TC-CBDE is safe and effective in the majority of cases of CBDS. The incidence of recurrence is low but there are some risk factors, such as number of stones >3 with biliary sludge, which do not favor the successful outcome of the procedure. In such cases, it is essential that the TC-CBDE is integrated with other procedures which, although more complex, assure the clearance of the bile duct.

Hypocalcemia is the most frequent major complication following total thyroidectomy (TT), delaying timely hospital demission. We prospectively evaluated the diagnostic utility of parathyroid hormone (PTH) measured one hour after TT and the delta (post-minus pre-surgery) PTH in order to determine which biomarker best predicted post-surgery hypocalcemia. Ninety-six consecutive patients, with either plurinodular goiter, Graves' disease or cervico-mediastinal goiter (22 (23%) men and 74 (77%) women, mean age 48.5 ± 15.2 and 47.9 ± 13.2 years, respectively), scheduled to undergo TT were enrolled. PTH was measured prior and one hour after surgery. Delta PTH was defined as one-hour post-surgery values minus pre-surgery PTH level. Hypocalcemia was defined as a calcemia under 8.0 mg/dL. Receiver operating characteristic (ROC) analysis was used to evaluate the Area Under Curve (AUC), sensibility and specificity of the two biomarkers for the occurrence of hypocalcemia. Forty-nine (51%) patients presented biochemical values under the cut-off but only 17 (18%) had clinical symptoms. Both variables yielded statistically significant AUC (PTH one-hour post surgery: 0.654; p = 0.0403; 95%CI: 0.519-0.773 and delta PTH: 0.659; p = 0.0263; 95%CI: 0.527-0.776). Although comparison of the two ROC curves did not yield significant differences, delta PTH yielded a better sensitivity and PTH one-hour post-TT yielded a marginally better specificity (sensitivity of 50% and 87% and specificity of 76% and 67% for cut-offs of <39.8 pg/dl and <54.5 pg/dl, respectively). Both biomarkers have similar diagnostic accuracy for hypocalcemia, and can be used to indicate when supplemental therapy should be implemented in order to favor a timely discharge.

The definition of substernal goiter (SG) is based on variable criteria leading to a considerable variation in the reported incidence (from 0.2% to 45%). The peri- and postoperative complications are higher in total thyroidectomy (TT) for SG than that for cervical goiter. The aim of this study was to evaluate the preoperative risk factors associated with postoperative complications. From 2002 to 2014, 142 (8.5%; 98 women and 44 men) of the 1690 patients who underwent TT had a SG. We retrospectively evaluated the following parameters: sex, age, histology, pre- and retrovascular position, recurrence, and extension beyond the carina. These parameters were then related to the postoperative complications: seroma/hematoma, transient and permanent hypocalcemia, transient and permanent laryngeal nerve palsy, and the length of surgery. The results were further compared with a control group of 120 patients operated on in the same period with TT for cervical goiter. All but two procedures were terminated via cervicotomy, where partial sternotomies were required. No perioperative mortality was observed. Results of the statistical analysis (Student’s t-test and Fisher’s exact test) indicated an association between recurrence and extension beyond the carina with all postoperative complications. The group that underwent TT of SG showed a statistically significant higher risk for transient hypocalcemia (relative risk =1.767 with 95% confidence interval: 1.131–2.7605, P=0.0124, and need to treat =7.1) and a trend toward significance for transient recurrent laryngeal nerve palsy (relative risk =6.7806 with 95% confidence interval: 0.8577–53.2898, P=0.0696, and need to treat =20.8) compared to the group that underwent TT of cervical goiter. TT is the procedure to perform in SG even if the incidence of complications is higher than for cervical goiters. The major risk factors associated with postoperative complications are recurrence and extension beyond the carina. In the presence of these factors, greater care should be taken.

Background We utilized transcystic clearance and intra-operative papillotomy through a rendezvous technique for the treatment of cholecysto-choledocolithiasis. The goal of this study was to evaluate the reliability of pre-operative parameters to address the most suitable surgical procedure. Methods A total of 180 patients affected by calculi of the gallbladder and bile duct underwent the single-stage treatment. According to several pre-operative parameters, 141 patients had to supposedly undergo transcystic clearance of the bile duct, while 39 patients had to be treated with the rendezvous technique. All patients were treated with the sequential procedure: first, we tried the transcystic procedure and, if there was a failure, we used a rendezvous technique. We prospectively analysed each group based on a series of variables such as sex, age, operative time, success rate of proposed treatment, conversion rate, post-operative complications and hospital stay. Results Transcystic clearance was successful in 134 out of 141 patients (95.0%), while 2 patients needed to undergo a laparo-endoscopy procedure (failure). Thirty-five out of 39 patients (89.7%) obtained common bile-duct (CBD) clearance through the rendezvous technique, while 1 patient obtained clean-up through the simple transcystic procedure (failure). Five out of 141 patients with transcystic clearance and 3 out of 39 patients with the rendezvous technique underwent laparotomy CBD clearance with conversion rates of 3.5% and 7.7%, respectively. Post-operative complications showed similar percentages for both procedures. However, the surgical time turned out to be longer for the rendezvous technique. Conclusions The one-stage procedure for the treatment of cholecysto-choledocolithiasis was possible in 94% of the cases utilizing a surgical technique selected according to the patient’s case history. The pre-operative parameters, such as jaundice, CBD diameters and stone diameters, have certified their reliability as good predictors of the most suitable procedure to follow.

Patients with symptomatic gallstones present common bile duct stones in approximately 10% of cases. It is possible to resolve both gallbladder and bile duct stones with a single procedure. The aim of this study is to determine the effectiveness of a single stage procedure for gallbladder and bile duct stones in the elderly patients and to expose the differences between the various techniques. From January 2008 to December 2013, we treated 1540 patients with gallbladder stones. In 152 cases, we also found bile duct stones. 150 of these were treated in a single stage procedure. We divided our patients into 2 groups: Group A was younger than 65 (104 patients); Group B was 65 or older (46 patients). We retrospectively compared sex, ASA score, conversion rate, success rate, post-operative complications, hospital stay, and treatment method. We had no intra-operative mortality. 1 patient in Group B, heart condition (ASA 4), died with multiple organ failure (MOF) 10 days after his operation. ASA score: 3.5 ± 0.5 in A vs 2 ± 0.9 in B (P 0.001), post-operative complications 6% in A vs 18.1% in B (P 0.0325) and hospital stay 4.1 ± 2.3 in A vs 9.5 ± 5.5 in B (P 0.0001) were significantly higher in Group B. No differences were found in term of success rate: 94% in A vs 90% in B (P 0.4944). The procedure used to obtain the clearance of the bile duct showed a different success rate across the two groups: for the patients under 65 years old, trans-cystic clearance (TC-CBDE) was successful in 90% of cases, and only 51% for those older than 65, where we had to recall 49% for laparo-endoscopic rendez-vous (RV-IOERC) (P 0.0014). In conclusion, single stage treatment is safe and effective also to elderly patients. The methods used in patients being younger than 65 years old is what appeared to be significantly different.