Diagnosis and treatment of primary thyroid lymphoma from a surgical perspective: a multi-institutional study.

PURPOSE: Surgery of primary thyroid lymphoma (PTL) has been mostly limited to diagnostic work-up. This study aimed to further study its potential role. METHODS: This was a retrospective study from a multi-institutional registry of PTL patients. Clinical, diagnostic work-up (fine needle aspiration, FNA; core needle biopsy, CoreNB), contribution of surgery (open surgical biopsy, OpenSB; thyroidectomy), histology subtype, and outcome data were evaluated. RESULTS: Some 54 patients were studied. Diagnostic work-up included FNA in 47 patients, CoreNB in 11, and OpenSB in 21. CoreNB yielded the best sensitivity (90.9%). Thyroidectomy was performed in 14 patients with other diagnosis (incidental PTL), in 4 for diagnosis and in 4 for elective treatment of PTL. Incidental PTL was associated with not performed FNA nor CoreNB (OR 52.5; P = 0.008), mucosa-associated lymphoid tissue (MALT) subtype (OR 24.3; P = 0.012), and Hashimoto's thyroiditis (OR 11.1; P = 0.032). Lymphoma-related death (10 cases) mostly occurred within the first year after diagnosis and was associated with diffuse large B-cell (DLBC) subtype (OR 10.3; P = 0.018) and older patients (OR 1.08 for every 1-year increase; P = 0.010). There was a trend towards lower mortality rate in patients receiving thyroidectomy (2/22 versus 8/32, P = 0.172). CONCLUSION: Incidental PTL accounts for most of thyroid surgery cases and are associated with incomplete diagnostic work-up, Hashimoto's thyroiditis and MALT subtype. CoreNB appears to be the best tool for diagnosis. Most of PTL deaths occurred during the first year after diagnosis and mostly related to systemic treatment. Age and DLBC subtype are poor prognostic factors.

Situación actual de la cirugía endocrina en régimen ambulatorio en España. Revisión sistemática de la literatura existente / Current situation of outpatient endocrine surgery in spain. Systematic review of the existing literature

En los últimos 20 años la cirugía en régimen ambulatorio se ha impuesto como una realidad cotidiana. Se ha convertido en un estándar para ciertas cirugías en casos seleccionados. La cirugía tiroidea y paratiroidea han sido unos de los procedimientos que se han implantado en muchas unidades de CMA, pero todavía hay reticencias a su realización y no existen muchas publicaciones al respecto en el ámbito nacional. Por ello, revisamos la literatura publicada en revistas indexadas respecto a la cirugía tiroidea y paratiroidea en régimen ambulatorio en España en los últimos 20 años (AU)

In the last 20 years ambulatory surgery has established itself as a daily reality. It has become a standard for certain surgeries in selected cases. Thyroid and parathyroid surgery have been one of the procedures that have been implemented in many units, but there is still reluctance to carry them out and there are not many publications on the matter at the national level. For this reason, we reviewed the literature published in indexed journals regarding thyroid and parathyroid surgery in outpatient settings in Spain in the last 20 years (AU)

Experiencia inicial en la radiolocalización intraoperatoria del adenoma paratiroideo con freehand SPECT y valoración comparativa con gammacámara portátil / Initial experience in intraoperative radiolocalization of the parathyroid adenoma with freehand SPECT and comparative assessment with portable gamma-camera

Presentamos nuestra experiencia inicial con freehand SPECT en la radiolocalización intraoperatoria del adenoma paratiroideo en 2 pacientes, uno de ellos mediastínico. Existe solo una publicación anterior de 3 pacientes con adenomas en localización paratiroidea habitual. Aportamos además por primera vez una valoración comparativa de resultados con gammacámara portátil en la misma intervención. Se obtuvieron imágenes con gammacámara portátil y reconstrucción 3 D con freehand SPECT en qui- rófano desde 15 min tras administración iv de 5 mCi de 99m Tc-MIBI, localizándose los 2 adenomas con ambos equipos, comprobando la actividad de la pieza extirpada y ausencia de captación significativa en el lecho postexéresis, con confirmación mediante PTH intraoperatoria pre- y postextirpación, anatomía patológica y seguimiento clínico durante 10 meses. Aunque con ambos equipos se consiguió la localiza- ción intraoperatoria correcta de los adenomas paratiroideos y confirmación de su extirpación, freehand SPECT aportó adicionalmente la profundidad (mm) del adenoma respecto al borde cutáneo, muy útil en cirugía radioguiada mínimamente invasiva (AU)

