22 research outputs found
Persistent and recurrent hyperparathyroidism - Attitude
No full textParathyroidectomy is the only curative treatment for pHPT, with a
success rate up to 98% if performed by experienced surgeons.
Is desmoplastic stromal reaction useful to modulate lymph node dissection in sporadic medullary thyroid carcinoma?
No full textBackground: Guiding surgical extent of sporadic medullary thyroid carcinoma on the basis of solely basal calcitonin levels has been questioned because of the potential postoperative complications and uncertain oncologic benefit. Desmoplastic stromal reaction has re-emerged as a promising marker of nodal metastases. We aimed to analyze the value of desmoplastic stromal reaction in tailoring surgical strategy as well as revisit the role of known predictive factors such as basal calcitonin. Methods: We retrospectively analyzed operations for medullary thyroid carcinoma between 1997 and 2022, including patients whose specimens were available for desmoplastic stromal reaction evaluation (2018–2022). Risk factors for nodal metastases were assessed using univariable and multivariable analyses. Predictors of nodal metastases and potential basal calcitonin thresholds with optimal sensitivity, specificity, positive predictive value, and negative predictive value were evaluated. Results: Among 246 medullary thyroid carcinomas, 139 sporadic unifocal cases were eligible and 57 patients were retrospectively evaluated for desmoplastic stromal reaction. After univariable analysis, desmoplastic stromal reaction positivity (P = .002), basal calcitonin >113 pg/mL (P = .004), and lesion size >20 mm (P = .042) were significantly associated with nodal metastases. After backward stepwise logistic regression, desmoplastic stromal reaction positivity and basal calcitonin >113 pg/mL resulted in being independent risk factors for nodal metastases. Desmoplastic stromal reaction positivity showed a 100% sensitivity, an 82.5% specificity, an 18.4% positive predictive value, and a 100% negative predictive value for nodal metastases. Conclusion: Our results suggest that for minimal desmoplastic stromal reaction– disease, prophylactic lateral neck dissection could be avoided. In contrast, lateral neck dissection should be strongly considered in cases of advanced disease (desmoplastic stromal reaction positivity and basal calcitonin >500 pg/mL). In case of desmoplastic stromal reaction positivity and bCT <500 pg/mL, the extension of lymph node dissection should be tailored to patient and lesion features
Robotic adrenalectomy: comparison of DaVinci, HUGOTM-RAS and Versius® platforms-a preliminary retrospective analysis
No full text: Robot-assisted adrenalectomy (RAA) has emerged as an advantageous approach in challenging cases and suspicious lesions, although high costs represent the main drawback to its broader application. Besides Da-Vinci, new platforms have been recently launched on the market and need to be validated in clinical practice. DaVinci, HUGOTM-RAS and Versius® platforms were introduced in our center in 2012, 2022, and 2024, respectively. We aimed to compare the perioperative outcomes of these robotic platforms. Among 730 adrenalectomies (2012-2024), 149 (20.4%) RAAs were performed. All procedures performed by means of HUGOTM-RAS and Versius® platforms were compared with similar procedures (in terms of patient's and lesion's features) performed with the DaVinci technology in the same period (2022-2024). Ten patients were included in each group. Patients' and lesions' features were similar. Median BMI and lesions' size were 27.9, 24.9, and 26.1 kg/m2 and 42.5, 42.5, and 32.5 mm in DaVinci, HUGOTM-RAS, and Versius® groups, respectively (p = 0.360, p = 0.236). The groups were comparable for docking time, console time, and operative time (5 vs. 5 vs. 7 min, p = 0.059, 58.5 vs. 58 vs. 39 min, p = 0.393, 109.5 vs. 110.5 vs. 104.1 min, p = 0.668, respectively). No conversion or perioperative complications were registered. Postoperative hospital stays were similar (2 days in all groups, p = 0.629). RAA, whatever platform is used, confirmed to be a safe and effective approach, potentially expanding indications for minimally invasive adrenalectomy. Even though new platforms have been applied in less demanding cases in our learning curve phase, the introduction of new different platforms may lead to a costs reduction, thus to a broader diffusion of RAA
