Barbara Mullineris

Laparoscopic distal pancreatectomy: results on a consecutive series of 58 patients.

Objective:To describe the clinical characteristics, indications, technical procedures, and outcome of a consecutive series of laparoscopic distal pancreatic resections performed by the same surgical team. Summary Background Data:Laparoscopic distal pancreatic resection has increasingly been described as a feasible and safe procedure, although accompanied by a high rate of conversion and morbidity. Methods:A consecutive series of patients affected by solid and cystic tumors were selected prospectively to undergo laparoscopic distal pancreatectomy performed by the same surgical team. Clinical characteristics as well as diagnostic preoperative assessment and intra- and postoperative data were prospectively recorded. A follow-up of at least 3 months was available for all patients. Results:Fifty-eight patients underwent laparoscopic resection between May 1999 and November 2005. All procedures were successfully performed laparoscopically, and no patient required intraoperative blood transfusion. Splenic vessel preservation was possible in 84.4% of spleen-preserving procedures. There were no mortalities. The overall median hospital stay was 9 days, while it was 10.5 days for patients with postoperative pancreatic fistulae (27.5% of all cases). Follow-up was available for all patients. Conclusions:Our experience in 58 consecutive patients was characterized by the lack of conversions and by acceptable rates of postoperative pancreatic fistulae and morbidity. Laparoscopy proved especially beneficial in patients with postoperative complications as they had a relatively short hospital stay. Solid and cystic tumors of the distal pancreas represent a good indication for laparoscopic resection whenever possible.

Secondary and Tertiary Hyperparathyroidism: Causes of Recurrent Disease After 446 Parathyroidectomies

ObjectiveTo determine, in a series of patients with secondary and tertiary parathyroid hyperplasia, whether the type of parathyroidectomy (subtotal, total with autotransplantation, or total), the histologic pattern of the parathyroid tissue, or the proliferative index, as determined by Ki-67 analysis, could predispose patients to recurrent hyperparathyroidism. Summary Background DataRecurrent hyperparathyroidism appears in 10–70% of the patients undergoing surgery for secondary or tertiary hyperparathyroidism. The incidence could be related to the type of operation (Rothmund) but also depends on the histologic pattern of the glands removed (Niederle). MethodsThe retrospective investigation was performed on 446 patients undergoing parathyroid surgery. They were also studied in relation to the possibility of renal transplantation. In this population, two homogeneous groups were subsequently identified (23 patients with clear signs of recurrence and 27 patients apparently cured); they were studied from the histologic and immunohistochemical point of view using antibody to Ki-67 antigen. ResultsSubtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy produced similar results when considering the regression of osteodystrophy, pruritus, and ectopic calcification. As one could anticipate, tota1parathyroidectomy increased the incidence of hypoparathyroidism. The percentage of recurrence was 5% to 8% after subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy, and only after incomplete parathyroidectomy did this percentage climb to 34.7%. In the recurrence group, the nodular form was more common and the proliferative fraction detected by Ki-67 was 1.9%; it was 0.81% in the control group. ConclusionsBecause more radical procedures were not more effective, the authors favor a less radical procedure such as subtotal parathyroidectomy. Histologic patterns and proliferative fraction could be useful indices of a recurrence, and these patients should be watched closely after surgery.

Optimizing efficacy of quick parathyroid hormone determination in the operating theater

The usefulness of intraoperative parathyroid hormone (PTH) monitoring has been extensively documented in primary hyperparathyroidism (HPT), whereas few data have been published on its use in reoperations or in secondary and tertiary HPT. We report our initial experience with a rapid (12 min response) PTH immunochemiluminometric assay performed in the operating room during surgery in 12 patients with primary HPT, 16 end-stage renal disease patients with secondary HPT and five kidney transplanted subjects with tertiary HPT. Blood samples were taken at baseline, within 10 min after resection and subsequently at various intervals whenever needed. The mean PTH levels before and after parathyroidectomy were 230.5 pg/mL (range 69–842) and 47.3 pg/mL (range 5–184), respectively, in primary HPT, 855.0 pg/mL (416–1655) and 202.2 pg/mL (53–440) in secondary HPT, and 205.6 pg/mL (116–301) and 45.4 pg/mL (18–97) in tertiary HPT. All patients but one had a significant percentage decline from pre-excision values (mean 76.9%, 76.0%, and 76.1% in primary, secondary and tertiary HPT, respectively). While a reduction of more than 50% was observed in 30 out of 33 patients after the first intraoperative sampling, additional measurements were performed in 10 cases. On-site PTH monitoring with this user-friendly and reliable system has proved helpful in targeting PTH tests to give the surgeon a rapid and accurate assessment of the intervention. The development of optimal PTH sequence strategies with decision-focused analytical and clinical limits will improve the efficacy of “point-of-care” PTH assay and resource utilization.

Zenker diverticulectomy: first report of robot-assisted transaxillary approach.

Standard surgical treatment of Zenker’s diverticulum consists of open cricopharyngeal myotomy with diverticulectomy. A rigid or flexible endoscopic approach allowing a cricopharyngeal myotomy without diverticulectomy is currently considered as a less invasive alternative to open surgery with reportedly comparable symptom relief at short term follow-up. In recent years, high safety and efficacy of a transaxillary gasless robotic access to the thyroid gland has been shown. The present study describes the feasibility and preliminary results of robot-assisted transaxillary approach for cricopharyngeal myotomy and excision of Zenker’s diverticulum. Patients with troublesome dysphagia and radiological evidence of Zenker’s diverticulum underwent a robot-assisted cricopharyngeal myotomy and diverticulum excision using left transaxillary access with the support of endoscopic assistance. One month after intervention, symptoms were reevaluated and a barium swallow study was performed. Four patients with symptomatic Zenker’s diverticulum were successfully operated. No adverse event was recorded. One month after intervention, total dysphagia remission was declared by all four patients and there was no evidence of diverticulum recurrence at radiology. According to our preliminary data, left transaxillary robot-assisted approach for the surgical management of Zenker’s diverticulum is feasible, safe and effective. Whether our encouraging results will be confirmed in larger patient cohorts with prolonged follow-up, the robot-assisted transaxillary Zenker’s diverticulectomy may represent an alternative to traditional open diverticulectomy when endoscopic interventions cannot be performed or have failed.