Initial experience is presented by using freehand SPECT in the intraoperative radiolocalization of a parathyroid adenoma in 2 patients, one which was mediastinal. There is only one previous publication including 3 patients with parathyroid adenomas in usual parathyroid localizations. We also report for the first time a comparative assessment of results with portable gammacamera during the same surgery. In the operating room, we obtained images with portable gamma-camera and 3 D reconstruction with freehand SPECT from 15 min after iv injection of 5 mCi of 99m Tc-MIBI. Both devices enabled the 2 adenomas to be detected intraoperatively, as well as checking activity of the excised gland and absence of significant uptake in surgical bed, with confirmation by intraoperative pre-postsurgical PTH levels, pathology and clinical follow-up for 10 months. Both devices accurately located the parathyroid adenomas intraopera- tively, as well as confirmation of their extirpation, but freehand SPECT provided additional information of adenoma depth (mm) from the skin border, very useful for minimally invasive radio-guided surgery (AU)

[Initial experience in intraoperative radiolocalization of the parathyroid adenoma with freehand SPECT and comparative assessment with portable gamma-camera]. / Experiencia inicial en la radiolocalización intraoperatoria del adenoma paratiroideo con freehand SPECT y valoración comparativa con gammacámara portátil.

Initial experience is presented by using freehand SPECT in the intraoperative radiolocalization of a parathyroid adenoma in 2 patients, one which was mediastinal. There is only one previous publication including 3 patients with parathyroid adenomas in usual parathyroid localizations. We also report for the first time a comparative assessment of results with portable gammacamera during the same surgery. In the operating room, we obtained images with portable gamma-camera and 3 D reconstruction with freehand SPECT from 15 min after iv injection of 5 mCi of (99m)Tc-MIBI. Both devices enabled the 2 adenomas to be detected intraoperatively, as well as checking activity of the excised gland and absence of significant uptake in surgical bed, with confirmation by intraoperative pre-postsurgical PTH levels, pathology and clinical follow-up for 10 months. Both devices accurately located the parathyroid adenomas intraoperatively, as well as confirmation of their extirpation, but freehand SPECT provided additional information of adenoma depth (mm) from the skin border, very useful for minimally invasive radio-guided surgery.

Aportación de la gammagrafía intraoperatoria en la detección del adenoma paratiroideo intratiroideo / Contribution of intraoperative scintigraphy to the detection of intrathyroidal parathyroid adenoma

Los adenomas paratiroideos intratiroideos (API) representan una causa rara de hiperparatiroidismo primario cuya localización dificulta la adecuada extirpación quirúrgica. Presentamos el caso de una paciente diagnosticada de adenoma paratiroideo por gammagrafía prequirúrgica en la que finalmente durante la paratiroidectomía la localización de la lesión fue intratiroidea. Consideramos que la aportación de la gammagrafía paratiroidea intraquirúrgica con 99mTc-MIBI mediante gammacámara portátil es muy útil en la extirpación de los adenomas paratiroideos e imprescindible en el caso concreto de los API (AU)

The intrathyroidal parathyroid adenomas (IPA) represent a rare cause of primary hyperparathyroidism whose location difficults appropriate surgical removal. We present the case of a patient diagnosed of parathyroid adenoma by presurgical scintigraphy in which finally during the parathyroidectomy, the lesion location was intrathyroidal. We consider that the intrasurgical parathyroid scintigraphy with 99mTc-MIBI by portable gammacamera is useful in the parathyroid adenomas removal and essential in the case of IPA (AU)

[Contribution of intraoperative scintigraphy to the detection of intrathyroidal parathyroid adenoma]. / Aportación de la gammagrafía intraoperatoria en la detección del adenoma paratiroideo intratiroideo.

The intrathyroidal parathyroid adenomas (IPA) represent a rare cause of primary hyperparathyroidism whose location difficults appropriate surgical removal. We present the case of a patient diagnosed of parathyroid adenoma by presurgical scintigraphy in which finally during the parathyroidectomy, the lesion location was intrathyroidal. We consider that the intrasurgical parathyroid scintigraphy with (99m)Tc-MIBI by portable gammacamera is useful in the parathyroid adenomas removal and essential in the case of IPA.

