Search

Kidney transplant patients are subject to an increased risk of developing cancer due to immunosuppressive therapy. On the contrary, the incidence of neoplasm on renal graft is low. In the case of graft tumors, a balance must be made between maintaining the functionality of the graft and radical treatment of the tumor. In the case of small tumors, it is possible to perform a nephron-sparing surgery, which allows to treat cancer with low recurrence rates and maintenance of renal function. In this study, we evaluate the management of graft tumors in a single transplant center. We registered three cases of graft tumors per 633 transplantations in a 20-year period with a calculated incidence of 0.47%. In all cases, thanks to a regular follow-up, it was possible to diagnose the neoplasm at an early stage and treat it by a nephron-sparing technique. It was thus possible to ensure the healing from the tumor and preservation of the function of the kidney graft. We report, in fact, a good maintenance of kidney function and the absence of recurrence at a long follow-up.

Introduction. Improving the prognosis of breast cancer patients is of utmost importance in terms of increasing survival rates. Modern medicine has therefore prioritized better quality of life for patients, even after the disease, through a better management of the potential long-term side effects induced by anticancer treatments. Fertility preservation and family planning are therefore crucial issues to be addressed in all cancer patients of reproductive age. Along those lines, a new branch of medicine with distinct multidisciplinary characteristics has developed over the years: oncofertility. Although both national and international guidelines value reproductive counseling as an essential aspect of the diagnostic-therapeutic pathway, part and parcel of the informed consent process, it is not included within the protocols adopted by the operating units for the care and management of neoplastic diseases. Objective. This study aimed to evaluate the activity of the Breast Unit of the Policlinico Umberto I Hospital, Rome, Italy, and the degree of compliance with guidelines. By knowing the strengths and weaknesses of such approaches, the standards of care offered to breast cancer patients can be improved. Materials and methods. A retrospective study based on a review of medical records was conducted between 2014 and 2021. Patients under 40 years of age diagnosed with non-metastatic malignancies were included who received chemotherapy treatment, namely neoadjuvant, adjuvant or adjuvant hormone therapy. Results. The data were extracted from the medical records of 51 patients who met the inclusion criteria, 41% of whom received reproductive counseling, and of these, 43% decided to undertake a path of fertility preservation. Factors such as the absence of children and young age reportedly favored both the interest in counseling proposals by the medical staff and the decision to undertake a path of fertility preservation. Conclusions. The study shows that there has been growing interest in the topic of oncofertility, especially in light of law 219/2017. Therefore, since 2018, multiple proposals for reproductive counseling have been set forth, but there was not an equally growing demand for fertility preservation practices, which can be explained by the invasive nature of such practices, the patients’ concern about their own state of health, and poor or inadequate information. Such impediments highlight the importance of standardized counseling and the need for a multidisciplinary medical team to support the patient in the decision-making process. The study also revealed a drop in the number of patients receiving counseling due to the COVID-19 pandemic, contrary to the positive trend that was recorded prior to the pandemic.

Transplant renal artery stenosis (TRAS) is a common vascular complication after kidney transplantation, leading to worsening or refractory hypertension, deterioration in renal function, and possible cause of graft loss. Early diagnosis and an appropriate treatment are crucial for organ preservation. Endovascular treatment, including percutaneous transluminal angioplasty and stent implantation, is considered the first-line therapy for TRAS. Here we report the case of a 69-year-old woman with end-stage renal disease for chronic kidney disease not biopsy proven, who underwent a kidney transplant from expanded criteria donors on December 2018. Postoperative course was characterized by delayed graft function. Doppler ultrasonography (US) showed an increase of peak systolic velocity at the origin of the renal artery, and parvus-tardus waveform in periferic graft arteries and an abdominal computed tomography scan confirmed a stenosis at the origin of the main renal artery (TRAS). The patient underwent a percutaneous transluminal angioplasty. It was not possible to place a stent at the particular location of the stenosis at the anastomosis. Despite the improvement of the graft's perfusion, monitored with Doppler US, the patient showed a very poor improvement in renal function and remained on hemodialysis for months. A percutaneous needle biopsy reported a normal renal parenchyma and excluded acute rejection. During this period, the patient received immunosuppressive therapy. About 6 months after the transplant, the patient had an unexpected and slow renal function recovery until she was weaned completely from hemodialysis.

