Domenico Giannotti

Play to Become a Surgeon: Impact of Nintendo WII Training on Laparoscopic Skills

Background Video-games have become an integral part of the new multimedia culture. Several studies assessed video-gaming enhancement of spatial attention and eye-hand coordination. Considering the technical difficulty of laparoscopic procedures, legal issues and time limitations, the validation of appropriate training even outside of the operating rooms is ongoing. We investigated the influence of a four-week structured Nintendo® Wii™ training on laparoscopic skills by analyzing performance metrics with a validated simulator (Lap Mentor™, Simbionix™). Methodology/Principal Findings We performed a prospective randomized study on 42 post-graduate I–II year residents in General, Vascular and Endoscopic Surgery. All participants were tested on a validated laparoscopic simulator and then randomized to group 1 (Controls, no training with the Nintendo® Wii™), and group 2 (training with the Nintendo® Wii™) with 21 subjects in each group, according to a computer-generated list. After four weeks, all residents underwent a testing session on the laparoscopic simulator of the same tasks as in the first session. All 42 subjects in both groups improved significantly from session 1 to session 2. Compared to controls, the Wii group showed a significant improvement in performance (p<0.05) for 13 of the 16 considered performance metrics. Conclusions/Significance The Nintendo® Wii™ might be helpful, inexpensive and entertaining part of the training of young laparoscopists, in addition to a standard surgical education based on simulators and the operating room.

Diagnostic Accuracy and Interobserver Agreement of Quasistatic Ultrasound Elastography in the Diagnosis of Thyroid Nodules

PURPOSE To assess the best technique and the diagnostic accuracy of Quasistatic Ultrasound Elastography (QUE) in thyroid nodules. Interobserver agreement was also evaluated. MATERIALS AND METHODS A preliminary study of 50 patients with 54 thyroid nodules was performed with quantitative software in order to define the best cut-off value of different imaging methods. All patients underwent total thyroidectomy and histopathology findings served as the standard of reference. Thereafter, 154 nodules in 137 consecutive patients were prospectively evaluated by three operators. Findings at fine-needle aspiration cytology and histopathology (N = 60) served as the standard of reference. RESULTS The most accurate technique was the axial peri-intranodular measurement method which achieved an area under the ROC curve of 0.961 (95 %CI 0.848 - 1.00) and had an optimal cut-off value of 3.00. QUE in the differentiation of thyroid nodules showed for operator 1: sensitivity 90 % (95 %CI 73.5 - 97.9 %), specificity 92.7 % (95 %CI 86.7 - 96.6 %), LR+ 12.40 (6.54 - 23.50), LR- 0.11 (0.04 - 0.32) and accuracy 91.4 % (95 %CI 85.4 - 97.3 %); for operator 2: sensitivity 86.7 % (95 %CI 69.3 - 96.2 %), specificity 87.1 % (95 %CI 79.9 - 92.4 %), LR+ 6.72 (4.16 - 10.80), LR- 0.15 (0.06 - 0.38) and accuracy 86.9 % (95 %CI 80.0 - 93.7 %); for operator 3: sensitivity 80 % (95 %CI 61.4 - 92.3 %), specificity 83.9 % (95 %CI 76.2 - 89.9 %), LR+ 4.96 (3.20 - 7.70), LR- 0.24 (0.12 - 0.49) and accuracy 81.9 % (95 %CI 74.0 - 89.9 %). Interobserver agreement values between operator 1 and operator 2 (k = 0.79) (p < 0.05, 95 %CI 0.684 - 0.904), between operator 1 and operator 3 (k = 0.73, 95 %CI: 0.607 - 0.854) and between operator 2 and operator 3 (k = 0.71, 95 %CI: 0.584 - 0.835) were significant. CONCLUSION QUE provides accurate quantitative evaluation of thyroid nodules with low interobserver variability.

