Consideraciones quirúrgicas del bocio amiloide / Surgical considerations about amyloid goiter

La amiloidosis es un síndrome poco frecuente, constituido por un conjunto de trastornos que tienen en común el depósito extracelular de proteínas fibrilares. De ello resultan alteraciones funcionales y estructurales de los órganos afectados, dependientes de la localización e intensidad del depósito.La infiltración amiloide del tiroides puede verse en el 50% de la amiloidosis primaria y hasta en el 80% de la forma secundaria. El bocio amiloide (BA) es una verdadera rareza, habitualmente asociado a la forma secundaria. El BA puede tener indicación quirúrgica, generalmente justificada por problemas compresivosComunicamos el caso de un paciente con un gran BA en el curso de una amiloidosis secundaria asociada a una artritis idiopática juvenil de inicio poliarticular, al que se le practicó una tiroidectomía total. Revisamos la literatura, intentando aportar pautas de actuación y algunas consideraciones quirúrgicas sobre esta rara afección (AU)

Amyloidosis is an uncommon syndrome consisting of a number of disorders having in common an extracellular deposit of fibrillary proteins. This results in functional and structural changes in the affected organs, depending on deposit location and severity.Amyloid infiltration of the thyroid gland may occur in 50% and up to 80% of patients with primary and secondary amyloidosis respectively. Amyloid goiter (AG) is a true rarity, usually found associated to secondary amyloidosis. AG may require surgical excision, usually because of compressive symptoms.We report the case of a patient with a big AG occurring in the course of a secondary amyloidosis associated to polyarticular onset juvenile idiopathic arthritis who underwent total thyroidectomy. Current literature is reviewed, an attempt is made to provide action guidelines, and some surgical considerations on this rare condition are given (AU)

Surgical considerations about amyloid goiter.

Amyloidosis is an uncommon syndrome consisting of a number of disorders having in common an extracellular deposit of fibrillary proteins. This results in functional and structural changes in the affected organs, depending on deposit location and severity. Amyloid infiltration of the thyroid gland may occur in 50% and up to 80% of patients with primary and secondary amyloidosis respectively. Amyloid goiter (AG) is a true rarity, usually found associated to secondary amyloidosis. AG may require surgical excision, usually because of compressive symptoms. We report the case of a patient with a big AG occurring in the course of a secondary amyloidosis associated to polyarticular onset juvenile idiopathic arthritis who underwent total thyroidectomy. Current literature is reviewed, an attempt is made to provide action guidelines, and some surgical considerations on this rare condition are given.

Chyle fistula in right cervical area after thyroid surgery.

Thoracic duct injury is an infrequent (1-2.5%) but severe complication after neck surgery, leading to nutritional, metabolic and immunologic deficiencies. We report a case of a 34-year-old woman with a right thoracic duct injury after surgery of a thyroid medullar cancer effectively treated with conservative management (parenteral nutrition and intravenous somatostatin). Optimal treatment of these patients is unclear, without a clear limit between conservative and surgical treatment.

[Laparoscopic splenectomy: 7-year experience]. / Esplenectomía laparoscópica: Experiencia de 7 años.

BACKGROUND: Laparoscopic splenectomy is an effective and safe technique in the management of benign splenic pathologies. METHODS: We reviewed our 7-year experience to evaluate utility and safety of this procedure. RESULTS: Laparoscopic splenectomy was performed in 20 patients (13 women, 7 men), with a mean age of 49 years. Pathology included 19 cases of idiopathic thrombocytopenic purpura (ITP) and one case of autoimmune hemolytic anemia. Mean operative time was 165 min, including anesthetic procedure. There was only one conversion to open surgery. Accessory spleens were detected in 15% of patients. Early remission of hematological disorders was achieved in 70% of the cases and long-term remission in 90%. The complications rate was 20%, including two cases of subphrenic hematoma, one case of acute focal pancreatitis and one case of thrombosis of the portal venous system; all recovered with no sequelae. Mortality rate was 0%. CONCLUSIONS: Laparoscopic splenectomy obtains results identical to those of open surgery in terms of efficacy and safety but with the benefits of laparoscopic surgery. Therefore, it should be considered as the procedure of choice for the treatment of benign hematological pathologies unresponsive to medical therapy.

[Laparoscopic adrenalectomy]. / Adrenalectomía laparoscópica.

