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Compared to standardized minimally invasive colorectal procedures, there is considerable perioperative heterogeneity in loop ileostomy reversal. This study aimed to investigate the current perioperative practice and technical variations of loop ileostomy reversal following rectal cancer surgery. A nationwide online survey was conducted among members of the Italian Society of ColoRectal Surgery (SICCR). A link to the questionnaire was sent via mail. The survey consisted of 31 questions concerning the main procedural steps and application of the ERAS protocol after loop ileostomy reversal. Overall, 219 participants completed the survey. One respondent in four used a combination of water-soluble contrast studies (WSCS) and digital rectal examination to assess the integrity of the anastomosis before ileostomy closure. Conversely, 17.8% of them used either only WSCS or only endoscopy. Surgeons routinely perform hand-sewn or stapled anastomoses in 45.2% and 54.8% of the cases, respectively. Side-to-side antiperistaltic stapled anastomosis was the most performed anastomosis (36%). Most surgeons declared that they have never used prostheses for abdominal wall closure (64%), whereas 35% preferred retromuscular mesh placement in selected cases only. Forty-six respondents (66.7%) reported using interrupted stitches for skin closure, while 65 (29.7%) a purse-string suture. Furthermore, skin approximation at the stoma site using open methods was significantly more common among surgeons with greater experience in ileostomy reversal (p = 0.031). Overall, a good compliance with the ERAS protocol was found. However, colorectal surgeons were significantly more likely to follow the ERAS pathway than general surgeons (p < 0.05). Surgeons use different anastomotic techniques for ileostomy reversal after rectal cancer surgery. Based on current evidence, purse-string skin closure and ERAS pathway should be implemented, while the role of mesh prophylactic strategy needs to be explored further., (© 2024. Italian Society of Surgery (SIC).)

Background: Patients with pancreatic ductal adenocarcinoma (PDCA) carrying impaired mismatch repair mechanisms seem to have an outcome advantage under treatment with conventional chemotherapy, whereas the role for the tumor mutation burden on prognosis is controversial. In this study, we evaluated the prognostic role of the mutated genes involved in genome damage repair in a real-life series of PDAC patients in a hospital-based manner from the main Institution deputed to surgically treat such a disease in North Sardinia., Methods: A cohort of fifty-five consecutive PDAC patients with potentially resectable/border line resectable PDAC (stage IIB-III) or oligometastatic disease (stage IV) and tumor tissue availability underwent next-generation sequencing (NGS)-based analysis using a panel containing driver oncogenes and tumor suppressor genes as well as genes controlling DNA repair mechanisms., Results: Genes involved in the both genome damage repair (DR) and DNA mismatch repair (MMR) were found mutated in 17 (31%) and 15 (27%) cases, respectively. One fourth of PDAC cases (14/55; 25.5%) carried tumors presenting a combination of mutations in repair genes (DR and MMR) and the highest mutation load rates (MLR-H). After correction for confounders (surgery, adjuvant therapy, stage T, and metastasis), multivariate Cox regression analysis indicated that mutations in DR genes (HR = 3.0126, 95% CI 1.0707 to 8.4764, p = 0.0367) and the MLR (HR = 1.0018, 95%CI 1.0005 to 1.0032, p = 0.009) were significantly related to worse survival., Conclusions: The combination of mutated repair genes and MLR-H, which is associated with a worse survival in our series of PDAC patients treated with conventional chemotherapy protocols, might become a predictive biomarker of response to immunotherapy in addition to its prognostic role in predicting survival., (© 2024. The Author(s).)

Background: Anastomotic leakage (AL) is one of the most severe complications in colorectal surgery. Currently, no predictive biomarkers of AL are available. The aim of this study was to investigate the role of C reactive protein (CRP) to albumin ratio (CAR) as a predictor of AL in patients undergoing elective surgery for colorectal cancer., Materials and Methods: Data on 1183 consecutive patients surgically treated for histologically proven colorectal cancer in the surgical units involved in the study were collected. Data included sex, age, BMI, ASA score, Charlson comorbidity index, localization, histology and stage of the disease, as well as blood tests including albumin and CRP at the 4th postoperative day. Differences in CAR between patients who developed AL and those who did not were analyzed, and the ability of CAR to predict AL was investigated with ROC analysis., Results: CAR was significantly higher in patients with AL in comparison to those without, at the 4th postoperative day. In ROC analysis CAR showed a good ability in detecting AL (AUC 0.825, 95%CI: 0,786-0,859), greater than those of CRP and albumin alone. CAR also showed a high ability in detecting postoperative deaths (AUC 0.750, 95% CI 0,956-0,987). These findings were confirmed in multivariate analysis including the most relevant risk factors for AL., Conclusion: Our study evidenced that CAR, an inexpensive and widely available laboratory biomarker, adequately predicts AL and death in patients who underwent elective surgery for colorectal cancer., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The new coronavirus disease 2019 (COVID-19) pandemic has resulted in a global health emergency that has also caused profound changes in the treatment of cancer. The management of hepatocellular carcinoma (HCC) across the world has been modified according to the scarcity of care resources that have been diverted mostly to face the surge of hospitalized COVID-19 patients. Oncological and hepatobiliary societies have drafted recommendations regarding the adaptation of guidelines for the management of HCC to the current healthcare situation. This review focuses on specific recommendations for the surgical treatment of HCC ( i.e. , hepatic resection and liver transplantation), which still represents the best chance of cure for patients with very early and early HCC. While surgery should be pursued for very selected patients in institutions where standards of care are maintained, alternative or bridging methods, mostly thermoablation and transarterial therapies, can be used until surgery can be performed. The prognosis of patients with HCC largely depends on both the characteristics of the tumour and the stage of underlying liver disease. Risk stratification plays a pivotal role in determining the most appropriate treatment for each case and needs to balance the chance of cure and the risk of COVID-19 infection during hospitalization. Current recommendations have been critically reviewed to provide a reference for best practices in the clinical setting, with adaptation based on pandemic trends and categorization according to COVID-19 prevalence., Competing Interests: Conflict-of-interest statement: The authors do not have any conflicts of interest relevant to this article., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Colorectal cancer (CRC) is the third most frequent cancer worldwide and the second cause of cancer deaths. Increasing evidences supports the idea that the poor prognosis of patients is related to the presence of cancer stem cells (CSCs), a cell population able to drive cancer recurrence and metastasis. The deregulation of microRNAs (miRNAs) plays a role in the formation of CSC. We investigated the role of hsa-miR-486-5p (miR-486-5p) in CRC, CSCs, and metastasis, in order to reach a better understanding of the biomolecular and epigenetic mechanisms mir-486-5p-related. The expression of miR-486-5p was investigated in three different matrices from CRC patients and controls and in CSCs obtained from the CRC cell lines HCT-116, HT-29, and T-84. In the human study, miR-486-5p was up-regulated in serum and stool of CRC patients in comparison with healthy controls but down-regulated in tumor tissue when compared with normal mucosa. miR-486-5p was also down-regulated in the sera of metastatic patients. In vitro, miR-486-5p was down-regulated in CSC models and it induced an inhibitory effect on stem factors and oncogenes in the main pathways of CSCs. Our results provide a step forward in understanding the role of mir-486-5p in CRC and CSC, and suggest that further studies are needed to investigate its diagnostic and prognostic power, possibly in combination with other biomarkers.

