Francesco Amico

Recurrent laryngeal nerve injury in thyroid surgery: Clinical pathways and resources consumption

The impact of recurrent laryngeal nerve (RLN) injury management in thyroid surgery seems to be relevant to patients, National Healthcare System (NHS), and society.

Standardizing or Tailoring Bariatric Surgery

It is well known how obesity has a complex and multifactorial pathogenesis and represents a major risk factor for various metabolic, cardiovascular, respiratory, articular, and gastrointestinal diseases. On this regard, it is clear how evaluation and treatment of obese patients must to be interdisciplinary and integrated. Moreover, bariatric surgery consists of different types of operations carried out through different techniques, the main ones being of restrictive or malabsorbitive. In a previous letter [1], we focused on the need of standardization in bariatric surgery in relation to the age of the patient. Facing the heterogeneous aspects of obesity and its overall and surgical treatment, we may ask whether it is still worthwhile to talk about and look for standardization or it is better to consider bariatric surgery as a patient-tailored treatment. It is undoubtedly mandatory to look for standardization of different surgical techniques to allow reproducibility and comparability and to minimize complications. Nevertheless, if we mainly consider the indications of each type of procedure, do we really feel a need for standardization? Or maybe, are we asked to strictly tailor the best surgical procedure on the specific features of the patient? The obese patient may present sometimes a kaleidoscopic variety of clinical features that must be taken into account when planning the better surgical treatment. Classic anthropometric parameters, with all the limits of sensitivity related to BMI, are not the only ones that must be considered [2]. Eating habits, age, psychologic profile, related morbidity, ASA score, presence of hiatal hernia and gastroesophageal reflux, gastritis, gastric precancerous lesions, symptomatic cholelitiasis, bowel inflammatory disease, and previous abdominal surgery must also be taken into account. All the above-cited issues may impact on the choice of the more appropriate therapeutic way to follow and particularly of the more appropriate surgical procedure available. Sequentiality of treatment is another element to evaluate in the complex and articulated decision-making process. Obesity is a chronic disease; hence, its treatment cannot be a one-shot procedure limited in time. Redo surgery must not be considered always a failure of the primary surgery but in many cases must be interpreted as a normal step-by-step pathway in obesity treatment, above in all in young patients. In conclusion, we must discern the need of surgical technique standardization from the need to standardize the choice of surgical procedure type that we want to propose to the patients. The high complexity of the obese patients suggests that the type of surgery must be carefully calibrated on their overall clinical features evaluated during preoperative workup. The aim of standardizing the indications supposing the use of algorithms seems at least difficult to perform and quite far from everyday clinical practice.

Treatment of aortoiliac occlusive or dilatative disease concomitant with kidney transplantation: how and when?

BACKGROUND AND PURPOSE Aortoiliac (AI) lesions (both dilatative and occlusive) can occur in kidney allograft recipients. The correct timing of vascular imaging and treatment is controversial. Aim of the present paper is to report our experience. METHODS between January 2010 and December 2012, 106 patients included in our waiting list for kidney transplant underwent computed tomography (CT) angiogram to study AI axis. In 21 cases an AI lesion was identified before transplant. In 3 cases surgery was mandatory before kidney transplant, and in 18 cases lesions were treated simultaneously with kidney transplantation. MAIN FINDINGS AI pathology distribution was as follows: 15 iliac stenoses treated with thromboendarterectomy (TEA), 2 Leriche syndrome and 1 aortic aneurism treated with an aortobisiliac bypass (AI-BP), and 3 aneurysms treated with endovascular aortic repair (EVAR). In two cases a postoperative hematoma occurred. In one case occlusion of a stent-graft branch was treated with a femoro-femoral crossover bypass and transplant was then performed on the contralateral iliac axis. Perioperative mortality was 0%, and graft survival rate was 100% at 1 year in all cases. CONCLUSIONS A CT angiogram is useful in order to detect AI lesions and to be able to evaluate the best treatment option for the kidney transplantation and the correct timing for additional vascular surgery. The EVAR procedure should be safe, and does not compromise anastomosis success and graft survival, with less postoperative complications than open surgery.