INTRODUCTION: In the last few years, laparoscopic adrenalectomy has become widely used in the management of adrenal disease. MATERIAL AND METHOD: We reviewed our experience of 24 patients who underwent laparoscopic adrenalectomy between 1998 and 2006. RESULTS: Surgery was indicated for Cushing's syndrome in 46% of the patients, aldosteronoma in 25%, incidentaloma in 21% and pheochromocytoma in 8%. A lateral transabdominal approach was employed in all patients. The mean age of the patients was 50.4 years (17 women and 7 men). Left unilateral adrenalectomy was performed in 63% of the patients, right unilateral adrenalectomy in 29% and bilateral adrenalectomy in 8%. The conversion rate was 4%. The mean operating time was 134 minutes in unilateral approaches and 245 minutes in bilateral approaches. The mean size of the gland was 4 cm. The complications rate was 4% and there was no mortality. Disease control was achieved in 96% of the patients after a mean follow-up of 49 months. CONCLUSIONS: Laparoscopic adrenalectomy should be considered the procedure of choice for the surgical management of benign adrenal disease.

Adrenalectomía laparoscópica / Laparoscopic adrenalectomy

Introducción. La adrenalectomía laparoscópica es una técnica que se ha popularizado en los últimos años en el manejo de la afección adrenal. Material y método. Revisamos nuestra experiencia de 24 casos de adrenalectomía laparoscópica entre 1998 y 2006. Resultados. En el 46% de los casos la indicación fue por síndrome de Cushing; en el 25%, aldosteronoma; en el 21%, incidentaloma, y en el 8%, feocromocitoma. El abordaje fue por vía transabdominal lateral en todos los pacientes. La media de edad de los pacientes fue 50,4 años y se trataba de 17 mujeres y 7 varones. Se realizó adrenalectomía unilateral izquierda en el 63% de los casos, unilateral derecha en el 29% y bilateral en el 8%. La tasa de conversión a cirugía abierta fue el 4%. La duración media de la intervención fue 134 min en los abordajes unilaterales y 245 min en los bilaterales. El tamaño medio de la glándula fue 4 cm. La tasa de complicaciones fue del 8% y no hubo mortalidad. Se consiguió control de la enfermedad de base en el 96% de los pacientes tras un seguimiento medio de 49 meses. Conclusiones. La adrenalectomía laparoscópica debe ser considerada como el procedimiento de elección para el tratamiento quirúrgico de las enfermedades adrenales benignas (AU)

Introduction. In the last few years, laparoscopic adrenalectomy has become widely used in the management of adrenal disease. Material and method. We reviewed our experience of 24 patients who underwent laparoscopic adrenalectomy between 1998 and 2006. Results. Surgery was indicated for Cushing's syndrome in 46% of the patients, aldosteronoma in 25%, incidentaloma in 21% and pheochromocytoma in 8%. A lateral transabdominal approach was employed in all patients. The mean age of the patients was 50.4 years (17 women and 7 men). Left unilateral adrenalectomy was performed in 63% of the patients, right unilateral adrenalectomy in 29% and bilateral adrenalectomy in 8%. The conversion rate was 4%. The mean operating time was 134 minutes in unilateral approaches and 245 minutes in bilateral approaches. The mean size of the gland was 4 cm. The complications rate was 4% and there was no mortality. Disease control was achieved in 96% of the patients after a mean follow-up of 49 months. Conclusions. Laparoscopic adrenalectomy should be considered the procedure of choice for the surgical management of benign adrenal disease (AU)

Portal vein thrombosis after laparoscopic splenectomy in benign hematologic diseases.

INTRODUCTION: Portal vein thrombosis is an unfrequent, but potentially deadly, complication of the laparoscopic splenectomy procedure. The laparoscopic approach has shortened the duration of hospital stay; portal vein thrombosis may appear after the patient has left the hospital, determining a later diagnosis. Because of the mild, nonspecific symptoms, the diagnosis can even be missed and only achieved when chronic complications take place. OBJECTIVES: In this study, we aimed to determine the appearance of portal vein thrombosis in a consecutive series of patients who underwent laparoscopic splenectomy by performing a contrast-enhanced computed tomography (CT) scan postoperatively. MATERIALS AND METHODS: A transversal study was established, performing in 2005 a contrast-enhanced CT scan on 20 patients who underwent laparoscopic splenectomy between 1999 and 2005 at Ramón y Cajal University Hospital (Madrid, Spain). The presence of thrombosis in the splenoportomesenteric axis was investigated. RESULTS: Two (2) cases (10%) of portal vein thrombosis were detected: 1 symptomatic case, 7 days after surgery, was treated with anticoagulation, resulting in the disappearance of the thrombus in a new CT scan 6 months later; the second case was asymptomatic and was discovered during the performance of this study. CONCLUSIONS: The contrast-enhanced CT scan shows the best accuracy for the diagnosis of portal vein thrombosis, and it must be performed when any clinical manifestation appear; also, it must still be determined if a contrast-enhanced CT scan should be systematically performed in high-risk thromboembolic patients. An ultrasound Doppler may present many diagnostic errors. It is probably advisable to prolong the antithromboembolic prophylaxis.

