Renzo Dionigi

The effects of total parenteral nutrition on immunodepression due to malnutrition.

An experimental study was performed in 16 dogs to investigate the effects of sub-acute malnutrition on humoral and cellular immunity and phagocytic functions and, subsequently, to investigate the ability of total parenteral nutrition (TPN) to restore abnormal immunological variables. Deficiencies of IgG, C3, primary immune response to sheep red blood cells (SRBC),lymphocyte counts, lymphocyte response to phytohemagglutinin (PHA), and neutrophi chemotaxis were found to be caused by malnutrition. Nutritional repletion by means of TPN resulted in a return to normal or supranormal serum concentrations of IgG, IgM, and C3, and the primary immune response to SRVC was prompter and higher. Moreover, TPN resulted in restoration of normal neutrophil chemotactic responses. TPN did not improve lymphocyte response to PHA in these experiments. The study demonstrates that subacute malnutrition results in broad based deficiencies of the immunological response of the type that predispose to infection and that the proper use of TPN can correct most of these abnormalities.

Result of liver resection as treatment for metastases from noncolorectal cancer.

While liver resection for metastatic disease from colorectal cancer extends survival in selected patients, the efficacy of hepatectomy for metastases from other malignancies has not been defined.

What is the learning curve for intraoperative neuromonitoring in thyroid surgery

BACKGROUND The study describes the initial experience and learning curve of intraoperative neuromonitoring (IONM) during thyroidectomy. We describe the prevalence and patterns of IONM technical problems. METHODS Prospective series of 152 consecutive thyroid operations (304 nerves at risk) were analyzed. Standard technique consists of monitoring vagal and RLNs before, during and after resection. Personal gain of experience was defined by the preceding number of thyroid operations. To establish the number of thyroidectomies required before achieving an effective and safe IONM technique, all of the procedures were divided into three chronological groups of about 50 cases (groups 1, 2, and 3). RESULTS Patients (90%) had successful IONM with initial endotracheal tube position. Fifteen patients (10%) needed further tube adjustment. Out of 15 patients 14 (93%) were due to non-optimal contact of endotracheal surface electrodes to vocal cords. Tube malrotation was the main reason for initial failure (53%). The success rates of prompt IONM technique were 80% in group 1, 92% in group 2, and 98% in group 3 (p<0.05). Mean operating time was low in group 3 (p<0.03). Vagus and RLNs were localized and monitored in all the cases (100%). The incidence of temporary RLN injury was 2.6%. No permanent complications occurred. Negative EMG response indicated an altered function of RLN and stage thyroidectomies were scheduled. Transient RLN palsies were seen without changes during the entire study period. CONCLUSIONS This is the first series of thyroidectomies with standardized IONM technique performed in Italy. Neuromonitoring was effective in providing identification and function of laryngeal nerves. IONM successful rates were affected considerably by the extent of surgical and anaesthesiological experiences, starting with relatively low rates in the beginner group and then increasing. We assessed the learning curve: improved operative variables and safe technique were seen in about 50 patients.

Neuroendocrine carcinomas of the breast

INTRODUCTION Neuroendocrine (NE) breast cancers encompass a heterogeneous group of tumours showing morphological features similar to those of NE neoplasms of the gut and lung and expressing one or more neuroendocrine markers (neuron specific enolase, chromogranins synaptophysin) in at least 50% of tumour cells. They are rare lesions representing about 2-3% of all breast cancers and affecting more frequently elderly patients. AIM Prospective observational study is to analyse the clinico-pathological aspects of NE carcinomas of the breast undergone surgical resection compared to breast carcinomas with a minor neuroendocrine component and to conventional invasive ductal or lobular cancers. MATERIAL AND METHOD Thirty-five consecutive breast carcinomas showing morphological features suggestive of an endocrine differentiation were selected among breast cancers undergone surgical treatment during the period of January 1979-December 2004. RESULTS The 35 patients were divided into two categories: 13 neuroendocrine carcinomas (NECs) and 22 ductal carcinomas with a minor neuroendocrine component (DC-NE). The average follow-up was 60 months. The patients with CNE developed breast cancer in an advanced age compared to the patients with infiltrating ductal carcinoma NAS or infiltrating lobular carcinoma. We did not find recurrent disease in the NEC group, while it was observed in 2 patients (9%) with DC-NE, in 6 cases (17%) with infiltrating ductal carcinoma NAS and in 7 cases (20%) with infiltrating lobular carcinoma. DISCUSSION The CNE compared with the infiltrating ductal and lobular carcinoma are statistically different in relation to the expression of the receptor of c-erb-B2, p53, progesterone, for the lymph node state at diagnosis and the risk of reappearance of breast tumour. Our study confirms the choice to consider the neuroendocrine carcinoma of the breast as a separate histological group and seems to suggest a less aggressiveness of this type of tumour.

Visualization versus Neuromonitoring of Recurrent Laryngeal Nerves during Thyroidectomy: What About the Costs?

