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Pancreatic neuroendocrine tumors (pNETs) represent about 7% of all NETs, 8.7% of gastroenteropancreatic NETs (GEP-NETs) and 1-2% of all pancreatic neoplasms. In the last two decades, the increased diagnosis of pNETs has generated great interest and the development of different classifications, grading and staging systems. Recently, several trials were performed in order to improve the knowledge of biomarkers and imaging and to provide an early diagnosis, but their role is still under debate. Nowadays, surgery represents the only curative approach for pNETs. Approximately 90% of pNETs are silent and non-functional; therefore, most patients are diagnosed in late stage and present metastatic (60%) or locally unresectable advanced disease (21%) with a poor prognosis. Not many therapeutic options are available for pNETs, with different treatments for G1-G2 and G3 tumors, because these diseases are still rare and trials are made up of few series of patients. At present, medical treatments is controversial. On these bases, we believe that a multidisciplinary team composed of surgeons, oncologists, endocrinologists, radiation oncologists, radiologists, pathologists and medicals nuclear is required. This paper presents a review of present state-of-the-art in the field of pNETs. Pancreatic neuroendocrine tumors (pNETs) represent about 7% of all NETs, 8.7% of gastroenteropancreatic NETs (GEP-NETs) and 1-2% of all pancreatic neoplasms. In the last two decades, the increased diagnosis of pNETs has generated great interest and the development of different classifications, grading and staging systems. Recently, several trials were performed in order to improve the knowledge of biomarkers and imaging and to provide an early diagnosis, but their role is still under debate. Nowadays, surgery represents the only curative approach for pNETs. Approximately 90% of pNETs are silent and nonfunctional; therefore, most patients are diagnosed in late stage and present metastatic (60%) or locally unresectable advanced disease (21%) with a poor prognosis. Not many therapeutic options are available for pNETs, with different treatments for G1-G2 and G3 tumors, because these diseases are still rare and trials are made up of few series of patients. At present, medical treatments is controversial. On these bases, we believe that a multidisciplinary team composed of surgeons, oncologists, endocrinologists, radiation oncologists, radiologists, pathologists and medicals nuclear is required. This paper presents a review of present state-of-the-art in the field of pNETs. (c) 2016 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.

Background Pancreatic neuroendocrine tumors (pNETs) are uncommon entities. pNETs are often small, slow growing, clinically silent neoplasms. However, they have an almost unpredictable biological behaviour with a not negligible malignant potential. Surgery still represents the treatment of choice, but the high morbidity associated to the enucleation or the formal pancreatectomy should be considered in the decision of the proper treatment. Management of these neoplasms is still debated, and indications for a conservative observational approach and for parenchyma sparing resections are not yet standardized. Method We review the state of art on the indications for the conservative management of pNETs. Searches on MEDLINE database were performed to identify articles reporting prognostic systems, biochemical screening, observational management, medical treatment and surgical strategies for pNETs. Discussion Currently, an accurate ‘wait-and-see' policy is recommended by the European Neuroendocrine Tumor Society (ENETS) only for non-functioning pNETs (NF-pNETs) A biochemical screening, based on sampling of serum levels of pancreatic polypeptide (PP) and chromogranin A, can address to early conservative surgery for MEN-1 associated NF-pNETs The subtotal (80%) distal pancreatectomy first proposed by Thompson, often with the enucleation of possible pancreatic head tumors, still represents a good compromise between oncological radicality and prevention of pancreatic endocrine/exocrine insufficiency caused by standard radical resections for the treatment of inherited syndromes associated with NF-pNETs >2 cm and symptomatic F-pNETs of any size. Conclusion More studies are needed to further clarify and predict the biologic behaviour of pNETs and increase the indications for conservative observational management and parenchyma sparing pancreas resections.

The triad composed by α-Klotho, fibroblast growth factor-23, and its receptor are involved in the pathogenesis of chronic kidney disease–mineral and bone disorder. A disintegrin and metalloproteinase 17 (ADAM17) is a metalloproteinase causing the proteolytic shedding of α-Klotho from the cell membrane, and its role in chronic kidney disease–mineral and bone disorder is not yet known. We studied the circulating levels of the above-mentioned mediators in patients with secondary hyperparathyroidism due to uremia, compared to control subjects, as well as in patients with primary hyperparathyroidism. We also measured the immunofluorescence pattern of the relevant tissue proteins in specimens obtained from patients undergoing parathyroid surgery for secondary compared to primary hyperparathyroidism. Results showed that α-Klotho tissue levels are reduced, in the presence of increased ADAM17 tissue levels. In addition, we showed increased serum levels of the main product of ADAM17 proteolytic activity, tumor necrosis factor-α. Thus, we found a paradoxical situation, in secondary compared to primary hyperparathyroidism, that is, that in the face of increased tumor necrosis factor-α in circulation, both soluble and tissue α-Klotho are reduced significantly, despite increased tissue ADAM17. In conclusion, tissue and serum levels of α-Klotho seem to have become independent from the regulation induced by ADAM17, which constitutes therefore another tassel in the impaired α-Klotho–FGF23 receptor axis present in uremia.

Prophylactic central neck dissection in clinically node-negative patients remains controversial. The aim of this multicenter retrospective study was to determine the rate of metastases in the central neck in clinically node-negative differentiated thyroid cancer patients, to examine the morbidity, and to assess the risk of regional recurrence in patients treated with total thyroidectomy with concomitant bilateral or ipsilateral central neck dissection compared with those undergoing total thyroidectomy alone. 258 consecutive clinically node-negative patients were divided into three groups according to the procedures performed: total thyroidectomy only (group A), total thyroidectomy with concomitant ipsilateral central neck dissection (group B), and total thyroidectomy combined with bilateral central neck dissection (group C). Mean operative time and postoperative stay were shorter in Group A (p < 0.01). The incidence of postoperative transient hypoparathyroidism was lower in Group A (p = 0.03), whereas no differences in the incidence of permanent hypoparathyroidism and nerve palsy were present. Postoperative radioactive iodine administration was higher in group B and particularly C (p = 0.03) compared with group A. There were no statistically significant differences in terms of regional recurrence. Differentiated thyroid cancer has a high rate of central lymph node metastasis even in clinically node-negative patients; in the present study there was no statistically significant difference in the rates of locoregional recurrence between the three modalities of treatment. Total thyroidectomy appears to be an adequate treatment for clinically node-negative differentiated thyroid cancer. Prophylactic central neck dissection might be considered for differentiated thyroid cancer patients with large tumor size or extrathyroidal extension.

Context: Tumor angiogenesis is determined by host genetic background rather than environment. Germline single nucleotide polymorphisms (SNPs) of the vascular endothelial growth factor (VEGF) pathway have demonstrated prognostic value in different tumors. Objectives: Our main objective was to test the prognostic value of germline SNPs of the VEGF pathway in nonadvanced differentiated thyroid cancer (DTC). Secondarily, we sought to correlate analyzed SNPs with microvessel density (MVD). Design: Multicenter, retrospective, observational study. Setting: Four referral centers. Patients: Blood samples were obtained from consecutive DTC patients. Genotyping was performed according to the TaqMan protocol, including 4 VEGF-A (-2578C>A, -460T>C, +405G>C, and +936C>T) and 2 VEGFR-2 (+1192 C>T and +1719 T>A) SNPs. MVD was estimated by means of CD34 staining. Outcome measures: Rate of recurrent structural disease/disease-free survival (DFS). Difference in MVD between tumors from patients with different genotype. Results: Two hundred four patients with stage I-II DTC (mean follow-up, 73 ± 64 months) and 240 patients with low- to intermediate-risk DTC (mean follow-up, 70 ± 60 months) were enrolled. Two "risk" genotypes were identified by combining VEGF-A SNPs -2578 C>A, -460 T>C, and +405 G>C. The ACG homozygous genotype was protective in both stage I-II (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.01 to 1.43; P = 0.018) and low- to intermediate-risk (OR, 0.14; 95% CI, 0.01 to 1.13; P = 0.035) patients. The CTG homozygous genotype was significantly associated with recurrence in stage I-II (OR, 5.47; 95% CI, 1.15 to 26.04; P = 0.018) and was slightly deleterious in low- to intermediate-risk (OR, 3.39; 95% CI, 0.8 to 14.33; P = 0.079) patients. MVD of primary tumors from patients harboring a protective genotype was significantly lower (median MVD, 76.5 ± 12.7 and 86.7 ± 27.9, respectively; P = 0.024). Conclusions: Analysis of germline VEGF-A SNPs could empower a prognostic approach to DTC.