Intraoperative Retrograde Intrarenal Surgery (RIRS) as a Good Management Option for Large Ureteropelvic Impacted Stone of Transplanted Kidney

Introduction Urolithiasis is a rare complication following kidney transplantation. Many of the clinical features of urinary stones after transplantation differ from those of non- transplant patients, but the course is essentially similar to that in non-transplant patients with lithiasis. The management of kidney stones has evolved radically over the years and involved extracorporeal shock wave lithotripsy (ESWL), flexible ureteroscopy and in situ lithotripsy, percutaneous nephrolithotomy (PCNL), open pyelolithotomy and open cystolitholapaxy. Retrograde URS with laser lithotripsy and/or basket extraction is a reasonable option for treating small and large stones also in transplanted kidney. In order to overcome the difficulty of complex anatomy typical of non-native ureter, ureteroscope can be introduced through a small surgical ureterotomy allowing quite complete stones clear. Matherials and Methods We present surgical treatment and outcome in a 69-year-old male patient with a large ureteropelvic impacted stone of transplanted kidney one year and three months after transplantation. The transplated ureter and the ureteroneocystotomy was identified at the right anterior bladder wall. Ureterotomy was performend on the third part of transplated urether, the double J stent was removed and the ureter was eventually cannulated. Retrograde pyelography revealed an angulation of the mid-ureter toward the renal pelvis seen medially. Access was established with both a standard teflon wire and a superstiff teflon guidewire. A flexible ureteroscope was advanced beyond the midureter through ureterotomy into the transplanted kidney. Laser lithotripsy was then effectively performed in the standard manner by means of 200/273&mgr;m Holmium laser fibers. A tipless nitinol basket was used to extract the fragments. Discussion Native anatomy makes ureteroscopy simple. The orthotopic location of the ureteral orifices allow the urologist to take advantage of the bladder trigone as a backbone to advance wires and ureteroscopes. This is lost in cases as in that one described previously, where the non-native ureter is in a more anterior location. The last attempt to remove pelvic stones in trasplanted kidneys is to introduce the ureteroscope through surgical ureterotomy. In this way is possible to avoid surgical incision of renal pelvis itself which is very difficult to isolate considering its proximity to vascular structures. Conclusion Upper urinary tract endoscopy has long been established as a safe and efficient means of managing urolithiasis with great success. With technological advances, ureteroscopy has evolved into a powerful tool in the armamentarium of the urologist. Management of patients with complex anatomy is now possible while avoiding more invasive interventions such as percutaneous nephrostolithotomy or surgical pyelotomie. Figure. No caption available.

Real-time Intraoperative Fluorescent Lymphography: A New Technique for Lymphatic Sparing Surgery

BACKGROUND Many surgical procedures can produce persistent lymphorrhea, lymphoceles, and lymphedema after lymph node and lymph vessel damage. Appropriate visualization of the lymphatic system is challenging. Indocyanine green (ICG) is a well-known nontoxic dye for lymphatic flow evaluation. ICG fluorescence-guided lymphography has emerged as a promising technique for intraoperative lymphatic mapping. OBJECTIVE Our goal was to develop a high spatial resolution, real-time intraoperative imaging technique to avoid or recognize early deep lymphatic vessel damage. METHODS We intraoperatively performed ICG fluorescence-guided lymphography during a kidney transplant. ICG was injected in the subcutaneous tissue of the patients groin in the Scarpas triangle. A dedicated laparoscopic high-definition camera system was used. RESULTS Soon after ICG injection, the lymphatic vessels were identified in the abdominal retroperitoneal compartment as fluorescent linear structures running side by side to the iliac vessels. Surgical dissection was therefore performed, avoiding iatrogenic damage to major lymphatic structures. Another ICG injection at the end of the procedure confirmed that the lymphatic vessels were intact without lymph spread. CONCLUSIONS Intraoperative lymphatic mapping with an ICG fluorescence-sensitive camera system is a safe and feasible procedure. ICG real-time fluorescence lymphography can be used to avoid or recognize early deep lymphatic vessel damage and reduce postoperative complications related to the lymphatic system.

Malignancy as a risk factor in single-stage combined approach for simultaneous elective surgical diseases

OBJECTIVE To identify morbidity and mortality risk factors in patients with synchronous diseases who underwent single-stage combined (SSC) surgery. METHODS We considered data of 328 patients, each with multiple, elective, synchronous surgical problems treated by a SSC operation. By univariate and multivariate analysis we evaluated many patient-, disease - or treatment-related variables with respect to post-operative mortality, morbidity, and hospital stay. RESULTS Two combined procedures were synchronously performed in 283 patients (86%), 3 combined procedures in 45 patients (14%). Post-operative mortality and morbidity rates were 3% and 24%, respectively, and median duration of hospital stay was 9 days. The occurrence of a surgical oncology procedure emerged as the most important independent risk factor for post-operative mortality and morbidity. CONCLUSIONS The safety of SSC surgery for the treatment of synchronous problems appears similar to that of multi-stage procedures. The understanding of risk factors for this surgical approach could be useful in order to improve patient selection.