Energy based vessel sealing devices in thyroid surgery: A systematic review to clarify the relationship with recurrent laryngeal nerve injuries

Background and objectives: The principal complications associated with thyroid surgery consist in postoperative recurrent laryngeal nerve (RLN) palsy, hypoparathyroidism, intra-operative and post-operative hemorrhage. In this paper, structured as a literature review, we describe the current knowledge and the technical improvements currently employed in the field of thyroid surgery, focusing on the contribution of energy based devices in relation with the reduction of the operating time and the odds of possible complication. Materials and methods: a relevant systematic literature search on Pubmed was carried out including works from 2004 through 2019, selecting studies providing information on the energy based devices employed in surgeries and statistic data concerning RNL (transient and permanent) injury and operative time. Results: Nineteen studies were reviewed, dealing with 4468 patients in total. The operative variables considered in this study are: employed device, number of patients, pathological conditions affecting the patients, surgical treatment, RNL injury percentage and the operating time, offering an insight on different patient conditions and their relative operative outcomes. A total of 1843 patients, accounting to the 41.2% of the total pool, underwent the traditional technique operation, while 2605 patients (58.3%) were treated employing the energy based devices techniques. Thyroidectomy performed by approaches different from traditional (for example robotic, MIVAT (Mini Invasive Video Assisted thyroidectomy)) were excluded from this study. Conclusions: The energy-based vessel sealing devices in study, represent a safe and efficient alternative to the traditional clamp-and-tie hand technique in the thyroidal surgery scenario, granting a reduction in operating time while not increasing RNL injury rates. According to this information, a preference for energy based devices techniques might be expressed, furthermore, a progressively higher usage rate for these devices is expected in the near future

Choosing a similarity index to quantify gait data variability

Repeatability and reproducibility of joint kinematics can be assessed through Similarity Indices (SI) quantifying their pattern variability. These include: Coefficient of Multiple Correlation (CMC) [1]; Mean Absolute Variability (MAV) [2]; and Linear Fit Method (LFM) [3], which accounts for scaling (a1), offset (a0) and truthfulness of the linear model between the curves (R2). Among gait cycles, the intra-subject variability for a given joint is due to physiological fluctuations of the range of motion (ROM) and time shift. SIs might be differently affected for each joint, due to their different ROMs, and by marker positioning, leading to offsets among gait curves. This paper aims to investigate the effects that each of these sources of curve variability has on the SIs, in order to provide indications on which is the most suitable for the assessment of gait similarity

Strangulated hiatal hernia remains a challenge in surgical emergency: Literature review and our experience

Introduction. Upside-down stomach (UDS) is the rarest type of hiatal hernia (<5%). It is characterized by herniation of the entire stomach or most gastric portions into the posterior mediastinum. It is a very rare condition and it is associated with a risk of incarceration as well as volvulus development. All of these complications represent true emergencies as life-threatening conditions. Material & methods. Case 1: A 62-year-old woman with an incarcerated and ischemic paraesophageal hiatal hernia with a stomach perforation. A total gastrectomy was performed with a Roux en-Y esophago-jejunostomy. The patient was discharged after 15 days without any complication. Case 2: A 84-year-old woman with the evidence at the computer tomography scan all of her stomach and parts of her jejunum and pancreas were drawn into the hernia sac herniated in her thorax. An exploratory laparotomy was performed which showed edematous intraperitoneal portion of the pyloric antrum, a total gastrectomy was performed and Roux en-Y esophago-jejunostomy was performed. The patient was placed in the intensive care unit, where she was instable and she developed sepsis. She died on 7th postoperative day. Case 3: A 76-year-old man presented in our department as emergency with the diagnosis of an incarcerated and ischemic paraesophageal hiatal hernia. An exploratory laparotomy was performed which showed an incarcerated and strangulated hiatal hernia. A section of the cardias and the body of the stomach was performed. The patient was placed in the intensive care unit, where he was instable and he developed sepsis which caused his death. Discussion. Surgery for incarcerated paraesophageal hernia or upside-down stomach has to be performed emergently as incarceration can become irreversible and severe bleeding can occur due to distension and vascular dilation. Moreover, ischemia and gastric perforation are on the verge. However, there are no clear evidence or existing guidelines on the management of acute paraesophageal hernia or upside-down stomach. In our literature review we analyzed clinical case reports and case series studies of strangulated hiatal hernia published between 2013 and 2019 published in PubMed. Conclusion. Management of strangulated hiatal hernia remains a challenge in general surgery. Open approach is suggested for unstable patients and an emergent laparoscopic reduction and repair is reasonable in stable patients

Management of bile duct injuries after cholecystectomy: Therapeutic approach and examination of possible sources of error. Report of 2 cases

