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Port-a-cath catheterization is often required for those patients who need long-term therapies (malnutrition, neoplasm, renal failure, other severe diseases). The use of ports for a wide range of indications is not exempt from complications. Ultrasound-guided central venous catheterization (CVC) is a safe and fast technique for the introduction of the catheter inside a central vein. This retrospective study reports our experience with US-guided CVC in patient eligible for port-a-cath implantation.From January 2007 to March 2017, 108 CVC (out of 770 procedures), were positioned using an ultrasound guide, with the new "one-shoot technique" (group 1) and the classic Seldinger technique (group 2).One-shoot techniques showed a reduced operative time, in comparison to Seldinger technique, with a negligible minor complication rate. No major complication were evidenced.CVC is a safe procedure, although not free from complications. Ultrasonography enhances safety of the procedure by decreasing puncture attempts and complications; it is helpful in patients with vascular anatomical variations, with no visualized or palpable landmarks or for patients with coagulation disorders.

Patients with thoracic trauma constitute one third of all the trauma cases, in west Sicily were recorded 941 thoracic trauma during the period between 2006 and 2009. Sicily is one of the Italian regions with the highest rate of obesity: some studies have demonstrated that obesity is an independent risk factor for mortality in high energy blunt traumas.This study was conducted with trauma patients older than 20 years old who presented to our Department during the last five years. We only included thoracic injuries and politrauma with a thoracic involvement and a BMI25. Patients were divided into two groups: HET and LET patients.Thoracic trauma was more common in patients with a BMI25 than in normo-weight and clinic admission rate, length of hospital stay and ISS score increased in proportion with the increase of BMI. Both HET (high energy trauma) and LET (low energy trauma) revealed that overweight, obese and morbidly obese patients had greater admissions and length of hospital stay.The overweight and obese population has increased substantially over the last two decades and 61,5% of the Sicilian population is above normal weight. A large body mass with excess adiposity may contribute to HET injuries in several ways. Obesity has a number of comorbidities that reduce chances of recovery in overweight and obese patients experienced thoracic trauma both HET and LET.Obesity increases morbidity independently of injury severity in thoracic trauma patients. As BMI increased, length of hospital stay increased and prognosis deteriorates.BMI, Obesity, Thoracic trauma.Circa un terzo di tutti I casi di trauma è rappresentato da trauma del torace. Nella Sicilia occidentale, tra il 2006 e il 2009, sono stati riportati 941 casi di trauma del torace. La Sicilia è una delle regioni italiane con il tasso di obesità maggiore: alcuni studi hanno dimostrato come l’obesità rappresenti un fattore di rischio per mortalità nei traumi contusivi ad alta energia.Questo studio è stato condotto su pazienti traumatizzati, di età superiore a 20 anni, afferiti al nostro Dipartimento negli ultimi cinque anni. Nel campione abbiamo selezionato solo I trauma del torace e I politraumi con interessamento toracico e pazienti con BMI25. I pazienti sono stati suddivisi in due gruppi: HET e LET.I trauma del torace sono più comuni in pazienti con BMI25 che nei normo-peso. Tasso di ammissione ospedaliera, durata della degenza e indice ISS aumentano all’aumentare del BMI sia negli HET che nei LET.La popolazione sovrappeso e obesa è aumentata nelle ultime due decadi; il 61,5% dei siciliani sono sovrappeso. Una massa corporea con eccesso di adipe sembra contribuire alla morbilità nei traumi ad alta energia. L’obesità si accompagna a comorbidità che riducono le possibilità di recupero nei pazienti sovrappeso e obesi con un trauma toracico ad alta e a bassa energia.L’obesità aumenta la morbilità indipendentemente dalla gravità delle lesioni nei pazienti con trauma toracico. All’aumentare del BMI, si allunga la durata della degenza ospedaliera e la prognosi peggiora.

