Gregorio Patrizi

Prospective evaluation of multiparametric ultrasound and quantitative elastosonography in the differential diagnosis of benign and malignant thyroid nodules: Preliminary experience

PURPOSE To assess the clinical value of quantitative elastosonography compared with multiparametric ultrasound in differentiating the nature of thyroid nodules. METHODS AND MATERIALS Ninety-seven consecutive patients (32 males, 65 females, mean age, 54 years, range 20-81 years) with thyroid nodules previously detected at color-Doppler ultrasound (CDUS), were prospectively examined with elastosonography with dedicated quantitative software (Elasto-Q, Toshiba) before surgery. Ultrasound examination and elastosonography were evaluated by two investigators in consensus. US features, color-Doppler pattern, and strain ratio value were evaluated. Sensitivity and specificity of CDUS and sono-elastography were compared using X(2) test and ROC curves. RESULTS Sensitivity and specificity of hypoechogenicity, irregular margins or suspicious halo features, CDUS blood flow pattern, and strain ratio in the diagnosis of malignant nodules were 56.8%, 62.2%, 54.1% and 97.3% and 71.7%, 93.3%, 28.3%, and 91.7%, respectively. Elastosonography was more sensitive and specific than all ultrasonographic features in predicting malignancy of the thyroid nodules (p<0.0001). According to elastosonographic features the lesions characterized by strain ratio ≥ 2 were highly likely to be of malignant nature (p<0.0001, O.R. 396, 95%, CI: 44-3530). CONCLUSIONS The results of the present study suggest that elastosonography with Q system is a valuable tool in the characterization of thyroid nodules and it seems to be far more accurate than CDUS. These findings as well as those of previous studies support its use in selecting patients who are candidates for surgery.

Low-volume plus ascorbic acid vs high-volume plus simethicone bowel preparation before colonoscopy

AIM To investigate the effectiveness of low-volume plus ascorbic acid [polyethylene glycol plus ascorbic acid (PEG + Asc)] and high-volume plus simethicone [polyethylene glycol plus simethicone (PEG + Sim)] bowel preparations. METHODS A total of one hundred and forty-four outpatients (76 males), aged from 20 to 84 years (median age 59.5 years), who attended our Department, were divided into two groups, age and sex matched, and underwent colonoscopy. Two questionnaires, one for patients reporting acceptability and the other for endoscopists evaluating bowel cleansing effectiveness according to validated scales, were completed. Indications, timing of examination and endoscopical findings were recorded. Biopsy forceps were used as a measuring tool in order to determine polyp endoscopic size estimation. Difficulty in completing the preparation was rated in a 5-point Likert scale (1 = easy to 5 = unable). Adverse experiences (fullness, cramps, nausea, vomiting, abdominal pain, headache and insomnia), number of evacuations and types of activities performed during preparation (walking or resting in bed) were also investigated. RESULTS Seventy-two patients were selected for each group. The two groups were age and sex matched as well as being comparable in terms of medical history and drug therapies taken. Fourteen patients dropped out from the trial because they did not complete the preparation procedure. Ratings of global bowel cleansing examinations were considered to be adequate in 91% of PEG + Asc and 88% of PEG + Sim patients. Residual Stool Score indicated similar levels of amount and consistency of residual stool; there was a significant difference in the percentage of bowel wall visualization in favour of PEG + Sim patients. In the PEG + Sim group, 12 adenomas ≤ 10 mm diameter (5/left colon + 7/right colon) vs 9 (8/left colon + 1/right colon) in the PEG + Asc group were diagnosed. Visualization of small lesions seems to be one of the primary advantages of the PEG + Sim preparation. CONCLUSION PEG + Asc is a good alternative solution as a bowel preparation but more improvements are necessary in order to achieve the target of a perfect preparation.

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.

Prospective evaluation in 123 patients of strain ratio as provided by quantitative elastosonography and multiparametric ultrasound evaluation (ultrasound score) for the characterisation of thyroid nodules.

