Bilateral Neck Exploration in Primary Hyperparathyroidism—When Is It Selected and How Is It Performed?

Background  

Although most patients with primary hyperparathyroidism (PHPT) are ideal candidates for minimally invasive parathyroidectomy, some will have more than one enlarged gland and require bilateral neck exploration to achieve biochemical cure. We evaluated the clinical evidence for when to choose bilateral neck exploration for patients with PHPT.     

Does Previous Head and Neck Irradiation Increase the Chance of Multigland Disease in Patients with Hyperparathyroidism?

Background  

Exposure to therapeutic radiation, whether used to treat lymphoma, breast cancer, or benign conditions, such as acne, is thought to cause an increased risk for thyroid and/or parathyroid neoplasia. We therefore investigated whether patients with a history of head/neck irradiation and hyperparathyroidism (HPT) had a higher incidence of multigland disease.     

Muscle Function Is Impaired in Patients With “Asymptomatic” Primary Hyperparathyroidism

Background

Patients with “asymptomatic” primary hyperparathyroidism (PHPT) often describe improvement after surgery.

Methods

We evaluated muscle and balance function, quality of life (QoL), and well-being in 58 PHPT patients and 58 population-based matched controls in a cross-sectional study. We tested whether patients considered “asymptomatic” according to international guidelines have functional impairment.

Results

Mean age of the patients and controls was 59 years, and 47 (81 %) were women. Patients had higher levels of plasma PTH and ionized calcium. Creatinine and 25-hydroxyvitamin D levels did not differ between groups. Altogether, 16 (28 %) patients were “asymptomatic.” Compared with controls, PHPT was associated with significantly lower QoL in all eight domains of the short form-36 questionnaire, lower well-being (WHO Five Well-Being Index; p < 0.001), and impaired postural stability during normal standing with eyes open (p < 0.05) or closed (p < 0.001). Maximum isometric muscle strength was reduced in both upper (p < 0.01) and lower (p < 0.001) extremities. Physical performance was decreased during 10 repeated chair stands (p < 0.001) and time to walk 3 m forward and back (p < 0.05). Restricting analyses to “asymptomatic” patients showed significantly lower muscle strength at knee extension and flexion and impaired postural stability than in matched controls.

Conclusions

PHPT is associated with deleterious effects on muscles and QoL. Impairments also apply to patients with mild disease, normally considered “asymptomatic.” This may explain why “asymptomatic” patients report improvements following surgery. The impaired muscle function may contribute to increased fracture risk independent of bone mineral density.     

Is There an Optimal Time for Parathyroidectomy in Patients with Secondary Hyperparathyroidism?

World Journal of Surgery -     

Pasieka’s Parathyroid Symptoms Scores Correlate with SF-36 Scores in Patients Undergoing Surgery for Primary Hyperparathyroidism

Background Parathyroidectomy for primary hyperparathyroidism (PHPT) is expected to trigger an improvement in the quality of life. This has been demonstrated previously by using the SF-36 questionnaire, whose interpretation is difficult in routine clinical practice. As an alternative, the 13-item questionnaire developed by Pasieka et al. can be used to assess the severity of symptoms on a visual analogue from which a parathyroid assessment of symptoms score (PAS) can be calculated. The purpose of this study was to correlate results of these two assessment tools. Methods Prospective case-series study recruiting consecutive unselected patients who underwent successful parathyroidectomy for PHPT. SF-36(v2) and Pasieka’s questionnaires were collected before parathyroidectomy and at 3, 6, and 12 months postoperatively. Results Between November 2005 and December 2006, 101 patients were diagnosed with PHPT (30 men; aged 18–89 years). Preoperative PAS ranged 0–1040 and did not correlate with the severity of hypercalcemia (2.91 ± 0.25; range, 2.56–3.4 mmol/l). Scores from the SF-36 questionnaire were under the 50th percentile for the normal population in three domains (vitality, emotional role, and physical role). Minimally invasive parathyroidectomy was performed in 69 patients and bilateral cervical exploration in 32 patients. All were found to have a single parathyroid adenoma and were normocalcemic at 3–12 months after parathyroidectomy. At follow-up, there was a significant reduction of PAS from 460 ± 257 preoperatively to 254 ± 234 at 3 months postoperatively (n = 72), to 245 ± 215 at 6 months (n = 50), and 249 ± 212 at 12 months (n = 63) (p < 0.05, Student’s t-test). There was a significant and persistent improvement in five domains of SF-36 questionnaire: bodily pain, general health, vitality, social functioning and mental health. Overall analysis of 244 assessments using both questionnaires demonstrated a negative correlation between increasing PAS and decreasing mental component scores and physical component scores of the SF-36 assessment (r² = 0.372 and 0.301, respectively). Conclusions Pasieka’s parathyroid assessment of symptom scores (PAS) correlate with SF-36 questionnaire scores. Because PAS allows easier and faster analysis, we advocate that Pasieka’s questionnaire should be integrated into the assessment of patients with PHPT as a reliable tool to identify symptomatic changes that correlate with improved quality of life.     