Robotic-assisted Roux-en-Y gastric bypass with the novel platform HugoTM RAS: preliminary experience in 15 patients
No full textRobotic assisted surgery is a rapidly developing field in bariatric surgery. Its wide diffusion has led to the development and standardisation of robotic assisted approaches for various bariatric operations. However, further application has been limited thus far due to issues of cost-effectiveness and accessibility. The introduction of new robotic platforms may help overcome those obstacles. In this study, we present the first fifteen cases of Roux-en-Y Gastric Bypass (RYGB) operations performed with the new HugoTM RAS system (Medtronic, Minneapolis, MN, USA). From January to March 2023, consecutive patients scheduled for minimal invasive Roux-en-Y-Bypass were randomly selected and underwent the procedure robotic-assisted with the new platform. No exclusion criteria were applied. Seven female and eight male patients with a median BMI of 42 (range: 36–50) and obesity-related comorbidities in eight cases underwent RYGB. The median docking time was 7 min (range: 6–8.5) and the median console time was 100 min (range: 70–150). Procedures were performed without intraoperative complications and no conversion to laparoscopy or open surgery was noted. Operative times were indicative of a steep learning curve. No early post-operative complications were observed. Based on our initial experience, RYGB with the HugoTM RAS system is promising and may be integrated in established robotic programmes without requiring a long adaptation period
Impact of en bloc extended R0 resections on oncological outcome of locally advanced adrenocortical carcinoma
No full textIn locally advanced adrenocortical carcinoma (ACC) (ENSAT stage III – S-III) R0 surgery, involving en bloc extended resections, is the only potential curative treatment. We evaluated oncological outcomes and complications rate in S-III patients who underwent extended resection in comparison with stage I/II (S-I/II). Among 1098 adrenalectomies over 27 years (1997 –2024) in a tertiary referral center, medical records of ACC patients were reviewed, excluding stage IV and not-multivisceral resections in S-III patients. Forty-eight patients met the inclusion criteria: 6 S-I (12.5%), 36 S-II (75%) and 6 S-III (12.5%) patients. The latter patients’ cohort underwent multivisceral en bloc resections (3 total nephrectomies, one renal vein thrombectomy, one splenopancreasectomy associated with total nephrectomy, left hemicolectomy and omentectomy, one liver S6-S7-S8 resection). Open adrenalectomy was scheduled in all S-III patients. Minimally-invasive approach was scheduled in 21 (50%) S-I/II patients. Conversion to open adrenalectomy was registered in 5 out these 21 patients. Locoregional and distant disease recurrences were registered in 19% of S-I/II vs 33.3% of S-III patients and 28.6% of S-I/II vs 66.7% of S-III patients, respectively (p = 0.420, p = 0.064). Postoperative complications were observed in 21.4% of S-I/II patients and 16.7% of S-III patients (p = 0.788). Kaplan–Meier DFS and OS curves were comparable among the two groups (p = 0.255, p = 0.459, respectively). After univariable analysis, hyperfunction and chemotherapy were significantly associated with locoregional disease recurrence (p = 0.02, p = 0.04, respectively). OS and DFS of S-III ACC patients undergoing extended en bloc R0 resections were comparable to those of S-I/II patients, without increased postoperative morbidity
Comparison between DaVinci® and HugoTM-RAS Roux-en-Y Gastric Bypass in bariatric surgery
No full textThe application of a robotic platform in the bariatric surgical field is intended to enhance the already established advantages of minimally invasive surgery in terms of both technical and clinical outcomes. These advantages are especially relevant for technically challenging multiquadrant operations such as Roux-en-Y Gastric Bypass (RYGB). Consequently, robotic-assisted surgery has emerged as a possible application for bariatric surgeries. The study attempts to assess feasibility and safety of the HugoTM-Robotic-Assisted Surgery System (HugoTM-RAS) platform compared to the DaVinci® Surgical System (DaVinci®-SS) with a focus on complication rates and operative times. We