Fibroblast Growth Factor Receptor-2 Expression in Thyroid Tumor Progression: Potential Diagnostic Application

Fibroblast growth factor receptor-2 (FGFR-2) plays an important role in tumorigenesis. In thyroid cancer it has been observed a FGFR-2 down-modulation, but the role of this receptor has not been yet clarified. Therefore, we decided to examine the expression of both FGFR-2 isoform, FGFR-2-IIIb and FGFR-2-IIIc, in different histological thyroid variants such as hyperplasia, follicular adenoma and papillary carcinoma. Immunohistochemistry and quantitative Real-Time PCR analyses were performed on samples of hyperplasia, follicular adenoma and papillary carcinoma, compared with normal thyroid tissue. Thyroid hyperplasia did not show statistically significant reduction in FGFR-2 protein and mRNA levels. Interestingly, in both follicular adenoma and papillary carcinoma samples we observed a strongly reduced expression of both FGFR-2 isoforms. We speculate that FGFR-2 down-modulation might be an early event in thyroid carcinogenesis. Furthermore, we suggest the potential use of FGFR-2 as an early marker for thyroid cancer diagnosis.

Recurrent differentiated thyroid cancer: to cut or burn

The term “relapse carcinoma” is used improperly to indicate either a local or loco-regional relapse or a systematic metastatsis [1]. Local relapse (LR) after thyroidectomy for cancer is “the repetition of the neoplastic lesion in proximity of the previous intervention of excision” [2]. According to Duren [3] relapses of thyroidal carcinoma need to be classified as: local (LR): that may present itself in the residual thyroid lobe or in the thyroid bed where surgery was performed; loco-regional (RLR): that may present in the cervical lymph nodes of the central compartment or lateral-cervical nodes; and metastasis in distance (MD). The MD are frequently synchronous with LR or RLR; they have haematogenous genesis and concern most frequently the lungs and skeleton. There is controversy over how to catergorize the relapse in the thyroidal bed with infiltrations of neighbouring organs (periodontal structures muscles, thyroidal cartilage, cricoid, laryngeal nerves, etc. and the neighbouring organs oesophagus, trachea, larynx). As per the classification proposed by Duren [3] these should be considered as LR, whereas according to Mozzillo and Pezzullo [1] they are categorised as RLR. The RLR at the level of the cervical lymphnodal stations represents an ulterior problem: are these true relapses, residual cancer, or recurrence in progression? Caraco [4], in his report to the ninety-fourth Congress of the Italian Society of Surgery, specified that local recurrences are only those recurrences that are characterized by the appearance of neoplastic tissue in the thyroidal lodge, in the residual parenchyma, and in the adjacent structures, excluding the lymph nodes [5,6]. In nearly 53% of cases the relapse is reported in RLR, in 28% in LR, and in 13% the MD is present of these 6% of cases have mixed relapses [7]; the prognosis of LR is however, better than that of the others [8]. The differentiated tumors of the thyroid are slow growing and due to this rarely reach notable dimensions or result in metastasis in lymph and/or haematic systems [2]. Only 10% of patients die from differentiated thyroid cancer [9]. Most of the local relapses occur within the first five years of the excision of the primary cancer [5,6,10-12], however, the recurrence can occur as late as 20 years after the initial diagnosis and treatment [13]. An accurate evaluation of incidence of LR is possible solely with a considerable number of treated patients and lengthy follow-up that is not available at most centres and hence this kind of information can be obtained from the date from centres that have high volume of thyroid carcinoma and good follow-up like Mayo Clinic or Lahey Clinic [5,6,13] or through observational studies at several other medical centres [14]. Currently relapses represent a rare event in patients who undergo removal of thyroidal carcinoma (3-13%) [5,6,10-12,15-17]. This is due to the ever increasing frequency of total thyroidectomy for management of cancer [18]. The complete excision of the thyroidal parenchyma prevents local recurrence. Giovanni Razzaboni in “Treatise on Prognostic Surgery” (1938) stated that “The most rational operating method, so long as not free from grave consequences of another kind, remains the total extra-capsular thyroidectomy, so as is used, when possible, for the surgical removal of whatever other tumour” [19]. he further emphasized in his work published after his death in 1956 entitled “Treatise on Clinical Therapeutic Surgery” that “Only an removal of this capacity justifies, in the face of a proven malignant tumour, surgical intervention, any other incomplete or partial demolition does nothing but accelerate the ready reoccurrences, even in a very short time” [20]. * Correspondence: cirocchiroberto@yahoo.it General and Emergency Surgical Unit. Department of Surgical Sciences, Radiology and Dentistry. University of Perugia, Perugia, Italy Full list of author information is available at the end of the article Cirocchi et al. World Journal of Surgical Oncology 2011, 9:89 http://www.wjso.com/content/9/1/89 WORLD JOURNAL OF SURGICAL ONCOLOGY