The most appropriate surgical management of "follicular neoplasm/suspicious for follicular neoplasm" lesions, is still controversial. Analysing and comparing the experience of two units for endocrine surgery, we retrospectively evaluated 721 patients, surgically treated after a follicular neoplasm diagnosis. Total thyroidectomy was routinely performed in one Institution, while in the other one it was selectively carried out. The main criteria leading to hemythyroidectomy were a single nodule, the age ≤45 years, the absence of thyroiditis or clinical/intraoperative suspicion of malignancy. Total thyroidectomy was performed in 402/721 patients (55.7%), hemythyroidectomy in 319/721 cases (44.2%) and a completion thyroidectomy in 51/319 cases (15.9%). The overall malignancy rate was 24% (176/721 patients), respectively 16% (51/319 patients) following hemythyroidectomy, and 31% (125/402 patients) following total thyroidectomy. Definitive recurrent laryngeal nerve paralysis and permanent hypoparathyroidism were not reported in hemythyroidectomy patients in which lower mean hospitalization and costs were observed. Considering the low-risk of follicular neoplasm solitary lesions, hemythyroidectomy is still the safest standard of care with lower hospitalization and costs. In case of multiglandular disease or thyroiditis, that might be associated with a higher risk of cancer, total thyroidectomy should be recommended. Further investigation is warranted to achieve a better preoperative follicular neoplasm diagnostic accuracy in order to reduce the amount of unnecessary surgical operations with a diagnostic aim.

Background In clinically node-negative patients with differentiated thyroid cancer (DTC), indications for routine central lymph node dissection (RCLD) are the subject of intensive research, and surgeons are divided between the pros and cons of this surgery. To better define the role of neck dissection in the treatment of DTC, we analyzed retrospectively the results in three centers in Italy. Methods The clinical records of 752 clinically node-negative patients with DTC who underwent operative treatment between January 1998 and December 2005 in three endocrine surgery referral units were evaluated retrospectively. The complications and medium- and long-term outcomes of total thyroidectomy (TT) alone (performed in 390 patients: group A) and TT combined with bilateral RCLD (362 patients: group B) were analyzed and compared. Results The incidence of permanent hypoparathyroidism and permanent unilateral vocal folds was 1% and 0.8% in group A and 3.6% and 1.7% in the group B, respectively. Bilateral temporary recurrent nerve palsy was observed in one of the 362 patients in group B. After a follow-up of 9.5 ± 3.5 years (mean ± SD), the locoregional recurrence rate with positive cervical lymph nodes was not substantially significantly different between the two groups. Conclusion In our series, TT combined with bilateral RCLD was associated with a greater rate of transient and permanent complications. Similar incidences of locoregional recurrence were reported in the two groups of patients. Considering the recent trend toward routine central lymphadenectomy, further studies are needed to evaluate the benefits of these different approaches.

Background: Acute respiratory failure is a rare life threatening complication following thyroid surgery and its incidence is reported as high as 0.9%. Clinical presentation of severe acute respiratory failure is characterized by dyspnea, inspiratory airways distress, hypoxia and its standard current management is the orotracheal intubation and safe extubation. In case of persistent distress, tracheotomy is mandatory. The Authors, analysing a large acute respiratory failure clinical series, describe an innovative treatment of this severe condition: the nasotracheal prolonged safe extubation.Methods: Patients treated at our Intensive Care Unit for acute respiratory failure following thyroid surgery from January 2004 to December 2013, were reviewed. Demographic data including gender, age, clinical presentation, laryngoscopic findings, management and outcome during a 24-months follow-up after treatment were collected and evaluated. Moreover, the strategy for prolonged nasotracheal safe extubation was carefully described.Results: Nineteen out of the 2853 patients scheduled for thyroid surgery (0.66%) at our University Hospital, developed post-operative acute respiratory failure. All of them were treated by nasotracheal prolonged safe extubation. The success rate in avoiding highly invasive treatment was of 84.2%, since only 3 patients needed definitive tracheotomy (15.7%).Conclusions: In our series, the prolonged safe extubation reduced the almost totality of expected tracheotomies in patients with acute respiratory failure following thyroid surgery (84.2%), demonstrating its feasibility and efficacy. It was a well tolerated and minimal invasive procedure that allowed a good respiratory ability and a fast clinical resolution of the laryngeal functional impairment. (C) 2017 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Solitary fibrous tumor (SFT) is a rare spindle cell neoplasm, usually occurring in the pleura. Pararenal SFT, mimicking adrenal glands or renal tumor, as here described, is extremely rare. We report a case of a suprarenal right SFT, incidentally discovered by abdominal ultrasound in a 54-year-old woman carrying a point neurofibromatosis 1 (NF) gene mutation. Preoperative diagnostic work-up was ineffective to evaluate its origin, and an open radical right nephrectomy was therefore undertaken. Immunohistochemical assay showed a positivity for CD34, CD99 and Bcl-2, so suggesting a diagnosis of SFT. According to our knowledge, the association between this type of tumor and NF1 gene mutation has never been described. In case of pararenal tumors, a more detailed preoperative diagnosis could be useful to better plan the extension of resection, allowing, in selected cases, a nephron-sparing surgery. More studies are needed to better analyze the relationship between NF1 gene mutation and SFT.

Pheochromocytoma (PCC), a rare neuroendocrine tumor, shows a prevalence ranging between 0.1% and 0.6% in individuals suffering from hypertension. To date, an increasing number of patients with hereditary forms or subclinical PCCs have been diagnosed. We reviewed the main controversies and the most recent updates, especially inheritance genetics and surgical management. According to the “rule of 10”, in 1/10 patients with pheochromocytoma it is malignant, in 1/10 of cases the tumor is bilateral, in 1/10 extra-adrenal and in 1/10 familial. Surgical resection, the only curative treatment, carries a high risk of hypertensive crises due to massive catecholamine release. Alpha 1 blocker therapy, alone or in combination with beta blockers, calcium antagonists, and plasma volume expansion, is the most commonly used preoperative treatment protocol. Minimally invasive adrenalectomy (laparoscopic and retro-peritoneoscopic) allows earlier mobilization and recovery, reducing the risk of pulmonary infections and thromb-oembolic complications, and is associated with lower morbidity and mortality rates than traditional surgery; it is currently considered the gold standard for the treatment of adrenal tumors ≤6 cm in diameter and weighing

In the last years, especially thanks to a large diffusion of ultrasound-guided FNBs, a surprising increased incidence of differentiated thyroid cancer (DTC), "small" tumors and microcarcinomas have been reported in the international series. This led endocrinologists and surgeons to search for "tailored" and "less aggressive" therapeutic protocols avoiding risky morbidity and useless "overtreatment". Considering the most recent guidelines of referral endocrine societies, we analyzed the role of routine or so-called prophylactic central compartment lymph node dissection (RCLD), also considering its benefits and risks. Literature data showed that the debate is still open and the surgeons are divided between proponents and opponents of its use. Even if lymph node metastases are commonly observed, and in up to 90% of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is subject to intensive research and the best indications of lymph node dissection are still controversial. Identification of prognostic factors for central compartment metastases could assist surgeons in determining whether to perform RLCD. Considering available evidence, a general agreement to definitely reserve RCLD to "high-risk" cases was observed. More clinical researches, in order to identify risk factors of meaningful predictive power and prospective long-term randomized trials, should be useful to validate this selective approach. In the last years, especially thanks to a large diffusion of ultrasound-guided FNBs, a surprising increased incidence of differentiated thyroid cancer (DTC), "small" tumors and microcarcinomas have been reported in the international series. This led endocrinologists and surgeons to search for "tailored" and "less aggressive" therapeutic protocols avoiding risky morbidity and useless "overtreatment". Considering the most recent guidelines of referral endocrine societies, we analyzed the role of routine or so-called prophylactic central compartment lymph node dissection (RCLD), also considering its benefits and risks. Literature data showed that the debate is still open and the surgeons are divided between proponents and opponents of its use. Even if lymph node metastases are commonly observed, and in up to 90 % of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is subject to intensive research and the best indications of lymph node dissection are still controversial. Identification of prognostic factors for central compartment metastases could assist surgeons in determining whether to perform RLCD. Considering available evidence, a general agreement to definitely reserve RCLD to "high-risk" cases was observed. More clinical researches, in order to identify risk factors of meaningful predictive power and prospective long-term randomized trials, should be useful to validate this selective approach.