Background: The aim of this study was to evaluate a series of blood count inflammation indexes in predicting anastomotic leakage (AL) in elective colorectal surgery., Methods: Demographic, pathologic, and clinical data of 1432 consecutive patients submitted to colorectal surgery in eight surgical centers were retrospectively evaluated. The neutrophil to lymphocyte (NLR), derived neutrophil to lymphocyte (dNLR), lymphocyte to monocyte (LMR), and platelet to lymphocyte (PLR) ratios were calculated before surgery and on the 1st and 4th postoperative days, in patients with or without AL., Results: There were 106 patients with AL (65 males, mean age 67.4 years). The NLR, dNLR, and PLR were significantly higher in patients with AL in comparison to those without, on both the 1st and 4th postoperative days, but significance was greater on the 4th postoperative day. An NLR cutoff value of 7.1 on this day showed the best area under the curve (AUC 0.744; 95% CI 0.719-0.768) in predicting AL., Conclusions: Among the blood cell indexes of inflammation evaluated, NLR on the 4th postoperative day showed the best ability to predict AL. NLR is a low cost, easy to perform, and widely available index, which might be potentially used in clinical practice as a predictor of AL in patients undergoing elective colorectal surgery.

Colorectal cancer (CRC) is a deadly tumour in Western countries characterized by high cellular/molecular heterogeneity. Cancer stem cells (CSC) act in cancer recurrence, drug-resistance and in metastatic epithelial-to-mesenchymal transition. microRNAs (miRNAs) contribute to cancer is increasing, and miRNA roles in CSC phenotype and fate and their utility as CRC biomarkers have also been reported. Here, we investigated miR-21, miR-221, miR-18a, miR-210, miR-31, miR-34a, miR-10b and miR-16 expression in experimental ALDH + and CD44 + /CD326 + colorectal CSCs obtained from the human CRC cell lines HCT-116, HT-29 and T-84. Then, we moved our analysis in cancer tissue (CT), healthy tissue (HT) and serum (S) of adult CRC patients (n=12), determining relationships with clinical parameters (age, sex, metastasis, biochemical serum markers). Specific miRNA patterns were evident in vitro (normal, monolayers and CSCs) and in patients' samples stratified by TNM stage (LOW vs HIGH) or metastasis (Met vs no-Met). miR-21, miR-210, miR-34a upregulation ad miR-16 dowregulation associated with the CSCs phenotype. miR-31b robustly overexpressed in monolayers and CSCs, and in CT ad S of HIGH grade and Met patients, suggesting a role as marker of CRC progression and metastasis. miR-18a upregulated in all cancer models and associated to CSC phenotype, and to metastasis and age in patients. miR-10b downregulated in CT and S of LOW/HIGH grade and no-Met patients. Our results identify miRNAs useful as colorectal CSC biomarker and that miR-21, miR-210, miR-10b and miR-31b are promising markers of CRC. A specific role of miR-18a as metastatic CRC serum biomarker in adult patients was also highlighted., Competing Interests: CONFLICTS OF INTEREST The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflicts of interest., (Copyright: © 2020 Farace et al.)

