Valor de la ecoendoscopia transesofágica en el diagnóstico de localización en el hiperparatiroidismo primario

Aim

Our aim was to estimate the usefulness of oesophageal endoscopic ultrasound in the accurate location of recurrent or persistent primary hyperparathyroidism (HPT).

Material and method

A total of 352 patients with primary hyperparathyroidism were operated on over the last seven years. A preoperative parathyroid 99Tc- sestamibi gammagraphy and an intraoperative PTH determination were performed routinely. Only 5 patients (1.4%) had localization problems: three with persistent HPT after parathyroid extirpation, one recurrent HPT and one HPT after a right hemithyroidectomy. An oesophageal endoscopic ultrasound was carried out before any new exploratory neck surgery in order to find the definitive location.

Results

The endoscopic ultrasound showed a clear image of adenoma with an accurate location in four patients. No tumour was present in one patient. All five patients were operated on. The exact location was confirmed in the four patients with positive endoscopic ultrasound images. The fifth surgical exploration revealed a parathyreosis. All five patients had a favourable post-operative period, with no nerve lesions or morbidity associated with the endoscopic ultrasound.

Conclusions

Oesophageal endoscopic ultrasound is a very useful diagnostic tool in HPT patients with location problems, particularly in cases having anatomical changes due to previous surgery. It is a procedure that helps the surgeon to make a more selective and efficient exploration of parathyroid glands.     

El abordaje multidisciplinar es útil para la optimización de la hemoglobina preoperatoria en cirugía neoplásica colorrectal

Introduction

Optimising haemoglobin (Hb) levels less than 13 g/dl in the preoperative period can reduce the transfusion rate. With this aim, we developed a multidisciplinary protocol in our hospital for the treatment of patients proposed for colorectal cancer surgery.

Patients and method

A study was conducted on 437 patients who had surgery performed for colorectal cancer in the period 2005-2009. The data recorded were: demographic data, Hb and iron metabolism (Fe) at the time of diagnosis, Hb on the day of the surgery and on discharge, tumour location, preoperative adjuvant treatment (chemotherapy and/or radiotherapy), tumour stage (TNM), iron treatment, transfusion rate, and complications at 30 days. Patients were classified into Group A; Hb < 13 g/dl and/or abnormal Fe metabolism, and Group B; Hb > 13 g/dl and/or normal Fe metabolism.

Results

Of the total, 53.3% were in Group B and were treated with Fe; 73.6% intravenous (IV), and the rest oral. The mean dose of IV Fe was 867 mg. The mean intraindividual difference between the Hb on the day of surgery and at the initial value, increased by 0.6 g/dl in Group A, while it decreased by 0.8 g/dl in Group B. The mean intraindividual difference between the Hb at discharge and the diagnosis decreased by 0.4 g/dl in Group A compared to 2.5 g/dl in Group B. The overall transfusion rate was 8.6%. No statistically significant differences were observed in complications.

Conclusions

A multidisciplinary and early treatment of colorectal cancer enables patients with a low haemoglobin (Group A) to be optimised, as well as achieving a lower transfusion rate.     

Cáncer de recto: qué pacientes se benefician de la radioterapia

The prognosis of patients with rectal cancer has improved in recent years, particularly as regards the lower probability of local recurrence. These positive results are obtained through correct preoperative staging and an adequate surgical resection of the affected lesion, as well as a multidisciplinary therapeutic approach. Based on the available scientific evidence, our aim is to clarify the framework in which options for the right therapy can be taken, especially in relation to the preoperative staging and its limitations, with regards to radiotherapy and its indications. We also emphasize the need of a tailor-made approach for each case.     

Relación entre concentración intraoperatoria de parathormona y evolución postoperatoria del hiperparatiroidismo primario

Introduction

The relationship between the intra-operative concentration of parathyroid hormone (IOPTH) and the long-term outcome of patients intervened due to primary hyperparathyroidism (PHPT).

Patients and methods

A prospective observational study was performed with 120 patients. Three determinations were made of PTH in blood: baseline, when the diseases gland was located, and 10 minutes after its extirpation. The calcium, PTH and vitamin D (25-OH-D3) levels were measured during follow up.

