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Foreign body (FB) ingestion in the upper gastrointestinal (GI) tract is a relatively common emergency presenting numerous diagnostic and therapeutic challenges. Adults most frequently ingest FBs accidentally while eating solid food. The esophagus accounts for 57% to 75% of all FBs impactions in GI tract. More than 80% FB pass spontaneously, around 10-20% require an endoscopic removal, and less than 1% have to be treated surgically, depending on the nature and location of the FB. A 68 years old man presented to the Emergency Department complaining of a mild dysphagia since two days before. A laryngeal endoscopy showed edema of the right aryepiglottic fold; salivary stagnation hiding the pyriform sinus; edema of the right vocal cord; the airway caliber was adequate. A chest radiograph showed a dental prosthesis, probably ingested during a seizure, in the upper esophageal tract. The patient developed dyspnea and phonation difficulty due to neck swelling. An urgent CT scan showed signs of esophageal perforation and diffuse edema. A multidisciplinary equipe was assembled to properly treat the patient. In the operating room, two attempts of retrieval with a flexible and a rigid endoscope failed because the dental prosthesis was stuck in the right pyriform sinus. After a careful evaluation of the FB location, the surgeon performed a right cervicotomy, uncommon when compared with the traditional left side approach to the neck, and retrieved it through an esophagotomy. A nasogastric tube was inserted and a paraesophageal 19 Ch drain in aspiration was placed in situ. Over time, no signs of esophageal leakages were detected post-operatively and eventually the patient was able to feed with solid foods without complications. Any esophageal FB may cause potentially fatal injuries, therefore it must be retrieved within 12 to 24 hours. An endoscopic approach should be attempted first, with surgery being the extrema ratio. The surgical approach depends on the nature and location of the FB. A left cervical approach should not be regarded as dogmatic, and a right-sided approach, being equally safe and effective from a surgical point of view, could be appropriately chosen when clinically indicated.

BACKGROUND Intestinal metastases from breast cancer (BC) arerare; available data depend mainly on case reports and case series. AIM To conduct a review of the literature regarding presentation, diagnosis, treatment and survival of patients with intestinal metastasis from BC. METHODS We identified all articles that described patients with intestinal metastasis (from duodenum to anum) from BC using MEDLINE (1975 to 2020) and EMBASE (1975 to 2020) electronic databases. RESULTS We found 96 cases of intestinal metastasis of BC. Metastasization involved large bowel (cecum, colon, sigmoid, rectum) (51%), small bowel (duodenum, jejunum, ileum) (49%), and anum (< 1%). Median age of patients was 61-years. The most frequent histology was infiltrating lobular carcinoma followed by infiltrating ductal carcinoma. In more than half of patients, the diagnosis was made after the diagnosis of BC (median: 7.2 years) and in many cases of emergency, for bowel obstruction, bleeding or perforation. Diagnosis was achieved through endoscopy, radiological examination or both. In most of the cases, patients underwent surgery with or without systemic therapies. Survival of patients included in this review was available in less than 50% of patients and showed an overall median of 12 mo since diagnosis of the intestinal metastasis. CONCLUSION Although, intestinal metastases of BC are considered a rare condition, clinicians should consider the possibility of intestinal involvement in case of abdominal symptoms even in acute setting and many years after the diagnosis of BC, especially in patients with a histology of lobular carcinoma.