Objective: Deciduoid mesothelioma is a rare variant of malignant epithelioid mesothelioma. It often involves the peritoneum, but also thoracic cases have been reported. The aim of the present review is to describe the demographic, clinical, radiological, and pathological features of such a rare variant of thoracic mesothelioma, and the state of the art regarding the therapeutic approaches currently available., Data Source: English-language articles published from 1985 to June 2016, and related to thoracic deciduoid mesothelioma cases were retrieved using the Pubmed database., Study Selection: The search terms were "mesothelioma," "thoracic mesothelioma," "epithelial mesothelioma," "pleural mesothelioma," and "deciduoid mesothelioma.", Results: Forty-four cases included in 16 articles, published in the period under investigation, were analyzed in detail., Conclusions: The mean age of the patients was 63 years, and the male to female ratio 1.7:1. Approximately 58% had exposure to asbestos, and 73% had a smoking history; familiarity was rarely reported. The most common anatomical site of origin was the right pleura, and the most frequent clinical manifestations were chest pain, dyspnea, cough, and weight loss. Thoracic X-ray and computed tomography were the imaging techniques most employed for diagnosis and surgical planning. The pathological diagnosis was obtained by examination of surgical or biopsy specimens in most cases. The best treatment strategy of deciduoid mesothelioma is a matter of debate; nevertheless a multidisciplinary approach is currently the best option for the choice of the adequate therapeutic scheme., (© 2017 John Wiley & Sons Ltd.)

Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease with a broad spectrum of clinical presentations and incompletely understood pathogenesis. This autoimmune disease is characterized by alterations in both the innate and adaptive immune system that lead to the loss of immunologic tolerance. In autoimmune diseases particularly in SLE, early diagnosis, flare or remission phases can be difficult to identify. Proteomics can help to find new therapeutic targets and it also could help to better understand the cellular mechanisms. The aim of this study was to observe the variations in plasma and Peripheral Blood Mononuclear Cells (PBMCs) proteome in order to increase our knowledge about pathogenesis and to find possible diagnostic markers and/or therapeutic targets for improving diagnosis and treatment. The comparative proteomic analyses showed that several proteins were differentially expressed in the PBMCs from SLE patients. Among these, PRDX2 may be used as candidate biomarker or target protein for further investigations. In plasma, we showed that plasma clusterin levels increased in SLE patients compared to healthy controls, but this increase is not statistically significant. These proteomic results provide suggestions for understanding the molecular mechanisms of SLE, as well as the physiological changes correlated with SLE disease., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Micro-RNA (miRNA) are a family of small non-coding ribonucleic acids that inhibits post-transcriptionally the expression of their target messenger RNA (mRNA). We are interested in studying the involvement of miRNA in longevity and autoimmune diseases. In this study we compared the different expression of seven microRNAs between human plasma healthy controls, plasma samples of centenarians and samples from patients with rheumatoid arthritis. We used the Life Technologies' protocol to quantify seven miRNAs from 62 plasma samples: 20 healthy human controls, 14 centenarians, 28 patients with rheumatoid arthritis. TaqMan MicroRNA assays were used to analyze the expression profiles of miR-125b-5p, miR-425-5p, miR-200b5p, miR-200c-3p, miR-579-3p, miR-212-3p, miR-21-5p and miR-126-3p. The relative expression of mature miRNAs was analyzed using software REST. Our results show that miR-425-5p, miR-21 and miR-212 significantly decreased in centenarians and in patients with rheumatoid arthritis compared with controls. Furthermore in this work we highlight a connection between corticosteroid treatment and miRNAs expression., Competing Interests: Conflicts of Interest: The authors declare no conflict of interest.

Introduction: Carcinoma showing thymous-like elements (CASTLE) is a rare tumor with only a few cases described in the scientific literature. The aim of the present review is to analyze the data available on the therapeutic options employed in CASTLE tumors and to outline the best surgical management to adopt., Materials and Methods: English-language articles published from 1985 through November 2016, and related to CASTLE cases were retrieved using the Pubmed database and specific key-words., Results: Eighty seven cases included in 23 papers, published in the period under investigation, were analyzed in detail. The mean age of the patients was 50.2 years and the male to female ratio 1:1.2. There were performed 31 (35.6%) lobectomies, 29 (33.3%) total thyroidectomies, 15 (17.2%) subtotal thyroidectomies, 4 (4.6%) excisions, 3 (3.4%) partial thyroidectomies, 1 (1.1%) hemithyroidectomy, and 8 (9.2%) additional procedures including tracheal, pharyngeal, and esophageal resections. Lymph node dissection and radiotherapy were associated in 59 (67.8%) and 44 (50.6%) cases respectively. Among the patients with available data 62 (75.6%) were free of disease, 16 (19.5%) were alive with disease, 3 (3.7%) died for the disease, and 1 (1.2%) died for cerebrovascular complications at the time of follow-up. Globally 20 (24.4%) cases of local or distant recurrence were reported. Surgery and radiotherapy, alone or in combination were the treatments most frequently used for recurrences., Conclusions: CASTLE is a rare tumor which generally respond well to complete surgical resection and adjuvant radiotherapy. These treatments can be further employed for the recurrences, which occur in 24.4% of the cases, along with specific chemotherapy regimens and palliative procedures., Key Words: Cancer, CASTLE, Excision, Lobectomy, Thymous-like elements, Thyroidectomy.