Thyroid microcarcinoma (TMC) it's a rare type of differentiated thyroid cancer, which according to the World Health Organization measures 10 mm or less. Accounting 7-16 % of all thyroid carcinomas, it occurs at any age, more frequently in men, with a female to male ratio of 1:3. More frequently histotype is the papillary subset, PTCM. Aim of this study is to retrospectively evaluate the patients diagnosed with TMC in terms of their clinical and histopathological features. In our institution we collected 23 cases of TMC sampled on 338 plongeant being operated. All the tumors, in our study, were found incidentally during the treatment of benign thyroid diseases. All the sample were analyzed and prepared using the same frozen section technique. Surgical pathology identified 11 papillary microcarcinomas, 10 follicular microcarinomas, 1 oncocytary microcarcinomas and in 1 patient was found only a focal tireocitary transformation. TMC's prognosis and treatment is still a subject of controversy We propose our approch consisting in total thyroidectomy (less than 5 gr residual thyroid tissue), being considered the low rate of post-operative complications, and recurrences: all patients are disease-free at the median follow-up of 78 months (range 96 to 30 months). We have considered either the less malignancy habit of this neoplasia either its well prognosis.Il microcarcinoma tiroideo è un tipo raro di tumore tiroideo differenziato, che secondo il WHO misura 10 mm o meno. Costituisce il 7-16% di tutti i carcinomi tiroidei, e insorge a qualsiasi età,più frequentemente negli uomini,con un rapporto femmina-maschio di 1:3. Più frequentemente l’istotipo è il tipo papillare. Scopo di questo studio è di valutare in maniera retrospettiva i patienti con microcarcinoma tiroideo rispetto alle loro caratteristiche cliniche e istopatologiche. Nel nostro istituto abbiamo raccolto 23 casi di microcarcinoma tiroideo campionati su 338 gozzi operati. Tutti i tumori nel nostro studio sono stati trovati incidentalmente durante il trattamento di patologie benigne della tiroide. Tutti i campioni sono stati analizzati e preparati usando la stessa tecnica su sezioni congelate. All’esame istologico sono stati identificati 11 microcarcinomi papillari,10 microcarcinomi follicolari e in 1 paziente è stata ritrovata solo una trasformazione focale tireocitaria. La prognosi e il trattamento del microcarcinoma tiroideo è ancora oggetto di controversia. Noi proponiamo il nostro approccio che consiste nella tiroidectomia totale (meno di 5gr gi tessuto tiroideo residuo) , che viene considerata a basso tasso di complicanze post-operatorie e recidiva: tutti i pazienti sono liberi di malattia per un follow up medio di 78 mesi (range tra 30 e 96 mesi) .

In the last decades, minimally invasive transperitoneal laparoscopic adrenalectomy has become the standard of care for surgical resection of the adrenal gland tumors. Recently, however, adrenalectomy by a mininvasive retroperitoneal approach has reached increasingly popularity as alternative technique. Short hospitalization, lower postoperative pain and decrease of complications and a better cosmetic resolution are the main advantages of these innovative techniques. In order to determine the better surgical management of adrenal neoplasms, the Authors analyzed and compared the feasibility and the postoperative complications of minimally invasive adrenalectomy approaches. A systematic research of the English literature, including major meta-analysis articles, clinical randomized trials, retrospective studies and systematic reviews was performed, comparing laparoscopic transperitoneal adrenalectomy versus retroperitoneoscopic adrenalectomy. Many studies support that posterior retroperitoneal adrenalectomy is superior or at least comparable to laparoscopic transperitoneal adrenalectomy in operation time, pain score, blood loss, hospitalization, complications rates and return to normal activity. However, laparoscopic transperitoneal adrenalectomy is up to now a safe and standardized procedure with a shorter learning curve and a similar low morbidity rate, even for tumors larger than 6 cm. Nevertheless, further studies are needed to objectively evaluate these techniques, excluding selection bias and bias related to differences in surgeons' experiences with this approaches. (c) 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

BACKGROUND: Pancreatic neuroendocrine tumors (pNETs) are uncommon entities. pNETs are often small, slow growing, clinically silent neoplasms. However, they have an almost unpredictable biological behaviour with a not negligible malignant potential. Surgery still represents the treatment of choice, but the high morbidity associated to the enucleation or the formal pancreatectomy should be considered in the decision of the proper treatment. Management of these neoplasms is still debated, and indications for a conservative observational approach and for parenchyma sparing resections are not yet standardized. METHOD: We review the state of art on indications for the conservative management of pNETs. Searches on MEDLINE database were performed to identify articles reporting prognostic systems, biochemical screening, observational management, medical treatment and surgical strategies for pNETs. DISCUSSION: Currently, an accurate 'wait-and-see' policy is recommended by the European Neuroendocrine Tumor Society (ENETS) only for non-functioning pNETs (NF-pNETs) 2 cm and symptomatic F-pNETs of any size. CONCLUSION: More studies are needed to further clarify and predict the biologic behaviour of pNETs and increase the indications for conservative observational management and parenchyma sparing pancreas resections.

Summary objective To investigate whether the addition of iodized salt to daily diet in thyroidectomized patients for nontoxic goitre could influence the effectiveness of nonsuppressive l-thyroxine (L-T4) therapy on thyroid remnant size, during 12 months’ follow-up after thyroid surgery. design and patients A consecutive series of selected 139 patients (26 males, 113 females; median age 45 years, range 30–69 years) living in a moderate iodine-deficient area, and undergoing thyroid surgery for nontoxic multinodular goitre, was enrolled. Patients were assigned randomly to two different therapeutic regimens: 70 patients received L-T4 therapy alone (Gr. L-T4), while the remaining 69 patients took iodized salt on a daily basis in addition to L-T4 treatment (Gr. L-T4 + I). In both groups, the initial L-T4 dose was 1·5 µg/kg/day, which, in our experience, has been shown to be intermediate between suppressive and replacement doses. To avoid the risks of mild thyrotoxicosis and to limit the excessive TSH stimulation of the thyroid remnant, the L-T4 dose was adjusted in those patients with serum TSH levels outside the lowest two-thirds of the normal range (0·3–2·5 mU/l). An ultrasound evaluation of thyroid remnant size was performed after thyroid surgery and 12 months later. results After surgery, the median thyroid remnant volume was 3·5 ml (range 0·4–13·9 ml) in Gr. L-T4 and 4·6 ml (range 0·5–12·7 ml) in Gr. L-T4 + I (P = 0·06). After 1 year of follow-up, the patients treated with L-T4 + I obtained a remnant volume reduction (−39·7%, range −87·0% to +91·2%) significantly (P = 0·006) greater than that observed in patients assuming L-T4 alone (−10·2%, range −89·4% to +85·0%). However, the percentage of patients showing an increase in remnant size in the months following surgery was higher in Gr. L-T4 than in Gr. L-T4 + I (22/60 vs. 9/66; P = 0·01). In Gr. L-T4 patients the thyroid remnant volume variation throughout 12 months of treatment was correlated significantly with the size of the thyroid remnant found at the first ultrasound evaluation (R2 = 0·3; P

Objectives: Acute respiratory failure (ARF) is a complication following thyroid surgery; its incidence is reported as high as 0.9%. Through an illustrative case series, we present an alternative treatment of this peculiar ARF: the nasotracheal Prolonged Safe Extubation (PSE). Methods: Patients treated at our Intensive Care Unit for ARF following thyroid surgery from January 2004 to December 2009, were reviewed. Demographic data including gender, age, clinical presentation, laryngoscopic findings, management and outcome during a 24-months follow-up after treatment were collected and evaluated. The strategy for prolonged nasotracheal safe extubation is presented. Results: Twelve out of the 1713 patients scheduled for thyroid surgery (0.7%) at our university hospital, developed post-operative ARF. All of them were treated by nasotracheal prolonged safe extubation. The success rate in avoiding highly invasive treatment was of 83.3%, since only 2 patients needed tracheotomy (16.7%). Conclusions: The prolonged safe extubation reduced the amount of expected tracheotomies in patients with ARF following thyroid surgery. Thanks to its minimal invasiveness, and to the high degree of comfort, it was well tolerated.