Randomized clinical trial of pancreaticogastrostomy versus pancreaticojejunostomy on the rate and severity of pancreatic fistula after pancreaticoduodenectomy.

BACKGROUND: Anastomotic leakage of pancreaticojejunostomy (PJ) remains the single most important source of morbidity after pancreaticoduodenectomy (PD). The primary aim of this randomized clinical trial comparing PG with PJ after PD was to test the hypothesis that invaginated PG would result in a lower rate and severity of pancreatic fistula. METHODS: Patients undergoing PD were randomized to receive either a duct-to-duct PJ or a double-layer invaginated PG. The primary endpoint was the rate of pancreatic fistula, using the definition of the International Study Group on Pancreatic Fistula. Secondary endpoints were the evaluation of severe abdominal complications (Clavien-Dindo grade IIIa or above), endocrine and exocrine function. RESULTS: Of 123 patients randomized, 58 underwent PJ and 65 had PG. The incidence of pancreatic fistula was significantly higher following PJ than for PG (20 of 58 versus 10 of 65 respectively; P = 0.014), as was the severity of pancreatic fistula (grade A: 2 versus 5 per cent; grade B-C: 33 versus 11 per cent; P = 0.006). The hospital readmission rate for complications was significantly lower after PG (6 versus 24 per cent; P = 0.005), weight loss was lower (P = 0.025) and exocrine function better (P = 0.022). CONCLUSION: The rate and severity of pancreatic fistula was significantly lower with this PG technique compared with that following PJ. REGISTRATION NUMBER: ISRCTN58328599 (http://www.controlled-trials.com).

Preoperative weight loss in patients with indication of bariatric surgery: which is the best method? / Pérdida de peso preoperatoria en pacientes con indicación de cirugía bariatrica: ¿Qué método es mejor?

Background: Surgery is the only effective treatment for people with a body mass index (BMI) greater than 40Kg/m2 or even greater than 35 Kg/m2 when some diseases like diabetes or hypertension appear. In order to minimize surgical risk and improve postoperative results, preoperative preparation it’s very important. “Acute” preoperative weight loss just before surgery plays a crucial role in that preparation and can be achieved through different ways like a low calorie diet, a very low calorie diet or with the use of an intragastric balloon. The advantages or particularities of every one of them will be summarized in this article. Material and methods: Literature review of the benefits, risks and complications of preoperative weight loss through a low calorie diet, a very low calorie diet or intragastric balloon placement. Results: Seven of thirteen initially selected reports from Medline search were considered relevant, including a total 371 patients (240 patients treated with low calorie diet, 90 with very low calorie diet and 41 cases of intragastric balloon placement). We found that weight loss was greater in patients with very low calorie diets and intragastric balloon groups but with a slightly increase in morbidity and cost. Conclusion: Although there are no comparative studies, data from the literature results show that diets very low in calories are more effective and require less time than low-calorie diets and cheaper with fewer side effects than the intragastric balloon (AU)

Introducción: La cirugía es el único tratamiento efectivo para aquellas personas con un índice de masa corporal (IMC) superior a 40 kg/m2 o incluso superior a 35kg/m2 cuando existen enfermedades asociadas como la diabetes o la hipertensión. La preparación preoperatoria de estos pacientes es fundamental para disminuir los riesgos del acto quirúrgico y mejorar los resultados postoperatorios. La pérdida “aguda” de peso previo a la cirugía, uno de los pilares fundamentales de dicha preparación, se puede conseguir por diferentes medios como son una dieta baja en calorías, una dieta muy baja en calorías o la colocación de un balón intragástrico. En el siguiente artículo analizaremos las ventajas e inconvenientes de cada uno de ellos. Material y métodos: Revisión de la literatura de los beneficios, riesgos y complicaciones de la pérdida de pesopreoperatoria mediante la dieta baja en calorías, la dieta muy baja en calorías o la colocación del balón intragástrico. Resultados: Siete estudios fueron considerados relevantes, de los trece seleccionados inicialmente de la búsqueda en Medline, incluyendo un total de 371 pacientes(240 pacientes fueron tratados con una dieta baja en calorias, 90 con una dieta muy baja en calorias y a 41 se les implantó un balón intragástrico). La pérdida de peso fue mayor en los pacientes con una dieta muy baja en calorías y en los pacientes que se les colocó un balón intragástrico, sin embargo estos pacientes presentaron un ligero incremento en la morbilidad y los costes. Conclusión: Aunque no existen estudios comparativos, los resultados de la búsqueda bibliográfica sugieren quelas dietas de muy bajo contenido calórico son más efectivas y necesitan menos tiempo que las dietas de bajo contenido calórico, y más económicas y con menos efectos secundarios que el balón intragástrico (AU)

Preoperative weight loss in patients with indication of bariatric surgery: which is the best method?

