Outcomes following the Kawashima procedure for single-ventricle palliation in left atrial isomerism.

OBJECTIVES: Patients with left atrial isomerism and interrupted inferior vena cava palliated with a superior cavopulmonary connection or Kawashima procedure (KP) have a high incidence of developing pulmonary arteriovenous malformations. The necessity for hepatic vein redirection (HVR) and its timing remains a controversy. We aimed to assess the clinical outcome of patients with left atrial isomerism following a KP. The main end points were death, requirement for HVR and the impact of HVR on oxygen saturation. METHODS: Retrospective review of 21 patients with a diagnosis of left atrial isomerism, interruption of the inferior vena cava and single-ventricle physiology managed with a KP at a single centre between January 1990 and March 2010. RESULTS: Twenty-one patients had a KP, with 12 subsequently undergoing HVR. There was relatively a constant monthly decrement in the proportion of patients who were free from death or HVR up until 60 months following the KP, with a dramatic increase in the hazard after this time. The Cox proportional hazards regression model demonstrated a reduced early risk for HVR or death in patients who underwent pulmonary artery banding versus arterial shunt as the primary procedure (hazard ratio: 0.10; P = 0.01), and an increased risk with bilateral superior vena cavas (SVCs) (hazard ratio: 3.4; P = 0.04) and age at KP (hazard ratio: 1.02 per month increase in age at KP; P = 0.02). HVR mortality was relatively high with 3 of 12 patients dying in the early postoperative period with profound cyanosis. The timing of HVR after the KP did not influence the postoperative rate of increase in oxygen saturation. CONCLUSION: These findings confirm that the majority of patients who undergo a KP will require HVR. Patients who are older at the time of the KP or having an initial arterial shunt or bilateral SVCs are at higher risk of HVR or death. The relatively high mortality at HVR was characterized by severe postoperative cyanosis.

The additional value of intraoperative parathyroid hormone assessment is marginal in patients with nonfamilial primary hyperparathyroidism: a prospective cohort study.

BACKGROUND: The success of minimally invasive parathyroidectomy is attributed to evolving preoperative imaging techniques and intraoperative parathyroid hormone (IOPTH) measurement. The additional value of IOPTH measurement in patients undergoing surgery for primary hyperparathyroidism (pHPT) was evaluated. METHODS: Between 1999 and 2010 there were 119 patients who underwent surgery for pHPT at our institutions. In all patients, preoperative imaging was performed and IOPTH samples were collected prospectively but the results were not disclosed during surgery. RESULTS: Postoperative calcium level normalized in 114 patients (96%). The 5 surgical failures represented the maximum yield of IOPTH sampling. Three of these patients would have been identified intraoperatively by an inadequate IOPTH decrease, whereas IOPTH decreased inaccurately in the other 2 patients. In addition, in 1 of these 3 patients no abnormal gland was found during minimally invasive parathyroidectomy and subsequent conventional neck exploration. Therefore, only 2 reoperations would have been prevented (1.7%). CONCLUSIONS: IOPTH would have changed the outcome in 2 patients, increasing the biochemical cure rate from 96% to 98%. We believe that although it can be helpful in certain cases, it may not be necessary routinely in patients treated for pHPT.

Shifting incidence of solitary adenomas in the era of minimally invasive parathyroidectomy. A multi-institutional study.

BACKGROUND: Previously, when a conventional neck exploration (CNE) without preceding diagnostic imaging was the surgical treatment for patients with primary hyperparathyroidism (pHPT) solitary adenomas were observed in 69-88% of patients. The advent of minimally invasive parathyroidectomy (MIP), aiming at a preoperatively identified parathyroid abnormality may be associated with a different incidence of solitary and multiglandular parathyroid disease. MATERIALS AND METHODS: In a cohort of 467 patients with sporadic pHPT who preferentially underwent MIP in four hospitals in the same geographical region, the incidence of solitary adenomas, multiple adenomas, and multiglandular hyperplasia (MGD) was evaluated. RESULTS: A total of 367 patients were scheduled for MIP; 100 patients underwent a planned CNE. The overall surgical success rate of the first operation was 93%, and the cumulative success rate, including a second operative procedure, was 99%. Normocalcemia resulted from removing 1 abnormal PG in 426 patients (91%) and more than one abnormal gland in 35 patients (8%). A parathyroid carcinoma was diagnosed in four of the 426 patients with a single abnormal gland. Four gland hyperplasia was observed in 1 patient. In hospitals where diagnostic workup usually consisted of ultrasound (US) and computed tomography (CT) the incidence of solitary adenomas was 88%, compared with 96% in hospitals where MIBI, US, and CT were used preoperatively (P = 0.007). CONCLUSIONS: A higher frequency of solitary adenomas was observed than historically reported. The extent of the preoperative workup influences the number of observed solitary adenomas.

Intraobserver and interobserver variability and spatial differences in histologic examination of carotid endarterectomy specimens.

INTRODUCTION: Studies using histologic examination and protein analysis of atherosclerotic plaques are increasingly being performed, but reproducibility of plaque histology and variation of plaque composition among different parts of the plaque, which are key to reliability of these studies, are relatively unexplored. Therefore, this study investigated the intraobserver and interobserver variability of plaque histology and spatial variability in plaque composition. METHODS: Atherosclerotic plaques (n = 100) obtained during carotid endarterectomy were divided into 0.5-cm segments. Paraffin sections were stained and semiquantitatively analyzed (four categories: no, minor, moderate, and heavy) for fat, macrophages, smooth muscle cells, collagen, calcification, thrombus, and overall phenotype. First, to determine the intraobserver and interobserver reproducibility, two independent observers independently analyzed the plaques. Second, to investigate spatial variability in plaque composition, histologic appearances of the culprit lesions (0-segment) were compared with the histologic appearances of adjacent (+5 mm) and more distant (+10 mm) plaque segments of 30 specimens. RESULTS: The kappa values for intraobserver variability of fat, macrophages, smooth muscle cells, collagen, calcifications, thrombus, and overall phenotype were 0.83, 0.85, 0.71, 0.63, 0.81, 0.80, and 0.86, respectively, and kappa values for interobserver variability were 0.68, 0.74, 0.54, 0.59, 0.82, 0.75, and 0.71, respectively. Comparison of the histologic scorings of adjacent segments revealed a mean kappa of 0.40 (range, 0.33 to 0.60). When the culprit segment was compared with the more distant segment, the mean kappa was 0.24; however, in 91% of cases, the difference between the culprit segment and the distal segment was one category or less. CONCLUSION: Semiquantitative analysis of carotid atherosclerotic plaque histology was well reproducible, both intraobserver and interobserver. Although variation between different plaque segments in histologic appearance was observed, differences were small in almost all cases. Variability in histologic examination needs to be taken into account in studies comparing plaque imaging with histopathology and plaque research studies.