Role of cyclase activating parathyroid hormone (1-84 PTH) measurements during parathyroid surgery: potential improvement of intraoperative PTH assay

SUMMARY BACKGROUND DATA: Quick intraoperative parathyroid hormone assays are widely used as a guide to the adequacy of resection during parathyroid surgery. However, some authors have reported a 15% error rate of these assays because of the presence of false-positive and false-negative results. Recently the authors have found that most commercial intact PTH (iPTH) assays cross-react with non-(1-84) PTH (likely 7-84 PTH) and that the proportional levels of non-(1-84) PTH in patients were variable in a much wider range, accounting mostly for 20% to 60% of the immunoreactivity in samples obtained from hyperparathyroid patients. A cyclase activating PTH (CAP) measured by a novel immunoradiometric assay was shown to measure specifically 1-84 PTH. Using a CAP assay, the authors studied the rate of decline of CAP after parathyroidectomy and compared it with iPTH as measured by the Nichols intact PTH immunoradiometric assay. METHODS: This study comprised 29 patients with primary hyperparathyroidism (pHPT) caused by a single adenoma and 7 patients with secondary hyperparathyroidism (secondary HPT) who underwent parathyroidectomy. Blood samples were drawn after anesthesia, before excision of one enlarged parathyroid gland in pHPT and of the last gland in secondary HPT, and at 5, 10, and 15 minutes after excision. The 7-84 PTH level was calculated by subtracting the CAP value from the iPTH value. RESULTS: The percentage of 7-84 PTH in iPTH in plasma samples was 27.5 +/- 14.4% in pHPT and 39.6 +/- 15.1% in secondary HPT. In pHPT patients the plasma CAP and iPTH value decreased to 23.4 +/- 10.8 and 32.0 +/- 11.3% of the preexcision level at 5 minutes, 10.6 +/- 7.7 and 21.1 +/- 8.8% at 10 minutes, and 8.5 +/- 4.9 and 16.1 +/- 6.8% at 15 minutes after removal of the enlarged gland, respectively. At 5 minutes, CAP levels of all 29 pHPT patients had decreased to less than 40% of the preparathyroidectomy level; however, 7 (24%) patients still had an iPTH level of more than 40%. In secondary HPT patients, CAP and iPTH values had dropped to 43.3 +/- 20.2 and 66.1 +/- 19.7% at 5 minutes, 28.6 +/- 16.6 and 53.6 +/- 18.1% at 10 minutes, and 14.2 +/- 9.0 and 41.0 +/- 12.9% at 15 minutes after removal of the last enlarged gland, respectively. At 10 minutes, CAP levels of all seven secondary HPT patients had decreased to less than 50% of the preexcision level; however, three (43%) patients still had an iPTH level of more than 50%. In pHPT and secondary HPT, the 7-84 PTH level had dropped to 57.4 +/- 85.9 and 62.1 +/- 84.9%, respectively, of the preexcision value 15 minutes after removal of the enlarged gland or glands. CONCLUSIONS: The percentage of 7-84 PTH in iPTH in plasma samples varies substantially between patients with HPT. In both pHPT and secondary HPT, the plasma CAP value decreased more rapidly than iPTH after parathyroidectomy, depending on the amount of 7-84 PTH in circulation. These results suggest that the CAP assay may be a more useful adjunct to parathyroidectomy than the currently used iPTH assay.     

Migration of the lag screw within the femoral head: a comparison of the intramedullary hip screw and the Gamma Asia-Pacific nail