Introduction: We evaluated the impacts of a series of novel histopathological factors on clinical-surgical outcomes and survival of patients who underwent surgery for colorectal cancer liver metastasis, with and without neoadjuvant chemotherapy., Materials and Methods: A prospective database including 150 consecutive patients who underwent 183 hepatic resections for metastatic colorectal cancer was evaluated. Among them, 74 (49.3%) received neoadjuvant chemotherapy before surgery. The histopathological factors studied were: a) microsatellitosis, b) type and pattern of tumour growth, c) nuclear grade and the number of mitoses/mm(2), d) perilesional pseudocapsule, e) intratumoural fibrosis, f) lesion cellularity, g) hypoxic-angiogenic perilesional growth pattern, and h) the tumour normal interface., Results: Three or more metastatic lesions, R1 resection margins, and <50% tumour necrosis were prognostic factors for a worse OS, but only the former was confirmed to be an independent prognostic factor in the multivariate analysis. Furthermore, tumour fibrosis <40% and cellularity >10% were predictive of a worse neoadjuvant therapy response, but these findings were not confirmed in the multivariate analysis. Finally, tumour necrosis <50%, cellularity >10%, and TNI >0.5 mm were prognostic factors for a worse DFS and AS in the univariate but not in the multivariate analysis., Conclusions: Several factors seem to influence the outcomes of surgery for colorectal cancer liver metastasis, especially the number of the lesions, the margins of resection, the percentage of necrosis and fibrosis, as well as the cellularity and the TNI., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: This article describes the demographic, clinical, pathological and prognostic features of breast nodular fasciitis through a comprehensive review of the cases reported in modern literature., Material and Methods: English-language articles published from January 1970 to October 2015 and related to breast nodular fasciitis were non-systematically retrieved using the PubMed database. Titles, abstracts and references were evaluated in order to include the most relevant studies. The demographic characteristics of the patients and the signs and symptoms of the disease were reviewed, as well as the results of the radiological and diagnostic procedures employed and of the treatments adopted., Results: 26 papers reporting on 28 cases were enrolled; however, manuscripts published before 1990 were excluded because of old methodologies, technologies and clinical approaches. Thus, 22 cases included in 20 papers were analyzed in detail., Conclusion: The rarity and the unspecific clinical and radiological characteristics of breast nodular fasciitis make the differential diagnosis and management challenging. Knowledge of the clinical, pathological and prognostic aspects of this condition is crucial for breast care specialists in order to improve their diagnostic and therapeutic interventions.

Unlabelled: Ectopic thyroid goiter accounts approximately for 1% of all substernal goiters and for 10-15% of all mediastinal masses. Sternotomy is generally accepted as the most adequate approach for the removal of ectopic thyroid goiters of the anterior mediastinum. We report two cases of mediastinal ectopic goiter removal through a cervical incision, without sternotomy. The technique is based on a careful and gentle traction of the mass by means of traction stitches and simultaneously on a blunt digital dissection, in order to exteriorize the lesion in the neck, as much as necessary to ligate its vascular pedicle before completing the removal. When performed with caution and precision, this approach can avoid sternotomy in selected patients with ectopic thyroid goiter., Key Words: Ectopic thyroid, Sternotomy, Thyroidectomy.

Introduction: The aim of this study is to evaluate the impact of transthoracic endoscopic sympathectomy on plantar hyperhidrosis in patients operated on for upper limb hyperhidrosis., Materials and Methods: From 2003 to 2011, 41 consecutive patients underwent videothoracoscopic T3-T4 sympathicotomy or T3-T4 ganglion block at our Unit for upper limb hyperhidrosis. Twenty-one (51%) were affected by palmar hyperhidrosis and 20 (49%) by palmar and axillary hyperhidrosis combined. The patients affected by the plantar form were 26 (63%). Clinical follow-up was performed at 3, 6 and 12 months after surgery. Phone interviews and/or clinical assessment were made after a variable period of time (range 6 months to 8 years) to asses long term results., Results: Plantar hyperhidrosis improved in 14 patients, which represents the 54% of the sufferers and the 34% of all patients. It was partially regressed in 11 patients (79%) and resolved in 3 cases (21%). There were not significant differences between patients treated with sympathicotomy and those treated with ganglion block., Conclusions: Transthoracic endoscopic sympathectomy performed through T3-T4 sympathicotomy or ganglion block improves plantar hyperhidrosis in approximately 54% of the affected patients, with a partial and complete resolution rate of 79% and 21% respectively.

Aim: Rectal neoplasm excision is a challenging issue in gastrointestinal endoscopy and surgery. This technical note describes a hybrid method for the excision of challenging rectal neoplasms., Method: The procedure consists of the combined use of classic endoscopy and transanal endoscopic microsurgical instrumentation for full-thickness removal of a recurrent rectal polyp in a patient who had previously undergone endoscopic excision of a Tis rectal adenocarcinoma, located behind the valve of Houston and 9 cm from the anal verge., Results: The lesion was removed completely in 50 min with no operative complication. The patient's postoperative course was uneventful, and she was discharged after 5 days. Pathological examination of the specimen confirmed complete resection of the lesion with adequate disease-free margins., Conclusion: Hybrid transanal endoscopic microsurgery successfully combines the precision and flexibility of classic endoscopy with the radicality and safety of transanal endoscopic microsurgery for the treatment of demanding benign or early-stage malignant rectal tumours., (Colorectal Disease © 2013 The Association of Coloproctology of Great Britain and Ireland.)