Spider surgical system versus multiport laparoscopic surgery: performance comparison on a surgical simulator

BackgroundThe rising interest towards minimally invasive surgery has led to the introduction of laparo-endoscopic single site (LESS) surgery as the natural evolution of conventional multiport laparoscopy. However, this new surgical approach is hampered with peculiar technical difficulties. The SPIDER surgical system has been developed in the attempt to overcome some of these challenges. Our study aimed to compare standard laparoscopy and SPIDER technical performance on a surgical simulator, using standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS).MethodsTwenty participants were divided into two groups based on their surgical laparoscopic experience: 10 PGY1 residents were included in the inexperienced group and 10 laparoscopists in the experienced group. Participants performed the FLS pegboard transfers task and pattern cutting task on a laparoscopic box trainer. Objective task scores and subjective questionnaire rating scales were used to compare conventional laparoscopy and SPIDER surgical system.ResultsBoth groups performed significantly better in the FLS scores on the standard laparoscopic simulator compared to the SPIDER.Inexperienced group: Task 1 scores (median 252.5 vs. 228.5; p = 0.007); Task 2 scores (median 270.5 vs. 219.0; p = 0.005).Experienced group: Task 1 scores (median 411.5 vs. 309.5; p = 0.005); Task 2 scores (median 418.0 vs. 331.5; p = 0.007).Same aspects were highlighted for the subjective evaluations, except for the inexperienced surgeons who found both devices equivalent in terms of ease of use only in the peg transfer task.ConclusionsEven though the SPIDER is an innovative and promising device, our study proved that it is more challenging than conventional laparoscopy in a population with different degrees of surgical experience. We presume that a possible way to overcome such challenges could be the development of tailored training programs through simulation methods. This may represent an effective way to deliver training, achieve mastery and skills and prepare surgeons for their future clinical experience.

Giant Cardiac Hydatid Cyst in Children: Case Report and Review of the Literature

Cardiac echinococcus is a rare affliction of the heart caused by the tapeworm Echinococcus granulosus. Primary echinococcosis of the heart represents 0.5–2% of all hydatid disease cases in endemic regions. It evolves slowly, explaining its rarity in children. We report the case of a 11-year-old child affected by a giant cardiac cyst of the left ventricle (LV). The patient underwent cardiac surgery and medical treatment. A retrospective review of the current literature was realized. We found 18 cases: the mean age was 11-years old. Nine cysts were localized in the LV, four in the interventricular septum, three in the right ventricle, and two in the right atrium. All underwent surgery except six patients. Routine echocardiographic screening may be useful in endemic regions where infestation is common. Cardiac echinococcus should be diagnosed in the early and uncomplicated stages and be removed surgically even in asymptomatic patients.

Acute abdominal pain in a 24-year-old woman: Fitz- Hugh-Curtis syndrome associated with pyelonephritis

Fitz-Hugh-Curtis syndrome is an inflammatory disease ofthe liver capsule that occurs as a complication of pelvicinflammatory disease in approximately 25% of cases. Themost common etiological agents are Chlamydia trachomatisand Neisseria gonorrhoeae. Classically, it manifests as acuteright upper quadrant pain, which can sometimes beconfused with pyelonephritis or a primitive condition ofhepatobiliary origin or the digestive tract. A correctdiagnosis is often difficult. Ultrasonography and computedtomography (CT) may be helpful in the differentialdiagnosis of other forms of peritonitis localized in the rightabdominal quadrants, and serology, urine cultures andcervical swabs are generally used to isolate the responsibleorganism. The differential diagnosis could include Chilaiditisyndrome (interposition of a colonic segment between theliver and diaphragm with occlusion) or exudative peritoni-tis from salpingitis. We describe the clinical case of a 24-year-old Caucasian woman who presented with acute rightupper quadrant pain, positive Murphy’s sign, neutrophilicleukocytosis, and fever.