BACKGROUND: Surgery is the only effective treatment for people with a body mass index (BMI) greater than 40 Kg/m² or even greater than 35 Kg/m² when some diseases like diabetes or hypertension appear. In order to minimize surgical risk and improve postoperative results, preoperative preparation it's very important. "Acute" preoperative weight loss just before surgery plays a crucial role in that preparation and can be achieved through different ways like a low calorie diet, a very low calorie diet or with the use of an intragastric balloon. The advantages or particularities of every one of them will be summarized in this article. MATERIAL AND METHODS: Literature review of the benefits, risks and complications of preoperative weight loss through a low calorie diet, a very low calorie diet or intragastric balloon placement. RESULTS: Seven of thirteen initially selected reports from Medline search were considered relevant, including a total 371 patients (240 patients treated with low calorie diet, 90 with very low calorie diet and 41 cases of intragastric balloon placement). We found that weight loss was greater in patients with very low calorie diets and intragastric balloon groups but with a slightly increase in morbidity and cost. CONCLUSION: Although there are no comparative studies, data from the literature results show that diets very low in calories are more effective and require less time than low-calorie diets and cheaper with fewer side effects than the intragastric balloon.

Utilidad de la especialización en cirugía endocrina de una unidad del servicio de cirugía general: análisis tras 500 tiroidectomías consecutivas / Utility of specialization in endocrine surgery in a general surgery department: analysis of 500 consecutive thyroidectomies

Introducción. Actualmente está admitido que la subespecialización dentro de la cirugía general mejora la profundización en los diferentes campos de investigación. Los autores se plantean si vale la pena crear unidades de cirugía endocrina en los hospitales de máximo nivel, no sólo desde el punto de vista investigador, sino desde el punto de vista asistencial y de gestión. Material y métodos. Se hace una valoración retrospectiva de 500 tiroidectomías consecutivas, comparando las realizadas por facultativos especialistas de la Unidad de Cirugía Endocrina con las llevadas a cabo por otros facultativos del servicio. También se compararon las 100 primeras con las 100 últimas de entre las realizadas por facultativos de la unidad. Los parámetros valorados, entre otros, fueron los tipos de intervenciones, las complicaciones y las estancias. Resultados. La tasa de complicaciones fue significativamente mayor en el grupo de pacientes operados por facultativos no pertenecientes a la unidad, con complicaciones transitorias en el 22,2 por ciento de los pacientes y definitivas en el 10,7 por ciento. En el grupo de pacientes operados por facultativos de la unidad las complicaciones definitivas fueron prácticamente nulas; las transitorias representaron el 12,9 por ciento y las definitivas, el 0,2 por ciento. Al comparar las primeras 100 realizadas con las 100 últimas dentro de la unidad, no se apreciaron cambios en las complicaciones, sin embargo, las estancias variaron significativamente desde 4,27 a 0,96 días de estancia total. Conclusiones. La creación de unidades de cirugía endocrina en los servicios de cirugía de los hospitales de máximo nivel no sólo mejora el nivel de conocimientos, sino que mejora significativamente los resultados asistenciales y la eficiencia del servicio en los pacientes sometidos a tiroidectomía. (AU)

Utilidad de un índice orientativo de la actividad asistencial hospitalaria como herramienta de gestión / Usefulness of a guiding index of the nursing activity in the hospital as a management tool

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Consecución de proyectos ambiciosos de gestión mediante el control organizado del caos. Cómo pasar en un día de una demora de ocho meses para la primera visita a una demora de 48 horas / The attainment of ambitious management projects via the organized control of chaos. How to reduce in one day a delay of eight months for the first visit to a delay of 48 hours