Introduction: In this report, we present the case of a patient affected by appendiceal cystadenoma, a colorectal adenocarcinoma, and a concomitant bladder carcinoma, as well as the results of the molecular study of the most relevant mutational pathways involved in these tumors., Case Presentation: A 68-year-old Italian man was admitted to our unit complaining of macrohematuria, rectorrhagia, and rectal tenesmus for about 2 months. A colonoscopy showed the presence of a rectal lesion at 11cm from the anal margin; multiple biopsies were performed and a diagnosis of moderately differentiated adenocarcinoma was made. Abdominal ultrasonography and total body computed tomography performed subsequently to stage the rectal cancer showed the presence of two round nodules, interpreted as swollen lymph nodes of neoplastic origin, at the anterior aspect of the iliopsoas muscle and a budding lesion affecting the bladder. The patient underwent transurethral biopsy of the lesion in the right retrotrigonal region; the diagnosis was grade II urothelial carcinoma. The patient underwent an open anterior rectal resection with loco-regional lymphadenectomy. An enlarged appendix and a voluminous whitish soft-tissue lesion requiring an appendicectomy were detected perioperatively. Transurethral resection of the bladder lesion was also performed. The histological examination revealed that the nodular lesions in the appendix were due to a cystadenoma. For mutation analysis, genomic deoxyribonucleic acid was isolated from tumor tissue samples; for PIK3CA mutations, screening revealed that all three samples analyzed carried mutations in exon 9., Conclusions: Appendiceal mucoceles are rare but require adequate surgical treatment, given their malignant potential and the possibility of causing peritoneal pseudomyxoma. It is essential to make a correct preoperative evaluation based on a colonoscopy rather than ultrasound and computed tomography to exclude synchronous neoplasias often associated with mucoceles and to plan the optimum surgical strategy. The association between appendiceal mucoceles and other neoplasias is relatively frequent, especially with colorectal cancer. Oncogenic activation in the PIK3CA-depending pathway may contribute substantially to the pathogenesis of the different solid tumors in the same patient.

Introduction: In this study we retrospectively reviewed data on 311 consecutive elective cholecystectomies, performed for benign disease (cholelithiasis, cholecystitis) in our institution in the last six years, in order to determine the frequency of unexpected gallbladder pre-neoplastic and neoplastic lesions and analyse their clinical, diagnostic and therapeutic features., Materials and Methods: Three hundred eleven consecutive patients underwent elective cholecystectomy for benign gallbladder disease in our Institution from January 2005 to March 2011. Clinical records and histo-pathological reports were reviewed in order to detect occult gallbladder pre-neoplastic and neoplastic lesions and describe the clinical, diagnostic and therapeutic findings. Eight patients were excluded for lacking of important clinical data., Results: Out of 303 patients examined, 26 (8.6%) were found to be affected by a concomitant pre-neoplastic or neoplastic lesion. Ten (3.3%) were found to have a benign lesion, 13 (4.3%) a dysplasia of the gallbladder epithelium and 3 (1%) a gallbladder adenocarcinoma., Discussion: Dysplasia was found in 4,3% of cases and surgery represents the interruption of an eventual malignant evolution. Adenomiomatosis and adenomas represent the most frequent benign occult lesions discovered; surgery is the definitive cure for such lesions. Occult gallbladder adenocarcinoma was detected in 1% of cases in absence of any preoperative clinical or radiological suspect. Cholecystectomy is curative in stage T1a disease, while a re-resection is necessary for more invasive non metastatic disease.

The aim of this study was to evaluate the impact of patient age on the number of lymph nodes dissected during surgery for colorectal cancer. Clinical and histopathological data of 231 consecutive patients who underwent elective surgery for colorectal cancer were reviewed retrospectively. Patients were divided into those aged ≤70 years and >70 years. Our findings suggest that patient's age influences the number of lymph nodes detected in surgical specimens; this number was lower in patients aged >70 years and decreased with further aging.

The aim of this study was to analyze and describe the epidemiological characteristics and trends of thyroid cancer in the province of Sassari (Sardinia, Italy), an area with epidemic thyroid goiter, in the period 1992-2010. Data were obtained from the local tumor registry which makes part of a wider registry web, coordinated today by the Italian Association for Tumor Registries. An increasing trend in the incidence of thyroid cancer in the province of Sassari was evidenced. This trend seems to follow the general worldwide trend and does not seem to be related to the high incidence of thyroid goiter in the area. The frequencies of the different histological subtypes were similar to those reported in numerous national and international reports. Women are affected earlier than men and, therefore, suffer greater professional, economic, and social impacts. Overall mortality is low and a relative 5-year survival is excellent, especially in comparison to other malignancies.

Aims and Background: Sentinel lymph node biopsy is the standard method for axillary lymph node staging in patients with early stage breast cancer. The aim of the study was to evaluate the necessity of axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastasis or isolated tumor cells., Methods: Sentinel lymph node biopsy was performed in 136 patients for breast cancer staging: 16 of them (11.7%) were found to have micrometastasis or isolated tumor cells and underwent axillary lymph node dissection. Micrometastases were considered when tumor invasion was ≤ 2 mm and >0.2 mm in diameter and isolated tumor cells when detected alone or in clusters of <0.2 mm in diameter. The dissection of the three axillary lymph node levels of Berg was performed in all cases., Results: Two patients (12.5%) presented isolated tumor cells and 14 (87.5%) micrometastasis in the sentinel lymph node. Among them, 25% presented nonsentinel axillary lymph node tumor invasion, whereas 75% had no further nodal involvement., Conclusions: Results suggest that micrometastasis or isolated tumor cells of the sentinel lymph node represent the only site of cancer involvement of the axilla, especially in patients with early breast tumors, and that axillary lymph node dissection may be unnecessary in these cases and represent an overtreatment.