Introduction Parathyroidectomy (PTx) is recommended in patients affected by secondary hyperparathyroidism (2HPT) of chronic kidney disease-mineral bone disorders (CKD-MBD), resistant to medical treatment. Analyzing total parathyroidectomy with muscular or subcutaneous autoimplantation (TPai) outcomes in hemodialysis (HD) 2HPT patients, and monitoring intact parathyroid hormone (iPTH) levels, we evaluated long-term functional results of subcutaneous parathyroid glandular tissue autoimplantation. Methods 40 HD 2HPT patients, resistant to medical treatment, and awaiting for renal transplantation, underwent total parathyroidectomy with subcutaneous autoimplantation of 9-12 fragments of not nodular hyperplasia parathyroid tissue in not dominant forearm. iPTH were analyzed 24 hours, and 3-6-12-24 months after surgery. The 1.08-6.99 pmol/L range was taken as reference of normal iPTH level based on which eu- (1.08-6.99), hypo- (< 1.08), aparathyroidism (0) and persistence or relapse ( > 6.99) of disease were determined. Results In every case PTai determined an extraordinary improvement of quality of life, associated with a notable reduction of iPTH serum level. Immediate normalization of iPTH was achieved in 50% of cases; hypoparathyroidism in 25% of cases and persistence of disease in 25% were observed. Long term follow-up showed a reduction of hypoparathyroidism and an increase of relapse rate up to 20%. Grafting resection was never performed. Discussion Subcutaneous autotrasplantation is a very simple and fast surgical technique. Nevertheless, similar success and recurrence rates were reported following muscular or subcutaneous grafting, as confirmed in our experience. Conclusions Subcutaneous grafting was effective as muscular implantation, with comparable functional results, but avoiding its potential complications. Introduction: Parathyroidectomy (PTx) is recommended in patients affected by secondary hyperparathyroidism (2HPT) of chronic kidney disease-mineral bone disorders (CKD-MBD), resistant to medical treatment. Analyzing total parathyroidectomy with muscular or subcutaneous autoimplantation (TPai) outcomes in hemodialysis (HD) 2HPT patients, and monitoring intact parathyroid hormone (iPTH) levels, we evaluated long-term functional results of subcutaneous parathyroid glandular tissue autoimplantation.Methods: 40 HD 2HPT patients, resistant to medical treatment, and awaiting for renal transplantation, underwent total parathyroidectomy with subcutaneous autoimplantation of 9-12 fragments of not nodular hyperplasia parathyroid tissue in notdominant forearm. iPTH were analyzed 24 h, and 3-6-12-24 months after surgery. The 1.08-6.99 pmol/L range was taken as reference of normal iPTH level based on which eu- (1.08-6.99), hypo-(< 1.08), aparathyroidism (0) and persistence or relapse (>6.99) of disease were determined.Results: In every case PTai determined an extraordinary improvement of quality of life, associated with a notable reduction of iPTH serum level. Immediate normalization of iPTH was achieved in 50% of cases; hypoparathyroidism in 25% of cases and persistence of disease in 25% were observed. Long term follow-up showed a reduction of hypoparathyroidism and an increase of relapse rate up to 20%. Grafting resection was never performed.Discussion: Subcutaneous autotrasplantation is a very simple and fast surgical technique. Nevertheless, similar success and recurrence rates were reported following muscular or subcutaneous grafting, as confirmed in our experience.Conclusions: Subcutaneous grafting was effective as muscular implantation, with comparable functional results, but avoiding its potential complications. (C) 2014 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

Primary smooth muscle tumors of the thyroid gland are extremely rare neoplasms. Due to their rarity, clinical case studies concerning management are lacking. According to a literature review, only 19 cases of primary thyroid leiomyosarcomas (TLs) have been reported. In the majority of patients, the prognosis is poor since adjuvant radiochemotherapy is ineffective on local recurrence and on long-term survival. In this study, we report the case of a 77-year-old male affected by a rapidly enlarging mass of the anterior neck, associated with bilateral lung metastases, and increasing dysphagia and dyspnea during the previous 6 months. A Tir4 neoplasm fine needle cytological diagnosis of the right thyroid lobe was reached and the patient underwent total thyroidectomy (TT). Definitive histological examination identified a TL. The patient succumbed 40 days later due to respiratory distress. A literature review was performed and TL differential diagnoses, management, including alternative treatment strategies, and adjuvant therapy were analyzed. TL is an aggressive rare mesenchymal malignant tumor. Although an improved multimodal approach is often necessary, TT and neck dissection represent the treatment of choice and are often the only possible therapy. Adjuvant radiochemotherapy appears to be ineffective and a high mortality rate is observed. TL remains a fatal tumor, and innovative and more effective therapeutic strategies to improve management and outcomes are required.

Introduction: In the surgical management of the patients with Cushing syndrome (CS), minimal invasive adrenalectomy (MA) has become the procedure of choice to treat adrenal tumors with a benign appearance � 6 cm in diameter. Authors evaluated medium- and long-term outcomes of laparoscopic adrenalectomy (LA) for CS or subclinical CS (sCS), performed for ten years in an endocrine surgery unit. Methods: We retrospectively reviewed 21 consecutive patients undergone LA for CS or sCS from 2003 to 2013. Postoperative clinical and cardiovascular status modifications and surgical medium and long-term outcomes were analyzed. Results: In each patient surgery determined a normalization of the hormonal profile. There was no mortality neither major post-operative complications. Mean operative time was higher during the learning curve, there was no conversion, and morbidity rate was 6.3%. Regression of the main clinical symptoms occurred slowly in twelve months. Conclusions: LA is a safe, effective and well-tolerated procedure for the treatment of CS and sCS reducing arterial blood pressure, body weight and fasting glucose levels. Following the learning curve a morbidity rate similar to that reported in the MA series for other adrenal diseases is observed. © 2014 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.

Background: In chronic hemodialysis patients with secondary hyperparathyroidism, pathological modifications of bone and mineral metabolism increase the risk of cardiovascular morbidity and mortality. Parathyroidectomy, reducing the incidence of cardiovascular events, may improve outcomes; however, its effects on long-term survival are still subject of active research. We compared, in hemodialysis patients, the results of parathyroidectomy, in terms of cardiovascular outcomes and mortality, with those present in patients following medical treatment only, prior to the diffusion of calcimimetics. Methods. From January 2004 to December 2006, 30 hemodialysis patients, affected by severe and unresponsive secondary hyperparathyroidism, underwent parathyroidectomy - 15 total parathyroidectomy and 15 total parathyroidectomy + subcutaneous autoimplantation. During a 5-year follow-up, patients did not receive a renal transplantation and were evaluated for biochemical modifications and major cardiovascular events - death, cardiovascular accidents, myocardial infarction and peripheral vascular disease. Results were compared with those obtained in a control group of 20 hemodialysis patients, affected by secondary hyperparathyroidism, and refusing surgical treatment, and following medical treatment only. Results: The groups were comparable in terms of age, gender, dialysis vintage, and comorbidities. Postoperative cardiovascular events were observed in 18/30 - 54% - surgical patients and in 4/20 - 20%- medical patients, with a mortality rate respectively of 23.3% in the surgical group vs. 15% in the control group. Parathyroidectomy was not associated with a reduced risk of cardiovascular morbidity and survival rate was unaffected by surgical treatment. Conclusions: In secondary hyperparathyroidism hemodialysis patients affected by severe cardiovascular disease, surgery did not modify cardiovascular morbidity and mortality rates. Therefore, in secondary hyperparathyroidism hemodialysis patients, resistant to medical treatment, only an early indication to calcimimetics, or surgery, in the initial stage of chronic kidney disease - mineral bone disorders, may offer a higher long-term survival. Further studies will be useful to clarify the role of secondary hyperparathyroidism in determining unfavorable cardiovascular outcomes and mortality in hemodialysis population. © 2013 Conzo et al.; licensee BioMed Central Ltd.