Results

A decrease in IOPTH > 50% was observed in 96 (80%) patients, and the post-extirpation value returned to the normal range (Group I), in 18 (15%) a decrease of > 50% but the final value remained higher than normal (Group II) and in 6 (5%) the decrease was < 50% (Group III). Persistent PHPT was detected during follow up in 6 patients (5%): one in Group I (1%), 3 (16.7%) in II and 2 (33.3%) in group III (P < .001). The risk of persistent PHPT was higher in Group II (odds ratio: 19; 95% CI: 1.85-194) and in Group III (odds ratio: 47; 95% CI: 3.53-639). There were no cases of recurrent PHPT. A normal calcium with an increased PTH was detected in 20 patients of Group I (20.8%), 11 (61.1%) in II and 3 (50%) in III (P < .001). These patients had a lower concentration of post-operative vitamin D (17 ng/ml, range: 24; compared to 28 ng/ml, range: 21) (P = .008) and higher frequency of hypovitaminosis D (70.6% compared to 26.2%) (P>.001).

Conclusion

The risk of persistent PHPT is higher when the IOPTH decreases more than 50% but still remains high.     

Current treatment practices for anemia in patients with chronic kidney disease and future opportunities with hypoxia-inducible factor prolyl hydroxylase inhibitors: a narrative review

Purpose

To investigate current treatment practices for anemia in patients with chronic kidney disease (CKD), issues surrounding current treatment practices, and the hypoxia-inducible factor prolyl hydroxylase inhibitors (HIF-PHI) that are currently in clinical trials.

Summary

Treatment of anemia in patients with CKD has traditionally included iron supplementation and erythropoiesis-stimulating agents (ESAs). However, due to adverse cardiovascular (CV) events and hypo-responsiveness to ESA therapy, new agents are currently in clinical trials to treat anemia in patients with CKD. The HIF-PHIs stimulate erythropoiesis and regulate iron metabolism and are attractive alternatives to iron supplementation and ESAs.

     

Tratamiento de la eventración subxifoidea: técnica de doble malla ajustada al defecto

Introduction

Subxiphoid incisional hernia has characteristics that differentiate it from the rest and make it a distinctive entity. The fact that it has its sac very near the rib cage and sternum determines the pressure in the margins. The repair, by open or by laparoscopic approach, has not demonstrated good results despite the generalised use of a prosthesis. They are uncommon, and have a significant comorbidity in patients (severe heart diseases, transplants, immunosuppressed), after surgery of the hepato-bilio-pancreatic area with transverse incisions, or very high mid-laparotomies for gastro-oesophageal surgery.

Material and methods

A new technique has been developed in our Unit, based on a double mesh and adapted to the anatomical and physiological characteristics of the region. The series consisted of 35 consecutive patients operated on between 2004 and 2010, following an agreed surgical and management protocol.

Results

There were no significant complications -the most frequent (17.4%) was a seroma- except one case of a wound infection due to skin ischaemia in one patient who had had multiple operations and a transplant. During the post-surgical follow up to the present (between 4 and 80 months), there has been no recurrence of the incisional hernia and no significant local discomfort has been reported.

Conclusions

The «adjusted double mesh» technique achieved good results in our hands, from the surgical point of view (reproducibility, recurrence), and for the patient, with minimal discomfort and recovery of quality of life.     

Immobilités laryngées unilatérales après chirurgie de la glande thyroïde

Background

The authors studied a cohort of 154 patients with unilateral vocal cord paresis following thyroidectomy, analyzing the pathogenesis, symptomatology, spontaneous evolution, and management of this complication.

Objective

This retrospective study distinguished between vocal cord paresis due to recurrent laryngeal nerve injury or due to injury of the cricoarytenoid articulation. We assessed the influence multiple variables on therapeutic management. The results and complications of currently-employed surgical techniques to remedy unilateral vocal cord paresis were defined.