Background. T-cell mediated acute rejection (aTCMR) is still an issue in kidney transplantation for it is associated with chronic rejection, graft loss, and overall worse outcomes. For these reasons, a standard non-invasive molecular tool to detect is desirable to offer a simpler monitoring of kidney transplant recipients (KTRs). The purpose of our study was to examine, in peripheral blood before and after transplantation, the expression patterns of regulatory T cell (Treg)-related genes: the forkhead box P3 (FOXP3) and the two CTLA-4 isoforms (full-length and soluble) to predict aTCMR onset, de novo donor-specific antibodies (DSA) development and renal dysfunction one year after transplantation. Methods. We profiled by using a relative quantification analysis (qRT-PCR 2-∆∆CT) the circulating mRNA levels of these biomarkers in peripheral blood of 89 KTRs within the first post-transplant year (at baseline and 15, 60, 365 days after transplantation and when possible at acute rejection) and compared the results with 24 healthy controls. Results. The three mRNA levels drastically reduced 15 days after transplantation and gradually recovered at one year in comparison with baseline, with very low levels by the time of aTCMR for FOXP3 (RQ=0.445, IQR=0.086-1.264, p=0.040). Healthy controls exhibited higher FOXP3 levels than patients at baseline (median RQ: 2.132, IQR=1.664-2.895 vs. p=0.005). Noteworthy, solCTLA-4 displayed a dual profile: on the one hand, at multivariate analysis solCTLA-4 transcripts at 15 days were associated with an increased risk of aTCMR over time (HR=3.905, 95%CI: 0.958-15.916, p=0.050), and graft dysfunction at one year (AOR=3.683, 95%CI=1.165-12.079, p=0.027); on the other hand, pre-transplant levels showed a protective association with de novo DSAs development (HR=0.189, 95%CI=0.078-0.459, pConclusions. Peripheral blood mRNA levels of Treg-associated molecules might help shape immunosuppression, tailor monitoring and achieve a better long-term clinical course of kidney transplantation in the wake of “precision medicine”. While the potential of these molecules as a therapeutic target needs further investigation, we found out preliminary evidence that solCTLA-4 can qualify as a candidate non-invasive biomarker of cellular and humoral alloreactivity in clinical transplantation.

Primary small bowel melanoma is a very rare clinical entity with a paucity of publications in literature. Most cases of gastrointestinal melanomas are metastatic lesions arising generally from primary lesion of the skin, eyes, or anus. We present a case of a small bowel intussusception with primary malignant melanoma as lead point and a gluteal melanoma metastasis after four years free from disease.A 77-year-old female has come to our attention with signs and symptoms of intestinal occlusion. She was subjected to a computerized tomography (CT) of the abdomen and pelvis that revealed small bowel intussusception caused by intestinal polypoid lesion. She was treated with a bowel resection. The histological exam has shown the presence of an amelanocytic malignant melanoma. The examination of skin, eyes, esophagus, colon and anus, a tot al body contrast- enhanced CT and a bone scintigraphy were negative for primary melanoma. So, the final diagnosis was primary melanoma of the ileum. After four-years disease-free survival, the patient came back to our attention for a gluteal melanoma metastasis, that was surgically removed. Afterwards she started immunotherapy, that is still ongoing.The diagnosis and the treatment of primary intestinal melanoma is a challenging due to the lack of scientific indications. Our case shows how an early diagnosis, although accidental, can offer a good survival free from disease. Moreover, a careful follow-up of our patients allows us to promptly identify neoplasm recurrence or distant metastasis that can be treated with surgery and systematic therapy.Intussusception, Primary bowel melanoma.Il melanoma intestinale è una patologia estremamente rara e molto spesso difficile da diagnostica a causa della mancanza di manifestazioni sintomatologiche precoci e specifiche. La diagnosi tardiva e la rapidità con cui questa neoformazione diffonde attraverso i vasi sanguigni intestinali sono le due principali cause della sua peggiore prognosi rispetto al melanoma cutaneo. Raramente può presentarsi con sintomi intestinali aspecifici quali dolore addominale cronico, occlusione intestinale, rettorragia e calo ponderale il più delle volte nelle fasi avanzate della malattia. Una presentazione clinica acuta che richiede un intervento chirurgico urgente, come nel nostro caso, può permette una diagnosi precoce, seppure accidentale, e quindi assicurare un trattamento radicale con una buona sopravvivenza dei pazienti. L’esistenza dei melanomi primitivi intestinali è sicuramente oggetto di dibattito, ma l’assenza di lesioni melanocitiche cutanee, oculari e anali permette di escludere la presenza di un melanoma metastatizzato, rinforzando l’ipotesi di una lesione primitiva intestinale confermata dall’esame istologico definitivo. Data la sua bassa incidenza non esistono dei protocolli condivisi di trattamento. Sicuramente la resezione chirurgica ampia della neoformazione, con margini negativi, e l’asportazione dei linfonodi mesenteriali corrispondenti permette una buona sopravvivenza dei pazienti. Un attento follow-up a lungo termine con esame dermatologico, visita oculistica, visita chirurgica, gastroscopia e colonscopia periodiche permettono di individuare precocemente eventuali secondarismi trattabili chirurgicamente e con terapia sistemica, in particolar modo immunoterapia.