Objectives. Laparoscopic cholecystectomy (LC) is today the "gold standard" treatment of gallbladder stones. Role of LC is still debated in the presence of abdominal scars due to the frequent post-operative adhesions which make access to the peritoneal cavity difficult. This study aim to assess role and outcomes of LC on a previous abdominal surgery on the scarred abdomen. Materials and Methods. we have carried out a retrospective study on 499 consecutive patients who had undergone LC from 2009 to 2015; 21 of these (4.2%) undergone previous abdominal surgery. In all 21 cases the pneumoperitoneum was established with Veress needle at the Palmer's point and the procedure was carried out after adhesiolysis in 62% of cases. Results. the mean operative time was 79±12 minutes; none of the patients with previous abdominal surgery required conversion to open cholecystectomy and there were no postoperative complications related to Veress introduction or to the adhesiolysis. The difficult dissection and adhesiolysis were more frequent in the patients with upper abdomen scar (62%) respect to lower abdomen scar (38%). Conclusion. patients with scarred abdomen for previous abdominal surgery had obviously more adhesions in the abdomen than patients without preceding surgery, but today previous abdominal surgery should not constitutes absolute contraindications to LC. Moreover, patients with previous lower abdominal incisions had fewer adhesions in the upper abdomen than did patients with upper incision and, probably, in these cases adhesiolysis is unnecessary, if the surgical field is well exposed whereas adhesiolysis is mandatory when the adhesions are thick and widespread, to the anterior and posterior abdominal wall.

Obiettivi. Con questa revisione della letteratura ci proponiamo di valutare quali sono i fattori che possono essere valutati nei pazienti da sottoporre a tiroidectomia ai fini di una migliore gestione preoperatoria e post-operatoria dell’ipoparatiroidismo transitorio e definitivo. Discussione. L’ipoparatiroidismo transitorio è una complicanza potenzialmente grave che include una vasta gamma di segni e sintomi che permane solo per poche settimane dopo l’intervento chirurgico. L’ipoparatiroidismo definitivo si verifica quando è necessario un trattamento medico per un periodo maggiore di 12 mesi. I fattori di rischio che ne possono influenzare l’insorgenza in seguito ad interventi di tiroidectomia sono molteplici: biochimici preoperatori e post opera- tori, il sesso femminile, la malattia di Graves e le malattie neoplastiche della tiroide, l’abilità del chirurgo e la tecnica chirurgica utilizzata. Il trattamento medico prevede la somministrazione di calcio, vitamina D e talvolta magnesio. Conclusioni: Anche se i fattori biologici e biochimici legati al paziente ricoprono una certa importanza nella correlazione con l’ipoparatiroidismo, riteniamo che i fattori causali più importanti sono da correlare alle variabili intraoperatorie come l’esperienza del chirurgo e la tecnica utilizzata che deve mirare alla visualizzazione e al rispetto in situ delle paratiroidi. Aims. This review evaluates those main risk factors that can affect patients undergoing thyroidectomy, to reach a better pre- and post-operative management of transient and permanent hypoparathyroidism. Discussion. The transient hypoparathyroidism is a potentially severe complication of thyroidectomy, including a wide range of signs and symptoms that persists for a few weeks. The definitive hypoparathyroidism occurs when a medical treatment is necessary over 12 months. Risk factors that may influence the onset of this condition after thyroidectomy include: pre- and post-operative biochemical factors, such as serum calcium levels, vitamin D blood concentrations and intact PTH. Other involved factors could be summarized as follow: female sex, Graves' or thyroid neoplastic diseases, surgeon's dexterity and surgical technique. The medical treatment includes the administration of calcium, vitamin D and magnesium sometimes. Conclusions. Although biological and biochemical factors could be related to iatrogenic hypoparathyroidism, the surgeon's experience and the used surgical technique still maintain a crucial role in the aetiology of this important complication.

Bone metastasis is a frequent and early complication of breast cancer. This case report describes a technique for a partial exeresis of the sternum and the reconstruction of the pleura with autologous dermis from the lower abdomen and the loss of substance with a myocutaneous flap.We describe the case of a 50-year old woman with a sternal excavated lesion with pathologic fracture due to an invasive adenocarcinoma, treated with a partial exeresis of the sternum and the reconstruction with a myocutaneous flap.The patient doesn't show evidence of recurrent disease and the stability of her chest well preserved.Metastatic breast cancer to the sternum, if detected early and treated aggressively, holds the possibility of such a cure.Breast cancer, Sternal metastasis, Sternectomy.Le metastasi ossee sono sono una complicanza frequente e precoce del carcinoma della mammella. Questo caso clinic descrive una tecnica per una sternectomia parziale e ricostruzione della pleura con derma autologo dai quadrati inferiori dell’addome e della perdita di sostanza con un lembo mio cutaneo.Riportiamo il caso di una donna di 50 anni con una lesione escavata dello sterno e consensuale frattura patologica da adenocarcinoma invasivo, trattato con exeresi parziale dello sterno e ricostruzione con un lembo mio cutaneo.La paziente non ha mostrato evidenza di recidiva di malattia e la stabilità della parte toracica era preservata.Le metastasi sternali da carcinoma della mammella, se diagnosticati precocemente e trattati in maniera aggressiva con intento radicale, offrono una possibilità di guarigione.