Patients and methods

Injury to the recurrent laryngeal nerve was the cause of vocal cord paresis in 98% of cases; injury to the cricoarytenoid articulation accounted for only 2% of cases. When the recurrent laryngeal nerve had not been actually transected, spontaneous recovery of vocal cord function occurred in 36% of cases. No spontaneous recovery was noted when the nerve had been divided. The interval to recovery of cord function ranged from 2 to 15 months (median: 4 months). Spontaneous recovery of vocal cord function had occurred in 90% of these patients by the 9th postoperative month. Three factors significantly influenced the decision to perform a median transposition of the injured vocal cord: known transection of the recurrent laryngeal nerve, the interval to consultation with an ENT specialist, and the severity of dysphonia. Medial transposition of the injured vocal cord resulted in an immediate improvement in the quality of voice and speech with no major complications.

Conclusion

Unilateral vocal cord paresis occurring after thyroidectomy is not always symptomatic and is not uniformly due to injury of the recurrent laryngeal nerve. Management does not always require surgical reintervention. The practical and medico-legal consequences of these injuries are discussed.     

New concepts in the diagnosis and management approach to iron deficiency in candidates for metabolic surgery: should we change our practice?

The near universal presence of chronic low-grade systemic inflammation among patients with severe obesity disrupts iron homeostasis and underlies the association between obesity and iron deficiency. Immune activation and inflammation result in a reduction in circulating iron and diminished iron bioavailability for erythropoiesis. Inflammation also alters blood levels of commonly measured markers of iron nutrition status, which makes the diagnosis of iron deficiency difficult and has led to new recommendations regarding laboratory markers for the diagnosis. Recent evidence using these newly recommended laboratory markers, which include levels of ferritin, C-reactive protein, and transferrin saturation, suggests that the actual prevalence of iron deficiency among candidates for metabolic surgery may be double or triple the prevalence identified by low levels of ferritin alone. Thus large numbers of surgical candidates have iron deficiency that has been heretofore largely unrecognized and inadequately treated. The assessment of iron status using the currently recommended markers in the presence of chronic inflammatory diseases and repletion of depleted stores for surgical candidates with deficiency during the preoperative period present an important opportunity for mitigating this condition in postoperative patients.     

Tracheal malignant melanoma: successful outcome with tracheal resection

Primary tracheal malignant melanomas are uncommon neoplasms: only five cases have been reported. Different therapeutic approaches are described, with a short life expectancy observed. We report a case of a young woman with a primary tracheal malignant melanoma who underwent complete tracheal resection and is free of disease 4 years after surgical treatment.     

Preoperative methods to improve erythropoiesis

Preoperative anemia creates a challenge for surgical treatment and patient outcomes after major surgery. Prior to a surgical intervention, it is optimal to increase erythropoiesis to improve oxygen transport through the bloodstream for patients at high risk of anemia and to avoid the complications of allogeneic blood transfusion. In this way, patients could receive predeposited autologous blood or, during the surgical procedures, undergo acute normovolemic hemodilution. This approach is allowed by the use of recombinant human erythropoietin in association with erythropoiesis-inducing factors such as iron and folic acid. In this article, we discuss the recent clinical evidences.     

Invaginación intestinal en el adulto: presentación de un caso y revisión de la literatura médica española

Introduction

Intestinal invagination in the adult is an uncommon condition, often manifested by non-specific chronic or sub-acute symptoms. In the majority of occasions there is an organic lesion. There are currently no large patient series published in the literature to help define the management of these patients.

Material and method

A review of case series published in the Spanish literature. A data base of patients over 15 years old was designed. Data was extracted from national clinical cases using Internet resources. Our own recent clinical case is added.

Results

A series of 30 adults with intestinal invagination was obtained (29 cases from the review and one own). The median age was 45 years (19–84 years) and 17/30 (57%) were males. A total of 27/30 patients had abdominal pain and 8/30 (28%) cases had established intestinal obstruction. The preoperative diagnosis of invagination was made in 25/30 (83%) of patients. The invaginations were; enteroenteric, 61%; colocolic, 12%; enterocolic, 21%; and gastrojejunal, 6%. A total of 85% of the invaginations were associated with a proliferative lesion and 43% of the latter were malignant.

Conclusions

The diagnosis of invagination in the adult is usually made preoperatively. There are no data to support intestinal resection without performing a reduction. Resection must be the norm and the presence of lymph nodes is no argument to perform large resections.     

