Predicción de hipocalcemia postiroidectomía mediante determinación de PTH rápida / Prediction of post-idroidectomy hypocalcemia through rapid PTH determination

INTRODUCCIÓN: La hipocalcemia es la complicación que condiciona el postoperatorio de la tiroidectomía. El objetivo de este trabajo es identificar criterios bioquímicos de riesgo de hipocalcemia analizando niveles de paratohormona rápida (PTHir) pre y postiroidectomía y de calcemias postoperatorias. MÉTODOS: Se recoge una serie consecutiva de 310 tiroidectomías totales, obteniendo muestras de PTHr basal y tras 10 minutos postiroidectomía, junto a calcemias séricas cada 12 horas. Se estudian dos grupos, A normocalcémicos, B hipocalcémicos. Se calcula la sensibilidad, especificidad, valor predictivo positivo y negativo en relación con la hipocalcemia utilizando las curvas ROC y sus áreas bajo la curva. Se analiza un grupo control de 48 hemitiroidectomías para comparar los efectos de la cirugía sobre la secreción de PTH. RESULTADOS: De los 310 pacientes, 202 (65,1%) se mantuvieron normocalcémicos y asintomáticos (grupo A), 108 (34,9%) presentaron hipocalcemia Grupo B, precisando calcio oral (79 sintomáticos). Tras el análisis de varios puntos de corte, combinando un gradiente de descenso de PTHr del 60% o una calcemia menor de 7,4 mg/dL a las 24 horas se consigue una sensibilidad del 100% sin dejar falsos negativos. Comparando con el grupo de control existe una diferencia significativa respecto de las calcemias y la PTHr postoperatorias. CONCLUSIONES: La tiroidectomía total afecta la función paratiroidea con descenso evidente de PTHr y riesgo de hipocalcemia. La combinación de un descenso del 60% o la calcemia inferior a 7,4 mg/dL a las 24 horas obtiene una sensibilidad del 100% para la predicción de pacientes en riesgo de hipocalcemia

INTRODUCTION: Hypocalcemia is the most frequent complication after thyroidectomy. The aim of this work is to identify biochemical risk factors of hypocalcemia using quick perioperative (pre and post-thyroidectomy) intact parathyroid hormone (PTHi) and postoperative calcemias. METHODS: In a consecutive series of 310 total thyroidectomies, samples of quick PTHi at the anaesthetic induction and 10 minutes after surgery, together with serum calcemias every 12 hours were obtained. The sensitivity, specificity, positive and negative predictive value are analyzed and related to hypocalcemia. A control group of hemithyroidectomies is also analyzed to compare the effects of surgery on PTH secretion. RESULTS: Of the 310 patients, 202 (65.1%) remained normocalcemic and asymptomatic (group A), 108 (34.9%) presented hypocalcemia (Group B), requiring oral calcium (79 symptomatic). After analysis of several cut-off points, combining a PTHr drop gradient of 60% or calcemia inferior to 7.4 mg/dl at 24 hours, a sensitivity of 100% is achieved without leaving false negatives. Compared to the control group, there is a significant difference with respect to the post-operative calcemias and PTHr, p < 0.001. CONCLUSIONS: Total thyroidectomy affects parathyroid function with evident decrease in rPTH and risk of hypocalcemia. The combination of PTHr decrease of 60% or less than 7.4 mg/dl calcemia at 24 hours gives a 100% sensitivity for predicting patients at risk of hypocalcemia

Prediction of post-idroidectomy hypocalcemia through rapid PTH determination. / Predicción de hipocalcemia postiroidectomía mediante determinación de PTH rápida.

INTRODUCTION: Hypocalcemia is the most frequent complication after thyroidectomy. The aim of this work is to identify biochemical risk factors of hypocalcemia using quick perioperative (pre and post-thyroidectomy) intact parathyroid hormone (PTHi) and postoperative calcemias. METHODS: In a consecutive series of 310 total thyroidectomies, samples of quick PTHi at the anaesthetic induction and 10 minutes after surgery, together with serum calcemias every 12 hours were obtained. The sensitivity, specificity, positive and negative predictive value are analyzed and related to hypocalcemia. A control group of hemithyroidectomies is also analyzed to compare the effects of surgery on PTH secretion. RESULTS: Of the 310 patients, 202 (65.1%) remained normocalcemic and asymptomatic (group A), 108 (34.9%) presented hypocalcemia (Group B), requiring oral calcium (79 symptomatic). After analysis of several cut-off points, combining a PTHr drop gradient of 60% or calcemia inferior to 7.4 mg/dl at 24 hours, a sensitivity of 100% is achieved without leaving false negatives. Compared to the control group, there is a significant difference with respect to the post-operative calcemias and PTHr, p < 0.001. CONCLUSIONS: Total thyroidectomy affects parathyroid function with evident decrease in rPTH and risk of hypocalcemia. The combination of PTHr decrease of 60% or less than 7.4 mg/dl calcemia at 24 hours gives a 100% sensitivity for predicting patients at risk of hypocalcemia.

