Startseite Diagnostic yield and safety of C-TBNA in elderly patients with lung cancer
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Diagnostic yield and safety of C-TBNA in elderly patients with lung cancer

  • Carolina Vitale EMAIL logo , Antonio Galderisi , Angelantonio Maglio , Paolo Laperuta , Rosa Maria Di Crescenzo , Carmine Selleri , Antonio Molino und Alessandro Vatrella
Veröffentlicht/Copyright: 19. November 2016
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Aus der Zeitschrift Open Medicine Band 11 Heft 1

Abstract

Conventional transbronchial needle aspiration (C-TBNA) is a minimally invasive technique used primarily in the diagnosis and staging of lung cancer. Currently lung cancer is mostly considered a disease of the elderly and the management of this disease in older patients is a growing concern.

In this study we aimed to assess the diagnostic yield and safety of C-TBNA in elderly patients.

A retrospective review of 88 consecutive C-TBNA procedures for nodal staging in suspected or confirmed primary lung cancer or pathological confirmation in suspected advanced lung cancer was performed. Patients were divided into less than 70 (<70yrs) or 70 and older (≥70yrs) age groups for analysis. There were no significant differences either in the diagnostic yield (69% in patients aged < 70 yrs and 74% patients aged ≥ 70 yrs (p=0.5) nor in the complication rate (respectively 8.8% in patients aged < 70 yrs and 6.9% in patients aged ≥ 70 yrs (p=0.7) between the two age groups. Reported complications were minor bleeding and poor tolerance; no major complications were observed.

Based on our experience, C-TBNA represents a useful and safe alternative procedure for the diagnosis and staging of lung cancer in elderly patients.

Keywords: Bronchoscopy; Transbronchial needle aspiration – TBNA; lung cancer; elderly

1 Introduction

Conventional transbronchial needle aspiration (C-TBNA or TBNA) is a minimally invasive technique used to obtain diagnostic samples from peribronchial or submucosally located lesions [1-43]. For over 30 years, until the introduction of endobronchial ultrasound guided (EBUS)-TBNA, conventional TBNA was considered the standard bronchoscopic modality for the evaluation of undiagnosed mediastinal lymphadenopathy [1-43].

C-TBNA can be used in various pathological conditions but is used primarily for obtaining mediastinal or hilar lymph node tissue for the diagnosis and staging of bronchogenic carcinoma [1-43].

Lung cancer is one of the leading causes of cancer deaths worldwide. It is mostly considered a disease of the elderly: the median age at diagnosis is 70 years and the incidence of lung cancer increases with age [29]. Data from cancer statistics revealed that in United States in 2011, 82 % of those living with lung cancer were 60 years of age or older [30].

Currently, the management of lung cancer in older patients is a growing concern, particularly with the increase of elderly population [29,30].

Accurate staging is crucial to evaluate the most appropriate therapy and the prognosis of lung cancer. Although the recent advancements in imaging modalities, such as computed tomography (CT) and positron emission tomography (PET), have drastically improved the detection and evaluation of lung cancer, these non-invasive methods do not provide definitive disease confirmation and have limitations in nodal staging.

A meta-analysis of both CT (sensitivity 51%) and PET scan (sensitivity 75%) showed relatively low sensitivity for the detection of nodal metastases, underlining the importance of pathological nodal staging [31].

Until recently, mediastinoscopy has been the “gold standard” to establish mediastinal involvement. However the use of mediastinoscopy, performed in an operative suite under general anesthesia, is potentially limited in older patients with concomitant diseases.

Several studies assessed the usefulness and safety of C-TBNA in diagnosis and staging of lung cancer; however data about the efficacy of this procedure in elderly populations are scant.

In the present study, we aimed to assess the diagnostic yield and safety of C-TBNA in older patients.

2 Patients and methods

We performed a retrospective review of 88 consecutive C-TBNA procedures for nodal staging in suspected or confirmed primary lung cancer or pathological confirmation in suspected advanced lung cancer.

All the procedures were performed on an inpatient basis, in the bronchoscopy unit at San Giovanni di Dio e Ruggi d’Aragona Hospital of Salerno from 2010 to 2015.

The procedures were done as part of the routine clinical care. Informed consent for the procedure was obtained from all the patients. Ethical approval for the study was not required as the intervention and data collection form part of our standard clinical care.

