Parathyroid surgery in the elderly.

INTRODUCTION: The prevalence of primary hyperparathyroidism (PHPT) is expected to increase in developed nations as the aged population grows. This review discusses issues related to PHPT in the elderly population with a focus on differences in disease presentation, medical and surgical management, and outcomes. METHODS: Literature review of English-language studies of PHPT or parathyroidectomy (PTx) in the elderly was performed. Surgical literature reviewed included original clinical studies published after 1990. Priority was given to studies with >30 patients where institutional practice and outcomes have not changed significantly over time. RESULTS: Elderly patients primarily present with nonclassic symptoms of PHPT that can sometimes be missed in favor of other diagnoses. They have equivalent surgical outcomes, including morbidity, mortality, and cure rates, compared with younger patients, although their length of hospital stay is significantly longer. Several recent studies demonstrate the safety and efficacy of outpatient, minimally invasive parathyroidectomy in an elderly population. Patients are referred for PTx less frequently with each advancing decade, although surgical referral patterns have increased over time in centers that offer minimally invasive parathyroidectomy. Elderly patients experience increased fracture-free survival after PTx. The majority of elderly patients report symptomatic relief postoperatively. CONCLUSION: PTx can offer elderly patients with PHPT improved quality of life. PTx is safe and effective in elderly patients, and advanced age alone should not deter surgical referral.

The correlation of near-infrared spectroscopy with changes in oxygen delivery in a controlled model of altered perfusion.

Alterations in regional tissue perfusion may precede global indications of shock. This study compared regional tissue oxygenation saturation (StO2) using near-infrared spectroscopy with standard hemodynamic and biochemical variables in 40 patients undergoing cardiopulmonary bypass (CPB). Mean arterial pressure, cardiac output, oxygen delivery, arterial blood gases, and lactate were recorded at specific intervals during surgery. Data were organized by stage of procedure, and the relationship of StO2 to established parameters was investigated. With initiation of CPB, StO2 declined by 12.9 per cent (standard deviation +/- 14.75%) with a delayed increase in lactate from 0.9 (interquartile range [IQR], 0.6-1.5) mmol/L to 2.3 (IQR, 1.8-2.5) mmol/L. The minimum StO2 value preceded the maximum lactate level by an average time of 93.9 (standard deviation +/- 86.3) minutes. Additionally, a decrease in StO2 corresponded with an increase in base deficit of 4.84 (standard deviation +/- 2.37) mEq/L over the same period. Calculated oxygen delivery decreased from a baseline value of 754 (IQR, 560-950) mL/min to 472 (IQR, 396-600) mL/min with initiation and maintenance of CPB. For patients undergoing CPB, StO2 is a reliable, noninvasive monitor of perfusion, which correlates well with oxygen delivery and identifies perfusion deficits earlier than lactate or base deficit.

Mesenteric injuries after blunt abdominal trauma: delay in diagnosis and increased morbidity.

Mesenteric injuries after blunt abdominal trauma are infrequent and difficult to diagnose. We investigated whether a delay in diagnosis of more than 6 hours had a significant impact on morbidity, mortality, and length of stay at our Level I trauma center. A retrospective chart review spanning the period from January 1995 to September 2005 identified 85 patients with laparotomy-confirmed mesenteric injuries, 81 of whom survived to hospital discharge. Nineteen (23%) of the 81 patients had a delay in diagnosis of greater than 6 hours. After controlling for identified confounders, we found that the delayed diagnosis group experienced 30 per cent longer hospital stays (P = 0.03), 55 per cent longer intensive care unit stays (P = 0.006), and 38 per cent longer duration of mechanical ventilation (P = 0.05). Patients in the delayed group also had significantly higher odds of developing acute respiratory distress syndrome, as well as trends toward higher odds of wound infection, pneumonia, multiple organ dysfunction syndrome, abdominal compartment syndrome, renal failure, and ileus. No significant difference in mortality was observed among all 85 patients (P = 0.67). Thus, in contradiction to some previous studies, our review indicates that a delay in the diagnosis of mesenteric injuries results in significantly increased morbidity and hospital and intensive care unit lengths of stay.