Fundamento: El carácter cambiante de las necesidades a solucionar por las organizaciones sanitarias obliga con bastante frecuencia al cambio de planteamientos organizativos. Con el fin de evitar las demoras excesivas para la primera visita del Facultativo Especialista, se instituyó en el Centro de Especialidades adscrito al Hospital un proyecto de citación inmediata en menos de 48 horas, decidiendo su implementación radical, a pesar de asumir la generación inicial de un proceso de caos. Método: Todos los pacientes nuevos eran citados para ser visitados en 24-48 horas. Las visitas sucesivas se citaban por los propios médicos en su consulta. Las visitas citadas con anterioridad eran respetadas. Para paliar el caos creado, se puso en marcha un sistema continuado de información a todas las personas implicadas, previendo además las áreas donde sería necesario aumentar o redistribuir recursos. Resultados: Dadas las características del proyecto, los objetivos se alcanzaron desde el primer día. El caos generado fue muy importante, pero las medidas de control fueron suficientes para controlarlo. De una demora media inicial de 62 días se pasó inmediatamente a una demora de dos días, si bien con problemas de funcionamiento. Un año después se mantenía en 5,9 días, sin ningún tipo de problema. Conclusiones: La introducción radical de cambios organizativos en un sistema sanitario conduce a una situación inicial de caos. Sin embargo, con medidas de control adecuadas, ésta puede ser la mejor fórmula para alcanzar objetivos ambiciosos de gestión. (AU)

[Arterial embolisms in the upper and lower limbs: a clinical review]. / Embolias arteriales en miembros superiores e inferiores: revisión clínica.

A clinical review about the subjects is made. Percentages and comparisons between lower and upper limbs were established. Correlation with statistics from other authors are presented.

Myocardial protection by retrograde cardioplegic perfusion in the presence of acute coronary artery obstruction. An experimental study.

To investigate retrograde delivery of cardioplegic solutions as a means of enhancing myocardial protection in the presence of coronary artery occlusion, a two-part experimental model was devised. In part 1 (in vitro) the possibility of retroperfusing the entire myocardium during acute occlusion of the left anterior descending artery (LAD) was assessed. In part 2 (in vivo) acute LAD occlusion was performed in dogs, and during 2 hours of aortic cross-clamping crystalline cardioplegic solution was infused at 20-minute intervals. In group I the infusion was antegrade, via the aortic root, and in group II it was retrograde, via the coronary sinus. Thereafter the LAD snare was released and the dogs were weaned from bypass. Delivery of cardioplegia through the aortic root was associated with depression of ventricular function, poor myocardial cooling and severe cellular damage. With the retrograde procedure there was significantly improved recovery of left ventricular function, uniform myocardial cooling and better preservation of cellular morphology.

[The influence of attending theory classes and other factors on the academic performance of undergraduate surgery students]. / Influencia de la asistencia a las clases teóricas y otros factores en el rendimiento académico de alumnos pregraduados en Cirugía.

The authors have studied the influence of the academic history, class attendance, and use of commission notes on the student's academic performance, evaluated by the final marks, on a population of 335 sixth year students taking a surgical pathology course at the School of Medicine. The results show that previous marks correlate with the final surgery mark, that class attendance does not determine significant differences in the student's performance, and that the use of commission notes is widely spread conditioning a mediocre undergraduate [correction of pregraduate] theoretical education [correction of formation].

[Peptic stenoses of the esophagus]. / Estenosis pépticas del esófago.

The authors present a series of 32 cases of reflux peptic strictures of the esophagus. The mean age of the patients is 54 years, with a 3/1 predominance of males. The etiologic antecedent was hiatal hernia in every case, with a clinical time of evolution of 29 months, dysphagia being the most frequent symptom (100%). Complementary diagnosis was based fundamentally on endoscopy and barium transit, explorations that also allow exclusion of other pathologies. All the patients underwent medical treatment, this being the only treatment in 4 cases. The other 28 cases were treated surgically. The technique used was, in the cases in which the esophagus could be dilated, dilatation associated with an antireflux technique, and when not dilatable, resection with reconstruction using stomach (Sweet) or colonoplasty. The global mortality was two patients (5.2%). Patients were followed-up for a minimum of 2 years and the global results have been good, with recurrence in 3 cases (7.7%). Postoperative dysphagia appeared in 17 cases (44.7%), in all of the transitory.