Background: Bile duct injuries is the primary concern of general surgeons during and after cholecystectomy, with an incidence ranging from 0.08% to 0.4%. Through the description of two cases we intend to discuss the management of most frequent types of bile duct injuries after cholecystectomy and examine some possible sources of error. Case reports: We have treated 2 cases previously operated by other surgical teams. Case report 1: patient undergoing laparoscopic cholecystectomy with lesion of the main bile duct, treated with its reconstruction with positioning of a T-drainage tube. Case report 2: patient with jaundice previously treated for incarcerated incisional hernia and gallbladder stones. We verified the presence of a stenosis of the main bile duct which was resolved with the positioning of a T-tube drainage Discussion: Many descriptions and classifications regarding iatrogenic lesions of the bile duct after cholecystectomy have been described, although some of them represent a good guide on the surgical approach to be adopted, but the surgical skills possessed by the operator remain the most important variables Conclusions: All possible precautions must be considered in order to avoid the possibility of damaging the biliary tree. In our opinion an anterograde approach during cholecystectomy offers greater safety

How emergency surgery has changed during the COVID-19 pandemic: A cohort study

Introduction: Various surgical societies constantly update their recommendations in order to adapt surgical activity on current Pandemic conditions. The aim of this study is to analyze how hospitalizations and emergency operations have changed in our Department of Medical and Surgical Sciences in the Hospital of Foggia during covid-19 pandemic. Methods: Our cohort-study was conducted by analyzing two groups of patients admitted to the Department of Medical and Surgical Sciences of the Hospital of Foggia: those admitted during the no-covid period from March 09th, 2019 to May 09th, 2019 and those during the covid period from March 09th, 2020 to May 09th, 2020. Results: A total of 750 patients admitted during the no-covid period of 2019 and 171 during the covid period of 2020, of these 222 were emergency admission during 2019 and 97 during 2020, 528 were elective admission during 2019 and 74 during 2020. Of the emergency admissions (222 during 2019 and 97 during 2020), 91 were operated during the no covid period in 2019 and 52 during the covid period in 2020. The mean Mannheim Peritonitis Index Score, that is a scoring system used in peritonitis which is simple and cost-effective, were 15.6 during the no covid period of 2019 and 22.2 during the covid period of 2020. We observed 29 post-operative complications during 2019 and 26 during 2020. Conclusions: Contraction of admissions for urgent and emergent conditions in the first period of lockdown has been followed from some positive effects as well as aggravating consequences

Beta-Catenin/HuR Post-Transcriptional Machinery Governs Cancer Stem Cell Features in Response to Hypoxia

Hypoxia has been long-time acknowledged as major cancer-promoting microenvironment. In such an energy-restrictive condition, post-transcriptional mechanisms gain importance over the energy-expensive gene transcription machinery. Here we show that the onset of hypoxia-induced cancer stem cell features requires the beta-catenin-dependent post-transcriptional up-regulation of CA9 and SNAI2 gene expression. In response to hypoxia, beta-catenin moves from the plasma membrane to the cytoplasm where it binds and stabilizes SNAI2 and CA9 mRNAs, in cooperation with the mRNA stabilizing protein HuR. We also provide evidence that the post-transcriptional activity of cytoplasmic beta-catenin operates under normoxia in basal-like/triple-negative breast cancer cells, where the beta-catenin knockdown suppresses the stem cell phenotype in vitro and tumor growth in vivo. In such cells, we unravel the generalized involvement of the beta-catenin-driven machinery in the stabilization of EGF-induced mRNAs, including the cancer stem cell regulator IL6. Our study highlights the crucial role of post-transcriptional mechanisms in the maintenance/acquisition of cancer stem cell features and suggests that the hindrance of cytoplasmic beta-catenin function may represent an unprecedented strategy for targeting breast cancer stem/basal-like cells

Four year follow-up of a randomised controlled trial comparing open and laparoscopic Nissen fundoplication in children

OBJECTIVE: To evaluate the 4-year results following a randomised controlled trial (RCT) comparing open (ONF) and laparoscopic (LNF) Nissen fundoplication in children. BACKGROUND: It is assumed that long-term results of ONF and LNF are comparable. No randomised studies have been performed in children. METHODS: A follow-up study was performed in children randomised to ONF or LNF (clinicaltrials.gov identifier NCT00259961). Recurrent gastro-oesophageal reflux (GER) was documented by upper gastrointestinal contrast study and/or 24-h pH study. Nutritional status, retching and other symptoms were investigated. A questionnaire was used to assess the quality of life before and after surgery. RESULTS: Thirty-nine children were randomised to ONF (n=20) or LNF (n=19). There were 15 ONF and 16 LNF neurologically impaired children. One patient (ONF group) was lost to follow-up. Follow-up was 4.1 years (3.1–5.3) for ONF group and 4.1 years (2.6–5.1) for LNF group (p=0.9). Seven neurologically impaired children had died by the time of follow-up (3 ONF, 4 LNF). Incidence of recurrent GER was 12.5% in the ONF and 20% in the LNF (p=ns). One patient in each group underwent redo-Nissen fundoplication. Nutritional status improved in both groups, as indicated by a significant increase in weight Z-score (p<0.01). Gas bloat and dumping syndrome were present in both groups (p=ns). Incidence of retching was lower in the laparoscopic group (p=0.01). Quality of life improved in both groups (p=ns). CONCLUSIONS: Open and laparoscopic Nissen provide similar control of reflux and quality of life at follow-up. LNF is associated with reduced incidence of retching persisting at 4-year follow-up. TRIAL REGISTRATION NUMBER: NCT00259961