Aim: Intraperitoneal drains are often placed during emergency colorectal surgery. However, there is a lack of evidence supporting their use. This study aimed to describe the efficacy and safety of intraperitoneal drain placement after emergency colorectal surgery. Method: COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS) is a prospective, international, cohort study into which consecutive adult patients undergoing emergency colorectal surgery were enrolled (from 3 February 2020 to 8 March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included rate and time-to-diagnosis of postoperative intraperitoneal collections, rate of surgical site infections (SSIs), time to discharge and 30-day major postoperative complications (Clavien-Dindo III-V). Multivariable logistic and Cox proportional hazards regressions were used to estimate the independent association of the outcomes with drain placement. Results: Some 725 patients (median age 68.0years; 349 [48.1%] women) from 22 countries were included. The drain insertion rate was 53.7% (389 patients). Following multivariable adjustment, drains were not significantly associated with reduced rates (odds ratio [OR] =1.56, 95% CI: 0.48-5.02, p=0.457) or earlier detection (hazard ratio [HR] =1.07, 95% CI: 0.61-1.90, p=0.805) of collections. Drains were not significantly associated with worse major postoperative complications (OR=1.26, 95% CI: 0.67-2.36, p=0.478), delayed hospital discharge (HR=1.11, 95% CI: 0.91-1.36, p=0.303) or increased risk of SSIs (OR=1.61, 95% CI: 0.87-2.99, p=0.128). Conclusion: This is the first study investigating placement of intraperitoneal drains following emergency colorectal surgery. The safety and clinical benefit of drains remain uncertain. Equipoise exists for randomized trials to define the safety and efficacy of drains in emergency colorectal surgery.

Patient: Female, 52-year-old Final Diagnosis: Stage IA serous borderline ovarian tumor Symptoms: Abdominal distention • reflux • early satiety • constipation • difficulty in ambulation • dyspnea Clinical Procedure: — Specialty: Anesthesiology • Obstetrics and Gynecology • Plastic Surgery • Radiology • Surgery Objective: Rare disease Background: In contemporary gynecological practice, encountering giant ovarian tumors is a rarity. While most are benign and of the mucinous subtype, the borderline variant only accounts for approximately 10% of these cases. This paper addresses the paucity of information about this specific subtype, emphasizing critical elements of managing borderline tumors that can pose life-threatening complications. Additionally, a review of other documented cases of the borderline variant in the literature is also included to foster a deeper understanding of this uncommon condition. Case Report: We present the multidisciplinary management of a 52-year-old symptomatic woman with a giant serous borderline ovarian tumor. Preoperative assessment showed a multiloculated pelvic-abdominal cyst responsible for compression of the bowel and retroperitoneal organs, and dyspnea. All tumor markers were negative. Together with anesthesiologists and interventional cardiologists, we decided to perform a controlled drainage of the cyst of the tumor, to prevent hemodynamic instability. Subsequent total extrafascial hysterectomy, contralateral salpingo-oophorectomy, and abdominal wall reconstruction, followed by admission to the intensive care unit, were also conducted by the multidisciplinary team. During the postoperative period, the patient experienced a cardiopulmonary arrest and acute renal failure, which were managed by dialysis. After discharge, the patient underwent oncologic followup, and after 2 years, she was found to be completely recovered and disease free. Conclusions: Intraoperative controlled drainage of Giant ovarian tumor fluid, planned by a multidisciplinary management team, constitutes a valid and safe alternative to the popular choice of “en bloc” tumor resection. This approach avoids rapid changes in body circulation, which are responsible for intraoperative and postoperative severe complications.

