Valeria Vitale

Can Sequential 18F-FDG PET/CT Replace WBC Imaging in the Diabetic Foot?

White blood cell (WBC) scintigraphy is considered the nuclear medicine imaging gold standard for diagnosing osteomyelitis in the diabetic foot. Recent papers have suggested that the use of 18F-FDG PET/CT produces similar diagnostic accuracy, but clear interpretation criteria have not yet been established. Our aim was to evaluate the role of sequential 18F-FDG PET/CT in patients with a high suspicion of osteomyelitis to define objective interpretation criteria to be compared with WBC scintigraphy. Methods: Thirteen patients whom clinicians considered positive for osteomyelitis (7 with ulcers, 6 with exposed bone) were enrolled. The patients underwent 99mTc-exametazime WBC scintigraphy with acquisition times of 30 min, 3 h, and 20 h and sequential 18F-FDG PET/CT with acquisition times of 10 min, 1 h, and 2 h. A biopsy or tissue culture was performed for final diagnosis. Several interpretation criteria (qualitative and quantitative) were tested. Results: At final biopsy, 7 patients had osteomyelitis, 2 had soft-tissue infection without osteomyelitis, and 4 had no infection. The best interpretation criterion for osteomyelitis with WBC scintigraphy was a target-to-background (T/B) ratio greater than 2.0 at 20 h and increasing with time. A T/B ratio greater than 2.0 at 20 h but stable or decreasing with time was suggestive of soft-tissue infection. A T/B ratio of no more than 2.0 at 20 h excluded an infection. Thus, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for osteomyelitis were 86%, 100%, 100%, 86%, and 92%, respectively. For 18F-FDG PET/CT, the best interpretation criterion for osteomyelitis was a maximal standardized uptake value (SUVmax) greater than 2.0 at 1 and 2 h and increasing with time. A SUVmax greater than 2.0 after 1 and 2 h but stable or decreasing with time was suggestive of a soft-tissue infection. An SUVmax less than 2.0 excluded an infection. 18F-FDG PET at 10 min was not useful. Using these criteria, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for osteomyelitis were 43%, 67%, 60%, 50%, and 54%, respectively. Combining visual assessment of PET at 1 h and CT was best for differentiating between osteomyelitis and soft-tissue infection, with a diagnostic accuracy of 62%. Conclusion: 18F-FDG PET/CT, even with sequential imaging, has a low diagnostic accuracy for osteomyelitis and cannot replace WBC scintigraphy in patients with diabetic foot.

Laparoscopic cholecystectomy in day surgery: Feasibility and outcomes of the first 400 patients

BACKGROUND The aim of this study was to evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in a day surgery setting in Italy. MATERIAL AND METHODS Between March 2003 and June 2011, in our institution 439 patients were selected for day surgery LC. To evaluate the efficacy and safety of the procedure, postoperative complications, pain, nausea and vomiting were monitored at 4, 8, and 24 h after surgery. Patients admitted for an overnight stay or readmitted after discharging were also monitored. RESULTS Over 8 years we performed 400 LC in day surgery setting and no conversion or major intraoperative complication were detected. A total of 387 patients (96.7%) were successfully discharged after 8-10 h of observation. Postoperative monitoring showed good pain control (mean VAS score 1.5) and only 3 (0.7%) of the 7 patients who experienced major pain were admitted. Twenty-seven patients (6.7%) experienced PONV and 9 (2.2%) of these required admission. None of the patients needed to be readmitted after discharging. The satisfaction questionnaire administered at 1 month office visit showed that 380 patients (95%) were satisfied with day surgery LC. CONCLUSIONS Our success rate of 96.7% can be attributed to strict adherence to the patient selection criteria. The main reasons for hospital admission were pain and PONV; adequate control of these represents the key of success for day surgery LC. This study confirms the feasibility and safety of LC performed in day surgery setting.

Importance of perforating vessels in nipple-sparing mastectomy: an anatomical description

Background Nipple-sparing mastectomy (NSM), understood as an oncologically valid procedure, is relatively new, and is an evolution of traditional mastectomy, particularly in relation to breast-conserving surgery. The anterior perforating branches are responsible for the cutaneous vascularization of the breast skin, and their preservation is a fundamental step to avoid possible postoperative necrosis. Therefore, evaluating the potential complications of cancer-related reconstructive surgical procedures such as NSM, both the distance of the tumoral lesion from the skin and the surgical incision site should be carefully considered. The preferred site of incision corresponds to the inframammary fold or possibly the periareolar area. Methods We retrospectively reviewed 113 patients who underwent NSM from January 2005 to October 2012 to evaluate skin complications. The anatomical study was performed by magnetic resonance imaging of the breast. Results Only one of the 113 women who had undergone a NSM procedure had total necrosis (0.9%) and six patients had partial necrosis (5.8%) of the nipple-areola complex.