Is Focused Minimally Invasive Parathyroidectomy Appropriate for Patients With Familial Primary Hyperparathyroidism?

Background  

The aim of this study was to determine whether a focused minimally invasive parathyroidectomy (MIP) for patients with primary hyperparathyroidism and concordant pre-operative localization studies is appropriate for patients with a family history of the disease. Familial hyperparathyroidism may be seen as a chronic disease in which recurrence is inevitable. Patients frequently undergo subtotal or total parathyroidectomy for perceived 4-gland parathyroid hyperplasia in an attempt to reduce this risk. Controversy remains regarding whether a MIP is appropriate in this setting.     

Can a Lightbulb Sestamibi SPECT Accurately Predict Single-Gland Disease in Sporadic Primary Hyperparathyroidism?

Background Technetium-99m sestamibi scintigraphy with single photon emission computed tomography (SPECT) is widely used to guide minimally invasive exploration in patients with sporadic primary hyperparathyroidism (SPH), although its sensitivity in multiglandular disease is limited. We examined the incidence of missed multiglandular disease and associated anatomic findings when sestamibi SPECT was positive for a single intense focus of delayed tracer uptake, termed a lightbulb scan (LBS). Methods Prospectively entered data from 764 patients with SPH treated with initial parathyroid exploration from March 5, 2000, to December 31, 2006, were reviewed. A single radiologist performed blinded interpretation of 585 available sestamibi SPECT images, classifying 167 (28.5%) patients with a LBS. Clinical findings were compared among LBS patients with a single adenoma (true positive) and LBS patients with multiglandular disease (false negative). Results One hundred fifty of 167 (89.8%) LBS patients had a single adenoma and 3 (1.8%) had carcinoma. Multiglandular disease was anatomically present in 14 of 167 (8.4%) LBS patients compared with 60 of 418 (15.6%) non-LBS patients (p = 0.05). Parathyroid hyperplasia occurred less frequently in LBS patients [5/167 (3%)] compared with non-LBS patients [36/418 (8.6%)], (p = 0.02), while double adenomas occurred equally often in LBS patients [9/167 (5.4%)] compared with non-LBS patients [24/418 (5.7%)], (p = 0.87). Double adenomas in LBS patients were more likely ipsilateral (7/9, p = 0.005) and left-sided (7/7, p = 0.008). LBS patients with multiglandular disease were more likely to have a history of neck irradiation, prior neck exploration, and concomitant thyroid pathology. Conclusions In patients with SPH, sestamibi SPECT studies show a single bright focus of uptake in only 29% of patients. LBS findings do not exclude multiglandular disease. To avoid unacceptable rates of failure at initial parathyroid exploration, the expert surgeon should use validated adjuncts such as intraoperative PTH monitoring or four-gland exploration.     

Is Radical Surgery Feasible in Liver Hydatid Cysts in Contact with the Inferior Vena Cava?

Background

Cysts in contact with the inferior vena cava (IVC) represent a challenge for hepato-pancreatico-biliary surgeons. Although the literature on the topic is scarce, the most widely accepted approach is conservative surgery. Partial cyst resection is recommended, because radical resection is considered a high-risk procedure.

Study design

This was a retrospective study over the period January 2007–December 2012. We operated on 103 patients with liver hydatidosis. A total of 32 patients (31 %) had a liver cyst in contact with the IVC. We proposed a cyst classification based on location of the cyst and length of contact and degrees of involvement of the IVC.

Results

Median size of the contacting cyst measured by computed tomography (CT) was 12 cm. On CT, median length of contact with the IVC was 37 mm. The median degree of involvement was 90°. Radical surgery was performed in 20 patients (62.5 %). No IVC resection was done. Morbidity rate was 28 %, and mortality was 3 %. In follow-up (median 27 months), no relapses or problems related to IVC flow were detected. Postoperative stay and transfusion rate were higher in the conservative surgery group, but these patients presented fewer complications. There was no relationship between circumferential grades and length of contact with the IVC and the type of surgery performed.

Conclusions

Liver hydatid cysts in contact with the IVC are large cysts usually located in the right liver. They do not normally cause clinical symptoms related to IVC contact. Radical surgery is feasible, and was performed in 60 % of our series, but it is technically demanding. We propose a classification of cysts in contact with the IVC.     

Primary Hyperparathyroidism and Negative Tc99 Sestamibi Imaging: To Operate or Not?

Background

The indications for surgery in primary hyperparathyroidism (1HPT) are the same for patients with and without localization on imaging. However, patients with negative imaging may not be referred for surgery or the surgeon may be reluctant to operate. We compare outcomes in patients with negative imaging to those with localization.