PurposeThis study was done to compare quantitative elastosonography and ultrasound analysis in the characterisation of thyroid nodules.Materials and methodsFrom July 2009 to September 2011, 123 patients with 147 thyroid nodules were included in our study. All patients enrolled had to undergo thyroidectomy because of nodular thyroid disease (goitre or nodules). After preliminary examination with conventional ultrasound (US) and colour Doppler US, the patients were examined with elastosonography, using high-level equipment (Toshiba Aplio XG) and quantitative software (Elasto-Q). Each lesion was characterised using an US score (echogenicity, borders, microcalcifications and colour Doppler pattern), and then by elastosonographic strain ratio. Each patient subsequently underwent thyroidectomy. Histological results were used as the gold standard.ResultsHistological examination demonstrated 89 benign and 58 malignant lesions. On average, the strain ratio value was 2.84±2.69 (range, 0.05–14.5; p=0.001). Sensitivity and specificity of the US score were about 56% and 72%, respectively, whereas those of the strain ratio were 93% and 89%, using a cut-off of 2 obtained with receiver operating characteristic (ROC) curve analysis. Elastosonography was more accurate than US and colour Doppler US in characterising thyroid nodules (p=0.002).ConclusionsQuantitative elastosonography is a useful diagnostic tool in the evaluation of thyroid lesions, and can be used to limit fine-needle aspiration cytology and improve the selection of patients for thyroidectomy.RiassuntoObiettivoScopo del presente lavoro è stato confrontare elastosonografia quantitativa ed analisi ecografica nella caratterizzazione del nodulo tiroideo.Materiali e metodiTra luglio 2009 e settembre 2011 sono stati arruolati 123 pazienti con 147 noduli candidati all’intervento di tiroidectomia totale per la presenza di patologia nodulare tiroidea. Dopo valutazione preliminare con ecografia e color Doppler, i pazienti sono stati sottoposti ad elastosonografia, mediante software quantitativo Elasto-Q con apparecchiatura Toshiba Aplio XG. Ogni nodulo è stato caratterizzato mediante ecoscore (ecogenicità, margini, microcalcificazioni, pattern color Doppler) e indice di deformabilità (strain ratio). I risultati istologici sono stati utilizzati come gold standard.RisultatiI noduli esaminati sono risultati benigni in 89 casi e maligni in 58. Alla valutazione elastosonografica la media dei valori di strain ratio è stata 2,84±2,69 (p=0,001). Si sono ottenuti valori di sensibilità e specificità rispettivamente 56% e 72% per l’eco-score e 93% e 89% per lo strain ratio, utilizzando un cut-off pari a 2, con un valore predittivo positivo del 55% e dell’82% rispettivamente. La tecnica elastosonografica ha mostrato maggiore accuratezza dell’ecografia e del color Doppler nella caratterizzazione delle lesioni tiroidee (p=0,002).ConclusioniL’elastosonografia quantitativa è uno strumento valido per la caratterizzazione dei noduli tiroidei, utile per ridurre il ricorso all’agoaspirato, in particolare nei casi incerti.

Anatomical lymph node mapping in normal mesorectal adipose tissue

PURPOSE: In view of divergent outcomes of surgery for rectal cancer despite standard protocols, the aim of this study was to provide a basis for improving lymph node assessment by defining the number, shape, and distribution of all lymphatic structures in the mesorectum. METHODS: Cadavers from 6 males and 6 females who died from causes other than colorectal or neoplastic pathologies were studied. Rectum and mesorectum were excised en bloc. The adipose tissue was separated from the rectum and divided into 9 sections before fixing the specimen in paraffin, cutting into smaller portions, and staining with hematoxylin and eosin. Slides were analyzed with an optical microscope, and identified lymph nodes were counted in each section. RESULTS: The mean age of the deceased was 52.7 (range, 26–65) years. No evidence of previous history of neoplastic pathology or any type of premortal colorectal inflammatory process was found. A total of 412 lymph nodes were identified, with a mean of 34.3 (SD, 2.1; range, 31–37) lymph nodes per cadaver. The mean number of lymph nodes differed significantly across levels of the mesorectum, with 22.2 lymph nodes in the upper, 9.8 in the middle, and 2.3 in the lower sections; 266 (64.6%) of all lymph nodes were located in the upper third of the mesorectum. Distribution density was higher in the proximal posterior sections, with 197 lymph nodes (47.8%) in the upper 2 thirds of the posterior mesorectum. Node diameter was less than 5 mm in 330 (80%) of 412 nodes. CONCLUSIONS: Our study confirmed that more than 30 lymph node units normally exist in the mesorectal area. In view of previous studies demonstrating advantages of increasing the number of lymph nodes evaluated, staging of rectal cancer might be improved by counting more than 12 lymph nodes per specimen.

Endovascular repair for acute mesenteric ischemia: case report

Methods We present a case of a 75-year-old patient with acute occlusive mesenteric ischemia that was successfully treated with endovascular intervention. Angiography revealed high-grade stenosis of the proximal tract of the SMA. Immediate option for endovascular therapy was made, and a MARIS self-expandable 6x40 mm stent was positioned. The patient was discharged 2 days after with full recovery from the symptoms.

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.

A Retrospective Case-Control Study Evaluating the Bowel Preparation Quality during Surveillance Colonoscopy after Colonic Resection

Purpose. Bowel preparation for surveillance endoscopy following surgery can be impaired by suboptimal bowel function. Our study compares two groups of patients in order to evaluate the influence of colorectal resection on bowel preparation. Methods. From April 2010 to December 2011, 351 patients were enrolled in our retrospective study and divided into two homogeneous arms: resection group (RG) and control group. Surgical methods were classified as left hemicolectomy, right hemicolectomy, anterior rectal resection, and double colonic resection. Bowel cleansing was evaluated by nine skilled endoscopists using the Aronchick scale. Results. Among the 161 patients of the RG, surgery was as follows: 60 left hemicolectomies (37%), 62 right hemicolectomies (38%), and 33 anterior rectal resections (20%). Unsatisfactory bowel preparation was significantly higher in resected population (44% versus 12%; P value = 0.000). No significant difference (38% versus 31%, P value = ns) was detected in the intermediate score, which represents a fair quality of bowel preparation. Conclusions. Our study highlights how patients with previous colonic resection are at high risk for a worse bowel preparation. Currently, the intestinal cleansing carried out by 4 L PEG based preparation does not seem to be sufficient to achieve the quality parameters required for the post-resection endoscopic monitoring.