Francesco Milone

Thyroid Nodules and Related Symptoms Are Stably Controlled Two Years After Radiofrequency Thermal Ablation

BACKGROUND Percutaneous radiofrequency thermal ablation (RTA) is a promising new therapeutic approach to manage thyroid nodules (TNs). The aim of this study was to investigate the long-term effectiveness of RTA in inducing shrinkage of TNs as well as in controlling compressive symptoms and thyroid hyperfunction in a large series of elderly subjects with solid or mainly solid benign TNs. METHODS Ninety-four elderly patients with cytologically benign compressive TNs were prospectively enrolled in the study; 66 of them had nontoxic goiter and 28 had toxic or pretoxic goiter. RTA was performed by using a RITA StarBurst Talon hook-umbrella needle inserted in every single TN under ultrasonographic real-time guidance. TN volume, TN-related compressive symptoms and thyroid function were evaluated at baseline and 12 to 24 months after RTA. RESULTS All TNs significantly decreased in size after RTA. The mean decrease in TN volume 12 months after RTA was from 24.5 +/- 2.1 to 7.5 +/- 1.2 mL (p < 0.001), with a mean percent decrease of 78.6 +/- 2.0%. Two years after RTA, a 79.4 +/- 2.5% decrease of TNs size was observed. Compressive symptoms improved in all patients and completely disappeared in 83 of 94 (88%) patients. Hyperthyroidism resolved in most patients allowing methimazole therapy to be completely withdrawn in 79% of patients with pretoxic and toxic TNs (100% with pretoxic TNs and 53% with toxic TNs). The treatment was well tolerated by all patients. No patient needed hospitalization after RTA and no major complications were observed. CONCLUSIONS RTA is an effective and simple procedure for obtaining lasting shrinkage of TNs, controlling compressive symptoms, and treating thyroid hyperfunction. When performed in experienced medical centers, RTA may be a valid alternative to conventional treatments for nontoxic and pretoxic TNs. It is particularly attractive for elderly people for whom surgery and radioiodine therapy are often contraindicated or ineffective.

Hypertension in acromegaly and in the normal population: prevalence and determinants

Background  The GH/IGF‐I axis has a relevant role to play in the cardiovascular system but its implication in the pathogenesis of hypertension in the normal population and in acromegaly is not yet clear.

Effect of bariatric surgery on obesity-related infertility

BACKGROUND There is a strong association between obesity and infertility, and weight loss can increase fecundity in obese women. In an attempt to determine the effect of bariatric surgery on obesity-related infertility, we reviewed the fertility outcomes after intragastric balloon placement, adjustable gastric banding, sleeve gastrectomy, and gastric bypass in childbearing women with a diagnosis of infertility at a university hospital in Italy. METHODS This was a retrospective study of 110 obese infertile women. We evaluated the effectiveness of bariatric surgery in improving fertility, assessing the influence of age, surgical technique, co-morbidities (hypertension and diabetes), weight loss, and body mass index before and after surgery. RESULTS Of these 110 women who had tried unsuccessfully to become pregnant before weight loss, 69 became pregnant afterward. The pregnancies proceeded without complications and ended with a live birth. Only the weight loss (odds ratio 20.2, P = .001) and the achieved body mass index (P = .001) after surgery were the predictors of pregnancy. CONCLUSION Bariatric surgery might be effective in young infertile obese women who wish to become pregnant. Weight loss appears to be independent from the surgical technique in determining the increase in the pregnancy rate as well as the body mass index achieved at pregnancy.

PRL Secreting Adenomas in Male Patients

Prolactinomas are the most frequent pituitary tumors and their frequency varies with age and sex, occurring most frequently in females between 20–50 yr-old. In men, hyperprolactinaemia is often present for many years without symptoms, as generally the most important symptoms are the decrease in libido and/or sexual potency both underestimated by the majority of the patients. Prolactin (PRL) plays a role in the process of spermatogenesis, and normal serum PRL levels are required for normal testicular function. On the other hand, hyperprolactinaemia has multiple negative effects on the gonadal axis. As a consequences hyperprolactinemic males show alteration of sexual potency and seminal fluid quality. Cabergoline treatments is able to induce normalization of PRL levels and a reduction of tumor mass in the majority of patients and consequently restoring the normal semen quality and ameliorating the quality of life of men with pituitary PRL-secreting adenoma.

Magnetic resonance imaging and abdominal wall hernias in aortic surgery.

BACKGROUND The aim of this study was to evaluate the incidence of abdominal wall hernias (AWH) in patients operated on for abdominal aortic aneurysm (AAA) compared with patients treated for aortoiliac occlusive disease. The efficacy of MRI in early diagnosis of AWH also was studied. STUDY DESIGN One hundred fourteen patients operated for either AAA (51 patients, group A) or aortoiliac occlusive disease (63 patients, group B) constitute the study. The presence of AWH onset was evaluated by clinical observation followed by ultrasonography. Data acquired by ultrasonography were compared with those obtained by MRI to determine the efficacy of this diagnostic tool in all 114 patients. The prevalence of inguinal hernias in both groups also was determined. RESULTS A significant difference was found in the incidence of AWH. AWH developed in 31.7% (16 of 51) of group A patients and 17.4% (11 of 63) of group B patients (p < 0.03). A significant prevalence ofinguinal hernias was detected in group A (p < 0.01). The Cox hazard regression analysis revealed as independent predictors of postoperative AWH only the presence of AAA and a history of laparotomy. CONCLUSIONS Ours and other studies recall collagen synthesis disorders to explain the statistical association observed among AAA, inguinal hernias, and AWH. MRI, especially in patients at risk, appears to be an effective diagnostic approach to early detection of AWH.