Methods

A review of patients who underwent primary operation for 1HPT with a preoperative Tc99 sestamibi I-123 (MIBI) scan was conducted. Imaging, laboratory, operative findings, pathologic findings, and outcomes were used to compare patients with negative scans to those with localization.

Results

A total of 2,681 patients had an operation for 1HPT with preoperative MIBI. MIBI imaging was negative in 136 (5.7 %). The negative MIBI group had a lower calcium (10.9 vs. 11.0?mg/ml, P?=?0.02), phosphorus (2.9 vs. 3.1?mg/dl, P?P?=?0.02) and no difference in parathyroid hormone, 25-OH vitamin D, or bone loss. Multigland resection was higher with a negative scan (32 vs. 13 %, P?P?P?=?0.04) and parathyroid hormone (98 vs. 196?pg/ml, P?=?0.03) than those not cured. Patients with both a negative ultrasound result and negative MIBI had a cure rate of 89 %.

Conclusions

A curative operation is performed at an acceptably lower rate with negative MIBI imaging. A decision for surgery with a negative MIBI finding should consider lower cure rates and symptom severity.     

Increased Mortality in Patients Hospitalized with Primary Hyperparathyroidism during the Period 1977–1993 in Denmark

The aim of the present study was to determine whether patients with the incident hospital diagnosis of primary hyperparathyroidism (PHPT) in Denmark during the period 1977–1993 had an increased mortality from cardiovascular disease and cancer compared to the rest of the Danish population. In a random sample of half of the Danish population, all patients with an incident hospital diagnosis of PHPT were identified in the National Hospital Patients Register. The mortality in the cohort was analyzed and compared with the background population. A cohort of 1578 patients was identified. Follow-up of 1179 women and 376 men, who did not die in the same month as the incident PHPT diagnosis, was made through 1993. Of these, 312 (20%) died within the follow-up period. The standard mortality ratio (SMR) for women was 1.7 (95% confidence interval [95% CI]: 1.5–1.9). SMR for men was 1.6 (95% CI: 1.3–2.0). In women an increased mortality from ischemic heart disease, cerebrovascular disease, and cancer was found. In men an increased mortality from cerebrovascular disease and cancer was found.     

Is Local Resection of Anal Canal Tumors Feasible with Transanal Endoscopic Surgery?

World Journal of Surgery - An important drawback of local surgery for lesions in the anal canal is the difficulty of achieving en bloc full-thickness resections. The aim of this study is to...     

Is pH Testing Necessary Before Antireflux Surgery in Patients with Endoscopic Erosive Esophagitis?

Introduction

The relationship between the Los Angeles (LA) grade of esophagitis and acid exposure by pH monitoring is unclear. The aim of this study was to correlate the results of pH testing in patients with esophagitis to determine at what LA grade of esophagitis a pH test is not necessary.

Methods

A retrospective review was performed of the records of all patients who underwent upper endoscopy and were found to have esophagitis graded using the LA system and who had pH monitoring from 2014 to 2016. An abnormal pH test was determined based on the DeMeester score.

Results

There were 56 patients with a median age of 57 years. Esophagitis was LA grade A in 19, B in 20, C in 15 and D in 2 patients. An abnormal pH score was present in 47 patients (84%). All patients with C or D esophagitis had an abnormal pH score compared to 79% and 75% of patients with A and B esophagitis, respectively.

Conclusions

The presence of LA C or D esophagitis was always associated with increased esophageal acid exposure on pH testing and is proof of reflux disease. However, pH testing is recommended prior to antireflux surgery in patients with LA A or B esophagitis.

     

Is Neck Dissection Necessary After Induction Plus Concurrent Chemoradiotherapy in Complete Responder Head and Neck Cancer Patients with Pretherapy Advanced Nodal Disease?

Background

The aim of the present study was to assess, in the setting of a single-institution prospective clinical trial, the necessity of planned neck dissection (PND) in physically and radiologically complete responders with pretherapy advanced nodal disease.

Methods

Between January 2000 and July 2007 a total of 139 patients were enrolled to receive a regimen of platinum-based multidrug induction-concurrent chemoradiotherapy (IC/CCRT). A total of 75 of the enrolled patients with advanced nodal disease were included in this retrospective study. Between 8 and 12 weeks from the end of treatment, the response to IC/CCRT was evaluated by fiber-optic endoscopy and head and neck contrast-enhanced computed tomography or magnetic resonance imaging.

Results

The complete clinical response (cCR) rate was 68 %. Among the 51 patients who achieved locoregional cCR at the end of CCRT, 8 underwent PND according to the study recommendation. Of the 43 patients with cCR who did not undergo PND, 2 patients (4.7 %) experienced isolated regional recurrences with the 5-year regional control being 82 %. Patients with cCR did not have a significantly lower regional control compared with patients with cCR who underwent ND (P = .962). Pathological evidence of residual disease was found in 81 % of the patients with less than cCR who underwent ND.

