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L' agoaspirato tiroideo sotto guida elastosonografica: studio prospettico randomizzato e revisione della Letteratura
Full text linkL' agoaspirato ecoguidato (FNA) rappresenta ad oggi il gold standard per la diagnosi della patologia nodulare tiroidea. L’esame è caratterizzato da un basso tasso di complicanze e da una buona tollerabilità da parte del paziente. Nonostante l’agoaspirato presenti una elevata sensibilità e specificità, è tuttavia gravato da una certa percentuale di campioni non diagnostici che si attesta a seconda delle varie casistiche tra il 10 ed il 30%. Un prelievo non diagnostico può portare a procedure ripetute, aumentando la morbilità del paziente, i costi, nla probabilità di complicanze ed il ritardo nella diagnosi.
Un altro importante limite dell'esame citologico è rappresentato dai prelievi "indeterminati", classificati come TIR 3, per i quali i soli criteri citologici non sono sufficienti a definire la benignità o malignità della lesione. I noduli tiroidei TIR 3 risultano infatti maligni all'istologia in una percentuale compresa tra il 10 e il 30% a seconda delle diverse casistiche.
Le linee guida della Società Italiana di Anatomia Patologica e Citologia Diagnostica sulla classificazione citologica dell’agoaspirato tiroideo suddividono questa categoria in due sottocategorie, TIR 3A, con un rischio di malignità atteso del 5-10%, e la categoria TIR 3B con un
rischio del 15-30%. Le linee guida indicano la chirurgia come trattamento di scelta solo per la categoria TIR 3B, mentre per la categoria a rischio minore è consigliabile il follow-up clinico e l’eventuale ripetizione dell’esame a distanza.
Tuttavia, nonostante lo sforzo classificativo, la categoria TIR3 rischia spesso di configurarsi, sia per il patologo che per il clinico, come una vera e propria "zona grigia".
Recentemente l’elastosonografia ha attirato notevole interesse per la sua capacità di differenziare la patologia nodulare tiroidea benigna da quella maligna, in base alle caratteristiche di elasticità dei tessuti. Dal momento che tale metodica è in grado di definire, anche all’interno dello stesso nodulo, aree con maggiore o minore ‘rigidità’, abbiamo ipotizzato che ottenere una mappa della lesione nodulare potesse ‘guidare’ il prelievo citologico sulla zona ottimale da campionare.
Dopo aver analizzato sistematicamente le più recenti evidenze scientifiche inerenti l'elastosonografia e la citoaspirazione tiroidea, è stato condotto uno studio prospettico randomizzato sull' applicazione della tecnologia elastosonografica all' esame citoaspirativo tirodeo.
Lo studio ha compreso un totale di 62 pazienti (50 F, 12 M, età media 40,1 ± 5,2 anni, range: 28-68 anni) randomizzati in due gruppi: Gruppo A (31 pazienti) con nodulo tiroideo sottoposto a FNA convenzionale (ecoguidato), Gruppo B (31 pazienti) con nodulo tiroideo sottoposto a FNA con selezione dell'area da campionare mediante esame elastosonografico.
Il campionamento effettuato sotto guida elastosonografica delle aree caratterizzate da maggior rigidità (colore blu) ha prodotto una percentuale di prelievi non diagnostici pari al 6.4 % (2 TIR1) mentre la percentuale di agoaspirati non diagnostici eseguiti sotto guida ecografica (9 TIR 1) è stata del 29 % (p=0.02). La distribuzione nei Gruppi A e B delle altre categorie diagnostiche non ha presentato differenze statisticamente significative (p >0.05). La sensibilità e la specificità delle due diverse metodiche citoaspirative sono risultate sostanzialmente sovrapponibili.
L’ applicazione della metodica elastosonografica ha determinato una riduzione degli agoaspirati non diagnostici (TIR 1) del 22,6%, supportando l'ipotesi che una mappa elastosonografica della formazione nodulare possa efficacemente guidare il prelievo citologico sulla zona ottimale da campionare, riducendo i costi, le complicanze e soprattutto il disconfort per il paziente derivante dalla reiterazione dell' esame.
Sebbene tali risultati siano supportati da una ridotta numerosità campionaria, aprono nuove prospettive nella ricerca e nello sviluppo di metodiche innovative, capaci di incrementare l'accuratezza diagnostica dell'agoaspirato tiroideo
Postpartum deep vein thrombosis and pulmonary embolism in twin pregnancy: undertaking of clinical symptoms leading to massive complications.
No full textLong-term results after laparoscopic sleeve gastrectomy in a large monocentric series
No full textBackground: Laparoscopic sleevegastrectomy(SG)hasgainedgreatpopularityasastand-alone
bariatric procedurebecauseshort-andmid-termoutcomesintermsofweightlossandresolutionof
co-morbidities havebeenverypositive.However,long-termresultsfromlargeseriesstillaresparse.
Objectives: To evaluatethelong-termclinicaloutcomesofSGinalargeseriesofpatients
undergoing SGasastand-aloneprocedure.