This review evaluates those main risk factors that can affect patients undergoing thyroidectomy, to reach a better pre- and post-operative management of transient and permanent hypoparathyroidism.The transient hypoparathyroidism is a potentially severe complication of thyroidectomy, including a wide range of signs and symptoms that persists for a few weeks. The definitive hypoparathyroidism occurs when a medical treatment is necessary over 12 months. Risk factors that may influence the onset of this condition after thyroidectomy include: pre- and post-operative biochemical factors, such as serum calcium levels, vitamin D blood concentrations and intact PTH. Other involved factors could be summarized as follow: female sex, Graves' or thyroid neoplastic diseases, surgeon's dexterity and surgical technique. The medical treatment includes the administration of calcium, vitamin D and magnesium sometimes.Although biological and biochemical factors could be related to iatrogenic hypoparathyroidism, the surgeon's experience and the used surgical technique still maintain a crucial role in the aetiology of this important complication.

Introduction. Herpes simplex esophagitis is well recognized in immunosuppressed subjects, but it is infrequent in immunocompetent patients. We present a case of HSE in a 53-year-old healthy man. Materials and Methods. The patient was admitted with dysphagia, odynophagia, and retrosternal chest pain. An esophagogastroduodenoscopy revealed minute erosive area in distal esophagus and biopsies confirmed esophagitis and findings characteristic of Herpes Simplex Virus infection. Results. The patients was treated with high dose of protonpump inhibitor, sucralfate, and acyclovir, orally, with rapid resolution of symptoms. Discussion. HSV type I is the second most common cause of infectious esophagitis. The majority of symptomatic immunocompetent patients with HSE will present with an acute onset of esophagitis. Endoscopic biopsies from the ulcer edges should be obtained for both histopathology and viral culture. In immunocompetent host, HSE is generally a self-limited condition. Conclusions. HSE should be suspected in case of esophagitis without evident cause, even if the patient is immunocompetent. When the diagnosis of HSE is confirmed, careful history and assessment for an immune disorder such as HIV infection is crucial, to look for underlying immune deficiency.

Background: There are controversies about the adequacy of tumor tissue sample on which the sequencing of molecular diagnosis could be performed to achieve the targeted-therapy on lung cancer. The aim of this study is to demonstrate the role of the Laser Microdissection Pressure Catapulting (LMPC) technique to obtain adequate tumor tissue sample for the molecular analysis of gene mutations in the target therapy of lung cancer. Findings: From a consecutive series of 24 patients with a diagnosis of locally-advanced or metastatic Non Small Cell Lung Cancer (NSCLC), we performed 29 diagnostic procedures using the system of LMPC, to obtain an homogeneous samples where it was possible to run the sequencing of the 4 most frequently mutated exons of Epidermal Growth Factor Receptor (EGFR) (exon 18, 19, 20, 21). Results: There were 14 males (58.3%) and 10 females (41.7%), with a mean age of 61 years old. Twenty one patients were affected by adenocarcinomas, 2 by squamous cell carcinomas and 1 by large cell carcinoma. We were able to obtain the sequencing on 26 out 29 samples (89,6%) for EGFR mutation. EGFR mutation rate in our population was 7,7%. In 5 samples, we found a polymorphism in exon 20 and one of them carried a mutation on exon 18 as well. In another sample we found the deletion of exon 19. On the other 20 samples we did not find any mutation. Conclusions: Our preliminary data suggest that the LMPC technique permits to obtain the tumor cells sample more homogeneous facilitating the application of biological molecular analysis for EGFR-gene mutation in a larger number of patients with NSCLC.

Introduction: Central Venous Catheterization is necessary in uremic patient (before dialysis) and many other conditions. In this study we demonstrated the advantages of ultrasonography to perform the procedure. Materials and methods: 48 uremic patient were submitted to ultrasound-guided central venous catheterization. The procedure was performed following the Seldinger “one shot” technique. Results: The mean operative time was 4 minutes, with a high rate of success (100%) and a low percentage of complications (2%). Conclusion: The ultrasound-guided central venous catheterization is a safe procedure, rapid and easy to perform. The procedure has a low rate of failures and complications and a high rate of success. It is suitable in all patients with vascular anatomical variations, “difficult neck”, or coagulation disorders.