OBJECTIVES: To study the functional difference in the performances of sliding femoral head screws by comparing the displacement of the screw in relation to the femoral head in hips treated with the Gamma Asia-Pacific nail (GN) and hips treated with the intramedullary hip screw (IMHS). STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Displacement of the femoral head screw in relation to the femoral head was measured in fifty-six elderly patients with intertrochanteric fractures who were treated with an IMHS or GN. Displacement of the femoral head screw was determined by comparing screw position in the immediate postoperative radiograph with a film taken 3 months after surgery. RESULTS: In the GN group, significant displacement of the screw was observed with 3.8 +/- 3.8 percent translation in the horizontal axis (P < 0.005) and 4.3 +/- 5.1 percent displacement in the vertical axis (P < 0.05) in comparison with the diameter of the femoral head. In comparison, displacement of the femoral head screw was not observed with the IMHS (P = 0.48 for horizontal, P = 0.18 for vertical). Total displacement of the femoral head screw in relation to the femoral head in the GN was twice that observed in the IMHS (P < 0.001). CONCLUSION: These results indicate that the displacement of the femoral head screw of the IMHS was less than the lag screw of the GN. However, it is still unknown whether this smaller displacement of the IMHS is clinically significant for reducing the rate of screw cut-out after surgery.     

Measurement of health-related quality of life in patients with chronic kidney disease in Japan with EuroQol (EQ-5D)

Background  

Chronic kidney disease (CKD) is a health-related quality-of-life (HRQOL) deteriorating disease which is not only a public health but also a socioeconomic problem. Interest in developing cost-effective interventions to control CKD has increased. The aim of this study was to measure HRQOL in terms of quality-adjustment weights for cost-effectiveness analysis using EQ-5D in patients with CKD. The relationships between the measured HRQOL and clinical indices/complications were also analyzed.     

Transient Liver Dysfunction after Laparoscopic Gastrectomy for Gastric Cancer Patients

Introduction The effect of laparoscopic surgery under CO₂ pneumoperitoneum on liver function is not clear. The aim of this study was to clarify whether laparoscopy-assisted distal gastrectomy (LADG) is associated with changes in liver function compared with open distal gastrectomy (ODG). Methods A total of 205 patients who underwent LADG (n = 147) or ODG (n = 58) between January 1994 and April 2004 were included in this study. Liver function tests—aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, total bilirubin—were examined before surgery and at 1, 3, and 7 days after surgery. The postoperative clinical course was compared between the two groups. Results AST levels on day 1 and ALT levels on days 1 and 3 were significantly higher in the LADG group. Albumin levels showed a marked decrease after operation in both groups, but the level recovered more rapidly in the LADG group than in the ODG group, showing significant differences on days 3 and 7. The total bilirubin levels remained unchanged from baseline. The postoperative complication rate was similar in the two groups, although 3 LADG patients among the 27 patients with liver disease suffered severe enteritis. Conclusions Transient liver dysfunction was documented in patients after laparoscopic gastrectomy under CO₂ pneumoperitoneum.     

Ictal SPECT analyzed by three-dimensional stereotactic surface projection in frontal lobe epilepsy patients

We analyzed preoperative ictal SPECT results from 18 frontal lobe epilepsy patients who underwent epilepsy surgery (mean age 22.9 years). Seizure onset at implanted subdural electrodes was defined as the epileptic focus in 16 of 18 patients. In two additional patients, the resected area on postoperative magnetic resonance images was defined as the epileptic focus. The radioisotope 99mTc-ECD was injected in all patients within 5 s after seizure onset. SPECT images were analyzed by three-dimensional stereotactic surface projection (3-D SSP). Areas of hyperperfusion identified by ictal SPECT were concordant with the site of epileptic focus in 11 patients (61.1%, concordant group) and were non-concordant in 7 patients (38.9%, non-concordant group). The non-concordant group had a higher number of patients with a history of acquired brain damages, such as encephalitis or brain surgery (p < 0.05). Only 3 of 11 patients in the concordant group showed areas of localized hyperperfusion within epileptic foci, whereas 8 patients showed areas of hyperperfusion extending to other regions. Ictal SPECT analyzed by 3-D SSP is useful as a mode of presurgical evaluation in frontal lobe epilepsy patients without a history of encephalitis or surgical treatment. We caution that rapid seizure spread may result occasionally in areas of hyperperfusion extending to adjacent or remote regions.     