Chordoma of thoracic vertebras is a very rare locally invasive neoplasm with low grade malignancy arising from embryonic notochordal remnants. Radical surgery remains the cornerstone of the treatment. We describe a case of multifocal T1-T2 chordoma, without bone and disc involvement, incidentally misdiagnosed as a paraganglioma, occurring in a 47-year-old male asymptomatic patient. Neoplasm was radically removed by an endocrine surgeon through a right extended cervicotomy. A preoperative reliable diagnosis of chordoma, as in the reported case, is often difficult. Radical surgery can provide a favorable outcome but, given the high rates of local recurrence of this neoplasm, a strict and careful follow-up is recommended. Although very rare, chordoma should be suggested in the differential diagnosis of the paravertebral cervical masses of unknown origin. Spine surgeon consultation and a FNB should be routinely included in the multidisciplinary preoperative work-up of these neoplasms.

In the last decades, a surprising increased incidence of differentiated thyroid cancer (DTC), along with a precocious diagnosis of "small" tumors and microcarcinomas have been observed. In these cases, better oncological outcomes are expected, and a "tailored" and "less aggressive" multimodal therapeutic protocol should be considered, avoiding an unfavorable even if minimal morbidity following an "overtreatment." In order to better define the most suitable surgical approach, its benefits and risks, we discuss the role of surgery in the current management of DTCs in the light of data appeared in the literature. Even if lymph node metastases are commonly observed, and in up to 90 % of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is still argument of intensive research, and indications and extension of lymph node dissection (LD) are still under debate. In particular, endocrine and neck surgeons are still divided between proponents and opponents of routine central LD (RCLD). Considering the available evidence, there is agreement about total thyroidectomy, therapeutic LD in clinically node-positive DTC patients, and RCLD in "high risk" cases. Nevertheless, indications to the best surgical treatment of clinically node-negative "low risk" patients are still subject of research. Considering on the one hand, the recent trend toward routine central lymphadenectomy, avoiding radioactive treatment, and on the other hand, the satisfactory results obtained reserving prophylactic LD to "high risk" patients, we think that further prospective randomized trials are needed to evaluate the best choice between the different surgical approaches.

Introduction Gallstone ileus (G.I.) is a mechanical bowel obstruction due to impaction of a large gallstone within the bowel and represents an uncommon complication of cholelithiasis. It accounts for 1-4% of all cases of mechanical bowel obstruction, up to 25% in patients over 65 years of age. Presentation Of Case A 75 year old male patient was referred to our hospital in March 2009 with clinical signs of bowel obstruction (abdominal pain and distension, post-prandial vomiting, absolute constipation) during the previous 3 days. A plain abdominal film demonstrated dilated bowel loops, air fluid levels and an image of a stone in the inferior left quadrant. Afterwards, diagnosis of Gallstone ileus was made by means of ultrasonography and colonoscopy. The patient underwent emergent laparotomy and a cholecysto-transverse colon fistula was observed. One-stage procedure consisting of enterolithotomy, cholecystectomy and fistula repair was performed. The post-operative course was complicated by a dehiscence of the colic suture with acute peritonitis. Therefore a colostomy was performed, followed by rapid recovery of general clinical conditions. Discussion Surgical treatment for G.I. by cholecysto-enteric fistula is still controversial. Enterolithotomy alone is best suited in all elderly patients with significant comorbidities. One-stage procedure - enterolithotomy, cholecystectomy and fistula repair - should be reserved for young, fit and low risk patients. In our case, mechanical obstruction was associated with a severe cholecystitis with a large fistula between gallbladder and transverse colon. Conclusion A “radical” surgical option could certainly be characterized by a significant morbidity.

Total thyroidectomy (TT) is the standard of care for differentiated thyroid cancer (DTC), but still there is no consensus about the role of routine use of prophylactic central lymph node dissection. The aim of this study was to analyze our results of TT without prophylactic central lymphadenectomy in the treatment of DTC. Clinical records, between January 1998 and December 2005, of 221 patients undergoing TT, without prophylactic central lymph node dissection, were retrospectively evaluated. Two hundred and eleven patients (95.47 %) also underwent radioiodine (RAI) ablation followed by thyroid stimulating hormone (TSH) suppression therapy. In patients with loco-regional lymph nodal recurrence, lateral and central lymph node dissection was performed. The incidence of permanent hypoparathyroidism (iPTH

Authors evaluated the effects of selective adrenergic blockade by means of doxazosin on blood pressure in 48 patients operated on for pheochromocytoma by a multicenter retrospective study. Age, tumor size, surgical approach, and operative time were analyzed as predictive factors of intraoperative hypertensive crises. Forty-eight patients underwent adrenalectomy—four open surgery and 44 laparoscopic surgery—for pheochromocytoma of adrenal glands from 1998 to 2008 after preoperative administration of doxazosin. Perioperative cardiovascular status modifications and surgical medium- and long-term outcomes were analyzed. There was no mortality, conversion rate was 4.5 per cent, and morbidity rate was 8.3 per cent. Intraoperative hypertensive crises (180/ 90 mmHg or higher) were observed in 14.5 per cent (seven of 48) of patients and were treated pharmacologically with no aftermath. None of the examined variables influenced the occurrence of intraoperative hypertensive episodes. Postoperative hypotension (lower than 90/60 mmHg) was observed in four of 48 patients (8.3%) and was treated by crystalloids and hydrocortisone. In the surgical treatment of pheochromocytoma, the preoperative adrenergic blockade by doxazosin does not prevent intraoperative hypertensive crises. Nevertheless, in our series, they were of short duration and were not associated with major cardiovascular complications. Perioperative hemodynamic instability was managed bypreoperative pharmacological treatment, allowing low morbidity.

Background Minimally invasive adrenalectomy for pheochromocytoma (PCC) is a complex surgical procedure especially because of the haemodynamic instability due to the excessive secretion of cathecolamines, which may result in a considerable risk of conversion and complications. Aim By a multicentric retrospective study, the authors reported the results of laparoscopic adrenalectomies in patients operated for adrenal pheochromocytomas with the aim of investigating the role of the laparoscopic approach in managing adrenal disease. Methods Sixty patients, preoperatively treated with a selective alpha1-blocker, underwent 61 laparoscopic adrenalectomies for PCC smaller or larger than 6 cm – group A (≤6 cm), group B (>6 cm). We compared the two groups of patients analyzing haemodynamic instability, operative time, conversion rate, incidence of complications, length of hospital stay and medium and long-term outcomes. Results In 23 cases tumor was >6 cm in diameter. Average operative time was 165 min, with a 5% conversion rate. There was no mortality and morbidity rate was 8.3%. Intraoperative hypertensive crises were registered in 15% of patients, whereas 5/60 patients had hypotensive crises. After comparing the two groups of patients, no statistically significant differences in terms of haemodynamic instability, operative time, conversion rate, morbidity and length of hospital stay were observed. Conclusions As a surgical treatment of pheochromocytomas, laparoscopic adrenalectomy is an effective and safe approach, in selected cases even for PCCs >6 cm in diameter, although patients with such large tumors may have a higher conversion rate and more intraoperative hypertensive crises. Preoperative selective adrenergic blockade does not prevent intraoperative hypertensive crises, but by facilitating the pharmacological management of the perioperative haemodynamic instability, may avoid the onset of major adverse cardiovascular complications.