BACKGROUND In contemporary gynecological practice, encountering giant ovarian tumors is a rarity. While most are benign and of the mucinous subtype, the borderline variant only accounts for approximately 10% of these cases. This paper addresses the paucity of information about this specific subtype, emphasizing critical elements of managing borderline tumors that can pose life-threatening complications. Additionally, a review of other documented cases of the borderline variant in the literature is also included to foster a deeper understanding of this uncommon condition. CASE REPORT We present the multidisciplinary management of a 52-year-old symptomatic woman with a giant serous borderline ovarian tumor. Preoperative assessment showed a multiloculated pelvic-abdominal cyst responsible for compression of the bowel and retroperitoneal organs, and dyspnea. All tumor markers were negative. Together with anesthesiologists and interventional cardiologists, we decided to perform a controlled drainage of the cyst of the tumor, to prevent hemodynamic instability. Subsequent total extrafascial hysterectomy, contralateral salpingo-oophorectomy, and abdominal wall reconstruction, followed by admission to the intensive care unit, were also conducted by the multidisciplinary team. During the postoperative period, the patient experienced a cardiopulmonary arrest and acute renal failure, which were managed by dialysis. After discharge, the patient underwent oncologic followup, and after 2 years, she was found to be completely recovered and disease free. CONCLUSIONS Intraoperative controlled drainage of Giant ovarian tumor fluid, planned by a multidisciplinary management team, constitutes a valid and safe alternative to the popular choice of "en bloc" tumor resection. This approach avoids rapid changes in body circulation, which are responsible for intraoperative and postoperative severe complications.

INTRODUCTION:Hypoparathyroidism represents a common complication following total thyroidectomy. To date, there is still no reliable and immediate postoperative parameter to establish which patients with postsurgical hypoparathyroidism will develop permanent hypoparathyroidism. The main purpose of the present study was to assess whether the intact parathyroid hormone (iPTH) value on the first postoperative day is a good predictor of permanent hypoparathyroidism. MATERIAL AND METHODS:Patients undergoing thyroidectomy in our unit between March 2018 and January 2020 were analysed. According to the iPTH value on the first postoperative day and on the basis of the detection threshold of the iPTH test used, patients were divided into two groups: Group A (iPTH ≥ 4.6 pg/mL) and Group B (iPTH < 4.6 pg/mL, undetectable). RESULTS:In total 426 patients were included: 364 in Group A and 62 in Group B. Permanent hypoparathyroidism occurred in 3 (0.82%) patients from Group A and in 26 (41.94%) from Group B (p < 0.001). When iPTH levels were < 4.6 pg/mL on the first postoperative day the sensitivity for the prediction of permanent hypoparathyroidism was 89.66%, the specificity was 90.93%, the positive predictive value (PPV) was 41.94%, the negative predicitive value (NPV) was 99.18% and the accuracy was 90.85%. CONCLUSIONS:An iPTH value < 4.6 pg/mL on the first postoperative day following total thyroidectomy has proven to be a good parameter for early identification of patients at high risk for permanent hypoparathyroidism. Moreover, we want to underline that in our experience no patient with an iPTH level > 6.5 pg/mL developed this complication.

Background: In thyroid surgery, achieving accurate haemostasis is fundamental in order to avoid the occurrence of complications. Energy-based devices are currently extensively utilized in this field of surgery. This study aims to compare Harmonic Focus and Thunderbeat Open Fine Jaw with regard to surgical outcomes and complications. Methods: Patients submitted to total thyroidectomy in our center, between January 2017 and June 2020, were retrospectively analysed. Based on the energy-based device utilized, two groups were identified: Group A (Harmonic Focus) and Group B (Thunderbeat Open Fine Jaw). Results: A total of 527 patients were included: 409 in Group A and 118 in Group B. About surgical outcomes, the mean operative time was significantly shorter in Group B than in Group A (p < 0.001), while as regards complications, the occurrence of transient recurrent laryngeal nerve injury was significantly greater in Group B than in Group A (p = 0.019). Conclusions. Both Harmonic Focus and Thunderbeat Open Fine Jaw have proven to be effective devices. Operative times were significantly shorter in thyroidectomies performed with Thunderbeat Open Fine Jaw; however, the occurrence of transient recurrent laryngeal nerve injury was significantly greater in patients operated on with this device.