A consecutive series of 63 untreated patients undergoing surgical resection for stage I-IV gastric adenocarcinomas (GCs) has been prospectively studied. Our purpose was to analyze the predictive relevance of DNA ploidy, S-phase fraction (SPF), and tissue levels of lysosomal proteinases cathepsin D (CD), cathepsin B (CB), cathepsin L (CL), and urokinase-type plasminogen activator (uPA) and that of the intracellular cysteine proteinase inhibitor stefin A on clinical outcome. All of the patients taking part in this study were followed up for a median of 73 months. DNA aneuploidy was present in 71% of the cases (45/63), whereas 9% of these (4/45) showed multiclonality. Both DNA ploidy and SPF were associated with tumor-node-metastasis (TNM) stage and node status, whereas only DNA ploidy was related to depth of invasion. CB, CL, uPA, but not CD, levels were significantly higher in GC as compared to paired normal mucosa, whereas stefin A levels were lower in tumor tissues. CB levels were significantly associated with TNM stage, nodal status, histological grade, and DNA ploidy. At univariate analysis, only node involvement, advanced TNM stage, DNA aneuploidy, and high SPF proved to be significantly related to quicker relapse and to shorter overall survival, whereas depth of invasion was related only to survival. With multivariate analysis, only high SPF (>15.2%) was related to risk of relapse (RR = 8.50), whereas high SPF and DNA aneuploidy were independently related to risk of death (RR = 1.88 and 2.09, respectively). Our preliminary prospective study has identified SPF and DNA ploidy as important biological indicators for predicting the outcome of patients with GC.

Propeller perforator flaps (PPFs) have long been proven as valid reconstructive tools for a wide range of soft tissue defects in different body regions. During the last decade, despite their numerous advantages, many authors have thoroughly analyzed outcomes of these flaps, sometimes discouraging their use mainly because of a high failure rate. Accurate patient selection, adequate preoperative planning, and an appropriate dissection technique seem to potentially improve outcomes. Our study provides a review of the relevant literature related to PPF complications and of our experience, describing reasons for failure, measures for preventing them, and approaches for a prompt evaluation and management of complications.

BACKGROUND Microsurgical training on rats before starting with clinical practice is a well-established routine. Animal model training is less widespread for perforator flaps, although these flaps represent a technical challenge. Unlike other flaps, they require specific technical skills that need to be adequately trained on a living model 1 : a cadaver is not enough because no bleeding, vessel damage, or vasospasm can be simulated. 2 The purpose of this study was to assess the suitability of the porcine abdomen as a training model for the deep inferior epigastric artery perforator (DIEAP) flap, commonly used in human breast reconstruction. METHODS A female swine (Sus scrofa domesticus, ssp; weight 25kg) was used. The procedure was performed with the pig under general anesthesia and in the supine position. A deep superior epigastric artery perforator (DSEAP) flap was harvested on the left side of the abdomen, including the 3 cranial nipples and stopping in the midline to spare the contralateral flap for another dissection (as in bilateral breast reconstructions in humans; Fig. 1). All steps of a DIEAP harvest were simulated: superficial vein harvest, suprafascial perforator dissection, intramuscular perforator harvest with preservation of the nerves, and flap isolation. Observation of capillary refill was used to confirm flap viability at the end of the dissection. The procedure was recorded by means of a GoPro camera and simultaneously with a head mounted (4× magnification) Loupecam system. Photographs were taken using 2 cameras during surgery at relevant time points. RESULTS At the end of the dissection, the flap was viable. The subcutaneous adipose tissue of the pig is less represented than in human and pigs have an additional muscular layer, the panniculus carnosus, which is the analogue of the human Scarpa's fascia. The rectus fascia is thinner. The perforators are lined in 2 rows: 1 lateral and 1 medial, as in the DIEAP, and the intercostal nerves cross the vessels, as happens in humans. The porcine rectus abdominis muscle is thinner than the human one, but vessels' branching faithfully reproduces the human model. 1 We identified 5 perforating vessels of more than 1mm in diameter (2 lateral and 3 medial). We isolated a lateral perforator first and a medial one last: the latter was eventually used to nourish the flap (Fig. 2). CONCLUSIONS The DSEAP flap allows one to closely reproduce all the steps of DIEAP flap harvesting and also to carry out the intramuscular dissection of 2 perforators for each side (up to 4 for each animal), confirming the adequacy of this pig model for microsurgical training. The deep superior epigastric artery is dominant in pigs. 3 Despite this anatomical difference, the DSEAP allows one to reproduce the main steps of DIEAP flap harvesting, providing an excellent training model. Moreover, the presence of double perforating rows allows simulating the dissection twice on each side.