Introduction: The utility of prophylactic drainage in colorectal surgery is controversial. The aim of the present article is to study the role of drainage tubes on the management of minor anastomotic dehiscences., Patients and Methods: We retrospectively review clinical reports of 18 consecutive patients with anastomotic dehiscence after open elective colorectal surgery. The mean age was 63 years and the male - female ratio was 5:1. Nine (50%) patients underwent re-operation for fecal peritonitis (group A) while the remaining nine (50%) were managed conservatively (group B). The parameters evaluated in both groups were: time of the anastomotic breakdown, clinical findings, amount of fluid drained the day of the dehiscence, diagnostic means used, length of stay and mortality., Results: Anastomotic leakages were observed medially after 3, 6 days from surgery in group A and after 5.6 days in group B. The most frequent clinical manifestations were: fecal material through the tubes (88.9%), pelvic pain (88.9%) and fever (77.8%). Patients in group A had a median faecal fluid flow of 235cc the day of the dehiscence and 130cc those in group B. Imaging was employed only in three cases in group A and in all cases in group B. The length of hospital stay was longer in patients treated surgically: 37 days versus 29 in those treated conservatively., Conclusions: Minor anastomotic leakages generally occur later than greater ones, they have a milder clinical presentation and can be managed conservatively with the use of drain tubes.

Unlabelled: The Authors report a case of a voluminous abdominal paraganglioma and a review of the literature on the surgical management of paragangliomas., Case Report: A 58 years old woman was admitted to our Institution with acute endocrine impairment and simultaneous intestinal necrosis resulting from the mass effect of the tumor on the mesenteric vessels. Clinical and biochemical preoperative work up posed the suspect of paraganglioma. Previous intensive care treatment, the patient, underwent surgical resection of the tumor and left hemicolectomy, with immediate remission of both endocrine and abdominal syndromes. Histological examination confirm the preoperative clinical hypothesis. Paragangliomas are rare tumors of the extra-adrenal chromaffin tissue. A paraganglioma may be discovered in the absence of any symptom. When symptomatic, the clinical findings are related to the hypersecretion of catecholamines or to the compression of several anatomical structures from a growing mass. Combined acute syndromes of hormonal impairment and contemporaneous mass effect, as in our case, are exceptional. The diagnosis of the secreting forms may be obtained on the basis of biochemical dosage of serum and urinary catecholamines and metanephrines. The assessment of malignancy for paragangliomas is not always feasible. Several imaging, cytological and histological parameters have been proposed as predictors of malignancy, but the only element widely accepted is the existence of distant metastasis. Surgery represents the treatment of choice for paragangliomas. Benign forms, catecholamine secreting forms and tumors compressing neighbouring anatomical structures can be treated surgically with success. In general, an accurate follow-up after complete resection must be considered.

Objective: To evaluate and compare the immediate and long-term outcomes of videothoracoscopic T2-T4 sympathectomy and T3-T4 sympathicotomy for the treatment of palmar and axillary hyperhidrosis., Methods: Between October 1993 and September 2007, we treated a total of 88 patients affected by palmar and axillary hyperhidrosis. Twenty-four patients underwent T2-T4 sympathectomy with 5-10 mm trocars (Group A), 43 T2-T4 sympathectomy with 2-5 mm trocars (Group B), 15 T3-T4 sympathicotomy with 5-10 mm trocars and 6 T3-T4 ganglion block with 2-5 mm trocars (Group C). The mean operative time, for each side, was 15 min for sympathicotomy and 28 min for sympathectomy. In September 2008, we recontacted 98% of patients (total 86), by telephone, to establish long-term results (follow-up range 1-15 years)., Results: In this series, we did not find any significant difference between T2-T4 sympathectomy and T3-T4 sympathicotomy in terms of postsurgical palmar anhidrosis or onset of compensatory hyperhidrosis, while both methods show high efficacy for remission of palmar hyperhidrosis. The slightly higher recurrence rate in our early experience (Group A) can be attributed to the learning curve. Using smaller trocars (2-5 mm), we reduced postsurgical intercostal pain and obtained better aesthetic results and a higher grade of patient's satisfaction., Interpretation: Thoracoscopic approach to hyperhidrosis has evolved in the last few decades with a consequent decrease in side effects. In this series, all patients experienced an improvement in quality of life even in case of recurrence or onset of compensatory hyperhidrosis. Due to these results, the shorter operative time and easier performance of sympathicotomy, we prefer this method.

Introduction: Hypocalcemia is the most frequent complication after total thyroidectomy (TT) and represents the main cause of prolonged hospital stay because of the need to monitor the calcemic status of the patients. The aim of this study is to evaluate the role of serum iPTH as a predictor of post-thyroidectomy hypocalcemia in order to allow patients' early and safe discharge., Materials and Methods: Fifty patients who underwent TT without autotransplantation of parathyroid tissue were prospectively included in the study The mean age was 52 years and the male/female ratio was 1/6. The iPTH serum level were determined 1 hour after the operation and the calcium serum values after 24 and 48 hours. The cut-off value assumed for testing the sensitivity, specificity, PPV and NPV was 16 pg/ml., Results: Nineteen patients (38%) presented hypocalcemia within 48 hours after TT and 16 of them (84.2%) had iPTH serum levels lower than 16 pg/ml. The normocalcemic patients were 31 (62%) and only 4 of them had iPTH serum levels inferior to the cut-off value. Postoperative iPTH serum level determined 1 hour after the operation had a sensibility of 84.2%, specificity of 87.1%, PPV and NPV of 90% and 80% respectively., Conclusions: The dosage of iPTH serum levels after total thyroidectomy reliably predicts patients who are likely to develop hypocalcaemia. It may be useful in clinical practice in order to reduce the number of postoperative blood tests and the hospital length of stay for the patients who are not at risk of postoperative hypocalcemia.