retrospectively reviewed bariatric procedures performed from January 2013 until December 2023. We included all robotic RYGBs performed using HugoTM-RAS and DaVinci®-SS platforms. The study utilized Propensity Score Matching (PSM) analysis to address bias in selection, matching patients based on age, gender, body mass index, comorbidities and past abdominal operations. One hundred thirty-five patients were identified: 90 DaVinci®-SS and 45 HugoTM-RAS procedures. After PSM, each group consisted of 45 patients. There was no discernible disparity observed in relation to early (≤ 30 days) postoperative complications rate (p = 1), mean operative time (for docking time, console time and total operative time: p = 0.176, p = 0.678, p = 0.229, respectively) and postoperative hospital stay (p = 0.052) between DaVinci®-RSS and HugoTM-RAS procedures. Our results suggest that application of both HugoTM-RAS and DaVinci®-SS robotic platforms to RYGB is related to comparable safety profiles. Although DaVinci®-SS remains the most widely adopted platform in clinical practice, this study underscores the potential role of the HugoTM-RAS to provide effective solutions in robotic bariatric procedures
Partial intraoperative signal recovery is associated with normal postoperative vocal cord motility in patients with intraoperative loss of signal
No full textLoss of signal (LOS) at intraoperative nerve monitoring (IONM) is defined as an >100 mV amplitude decrease and a >10% latency reduction and represents a predictor of postoperative impaired vocal cord motility (VCM). We aimed to evaluate if an intraoperative signal recovery (ISR) after LOS may predict a positive outcome of VCM. Among 5884 consecutive intermittent IONM-guided thyroidectomies (April 2021- March 2025) all the patients in whom a LOS was observed were evaluated. Topic and intravenous corticosteroids were administered to all of them. Eventual recovery was evaluated after 20 minutes. Patients with an ISR less than 50% compared to the baseline were included. The rate of vagal signal (VS) ISR was defined as a percent from the minimum value: VS-recovery–VS-minimal/VS-predissection–VS-minumum. ISR was correlated to VCM (ROC curve analysis). Among 169 patients with LOS, 65 (38.5%) showed ISR, with 48 (73.8%) of them exhibiting normal VCM on postoperative day 1 (POD-1). The remaining 17 patients with impaired VCM on POD-1 recovered normal VCM on POD-15 (7–10.8%) or POD-30 (10–15.4%). The AUC for impaired VCM at POD-1 was 0.938 (95% CI: 0.849–0.983, p <0.0001) and the ISR cut-off was 13%, with a 94.1% sensitivity and a 89.6% specificity. All patients with ISR >31% showed normal VCM. All patients with ISR <13% exhibited impaired motility at POD-15 but recovered at POD-30. ISR can predict full recovery of VCM. ISR >31% is associated with normal postoperative VCM and staged thyroidectomy could be avoided in this subgroup of patients with LOS
Is conservative treatment always safe in unifocal clinically T1a/node-negative papillary thyroid carcinoma?
No full textBackground: Management of clinically unifocal node-negative papillary thyroid carcinoma ≤1 cm (PTMC) is controversial with nonsurgical treatment as a potential alternative to thyroid lobectomy (TL). However, conservative strategies, such as active surveillance or thermal ablation, do not allow the evaluation of biological aggressive features or occult lymph node metastases (LNMs), which play a primary role as prognostic factors. Methods: Among 4216 thyroidectomies for malignancy (between September 2014 and September 2023), TL plus ipsilateral central neck dissection was performed in 203 (4.8%) unifocal N0 PTMCs. Completion thyroidectomy was accomplished in case of positive frozen section examination of removed nodes or within 6 months from index operation in presence of biological aggressive features. Results: Seventy-six out of 203 (37.4%) patients were staged pN1a and extranodal extension was detected in 5 (6.6%) patients. At final histology, biological aggressive features, including multifocality, lymphovascular invasion (LVI), extracapsular invasion, tumor aggressive subtypes, and BRAF-V600E mutation, were detected in 69 (34%), 93 (45.8%), 3 (1.5%), 30 (14.8%), and 7 (3.5%) patients, respectively. A comparative analysis between pN0 and pN1a patients showed younger age (p < 0.001), LVI (p = 0.037), and multifocality (p < 0.001) as risk factors for occult central LNMs. After logistic regression analysis, age (p < 0.001) and multifocality (p < 0.001) were confirmed as independent risk factors for nodal involvement. Conclusions: Although most PTMC has been widely defined as indolent disease, a non-negligible rate of patients may present one or more biologically aggressive features including nodal involvement. Nonsurgical management should be considered with caution to avoid undertreatment especially in the younger population