Preoperative localisation of pathological glands in patients with primary hyperparathyroidism (PHP) is the mainstay for mini-invasive parathyroidectomy. Nevertheless, a not negligible number of patients presents discordant or negative neck ultrasound (US) and 99mTc-Sestamibi (MIBI) scan. The aim of this study was to assess if a mini-invasive approach is feasible in this kind of patients. In this retrospective study were included patients that underwent parathyroidectomy for PHP. Patients were divided into two groups according to concordance of US and MIBI scan results. 242 patients were included: 183 had concordant preoperative studies, and 59 had discordant or negative studies. A mini-invasive approach was possible in 42 (72.9%) patients with unclear preoperative studies, whereas 12 (20.3%) additional patients required conversion to BNE. The incidence of persistent PHP was higher in patients with unclear preoperative studies (8.5% vs 2.7%), but this difference did not reach a statistical significance (p = 0.121). In patients with unclear preoperative studies, a negative result of intraoperative PTH allowed to avoid a persistent disease in 12 patients, while in 3 cases led to an unnecessary additional exploration. In patients with discordant preoperative studies a mini-invasive approach is feasible; in this setting, the use of intraoperative PTH is mandatory to reduce the incidence of persistent PHP.

Introduction/Background The aim of this retrospective study was to investigate the incidence of mesenteric lymph node (MLN) involvement in patients undergoing a bowel resection at the time of debulking surgery in advanced ovarian cancer (OC). Methodology OC patients undergoing rectosigmoid resection during primary debulking surgery or interval debulking surgery were recorded. The characteristics of mesenteric node involvement were evaluated. Results MLNs were detected in 29/54 patients (54%); the rate of MLN involvement was 61%. A progressive increase in the rate of metastatic MLNs was documented in association with depth of bowel infiltration (p=0.009). A statistic correlation between positive MLN and pelvic lymph nodes (PLN) (p=0.022), aortic lymph nodes (ALN) (p=0.005) was found. Conclusion OC patients undergoing rectosigmoid resection during debulking surgery revealed metastatic MLN involvement in 61% of cases. Metastatic MLN status is related to PLN and ALN metastases.

Abstract Background Many surgeons routinely place intraperitoneal drains after elective colorectal surgery. However, enhanced recovery after surgery guidelines recommend against their routine use owing to a lack of clear clinical benefit. This study aimed to describe international variation in intraperitoneal drain placement and the safety of this practice. Methods COMPASS (COMPlicAted intra-abdominal collectionS after colorectal Surgery) was a prospective, international, cohort study which enrolled consecutive adults undergoing elective colorectal surgery (February to March 2020). The primary outcome was the rate of intraperitoneal drain placement. Secondary outcomes included: rate and time to diagnosis of postoperative intraperitoneal collections; rate of surgical site infections (SSIs); time to discharge; and 30-day major postoperative complications (Clavien–Dindo grade at least III). After propensity score matching, multivariable logistic regression and Cox proportional hazards regression were used to estimate the independent association of the secondary outcomes with drain placement. Results Overall, 1805 patients from 22 countries were included (798 women, 44.2 per cent; median age 67.0 years). The drain insertion rate was 51.9 per cent (937 patients). After matching, drains were not associated with reduced rates (odds ratio (OR) 1.33, 95 per cent c.i. 0.79 to 2.23; P = 0.287) or earlier detection (hazard ratio (HR) 0.87, 0.33 to 2.31; P = 0.780) of collections. Although not associated with worse major postoperative complications (OR 1.09, 0.68 to 1.75; P = 0.709), drains were associated with delayed hospital discharge (HR 0.58, 0.52 to 0.66; P < 0.001) and an increased risk of SSIs (OR 2.47, 1.50 to 4.05; P < 0.001). Conclusion Intraperitoneal drain placement after elective colorectal surgery is not associated with earlier detection of postoperative collections, but prolongs hospital stay and increases SSI risk.

Objective Although thyroid and parathyroid surgery is considered a clean procedure with a low incidence of surgical site infections (SSIs), a great number of endocrine surgeons use antibiotic prophylaxis (AP). The aim of this study was to assess whether AP is significantly effective in reducing the incidence of SSIs in this kind of surgery. Data Sources A systematic literature search was performed with PubMed, Scopus, and ISI-Web of Science. Studies addressing the efficacy of AP in reducing the incidence of SSIs in thyroid and parathyroid surgery were included in the systematic review and meta-analysis. Review Methods The random effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated. Results A total of 6 studies with 4428 patients were included in the quantitative analysis. The incidence of SSI was 0.6% in the case group and 0.4% in the control group (odds ratio, 1.07; 95% CI, 0.3-3.81;P= .915). There was no evidence of heterogeneity among the studies (Q= 8.36,P= .138;I-2= 40.17). The analysis of several continuous moderators, including age, use of drain, and duration of surgery, did not generate any significant result. Conclusion AP is not effective in reducing the incidence of SSI in thyroid and parathyroid surgery and should be avoided, notwithstanding the negative impact on social costs and the risk of development of antibiotic resistance.