Prolonged peri-firing compression with a linear stapler prevents pancreatic fistula in laparoscopic distal pancreatectomy

Background  

Laparoscopic distal pancreatectomy (Lap-DP) is one of the most accepted laparoscopic procedures in the field of pancreatic surgery. However, pancreatic fistula remains a major and frequent complication in Lap-DP, as in open surgery. The aim of this retrospective study is to clarify the advantages of prolonged peri-firing compression (PFC) with a linear stapler for prevention of pancreatic fistula after laparoscopic distal pancreatectomy.     

Emergent right coronary artery thrombectomy with a jet aspiration thrombectomy catheter

A saline-jet aspiration thrombectomy (JAT) catheter was used in a patient with acute myocardial infarction. A right coronary arteriogram showed complete thrombotic occlusion at the proximal segment. With this catheter the thrombus was removed without complications in 5 sec. The patient underwent percutaneous transluminal coronary angioplasty and placement of a Palmaz-Schatz stent after successful thrombectomy. Thrombectomy with a JAT catheter was very useful in this patient.     

Interface pressure and stiffness of various elastic stockings during posture changes and exercise

The importance of measuring interface pressure and stiffness to characterize the elastic properties of materials has been stressed with regard to elastic stockings and elastic bandages. The objective of this study was to compare the pressure profiles of nine different elastic stockings and to quantify the effects of posture changes and exercise on compression. Using a pressure transducer (Air Pack Type Analyzer), the interface pressure associated with nine different elastic stockings was measured at level B1 during supine resting, standing, and exercise. The elastic stockings examined could be divided into two categories according to extensibility: short stretch (< 105% extensibility) and long stretch (> 105% extensibility). Short-stretch stockings include thick round-knitted stockings, firm round-knitted stockings, and flat-knitted stockings. Short-stretch stockings showed a higher peak working pressure and a larger pressure amplitude during exercise than long-stretch stockings. Short-stretch stockings can be expected to have more pronounced benefits for augmenting muscle pumping in the same way as short-stretch bandages. In selecting suitable elastic stockings for patients, the stiffness should be taken into account in addition to interface pressure.     

Radiofrequency ablation with hand-assisted laparoscopic surgery for the treatment of hepatocellular carcinoma in the caudate lobe

OBJECTIVE: To assess the feasibility and safety of radiofrequency ablation (RFA) with hand-assisted laparoscopic surgery (HALS) for hepatocellular carcinoma (HCC) in the caudate lobe with severe liver dysfunction. SUMMARY BACKGROUND DATA: HCC in the caudate lobe remains one of the most difficult locations where various treatments tend to pose problems regarding the optimal surgical approach. The technique of HALS has thus been proposed as a useful method for performing a safe RFA therapy. For this study, we assessed the feasibility and safety of RFA with HALS for the treatment of HCC in the caudate lobe with liver dysfunction. PATIENTS AND METHODS: Between July 1999 and February 2005, 5 patients who suffered from HCC in the caudate lobe were indicated for RFA. The percutaneous puncture was difficult and all patients have severe liver dysfunction with viral chronic hepatitis. Therefore, RFA was assisted by an inserted hand through a minimal skin incision under laparoscopic inspection. An intraoperative endoscopic ultrasound examination was performed before RFA to determine the tumor region. The hand-assisted minimal dissection around the caudate lobe was required to detect tumor and avoid injuries of other tissues. RFA for HCC was performed using a cooled-tip (Radionics Inc, Burligton, MA) connected to a RF generator under the programmed cyclic impedance. RESULTS: The surgical procedures consisted of 5 RFA to tumors in the caudate lobe with HALS, which was performed safely, and a postoperative computed tomography scan revealed a sufficient ablation in all patients. There was no operative mortality but 1 patient had minor bile leakage, which was treated conservatively, and all patients recovered and thus were eventually discharged. One patient had local recurrence after 3 months, 3 patients had tumor recurrences in another segment after 6 months. At a mean follow-up 32.2 months, all patients were still alive. CONCLUSIONS: RFA with HALS is considered to be a safe and feasible technique for HCC in the caudate lobe with liver dysfunction.