Background Laparoscopic cholecystectomy (LC) is generally safe and well-accepted. In rare cases, it is associated with complications (intra- e postoperative bleeding, visceral injury and surgical site infection). Splenic lesion has been reported only after direct trauma. We report an unusual case of splenic rupture presenting after “uncomplicated” LC. Case presentation A 77-year-old woman presented with distended abdomen, tenderness in the left upper quadrant and severe anemia 12 hours after LC. Clinical examination revealed hypovolemic shock. Abdominal computed tomography confirmed the diagnosis of splenic rupture, and the patient required an urgent splenectomy through midline incision. The post-operative course was uneventful and the patient was discharged on 7th postoperative day. Splenic injury rarely complicates LC. We postulate that congenital or post-traumatic adhesions of the parietal peritoneum to the spleen may have been stretched from the splenic capsule during pneumoperitoneum establishment, resulting in subcapsular hematoma and subsequent delayed rupture. Conclusions Splenic rupture is an unusual but life-threatening complication of LC. Direct visualization of the spleen at the end of LC might be a useful procedure to aid early recognition and management in such cases.

Purpose: In many places, especially in emergency department, central venous catheter is still inserted using anatomical landmark guidance with a success rate up to 97.6% and complications up to 15%. This study was aimed to determine by the support of ultrasono-graphy (US) the anatomical variations of the internal jugular vein (IJV) in relation with other structures of the neck, such as the common carotid artery (CCA). Material and Methods: 830 patients requiring central vein catheterization (CVC) were in-cluded in the analysis. The position of the IJV in relation to the other structures of the neck was demonstrated by portable ultrasonography. Results: The mean diameter of IJV was 10.3 mm in right and 10.5 mm in left side of neck, in male (p > 0.05) and 9.1 mm in right and 10.5 mm in left side of neck, in female (p > 0.05). The mean distance between IJV and CCA was 1.9 mm in right and 1.7 mm in left side of neck in male, and 2.0 mm in right and 2.2 mm in left side of neck in female. The mean distance of IJV from the skin surface was 9.8 mm in right and 10.0 mm in left side of neck in male, and 12.1 mm in right and 12.5 mm in left side of neck in female. On 25.54% we observed variations of internal jugular vein site. On 3.97% we observed a small caliber of internal jugular vein that could complicate the catheterization of the vein. On 1.8% was diagnosed a thrombus of internal jugular vein, that is considered as an ab-solute contraindication for a CVC. Conclusion: Different patients had anatomical variations that are important and should be knowed, in order to reduce the possibility of severe complications.

TTF-1 is expressed in the alveolar epithelium and in the basal cells of distal terminal bronchioles. It is considered the most sensitive and specific marker to define the adenocarcinoma arising from the terminal respiratory unit (TRU). TTF-1, CK7, CK5/6, p63 and p40 are useful for typifying the majority of non-small-cell lung cancers, with TTF and CK7 being typically expressed in adenocarcinomas and the latter three being expressed in squamous cell carcinoma. As tumors with coexpression of both TTF-1 and p63 in the same cells are rare, we describe different cases that coexpress them, suggesting a histogenetic hypothesis of their origin. We report 10 cases of poorly differentiated non-small-cell lung carcinoma (PD-NSCLC). Immunohistochemistry was performed by using TTF-1, p63, p40 (&Delta, Np63), CK5/6 and CK7. EGFR and BRAF gene mutational analysis was performed by using real-time PCR. All the cases showed coexpression of p63 and TTF-1. Six of them showing CK7+ and CK5/6&minus, immunostaining were diagnosed as &ldquo, TTF-1+ p63+ adenocarcinoma&rdquo, The other cases of PD-NSCLC, despite the positivity for CK5/6, were diagnosed as &ldquo, adenocarcinoma, solid variant&rdquo, in keeping with the presence of TTF-1 expression and p40 negativity. A &ldquo, wild type&rdquo, genotype of EGFR was evidenced in all cases. TTF1 stained positively the alveolar epithelium and the basal reserve cells of TRU, with the latter also being positive for p63. The coexpression of p63 and TTF-1 could suggest the origin from the basal reserve cells of TRU and represent the capability to differentiate towards different histogenetic lines. More aggressive clinical and morphological features could characterize these &ldquo, basal-type tumors&rdquo, like those in the better known &ldquo, basal-like&rdquo, cancer of the breast.