For every patient undergoing C-TBNA, a systematic examination of mediastinum was performed and criteria for sampling a lymph node were the following: a short axis greater than 10 mm on CT or abnormal nodal fluorodeoxyglucose avidity above that of the mediastinal blood pool on PET-CT.

Flexible bronchoscopy was performed through the nasal route, using the Olympus BF TE2 bronchofiberscope (Olympus, Japan) with a 2.8 mm working channel. For patient preparation, local anesthesia included application of 2% lignocaine jelly nasally along with spray application of lignocaine over the pharynx and vocal cords prior to and during insertion of the flexible bronchoscope. All the procedures were performed under conscious sedation. In patients over 70 years, mean doses of sedation were lower. Respiratory rate, heart rate, and pulse oximetric oxygen saturation was monitored throughout during the procedure.

Rapid on-site cytology examination (ROSE) was not available.

Cytological samples were considered diagnostic if results revealed malignant cells or polymorphous lymphocytes without any other findings (reactionary lymph node). Cytological samples were considered not diagnostic if results revealed inadequate cytological material or only bronchial epithelial cells, mucus, or blood elements.

3 Results

Overall 88 patients underwent C-TBNA. Patients were divided into less than 70 (<70 yrs) or 70 and older (≥70 yrs) age categories for analysis. Most of patients were male (74/88, 84%) and mean age was 68.3 ± 10.4 years (range, 43–83 years). 45 patients were less than 70 years (51.3%) and 43 (48.8%) were 70yrs or older. 14 patients were aged over 80 yrs. We evaluated the efficacy in nodal staging and pathological confirmation in advanced disease and the safety of C- TBNA.

The unpaired t-test was used to detect difference between data.

Overall the diagnostic yield of 88 procedures was 71.5% (63/88). The diagnostic yield was 69% (31/45) in the group of patients < 70 yrs and 74% (32/43) in the group of patients ≥ 70 yrs (p=0.5).

A specific diagnosis was made in 60% (27/45) of patients < 70 yrs and in 65% (28/43) of patients ≥ 70 yrs (p 0.6)

Apart from minor bleeding at biopsy sites, no major complication (significant bleeding, pneumothorax or pneumomediastinum) occurred due to C-TBNA. Overall three cases of poor tolerance were reported in the two age cohorts. No complications were recorded in the 14 patients aged over 80 years. There was no statistically significant difference in complication rate between the two age cohorts (8,8% (4/45) in patients aged < 70 yrs and 6.9% (3/43) in patients aged ≥ 70 yrs (p= 0.7)).

Results are reported in Table 1.

Table 1

Table of Results

Age Group< 70≥ 70
n45 (8F)43 (6F)
Diagnostic Yield31 (69%)32 (74%)p 0,5
PositivesSubtypes27(60%)28(65%)
Adenocarcinoma16 (59,2% of positives)15 (53,5% of positives)
Oat-cells8 (29.6% of positives)8 (28.7% of positives)
Squamous3 (11,1% of positives)5 (17.8% of positives)
NSCLC-NOS00
Metastates00
Complications4 (8.8%)3 (6,9%)p 0,7
Major complications00
Minor complications :
Minor bleeding2 (4,4%)2 (4,6%)
Poor tolerance2 (4,4%)1 (2,3%)

NSCLC-NOS = non-small-cell carcinoma “not otherwise specified;”

4 Discussion

The aim of this study was to evaluate the diagnostic yield and the safety of C-TBNA in elderly patients (defined as ≥ 70 yrs to correspond to the median age of lung cancer diagnosis and a common cut off point in clinical trials). The diagnostic yield of C-TBNA varies considerably among various studies. As reported in American College of Chest Physician 2013 guidelines (ACCP), mean sensitivity of C-TBNA for lung cancer was 76%, ranging from 14 to 100%. C-TBNA had a higher diagnostic yield for malignancy (64.7%) compared to non-malignant diseases (17.6%) [34, 35]. Nevertheless there are few data about efficacy and safety of this procedure in elderly patients with lung cancer.

In our study the diagnostic yield of 88 procedures was 73% overall. No significant difference in diagnostic yield was seen according to age threshold in the two groups, 69% in the group of patients aged less 70 years and 74% in the group of patients older than 70 yrs (p=0.5).

