorelaxation and excellent oxygenation during following manoeuvre that resulted atraumatic, were obtained. The small cannula of minitracheotomy was maintained closed during the operation and open for 24 hours thereafter to prevent obstructive complications. It was then removed.

Color Doppler and Duplex Doppler US were employed on 4 patients with clinically suspected pseudoaneurysms as a complication of femoral artery puncture after cardiac catheterization. Pseudoaneurysms were identified with Color Doppler US and their typical appearance was confirmed. The grey-scale findings did not allow an adequate differentiation between hematoma and pulsed hematoma without fibrous encapsulation: only Color Doppler US easily detected the track between damaged artery and blood collection and allowed a sample to be obtained for pulsed Doppler examination. Color Doppler US allowed an accurate and non-invasive diagnosis of groin masses after femoral artery catheterization.

The relationships between postoperative immunodepression and duration of general anesthesia, volume of blood transfusions, cortico-steroid administrations and amount of surgical trauma have ben studied, in cancer patients undergoing radical operations. Postoperative depression of cellular immunity, assayed by the lymphocyte blastogenic response to phytohemagglutinin, was significantly correlated with the amount of surgical trauma and did not correlate with blood transfusions and corticosteroid administrations, nor with the duration of anesthesia.

The effect of an intravenously administered lipid emulsion (Intralipid) on granulocyte functions has been studied. The study has been carried out in 20 healthy individuals, divided into two groups: 10 individuals have been infused with Intralipid 10% i.v.; the other 10 individuals (controls) have not been infused with any pharmacologically active solution. In all the subjects the following parameters have been studied: blood granulocyte count, granulocyte adherence and leucocyte chemotaxis. The results showed a transient fall of granulocyte adherence during the intralipid infusion; no alterations of granulocyte count and leucocyte chemotaxis were found.

The latest investigations in the field of clinical immunology have proposed ways of assessing immunological efficiency that have also been used to identify patients most susceptible to infectious complications. The assessment of delayed hypersensitivity response (DHR) using anamnestic antigens is currently the most common method. The results of a polycentric study are presented. The study was conducted on a group of healthy subjects from various Italian regions divided into three age classes. Positive responses to the MT were noted in 96.4% of the population studied. The incidence of energy was statistically higher among females than males, while the mean response to the MT expressed in millimetres was statistically higher in males. Though 7 antigens were administered, the responsive population reacted on average to 3. The highest incidence of positive responses was to Candida, with Trichophyton responsible for the fewest.

Sequential evaluation of lymphocyte blastogenic response (LBR) to PHA was performed in 10 melanoma patients and in 10 gastric cancer patients undergoing radical operations. Preoperative determinations showed a significant depression of LBR in both patient groups as compared to healthy controls. In patients operated for melanoma the average duration of anesthesia was 101 minutes and in patients who underwent gastric resection it was 192 minutes. In both patient groups a further significant depression of LBR was observed in the early postoperative period; however the LBR returned to preoperative levels more promptly in patients who underwent melanoma excision than in those who underwent gastric resection.

Postoperative infections are the most frequent cause of morbidity and mortality in surgical patients, considerably increasing the duration and cost of hospitalization. During the past decade the criteria for the administration of prophylactic antibiotics have been established and their proper use has caused a significant reduction of postoperative infections. The Authors review the indications to the use of local and systemic antibiotic prophylaxis; moreover, the general principles of antibiotic prophylaxis are presented and discussed, including problems related to the choice of antibiotic, dosage, timing and duration of administration, under different clinical circumstances and in various types of surgical operations.

The effects of glucose-1-phosphate (250-500 ml given by i.v. infusion over a period of 3-4 h for 3-5 days) on the quantity of exogenous insulin administered and on leukocyte adhesion and chemotaxis were studied in 4 groups of post-operative patients submitted to TPN (total parenteral nutrition), TPN + glucose-1-phosphate, standard infusion therapy and standard infusion therapy + glucose-1-phosphate respectively. With the use of glucose-1-phosphate the quantity of insulin administered could be significantly reduced (P less than 0.01) thereby an increased utilization of glucose, induced by the phosphorylated saccharide, was confirmed. Moreover, glucose-1-phosphate, through its action on intracellular sugar metabolism, increased leukocyte adhesion during TPN. This phenomenon might have a favourable effect on some of the functions carried out by these cells on the inflammatory response.

Cellular immunity has been studied in 92 patients with solid tumors undergoing surgery, in order to evaluate immunocompetence at the time of diagnosis and to assess the prognostic value of parameters of cellular immunity. The results show that total lymphocyte counts, T-lymphocyte counts and lymphocyte blastogenic responses are moderately depressed at diagnosis in the cancer patients as compared to age matched controls. These parameters of cell mediated immunity "in vitro" seem to be of limited prognostic value, since no correlation was found with the clinical course during the first 6 postoperative months. Depression of delayed hypersensitivity response to cutaneous antigens appeared to be an index of poor prognosis.

Some recent views on pathophisyology of "myasthenia gravis" are presented. The Authors explain the typical damage of myasthenia gravis, i.e. the progressively reduced muscolar function on the basis of an autoimmune derangement affecting the motor-end plates. The most commonly used types of treatment, both medical (i.e. antiChE, A.C.T.H., steroids and immunodepressant drugs) and surgical (thymectomy) are reviewed. The very important role of Intensive Care for the treatment either of myasthenia gravis "per se" or of possible consequences of some drugs (A.C.T.H. steroids) is also stressed. Finally the Authors present their results about their experience on 36 patients affected by myasthenia gravis and admitted to I.C.U. once (29 patients) or twice or more (7 patients). The Authors describe some practical problems presented by patients during their stay in I.C.U.