Mario Sianesi

Quality of Life in Uncomplicated Symptomatic Diverticular Disease: Is It Another Good Reason for Treatment?

Background: Quality of life (QoL) is becoming a major issue in the evaluation of any therapeutic intervention. Aims: To assess the QoL in patients with uncomplicated symptomatic diverticular disease (DD) and to elucidate the influence of two different treatments either on symptoms or QoL. Materials and Methods: 58 outpatients affected by uncomplicated symptomatic DD, admitted in our Gastroenterological Unit from October 2003 to March 2004, were enrolled. Patients were randomly assigned to two different treatments consisting of rifaximin or mesalazine for 10 days every month for a period of 6 months. QoL was evaluated by means of an SF-36 questionnaire and clinical evaluation was registered by means of a global symptomatic score (GSS) at baseline and after 6 months. Results: At baseline, lower values in all SF-36 domains were confirmed in patients with DD. Both rifaximin and mesalazine groups showed a significant reduction of their mean GSS (p < 0.01 and p < 0.001, respectively) and improvement of SF-36 mean scores after therapy, even though treatment with mesalazine showed better results. Conclusions: DD has a negative impact on QoL. Cyclic treatment with poorly absorbable antibiotics or anti-inflammatory drugs relieves symptoms and improves QoL.

The utility of serum PTH assessment 24 hours after total thyroidectomy.

BACKGROUND: Hypocalcemia is the most frequent complication following total thyroidectomy. This prospective study examines the predictive value of parathyroid hormone (PTH) levels measured 24 hours after surgery. MATERIAL AND METHODS: A total of 1006 consecutive patients (mean age, 54.8 years; female/male ratio, 4/1) underwent total thyroidectomy for benign or malignant thyroid from January 1995 to November 2003. Serum calcium, phosphorus, and PTH were measured preoperatively and at 24 hours after surgery. All patients underwent preoperative examination to assess cord motility. RESULTS: A total of 253 (25.1%) patients presented with hypocalcemia demonstrated by clinical and laboratory findings. In 101 cases the hypocalcemic syndrome manifested after 24 to 36 hours whereas in 5 of 101 cases, symptom onset was between 48 and 72 hours. Serum calcium levels lower than 7.5 mg/dL were recorded in all the 101 cases. In 239 of 253 cases serum calcium returned to normal values within 7 days following surgery. PTH at 24 hours was below normal levels in 49 of the 101 patients but was within normal limits in 52 cases. The incidence of hypocalcemia was higher in patients undergoing surgery for malignant thyroid (P < 0.05). CONCLUSIONS: We do not consider PTH levels at 24 hours postoperatively as predictive of hypocalcemia.

Connections between genetics and clinical data: Role of MCP-1, CFTR, and SPINK-1 in the setting of acute, acute recurrent, and chronic pancreatitis.

OBJECTIVES:Acute, acute recurrent, and chronic pancreatitis are inflammatory diseases with multifactorial pathogenic mechanisms. Genetic mutations and polymorphisms have been correlated with pancreatitis. The aim of this study was to investigate the association of cystic fibrosis transmembrane conductance regulator (CFTR) and serine protease inhibitor Kazal type 1 (SPINK-1) gene mutations and monocyte chemoattractant protein 1 (MCP-1) –2518A/G polymorphism with acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic pancreatitis (CP), and to associate genetic backgrounds with clinical phenotype in these three conditions.METHODS:One hundred eighteen AP, 64 ARP, 142 CP patients, and 88 normal controls were enrolled consecutively. We analyzed MCP-1 serum levels using enzyme-linked immunosorbent assay. Polymorphism −2518 of MCP-1 and SPINK-1 N34S gene mutations were determined by PCR–restriction-fragment length polymorphism. Sequence analysis was performed when necessary. Thirty-three CFTR mutations were analyzed in CP and ARP patients using multiplex DNA testing.RESULTS:Serum MCP-1 levels were significantly higher in all patients affected by pancreatic inflammatory diseases. Moreover, we found a significant over-representation of the MCP-1G allele in ARP patients. We found a statistically significant association of CFTR gene mutations with ARP, but not with CP. We did not find a statistically significant association of ARP or CP with the N34S SPINK-1 gene mutation. Interestingly, 39 of 64 ARP patients (61%) carried at least one genetic mutation and/or polymorphism. Five of 64 ARP patients had pancreas divisum and four of these five also carried the G allele.CONCLUSIONS:Analysis of a comprehensive range of potential susceptibility variants is needed to support modeling of the effects of genes and environment in pancreatitis. As such, beyond gene mutations, the context within which those mutations exist must be considered. In pancreatitis the context includes the inflammatory response, clinical features, and exogenous factors.