Setting: University hospitalinItaly.
Methods: A retrospectiveanalysisofprospectivelycollecteddatafrom182patientsundergoingSG
between 2006and2008intheauthors’ institution. Long-termoutcomesat6and7yearswere
analyzed intermsofweightlossandco-morbiditiesresolution.
Results: Mean initialbodymassindex(BMI)was45.9 7.3 kg/m2. Majorpostoperativecom-
plications occurredin8patients(5.4%):4leaks,2bleeding,1abdominalcollection,and1dys-
phagia. Allcomplicationsweremanagedconservatively.Onehundredforty-eightpatients(81.4%)
completed the72-month(6-year)follow-up.Thirty-sevenpatients(25%)reachedafollow-upof84
months. Atyear6follow-upthemeanBMIandthemeanpercentageofexcessweightloss(%EWL)
were 30.2kg/m2 and 67.3%,respectively.Meantotalbodyweightlosswas44.9kg,whilea%EWL
450 wasregisteredin123patients(83.1%).PreoperativeBMIdidnotsignificantly influence
postoperative %EWL.Remissionoftype2diabetesmellitus,arterialhypertension,obstructivesleep
apnea syndrome,andgastroesophagealreflux diseasesymptomsoccurredin83.8%,59.7%,75.6%,
and 64.7%ofpatients,respectively.
Conclusion: %EWL andresolutionofco-morbiditiesappeartobesustained6and7yearsafterSG.
Preoperative BMIisnotpredictiveforweightlossoutcome
Learning curve for laparoscopic sleeve gastrectomy. Role of training in a high-volume bariatric center
No full textBackground Since the great diffusion of laparoscopic
treatment of obesity, there is a growing interest concerning
the learning process for those surgeons who undertake the
bariatric activity. However, papers analyzing the learning
curve (LC) for sleeve gastrectomy (SG) are still scarce.
This study aims to investigate whether the LC for SG of a
novice bariatric surgeon might be positively influenced by
the training in a high-volume bariatric center (HVBC).
Methods Between October 2010 and January 2014, 128
patients underwent SG by the same young surgeon who
previously attended a 2-year training in a HVBC. His LC has
been divided into three consecutive periods: in the first
period (1st–47th SGs) he operated in the HVBC, while in the
second (48th–88th SGs) and third period (89th–128th SGs)
he moved to a novel department where surgical and ancillary
staff were initially not confident with bariatric procedures
but progressively owned the proper experience. Preoperative
characteristics, operative data, complications and postoperative
results of the three periods were compared.
Results Mean follow-up was 1 year. Preoperative
patients’ characteristics were homogeneous. No significant
differences have been registered among the three
periods concerning operative data, mortality, intra- and
post-operative complications, weight loss outcomes and
comorbidities’ resolution. Post-operative follow-up rates
at 6 and 12 months were 98.4 and 92.1 %, respectively.
Conclusions Long-lasting fellowship in a HVBC might
allow the novel bariatric surgeon to safely and proficiently
overcome the LC for SG, even in a new established bariatric
setting
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Role of Virtual Reality Simulators in the certification of bariatric surgeons
No full textAIMS: Several studies showed construct validity of virtual laparoscopic simulators for basic laparoscopic skills, however it is not yet clear whether the simulators can identify the actual experience of surgeons in more complex procedures such as laparoscopic Roux-en-Y gastric bypass. Our study tested the ability of the Lap Mentor simulator (SimbionixTM) to recognize the experience in advanced laparoscopic procedures assessing its role in the certification of bariatric surgeons.
METHODS: 30 surgeons were divided into two groups according to their experience in laparoscopic and bariatric surgery: General group included 15 general surgeons performing between 75 and 100 non bariatric laparoscopic procedures; Bariatric group included 15 bariatric surgeons performing between 50 and 100 laparoscopic bariatric procedures. Participants were tested on the laparoscopic simulator in one basic task (Task 1: eye-hand coordination) and in two tasks of the gastric bypass module (Task 2: creation of the gastric pouch, Task 3: gastro-jejunal anastomosis).
RESULTS: Comparing the groups, no significant differences were found in task 1 confirming the homogeneity of the two groups for basic laparoscopic skills. Analyzing the results from the gastric bypass module (bariatric vs. general), in task 2, significant differences (p < 0.05) were found in the median volume of the gastric pouch (22 vs. 48 cm3), in the percentage of fundus included in the pouch (8.8 vs. 30.1 %), in the complete dissection at the angle of His (14 vs. 4), and in safety parameters. In task 3, significant differences were found in the size and position of enterotomies.
CONCLUSIONS: Lap MentorTM simulator is able to recognize specific skills of bariatric surgeons also in technical details that affect long-term results of the procedure such as dissection at the angle of His and gastric pouch volume. Furthermore, the possibility of analyzing in details the performance can help define skills where the surgeon is more lacking. These findings suggest a potential role in tailoring the training to maximize improvement. The Lap Mentor may be proposed as a certification tool for bariatric surgeons
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