Modifications of transaxillary approach in endoscopic da Vinci-assisted thyroid and parathyroid gland surgery

Endoscopic surgery for treatment of thyroid and parathyroid pathologies is increasingly gaining attention. The da Vinci system has already been widely used in different fields of medicine and quite recently in thyroid and parathyroid surgery. Herein, we report about modifications of the transaxillary approach in endoscopic surgery of thyroid and parathyroid gland pathologies using the da Vinci system. 16 patients suffering from struma nodosa in 14 cases and parathyroid adenomas in two cases were treated using the da Vinci system at the ENT Department of Homburg/Saar University and in cooperation with the Department of General Surgery in New Sant’Agostino Hospital, Modena/Italy. Two different retractors, endoscopic preparation of the access and three different incision modalities were used. The endoscopic preparation of the access allowed us to have a better view during preparation and reduced surgical time compared to the use of a headlamp. To introduce the da Vinci instruments at the end of the access preparation, the skin incisions were over the axilla with one incision in eight patients, two incisions in four patients and three incisions in a further four patients. The two and three skin incisions modality allowed introduction of the da Vinci instruments without arm conflicts. The use of a new retractor (Modena retractor) compared to a self-developed retractor made it easier during the endoscopic preparation of the access and the reposition of the retractor. The scar was hidden in the axilla and independent of the incisions selected, the cosmetic findings were judged by the patients to be excellent. The neurovascular structures such as inferior laryngeal nerve, superior laryngeal nerve and vessels, as well as the different pathologies, were clearly 3D visualized in all 16 cases. No paralysis of the vocal cord was observed. All patients had a benign pathology in their histological examination. The endoscopic surgery of the thyroid and parathyroid gland can be performed using the da Vinci system and offers an excellent, intra-operative, 3D visualization of the neurovascular structures. The new incision modalities, use of a new retractor, and endoscopic preparation of the access made the surgery easier and safer using the transaxillary access to the thyroid and parathyroid glands. The modified skin incisions allowed an improved movement of the da Vinci arms during operation.

Zenker Diverticulum Treatment

Zenker’s diverticulum (ZD), first observed by Ludlow in 1769 [1], became widely known after it was described by Zenker and von Ziemssen [2] in 1878. The anatomy of ZD was described in detail by Killian in 1908.

Transaxillary Thyroidectomy and Parathyroidectomy

In the last ten years, minimally invasive approaches have increased their applications in neck surgery.

Well-Differentiated Carcinomas of the Thyroid Gland and Neoplasms of the Parathyroid Glands

Papillary carcinoma and follicular thyroid carcinoma, called well-differentiated carcinomas (WDCs) of the thyroid gland, account for ≈1% of human cancers, with an incidence between 0.5 and 10 per 100,000 per year, and increasing steadily. The increasing incidence is probably due to the early diagnosis of the subclinical disease (i.e., of papillary microcarcinomas) even though the SEER analysis conducted in 2009 by the National Cancer Institute showed an increase in well-differentiated tumors of the thyroid gland irrespective of size, including tumors > 4 cm in diameter [1]. Despite the steady increase in prevalence observed in the last few decades, the mortality from thyroid carcinoma is gradually decreasing. Survival data at 30 years after diagnosis indicate that the overwhelming majority of patients with papillary or follicular carcinoma are alive as a result of early diagnosis and multidisciplinary treatment programs.

Laparoscopic Pancreatic Surgery: What Have We Learnt in 10 Years?

The first great lesson we learned is that to achieve the best results you need skills and enthusiasm. Ten years ago two great Schools joined efforts to start a wonderful adventure: the Verona University school of pancreatic surgery, directed by Professor Paolo Pederzoli, and the Modena Hospital school of laparoscopic surgery, directed by Professor Gianluigi Melotti. This made it possible to standardize technique, to achieve very good results, and to specify indications and contraindications. Once again, Italy had climbed to the top of the international literature.

Chirurgia dell'IPT primitivo

RiassuntoIn questi ultimi anni, oltre alla strategia chirurgica tradizionale, che comporta una cervicotomia classica di 8–10 cm con riconoscimento di tutte e quattro le paratiroidi, asportazione dell’adenoma e biopsia di una paratiroide apparentemente normale, si sono sviluppate, grazie essenzialmente all’introduzione nella pratica clinica del dosaggio rapido intraoperatorio del paratormone, la chirurgia mininvasiva (MIP), la chirurgia videoassistita e videoscopica e la chirurgia radioguidata. La percentuale di successo dell’intervento chirurgico si assesta sul 95–99% in mani esperte, le paralisi ricorrenziali sono intorno allo 0,4% e l’ipoparatiroidismo definitivo è pari allo 0,2%. Dopo l’intervento in presenza di una modesta ipocalcemia sintomatica sono sufficienti supplementi di calcio e di vitamina D in forma attiva in grado di incrementare l’assorbimento intestinale del calcio. I pazienti sottoposti a intervento di paratiroidectomia per iperparatiroidismo primitivo necessitano di un follow-up di almeno 5 anni. La presenza di un centro di chirurgia endocrina dove poter studiare, operare e seguire i pazienti è un requisito importante per migliorare la qualà dei servizi offerti ai pazienti.