Intra-operative testing for parathyroid hormone: the Central Laboratory option.

BACKGROUND: Intra-operative PTH testing in the operating theatre has proven to be an accurate way to verify the removal of all pathological parathyroid tissue in primary hyperparathyroidism. Its limitation is the high cost. An alternative, more cost-effective procedure is proposed: intra-operative PTH dosage at the Central Laboratory. PATIENTS AND METHODS: Fifty-four patients underwent parathyroidectomy with intraoperative dosage of PTH at the Central Laboratory. Three blood samples were taken from each patient: just after the induction of anesthesia, 5 and 10 min after parathyroidectomy. The samples were sent to the Central Laboratory and analysed simultaneously. The results were phoned back to the theatre. The procedure was considered effective when PTH drop was >/=50% from basal value, 10 min after parathyroidectomy. RESULTS: 98.1% of patients proved recovered (average follow- up 31.1 months). The procedure had 3 false negatives, 1 false positive, with sensitivity, specificity, accuracy, positive predictive value and negative predictive value of 94.0%, 75.0%, 92.6%, 97.9%, and 50.0%, respectively. DISCUSSION AND CONCLUSION: The main disadvantage of the presented procedure is the long waiting time. Nevertheless this time is the same as that required for results from intra-operative histological examination, the only alternative to determine surgery effectiveness in centres where portable instrumentation for intra-operative PTH dosage in the operating theatre is not available. The advantage of intra-operative PTH at the Central Laboratory is the very low cost. If results in terms of sensitivity, specificity, accuracy, and cost are taken into consideration, intra-operative dosage of PTH at the Central Laboratory may be deemed a viable alternative to the operating theatre.

Hypercholesterolaemia is not associated with early atherosclerotic lesions in primary biliary cirrhosis.

BACKGROUND: Hypercholesterolaemia often occurs in primary biliary cirrhosis (PBC) as a result of chronic cholestasis, but whether these patients are exposed to greater cardiovascular risk is unknown. AIM: To establish whether hypercholesterolaemia is associated with subclinical atherosclerosis in PBC. PATIENTS: 103 consecutive patients with PBC (37 with total cholesterol > or =6.21 mmol/l) and 37 controls with hypercholesterolaemia, and 141 matched controls with normocholesterolaemia. METHODS: Ultrasound imaging of carotid artery to determine intima-media thickness (IMT) and stenosis. RESULTS: Controls with hypercholesterolaemia had higher IMT and prevalence of carotid stenosis compared with patients with hypercholesterolaemic PBC (mean (SD) 0.850 (0.292) mm v 0.616 (0.137) mm, p(c)<0.001; 43% v 19%, p(c) = 0.129) who, in turn, were similar to the 66 patients with normocholesterolaemic PBC (0.600 (0.136) mm; 5%). Compared with subjects with normocholesterolaemia, controls with hypercholesterolaemia, but not patients with hypercholesterolaemic PBC, had an increased risk of raised IMT (odds ratio (OR) 5.4, 95% confidence interval (CI) 2.5 to 11.9, p<0.001; and 0.7, 0.3 to 2.0, p = 0.543) or carotid stenosis (8.2, 3.4 to 20, p<0.001; and 2.5, 0.9 to 6.9, p = 0.075). In PBC, compared with younger patients without hypertension, the risk of increased IMT was OR (CI) 3.1 (0.6 to 17; p = 0.192) in patients with hypertension or old age, but not hypercholesterolaemia, and 4.6 (0.8 to 27; p = 0.096) in patients who also had hypercholesterolaemia. The corresponding figures for risk of stenosis were 3.6 (0.4 to 36; p = 0.277) and 15.8 (1.8 to 141; p = 0.014). CONCLUSIONS: Hypercholesterolaemia is not consistently associated with subclinical atherosclerosis in PBC, but should be treated if other risk factors for cardiovascular disease are also present. The search for factors that may protect patients with hypercholesterolaemic PBC against atherosclerosis should be encouraged.

Multidetector helical angio CT oblique reconstructions orthogonal to internal carotid artery for preoperative evaluation of stenosis. A prospective study of comparison with color Doppler US, digital subtraction angiography and intraoperative data.

AIM: The recent introduction to clinical practice of multidetector helical angio CT (MHACT) has generated a new interest in the diagnosis of carotid artery atherosclerosis. In recent years there has been a redefinition of the indications to carotid artery endarterectomy; there is a tendency to appraise plaque morphology and composition, and not only stenosis degree. The aim of this prospective study is to analyze the validity of MHACT in the diagnosis of atheromasic stenosis of the carotid bifurcation, in comparison with US color Doppler (USCD), digital subtraction angiography (DSA) and intraoperative evidence (OP). Special emphasis is given to the analysis of plaque composition and to precise evaluation of the stenosis percentage computed as an area rate on oblique reconstructions performed exactly orthogonal to the axis of the vessel at the point of maximal stenosis. METHODS: Twenty-seven carotid stenosis (in 24 patients) were preoperatively evaluated by USCD, MHACT, DSA. We calculated the stenosis degree with USCD, by the ECST method, both as a diameter rate and as a bidimensional value. By MHACT we computed the percentage of stenosis as an area rate, in an MPR oblique plane orthogonal to the vessel axis, at the point of maximal stenosis; by DSA we used NASCET and the common carotid artery method (CC). DSA measurements have been mathematically converted as area rate (NASCET2 and CC2). All the patients were operated on with the eversion technique (EEA); it was always possible to obtain an intact cylindrical specimen of the plaque and to perform a reliable and accurate evaluation of the degree of stenosis by sectioning and measuring it on the desk. We gave a score to the presence and amount of lipid and calcium components, and these data were compared to those obtained with the different diagnostic instruments. RESULTS: Statistical analysis of the 7 data sets showed an important underestimate of the angiographical method (DSA), even if the measurements were carried on by a precision caliper. The mathematical conversion of a linear stenosis rate into an area rate gives these values more reliability, indicating, as for NASCET2, non statistically significant differences when compared to surgical evidence, notwithstanding a high standard deviation. The rates obtained by USCD (area rate) and MHACT proved to be very accurate with respect to surgical evidence. In this study there was no significant difference in the detection of various components (lipid and calcium) of the atheromasic lesion, by MHACT and surgical evidence (OP). CONCLUSION: MHACT promises to be a very accurate instrument in the detection of plaque components and identification of the stenosis degree. It shows some limits in very calcific lesions and occasionally, in relevant cardiac failure, may be useless. Hence one feels the need to reassess the role of DSA, once considered the "gold standard", with more extensive prospective studies, including comparison with MHACT and USCD.