Not all results were verified with invasive methods such as mediastinoscopy or surgery due to different reasons such as a high rate of patient comorbidities, poor performance status, patient or family preference; as consequence, it’s likely that this group might contain false negative diagnoses, since C-TBNA is just a diagnostic procedure with a low sensitivity, but very high specificity [36].

Recently a large prospective study has demonstrated that EBUS-TBNA is a safe and well-tolerated procedure in elderly patients with lung cancer; nevertheless the additional training required and higher costs of this procedure prevent its routine use in all bronchoscopy centers [37]. Conventional TBNA is generally a safe procedure with a reported low incidence of complications. Potential complications are bleeding (severe bleeding occurs even after a major vessel puncture, a rarely reported event), pneumothorax or pneumomediastinum. In a meta-analysis of Holty et al., overall major complication rate (two major bleeds and one pneumothorax requiring chest tube) was 0.26% [37]. Other reported complications after C-TBNA procedures are fever, bacteremia and hemomediastinum [38, 39].

In our study no major complications occurred due to C-TBNA. As minor complications, minor bleeding and poor tolerance were reported, and their incidence wasn’t significantly different between the two age cohorts (respectively 8.8% in the group of patients aged less 70 years and 6.9% in the group of patients older than 70 yrs (p=0.7).

Based on our experience, C-TBNA should be considered a safe and efficacious procedure in diagnosis and staging of lung cancer before other more invasive procedures such as mediastinoscopy or surgery in elderly patients.

This study has several limitations: it’s a retrospective study, results didn’t include any comparison between C-TBNA results with invasive pathological sampling methods like mediastinoscopy or thoracotomy and analyses were mainly done to evaluate sampling success, thus adequate samples without any specific diagnoses may require further diagnostic procedures.

5 Conclusions

The management of lung cancer in the elderly is a current issue. Despite lung cancer being mostly considered a disease of the elderly, several studies show that older patients obtain lower histological confirmation rates, less accurate staging, and lower rates of definitive treatments than younger patients [40-43]. These differences are probably due to the perception that older patients might not be able to withstand invasive techniques and treatment.

In our study C-TBNA has been proven to be a safe and efficacious procedure in elderly patients with suspected or confirmed lung cancer. Recently EBUS-TBNA has been proven to be safe and well-tolerated in older patients however this procedure can be used more difficulty routinely since it is more complicated, requires additional training and has higher costs.

Based on our experience, C-TBNA still represents a very useful and safe alternative procedure for the diagnosis and staging of lung cancer in elderly patients.

6 Conflict of interest statement

Authors state no conflict of interest.

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Received: 2016-8-24
Accepted: 2016-9-6
Published Online: 2016-11-19
Published in Print: 2016-1-1

© 2016 Carolina Vitale et al.