Transaortic transcatheter aortic valve implantation with the Edwards SAPIEN valve: feasibility, technical considerations, and clinical advantages

The randomized Partner study [1] has recently shown superiority of transfemoral transcatheter aortic valve implantation, in patients who are not candidates for surgical aortic valve replacement, when compared with conventional nonsurgical therapies. In patients who are not candidates for the transfemoral approach because of peripheral vascular disease or other contraindications, deployment of the SAPIEN valve (Edwards Lifesciences, Irvine, CA) in an antegrade fashion can be achieved through the apex of the left ventricle. However this valuable technique carries specific risks inherent to the access route. Transaortic implantation, through an upper ministernotomy, offers a new alternative that could avoid complications related to the transapical approach.     

Toracotomía de urgencia. Indicaciones, técnica quirúrgica y resultados

Emergency thoracotomy is a surgical technique that has been extended in the last few years, and is currently included in advanced cardiopulmonary resuscitation protocols. Despite its proven use in patients with penetrating heart wounds, it is often not used due to lack of knowledge of the technique. Currently, the increase in chest wounds due to violence, traffic accidents, crashes or suicides, and advances in extra-hospital medical care systems, has currently awakened new interest in this technique.A review of emergency thoracotomy is presented in this article: indications, surgical technique, results, and its usefulness in the extra-hospital setting.     

Recurrent myasthenia gravis due to a pleural implant 3 years after radical thymectomy

Although recurrence of a thymoma is rare, pleural dissemination or local relapses have been described. We present a patient who underwent complete thymectomy for a thymoma, type AB according to the World Health Organization classification and stage II according to Masaoka, followed by adjuvant radiotherapy. Three years later, a relapse of the myasthenic symptoms occurred. An isolated pleural implant above the left diaphragm was removed by video-assisted thoracoscopy. Pathology confirmed the recurrence of the thymoma. As this is a rare occurrence, no precise therapeutic guidelines exist. In our case, surgical resection of the recurrence with adjuvant immunomodulating therapy for myasthenia provided good results.     

We Give Too Much Intravenous Iron

Dialysis patients have absolute and functional iron deficiencies. Traditionally, oral iron preparations have been insufficient to maintain iron stores to support erythropoiesis, especially in the setting of the ubiquitous use of erythropoiesis‐stimulating agents. This has led to the widespread adoption of intravenous iron protocols designed to maintain iron stores at levels that are much higher than for patients not on dialysis. These protocols are often developed by dialysis providers and may be largely independent of the treating nephrologist. Concerns about multiple risks associated with the use of intravenous iron persist. Despite this, mean ferritin levels in the United States have risen, partly due to more intravenous iron use and partly due to reduced erythropoiesis‐stimulating agent use. Questions about the relationship of intravenous iron to infection, cardiac, and hepatobiliary risks remain. The failure of oral iron preparations to maintain iron stores continues to prompt the use of intravenous iron. Recently, studies with oral ferric citrate as a phosphate binder have shown improved iron stores and maintenance of hemoglobin, and studies with soluble ferric pyrophosphate added to dialysate have shown both maintenance of iron stores and hemoglobin. With new iron options that affect iron stores in dialysis patients, the use of intravenous iron and its potential risks may wane.     

Plastic bronchitis: is thoracic duct ligation a real surgical option?

Plastic bronchitis is an unusual clinical scenario of unknown cause and occurs in multiple clinical settings. The disease is characterized by the development of arborizing, thick, tenacious casts of the tracheobronchial tree that results in airway obstruction. Patients with congenital heart disease who have undergone a Fontan operation are at high risk for having this problem develop. Management of this distressing situation is difficult with only palliative options being available, such as repeated bronchoscopies, inhaled heparin, tissue plasminogen activator, inhaled bronchodilators, or azithromycin. The patients with Fontan circuits have a myriad of unique complications develop, such as atrial arrhythmias, recurrent pleural effusions, chylothoraces, protein-losing enteropathy, and plastic bronchitis. High intrathoracic lymphatic pressures with nondemonstrable lympho-bronchial fistulas were believed to be the cause for the development of these recurrent bronchial casts in plastic bronchitis. Faced with recurrent plastic bronchitis resistant to medical management in 2 Fontan patients with normal Fontan pressures on cardiac catheterization, we decided to explore a surgical solution by performing a thoracic duct ligation. This resulted in complete resolution of the formation of casts in both patients, who were discharged home and remain asymptomatic on continued follow-up. Thoracic duct ligation provides a surgical cure for plastic bronchitis by decreasing intrathoracic lymphatic pressure and flow.     