Intimal arteritis (v-lesion) is a negative prognostic factor for kidney allograft survival. Early isolated v-lesions do not always represent a pathologic marker of acute T cell- or antibody-mediated rejection. In particular, in the case of transplant negative for C4d and donor-specific antibodies, such a finding can suggest an ischemic-reperfusion injury. There is an intense debate in the literature concerning the origin of this histologic feature. In the present study, we analyze how this argument can have a clinical relevance. Here we report a case of a 61-year-old woman with end-stage renal disease due to autosomal dominant polycystic kidney disease. The patient underwent kidney transplant from expanded criteria donor. Organs from expanded criteria donors are more prone to ischemic-reperfusion injury. Postoperative course was characterized by primary nonfunction of the graft. A first biopsy showed early isolated v-lesion in otherwise normal renal parenchymal. Simultaneously, a computed tomography scan revealed stenosis of the main renal artery. An endovascular stent was placed. Despite improved vascularization of the graft, no clinical response was observed and the patient remained anuric. A second biopsy was performed, showing T-cell mediated rejection (Banff Classification 1A). Despite pulse steroid, the patient lost the graft.

The graft nephrectomy is burdened by immunological and surgical complications. The main surgical complications of graft nephrectomy are hemorrhage, infections, vascular injury and death. The mortality is high, with percentages varying between 1.3 and 38%. Therefore, graft nephrectomy should be recommended only in selected cases. We conducted a retrospective study, comparing the data of 26 patients undergoing an allograft nephrectomy (2009–2013), without embolization of the renal artery (NO EMBO group) with the data of 40 patients undergoing an allograft nephrectomy (2014–2019), with embolization of the renal artery (EMBO group). We included only graft nephrectomies performed at least 6 months after transplantation. The patients included in the study were consecutive because until 2013 we did not perform the embolization of the renal graft artery. Afterwards, from 2014, instead, we routinely carry out embolization to all patients to be subjected to graft nephrectomy. We, therefore, wanted to analyze whether this surgical approach compared to the previous technique can lead to an improvement in morbidity and mortality, reducing the risk of bleeding and operating times. The examination of our data highlights that embolization of renal artery reduces the operating times of the explant, in addition the group subjected to embolization had less changes in hemoglobinemia and less blood loss.

Background COVID-19 is a new infectious disease which emerged in China in late 2019 and is now spreading around the world. Social distancing measures were needed to reduce transmission, and lockdown included restricted access to healthcare facilities. The impact of COVID-19 on transplant recipients is unknown but, considering their immunosuppression status and associated comorbidities, they should be considered a high risk population. Methods A kidney transplant center in Central Italy implemented a strategy to maintain follow-up of kidney transplant recipients by phone and e-mail during lockdown. Telephone interviews were used administer a clinical questionnaire to patients, and e-mail was used to receive the results of diagnostic tests conducted in outpatient settings. Results From March 17 to April 23, 2020, a total of 143 kidney transplant recipients were contacted. Twenty-eight patients needed in-hospital consultation for problems unrelated to COVID-19, 3 of whom needed hospitalization. Eleven patients were managed at home for mild urinary or respiratory diseases, and one was referred to the hematologist. We identified 2 suspected cases of COVID-19 infection, and referred them to hospital care. Immunosuppressive therapy was modulated, and intravenous corticosteroids and potentially effective antiviral therapy were administered, with a favorable outcome. Conclusion In the context of a lockdown, such as that occurring in response to COVID-19, we suggest implementing remote surveillance programs in kidney transplant recipients, with the help of any available technology, and offering medical consulting and logistic support as needed., Highlights • Lockdown has helped contain the transmission of COVID-19 in Italy. • Lockdown measures include reduced access to medical care for chronic conditions. • Kidney transplant recipients are fragile (immunosuppression and comorbidities). • Remote surveillance programs in fragile populations are needed. • Immunosuppression modulation is advised for COVID-19 in kidney transplant patients.

Background The causes of obstructed defecation syndrome (ODS) can actually be either functional or mechanical (primary or secondary deficit of the sensitivity, slow bowel transit, pelvic floor dyssynergia, internal and external rectal prolapse, recto-anal intussusceptions, anterior or posterior rectocele and pelvic prolapse of the bladder, uterus, bowel or sigma). The aim of our study was to evaluate the safety, efficacy and feasibility of stapled transanal rectal resection (STARR) procedure performed by a single or double stapler through clinical and functional outcomes for transanal stapled surgery. Methods From January 2016 to October 2017, ninety patients with ODS secondary to rectal prolapse, anal-rectal intussusception and anterior rectocele, that underwent to a STARR procedure were enrolled. Thirty of these underwent a STARR procedure with double circular stapler PPH-01 (Group A); 30 with single circular stapler CPH34HV with a purse string suture (Group B); and 30 with single circular stapler CPH34HV with a "parachute technique" (Group C). All patients were selected with clinical examination, Wexner score for fecal incontinence and ODS score for constipation. Patients also underwent a Defeco RMN for an anatomical and dynamic evaluation of the pelvic floor. Results No recurrence rates were observed in the three groups. The mean operative time was 46.3 minutes in group A; 34.5 minutes in group B; and 37.6 minutes in Group C. The volume of the resected specimen was 17 mL in group A; 15 mL in group B; and 16 mL in Group C. Complications were bleeding (3.3% in group A); fecal urgency (6.6% in group A, 10% in group B and 3.3% in group C); rectal hematoma (3.3% in group A). all symptoms significantly improved after the operation without differences between groups. Conclusions The STARR technique performed with a single stapler CPH34HV is safe, faster and less expensive than the STARR performed by a double PPH01. Besides, with the parachute technique, it is possible to resect asymmetric prolapses.

