LigaSure® versus clamp tie technique for thyroid surgery; decreased operative time versus increased inflammatory effect: a prospective randomized study.

OBJECTIVE: The aim of this study was to compare the LigaSure® Small Jaw Instrument (LSJI) with the conventional clamp-and-tie (CT) technique in thyroid surgery regarding complication rates (hematoma, hypocalcemia and recurrent nerve palsy), the duration of the operative procedure, and systemic and local inflammatory effects. PATIENTS AND METHODS: Fifty-four consecutive patients were randomized prospectively into two groups, a Conventional Clamp-Tie (CT) group and a LigaSure® Vessel Sealing System (LVSS) Group. Pre- and postoperative blood plasma samples were taken to measure the tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6), calcium, parathormon, CRP levels and WBC, as well as the lymphocyte subset (CD3, CD4, CD8, CD16/56, CD19) counts. The drain fluid samples were collected after the removal of the drains to measure the levels of IL-6 and TNF-α. RESULTS: Both groups showed significant changes regarding peripheral blood CD3+, CD4+, and CD8+ T cell levels (p < 0.05). In the LVSS group, the level of CD16+56+ NK cells showed a significant decrease compared with the CT group (p < 0.05). The IL-6 and TNF-α levels in the drainage fluid were significantly higher in the LVSS group. CONCLUSIONS: We demonstrated that LSJI can decrease operative time. Although the systemic inflammatory effect of LSJI remains inconclusive, the local inflammatory effect was significant, which could cause early and late postoperative problems.

Is Hashimoto's thyroiditis a prognostic factor for thyroid papillary microcarcinoma?

AIM: The relationship between papillary thyroid carcinoma (PTC) and accompanying Hashimoto's thyroiditis (HT) has been investigated extensively. However, there is no agreement among the authors. We aimed with this study to investigate this relationship in a limited subtype of PTC called papillary thyroid microcarcinoma (PTMC). PATIENTS AND METHODS: Between January 1999 and December 2012, 1923 thyroids were surgically resected in two referral centers and thoroughly inspected for evidence of PTMC. Of these patients, 172 who were diagnosed with PTMC had demographic and pathological features recorded. RESULTS: Fourteen patients (8.1%) were found to have CLN metastases. Eleven (78.6%) of the patients with CLN metastases had tumors larger than 5 mm, and 3 (21.4%) patients with CLN metastases had small tumors (≤ 5 mm), but there was no statistical significance (p > 0.05). Accompanying Hashimoto's thyroiditis (HT) was detected in 67 (39%) patients. The CLN metastasis rate was slightly higher in cases with HT in surrounding thyroid tissue. However, there was no statistical significance; the CLN rate was 6.7% (n=7) in patients without thyroiditis and 10.4% (n=7) with Hashimoto's thyroiditis. Insufficient FNA results in patients with thyroiditis were associated with HT (p < 0.05). CONCLUSIONS: Surgeons and other clinicians who play a role in the treatment of thyroid cancers should be aware that some PTMC cases may show a worse course, as with some PTCs, contrary to expectations.

JC virus-associated nephropathy in a renal transplant recipient and comparative analysis of previous cases.

We report JC virus (JCV)-associated nephropathy in a renal allograft recipient and summarize the clinical and laboratory data of the 8 previous cases. A 28-year-old male renal allograft recipient received a preemptive transplant from his father. Six months later, a kidney biopsy was performed because of deterioration of allograft function. Biopsy revealed tubulointerstitial mononuclear infiltrates with normal glomeruli; on hematoxylin and eosin staining, basophilic nuclear inclusions were seen in the nucleus of tubular cells. Urinary cytology failed to demonstrate decoy cells, but polymerase chain reaction of a urinary sample was positive for JCV 3.15 × 10(10) copies/mL. Additionally, polyomavirus (SV40) immunohistochemical staining was performed and was positive in the enlarged nuclei of tubular epithelial cells in the kidney biopsy sample. After the diagnosis of polyomavirus-associated nephropathy (PVAN) was confirmed by kidney biopsy, immunosuppressive agents were reduced. Intravenous immunoglobulin was administered 5 times at a dose of 500 mg/kg every other 3 weeks. Two months after diagnosis, the serum creatinine became stable and urinary viral load of JCV was decreased. Because viruria was still present, tacrolimus was converted to sirolimus. Four months after immunosuppressive agent conversion from tacrolimus to sirolimus, the viruria had disappeared. Review of the literature and our case demonstrates that male gender, previous acute rejection episode, low incidence of JCV viremia, PVAN pattern B histology, and reducing immunosuppression are the diagnostic touchstones for PVAN due to JCV.

Modified quantitative subjective global assessment of nutrition in patients on the renal transplant waiting list.

Subjective global assessment (SGA) of nutritional status is a widely used and validated method for identifying and classifying malnutrition. It has been thought that this semiquantitative feature restricts the reliability and precision of the SGA. Recently, in an effort to assess nutritional status, a modified quantitative SGA system has been devised in which scores are assigned for items or components of the SGA. This prospective study evaluated the correlation of the quantitative SGA with objective nutritional parameters and compared this method with conventional SGA in a group of patients on the renal transplant waiting list.

Sirolimus for rescue of steroid and anti-thymocyte globulin-resistant recurrent acute rejection after liver transplantation: report of one case.