Robot-assisted vs laparoscopic bariatric procedures in super-obese patients: clinical and economic outcomes
No full textThe increased operative time and costs represent the main limitations of robotic technology application to bariatric surgery. Robotic platforms may help the surgeon to overcome the technical difficulties in super-obese (SO, BMI ≥ 50 kg/m2) patients, in which multi-quadrant operations could be challenging. We aimed to evaluate the effect of robot-assisted (R) versus laparoscopic (L) approaches in Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) and Roux-en-Y Gastric Bypass (RYGB) in SO and Super-Super Obese (SSO, BMI ≥ 60 kg/m2) patients in terms of outcomes and cost-effectiveness. Bariatric procedures performed from 2012 to 2023 were retrospectively reviewed. The inclusion criteria were BMI ≥ 50 kg/m2, primary SADI-S or RYGB. Operative time (OT), early complications, post-operative stay (POS), overall costs and follow-up data were analyzed. A subgroup analysis for surgical procedures and SSO patients was also performed. Among 4596 patients, 174 RYGB and 91 SADI-S in BMI ≥ 50 kg/m2 patients were selected. After Propensity Score Matching analysis, two groups of patients were identified (laparoscopic and robot-assisted), each one composed of 18 RYGB and 26 SADI-S. Intraoperative and post-operative complication rates and POS were comparable. Mean OT was longer in robotic procedures compared with laparoscopy (199.1 ± 65.7 and 109.5 ± 39.1 min, respectively, p < 0.001). The difference in OT was eliminated after only SSO patients were included in the analysis (172.7 ± 24.1 vs 152.6 ± 26.2 min for R-SADI-S and L-SADI-S, respectively, p = 0.107). Robotic surgeries were associated with higher costs (8134.6 ± 1886.7 and 2386.7 ± 388.2 € in R-RYGB and L-RYGB, respectively; 7996.6 ± 873.1 and 3954.6 ± 631.1 € in R-SADI-S and L-SADI-S). Despite increased costs, robotic approach may represent an added value in more complex cases such as SSO patients
Robot-assisted vs laparoscopic lateral transabdominal adrenalectomy: a propensity score matching analysis
No full textBACKGROUND: Laparoscopic adrenalectomy (LA) is the gold standard treatment for adrenal lesions. Robot-assisted adrenalectomy (RAA) is a safe approach, associated with higher costs in absence of clear-cut benefits. Several series reported some advantages of RAA over LA in challenging cases, but definitive conclusions are lacking. We evaluated the cost effectiveness and outcomes of robotic (R-LTA) and laparoscopic (L-LTA) approach for lateral transabdominal adrenalectomy in a high-volume center. METHODS: Among 356 minimally invasive adrenalectomies (January 2012–August 2021), 286 were performed with a lateral transabdominal approach: 191 L-LTA and 95 R-LTA. The R-LTA and L-LTA patients were matched for lesion side and size, hormone secretion, and BMI with propensity score matching (PSM) analysis. Postoperative complications, operative time (OT), postoperative stay (POS), and costs were compared. RESULTS: PSM analysis identified 184 patients, 92 in R-LTA and 92 in L-LTA group. The two groups were well matched. The median lesion size was 4 cm in both groups (p = 0.533). Hormonal hypersecretion was detected in 55 and 54 patients of R-LTA and L-LTA group, respectively (p = 1). Median OT was significantly longer in R-LTA group (90.0 vs 65.0 min) (p 75 min (OR = 8.177, p = 0.048). CONCLUSIONS: The postoperative outcomes of R-LTA and L-TLA were similar in our experience. Despite the higher cost, RAA appears to be cost effective and economically sustainable in a high-volume center (60 adrenalectomies/year), especially if performed in challenging cases, including patients with large (> 6 cm) and/or functioning tumors. GRAPHICAL ABSTRACT: [Image: see text] SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00464-022-09663-3