Surgical palliation of previously resected thoracic sarcoma

Surgical palliation can improve quality of life, provide local control, and extend survival. However, oncologists often view surgical intervention as a drastic measure with prohibitive morbidity. During the past decade, surgical palliation has played a role in the management of many metastatic malignancies, including those of the colon, breast, prostate, and kidney. In concert with this, the morbidity and mortality associated with surgical interventions has continued to decline. We present 2 patients with thoracic sarcoma recurrences after pneumonectomy that were associated with symptomatic compression of pulmonary vessels and airway. Both patients underwent surgical resection, with immediate relief of symptoms, improved quality of life, and extended survival.     

The Influence of Need‐Based,Continuous, Low‐Dose Iron Replacement on Hemoglobin Levels in Hemodialysis Patients Treated With Erythropoiesis‐Stimulating Agents

Anemia is a common and important complication of chronic kidney disease. Treatment includes the use of erythropoiesis‐stimulating agents (ESAs) and iron supplementation. However, the optimal schedule of iron supplementation remains to be defined. Thirty‐one long‐term hemodialysis patients were treated for 1 year (period 1) with ESAs and an intermittent pulse regimen consisting of 100 mg of iron sucrose administered after different dialysis sessions depending on serum ferritin and other laboratory values, but no more than once per week. During the next 3 years (period 2), patients were treated with ESAs and need‐based, continuous, low‐dose iron. Iron doses were determined on the basis of values and changes of serum ferritin and transferrin saturation every fourth week after the longest interdialysis time interval. Iron doses ranged from 10 to 60 mg of iron sucrose and were given 1–3 times per week. If grounded, we gradually reduced or even abolished the iron doses. A significant increase in the hemoglobin concentration and hematocrit during period 2 in comparison with period 1 was observed. The use of ESAs did not change significantly during period 2 in comparison with period 1, while the use of iron was significantly lower in period 2. Significantly lower values were obtained for serum ferritin, saturation of transferrin, serum iron, and total serum iron‐binding capacity during period 2. A better response to ESA therapy (increase in hemoglobin and hematocrit) is achieved with need‐based, continuous, low‐dose iron replacement.     

Complicaciones del tratamiento de la oclusión del colon distal con prótesis endoluminales

Introduction

The high morbidity and mortality of emergency surgery, has led to the use of endoluminal self-expanding metal implants (stents) in the management of intestinal occlusion.The purpose of this study was to review the results of the management of intestinal occlusion treatment in a Colorectal Surgery Unit in those patients who had a stent implant, and the relationship between chemotherapy and complications.

Material and methods

A retrospective study was carried out on patients treated with a stent in a university hospital between 2004 and 2010.

Results

A total of 93 patients were treated, of which 77 were considered palliative for a stage IV neoplasm of the colon with non-resectable metastases or due to a performance status > 2. Other indications were 7 ASA IV patients with acute renal failure, 6 with benign disease, and 3 due to other causes.The technical and clinical success of the procedure was 93.5% and 78.5%, respectively. Delayed occlusion was 19.3% and perforation 6.4%. There was migration (2.1%) and intestinal bleeding (2.1%) and 1.1% with tenesmus. No significant differences were seen between complications and chemotherapy.The overall mortality was 17.2%.

Conclusions

Stents, as a definitive treatment option in palliative patients with and without chemotherapy, is an alternative treatment that is not exempt from complications. We believe that in patients with mortality risk factors and patients with tumours with non-resectable metastases it could be the initial treatment of choice.     

Right superior vena cava draining in the left atrium: anatomical, embryological, and surgical considerations

A newborn, with SDS (S = situs viscero-atrialis solitus, D = D-loop of the ventricles, S = solitus, normally related great arteries) anomalous drainage of the right superior vena cava in the left atrium, intact atrial septum, and anomalous drainage of the right superior pulmonary veins in the right superior vena cava, underwent surgical repair at our institution. This rare cyanotic, congenital, cardiac malformation is herein described with particular regard to its anatomical, embryological, and surgical implications.