This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

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  80. ARDS diagnosed by SpO2/FiO2 ratio compared with PaO2/FiO2 ratio: the role as a diagnostic tool for early enrolment into clinical trials
  81. Research Article
  82. Impact of sensory integration training on balance among stroke patients: sensory integration training on balance among stroke patients
  83. Review Article
  84. MicroRNAs as regulatory elements in psoriasis
  85. Review Article
  86. Influenza A(H1N1)pdm09 and postpandemic influenza in Lithuania
  87. Review Article
  88. Garengeot’s hernia: two case reports with CT diagnosis and literature review
  89. Research Article
  90. Concept of experimental preparation for treating dentin hypersensitivity
  91. Research Article
  92. Hydrogen water reduces NSE, IL-6, and TNF-α levels in hypoxic-ischemic encephalopathy
  93. Research Article
  94. Xanthogranuloma of the sellar region diagnosed by frozen section
  95. Case Report
  96. Laparoscopic antegrade cholecystectomy: a standard procedure?
  97. Case Report
  98. Maxillary fibrous dysplasia associated with McCune-Albright syndrome. A case study
  99. Regular Article
  100. Sialoendoscopy, sialography, and ultrasound: a comparison of diagnostic methods
  101. Research Article
  102. Antibody Response to Live Attenuated Vaccines in Adults in Japan
  103. Conference article
  104. Excellence and safety in surgery require excellent and safe tutoring
  105. Conference article
  106. Suggestions on how to make suboptimal kidney transplantation an ethically viable option
  107. Regular Article
  108. Ectopic pregnancy treatment by combination therapy
  109. Conference article
  110. Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy
  111. Regular Article
  112. Cusum analysis for learning curve of videothoracoscopic lobectomy
  113. Regular Article
  114. A meta-analysis of association between glutathione S-transferase M1 gene polymorphism and Parkinson’s disease susceptibility
  115. Conference article
  116. Plastination: ethical and medico-legal considerations
  117. Regular Article
  118. Investigation and control of a suspected nosocomial outbreak of pan-drug resistant Acinetobacter baumannii in an intensive care unit
  119. Regular Article
  120. Multifactorial analysis of fatigue scale among nurses in Poland
  121. Regular Article
  122. Smoking cessation for free: outcomes of a study of three Romanian clinics
  123. Regular Article
  124. Clinical efficacy and safety of tripterygium glycosides in treatment of stage IV diabetic nephropathy: A meta-analysis
  125. Special Issue on Italian Society for the Study of Vascular Anomalies
  126. Prevention and treatment of peritoneal adhesions in patients affected by vascular diseases following surgery: a review of the literature
  127. Special Issue on Italian Society for the Study of Vascular Anomalies
  128. Surgical treatment of recidivist lymphedema
  129. Special Issue on Italian Society for the Study of Vascular Anomalies
  130. CT and MR imaging of the thoracic aorta
  131. Special Issue on Italian Society for the Study of Vascular Anomalies
  132. Role of FDG-PET scan in staging of pulmonary epithelioid hemangioendothelioma
  133. Special Issue on Italian Society for the Study of Vascular Anomalies
  134. Sternal reconstruction by extracellular matrix: a rare case of phaces syndrome
  135. Special Issue on Italian Society for the Study of Vascular Anomalies
  136. Prenatal diagnosis, 3-D virtual rendering and lung sparing surgery by ligasure device in a baby with “CCAM and intralobar pulmonary sequestration”
  137. Special Issue on Italian Society for the Study of Vascular Anomalies
  138. Serum levels of inhibin B in adolescents after varicocelelectomy: A long term follow up
  139. Special Issue on Italian Society for the Study of Vascular Anomalies
  140. Our experience in the treatment of Malignant Fibrous Hystiocytoma of the larynx: clinical diagnosis, therapeutic approach and review of literature
  141. Special Issue on Italian Society for the Study of Vascular Anomalies