Dos casos extremos de presentación de tumores pancreáticos / Two exceptional cases of pancreatic tumor

El cáncer de páncreas es un tumor de mal pronóstico y la resección quirúrgica es el único tratamiento potencialmente curativo, pero pocos casos son candidatos por su presentación en estadios avanzados. Exponemos 2 casos extremos de presentación de tumores pancreáticos. Caso 1: varón de 59 años que presenta heces melénicas recidivantes a pesar de esclerosis endoscópica de ulcus duodenal. Se objetivó mediante tomografía computarizada (TC) una masa en cabeza pancreática con infiltración de la segunda porción del duodeno. La biopsia duodenal mostró carcinoma pobremente diferenciado. Se realizó duodenopancreatectomía paliativa. Caso 2: varón de 49 años con episodios esporádicos de dolor en hipocondrio derecho y antecedentes familiares de primero y segundo grado fallecidos de cáncer de páncreas. La TC y la resonancia magnética mostraron en la cabeza pancreática una lesión quística inferior de 1 cm. Una punción-aspiración con aguja fina mostró material mucoide y papilas con atipia celular. Ante el diagnóstico probable de cistoadenoma mucinoso se decidió realizar pancreatoduodenectomía (AU)

Pancreatic cancer carries a poor prognosis. The only potentially curative treatment is surgical resection. However, this procedure can only be performed in a few cases due to presentation of the tumor in advanced stages. We present 2 exceptional cases of pancreatic cancer presentation. Case 1: A 59-year-old man presented with recurrent melena despite endoscopic sclerosis of a duodenal ulcer. A computed tomography (CT) scan revealed a 7-cm mass in the head of the pancreas infiltrating the second portion of the duodenum. Duodenal biopsy showed a poorly differentiated carcinoma. Palliative pancreatoduodenectomy was performed. Case 2: A 49-year-old man presented with sporadic pain in the right hypochondrium and a familial history of pancreatic cancer in first and second degree relatives. CT and magnetic resonance imaging revealed a 1-cm cystic lesion in the head of the pancreas. Cytology showed mucoid material and atypia. Given a probable diagnosis of mucinous cystoadenoma, pancreatoduodenectomy was performed (AU)

[Laparoscopic vs open splenectomy in the treatment of idiopathic thrombocytopenic purpura]. / Esplenectomía laparoscópica o esplenectomía abierta en el tratamiento de la púrpura trombocitopénica idiopática.

INTRODUCTION: Laparoscopic splenectomy (LS) is gaining acceptance as an effective and safe alternative to open splenectomy (OS) in the treatment of benign hematologic disorders unresponsive to medical treatment. Among these disorders, the most important is idiopathic thrombocytopenic purpura (ITP). PATIENTS AND METHOD: We compared a cohort of 20 patients who had undergone LS in the previous 7 years, with a historical cohort of 38 patients who underwent OS between 1985 and 1999. All patients in the two groups were diagnosed with ITP unresponsive to medical treatment. RESULTS: The mean age of the patients was 41 years in the LS group and 39.7 in the OS group. Mean spleen size and weight were 11 cm and 150 g in the LS group and 9.9 cm and 190 g in the OS group. Preoperative platelet count was 78 x 10(9) in the LS group and 69 x 10(9) in the OS group. Accessory spleens were detected in 15% of patients in the LS group and in 16% of those in the OS group. The mean operative time was 180 minutes in LS and 85 minutes in OS (p < 0.001). The complications rate was 25% in LS and 21% in OS. The mean length of hospital stay was 3 days in the LS group and 9.4 days in the OS group (p < 0.001). No differences were observed in early and complete long-term remission. CONCLUSIONS: Compared with OS, LS requires a longer operative time and reduces hospital stay. Detection of accessory spleens, complication rates, and effectiveness in terms of early and long-term remission are similar in both procedures. In our opinion, LS should be considered the procedure of choice for the treatment of benign hematological disorders unresponsive to medical therapy.