Erdas, Enrico MD, PhD; Canu, Gian L. MD; Cappellacci, Federico MD; Medas, Fabio MD; Calò, Pietro G. MD, PhD Author Information

Background: Primary hyperparathyroidism (PHPT) is a common endocrine disorder. In the last few decades, the introduction of Rapid Intraoperative Parathyroid Hormone (ioPTH) monitoring has allowed to ensurance of the excision of all hyperfunctioning parathyroid tissues, reducing the risks of persistent and recurrent PHPT. However, the use of ioPTH is still debated among endocrine surgeons. Material and metbods: The objective of this systematic review and meta-analysis was to assess if ioPTH monitoring is able to reduce the incidence of persistent or recurrent PHPT. A systematic literature search was performed using PubMed, Scopus, ISI-Web of Science and Cochrane Library Database. Prospective and retrospective studies addressing the efficacy of ioPTH monitoring were included in the systematic review and meta-analysis. The random-effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated. Results: A total of 28 studies with 13,323 patients were included in the quantitative analysis. The incidence of operative failure was 3.2% in the case group and 5.8% in the control group. After excluding three outlier studies, the quantitative analysis revealed that ioPTH reduced significantly the incidence of postoperative persistent or recurrent PHPT. (Risk Difference = -0.02; CI = -0.03, -0.01; p < 0.001). There was no evidence of heterogeneity among the studies (Q = 19.92, p = 0.70; I2 = 0%). The analysis of several continuous moderators revealed that the effectiveness of ioPTH was larger in studies with lower preoperative serum calcium values and higher incidences of multiple gland disease. Conclusion: ioPTH monitoring is effective in reducing the incidence of persistent and recurrent PHPT. Its routine use should be suggested in the next guidelines regarding management of PHPT.

AIMPermanent hypoparathyroidism is the most common long-term complication after total thyroidectomy. The aim of the present study was to investigate the risk factors of this complication.MATERIAL AND METHODSPatients undergoing thyroidectomy in our Unit between January 2017 and February 2018 were retrospectively analysed. They were divided into 2 groups: those with normal parathyroid function in the long term were included in Group A, those who developed permanent hypoparathyroidism in Group B.RESULTSTwo hundred and eighty-five patients were included in this study: 271 in Group A and 14 in Group B. No statistically significant difference was found in terms of sex, age, extent of surgery, rate of retrosternal goiter, postoperative stay and histopathological findings between the 2 groups. On the contrary, mean operative time, rate of patients with PTH values < 6.3 pg/mL on postoperative day 1 and mean thyroid weight were significantly greater in Group B than in Group A (P = 0.049, P < 0.001, P = 0.014; respectively).CONCLUSIONSLong operative times, PTH levels < 6.3 pg/mL on postoperative day 1 and high thyroid weight have proved to be strong risk factors of permanent hypoparathyroidism after total thyroidectomy. Thus, in these cases a careful follow-up is highly recommended.KEY WORDSPermanent hypoparathyroidism, Risk factors, Total thyroidectomy.

Background: The aim of this retrospective study was to investigate clinical and pathological characteristics of the tall cell variant of papillary thyroid carcinoma compared to conventional variants. Methods: The clinical records of patients who underwent surgical treatment between 2009 and 2015 were analyzed. The patients were divided into two groups: those with a histopathological diagnosis of tall cell papillary carcinoma were included in Group A, and those with a diagnosis of conventional variants in Group B. Results: A total of 35 patients were included in Group A and 316 in Group B. All patients underwent total thyroidectomy. Central compartment and lateral cervical lymph node dissection were performed more frequently in Group A (42.8% vs. 18%, p = 0.001, and 17.1% vs. 6.9%, p = 0.04). Angiolymphatic invasion, parenchymal invasion, extrathyroidal extension, and lymph node metastases were more frequent in Group A, and the data reached statistical significance. Local recurrence was more frequent in Group A (17.1% vs. 6.3%, p = 0.02), with two patients (5.7%) in Group A showing visceral metastases, whereas no patient in Group B developed metastatic cancer (p = 0.009). Conclusions: Tall cell papillary carcinoma is the most frequent aggressive variant of papillary thyroid cancer. Tall cell histology represents an independent poor prognostic factor compared to conventional variants.