Infección por Actinomyces viscosus en trasplantado de riñón-páncreas / Actinomyces viscosus infection in a kidney-pancreas trasplanted patient

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[A randomized controlled trial of preoperative oral immunonutrition in patients undergoing surgery for colorectal cancer: hospital stay and health care costs]. / Estudio prospectivo y randomizado sobre inmunonutrición oral preoperatoria en pacientes intervenidos por cáncer colorrectal: estancia hospitalaria y costos sanitarios.

BACKGROUND: The use of enteral formulas with immunonutrients in patients with gastrointestinal malignancies susceptible to surgery can reduce postoperative morbidity, at the expense of reduced infectious complications, with the consequent reduction in hospital stay and health care costs. MATERIAL AND METHODS: Prospective randomized study. 84 patients operated on a scheduled basis for resectable colorectal cancer were recruited. In the group YES IN Impact © Oral was administered for 8 days (3 sachets a day), compared with the NOT IN group who did not receive it. RESULTS: 40.5% (17) patients without immunonutrition suffered infectious complications vs. 33.3% (14) of YES IN. In patients with rectal cancer NOT IN, 50% (8) suffered minor infectious complications (p=.028). In each group (YES IN, NOT IN, colon and rectal cancer) when infectious complications were observed, the variables total hospital stay and costs doubled, with significant differences. These variables showed higher values in the group NOT IN compared with those who received immunonutrition, although these differences were not statistically significant. CONCLUSIONS: NOT IN patients suffered infectious complications more frequently than YES IN, with significant results in the subgroup of patients with rectal cancer. The total hospital stay and costs were slightly higher in the group not supplemented, doubling in each category significantly (YES IN, NOT IN, colon and rectal cancer), when infectious complications were observed.

Compliance with recommendations on surgery for primary hyperparathyroidism-from guidelines to real practice: results from an Iberian survey.

PURPOSE: Knowledge about compliance with recommendations derived from the positional statement of the European Society of Endocrine Surgeons on modern techniques in primary hyperparathyroidism surgery and the Third International Workshop on management of asymptomatic primary hyperparathyroidism is scarce. Our purpose was to check it on a bi-national basis and determine whether management differences may have impact on surgical outcomes. METHODS: An online survey including questions about indications, preoperative workup, surgical approach, intraoperative adjuncts, and outcomes was sent to institutions affiliated to the endocrine surgery divisions of the National Surgical Societies from Spain and Portugal. A descriptive evaluation of the responses was performed. Finally, we assessed the correlation between the different types of management with the achievement of optimal results, defined as a cure rate equal or greater than the median of all interviewed institutions. RESULTS: Fifty-seven hospitals (41 Spanish, 16 Portuguese) answered the survey. First-ordered imaging tests were neck ultrasound and sestamibi scan. Facing negative or non-concordant results, 44 % of surgeons ordered additional tests before first-time surgery, and 84 % before reoperations. When indicated, selective parathyroidectomy was an acceptable option for 95 % of institutions as first-time surgery and for 51 % in reoperations. Intraoperative parathormone measurements were used by 92 % of departments. The surgical outcomes were good in most institutions (median cure rate 97 %) and were influenced mostly by the presence of an endocrine surgery unit in the surgical department (p = 0.038). CONCLUSIONS: Practice of Iberian endocrine surgeons is consistent with current recommendations on surgery for primary hyperparathyroidism, with variability in some areas.

Estudio cooperativo del Grupo Español de Trasplante de Páncreas (GETP): complicaciones quirúrgicas / Cooperative study of the Spanish Pancreas Transplant Group (GETP): Surgical complications