Thyroid disease and hyperparathyroidism are the most common endocrine disorders. The incidence of thyroid disease in patients with hyperparathyroidism ranges in the different series from 17 to 84%, and thyroid cancer occurs with an incidence ranging from 2 to 15%. The aim of our study was to analyze the management of elderly patients with concomitant thyroid and parathyroid disease in order to define the best surgical therapeutic strategy and avoid reoperations associated with a higher risk of complications. All consecutive patients (64 patients, age range 60–75 years), undergoing surgery for hyperparathyroidism, from January 2011 to June 2014, were retrospectively evaluated. Enrolled patients were divided into two study groups of patients affected by hyperparathyroidism with or without a concomitant thyroid disease. Out of 64 patients enrolled in our study (24 men, age range 60–75 years), affected by hyperparathyroidism, 34 had an associated thyroid disease and were treated with total thyroidectomy and parathyroidectomy. The group, who underwent parathyroidectomy associated with thyroidectomy, had no greater complications than the group receiving only parathyroidectomy. Thyroid disease must be excluded in patients affected by hyperparathyroidism. It is difficult to determine whether hyperparathyroidism can be considered a risk factor for thyroid disease, but an accurate preoperative study is essential for a surgery able to treat both thyroid and parathyroid disease. In this way, we avoid the elderly patient, with associated morbidity and increased surgical risk, to undergo a reoperation for thyroid disease, burdened with major complications.

According to the American Association of Cancer Research (AACR), a Cancer Stem Cell is a cell within a tumor that possesses the capacity to self-renew and to cause the heterogeneous lineages of cancer cells that constitutes the tumor [1]. Cancer Stem Cells (CSCs) are involved in the metastatic process, in the resistance to therapeutic treatments of many types of human cancers and consequently in the onset of recurrences. Numerous translational studies have been conducted to understand CSC characteristics and evaluate association between CSC-related biomarkers and clinical outcomes. The CSC theory can explain also a tumor relapse after that a tumor has been completely surgically removed (R0 macroscopical zero residual resection) or after an apparently complete response to chemotherapy. CSCs, in fact, showed a marked ability to reduce intracellular accumulation of chemotherapic agents by active drug extrusion, increased chemoresistance and survival, as well as elevated membrane transporter activity. In addition, it is possible that these cancer stem cells may nest in the "secured" (niche) sites of our body, where they may remain undisturbed for a long time, even years, until a stimulus arrives to awaken them, causing the disease to resume. CSCs, in fact, are able to use a variety of cellular pathways to survive to anticancer treatments. More recently CSCs have been described in several solid tumors, expressing specific biomarkers. Another field of research should be focused on the realization of diagnostic instruments to follow up patients after R0 surgical resection or after a complete response for an early detection and management of relapse and metastasis.

The surgical procedure of stapled haemorrhoidopexy is now considered safe, and its reliability is improving with experience and technical upgrading. Compared to conventional procedures, the short-term advantages of stapled haemorrhoidopexy include less postoperative pain, faster recovery and healing, whereas the disadvantages of the procedure in the long term include an increased possibility of recurrent prolapse. The percentage of symptomatic prolapse after stapled procedures widely varies in the several clinical trials described in the literature, ranging between 2 and 53.3 % [1]. Many shortand long-term complications of the different treatments for haemorrhoids (conventional, stapled or realized with different new devices) have been reported in the literature [2]. Less evidence is available about how to minimize these undesirable effects of stapling procedures, and there are no studies that describe and classify recurrences and the strategies to deal with them. We performed a retrospective study on 69 patients with recurrent prolapse after stapled haemorrhoidopexy [58 patients treated with a single-stapled procedure and 11 with a double-stapled procedure for prolapse and haemorrhoids (DSPPH)] who underwent re-intervention for recurrence. Prolapse over half of the circular anal dilator (CAD) is usually treated with a double stapling technique [3]. Thirty-five patients were female, and 34 were male. The mean age was 50 years (range 25–74 years). The follow-up was performed in the outpatient clinic at 1 week, 4 weeks and 6 months after surgery and yearly thereafter. The mean time until recurrence was 18 months (range 2–42 months) in the 58 patients, who had undergone a procedure for prolapse and haemorrhoids (PPH), and 12 months (range 2–42 months) in those who had undergone a DSPPH. The clinical onset of recurrence and the operations chosen are shown in Table 1. In the group of patients treated with PPH or DSPPH, bleeding requiring surgical revision occurred in one patient. Minor bleeding, managed with a local haemostatic device, was reported by one patient. In the patients treated with surgical excision, instead, bleeding occurred in one patient and required surgical revision. Urgency (n = 2) and anal pain (n = 2), which occurred in patients in both groups, spontaneously disappeared after surgery. In the patients who underwent surgical excision combined with PPH, no bleeding, urgency or persisting anal pain occurred. The mean follow-up after reoperative surgery lasted 40 months (range 23–96 months). No cases of second recurrence occurred. In the case of a mobile prolapse, this may be resected with stapler (PPH or DSPPH, depending on the amount of the prolapse that needs to be resected). On the contrary, in the case of a fixed prolapse, one or two piles, the choice should be surgical excision. In case of more than three multiple piles (C3), transrectal resection with a stapler (PPH or DSPPH) may be used. A PPH combined with Milligan–Morgan haemorrhoidectomy should be applied in & D. Pironi danielepironi@gmail.com