Background: The significance of nodal metastases, very common in papillary thyroid cancer, and the role of lymph node dissection in the neoplasm management, are still controversial. The impact of lymph node involvement on local recurrence and long-term survival remains subject of active research. With the aim to better analyze the predictive value of lymph node involvement on recurrence and survival, we investigated the clinico-pathological patterns of local relapse following total thyroidectomy associated with lymph node dissection, for clinical nodal metastases papillary thyroid cancer, in order to identify the preferred surgical treatment. Methods. Clinical records, between January 2000 and December 2006, of 69 patients undergoing total thyroidectomy associated with selective lymph node dissection for clinical nodal metastases papillary thyroid cancer, were retrospectively evaluated. Radioiodine ablation, followed by Thyroid Stimulating Hormone suppression therapy was recommended in every case. In patients with loco regional lymph nodal recurrence, a repeated lymph node dissection was carried out. The data were compared with those following total thyroidectomy not associated with lymph node dissection in 210 papillary thyroid cancer patients without lymph node involvement, at preoperative ultrasonography and intra operative inspection. Results: Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and permanent monolateral vocal fold paralysis were respectively 1.4 % (1/69) and 1.4% (1/69), similar to those reported after total thyroidectomy "alone". The rate of loco regional recurrence, with positive cervical lymph nodes, following 8 year follow-up, was 34.7% (24/69), higher than that reported in patients without nodal metastases (4.2%). A repeated lymph node dissection was carried out without significant complications. Conclusions: Nodal metastases are a predictor of local recurrence, and a higher rate of lymph node involvement is expected after therapeutic lymph node dissection associated with total thyroidectomy. The prognostic significance of nodal metastases on long-term survival remains unclear, and more prospective randomized trials are requested to better evaluate the benefits of different therapeutic approaches.

Epidemiological studies have demonstrated that the Mediterranean diet, which is rich in resveratrol, is associated with a significantly reduced risk of cardiovascular disease. However, the molecular mechanisms that underlie the beneficial effects of resveratrol on cardiovascular function remain incompletely understood. Therefore, we set out to identify the molecular target(s) mediating the protective action of resveratrol on vascular function. To this end, we performed vascular reactivity studies to evaluate the effects of resveratrol on superior thyroid artery obtained from 59 patients with hypertension and dyslipidemia. We found that resveratrol evoked vasorelaxation and reduced endothelial dysfunction through the modulation of NO metabolism via (1) an 5′ adenosine monophosphate–activated protein kinase–mediated increase in endothelial NO synthase activity; (2) a rise in tetrahydrobiopterin levels, which also increases endothelial NO synthase activity; and (3) attenuation of vascular oxidative stress, brought about by overexpression of manganese superoxide dismutase via an nuclear factor erythroid–derived 2-like 2–dependent mechanism. The effects of resveratrol on acetylcholine vasorelaxation were also tested in vessels from patients with nonhypertensive nondyslipidemia undergoing thyroid surgery. In this setting, resveratrol failed to exert any effect. Thus, our finding that resveratrol reduces endothelial dysfunction, an early pathophysiological feature and independent predictor of poor prognosis in most forms of cardiovascular disease, supports the concept that the risk of vascular events could be further reduced by adherence to a set of dietary and behavioral guidelines.

Metanephric adenoma (MA) is a rare benign tumor, diagnosis of which is often carried out after surgical treatment. In case of peripheral lesions, a partial nephrectomy (PN)—either open or laparoscopic may be preferred—and, furthermore, a radiofrequency (RF)-assisted procedure may facilitate adequate hemostasis. In November 2010, the authors performed a RF-assisted PN, according to Habib’s technique, using a 4-needle bipolar device, on a woman affected by a small exophytic MA of the right kidney. Fibrin glue was applied on the cut surface. Postoperative course was uneventful, and discharge was on postoperative day 4. MA is an extremely rare benign tumor with a favorable prognosis. In case of a preoperative cytological diagnosis, a careful follow-up has to be considered. PN represents the standard of care for small exophytic MA, and RF-assisted procedures allow an excellent hemostasis and a rapid conservative resection, with very low morbidity.

The Authors present their experience with laparoscopic total or subtotal colectomy (TC or SC) in three patients operated for intractable chronic slow transit constipation (STC), together with a review of literature.From July 2005 to July 2009 three young patients affected by STC, after meticulous preoperative instrumental work-up and after failure of medical treatment, were submitted to laparoscopic TC and ideo rectal anastomosis (IRA) in two cases and to laparo assisted SC followed by Ceco Rectal Anastomosis (CRA) in one case. Number of daily bowel motions, urgency soiling, incontinence, abdominal pain, bloating with special regard to patient's quality of life, were analyzed.All the interventions were completed via laparoscopic approach. No postoperative morbidity or mortality were observed. After twelve months, the patients referred two-three daily evacuation of soft stool, with a good continence and disappearance of abdominal pain and other relatives symptoms. They reported excellent satisfaction with the surgical results and a significant improvement of their quality of life.TC with IRA and CRA after SC represent the most effective and widely used surgical operations in the treatment of STC, in well selected patients, after failure of conservative treatment. According to Literature data, and in our experience, no significant differences in terms of postoperative morbidity or mortality neither in quality of life were observed between the two operations. It is well demonstrated the feasibility of the laparoscopic approach in treatment of colorectal pathologies with typically advantages of less invasive surgery, respect of parietal integrity, less postoperative pain and ileus, fewer postoperative adhesions, a reduced hospitalisation and finally a better cosmesis.Laparoscopic TC and IRA and CRA after laparo assisted SC represent efficacious operations in the treatment of STC offering a good postoperative quality of life and reduced morbidity compared to open surgery.

At the end of 1980’s, the introduction of mininvasive surgery in clinical practice represented a significant achievement of science and technology research, and laparoscopic cholecystectomy (LC) is nowadays considered a gold standard in the treatment of symptomatic cholelithiasis, according to well known and acknowledged advantages. Although experience is essential to avoiding rates of morbidity in any surgical procedure, in LC the effect of the learning curve does not seem to be the most important factor in minimizing the possibility of iatrogenic bile duct injuries (IBDI) because most of them are related to anatomic misdiagnoses and lapses from basic principles of biliary surgery. IBDI are still a severe complication of biliary surgery, characterized by high morbidity and in some cases significant mortality, often due to the onset of septic complications. They cause a costs rise, related to diagnostic and therapeutic procedures, and they are often associated with distressing litigations, frustrating for surgeons. Factors that may be related to IBDI include certain pitfalls believed to be inherent in the laparoscopic approach: the two-dimensional view and the absence of tactile sensation. However, an analysis of literature until 2005 shows that the “mini-invasive” approach is related to a higher incidence of iatrogenic bile duct injuries (IBDI), both of the main and accessory bile ducts. In 2002 Nuzzo (Nuzzo, 2002), by the means of an Italian survey, proved a three times higher incidence of IBDI than in open cholecystectomy (OC), showing about 300 bile duct injuries out of every 100000 cholecystectomies per year in Italy, pointing out in that country a considerable mortality, in most of cases related to sepsis, with a significant rise of morbidity and healthcare costs ensuing from hospital stay, instrumental investigations, and medium and long-term clinical follow-up. Moreover, IBDI are reported to have late severe aftermath, causing the surgeon frustration and expensive litigation. After accomplishing a learning curve for mini-invasive approach, led by an experienced surgeon, the most significant etiopathogenetic factors of IBDI are the misidentification of the main biliary tree (BT) and wrong manoeuvres to manage bleedings. Treatment of IBDI requires a multidisciplinary approach – namely endoscopy, interventional radiology and surgery – in referral centres