Temporary spinal cord stimulation for peripheral cholesterol embolism.

Cholesterol embolism is often an unrecognized complication of some cardiac and vascular procedures (i.e. coronarography, angioplasty, aortocoronary bypass, abdominal aortic aneurysmectomy) and of therapies affecting coagulation (thrombolysis, anticoagulation). The degree of pain associated with ischaemic and necrotic lesions secondary to cholesterol embolism involving the lower limbs is disproportionate to the extension of tissue involvement. Spinal cord stimulation (SCS) has been recognized as effective in relief of pain of ischaemic and neuropathic nature, although its mechanism of action is still not completely clear. The authors are unaware of previous reports of peripheral cholesterol embolism treated by SCS. Two case reports of inferior limb ischaemia secondary to cholesterol embolism in patients who had undergone cardiac invasive procedures. Temporary surgical implantation of SCS devices, which were removed after 4 to 6 weeks. Pain relief was achieved within 1 to 4 hours of surgical procedure. Any analgesic medications could be immediately discontinued. Pain control was effective and normal daily activities were rapidly regained. Ischaemic lesions healed within 4 to 6 weeks of SCS. Pain control is the most critical aspect of the management of peripheral cholesterol embolism without visceral organ involvement. SCS provided effective pain relief in the reported cases and its established ability to improve peripheral microcirculation allowed rapid resolution of necrotic lesions. Temporary SCS should be considered in the management of painful necrotic skin lesions secondary to iatrogenic cholesterol embolism.

Late rupture of an abdominal aortic aneurysm after Parodi's endoprosthesis replacement.

Endovascular surgery as a whole, and specifically in the context of aortic aneurysms, is a very interesting methodology the potential of which is increasingly being recognized. Follow up information on patients who underwent these procedures will be critical to validate the different techniques which have been developed and to identify the most appropriate situations for this type of surgical procedures. The authors present a case of aortic aneurysm rupture who had undergone Parodi's endoprosthesis placement two years before. CT angiographic evaluation showed a wide endoleak due to distal stent detachment, a complete dislodging of the endoprosthesis itself and retroperitoneal haematoma. Prosthesis replacement through a laparotomic approach was carried out and the patient was discharged 10 days postoperatively, surgically cured.

Brain involvement in extracranial internal carotid artery aneurysms.

BACKGROUND: No prospective study of extracranial internal carotid artery aneurysms (EICAA) has been reported to date. The aim of this study was to evaluate central nervous system complications associated with surgical intervention for EICAA. PATIENTS AND METHODS: A total of seven patients, representing all cases observed at our institution from December 1997 to December 1998, were entered in this prospective study. Three patients had bilateral involvement. The aneurysms were both atherosclerotic and dysplastic. All patients were males, with mean age of 70 years (range 65 to 74). Internal or common carotid artery to EICAAs diameter ratios were calculated on the angiograms. The transverse diameter as well as the craniocaudal extension of the lesions were accurately measured intraoperatively. Follow-up evaluations were performed at three, six and twelve months postoperatively, and consisted of a clinical evaluation by both a neurologist and a vascular surgeon who were not part of the primary surgical team. RESULTS: Six patients presented with neurological symptoms ranging from non-hemispheric TIAs to hemispheric stroke. One patient was asymptomatic. The severity of symptoms was correlated with the size of the aneurysm. Preoperative symptoms were more severe in EICAAs of > or = 3 cm in transverse diameter. One case had a postoperative stroke, no perioperative deaths occurred. All the internal carotid arteries operated on were patent during follow-up evaluations. No new neurologic event was observed during follow-up. CONCLUSIONS: The severity of central neurologic symptoms seems to depend on the size of the aneurysmatic lesion. Prompt surgical management of small EICAAs may reduce the occurrence of severe CNS complications, both preoperatively and postoperatively, due to the lower risk of embolization associated with small aneurysms compared to larger lesions.

[Primary jejunal liposarcoma]. / Liposarcoma primitivo del degiuno.

A case of primary jejunal liposarcoma is reported. Liposarcoma of the small intestine is very rare (four cases in the international literature). The early clinical symptoms of these malignancies are unclear non specific and for this reason the disease is often diagnosed at an advanced stage. The prognosis of these lesions is generally poor owing to the diffusion of the disease at the time of diagnosis. Usually small bowel neoplasms are preoperatively identified only in 27-72%. The percentage of surgical removal is from 65 to 80% according to the recent literature. Aim of this paper is to present a rare case of jejunal liposarcoma.