Conclusions

In physically and radiologically complete responders to IC/CCRT, a PND appears not justified. Conversely, PND should be performed in patients clinically suspected of having residual disease in the neck, as a significant proportion have viable tumor cell in post CCRT ND.

     

Short-Term Outcomes of Laparoscopic Rectal Surgery for Primary Rectal Cancer in Elderly Patients: Is it Safe and Beneficial?

Purpose  The role of laparoscopic resection in management of rectal cancer is still controversial. The purpose of this study was to evaluate whether laparoscopic rectal resection for rectal cancer could be safely performed in elderly patients. Methods  Forty-four elderly patients (≥75 years) undergoing laparoscopic rectal resection (group A) were compared with 228 younger patients (<75 years) undergoing laparoscopic rectal resection (group B) and 43 elderly patients (≥75 years) undergoing open rectal resection (group C). Results  The American Society of Anesthesiologists’ status was significantly higher in group A than in group B. Operative procedure, operating time, and estimated blood loss were comparable, and overall postoperative complications did not differ significantly between groups A and B (13.6% vs. 11.8%). Operating time was longer (256 vs. 196 min), but estimated blood loss was significantly less (25 vs. 241 ml) in group A than in group C. The rate of postoperative complications was lower (13.6% vs. 25.6%) in group A than in group C, but the difference was not statistically significant. Time to flatus (1.3 vs. 3.7 days), time to liquid diet (2.2 vs. 7.0 days), and hospital stay (19 vs. 22 days) were significantly shorter in group A than in group C. Conclusions  Laparoscopic rectal resection for elderly patients can be safely performed with similar postoperative outcomes as in younger patients and may have advantages in terms of faster gastrointestinal recovery and shorter length of hospital stay compared with open surgery.     

Is Silver Nitrate Pleurodesis for Patients with Malignant Pleural Effusion Feasible and Safe When Performed in an Outpatient Setting?

Background

The purpose of this study was to analyze the effectiveness and safety of silver nitrate pleurodesis (SNP) in patients with recurrent malignant pleural effusion (RMPE) when performed in an outpatient setting.

Materials and Methods

Prospective study including patients with RMPE recruited in a tertiary university-based hospital from February 2008 to June 2009. Elected patients underwent pleural catheter insertion (Day 1) followed by 0.5% SNP (Day 2), and on 7th day the drain was removed. All procedures were performed in an outpatient facility. Pleurodesis was considered successful when no additional pleural procedure was necessary by the 30th day. Complications were registered and graded according to the CTCAE3.0. Quality of life was evaluated before and 30 days after SNP.

Results

A total of 68 patients (54 female, 14 male, mean age: 57.3 years) were included. In addition, 7 had bilateral pleural effusions; therefore, 75 hemithoraces were drained. Also, 5 were excluded, and 70 hemithoraces (63 patients) underwent SNP. During the period of 30 days postpleurodesis, 8 deaths not related to the procedure occurred, and we lost contact with 10 patients who were followed elsewhere. At the 30th day, 48 hemithoraces (45 patients) were reevaluated, and 2 recurrences observed. The most frequent complication was pain—graded as 3 or more in 7 patients; infection occurred in 2 patients. Physical and environmental aspects of quality of life improved significantly after pleurodesis.

Conclusions

In this study, SNP could be performed safely in an outpatient setting, with pain the most frequent complication. Recurrences occurred in 4% of the patients.     

Is Interstitial Pneumonia in Patients with Collagen Diseases a Contraindication to Lung Cancer Surgery?

Purpose

Lung cancer surgery can be dangerous in patients with interstitial pneumonia (IP) as acute exacerbation of the IP may prove fatal. It remains unclear if patients with collagen diseases (CD), who often suffer from IP, are also at increased risk during lung cancer surgery.

Methods

We retrospectively examined 17 (3.1%) patients with CD among 545 patients who underwent surgery for lung cancer at our institution.

Results

Nine patients with rheumatoid arthritis, five with systemic sclerosis, two with Sjögren's disease, and one with systemic lupus erythematosus were enrolled in this study. Eleven patients (65%) were taking corticosteroids at the time of surgery. Fourteen patients underwent lobectomy and lymph node dissection, and three patients with pStage IA lung cancer underwent pulmonary wedge resection. Pathologically, 11 (65%) patients had IP with various inflammatory cellular infiltrations, and three (18%) had honeycombing of the lung. Postoperatively, none of the patients suffered acute exacerbation of their IP.

Conclusions

Despite the high incidence of IP in patients with lung cancer and CD, our results suggest that CD is not a contraindication to the surgical resection of lung cancer.