Resection of supernumerary mediastinal parathyroid as a treatment for persistent secondary hyperparathyroidism. / Resección de paratiroides mediastinal supernumeraria como tratamiento del hiperparatiroidismo secundario persistente.

BACKGROUND: Secondary refractory hyperparathyroidism (SHPT) is usually resolved with total parathyroidectomy. On the other hand, SHPT is associated with persistent hyperparathyroidism as a result of inadequate resection of the parathyroid tissue or by a fifth gland not previously detected. The objective of this work is to present the case of a patient with persistent SHPT and the surgical strategy used for the resection of a hyperfunctional ectopic parathyroid in the thorax. CLINICAL CASE: 48-year-old female, with a history of chronic kidney disease with persistent SHPT, as well as subtotal parathyroidectomy, subsequent resection of parathyroid remnants twice. She was treated with medical management without obtaining adequate response. Previous location of hypercaptant lesion by single photon emission computed tomography, the patient underwent a sternotomy with 3 × 2 cm mediastinal ectopic parathyroid fixed to aortic root. The patient evolved satisfactorily with a decrease in parathyroid hormone levels, with a 18-month follow-up of the procedure with normal paratohormone values and entered the renal transplant protocol while waiting for a donor. CONCLUSION: Sternotomy is a safe approach to perform parathyroidectomy of the ectopic gland, provided that it is well identified the site of the lesion and there are specific conditions appropriate to perform the procedure.

INTRODUCCIÓN: El hiperparatiroidismo secundario (HPS) refractario suele resolverse con paratiroidectomía total. Por otro lado, el HPS se asocia a hiperparatiroidismo persistente como resultado de una resección inadecuada del tejido paratiroideo o por una quinta glándula no detectada previamente. Se presenta el caso de una paciente con HPS persistente con la estrategia quirúrgica utilizada para la resección de una paratiroides ectópica hiperfuncionante en el tórax. CASO CLÍNICO: Mujer de 48 años con antecedente de enfermedad renal crónica con HPS persistente, paratiroidectomía subtotal y posterior resección de remanente de paratiroides en dos ocasiones. Se mantuvo con manejo médico sin obtener adecuada respuesta. Previa localización de una lesión hipercaptante por tomografía computarizada por emisión de fotón único se sometió a esternotomía con resección de paratiroides ectópica mediastinal de 3 × 2 cm, fija a la raíz aórtica. La paciente evolucionó satisfactoriamente, con descenso de la hormona paratiroidea. En seguimiento a 18 meses del procedimiento se mantiene con valores normales de hormona paratiroidea e ingresó a protocolo de trasplante renal a la espera de donador. CONCLUSIÓN: La esternotomía es un abordaje seguro para realizar la paratiroidectomía de la glándula ectópica, siempre y cuando se tenga bien identificado el sitio de la lesión y existan condiciones clínicas adecuadas para realizar el procedimiento.

[Deep neck abscess. Factors related to reoperation and mortality]. / Absceso profundo de cuello. Factores asociados con la reoperación y mortalidad.

BACKGROUND: Deep neck abscesses are major complications that arise of odontogenic, pharyngeal, or cervicofacial foci, mainly in patients with morbidities that facilitate the spread to other spaces. Many of them require surgical treatment, and an appropriate evaluation and surgical drainage is required to obtain the best results. AIM: To identify factors which relate to reoperation and mortality in patient submitted to surgical treatment due to deep neck abscess. METHODS: Review of all patients with deep neck abscess who underwent surgical treatment in a Head and Neck Surgery Department in a third-level hospital during a two year period. RESULTS: There were 87 patients, 44 of which were female. The median age was 49 years old. Thirty-five patients (40%) had comorbidities, diabetes mellitus being the most common, found in 30 (34%) patients. Twenty-one patients (24%) required reoperation (primarily due to inadequate surgical drainage). The risk factors identified with it were presence of comorbidities (mainly diabetes mellitus) (p< 0.05), multiple deep neck spaces involvement (p< 0.001) and an ASA score of three or above (p< 0.01). Eight patients died, for a mortality of 9%. The factors related to mortality were multiple deep neck spaces involvement (p< 0.01), bilateral involvement (p< 0.05) and reoperation (p< 0.001). CONCLUSION: Deep neck abscesses appropriate evaluation and a complete surgical drainage of all deep space neck abscesses are primordial to avoid reoperation and improve survival.