Minimally Invasive Video-Assisted Thyroidectomy: The Learning Curve

Background: MIVAT (minimally invasive video-assisted thyroidectomy) is a recent technique that requires a learning curve. Materials and Methods: From July 2005 to December 2006, we treated 100 from a total of 467 thyroidectomy patients with MIVAT. We divided the patients into 3 groups. The first 2 groups consisted of 25 patients each: group A (cases 1–25) and group B (26–50). We also divided patients into 2 groups based on our surgical experience: group A + B (cases 1–50) and group C (cases 51–100). Results: The operative times for groups A and B were 101.7 and 84.6 min, respectively (p < 0.03); those for groups A + B and C were 91.07 and 63.06 min, respectively (p < 0.004). Complications of hypocalcemia were observed in 6 cases (4 in the first 50 cases and 2 in the second 50), and complications of nerve palsy were observed in 2 cases from group A. Conclusions: After 25 cases, we observed that the MIVAT procedure allows for a lower mean operative time and a reduction of complications.

Cholecystectomy for acute cholecystitis: Timing of operation, bacteriologic aspects, and postoperative course

There is still considerable controversy among surgeons regarding the most opportune moment for surgical intervention in the case of acute cholecystitis. For this reason, 471 patients cholecystectomized for acute cholecystitis from 1970 through 1982 were studied. During the first period, there were two types of surgical intervention: during hospitalization after resolution of the acute episode, and during a second hospitalization 2 to 3 months later. During the second period, early cholecystectomy within 72 hours of the onset of symptoms became the option. Emergency operations did not reflect a surgical choice but rather conditions of necessity. The results of this study demonstrate that early cholecystectomy is preferred for a variety of reasons, the most important of these being a low incidence of positive results of bile culture in this phase, a negligible percentage of postoperative complications and mortality, and a short hospitalization period with resulting cost containment.

Hyperparathyroidism associated with thyroid pathology

BACKGROUND The pathological association between thyroid and parathyroid gland disease is here discussed. The multiphase analyzer has revealed a new type of subclinical primary hyperparathyroidism (HPP) and the role of surgery in these cases is not clear. METHODS This is a prospective study of all cases of thyroid disease in association with parathyroid disease treated surgically in our Institute from July 1999 to June 2001. RESULTS Of the 221 thyroidectomies carried out, 29 patients had an elevated preoperative serum level of parathyroid hormone (PTH). An ultrasonography examination was performed on all patients and a preoperative scanning with 99Tc-MIBI on 11 of 29 patients. We examined intraoperatively 19 cases of HPP (14 parathyroid adenoma, 5 hyperplasia). In 10 cases we observed a normal size of the parathyroid gland and we did not perform a parathyroidectomy. CONCLUSIONS All patients with elevated serum parathyroid hormone and serum calcium levels before thyroidectomy should be considered candidates also for surgery to the parathyroid glands. The pathological association between thyroid and parathyroid gland diseases is not rare. We must conduct an accurate neck exploration in all these cases.

Prevalence of Thyroid Cancer in Hyperthyroid Patients Treated by Surgery

A retrospective study has been carried out to evaluate the prevalence of malignant thyroid tumors in 202 patients submitted to surgery for hyperthyroidism. Thyroid cancer was diagnosed in 12 cases (5.9%); the final histologic examination revealed nine papillary carcinomas, one follicular carcinoma, and two Hürthle cell carcinomas. Concurrence of hyperthyroidism and thyroid cancer was more frequent in patients with single toxic adenomas than in those with toxic diffuse or multinodular goiters. In five cases thyroid malignancy was detected in the context of the hyperthyroid lesion (three toxic adenomas and two diffuse goiters). In eight patients the malignant lesion showed a maximum diameter of less than 1 cm, although in five of these cases unfavorable histologic features, such as minimal capsular invasion or multifocality, were present. All patients presenting with thyroid cancer are currently alive and apparently free of residual disease. It is concluded that hyperthyroid patients, particularly those with single toxic adenomas, should be carefully evaluated to exclude the presence of an associated malignancy and to plan the most appropriate therapeutic options.