About 5% of occult gastrointestinal bleeding derives from small intestinal lesions. The intraoperative enteroscopy (IOE), although the development of double-balloon enteroscopy and capsule endoscopy reduced the indications, is still valid to locate the bleeding site in some selected cases. An 88-year-old woman presenting to the emergency department with a severe anemia underwent the laparotomic exploration and IOE. A 15-mm laparoscopy trocar with a sterile camera drape was adopted to introduce a standard colonoscope through an enterotomy. The operation was safe and effective, without intraoperative morbidity and early complications related to surgery or endoscopy. We propose a technical solution during the IOE to minimize contamination of the surgical field. Although this technique is safe and feasible, further studies are needed to evaluate the method effectiveness.

Pelvic organ prolapse (POP) is a common accompaniment of advancing age. Current repair techniques incorporate transvaginal and transabdominal approaches with or without prosthetic mesh insertion. In this paper, we present the short- and medium-term results of a unit policy directed at patients with POP of combined abdominal rectopexy and Burch retropubic urethropexy without the use of prosthetic mesh assessing its safety profile in selected cases.Between January 2009 and January 2011, 16 women with tri-compartmental prolapse who had all undergone prior hysterectomy underwent combined surgical pelvic floor repair. Preoperative symptom assessment by validated questionnaires and clinical examination were pre- and postoperatively recorded. Cures were defined as either optimal or satisfactory outcomes based on combined clinical, radiological examinations and reported patient satisfaction.The mean age of the 16 patients was 57.2 years, and their mean BMI was 28.6 (±5 SD). Pelvic examination revealed a POP-Q stage III prolapse in 12 patients and stage IV in 4 patients. The mean operating time was 57.5 min (range 40-85), with a mean length of hospital stay of 4.5 days. Cystocele and enterocele resolution was noted in every case on dynamic magnetic resonance imaging (MRI).Our results in a small patient cohort employing a simple 'all-in-one' repair approach combining a retropubic colposuspension with an anterior rectopexy appear to be satisfactory. Further larger randomized studies are required, incorporating a laparoscopic arm in order to determine the longer-term effectiveness of this approach.

In patients with fecal incontinence who do not benefit from medical or behavioral treatments sacral nerve stimulation is now considered a first-line procedure. Although the efficacy of treatment appears to be sustained in the short and medium term, the long-term results of therapy are relatively unknown.We report the results of chronic sacral nerve stimulation in patients who have had more than 8 years of therapy.All patients who underwent sacral nerve stimulation for fecal incontinence from 1996 to 2002 were followed up prospectively. Data were collected prospectively by the use of bowel habit diaries and St Mark's continence scores. Treatment success was defined as50% reduction in episodes of fecal incontinence with sacral nerve stimulation in comparison with baseline symptoms.Between January 1996 and December 2002, 25 patients (male/female 2:23; median age, 54 years (range, 35-68 years) underwent temporary sacral nerve stimulation. Twenty-three (92%) patients had a greater than 50% improvement in their ability to defer defecation during the trial phase and were considered suitable for chronic stimulation. Over a median follow-up of 114 months (range, 96-164 months), full continence was maintained in 12 (48%) of the 23 patients who received a neurostimulator implant. Two patients lost efficacy at 48 and 60 months after permanent implant for unknown reasons and had the device removed. Three patients died at 3, 8, and 9 years after permanent implant because of unrelated comorbidities. Nine patients required a change of battery at a mean (SD) of 87 (13.5) months.Sacral nerve stimulation can maintain a persistent clinical benefit in the long term for the majority of patients. Some patients will experience deterioration in their symptoms over time, for reasons yet unknown.