El fracaso técnico en el trasplante de páncreas ha sido el principal responsable de la pérdida de los injertos. Desde hace unos años, el número de complicaciones se han reducido, y por tanto, la proporción de este problema. Objetivos El Grupo Español del Trasplante de Páncreas se plantea como objetivo de este estudio analizar la situación actual con relación a las complicaciones quirúrgicas y su gravedad. Material y métodos Se ha realizado un estudio retrospectivo y multicéntrico con 10 centros participantes, con un total de 410 pacientes trasplantados de páncreas entre enero de 2008 y diciembre de 2013. Resultados Un total de 316 trasplantes fueron simultáneos con riñón, 66 después de riñón, 10 solo de páncreas, 7 multiviscerales y 11 retrasplantes. El porcentaje de complicaciones quirúrgicas fue del 39% (161 pacientes). Un 7% de trombosis vasculares, 13% de hemorragias, 6% de pancreatitis del injerto, 12% de infecciones quirúrgicas y otras en menor proporción. Las reintervenciones alcanzaron el 25%. La gravedad de las complicaciones fueron del tipo iiib (13%), del tipo ii (12%) y del tipo iva (8,5%). La pérdida del injerto fue del 8%. La mortalidad precoz del 0,5%. Las operaciones por complicaciones tardías fueron el 17%. Conclusiones El número de complicaciones quirúrgicas tras el trasplante no es desdeñable: afectan a uno de cada 3 pacientes, son graves en uno de cada 5 y con pérdida del injerto en uno de cada 10 pacientes. Por tanto, sigue existiendo un porcentaje significativo de complicaciones quirúrgicas en este tipo de actividad, como se demuestra en nuestro país

Technical failure in pancreas transplant has been the main cause of the loss of grafts. In the last few years, the number of complications has reduced, and therefore the proportion of this problem. Objetives The Spanish Pancreas Transplant Group wanted to analyze the current situation with regard to surgical complications and their severity. Material and methods A retrospective and multicenter study was performed. 10 centers participated, with a total of 410 pancreas transplant recipients between January and December 2013. Results A total of 316 transplants were simultaneous with kidney, 66 after kidney, pancreas-only 10, 7 multivisceral and 11 retrasplants. Surgical complication rates were 39% (n = 161). A total of 7% vascular thrombosis, 13% bleeding, 6% the graft pancreatitis, 12% surgical infections and others to a lesser extent. Relaparotomy rate was 25%. The severity of complications were of type IIIB (13%), type II (12%) and type IVA (8.5%). Graft loss was 8%. Early mortality was 0.5%. The percentage of operations for late complications was 17%. Conclusions The number of surgical complications after transplantation is not negligible, affecting one in 3 patients. They are severe in one out of 5 and, in one of every 10 patients graft loss occurs. Therefore, there is still a significant percentage of surgical complications in this type of activity, as shown in our country

Cooperative Study of the Spanish Pancreas Transplant Group (GETP): Surgical Complications.

UNLABELLED: Technical failure in pancreas transplant has been the main cause of the loss of grafts. In the last few years, the number of complications has reduced, and therefore the proportion of this problem. OBJECTIVES: The Spanish Pancreas Transplant Group wanted to analyze the current situation with regard to surgical complications and their severity. MATERIAL AND METHODS: A retrospective and multicenter study was performed. 10 centers participated, with a total of 410 pancreas transplant recipients between January and December 2013. RESULTS: A total of 316 transplants were simultaneous with kidney, 66 after kidney, pancreas-only 10, 7 multivisceral and 11 retrasplants. Surgical complication rates were 39% (n=161). A total of 7% vascular thrombosis, 13% bleeding, 6% the graft pancreatitis, 12% surgical infections and others to a lesser extent. Relaparotomy rate was 25%. The severity of complications were of type IIIb (13%), type II (12%) and type IVa (8.5%). Graft loss was 8%. Early mortality was 0.5%. The percentage of operations for late complications was 17%. CONCLUSIONS: The number of surgical complications after transplantation is not negligible, affecting one in 3 patients. They are severe in one out of 5 and, in one of every 10 patients graft loss occurs. Therefore, there is still a significant percentage of surgical complications in this type of activity, as shown in our country.

Hiperparatiroidismo primario y crisis hipercalcémica aguda tóxica / Primary hyperparathyroidism and acute toxic hypercalcaemic crisis