A Correction to this paper has been published: https://doi.org/10.1007/s00384-021-03862-5

After a mitigation in the Summer season [1], the COVID-19 pandemic is progressing quickly in Europe. In Italy the COVID-19 total number of registered cases at the end of 2020 has reached over 2 million units with about 75,000 confirmed deaths, causing an excessive load to the national healthcare system [2–4]. Our region, Sardinia, showed an important increase in SARS-CoV-2 cases: the total number has reached quickly over 30,000 cases and 750 deaths attributable to COVID-19 [4], forcing local authorities to reorganize the hospitals, with a sharp reduction in ordinary surgical activities. In our Department of General and Endocrine Surgery of University Hospital of Cagliari, a non-dedicated COVID-19 hospital, activity was reduced from the first week of November, allowing only emergencies, oncological and not postponable procedures. Similarly as we have done in our previous work [5], we have herein analysed the patients admitted to our Department that underwent testing for SARS-CoV-2 Antibodies (Ab) to evaluate the difference of seroprevalence between Spring and Fall seasons, and to estimate the prevalence of SARS-CoV-2 infection in the setting of a non-dedicated COVID-19 hospital in a mild-incidence area. Between 1St September – 10Th December 2020, 121 patients were admitted to our Department for elective surgery, performed serologic tests for SARS-CoV-2 during the prehospitalization check, and were included in this study. All patients were asked for SARS-CoV-2 risk factors, including symptoms during the last 2 weeks and close contact with confirmed cases. A Chemiluminescent-Analytical-System (CLIA) for the detection of both IgM and IgG antibodies against SARS-Cov-2 Spike protein and N-protein on Maglumi platform (Snibe, Shenzhen, China) was employed (IgM cut-off 1.0 AU/mL, IgG cut-off 1.1 AU/mL). The main indication for elective surgery was thyroid and parathyroid disease in 57 (47.1%) cases, including thyroid malignancy, goiter and hyperparathyroidism. Surgery for breast, colorectal, skin cancer, and abdominal wall disease was also performed. All patients underwent a chest X-ray. No suspicious radiological signs were detected. All 121 patients underwent at least one nasopharyngeal swab before admission. RT-PCR was performed by GENESIG primerxdesign ® LTD, Chandels’ Ford UK on CFX96 BioRad, (Cycle Threshold from 20 to 40). Forty-one (33.9%) patients were males and 80 (66.1%) females, with a mean age of 58.6 ± 16.6 years. At serology, 8 (6.6%) patients tested positive for only SARS-CoV-2 specific IgM, and 5 (4.1%) for only SARS-CoV-2 specific IgG (Table 1). No patient tested positive for both SARS-CoV-2 specific IgM and IgG. In patients with positive serologic tests, we found IgM and IgG mean values of 2.9 ± 3.3 AU/ml and 2.4 ± 1.2 AU/ml, respectively. Thus, in our series, total seroprevalence for SARS-CoV-2 (IgG + IgM) was 10.7%.Table 1: SARS-CoV-2 Antibodies testing. Each square represents a patient. IgM cut-off is 1.0 AU/mL, IgG cut-off is 1.1 AU/mL.Overall, the mean hospital stay was 5.5 days (range 1–60). Nasopharyngeal swabs were negative in all the cases except one, whose positivity prevented hospitalization. In this patient, serologic test was positive for IgM (1.6 AU/ml) and negative for IgG. Subsequent epidemiological investigation revealed that the infection occurred in the family environment. Surgical related occurrences were observed in 18 (21.8%) patients: 10 cases of hypoparathyroidism and 5 cases of recurrent laryngeal nerve injury following total thyroidectomy, 2 post-operative bleeding who required revision surgery for haemostasis, and one surgical site infection following a colostomy closure. Due to the close contact with an operator who subsequently tested positive, two patients, whose serologic tests were both negative, were immediately quarantined in separate rooms. Subsequent nasopharyngeal swabs, performed at days 1–3 and 10, tested negative, no COVID-19 attributable symptoms occurred. All patients were contacted 15 days after discharge, to evaluate if symptoms due to SARS-CoV-2 infection had developed. As far as we know, no patient has developed relevant symptoms. The main limitation of this study is its monocentric nature, moreover, considering the high variability of the epidemiological distribution of the infection, it can't be considered representative