Aim “The De Garengeot’s hernia, from Rene De Garengeot, who was the first to describe the appendix inside a femoral hernia sac in 1731, is a rare type of crural hernia. The diagnosis is challenging and surgery must be performed without delay. The incidence of appendicitis in this type of hernia is about 0.08-0.13%. The aim of this work is to describe our experience in the management of this rare subtype of hernia in a 82-year-old women” Material and Methods “A 82-year-old patient with a right groin bulge presented to the Emergency. At the physical examination the abdomen was treatable; there was no sign of bowel obstruction. Blood test values were normal, except for a high PCR value. The US of the groin region demonstrated a right femoral hernia containing a bowel tract, irreducible at the probe’s pressure. The patient underwent surgery, with diagnosis of De Garengeot’s hernia; a direct hernia repair followed by an open appendectomy were performed. The patient did not present any complications and was discharged on the second postoperative day” Results “The De Garengeot hernia is a rare entity that requires an early treatment; the preoperative diagnosis is difficult and often clinical features are similar to a common incarcerated hernia. There are many surgical options for the management of the De Garengeot hernia, but there is not a consensus for the best surgical approach” Conclusions “De Garengeot's hernia is rare, being indistinguishable from an incarcerated femoral hernia in general. This case report is about a De Garengeot’s hernia patient, who presented a good recovery after surgery.”

Introduction: Intrathoracic goiters are associated with compression of nearby structures, triggering severe compressive symptoms. Total thyroidectomy is the gold standard to treat these cases. Case Presentation: A patient with a huge intrathoracic goiter suffering from compressive symptoms underwent a thorough clinical, functional and imaging assessment and underwent total thyroidectomy in an Endocrino-Metabolic surgical referral center; after the surgery she suffered from transient hypocalcaemia but was discharged without major complications and continued periodical endocrinological follow-up. Conclusion: Management of intra-thoracic goiter requires a multidisciplinary approach of a skilled team both pre, during and after surgery to maximize the safety and efficacy of the procedure and reduce or promptly manage surgical or medical complications.

Worldwide, the indications for thyroid surgery have been continuously extended among elderly patients in the last 20 years. The balance between treatment indication and surgical risk is certainly an interesting topic for every thyroid surgeon. This paper is a review of recent literature from January 2005 up to April 2017. We analyzed three principal subjects: indications for surgical treatment, medical complications and surgical complications. We can summarize the conclusions of our analysis, stating that age could not be considered as an absolute factor, but in relation to the comorbidities and the general clinical condition of the patient. Special risk indices dedicated to geriatric patients could be very useful in order to facilitate the decision-making process; however, relying on the current knowledge, we could state that there is value in providing surgery to geriatric patients in highly specialized and high-volume centers, where access to technology and its systematic use, coupled with surgeons' experience, could certainly avail the geriatric patient management.

The application of adrenal surgery has been spreading steadily in recent years. With the increased use of robotics in surgery, robotic adrenalectomy (RA), especially for the posterior retroperitoneoscopic approach, has been taken on by many high-volume institutions as a good option over the standard laparoscopic approach (LA). This paper reviews the recent literature from May 2010 up to November 2019 with the aim of analyzing RA complications in order to identify risk factors for complications after RA. We analyzed 7 principal risk factors for complication: body mass index (BMI), age, tumor size, tumor side, pathology, previous surgery, and surgeon experience. In the review, some studies identified tumor size, malignancy type, completion of learning curve and, and less clearly, previous ipsilateral upper mesocolic or retroperitoneal surgery, as risk factors for postoperative complications and failure of robotic surgery. Whether RA is meaningfully superior to the standard minimally invasive approach is still a subject of discussion. RA appears safer by virtue of its reduction in hospital stay, lower blood loss, and equivalent complication rates, and surgeons should prefer adrenalectomy over the LA. Despite these advantages, the operative time and the overall cost of the robotic procedure are higher than the LA. Further high-quality trials, especially those analyzing the specific risk factors for complications in robotic surgery, should be conducted in order to optimize the stratification of patients eligible for robotic surgery.