Haemorrhoidal disease is one of the most common anorectal disorders. The aim of this study is to compare the results, over the last 10 years, of stapled haemorrhoidopexy (SH) with those of standard Milligan–Morgan haemorrhoidectomy (M&M). Furthermore, we discuss the proper indications for each technique in terms of the lowest rate of complications and long-term results. Three hundred forty-three patients with different degrees of symptomatic haemorrhoids underwent SH or M&M from January 2005 to December 2007. Patients were divided into two groups, age and sex matched. The administration of painkillers drugs, antibiotics and laxatives, complication symptoms and hospital stay in all the patients were recorded after surgical treatment. The mean operative time was shorter in the stapled group compared to that in the open group (31 min versus 40 min). Postoperative pain, hospital stay and return to full activity were shorter in the stapled group. There was a significant difference in the wound healing time between the two groups. We noticed a higher rate of recurrence in patients treated with stapled haemorrhoidectomy for fourth-degree haemorrhoids. According to our experience, the Longo technique is indicated for the treatment of haemorrhoids of second- and third degree. In the latter grades of prolapse, the Milligan–Morgan haemorrhoidectomy can also be applied with good outcomes. We believe that, in case of irreducible prolapse, the M&M is to be preferred. However, operative management varies according to surgeon's interest and is tailored to meet the individual patient's need.

Intraoperative parathyroid hormone (iPTH) assay (QPTH) in combination with preoperative localization, permits a less invasive operative approach in the treatment of hyperparathyroidism. A 50% reduction of the intraoperative PTH level, mesured within 15 minutes with an immunochemestry system of III generation (ICMA), shows the completeness of the hypersecretive tissues surgical removal.From June 2003 to December 2005 a series of 39 patients underwent target parathyroidectomy with intraoperative parathyroid hormone assay for parathyroid disease. Intraoperative PTH was measured before, 5-10 and 20 minutes after parathyroidectomy. 79.5% of patients had secondary hyperparathyroidism, 29.5% had primary disease. In 38 patients (97,4%) the intraoperative PTH levels declined more than 70% and in only one patient (2,6%) intraoperative PTH levels declined less than 50%.QPTH has deeply modified the surgical approach to the treatment of hyperparathyroidism. Intraoperative measurement of iPTH is useful in prediction the complete removal of all parathyroid tissue after surgery for parathyroid disease, thus avoiding persistence or recurrence of disease and surgical failures. In well-studied cases QPTH can be considered a valid alternative to the intraoperative hystological examination.

Primary adenocarcinoma of the appendix is a rare malignancy that constitutes less than 0.5% of all gastrointestinal neoplasms. Usually the diagnosis is made only after histological examination of surgically removed inflamed appendix. Alternatively represent an unexpected finding, confirmed by frozen section, during surgery performed for acute appendicitis or other non appendiceal pathologies. Natural history is strongly influenced by anatomic peculiarities of the appendix that predispose to early spread and perforation. Frequently is associated with synchronous and metachronous colorectal or extraintestinal cancers. The correct management is the right hemicolectomy as a primary procedure in the case of preoperatively or intraoperatively diagnosis or as secondary procedure, after two-three weeks from appendectomy, when the microscopic examination of specimen reveals the presence of adenocarcinoma. Right hemicolectomy is the best treatment for all histologic types (colonic, mucinous, adenocarcinoid), in presence of perforation and even in Dukes A tumors. A careful intraoperative search for synchronous lesions and a life-long program of surveillance for the detection of early stage metachronous carcinomas are recommended. The Authors report a case of primary adenocarcinoma of the appendix occurred in a 78 year-old female patient, diagnosed incidentally during surgery performed for ileus from suspected cecal neoplasm.

Endoscopic mucosal resection is a potential alternative to surgery when submucosal invasion and lymph node involvement are excluded. We describe an en bloc resection of a large, focal, high-grade tubulovillous nonampullary adenoma of duodenal wall using hydroxypropyl methylcellulose as a lifting agent.

The goal of this study was to evaluate the complication rate of reoperative thyroid surgery and to find out the way to minimize the morbidity associated with it. We reviewed our experience in 622 patients, who underwent thyroid operation from January 2000 to September 2007. Among these ones, 76 were the patients who underwent reoperative thyroid surgery. Prior surgery in the 76 reoperations was: nucleo-resection in 9 pts (12.9%), lobectomy in 43 pts (55.5%), lobectomy+isthmectomy in 7 pts (9.3%), subtotal thyroidectomy in 17 pts (22.2%). Histologic examination revealed: benign lesions in 67 pts (88.15%), papillary cancer in 4 pts (5.26%), follicular cancer in 2 pts (2.63%), follicular adenoma in 1 pt (1.32%) and Hashimoto thyroiditis in 2 pts (2.63%). Complications included: section of recurrent laryngeal nerve, that was reconstructed in the same operation, and bilateral palsy of the recurrent laryngeal nerve so that was necessary to make a tracheotomy. One of the patient at the first thyroid surgery had monolateral palsy of the recurrent laryngeal nerve with dyspnoea and dysphonia. Temporary hypoparathyroidism (Ca8 mg/dl) occurred in 47.3% of the patients, who underwent reoperative thyroid surgery and in 45.2% of the patients, who underwent prior thyroid surgery. Conclusions. This study documents that reoperative thyroid surgery can be performed with little morbidity to the patient if precise operative rules are respected.