Esplenectomía laparoscópica o esplenectomía abierta en el tratamiento de la púrpura trombocitopénica idiopática / Laparoscopic vs open splenectomy in the treatment of idiopathic thrombocytopenic purpura

Introducción. La esplenectomía laparoscópica está ganando aceptación como alternativa segura y efectiva a la esplenectomía abierta en el tratamiento de trastornos hemáticos benignos refractarios a tratamiento médico, de los que la púrpura trombocitopénica idiopática es el más importante. Material y método. Comparamos una cohorte de 20 pacientes sometidos a esplenectomía laparoscópica (EL) en los últimos 7 años con una cohorte histórica de 38 casos sometidos a esplenectomía abierta (EA) entre 1985 y 1999. Todos los casos de ambos grupos estaban diagnosticados de púrpura trombocitopénica idiopática refractaria a tratamiento médico. Resultados. La media de edad de los pacientes del grupo EL era de 41 años, frente a 39,7 en el grupo EA. El tamaño medio y el peso medio del bazo fueron de 11 cm y 150 g en EL y 10,9 cm y 190 g en EA. El recuento plaquetario preoperatorio fue 78 x 109 en EL y 69 x109 en EA. Se detectaron bazos accesorios en el 15% de los casos del grupo EL y el 16% en el grupo EA. La duración media de la cirugía fue 180 min en EL y 85 min en EA (p < 0,001). La tasa de complicaciones fue del 25% en EL y el 21% en EA. La estancia media hospitalaria fue 3 días en el grupo EL y 9,4 días en el grupo EA (p < 0,001). No se observaron diferencias en las tasas de remisión precoz y remisión completa a largo plazo. Conclusiones. Comparada con la EA, la EL precisa mayor tiempo operatorio, son similares en la detección de bazos accesorios, la tasa de complicaciones y la efectividad en la remisión precoz y la remisión completa a largo plazo, y conlleva un menor tiempo de hospitalización. En nuestra opinión, la EL debe ser considerada el procedimiento de elección en el tratamiento de afecciones hemáticas benignas que no responden a tratamiento médico (AU)

Introduction. Laparoscopic splenectomy (LS) is gaining acceptance as an effective and safe alternative to open splenectomy (OS) in the treatment of benign hematologic disorders unresponsive to medical treatment. Among these disorders, the most important is idiopathic thrombocytopenic purpura (ITP). Patients and method. We compared a cohort of 20 patients who had undergone LS in the previous 7 years, with a historical cohort of 38 patients who underwent OS between 1985 and 1999. All patients in the two groups were diagnosed with ITP unresponsive to medical treatment. Results. The mean age of the patients was 41 years in the LS group and 39.7 in the OS group. Mean spleen size and weight were 11 cm and 150 g in the LS group and 9.9 cm and 190 g in the OS group. Preoperative platelet count was 78 x 109 in the LS group and 69 x 109 in the OS group. Accessory spleens were detected in 15% of patients in the LS group and in 16% of those in the OS group. The mean operative time was 180 minutes in LS and 85 minutes in OS (p < 0.001). The complications rate was 25% in LS and 21% in OS. The mean length of hospital stay was 3 days in the LS group and 9.4 days in the OS group (p < 0.001). No differences were observed in early and complete long-term remission. Conclusions. Compared with OS, LS requires a longer operative time and reduces hospital stay. Detection of accessory spleens, complication rates, and effectiveness in terms of early and long-term remission are similar in both procedures. In our opinion, LS should be considered the procedure of choice for the treatment of benign hematological disorders unresponsive to medical therapy (AU)

Conservative treatment for infiltrating breast cancer. Ten years follow-up experience.

INTRODUCTION: We retrospectively analyze our experience in conservative treatment for infiltrating advanced breast cancer before implementation of selective sentinel node biopsy, specially focusing on characteristics, incidence, treatment and evolution of local-regional recurrences, disease-free survival time, overall survival and patient's satisfaction. MATERIAL AND METHODS: From January 1984 to 31st December 1998, 739 female patients were operated in our institution, diagnosed as having infiltrating breast cancer. One hundred and eighty-eight patients (25.43%) received conservative treatment and they were followed up until December 2003. RESULTS: Average age when diagnosed was 50.42 years old (24-87 years). 53.19% of the patients were premenopausal. After a median follow-up of 129 months (60-198 months), 13 women (6.91%) presented local -regional recurrence and the disease-free time was 48.4 months (8-108 months). Global survival rate was 83.5% and disease free survival rate was 80.85%. CONCLUSIONS: The management of choice for early stage (I and II) infiltrating breast cancer is nowadays conservative, with a low local-regional recurrence rate and survival rate that are comparable to radical mastectomy, according to the literature. It's a safe and efficient method that let us preserve the breast with a good esthetical result. In selected cases, when a regional recurrence occurs, a second conservative management is possible with a good control of the disease, although the most widely accepted treatment in these cases is total mastectomy.