Objetivos: Describir las características clínicas y tratamiento quirúrgico de los pacientes con hipercalcemia aguda por hiperparatiroidismo primario (HPTP) y compararlas con las de otros pacientes con HPTP sin hipercalcemia aguda asociada. Material y métodos Estudio observacional prospectivo (1998-2010) sobre 158 pacientes con HPTP tratados mediante paratiroidectomía. Se identificaron aquellos con hipercalcemia aguda (>14mg/dl-3,5mmol/l- o >3mmol/l con síntomas de calciotoxicosis), se evaluaron sus características clínicas y terapéuticas y se compararon, mediante la U de Mann-Whitney y el test de Fisher, con los 146 pacientes con HPTP sin crisis hipercalcémicas. Resultados Doce pacientes (7,6%) presentaron hipercalcemia aguda con síntomas de calciotoxicosis y otros síntomas de cronicidad. Los valores preoperatorios de calcemia y PTH fueron 14,5±1,3mg/dl y 648,2±542pg/dl, respectivamente. Hubo 10 adenomas, una hiperplasia y un carcinoma. El peso medio de las piezas quirúrgicas fue 4.075±2.918 mg con un diámetro mayor de 27±14mm. Los gradientes de caída de PTH a los 10 y 25min fueron 79±18% y 92±6%. Las calcemias postoperatorias al alta y a los 6 meses fueron 8,2±0,7 y 9,1±0,9mg/dl. Las concentraciones plasmáticas de Ca, PTH y el peso y tamaño de las piezas quirúrgicas fueron mayores en los pacientes con crisis hipercalcémicas (p<0,001). No hubo diferencias en otros parámetros estudiados y en la tasa de curación. Conclusiones Las crisis hipercalcémicas fueron producidas por tumores más grandes, de mayor peso y que producían mayores concentraciones plasmáticas de Ca y PTH. Todos los pacientes presentaban síntomas de evolución crónica y la paratiroidectomía consiguió la curación (AU)

Objectives: To describe the clinical characteristics and surgical treatment of patients with acute hypercalcaemia due to primary hyperparathyroidism (PHPT) and compare them with other patients with PHPT without associated acute hypercalcaemia. Material and methods: A prospective, observational study (1998-2010) was conducted on 158patients with PHPT treated by parathyroidectomy. Those with acute hypercalcaemia(>14 mg/dl -3.5 mmol/L- or >3 mmol/L with symptoms of calcium toxicity) were evaluated by recording their clinical and treatment characteristics, and comparing them, using the Mann-Whitney U test and the Fisher test, with the 146 PHPT patients without hypercalcaemic crisis. Results: Twelve patients (7.6%) had acute hypercalcaemia with symptoms of calcium toxicity and other symptoms of chronicity. The preoperative calcium and PTH values were14.5 1.3 mg/dL and 648.2 542 pg/dL, respectively. There were 10 adenomas, 1 hyperplasia and 1 carcinoma. The mean weight of the surgical pieces was 4.075 2.918 mg, with a diameter greater than 27 14 mm. The gradients of PTH at 10 and 25 minutes were 79 18%and 92 6%, respectively. Post-operative calcium values on discharge and at 6 months were8.2 0.7 mg/dL and 9.1 0.9 mg/dL, respectively. The plasma concentrations of calcium, PTH, and the size of the surgical pieces were higher in patients with hypercalcaemic crisis(P<0.001). There were no differences in the other parameters studied or in the cure rate. Conclusions: Hypercalcaemic crises were caused by larger and heavier tumours that led to higher plasma Ca and PTH plasma concentrations. All patients had long-standing symptoms and parathyroidectomy led to cure of the disease (AU)

[Primary hyperparathyroidism and acute toxic hypercalcaemic crisis]. / Hiperparatiroidismo primario y crisis hipercalcémica aguda tóxica.

OBJECTIVES: To describe the clinical characteristics and surgical treatment of patients with acute hypercalcaemia due to primary hyperparathyroidism (PHPT) and compare them with other patients with PHPT without associated acute hypercalcaemia. MATERIAL AND METHODS: A prospective, observational study (1998-2010) was conducted on 158 patients with PHPT treated by parathyroidectomy. Those with acute hypercalcaemia (>14 mg/dl -3.5 mmol/L- or >3 mmol/L with symptoms of calcium toxicity) were evaluated by recording their clinical and treatment characteristics, and comparing them, using the Mann-Whitney U test and the Fisher test, with the 146 PHPT patients without hypercalcaemic crisis. RESULTS: Twelve patients (7.6%) had acute hypercalcaemia with symptoms of calcium toxicity and other symptoms of chronicity. The preoperative calcium and PTH values were 14.5 ± 1.3mg/dL and 648.2 ± 542 pg/dL, respectively. There were 10 adenomas, 1 hyperplasia and 1 carcinoma. The mean weight of the surgical pieces was 4.075 ± 2.918 mg, with a diameter greater than 27 ± 14 mm. The gradients of PTH at 10 and 25 minutes were 79 ± 18% and 92 ± 6%, respectively. Post-operative calcium values on discharge and at 6 months were 8.2 ± 0.7 mg/dL and 9.1 ± 0.9 mg/dL, respectively. The plasma concentrations of calcium, PTH, and the size of the surgical pieces were higher in patients with hypercalcaemic crisis (P<0.001). There were no differences in the other parameters studied or in the cure rate. CONCLUSIONS: Hypercalcaemic crises were caused by larger and heavier tumours that led to higher plasma Ca and PTH plasma concentrations. All patients had long-standing symptoms and parathyroidectomy led to cure of the disease.