Introduction: The term thyroid goiter is accepted worldwide, while the terms "substernal", "retrosternal" or "intrathoracic" are not clearly agreed on. The tendency to enlarge and to compress adjacent anatomical structures and the chance of malignancy impose the surgical excision as the principal treatment option. We present our experience on the management of substernal goiter and through this, a rapid review of the literature., Materials and Methods: The last seventeen years we treated 94 patients with substernal goiter. The mean age was 57 years and the male - female ratio was 1:5. All patients had preoperatory assessment with chest X ray, ultrasound and CT scan of the neck. We performed a total thyroidectomy through cervical access in 96.7% of cases and in 3.2% through sternotomic access., Results: We found 95.7% cases of anterior and 4.3% cases of posterior goiters, with only one ectopic goiter. Pathologic examination reveal 72.3% colloidocystic goiters, 18% adenomas, 7.4% carcinomas and 2.3% cases of thyroiditis. The most important postoperatory complications were: 2 cases of persistent hypoparathyroidism, 3 cases of recurrent damage and 2 cases of chylothorax. No deaths were observed., Conclusions: It is necessary a scientific agreement on the definition of substernal goiter, in order to uniform epidemiological and clinical data. Preoperative assessment is based on chest X ray, ultrasound and CT scan of the neck. Cervicotomic access represents the most frequent approach and total thyroidectomy is the procedure recommended. Postoperative complications are almost the same as for cervical goiters and mortality is nowadays extremely low.

Introduction: The treatment of colorectal cancer has changed radically in the last decades. Due to the great advances it is now often possible to subject patients to oncological radical treatments without applying to highly aggressive surgery, such as the Miles abdomino perineal resection, which requires a definitive colostomy. So nowadays we more and more apply to anterior resection of the rectum. Some recent studies about quality of life in patients who underwent anterior resection of the rectum focalized their attention on postoperative functional sequels. In particular incontinence, constipation, obstructed defecation and urgency are some of the symptoms which define the anterior resection syndrome, which can be efficiently treated by electrostimulation and biofeedback., Materials and Methods: A prospective study on 61 patients who underwent between 2002 and 2007 anterior resection of the rectum with total mesorectal excision for adenocarcinoma, has shown symptoms of anterior resection syndrome in 14 patients. Succeeding treatment with sphincter electrostimulation and biofeedback has shown improvement in all patients and complete resolution of the anterior resection syndrome in 10 patients who showed a great compliance and a steady improvement on quality of life., Discussion and Conclusions: Rehabilitative treatment with electrostimulation and biofeedback can sensibly reduce symptoms of anterior resection syndrome. An accurate manometric functional assessment is necessary before starting treatment with electrostimulation and biofeedback.

Primary sciatic nerve varices (SNV) lie within the sciatic nerve possibly causing chronic venous disease and sciatic pain as well. We report a series of 12 consecutive patients affected by symptomatic SNV. All of them were treated by echo-guided Tessari foam sclerotherapy (EGFSCL). Mean follow up lasted two years. Reflux through the sciatic veins, as the connected superficial varicose veins, disappeared in the entire cohort and only minor complications have emerged. EGFSCL seems to be both safe and effective, so representing a reliable and minimally invasive treatment.

Introduction: In this work we evaluate the role of mediastinoscopy and video-assisted thoracoscopy in the diagnosis and staging of coin lesion of the lung and of mediastinal masses., Materials and Methods: 72 patients, 55 males and 17 females, affected by lung coin lesion without any previous histological diagnosis have been admitted to our Institution from 1997 to 2007. Mean age was 59.4 for males (range 29-82) and 57.2 for females (range 14-79)., Results: Mediastinoscopy resulted to be diagnostic in 95% of cases. In just one case mediastinoscopy failed and video assisted thoracoscopy was performed, which permitted to obtain diagnosis. Video assisted thoracoscopy was able to lead to diagnosis in 98.1% of cases, as we observed only one failure. In this single case we converted the thoracoscopic approach to open, but although the conversion it was not possible to make diagnosis., Discussion: In these ten years, thanks to adequate indication for mediastinoscopy and video assisted thoracoscopy, the use of thoracotomy for diagnosis and staging of pulmonary neoplastic diseases has been reduced: thus we avoided 80% of unnecessary thoracotomies in patients affected by not resectable lung cancer, metastases (treated by atypical thoracoscopic resection) or benign diseases., Conclusion: The minimally invasive surgical exploration of mediastinum and thoracic cavity allows to obtain all necessary informations (in terms of histology and staging) to programme an adequate therapeutic protocol, reducing postoperative pain and hospital stay, in comparison to thoracotomy.

Introduction: Cystic and neuroendocrine pancreatic neoplasms are quite rare tumors which diagnosis is often difficult due to their non specific symptomatology and limited diagnostic accuracy of conventional diagnostic instruments. Their treatment is still controversial., Case Report: A young woman is admitted with abdominal pain and dyspepsia. Instrumental diagnosis reveals a cystic pancreatic lesion which seems to be malignant as CEA of pancreatic liquid is increased. The patient undergoes distal spleno-pancreatectomy and postoperative histological examination found IPMN associated with MCN and furthermore there was occasional diagnosis of a small neuroendocrine tumor in the pancreatic tail., Discussion: A correct diagnostic approach is indispensable for a correct therapeutic approach. Radical surgical treatment is indicated in all cases of main- and branch duct IPMN and in case of MCN with signs of malignant transformation. Surgical treatment is also the gold standard for pancreatic neuroendocrine tumors if they are singular and in M0 stage., Conclusions: In case of cystic and neuroendocrine neoplasms of the pancreas the preoperative diagnostic approach is often not enough to obtain a definite diagnosis. Review of literature and this case report show that a definite diagnosis can only be done after postoperative histological examination. Recent prospective studies suggest the possibility for a follow up instead of surgical treatment for some neuroendocrine tumors.