Multiple metastases of soft tissue visualized by technetium-99m-methylene diphosphonate scintigraphy: A case report

IntroductionLungs and liver are the most common sites of colorectal cancer metastases after regional lymph nodes, but metastases to unusual sites are reported. Heterotopic bone formation in soft tissues from colorectal cancer is a rare metastatic occurrence.Case presentationWe present the case of a 29-year-old Caucasian man affected by colon adenocarcinoma with multiple soft tissue metastases visualized by magnetic resonance imaging, computed tomography scan and scintigraphic bone scan. We suppose that these findings can be due to the fact that the tracer is concentrated in the ossification nidus of soft metastases.ConclusionsOur experience suggests that, in the presence of colon adenocarcinoma, a bone scan could be a sensible tool to highlight bone lesions or heterotopic bone nidus in soft tissues and that any subcutaneous lesion should be resected to avoid underestimating a potential malignancy.

Ascariasis mimicking a postoperative complication in colic resection for diverticular disease in Italy

A 56-year-old Peruvian man underwent colon resection for recurrent diverticular disease in our department without postoperative complications. A week after surgery, the patient was readmitted because of symptoms and signs of bowel obstruction. A computed tomography (CT) scan, with oral and transanal contrast, revealed a tubular intraluminal defect consistent with Ascaris lumbricoides bowel infestation (Figs. 1, 2). Therapy with albendazole was started. A concomitant anastomotic stenosis (Figs. 3, 4) was treated endoscopically.

Surgical treatment for primary hyperparathyroidism in the elderly: a single- center analysis

BackgroundsThe suspicion of a hyperparatiroidism is mostly guidedby the finding of an increase in serum calcium levels byroutine measurements. Primary hyperparathyroidism is acommon disease occurring in 0.2 to 0.5% of the popula-tion. The incidence in the United States is approxi-mately 100000 new cases per year and increases withage affecting up to 2% of elderly people [1].Materials and methodsFrom January 1995 to December 2009, 172 patientsunderwent operations for Hyperparathyroidism, 130 ofthese were Primary Hyperparathyroidism at our Depart-ment of General Surgery. Patients were divided into twogroups: patients of≤ 69 years old (Group A) andpatients of ≥ 70 years old (Group B). The following vari-ables were studied: demographic characteristics, co-mor-bidities, preoperative symptoms, laboratory values,operative procedures, postoperative complications andanatomo -pathological findings.ResultsGroup A: 110 patients operated 25 were male, 85 werefemale with a M:F ratio of 0.3:1. Mean age at admissionwas52.4(SD±12.9).Wereportedamorbidityrateof5.4% (6 patients) and a mortality rate of 0%. Group B:20 patients operated 6 were male, 16 were female with aM:F ratio of 0.25:1. Mean age at admission was 74.2 (SD±3.7). We reported a morbidity rate of 5% (1 patient)and mortality rate 0%.ConclusionsElderly patients with Hyperparathyroidism present avariety of symptoms that are often different from thoseseen in younger patients. They are more likely to mani-fest fatigue and psychiatric symptoms that are difficultto distinguish from those due to their age, therefore inthe majority of cases the suspicion of hyperparathyroid-ism is guided by the finding of an increase in serum cal-cium levels on a routine measurement. If serum calciumlevel is high or if hypercalcaemia is discovered, measure-ment of PTH confirms the diagnosis [2,3]. Cervicotomyand parathyroidectomy is still to be considered as thetreatment of choice in elderly patients with primaryhyperparathyroidism.