The peritoneal mesothelioma (PM) is a rare, benign or malignant, primary tumour, arising from the peritoneal membrane. The most frequent histological form is the malignant one with an incidence of 2-2.6 new cases per million per year. The symptomatology is insidious and poses difficult problems in the diagnosis and the treatment. Instrumental diagnostic investigations are useful only in the diagnostic orientation. Only the pathologic examination allows to distinguish a peritoneal carcinomatosis from PM. The prognosis of MPM is pour. An intense multimodal therapy, combining surgery with CT and RT, increases the survival rates in the patients with MPM. It has been proposed that hernia of abdominal wall play a role in the pathogenesis of this tumor. We believe that hypothesis seems unlikely considering the enormous discrepancy between the incidence of hernial pathology and PM.

Disease of the iliac fossa can often be accompanied by non-specific symptoms and some of these are exclusively caused by the compression of bulky masses of other neighboring structures. In young women a differential diagnosis is a non trivial task as several possible causes have to be taken into account. Thus, intraligamentary tumors, which are extremely rare finding, are frequently confused with uterus, ovary or intestinal tumors. Even if myomas are the most benign tumors of the female genital tract, broad ligament leiomyomas are an unusual finding in women of reproductive age. These tumors are often asymptomatic until they reach a volume likely to cause symptoms related to the mass pressure. An accurate patient's anamnesis and examination serve as a guide to further examinations. Ultrasound is the first line imaging as it can show ovarian or other pelvic mass and doesn't involve exposure to radiations in young patients, who can be pregnant. We describe the clinical presentation and imaging features of a broad ligament leiomyoma, which presented as an inguinal mass in a patient with a right iliac fossa pain. We also report our diagnostic process performing the differential diagnosis with other potential pathologies of RIF. In these cases, a preoperative disease classification discriminating the benign or malignant tumor nature is closely linked to the proper patient management.Le patologie occupanti le aree addominali inferiori sono frequentemente accompagnate da una sintomatologia aspecifica causata, il più delle volte, da compresione «ab estrinseco» a carico degli organi contigui. Nelle donne in età fertile la diagnosi differenziale gioca un ruolo di primo piano per una corretta gestione del paziente. Avviene così che alcune tipologie di tumori rari, come quelli intralegamentari, vengano confusi con tumori di altra proveninenza (utero, annessi o intestino). Alcuni tra questi, come il leiomioma del legamento largo, inusuali nelle donne giovani, insorgano e persistano senza alcuna manifestazione clinica sino al momento in cui il volume di massa non porti a compressioni nei confronti di strutture contigue. In questi casi una accurata anamnesi è fondamentale e deve essere sempre accompagnata da una indagine ecografica che accerti in maniera mininvasiva i l’origine ed i rapporti delle masse sospette. Vengono di seguito descritti: il percorso diagnostico e gestionale in un raro caso di leiomioma del legamento largo in una paziente con sintomatologia dolorosa in fossa iliaca destra. Nel nostro caso la diagnosi differenziale preoperatoria ha consentito un corretto approccio chirurgico discriminando sulla la natura benigna della lesione individuata.

In the last ten years the introduction of various open mesh and laparoscopic techniques has increased the interest in inguinal hernia surgery. Anyway controversy persists about the most effective inguinal hernia repair. The aim of this study was to compare the results of open mesh technique and laparoscopic transabdominal preperitoneal (TAPP) repair for inguinal hernia.We considered 584 patients, 532 man and 52 woman, between 19 and 86 years: 332 (56.8%) had open mesh repair and 252 (43.2%) laparoscopic TAPP repair of groin hernia. Operative time, complications, recurrences and time to normal activities were recorded in both groups (range follow-up 1-10 years).The median operative time was 71 min for open group and 92 min for TAPP group. No intraoperative complications were observed. Postoperative complication rate was 4,5% in patients open group and 3% in TAPP group. The recurrence rate was less than 1% in both groups (0,6% for open repair and 0,4% for laparoscopic repair). Significant difference was observed in the median time to return to normal activities: 9,8 days in TAPP group versus 13,4 days in open approach.Our experience confirmed the safety and effectiveness of laparoscopic transabdominal preperitoneal (TAPP) approach to inguinal hernia repair as excellent alternative to conventional surgery. The reduction of operative time, complications and recurrences is correlated to the surgeon's experience and learning curve.

The pelvic abscesses as complication of surgical operations or various pathologies is a delicate clinical situation because of the possible and unexpected evolution into a settic shock with a high risk of death. The authors report their personal experience of 16 cases undergone surgical treatment. They underline the importance of an early diagnosis, of a control of the patient general conditions with a specific antibiotic therapy, of the possibility to treat this pathology in a percutaneous way with the help of radiologic techniques or eventually by surgery.