BackgroundThe objective of the present study was to evaluate costs for thyroidectomy performed with the aid of intraoperative neural monitoring (IONM), which has gained widespread acceptance during thyroid surgery as an adjunct to the gold standard of visual nerve identification.MethodsThrough a micro-costing approach, the thyroidectomy patient-care process (with and without IONM) was analyzed by considering direct costs (staff time, consumables, equipment, drugs, operating room, and general expenses). Unit costs were collected from hospital accounting and standard tariff lists. To assess the impact of the IONM technology on hospital management, three macro-scenarios were considered: (1) traditional thyroidectomy; (2) thyroidectomy with IONM in a high-volume setting (5 procedures per week); and (3) thyroidectomy with IONM in a low-volume setting (1 procedure per week). Energy-based devices (EBD) for hemostasis and dissection in thyroidectomy were also evaluated, as well as the reimbursement made by the Italian Healthcare System on the basis of diagnosis related groups (DRGs), about €2,600.ResultsComparison between costs and the DRG fee shows an underfunding of total hospitalization costs for all thyroidectomies, regardless of IONM use (scenario 1: €3,471). The main cost drivers are consumables and technologies (25%), operating room (16%), and staff (14%). Hospitalization costs for a thyroidectomy with IONM range from €3,713 to €3,770 (scenarios 2 and 3), 5–7% higher than those for traditional thyroidectomy. Major economic differences emerge when an EBD is used (€3,969).ConclusionsThe regional DRG tariff for thyroid surgery is barely sufficient to cover conventional surgery costs. Intraoperative neural monitoring accounts for 5–7% of the hospitalization costs for a thyroidectomy.

Immunological Function and Nutritional Assessment

Theoretically, a large number of tests of immunologic functions could be used for nutritional assessment. However, many of these immunologic tests require specialized laboratory skills and take a long time to perform. These tests provide little additional information to the clinician concerning the nutritional status of the patient, compared to the data that can be obtained from a few simple, selected immunologic measurements. Only a few immunologic tests are sufficiently simple, reproducible, and reliable indicators of nutritional status to be of practical value for routine nutritional assessment. These are the total lymphocyte count and skin tests. At present, all of the other immunologic measurements that have been reviewed should be considered as research tools for nutritional assessment. Immunological tests can be affected by many clinical variables unrelated to nutrition, such as specific pathologic conditions, immunodepressive therapies, accidental or surgical trauma, and infection, and this fact should be considered when using immunological tests to assess nutritional status. Malnutrition suppresses the acute-phase response of plasma proteins. The measurement of the acute-phase response of selected acute-phase proteins can be a functional measurement of nutritional status.

Risk Factors in Surgery

Abstract Improved surgical and anesthetic techniques and postoperative care have not significantly changed wound infection rates over the last 30 years. Many risk factors, related both to the host and to the surgical practice, have been identified in different studies. Control of nosocomial infections has become more challenging recently, due to a widespread bacterial resistance to antibiotics and to more frequent surgical indications in elderly patients at increased risk. A change in the microbiology of postoperative infections has also been noticed, characterized by a greater incidence of infections caused by methicillin-resistant Staphylococcus aureus, by polymicrobic flora and by fungi. This paper reviews the most important risk factors encountered in general surgery, that we observed during a 6-year prospective study of wound infection carried out in our Department of Surgery at the University of Insubria in Varese. Furthermore, the epidemiologic data on wound infections recorded in 4,002 patients undergoing general surgical procedures (mostly gastrointestinal operations), are presented and discussed.

High-Dose Intravenous IgG for Treatment of Severe Surgical Infections

113 severely septic surgical patients, with an initial sepsis score ≧ 17 (mean: 23 ± 4) were prospectively randomized to receive either high-dose intravenous IgG (IVIG group) or placebo (control group

Safety of neural monitoring in thyroid surgery

During thyroid surgery, the functional integrity of the recurrent laryngeal nerve (RLN) is not only threatened by direct nerve injury resulting from accidental transection, clipping or ligation. In fact, indirect trauma, e.g. traction and compression occurring repeatedly throughout gland dissection, contribute to long-term nerve impairment. In order to avoid RLN lesions and preserve nerve function the surgeon must adhere to and comply with a strict standardized intraoperative neuromonitoring (IONM) technique to preserve results, quality and safety. IONM should be a team work between the surgeon and the anesthesiologist.

Surveillance of surgical site infections after thyroidectomy in a one-day surgery setting

BACKGROUND AND AIM Different studies underline the importance of hospital stay on the development of infectious complications. We performed an audit of surgical site infections (SSI) after thyroidectomy was performed in a one-day surgery setting. MATERIALS AND METHODS One hundred and twelve consecutive patients admitted between April 2007 and discharged before May 2008 were studied. Patient selection criteria for one-day surgery were specific medical and social-logistic status. The technique of thyroidectomy was standardized. RESULTS SSI affect 2.6% of patients undergoing thyroid surgery with short hospitalization. The incidence of SSI was 3.2% following thyroidectomy, 2% for lobectomy. Mean time interval to symptom onset was 3 days (range 2-6). Most likely organism was Staphylococcus aureus. WI was associated with prolonged ambulatory medications. CONCLUSIONS Rates of SSI are similar to those described in the literature with longer hospitalization. All SSI become evident only after patient discharge. Prevention of SSI is very much the responsibility of the persons working in the operating theater. Effort should be made to improve sterile technique. Appropriate antibiotic coverage is indicated when infection develops postoperatively.