  142. Delayed recurrent nerve paralysis following post-traumatic aortic pseudoaneurysm
  143. Special Issue on Italian Society for the Study of Vascular Anomalies
  144. Integrated therapeutic approach to giant solitary fibrous tumor of the pleura: report of a case and review of the literature
  145. Special Issue on Italian Society for the Study of Vascular Anomalies
  146. Celiac axis compression syndrome: laparoscopic approach in a strange case of chronic abdominal pain in 71 years old man
  147. Special Issue on Italian Society for the Study of Vascular Anomalies
  148. A rare case of persistent hypoglossal artery associated with contralateral proximal subclavian stenosis
  149. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  150. Contralateral risk reducing mastectomy in Non-BRCA-Mutated patients
  151. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  152. Professional dental and oral surgery liability in Italy: a comparative analysis of the insurance products offered to health workers
  153. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  154. Informed consent in robotic surgery: quality of information and patient perception
  155. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  156. Malfunctions of robotic system in surgery: role and responsibility of surgeon in legal point of view
  157. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  158. Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation
  159. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  160. Iatrogenic splenic injury: review of the literature and medico-legal issues
  161. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  162. Donation of the body for scientific purposes in Italy: ethical and medico-legal considerations
  163. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  164. Cosmetic surgery: medicolegal considerations
  165. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  166. Voluntary termination of pregnancy (medical or surgical abortion): forensic medicine issues
  167. Review Article
  168. Role of Laparoscopic Splenectomy in Elderly Immune Thrombocytopenia
  169. Review Article
  170. Endoscopic diagnosis and treatment of neuroendocrine tumors of the digestive system
  171. Review Article
  172. Efficacy and safety of splenectomy in adult autoimmune hemolytic anemia
  173. Research Article
  174. Relationship between gastroesophageal reflux disease and Ph nose and salivary: proposal of a simple method outpatient in patients adults
  175. Case Report
  176. Idiopathic pleural panniculitis with recurrent pleural effusion not associated with Weber-Christian disease
  177. Research Article
  178. Morbid Obesity: treatment with Bioenterics Intragastric Balloon (BIB), psychological and nursing care: our experience
  179. Research Article
  180. Learning curve for endorectal ultrasound in young and elderly: lights and shades
  181. Case Report
  182. Uncommon primary hydatid cyst occupying the adrenal gland space, treated with laparoscopic surgical approach in an old patient
  183. Research Article
  184. Distraction techniques for face and smile aesthetic preventing ageing decay
  185. Research Article
  186. Preoperative high-intensity training in frail old patients undergoing pulmonary resection for NSCLC
  187. Review Article
  188. Descending necrotizing mediastinitis in the elderly patients
  189. Research Article
  190. Prophylactic GSV surgery in elderly candidates for hip or knee arthroplasty
  191. Research Article
  192. Diagnostic yield and safety of C-TBNA in elderly patients with lung cancer
  193. Research Article
  194. The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?
  195. Research Article
  196. Self-gripping mesh versus fibrin glue fixation in laparoscopic inguinal hernia repair: a randomized prospective clinical trial in young and elderly patients
  197. Research Article
  198. Anal sphincter dysfunction in multiple sclerosis: an observation manometric study
https://doi.org/10.1515/med-2016-0084
Schlagwörter für diesen Artikel
Bronchoscopy; Transbronchial needle aspiration – TBNA; lung cancer; elderly
Creative Commons
BY-NC-ND 3.0