EFFICACY AND SAFETY OF RADIOFREQUENCY THERMAL ABLATION IN THE TREATMENT OF THYROID NODULES WITH PRESSURE SYMPTOMS IN ELDERLY PATIENTS

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The biological characterization of neuroendocrine tumors: The role of neuroendocrine markers

Neuroendocrine tumors (NET) may originate in different organs, from cells embriologically different but expressing common phenotypic characteristics, such as: the immuno-re-activity for markers of neuroendocrine differentiation (defined as “pan-neuroendocrine”), the capacity to secrete specific or aspecific peptide and hormones and the expression of some receptors, that are at the basis of the current diagnostic and therapeutical approach, peculiar to these tumors. NET have been conventionally distinguished in functioning, when associated with a recognized clinical endocrine syndrome, and non-functioning. However, this terminology may be misleading, since the great majority of NET may secrete neuroendocrine peptides, which can be employed as clinical markers for both diagnosis and follow-up. On the other hand, tissue immuno-reactivity for specific hormones does not always reflect secretory activity of the tumor cells. Finally, receptors and genetic markers are acquiring a relevant role in the characterization of NET, both improving knowledge of biology and physiopathology of NET, as well as in developing specific strategies to establish an early diagnosis and targeted therapies, to adopt prophylactic strategies in familial forms, and to identify more efficacious targets for therapy in the future.

Diagnostic and prognostic implications of the World Health Organization classification of neuroendocrine tumors

Background: Neuroendocrine differentiation of tumors is often difficult to establish. In the same manner, the evaluation of the prognostic role of neuroendocrine differentiation may constitute a relevant clinical problem. Although different classifications are used for neuroendocrine tumors (NET) of different origin, the last World Health Organization (WHO) classification of NET, originally proposed for gastroenteropancreatic tumors, has proved to be a practical tool to allow pathologists to uniform the diagnoses and re-classify these tumors into 3 main categories. Aim: The present study was carried out in order to evaluate diagnostic and prognostic implications of NET reclassification according to the last WHO classification of NET. Materials and methods: Thirty-one tumors with an initial diagnosis referable to a NET achieved before 1999 were independently evaluated by 3 pathologists on the basis of the 2000 WHO classification of NET. Immunohistochemistry for panneuroendocrine markers and Ki-67 was also performed in all cases. Results: Twelve, 14, and 4 tumors were respectively reclassified as well-differentiated NET, well-differentiated neuroendocrine carcinoma and poorly differentiated neuroendocrine carcinoma; 1 tumor was reclassified as mixed endocrine-exocrine tumor. Two or more neuroendocrine markers were expressed in all NET regardless of histotype, differentiation degree, and site of primary tumor. After revision, 10 of the 31 tumors under study (32%) changed histo-prognostic category when compared to the initial diagnosis. Ki-67 score was the best predictor of survival at the multivariate analysis. Conclusion: The WHO classification is suitable to accurately reclassify tumors with an initial diagnosis referable to a NET and to separate these tumors in 3 well-distinct histo-prognostic categories with relevant clinical implications. Ki-67 score seems to be a better predictor of survival than the degree of differentiation.

Safety and Efficacy of Barbed Suture for Gastrointestinal Suture: A Prospective and Randomized Study on Obese Patients Undergoing Gastric Bypass

BACKGROUND Laparoscopic intracorporeal suturing and knot tying for anastomosis are considered the most difficult laparoscopic skills to master. The aim of this study was to establish the safety and efficacy of barbed suture for intestinal sutures to close the gastrojejunal anastomosis in obese patients undergoing gastric bypass. STUDY DESIGN All consecutive patients undergoing gastric bypass were screened for enrollment in our study. Patients were randomly allocated to undergo knotless anastomosis with barbed suture (V-Loc™ 180; Covidien, Mansfield, MA) (case group) or knot-tying anastomosis with 3/0 polyglactin sutures (Polysorb(®); Covidien) (control group). The primary outcome was the time needed for the gastrojejunal anastomosis and the operative time. The secondary outcomes were the incidence of leak, bleeding, and stenosis and the evaluation of the cost of the different procedures evaluated. RESULTS Among the 60 consecutive patients enrolled in our study, 30 underwent knot-tying anastomosis, and 30 underwent knotless anastomosis. The time needed for the anastomosis was significantly less (P<.001) in the knotless group, whereas no significant differences were found between the two groups for operative time (P=.151). We recorded one leak in the control group and one leak in the case group (P=1.000). One bleeding in the case group (P=1.000) and no stenosis in either group was recorded. Finally, in our experience, the knotless anastomosis was cheaper than the knot-tying anastomosis (P<.001). CONCLUSIONS Our study appears to be encouraging to suggest the use of barbed suture for gastrointestinal anastomosis.

Late micronutrient deficiency and neurological dysfunction after laparoscopic sleeve gastrectomy: a case report

Although the micronutrient deficiencies and the related neurological manifestations are widely reported after malabsorbitive weight loss surgery, little is known about cerebral dysfunction secondary to micronutrient impairment in subjects undergoing restrictive interventions (that is, sleeve gastrectomy). We describe a case of a 27-year-old woman with a late development of a Wernickes encephalopathy (WE) and of severe polyneuropathy following a sleeve gastrectomy without any sleeve stenosis. The impact of WE after bariatric surgery is significantly underestimated. Such a risk should be taken into consideration also after restrictive weight loss surgery. Thus, surgeoun/clinicians involved in bariatric patients management must be aware of neurological sequelae related to this intervention.