of a large population. However, some reflections can be made, regarding the current seroprevalence, the complication rate and the utility of PPE. Antibody testing offers evidence of previous infection with SARS-CoV-2 or of recent exposure (correlated with transmission risk), being useful to determine the proportion of a population who has been infected to help predict future infection dynamics and health decisions [6]. In our previous work, we reported an estimated seroprevalence among patients admitted to surgery for SARS-Cov-2 specific IgM and IgG of 5.8%, highlighting that the real prevalence was higher than estimated in the official series (5.8% vs 2%) [5]. No further data on seroprevalence from official institutions have been published till August. According to the recrudescence of the pandemic, the seroprevalence among our unselected surgical patients has doubled when compared to the first period (10.7% vs 5.8%). This figure is widely higher than the prevalence officially reported from RT-PCR tests, which in Sardinia is about 2%, demonstrating that the amount of patients who are not highlighted with epidemic investigations is still high. Notably, other Italian authors have investigated the seroprevalence of SARS-Cov-2 in their regions, with extremely heterogeneous results based on the population studied and the latitude of the region under examination, with a seroprevalence ranging from about 2 to 4% in the southern regions and 23.1% in the northern regions [7–9]. Compared to the previous period, we observed a higher rate of surgical complications (21.8% vs 11.6%); we hypothesize that this data may be related to diagnostic and treatment delay caused by the first slowdown in surgical activity, which led to an increase in more complex definable cases. Although there have been close contacts established between staff who then tested positive and patients, we have not recorded infections within our unit. We think this data can be justified by the careful use by staff and patients of adequate PPE and rigorous hands washing after each contact. In conclusion, we believe that careful screening before admitting patients to the ward, combined with adequate use of PPE, could avoid the collapse of our health system and prevent further delays in the treatment of surgical diseases. Also, considering the recent evidence of the efficacy of the vaccines tested so far [10–12], healthcare staff should be vaccinated as soon as possible. Data availability statement The data used to support the findings of this study are available from the corresponding author upon request. Sources of funding No funding for the research was received. Ethical approval Ethical approval was not needed for this study. Author contribution Federico Cappellacci: design of the study, analysis of data, drafting the manuscript, final approval of the version to be published. Giacomo Anedda: acquisition of data, analysis of data, critical revision of the manuscript, final approval of the version to be published. Stefano del Giacco: critical revision of the manuscript, final approval of the version to be published. Ferdinando Coghe: Interpretation of data, critical revision of the manuscript, final approval of the version to be published. Riccardo Cappai: critical revision of the manuscript, final approval of the version to be published. Gian Luigi Canu: Interpretation of data, critical revision of the manuscript, final approval of the version to be published. Enrico Erdas: critical revision of the manuscript, final approval of the version to be published. Pietro Giorgio Calò: Interpretation of data, critical revision of the manuscript, final approval of the version to be published. Fabio Medas: design of the study, analysis and interpretation of data, drafting the manuscript, final approval of the version to be published. Davide Firinu: design of the study, interpretation of data, drafting the manuscript, final approval of the version to be published. Trial registry number Name of the registry: ClinicalTrials.gov. Unique Identifying number or registration ID: NCT04839913. Hyperlink to your specific registration (must be publicly accessible and will be checked): https://clinicaltrials.gov/ct2/show/NCT04839913. Guarantor Dott. Federico Cappellacci. Consent Informed consent was administered to each patient involved in the study. Declaration of competing interest The authors declare no conflicts of interest.