Antecedentes: los abscesos profundos de cuello son complicaciones de infecciones, principalmente de origen odontogénico y de vías aéreas superiores, que afectan con mayor frecuencia a pacientes con morbilidades que favorecen la diseminación de la infección. Muchos requieren tratamiento quirúrgico, evaluación y drenaje apropiado para obtener los mejores resultados. Objetivo: identificar los factores relacionados con la reoperación y la mortalidad en pacientes con drenaje quirúrgico por absceso profundo de cuello. Material y métodos: estudio longitudinal, retrospectivo, observacional y comparativo efectuado con base en la revisión de todos los pacientes con absceso profundo de cuello que se operaron en un servicio de cabeza y cuello de un hospital de tercer nivel. Resultados: se estudiaron 87 pacientes, 44 de ellos eran mujeres. La mediana de edad fue de 49 años. El 40% tenían comorbilidades (35 pacientes) y la diabetes melltitus fue la más frecuente en 30 pacientes (34%). Se reoperaron 21 pacientes (24%), la mayoría por drenaje incompleto. Los factores de riesgo identificados fueron: comorbilidades (principalmente diabetes mellitus) (p< 0.05), mayor número de espacios afectados (p< 0.001) y una escala de ASA III o mayor (p< 0.01). La mortalidad fue de 9% (ocho pacientes). Los factores relacionados con mortalidad fueron: mayor número de espacios afectados (p< 0.01), afectación bilateral (p< 0.05) y reoperación (p< 0.001). Conclusión: en abscesos profundos de cuello la evaluación preoperatoria y el drenaje quirúrgico completo de todos los espacios afectados son primordiales para evitar la reoperación y mejorar la supervivencia.

Thrombocytosis as a predictor of distant recurrence in patients with rectal cancer.

BACKGROUND AND AIMS: Thrombocytosis is frequently observed in patients with malignancy. We undertook this study to determine the prognostic value of thrombocytosis in patients with rectal cancer. METHODS: We performed a retrospective study of patients undergoing low anterior resection for rectal cancer between January 2000 and March 2007. Preoperative platelet count was measured before surgery. Postoperative platelets were determined 1 month after surgery. Two-tailed p values <0.05 were considered statistically significant. RESULTS: One hundred sixty three patients with rectal cancer were included in the study. Preoperative platelet count >350,000 was found in 8% of patients. Postoperative platelet count >350,000 was found in 6% of patients. Distant metastases were found in 17 patients (10.4%). Significant variables in the multivariate analyses were preoperative platelets >350,000 (p = 0.001), postoperative platelets >350,000 (p = 0.002), carcinoembryonic antigen >13 ng/dL (p = 0.003). Patients with preoperative platelet count <350,000 showed a 5-year survival rate of 81%, whereas patients with platelet count >350,000 had a 25-month survival [95% confidence interval (CI): 20-26]; p <0.001. Patients with postoperative platelets <350,000 showed a 5-year survival rate of 80%, whereas patients with platelets >350,000 showed a 3-year survival rate of 37.5% (p <0.05). CONCLUSIONS: Pre- or postoperative platelet count >350,000 is associated with poor survival in patients with rectal cancer. The measurement of platelets is a clinical marker useful to define the prognosis for patients with rectal cancer.

Factors associated with malignancy in patients with thyroid nodules.

BACKGROUND: Due to the development of diagnostic techniques, the incidence of thyroid nodule reporting is increasing. Most of these cases may be managed conservatively, but it is important to identify those with a high suspicion of malignancy. The aim of this study was to identify factors that relate to malignancy in patients with thyroid nodule. METHODS: We reviewed the files of all patients with thyroid nodule who underwent surgical treatment in a Head and Neck Surgery Department in a third-level hospital during a 3-year period. RESULTS: There were 114 patients; 103 were female. Median age was 48 years old with a mean nodule size of 3.3 cm. Surgeries performed were 54 hemithyroidectomies, 10 total thyroidectomies, 48 total thyroidectomies and central nodal dissection (level VI), 1 partial resection, and one istmectomy. In 64 patients, the final diagnosis was benign, adenoma being the most common diagnosis. In 50 patients the nodules were malignant, predominantly papillary carcinoma (42 cases). Factors related to malignant nodule were age < 40 years (p < 0.05), firm consistency (p < 0.01), fixed nodule (p < 0.01) and microcalcifications (p < 0.01) and solid or mixed appearance assessed by ultrasonography. CONCLUSIONS: This study shows that clinical characteristics and ultrasonography results may be used to identify high risk patients with thyroid nodules.