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

Background: Hypocalcemia is the most frequent complication after thyroidectomy. Serum calcium levels are reliable only 48–72 hours postoperatively. Early intact PTH (iPTH) has been proposed as early predictor of postoperative hypocalcemia. Our aim is to assess the ability of iPTH in predicting postoperative hypocalcemia. Methods: Two hundred and sixty patients underwent thyroidectomy with postoperative iPTH evaluation. The iPTH samplings were early performed after thyroidectomy. The calcium levels were dosed postoperatively. Age, sex, clinical diagnosis, obesity, comorbidities, previous neck surgery, preoperative therapy, type of surgery, dissectors used, lymphadenectomy, post-operative complications, reoperation and histological diagnosis were considered. The primary end-point was the postoperative hospital stay. The secondary end-points were serum calcium and iPTH. Three iPTH cut-offs were tested to assess which was the best value (10.0, 15.0, and 20.0 pg/mL). Results: The iPTH cut-off value of 10.0 pg/mL was the most accurate and specific for hypocalcemia. Comparing the iPTH value with the different values of calcium respectively 24 and 48 hours after surgery, a statistically stronger association with the serum calcium levels 48 hours postoperatively has been shown. iPTH ≥10 pg/mL 3–6 hours after surgery was strongly correlated to early discharge. Conclusions: The correlation of iPTH with hypocalcemia is significant since a few hours after surgery and the value of iPTH ≥10 pg/mL is able to select those patients for a safe and early discharge. The use of the iPTH might avoid unnecessary extensions of hospitalization.

BACKGROUND Transoral endoscopic thyroidectomy via vestibular approach (TOETVA) is currently considered the most promisingly scarless approach to the thyroid and has gained more acceptance. MATERIALS AND METHODS We described a case of faulty TOETVA. RESULTS The faulty TOETVA resulted in pneumomediastinum, diffuse subcutaneous emphysema, prolonged surgery, and anesthesia. CONCLUSIONS The important technical considerations during TOETVA, including the use of external retraction, the identification of the subplatysmal plane of dissection, CO2 insufflation settings, the learning curve, and patient selection, were described and discussed.

Background and Purpose The relationship between peri-operative blood transfusions (PBTs) and poor prognosis in gastric cancer (GC) patients is still debated. The aim of this study is to examine the real prognostic impact of PBTs in comparison to well-known prognostic factors. Methods We retrospectively analyzed a series of 224 patients who underwent surgery with curative intent for GC from January 1995 to December 2011. Among 224 patients, 46 (20%) required PBTs. Results The overall 5-year survival was 77% in non-transfused patients and 65% in patients who received PBTs (p = 0.03). PBTs did not further stratify any recognized prognostic category (such as pT or pN according to the 7th edition of the TNM staging system). Multivariate analysis including all known prognostic variables (both cancer- and non-cancer-related) did not select PBTs as an independent prognostic factor. Only preoperative hemoglobin and albumin level, pT and operative time were significantly associated with the requirement for PBTs. Conclusions The study showed a worse prognosis for transfused patients, but PBTs seem a confounding factor more than a prognostic indicator, as they are obviously affected by other variables.

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

Purpose: Papillary thyroid carcinomas (PTCs) and medullary thyroid carcinomas (MTCs) have always been considered different in terms of their incidence rates, cell origins, and histopathological features. Simultaneous occurrence of both disease entities is very rare. Methods: We describe a series of cases with simultaneous MTC and PTC occurrences in the thyroid gland. Results: From 2,897 patients (mean age, 49.2±12.5; 81% women) who underwent thyroidectomy for cancer between 2000 and 2015, we reviewed 11 cases of simultaneous occurrence of MTCs and PTCs. Multifocal PTC with simultaneous MTC was detected in 5 of the 11 cases (45%). Of these PTC patients, 2 had 2 foci, 2 had 3 foci, and 1 had 4 foci. There was 1 case of multifocal MTC with solitary PTC. One patient presented with “composite thyroid carcinoma” with mixed features of MTCs and PTCs. Eight patients (72%) presented an association with diffuse lymphocytic thyroiditis. The sizes of the tumors were 1.95±0.23 cm vs. 1.20±0.20 cm for PTCs and MTCs, respectively (P=0.531). The prevalence of extrathyroidal extension was 33.1% vs. 30.2% for PTCs and MTCs, respectively (P=0.282). All patients underwent total thyroidectomy and central neck node dissection. Radio iodine was delivered to 44% of patients. Follow-up review revealed 9 disease-free patients and 1 with local neck recurrence, while 1 patient died due to non-thyroid reasons. Conclusion: There are only 30 reports describing a total of 50 cases in the English literature regarding concurrent PTC and MTC in the same gland. This study represents one of the largest case series. Whether the incidence of another cancer in these patients is coincidental, or due to the possible activation of a common tumorigenic pathway for both follicular and parafollicular thyroid cells, remains to be elucidated.