In the surgical treatment of secondary hyperparathyroidism (2HPT) of chronic kidney disease (CKD), a parathyroidectomy (PTx) of 4 glands can only be presumed as 'total', and indications for autoimplantation are complex. Intraoperative rapid parathyroid hormone assay could be useful to predict a radical resection. We evaluated iPTH levels 20 min and 24 h after a 4-gland PTx in 35 patients to determine the predictive value of intraoperative iPTH assay. We analysed retrospectively 35 patients affected by 2HPT of CKD, 13 undergoing total parathyroidectomy (TP) and 22 TP + autoimplantation (TPai), after removing 4 glands in 33 cases and 5 glands in 2. Intact PTH assays were acquired after 40 min before induction of anaesthesia, after removing both ipselateral glands, at 20 min after surgery and on postoperative day 1. 20 min after 4-gland PTx, a decrease of iPTH levels >80 % of the preoperative value was observed in 27 of 35 cases (77.1 %) and 80 % of the preoperative value was observed in 27 of 35 cases (77.1 %) and < 80 % in 8 of 35 cases (22.8 %). In 6 of these 8 patients, iPTH levels were within the normal range 24 h after surgery. Although the intraoperative iPTH assays are of interest in the treatment of 2HPT, the predictive value of this method is not entirely satisfactory. In fact, a 4-gland PTx ensures euparathyroidism in most cases, even when intraoperative iPTH assays are not trustworthy; however, intraoperative iPTH assay, although not a perfect 'tool', is a proved aid for the surgeon in making his decision.

• Introduction In the treatment of secondary hyperparathyroidism (2HPT) of chronic kidney disease (CKD), calcimimetics, allosteric modulators of the calcium sensing receptor, inhibit glandular hyperplasia, and reduce significantly circulating parathyroid hormone (PTH) levels, showing a major impact on 2HTP management. • Case presentation We present the clinical case of a 41 years old Caucasian male, chronic haemodialysis (HD) patient, who underwent parathyroidectomy (PTx) for severe 2HPT resistant to cinacalcet (C) treatment. Preoperatively, 24 months after high dose C, a persistently elevated intact PTH serum level was observed, while a clear parathyroid gland hyperplasia regression was detected with ultrasound. Finally, a ”presumed total” 3 gland PTx, associated with hemythyroidectomy, was performed, followed by a hypoparathyroid state. Histopathological examination showed that the removed parathyroid glands were of small size, for a total weight of 1 gr, associated with a multifocal small papillary thyroid cancer. • Conclusion In management of 2HPT, C effectively reduces total parathyroid gland hyperplasia; however, persisting elevated iPTH serum level may be observed, demonstrating that reduced parathyroid hyperplastic tissue may be still associated with severe 2HPT. Even if calcimimetics are very effective in 2HPT treatment, further studies are necessary for a better understanding of their actions. Introduction. In the treatment of secondary hyperparathyroidism of chronic kidney disease, calcimimetics - allosteric modulators of the calcium-sensing receptor - inhibit glandular hyperplasia and significantly reduce circulating parathyroid hormone levels. They have a major impact on the management of secondary hyperparathyroidism. Case presentation. We present the clinical case of a 41-year-old Caucasian man undergoing chronic hemodialysis, who had a parathyroidectomy to treat severe secondary hyperparathyroidism resistant to cinacalcet treatment. Preoperatively, 24 months after high-dose cinacalcet hydrochloride, we observed a persistently elevated intact parathyroid hormone serum level, and detected clear parathyroid gland hyperplasia regression on ultrasound. We performed a three-gland parathyroidectomy, which was assumed to be total, associated with a hemithyroidectomy. Our patient then entered a hypoparathyroid state. A histopathological examination showed that the removed parathyroid glands were of small size, with a total weight of 1g, associated with a multifocal small papillary thyroid cancer. Conclusion: In the management of secondary hyperparathyroidism, cinacalcet hydrochloride effectively reduces total parathyroid gland hyperplasia. However, a persisting elevated intact parathyroid hormone serum level may be observed, demonstrating that reduced parathyroid hyperplastic tissue may still be associated with severe secondary hyperparathyroidism. Even if calcimimetics are very effective in secondary hyperparathyroidism treatment, further studies are necessary for a better understanding of their actions. © 2012 Conzo et al.; licensee BioMed Central Ltd.

Cutaneous melanoma is found in the head and neck in 15% of patients, in the limbs in 22%, in the trunk in 40% and in occult sites in 16%. There is usually an interval of at least 3 years between the diagnosis of primary melanoma and the identification of metastases. Primary melanoma metastasizes most frequently to the lymph nodes (73.6% cases) and the lungs (71.3% cases). The small intestine and the spleen are the sites of 36.5% and 30.6% respectively of the gastrointestinal metastases from melanoma. The cases reported provide evidence of the effect radical resection in patients with gastrointestinal metastases can have on survival. The cases and a review of the literature suggest that a careful and multidisciplinary follow-up is of crucial importance since it is the only means of identifying metastases when they can be still cured with surgical treatment.

The Authors report the case of a 9-year-old girl suffering from acute abdominal pain, combined with mild anaemia (Hb 10.9 g/dL), leukocytosis (24.3 x 10(3) cells/dL), and a large palpable mass in the upper left quadrant. The child underwent an appendectomy 20 days before the admission to our Department. The operation performed in urgency, as well as the removal of a bulky mass situated in the left flank and the right ovary whence it arose, made it clear that abdominal signs and symptoms were caused by the twisting and rupturing of a neoformation, that would hence cause an impressive hemoperitoneum. The histopathologic examination showed a three-germ layer mature mixed teratoma. Clinical, radiologic and biochemical test (alpha-FP, beta-hcG) performed in a postoperative 2 months follow-up revealed no residual disease.

A 21-year-old girl arrived at our hospital with a short history of hirsutism, facial pletora, amenorrhea, progressive weight gain and hypertension. The clinically suspected Cushing syndrome was then confirmed through chemical pathology. In fact, the results from hemato-chemical exams were: 45.5 Ig/dl cortisol, a DHEA sulphate8000 ng/ml, 7.2 pg/ml ACTH, 17OH-Progesterone 10.66 ng/ml, Delta-4 Androstenedione 5.2 ng/ml, UFC (Urine Free Cortisol)1000 mg/24h, FSH 0.8 mUI/ml, LH0.1 mUI/ml, Prolactin 13, 17, estradiol 96 pg/ml, and a bonded hypokalaemia, K+ 2,4 mEq/L. The echogram of the complete abdomen reveals, near the superior pole of the left kidney, the presence of a solid mass, not independent from the pole itself about 9.5 centimetres long, diagnosis confirmed to the TC abdomen and pelvis too, with or without mdc. This removed mass resulted, from the histological exam, in an adrenal carcinoma with a general and trabecular structure. Primal adrenal tumours are responsible for about 10% of Cushing syndrome cases. They present an annual incidence of 0.5 - 2.0 cases per million of inhabitants. The prognosis of adrenal ca remains low, with 5 year survival rate for 38% of diagnosed patients.

In spite of numerous studies on the subject, it is still unclear whether or not high ligation of the inferior mesenteric artery (at about 1 cm from its origin) improves the 5-year survival rate in patients operated on for colorectal cancer in comparison to low ligation (ligation below the origin of the left colic artery). From February 2000 to November 2001 40 patients with cancer of the colic segment between the descending sigmoid junction and the low rectum underwent surgical colorectal resection and low ligation of the inferior mesenteric artery. At the end of 5 years of observation we report a survival rate of 70% which is not very far from the value reported in the literature. In our study, the incidence of lymph-node metastases, inexistent in patients with T1 grading increases with the increase in the TNM T grading but does not depend on the location of the cancer. In our patients age below 65 years was a negative prognostic indicator because colorectal tumours in patients of that age are associated with a higher incidence of lymph-node metastases. On the basis of the data we obtained, it is also evident that the 5-year survival rate decreases in proportion to the increase in the distance of the lymph-node metastases from the mesenteric margin of the colon. In conclusion, in the treatment of cancers located between the descending sigmoid junction and the low rectum, we prefer to execute a low ligation of the inferior mesenteric artery because it exposes the patient to a lower risk of intra- and postoperative complications and also because several authors have demonstrated that high ligation with removal of lymph nodes at the origin of the artery for colorectal cancer does not improve the 5-year survival rate.