AIM:Parathyroid carcinoma (PC) represents a rare cause of primary hyperparathyroidism (PHPT). In this paper, among patients who underwent surgery for PHPT, we compared those with benign parathyroid disease with those affected by PC in terms of demographic and preoperative biochemical features. Moreover, we singularly described all 10 cases of PC treated at our Institution (including a case that occurred in a patient with tertiary hyperparathyroidism) and a brief review of the literature.MATERIAL AND METHODS:Patients undergoing surgery for PHPT in our Unit between 2003 and 2018 were retrospectively analysed. They were divided into two groups: Group A (benign parathyroid disease), Group B (PC). The case of PC that occurred in the patient with tertiary hyperparathyroidism was not included into the two groups.RESULTS:Three hundred and eight patients were included: 299 in Group A and 9 in Group B. The mean preoperative serum PTH value and mean preoperative serum calcium level were significantly higher in Group B than in Group A (P = 0.018, P = 0.027; respectively). Including the case of PC that occurred in the patient with tertiary hyperparathyroidism, 10 patients with PC were treated at our Institution. Among these, 3 underwent a re-exploration. Disease recurrence occurred in 1 (10%) patient, who developed a local recurrence and distant metastases.CONCLUSIONS:In the presence of PHPT characterized by particularly high preoperative levels of serum PTH and calcium this malignancy should be suspected. On the basis of our experience, we believe that extensive surgery is not always necessary.KEY WORDS:Hyperparathyroidism, Parathyroid carcinoma, Parathyroid surgery.

To date, in patients with differentiated thyroid cancer, central neck dissection is recommended in the presence of central compartment lymph node metastases. Differently, the efficacy of prophylactic central neck dissection in case of clinically node-negative differentiated thyroid carcinoma remains still uncertain. There are many arguments in favor and many against the execution of this surgical procedure. The most recent literature and latest guidelines have been reviewed and illustrated, paying particular attention to currently hottest and most discussed points. Prophylactic central neck dissection is associated with higher rates of postoperative complications, such as recurrent laryngeal nerve injury and hypoparathyroidism, with unclear oncological benefits. Thus, in the absence of lymph node involvement, this procedure should be avoided, reserving it for high-risk patients with advanced primary tumors. Moreover, to avoid serious complications, prophylactic central neck dissection should be performed by high-volume surgeons. KEY WORDS: Clinically node-negative differentiated thyroid cancer, Differentiated thyroid carcinoma, Prophylactic central neck dissection.

Authors declare no conflict of interest for this article.

Background Obesity is a growing public health concern in most western countries. More and more patients with high body mass index (BMI) are undergoing surgical procedures of all kinds and, in this context, obese patients are undergoing thyroid surgery more than ever before. The aim of the present study was to evaluate whether thyroidectomy can be considered safe in obese patients. Methods Patients undergoing thyroidectomy in our Unit between January 2014 and December 2018 were retrospectively analysed. Patients were divided into two groups: those with BMI < 30 kg/m 2 were included in Group A, while those with BMI ≥ 30 kg/m 2 in Group B. Univariate analysis was performed to compare these two groups. Moreover, multivariate analyses were performed to evaluate whether the BMI value (considered in this case as a continuous variable) had a significant role in the development of each individual postoperative complication. Results A total of 813 patients were included in this study: 31 (3.81%) were underweight, 361 (44.40%) normal-weight, 286 (35.18%) overweight, 94 (11.57%) obese and 41 (5.04%) morbidly obese. Six hundred and seventy-eight patients were included in Group A and 135 in Group B. At univariate analysis, the comparison between the two groups, in terms of operative time and thyroid weight resulted in statistically significant results ( P = 0.001, P = 0.008; respectively). These features were significantly higher in Group B than in Group A. About postoperative stay and complications, no statistically significant difference was found between the two groups. At multivariate analyses, only the development of cervical haematoma was statistically significantly correlated to the BMI value. Patients with high BMI had a lower risk of cervical haematoma ( P = 0.045, OR 0.797, 95% CI 0.638–0.995). Conclusions This study showed that obesity, in the field of thyroid surgery, is not associated with any increase of postoperative complications. Thus, it is possible to conclude that thyroidectomy can be performed safely in obese patients. Our result about operative times had no clinical significance.