The global aging of population will lead a greater number of elderly patients to undergo surgical procedure in a near future. Concerning gastric cancer, the impact of lymphadenectomy on survival has been demonstrated in RCTs, and extended lymphadenectomy is now considered as gold standard of treatment in non-early tumors. However, the role of age as a prognostic factor and the benefit of extended surgery in elderly/high-risk patients are not clearly defined yet. From our revision of literature, it seems that surgery for gastric cancer may have a further tailorization, considering not only the stage of disease, but also patients' age and comorbidities.

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

The objective is to compare the consequences of routine visualization (RV) and the application of intermitted (I-IONM), standardized (S-IONM), and continuous monitoring (C-IONM) of recurrent laryngeal nerve (RLN) management. RV includes that 698 RLNs managed solely with visual identification. In a second period 777, RLNs were handled by the I-IONM. The third period 768 RLNs monitoring was performed according to the standards. C-IONM via VN stimulation included 626 RLNs. The following issues were analyzed and compared per each period study: RLN identification rate, branching detection, assessment of NRLN, intraoperative recognizable nerve damage, stage thyroidectomy rate, transient or definitive lesions, bilateral nerve palsy, and recovery time. Significance for nerve identification rate was achieved (p = 0.03) when the statistical analysis was applied between RV vs. S-IONM and C-IONM. Extralaryngeal bifurcation was identified in 21, 44, 43, and 46 of RLN dissected, respectively, per period (p = 0.005). The incidence of paralysis in identified and unidentified RLN was 3.8 % (107/2806) and 82 % (52/63), respectively. Rates of temporary/permanent RLNP were 16.7/1.7, 5/1.1, 4.5/1, and 3.1/0 % per period study, respectively (p = 0.07). Recognizable intraoperatively nerve damage was, respectively, 15, 45, 100, and 100 % for period study (p = 0.03). The recovery of injured nerves was significantly faster in C-IONM group. S-IONM and C-IONM cumulate 40-stage procedures. The standardized technique, guidelines adherences, and C-IONM allowed to (1) increase RLN identification; (2) reduce the severity of injuries in terms of (a) reset bilateral RLNP, (b) faster recovery time, and (c) lower definitive RLNP; (3) gather detection of branching and NRLN; (4) recognize nerve stress; and (5) cumulate stage procedures.

Background and PurposeThis study analyzed the prognostic significance of the staging system based on the metastatic Node Ratio (NR) compared with the TNM staging system in patients with colorectal cancer.MethodsWe reviewed the data of 444 patients who underwent colorectal resection for cancer between January 2005 and December 2011. NR categories NR0 (0%), NR1 (1–19%) and NR2 (≥20%) were determined by the best cut-off approach at log-rank test. To compare the prognostic power of the NR versus pN, we plotted these different factors against the mortality estimates. Additionally, we evaluated the relationship between these variables and the extent of lymphadenectomy.ResultsBoth the NR and the pN classification significantly stratified patient outcomes (p < 0.0001), but the NR system seems to better discriminate prognostic subgroups than the pN. Furthermore, NR is less dependent on the extent of lymphadenectomy than pN.ConclusionsNR is a simple and reliable tool to stratify survival of colorectal cancer patients and it seems to have a higher prognostic power than the current pN system, because it is less dependent on the extent of lymphadenectomy.