Recently, the incidence of gastric cancer and the related percentage of mortality have been decreasing world-wide, especially in the industrialised countries. Surgery has commonly been opted for as primary treatment of this disease. However, the optimal extent of surgical intervention is still debated. Japanese surgeons have been the pioneers of perigastric and celiac tripod lymphadenectomies in an attempt to improve long-term survival and the postoperative disease-free period. In recent years, D2 resection has been compared with D1 resection, which consists in excision of the stomach along with its locoregional nodes. From March 2002 to January 2007, 70 interventions for gastric cancer were performed at the VII Division of General Surgery of the Second University of Naples. All patients underwent excision of the lymph nodes from stations 1 to 6 (D1) combined with excision of stations 7 to 12 (D2). In 32 cases (45.7%) there were no metastatic lymph nodes (NO), in 28 patients (40%) 1 to 6 nodes proved metastatic (N1), and in 10 cases (14.3%) from 7 to 15 nodes were metastasised (N2). The incidence of metastatic lymph nodes was 54.3% and the prevalence 13.6%. Metastatic lymph nodes were found mostly in T3 (15/24) and T4 (14/20) stage tumours rather than in T1 (3/12) and T2 (6/14) neoplasms. Two patients (2.86%) died within 60 days of the intervention. The overall postoperative morbidity and mortality rates were 21.43% and 2.86%, respectively. D2 gastrectomies without pancreatic resections present distinct advantages in terms of long-term survival and are associated with postoperative morbidity and mortality rates which are similar to those obtained after D1 node resection.

The authors report on a case of fibro-leiomyoma of the upper oesophagus. The patient presented dysphagia and oppressive retrosternal pain. Computed tomography and magnetic resonance of the thorax revealed a solid voluminous formation at the level of the posterior upper mediastinum. The US-endoscopy showed that this was a tumour originating from the esophageal wall with macroscopic characteristics of benignity, suggestive of a leiomyoma. The patient was treated by thoracotomy enucleation of the large tumour after sectioning the azygous vein on the same side as the lesion. Histological examination of the surgical resection confirmed that the tumour was a fibro-leiomyoma of the esophagus with a conspicuous vascular component and an interstitial inflammatory focus. The patient now appears to be asymptomatic and illness-free.

From February 2002 to December 2005, 424 operations for thyroid disease were performed in our institute. Twenty-two patients were suffering from Basedow's disease, 14 female and 8 male, mean age 36 years (range: 23 to 53 years). In each patient the diagnosis of Basedow's disease was made according to common clinical and laboratory criteria, by evaluation of the thyroid hormones, TSH and TRAB. Before operation all patients were rendered euthyroid with antithyroid drug treatment. Fourteen total thyroidectomies (64%) and 8 near-total thyroidectomies (36%) were performed. Postoperative thyroid function status was evaluated before, 3-4 weeks after the operation and then 3, 6,12 and 24 months postoperatively. The patients were classified as euthyroid (FT3-FT4 and TSH normal), hypothyroid (FT3 and/or FT4 reduced and TSH increased), or hyperthyroid (FT3-FT4 increased). In expert hands, surgical treatment appears to be capable of curing the hyperthyroidism of Basedow's disease effectively, with a very low and largely acceptable risk of complications. Among the different types of surgery, total thyroidectomy and near-total thyroidectomy are equally appropriate to ensure there is no risk of recurrence of hyperthyroidism.

Encrustation constitutes a serious complication of ureteral stent use and can result in difficult stent removal. We report the case of a patient with a retained ureteral stent for 3 years following a radical cystectomy.

To investigate whether the addition of iodized salt to daily diet in thyroidectomized patients for nontoxic goitre could influence the effectiveness of nonsuppressive L-thyroxine (L-T4) therapy on thyroid remnant size, during 12 months' follow-up after thyroid surgery.A consecutive series of selected 139 patients (26 males, 113 females; median age 45 years, range 30-69 years) living in a moderate iodine-deficient area, and undergoing thyroid surgery for nontoxic multinodular goitre, was enrolled. Patients were assigned randomly to two different therapeutic regimens: 70 patients received L-T4 therapy alone (Gr. L-T4), while the remaining 69 patients took iodized salt on a daily basis in addition to L-T4 treatment (Gr. L-T4 + I). In both groups, the initial L-T4 dose was 1.5 microg/kg/day, which, in our experience, has been shown to be intermediate between suppressive and replacement doses. To avoid the risks of mild thyrotoxicosis and to limit the excessive TSH stimulation of the thyroid remnant, the L-T4 dose was adjusted in those patients with serum TSH levels outside the lowest two-thirds of the normal range (0.3-2.5 mU/l). An ultrasound evaluation of thyroid remnant size was performed after thyroid surgery and 12 months later.After surgery, the median thyroid remnant volume was 3.5 ml (range 0.4-13.9 ml) in Gr. L-T4 and 4.6 ml (range 0.5-12.7 ml) in Gr. L-T4 + I (P = 0.06). After 1 year of follow-up, the patients treated with L-T4 + I obtained a remnant volume reduction (-39.7%, range -87.0% to +91.2%) significantly (P = 0.006) greater than that observed in patients assuming L-T4 alone (-10.2%, range -89.4% to +85.0%). However, the percentage of patients showing an increase in remnant size in the months following surgery was higher in Gr. L-T4 than in Gr. L-T4 + I (22/60 vs. 9/66; P = 0.01). In Gr. L-T4 patients the thyroid remnant volume variation throughout 12 months of treatment was correlated significantly with the size of the thyroid remnant found at the first ultrasound evaluation (R(2) = 0.3; P0.001). No such correlation was found in Gr. L-T4 + I patients, for whom the therapy maintains a similar effectiveness in patients with either a large or a small postsurgery thyroid remnant. In patients treated with L-T4 alone, the remnant volume variation was correlated significantly with the median serum TSH values attained in the course of treatment (R2 = 0.4; P0.001). The highest reduction in remnant volume was observed only by lowering the serum TSH concentrations. In patients treated with L-T4 plus iodine, instead, the thyroid remnant volume reduction occurred independently of the plasma TSH levels attained in the course of treatment.Our short-term prospective and randomized study leads us to conclude that, in patients living in a moderate iodine-deficient area and undergoing thyroid surgery for nontoxic goitre: (1) the iodine prophylaxis improves the effects of postsurgery nonsuppressive L-T4 therapy on thyroid remnant size. (2) In patients treated with L-T4 alone the therapeutic effectiveness decreases in the presence of a large postsurgery thyroid remnant. With the addition of iodine, the L-T4 maintains a similar efficacy in patients with either a large or a small remnant. (3) During treatment with L-T4 alone the highest therapeutic effectiveness is attained by lowering the plasma TSH concentration. With the addition of iodized salt to the daily diet the effects of L-T4 on remnant size are relevant independently of the TSH levels.

Repeated anastomotic recurrence (AR) of colonic cancer is uncommon. We report a case of a double-isolated AR after sigmoidectomy. In 2003, a 60-year-old woman underwent stapled sigmoid resection for a moderately differentiated adenocarcinoma. Further rectal bleeding occurred after six months, and colonoscopy detected an AR. Thus, an additional stapled colorectal anastomosis was performed. Ten months later, a colonoscopy detected a circumferential AR that prompted the completion of a second colorectal resection, with a double-stapled colorectal anastomosis. Twenty-four hours after surgery, a massive pulmonary embolism occurred, and the patient died within a few hours. At present, only six cases of repeated isolated AR have been described. Repeated segmental colorectal resections are generally associated with a favourable prognosis, with a median survival rate of 45 mo (range, 13-132 mo). Repeated isolated ARs are rare, and segmental colorectal resections are generally associated with long-term disease-free survival.