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Surgery remains the elective treatment. We retrospectively compared two group of patients, who underwent surgery for GIST before and after Imatinib advent in order to analyze the recurrence and survival rate.Two patient groups who underwent surgery for GIST, from January 1997 to December 2002 (Pre-Imatinib group) and from January 2003 to December 2008 (Post-Imatinib group) were compared. Patients were evaluated on the base of gender, age, clinical manifestations, primary location and metastasis positivity, tumor size, mitotic index, immunoreactivity for CD117 and the outcome, including date of death.In the Pre-IM group only one patient died for prostate cancer, 12 months after operation, the other died because of GIST with a 24.6 months of median survival rate (range 15-51). In the remaining 12 patients the median follow up period was 55 months (range 6-152 months). In the Post-IM group the mean follow up was 50.7 months (range 26-74) and they are still being assessed for oncological as well as surgical treatment.Early diagnosis and radical resection remain the standard of cure for GISTs. To date, the use of Imatinib lead to its utilization as adjuvant and neo-adjuvant therapy in adults. Our experience suggests that there is a correlation between the mutational status of KIT and clinical outcome. These aspects should be explored for targeted therapy that can effectively combine biological therapy to surgery.

Dear Sir The thymus plays a crucial role in the context of cellmediated immunity in the differentiation of T lymphocytes, not only during the embryogenesis and fetal period but also during the adulthood, even after its involution 1,2,3. It has been proved, indeed, that thymectomy in adult rat entails a decrease of the T-lymphocite response to mitogens and eventually its abolition 4,5,6. The removal of the thymus can decrease the activity of T-helper cells but in the same time it might enhance the activity of T-suppressor whose function is depressed in autoimmune diseases 7. The therapeutic role of thymectomy is proved in Myasthenia Gravis even if the exact mechanism underlying its effect remains largely unknown. The role of thymectomy as a treatment of autoimmune diseases other than Myasthenia Gravis (i.e. sistemic lupus erythematosus, rheumatoid arthritis, autoimmune hemolytic anemia, multiple sclerosis) has been investigated but the results of these studies are questionable 7. Our aim is to evaluate the role of thymectomy in order to clarify whether it may be regarded not just as therapeuytic, but, on the contrary, as a factor paving the way to the onset of autoimmune diseases. Therefore, the relevant literature has been taken into account along our study. Thymus has an important role in regulating immune reaction through its control on T-cell differentiation of both T-helper and T-suppressor/cytotoxic cells. That is the reason why thymectomy produces a shift in autoimmune diseases with disregulation of the immune networks2. After thymectomy, indeed, an induction and an acceleration of autoimmune processes has been observed. A relevant work focusing on those mechanisms was written by Gerli et al1 . In their work, the authors consider the long term immunologic effects of therapeutic thymectomy in patients with Myasthenia Gravis comparing 16 patients with Myasthenia Gravis and previous Thymectomy (at least 8 years before), 6 patients with Myasthenia Gravis and recent Thymectomy (1year) and 13 with Myasthenia Gravis non Thymectomized and 32 healthy subjects used as control. The study shows that the long term thymectomized patients had mild T-cell lymphopenia and an expansion of CD4+ and CD8+ cells. These serologic abnormalities were not detectable in not and recently thymectomized patients. Myasthenia Gravis and SLE are autoimmune disorders. They have positivity for antinuclear antibodies (ANA) and thymus hyperplasia. SLE is characterized by an alteration of the immune system that involves B cells and T lymphocites, resulting in polyclonal B cell activation and autoantybody production. The thymus deletes self-reactive T-cells with high avidity T-cell receptors for self antigens expressed in the thymus 8,9. This, hence, means that thymus has a protective role against autoimmunity. The prevalence of SLE in pts with Myasthenia Gravis has been reported 0,2%-2,7% 10. Cases in which the SLE has developed after thymectomy for Myasthenia Gravis have been reported in the literature, but there are also cases in which SLE developed before thymectomy in pts with both SLE and MG. Iwadate at al reported from a review of the literature in a period of 40 years (1963- 2004) 21 patients in whom LES developed after thymectomy. Their ages ranged from 11 to 66 years (mean 40.4 years) with SLE developing from 2 months to 13 years (mean 4.9 years) after thymectomy. Polyarthritis was the most common manifestation of SLE 11. The proof that thymectomy can facilitate the development of SLE can be traced in the cases reported by the literature. The prevalence of SLE among patients with thymoma varies between 1,5 and 10% 12. Boonen et al identified in a period of 20 years (1975-1998) 18 new cases of thymoma and SLE. In 39% of the patients SLE was diagnosed before detection of thymoma. In 33% of the patients, thymoma and SLE was found simultaneously and in 28% SLE was discovered after thymoma. In five cases thymectomy had no clear effect on SLE. In two cases an exacerbation was reported and in one case SLE was attenuated 11,13. However, Vaiopoulos et al 14 described in a series of 28 patients with both LES and Myasthenia Gravis, 17 cases in which LES developed before thymectomy.Thymectomy may thus be a precipitating factor for the development of SLE due to the loss of central tolerance and the overproduction of antibodies. Therefore, after a thymectomy, it is important to perform a timely follow up of the patient.