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  1. Research Article
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  82. Impact of sensory integration training on balance among stroke patients: sensory integration training on balance among stroke patients
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  88. Garengeot’s hernia: two case reports with CT diagnosis and literature review
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  90. Concept of experimental preparation for treating dentin hypersensitivity
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  92. Hydrogen water reduces NSE, IL-6, and TNF-α levels in hypoxic-ischemic encephalopathy
  93. Research Article
  94. Xanthogranuloma of the sellar region diagnosed by frozen section
  95. Case Report
  96. Laparoscopic antegrade cholecystectomy: a standard procedure?
  97. Case Report
  98. Maxillary fibrous dysplasia associated with McCune-Albright syndrome. A case study
  99. Regular Article
  100. Sialoendoscopy, sialography, and ultrasound: a comparison of diagnostic methods
  101. Research Article
  102. Antibody Response to Live Attenuated Vaccines in Adults in Japan
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  104. Excellence and safety in surgery require excellent and safe tutoring
  105. Conference article
  106. Suggestions on how to make suboptimal kidney transplantation an ethically viable option
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  108. Ectopic pregnancy treatment by combination therapy
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  110. Use of a simplified consent form to facilitate patient understanding of informed consent for laparoscopic cholecystectomy
  111. Regular Article
  112. Cusum analysis for learning curve of videothoracoscopic lobectomy
  113. Regular Article
  114. A meta-analysis of association between glutathione S-transferase M1 gene polymorphism and Parkinson’s disease susceptibility
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  116. Plastination: ethical and medico-legal considerations
  117. Regular Article
  118. Investigation and control of a suspected nosocomial outbreak of pan-drug resistant Acinetobacter baumannii in an intensive care unit
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  120. Multifactorial analysis of fatigue scale among nurses in Poland
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  122. Smoking cessation for free: outcomes of a study of three Romanian clinics
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  124. Clinical efficacy and safety of tripterygium glycosides in treatment of stage IV diabetic nephropathy: A meta-analysis
  125. Special Issue on Italian Society for the Study of Vascular Anomalies
  126. Prevention and treatment of peritoneal adhesions in patients affected by vascular diseases following surgery: a review of the literature
  127. Special Issue on Italian Society for the Study of Vascular Anomalies
  128. Surgical treatment of recidivist lymphedema
  129. Special Issue on Italian Society for the Study of Vascular Anomalies
  130. CT and MR imaging of the thoracic aorta
  131. Special Issue on Italian Society for the Study of Vascular Anomalies
  132. Role of FDG-PET scan in staging of pulmonary epithelioid hemangioendothelioma
  133. Special Issue on Italian Society for the Study of Vascular Anomalies
  134. Sternal reconstruction by extracellular matrix: a rare case of phaces syndrome
  135. Special Issue on Italian Society for the Study of Vascular Anomalies
  136. Prenatal diagnosis, 3-D virtual rendering and lung sparing surgery by ligasure device in a baby with “CCAM and intralobar pulmonary sequestration”
  137. Special Issue on Italian Society for the Study of Vascular Anomalies
  138. Serum levels of inhibin B in adolescents after varicocelelectomy: A long term follow up
  139. Special Issue on Italian Society for the Study of Vascular Anomalies
  140. Our experience in the treatment of Malignant Fibrous Hystiocytoma of the larynx: clinical diagnosis, therapeutic approach and review of literature
  141. Special Issue on Italian Society for the Study of Vascular Anomalies
  142. Delayed recurrent nerve paralysis following post-traumatic aortic pseudoaneurysm
  143. Special Issue on Italian Society for the Study of Vascular Anomalies
  144. Integrated therapeutic approach to giant solitary fibrous tumor of the pleura: report of a case and review of the literature
  145. Special Issue on Italian Society for the Study of Vascular Anomalies
  146. Celiac axis compression syndrome: laparoscopic approach in a strange case of chronic abdominal pain in 71 years old man
  147. Special Issue on Italian Society for the Study of Vascular Anomalies
  148. A rare case of persistent hypoglossal artery associated with contralateral proximal subclavian stenosis
  149. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  150. Contralateral risk reducing mastectomy in Non-BRCA-Mutated patients
  151. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  152. Professional dental and oral surgery liability in Italy: a comparative analysis of the insurance products offered to health workers
  153. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  154. Informed consent in robotic surgery: quality of information and patient perception
  155. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  156. Malfunctions of robotic system in surgery: role and responsibility of surgeon in legal point of view
  157. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  158. Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation
  159. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  160. Iatrogenic splenic injury: review of the literature and medico-legal issues
  161. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  162. Donation of the body for scientific purposes in Italy: ethical and medico-legal considerations
  163. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  164. Cosmetic surgery: medicolegal considerations
  165. Focus on Medico-Legal and Ethical Topics in Surgery in Italy
  166. Voluntary termination of pregnancy (medical or surgical abortion): forensic medicine issues
  167. Review Article
  168. Role of Laparoscopic Splenectomy in Elderly Immune Thrombocytopenia
  169. Review Article
  170. Endoscopic diagnosis and treatment of neuroendocrine tumors of the digestive system
  171. Review Article
  172. Efficacy and safety of splenectomy in adult autoimmune hemolytic anemia
  173. Research Article
  174. Relationship between gastroesophageal reflux disease and Ph nose and salivary: proposal of a simple method outpatient in patients adults
  175. Case Report
  176. Idiopathic pleural panniculitis with recurrent pleural effusion not associated with Weber-Christian disease
  177. Research Article
  178. Morbid Obesity: treatment with Bioenterics Intragastric Balloon (BIB), psychological and nursing care: our experience
  179. Research Article
  180. Learning curve for endorectal ultrasound in young and elderly: lights and shades
  181. Case Report
  182. Uncommon primary hydatid cyst occupying the adrenal gland space, treated with laparoscopic surgical approach in an old patient
  183. Research Article
  184. Distraction techniques for face and smile aesthetic preventing ageing decay
  185. Research Article
  186. Preoperative high-intensity training in frail old patients undergoing pulmonary resection for NSCLC
  187. Review Article
  188. Descending necrotizing mediastinitis in the elderly patients
  189. Research Article
  190. Prophylactic GSV surgery in elderly candidates for hip or knee arthroplasty
  191. Research Article
  192. Diagnostic yield and safety of C-TBNA in elderly patients with lung cancer
  193. Research Article
  194. The learning curve of laparoscopic holecystectomy in general surgery resident training: old age of the patient may be a risk factor?
  195. Research Article
  196. Self-gripping mesh versus fibrin glue fixation in laparoscopic inguinal hernia repair: a randomized prospective clinical trial in young and elderly patients
  197. Research Article
  198. Anal sphincter dysfunction in multiple sclerosis: an observation manometric study
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