Reconstruction of full-thickness chest wall defects usually entails the use of regional pedicled myocutaneous flaps as first-choice option. As defect complexity increases and local options are not available, microsurgical reconstruction is required to transfer reliable and well-vascularized tissues from distant sites. Size, anatomic location, presence of dead spaces, and extent of eventual bone defect should be assessed for proper selection of the flap. Regional recipient vessels should be previously identified and checked in order to consider alternatively the need of extension of distant recipient vessels through arteriovenous (AV) loops or vein graft interposition.

Background/Aim: Epithelial-mesenchymal communication plays a key role in tissue homeostasis and abnormal signaling contributes to chronic airways disease such as COPD. Most in vitro models are limited in complexity and poorly represent this epithelial-mesenchymal trophic unit. We postulated that cellular outgrowth from bronchial tissue would enable development of a mucosal structure that recapitulates better in vivo tissue architecture. Materials and Methods: Bronchial tissue was embedded in Matrigel and outgrowth cultures monitored using time-lapse microscopy, electrical resistance, light and electron microscopy. Cultures were challenged repetitively with cigarette smoke extract (CSE). Results: The outgrowths formed as a multicellular sheet with motile cilia becoming evident as the Matrigel was remodeled to provide an air interface; cultures were viable for more than one year. Immunofluorescence and electron microscopy (EM) identified an upper layer of mucociliary epithelium and a lower layer of highly organized extracellular matrix (ECM) interspersed with fibroblastic cells separated by a basement membrane. EM analysis of the mucosal construct after repetitive exposure of to CSE revealed epithelial damage, loss of cilia, and ECM remodeling, as occurs in vivo.Conclusions: We have developed a robust bronchial mucosal model. The structural changes observed following CSE exposure suggest the model should have utility for drug discovery and preclinical testing, especially those targeting airway remodeling.

Pancoast's syndrome is caused by malignant neoplasm of superior sulcus of the lung which produces destructive lesions of thoracic inlet and comes along with the involvement of brachial plexus and stellate ganglion. Computed tomography (CT) or magnetic resonance imaging (MRI) scans can detect early lesions otherwise missed by routine radiographs and can also define the local extent or metastatic progression of the disease. Protocols involving combinations of irradiation, chemotherapy, and surgery are currently being under investigation to determine the best management.This work reviewed the current diagnostic and therapeutic approaches to Pancoast's tumors.Patients with lung superior sulcus carcinoma should be considered for surgery only after an appropriate diagnostic assessment. The perfect candidate for surgery should have a confined to the chest disease with T3N0M0 staging. Inoperable patient with severe pain after irradiation therapy may benefit from palliative surgical resection. Medical therapy plays only a secondary role in lung cancers, patients with disseminated lung cancer might require palliative treatment and medical management of paraneoplastic syndrome symptoms. Following surgery, radiation and chemotherapy may improve local and systemic control by addressing individual adverse findings.The cooperation of surgeons, clinicians and radiologists represents the gold standard today and a multidisciplinary approach is essential to achieve the best outcome possible. Further studies are advisable in order to define the best surgical approach and the real advantage of mini-invasive surgery by comparison with open surgery.

AIM: The aim of this study is to assess, retrospectively, the incidence of secondary hypoparathyroidism after total thyroidectomy in patients with retrosternal goitre. MATERIAL AND METHODS: From January 2009 to September 2015, 622 patients who undergone total thyroidectomy for goitre, were retrospectively observed. The patients were divided into two group: Group A, including 58 patients with retrosternal goitre and Group B, including 562 patients with in situ goitre. Those patients with diseases of the parathyroid glands, assumption of drugs modifying calcium metabolism and who received blood transfusions before or after surgery, were excluded from the study. In both groups, a total thyroidectomy was performed under general anaesthesia. The upper and lower parathyroid glands in both groups were observed in situ as well. All surgical specimens underwent histological examination. RESULTS: Transient hypocalcaemia was observed in a higher percentage in group A (15% vs 7%, P

Although flap anatomy is well studied on cadavers and microsurgical techniques are well practiced on rats, still there are few training models for learning the techniques of perforator flap harvesting. The cadaver has no bloodstream, so accuracy of dissection cannot be evaluated and flap viability cannot be verified. Training on humans carries a high risk of flap damage. A living model for perforator flap harvest is needed to learn the technique before starting with its clinical application.