Objective: To determine the efficacy and safety of endovascular radiofrequency obliteration of refluxing greater saphenous veins in patients eligible for vein ligation and stripping, Method: From 2002 to 2007, 107 patients, classified a C2 CEAP, were treated. The ablation of the greater saphenous vein was performed using a radiofrequency generator and a VNUS Closer catheter, for endovascular radiofrequency ablation. This procedure avoids groin surgery. The catheter is inserted in the saphenous vein with the use of a introducer through the skin. When necessary, the procedure was complemented by phlebectomy (Muller's method). In all cases, the duplex/color ultrasound was used in guiding the pre- intra and post-operative phase., Results: The procedure was carried out in all cases without complications, with immediate improvement of clinical symptoms and immediate return to normal activities. At 5-year follow-up no recurrent varicose veins were detected, Conclusions: The endovenous radiofrequency ablation of the saphenous veins represents a valid alternative to GSF ligation and saphenous vein stripping. The rigorous application of the protocol, both before and after the operation, is an essential condition to keep complications to a minimum. Because of the long term results, the level of patient satisfaction, the ease with which the procedure is carried out, we have extended its adoption to patients with an advanced stage of the disease, whom in the past would have only been treated with stripping.

Intrathoracic anastomotic leakage is one of the major complications of esophageal surgery that can lead to high mortality rate. Depending on the clinical presentation, therapeutic options include surgical reintervention and conservative management with or without external drainage or stenting. In this paper, we report a series of three patients, two men and one woman, mean age of 55.6 years (range 34-68 years), having intrathoracic anastomotic leak after esophagogastrectomy treated by insertion of four covered self-expandable metal stents performed exclusively under fluoroscopic view. Complete resolution of the leakage was obtained in all patients. Despite the limited number of patients, conservative management of intrathoracic anastomotic leaks with covered self-expandable metal stents performed under fluoroscopic guidance has proved to be rapid, safe, and effective in all cases of this series.

Introduction: Lobular and ductal carcinomas in situ of the breast (LCIS and DCIS) origin from the ductal-lobular unit of mammary gland, but they are characterized for different morphologic patterns and evolution. In 1980 they represent 1.4% of diagnosis in breast biopsy, less of 5% of carcinomas of the breast. Actually in 7.5% of breast biopsy an in situ carcinoma is recognized (approximating 40% of breast cancers). Our purpose is to evaluate the different available strategies in the clinic management of DCIS and LCIS and, in case of surgical treatment, which reconstructive approach obtains satisfactory breast conformation., Materials and Methods: The study enclose 125 patients: 40 of them presented LCIS (32%) and 85 DCIS (68%). In 40 patients (32%) underposed to mastectomy was performed a reconstruction in cooperation with aesthetic surgeons. 35 of 40 women with LCIS are included in a follow-up programme, 5 of them had a bilateral mastectomy and reconstruction., Results: No recurrences were observed in patients affected by LCIS. Six patients underposed to wide excision for DCIS developed local recurrence, treated by mastectomy. No recurrences were observed in patients treated initially with mastectomy. Some complications correlated to reconstruction were detected., Conclusions: One of most controversial sights in breast pathology is the understanding of biological meaning of CLIS: in facts CDIS can be considered a pre-invasive cancer, CLIS is reasonably considerable only a risk indicator for developing breast cancer but it isn't a pre-neoplastic lesion. Very important is the reconstruction of the breast to improve the quality life of patients.

Aim: The authors analyse their personal series and compare it with reported data in order to assess the functional results sleeve lobectomy offers with respect to traditional techniques., Methods: Sixty-six sleeve lobectomies were carried out from 1986 to 2000. In 49 cases the operation was carried out on the basis of criteria of choice and in 17 of functional necessity. Three vascular sleeves and 5 tangential vascular plastic operations were associated. The disparity of lumen was corrected with oblique sections on the intermediate bronchus according to Merendino. In the case of reimplantation of the intermediate on the left main bronchus high frequency jet ventilation was necessary. The anatomoses were covered with broad pedunculated pleural strips. In 3 cases extramucosal myectomy of the medio-thoracic esophagus was carried out associated in 1 case with mucous resection and subsequent direct suture., Results: Morbility was 34.5% (21% atrial fibrillation, 7.5% parenchymal complications, 4.5% anastomotic complications and 1.5% mediastinitis). Mortality at 30 days was 6% (massive hemoptysis in 3 cases and respiratory failure in 1 case). The pTNM of the 57 survivors was IB in 35 cases, IIB in 6 and IIIA in 16. Follow-up showed 5-year survival of 62% for stage IB and 24% for stage IIIA., Conclusions: On the basis of their experience, with a postoperative mortality and a rate of complications comparable to literature data, the authors consider that sleeve lobectomy, although it presents postoperative problems requiring more prolonged clinical control, is preferable to traditional operations because of the functional advantages it offers patients with lung cancer.