“Adenomatous Polyps Of The Gallbladder” Adenomas oF the Gallbladder

The finding of adenomatous polyps of the gallbladder is a rare occurrence and an unusual clinical problem. Among 2,145 patients who underwent cholecystectomy for gallbladder disease only 9 (0.4 per cent) presented with adenomatous polyps. There were 6 women and 3 men, aged 17 to 70 years. Preoperative ultrasonographic diagnosis was made in only 1 of 7 patients with gallstones, in contrast polypoid lesions within a gallbladder without stones were easily confirmed by both ultrasonography and oral cholecystography in the remaining 2 patients. All polyps were 1.0 cm or less in size and without histologic evidence of malignant change. The clinical significance of this rare condition is discussed, with particular reference to a possible role in development of gallbladder carcinoma. Surgical treatment should be advocated regardless of clinical manifestation when the polyp exceeds 1.0 cm in diameter or rapid growth of the lesion is seen on ultrasonographic follow-up examinations.

A Comparison of Minimally Invasive Video-Assisted Parathyroidectomy and Traditional Parathyroidectomy for Parathyroid Adenoma

Background: Pre-operative imaging techniques for sporadic primary hyperparathyroidism (SPHPT) and intraoperative parathyroid hormone (ioPTH) have led to the wide spread use of minimally invasive surgical approaches. Study Design: In our prospectively collected database, 157 subjects with SPHPT and a preoperative diagnosis of parathyroid adenoma were treated with parathyroidectomy between January 2003 and November 2011. Subjects in group A were enrolled between January 2003 to September 2006, and underwent traditional parathyroidectomy with intraoperative frozen section and bilateral neck exploration. Subjects in group B were enrolled between September 2006 to November 2011, and underwent minimally invasive video-assisted parathyroidectomy (MIVAP) with ioPTH. Operative times and post-operative pain levels were compared between groups. Subjects were followed for a minimum of 6 months post-operatively and recurrence rates and complication rates were measured between groups. Results: 81 subjects were enrolled in group A, and 76 subjects were enrolled in group B. Pre-operative evaluation demonstrated that the groups were statistically similar. Significantly decreased operative times (28min vs. 62min) and post-operative pain levels were noted in group B. Recurrence rates were similar between group A (3.7%) and group B (2.6%). Conclusions: MIVAP with ioPTH demonstrated significantly improved operative times and post-operative pain levels, while maintaining equivalent recurrence rates.

The Node Ratio as Prognostic Factor after Curative Resection for Gastric Cancer

IntroductionThe depth of the tumor invasion and nodal involvement are the two main prognostic factors in gastric cancer. Staging systems differ among countries and new tools are needed to interpret and compare results and to reduce stage migration. The node ratio (NR) has been proposed as a new prognostic factor.Materials and MethodsWe retrospectively reviewed 282 patients who underwent curative resection for gastric cancer at Parma University Hospital between 2000 and 2007. TNM stage, NR, overall survival, survival according to nodal status, and survival according to the total number of nodes retrieved were calculated.ResultsAt univariate analysis, the TNM stage, number of metastatic nodes, NR, and depth of tumor invasion, but not the number of nodes retrieved, were significant prognosis factors. Patients with more than 15 nodes retrieved in the specimen survived significantly longer (p < 0.04). This was confirmed for all N or NR classes within N groups. There was a correlation between the number of nodes retrieved and N but not with the NR category. NR was an independent prognostic factor at Cox regression.ConclusionNR is a reliable and sensitive tool to differentiate patients with similar characteristics, probably more so than the TNM system. NR is not strictly related to the number of nodes retrieved and this may potentially decrease the stage migration phenomenon. More trials are needed to validate this factor.