Introduzione: L’iperparatiroidismo è un’alterazione fisiopatologica della secrezione di paratormone dovuta o da un rilascio autonomo e anomalo (iperparatiroidismo primario o terziario) da parte delle paratiroidi o da un’alterazione dell’omeostasi del calcio che stimola l’eccessiva produzione di paratormone (iperparatiroidismo secondario). Obiettivi: Il trattamento clinico dell’iperparatiroidismo secondario o terziario non è univoco. Sorge pertanto la necessità di una revisione delle attuali metodiche diagnostico-terapeutiche. Discussione: Nell’iperparatiroidismo secondario (2HPT) si ha una progressiva iperplasia delle paratiroidi e un incremento della produzione di paratormone. Tra le cause sono annoverate l’insufficienza renale cronica, la carenza di vitamina D, la sindrome da malassorbimento. L’iperparatiroidismo terziario (3HPT) è attualmente considerato uno stato di eccessiva secrezione autonoma di PTH a causa di un’2HPT di lunga data ed è di solito il risultato di una mancata soppressione della produzione di PTH. Le implicazioni fisiopatologiche sono sia di tipo scheletrico che extrascheletrico a carico dell’apparato cardiovascolare, del sistema nervoso, immunitario, emopoietico ed endocrino. Negli ultimi anni grazie all’introduzione di nuovi farmaci che consentono di ottenere una efficace inibizione della sintesi del paratormone si è avuto un miglioramento della sopravvivenza di questi pazienti. Nei casi di 2HPT e 3HPT che non rispondono a terapia medica i pazienti devono essere avviati all’intervento chirurgico. Conclusioni. Non ci sono ampi studi prospettici che confrontino il trattamento medico e chirurgico, la scelta quindi non risulta univoca e bisogna quindi tener conto del singolo caso e delle condizioni cliniche del paziente. INTRODUCTION: Hyperparathyroidism is an alteration of the pathophysiological parathyroid hormone (PTH) secretion due or an independent and abnormal release (primary or tertiary hyperparathyroidism) by the parathyroid or an alteration of calcium homeostasis that stimulates the excessive production of parathyroid hormone (secondary hyperparathyroidism). AIMS: There is not a standard, clinical or surgical, treatment for hyperparathyroidism. We review current diagnostic and therapeutic methods. DISCUSSION: In secondary hyperparathyroidism (2HPT) there is a progressive hyperplasia of the parathyroid glands and an increased production of parathyroid hormone. Several causes are proposed: chronic renal insufficiency, vitamin D deficiency, malabsorption syndrome. The tertiary hyperparathyroidism (3HPT) is considered a state of excessive autonomous secretion of PTH due to long-standing 2HPT and it's usually the result of a lack of suppression in the production of PTH. The pathophysiological implications are both skeletal and extraskeletal: it damages the cardiovascular system, nervous system, immune, hematopoietic and endocrine system. The introduction of new drugs has improved the survival of these patients, allowing the inhibition of the synthesis of PTH. Indication for surgical treatment is unresponsive medical therapy. CONCLUSIONS: There are no large prospective studies that comparing the medical and surgical treatment. The choice is not unique and we have to consider the singolar case and the clinical condition of the patient.

Background: Plasmoblastic lymphoma is a rare and aggressive subtype of diffuse large B cell lymphoma, which occurs usually in the jaw of immunocompromised subjects. Case presentation: We describe the occurrence of plasmoblastic lymphoma in the mediastinum and chest wall skin of an human immunodeficiency virus-negative 63-year-old Caucasian man who had had polycytemia vera 7 years before. At admission, the patient showed a superior vena cava syndrome, with persistent dyspnoea, cough, and distension of the jugular veins. Imaging findings showed a 9.7 × 8 × 5.7 cm mediastinal mass. A chest wall neoformation biopsy and ultrasound-guided fine-needle aspiration biopsy of the mediastinal mass allowed diagnosis of plasmoblastic lymphoma and establishment of an immediate chemotherapeutic regimen, with rapid remission of compression symptoms. Conclusions: Plasmoblastic lymphoma is a very uncommon, difficult to diagnose, and aggressive disease. The presented case represents the first rare mediastinal plasmoblastic lymphoma in a human immunodeficiency virus-/human herpesvirus-8-negative patient. Pathologists should be aware that this tumor does appear in sites other than the oral cavity. Fine-needle aspiration biopsy is a low-cost, repeatable, easy-to-perform technique, with a high diagnostic accuracy and with very low complication and mortality rates. Fine-needle aspiration biopsy could represent the right alternative to surgery in those patients affected by plasmoblastic lymphoma, being rapid and minimally invasive. It allowed establishment of prompt medical treatment with subsequent considerable reduction of the neoplastic tissue and resolution of the mediastinal syndrome.

Aim: The aim of this study is to investigate anatomical lung variations and vascular patterns using volumetric 3D computed tomography (CT) representations. Methods & results: We considered 24 major thoracic surgery performed in our ward. In these, we discovered some interesting anatomical variations of the main pulmonary fissures. These findings were not visible on the plain x-ray or during routine examination of a preoperative CT scan. After re-examination of 3D CT scan reconstruction the anatomical variations were detected. Discussion: General thoracic surgeons must familiarize themselves with anatomical variations in lungs. 3D images may aid the general thoracic surgeon in performing safer surgeries. Conclusion: 3D CT scan should be performed before surgery if possible.

ABSTRACT Aim: As part of the Catania symposium on lung metastasectomy we reviewed our practice of computed tomography (CT)-guided percutaneous transthoracic needle biopsy of pulmonary metastatic lesions with particular emphasis on diagnostic accuracy and nature of complications lesions. Materials & methods: 25 patients with metastatic lesions of the lung have been evaluated between May 2010 and February 2014. Inclusion criteria consisted of patients with histologically confirmed, metastatic disease of the lung, those receiving a CT-guided needle biopsy, were at least 18 years of age; and with adequate hepatic, renal and hematological function. We recorded also the size of the sampled lesions, their distance from the pleura, the complications encountered (pneumothorax and thoracostomy tube placement), the cytological diagnosis and the outcome in all the cases. Results: CT-guided percutaneous transthoracic needle biopsy were performed on 23 of 25 patients with suspected lung metastases. 17 males and six females with a mean age of 71.4 years. The mean size of lesions was 4.2 cm (range: 1 to 17 cm). For CT-guided needle biopsy, an 18 gauge semi-automatic needle biopsy device was used. Of 23 biopsies, 20 (87%) yielded a correct diagnosis with specific histological typing for metastasis. Pneumothorax was the most common complication occurring in four cases (5.7%). Conclusion: CT-guided percutaneous transthoracic needle biopsy is a firm, useful and safe technique for the diagnosis of suspected pulmonary metastases as it avoids open biopsy in most cases.

Nodular histiocytic/mesothelial hyperplasia (NHMH) is a benign localized alteration, first described in 1975 by Rosai in the hernia sac [1]. Few pulmonary cases have been reported in literature [2–6]. Sometimes it has been reported in the pericardium [7,8] or presenting as an inguinal mass [9]. The ‘mesothelial/monocytic incidental cardiac excrescence’, first described by Weinot et al. in 1994 [10] is now considered a similar lesion to NHMH [11]. It consists of a reactive proliferation of histiocytes and mesothelium secondary to chronic irritation and it has been observed in pleura-damaging processes, such as pneumothorax [5], or as consequence of cardiac catheterization, inflammation, mechanical or tumor stimulation [11]. The rarity of NHMH and the moderate cytological atypia often present, make this lesion difficult to diagnose. It can be easily confused with primary mesothelial lesions and neoplasms such as adenocarcinomas, granulosa cell tumors or Langerhans’ histiocytosis. We report a case of pleural NHMH in a patient with a subphrenic abscess, in which no pulmonary pathogenic noxa was evident. We hypothesize a transdiaphragmatic chronic irritation as a pathogenetic mechanism underlying NHMH.

ABSTRACT Lung metastasectomy is considered a safe and potentially curative procedure despite there is not a strong evidence that metastasectomy prolongs long-term survival in patients with lung metastases. Moreover, the debate is open regarding the best approach for lung metastasectomy, video-assisted thoracic surgery versus open approach. A systematic review of literature to clarify what is the best approach to prolong survival in patients with lung metastases was performed. Our study confirms that overall survival is equivalent for video-assisted thoracic surgery and thoracotomy, therefore the ‘gold standard’ surgical treatment for lung metastases remains a point of debate. The choice of the surgical approach still depends more on the single center or surgeon practice than on strong scientific evidence. A prospective randomized trial could clarify the question.