Sirolimus (SRL) not only displays prophylactic activity, it also reverses acute rejection (AR) in humans with ongoing refractory renal allograft rejection and chronic liver allograft rejection. The present case of a human liver allograft recipient documents the utility of SRL therapy for a patient experiencing ongoing resistant recurrent AR just after orthotopic liver transplantation (OLT) and liver dysfunction that had not abated after treatment with corticosteroids and antilymphocyte globulin. SRL was added to the mycophenolate mofetil/steroid regimen to treat the ongoing rejection. The patient was rescued with SRL, not experiencing AR again. To date the patient has exhibited no significant side effects after more than 6 months of SRL therapy and his clinical and general condition have been good; he is completely involved in daily life. SRL is a new and safe immunosuppressive agent for rescue in patients with early OLT and recurrent AR.

Hyperbaric oxygenation attenuates renal ischemia-reperfusion injury in rats.

BACKGROUND: Oxygen-derived free radicals play an important role in ischemia-reperfusion injury (IR). Hyperbaric oxygenation (HO) decreases free radical production. The aim of this study was to determine the effect of HO treatment on renal ischemia-reperfusion injury in rats. METHODS: Rats were divided into four groups. All groups underwent right nephrectomy. Group I served as the control group; group II had left renal ischemia-reperfusion; group III was pretreated with HO; and group IV, ischemia-reperfusion and HO pretreatment. Tissue malondialdehyde (MDA) and glutathione (GSH) levels were measured, and histopathologic damage scored. RESULTS: HO pretreatment significantly decreased tissue MDA levels and histopathologic scores among rats with IR. There was an increased GSH in HO-pretreated rats with IR; however, the difference was not significant. CONCLUSION: HO prior to ischemia displayed a beneficial effect on renal IR by reducing oxygen radical peroxidation of lipid membranes.

Appendix tumors in the era of laparoscopic appendectomy.

BACKGROUND: The safety of laparoscopic appendectomy for the management of incidentally discovered appendiceal tumors has not yet been established. METHODS: Appendiceal tumor cases managed by laparoscopy or laparotomy over a 10-year period were reviewed. RESULTS: The pathological diagnoses were 23 carcinoid and 20 cancerous lesions. The median patient ages were 36 and 69 years, respectively, for carcinoid and other tumors (p < 0.05). Acute appendicitis was present in 70% of carcinoid cases and 35% of other tumors (p < 0.05). Eight patients with carcinoid tumors were operated on by laparoscopy, whereas 15 underwent laparotomy. Laparoscopic and open procedures were performed in three and 17 patients with cancerous lesions, respectively. Invaded surgical margins were seen after laparoscopy in 20% of patients and open surgery in 6%. Synchronous colon carcinoma was detected in 14% of the patients with an appendix neoplasm. The 5-year survival rates were similar after both laparoscopic and open appendectomy for either carcinoid or other tumors. CONCLUSION: Laparoscopic appendectomy for appendiceal tumors seems to have a slightly higher rate of inadequate resection. However, it is not associated with a significantly worse patient prognosis than open appendectomy.

Medical problems occurring during the long-term follow-up after liver transplantation.

Liver transplantation is a standardized therapy for end-stage liver disease. With current immunosuppressive protocols and patient care, ten-year patient survival rate has reached 60%. Several medical complications may develop during this period, including renal dysfunction, hypertension, diabetes mellitus, hyperlipidemia, and metabolic bone disease. The aim of this article is to analyze long-term results of several clinical trials reporting common medical dysfunctions after liver transplantation and to discuss their management.

Beta cell replacement for the treatment of diabetes.

The replacement of insulin-producing beta cells by islet transplantation can efficiently reverse diabetes. The recent improvements in clinical results were made possible by transplanting higher islet masses and through the introduction of new immunosuppressive protocols that avoid diabetogenicity. The need for alternatives to continuous immunosuppression, and an unlimited source of glucose-sensitive, insulin-secreting tissue, is emerging. In this review we discuss the various key steps in islet transplantation and offer perspectives for future developments in the replacement of insulin-producing beta cells for the treatment of type I diabetes.

Pulmonary Rhizopus infection in a diabetic renal transplant recipient.

Infectious complications after renal transplantation remain a major cause of morbidity and mortality. Mucormycosis is a rare infection in renal transplant recipients; however, mortality is exceedingly high. Risk factors predisposing to this disease include prolonged neutropenia, diabetes, and patients who are immunosuppressed (Singh N, Gayowski T, Singh J, Yu LV. Invasive gastrointestinal zygomycosis in a liver transplant recipient: case report and review of zygomycosis in solid-organ transplant recipients, Clin Infect Dis 1995: 20: 617). Life-threatening infections can occur, as this fungus has the propensity to invade blood vessel endothelium, resulting in hematological dissemination. We report a case of cavitary Rhizopus lung infection, 2 months after renal transplantation, where the patient was treated successfully with Amphotericin B and surgical resection of the lesions with preservation of his allograft function. In this era of intensified immunosuppression, we may see an increased incidence of mucormycosis in transplant population. Invasive diagnostic work-up is mandatory in case of suspicion; Amphotericin B and, in selected cases, surgical resection are the mainstays of therapy.

Simultaneous pancreas-kidney transplantation at the Ohio State University Medical Center.

Simultaneous pancreas-kidney transplantation is becoming an accepted procedure for the treatment of Type I diabetic patients with end-stage renal disease. Its value in Type II diabetic patient remains to be evaluated. With the improvements in technical skills and immunosuppression medications, the procedure has become safer than those performed in the previous decade. However, the diabetic host is a high-risk individual. Careful evaluation and selection is prudent to keep excellent results with this scarce organ. As we have seen in this series, death is the number one cause of graft loss and better preoperative evaluation will continue to be of significant value to lower the mortality rate of SPK transplantation. We are moving to the use of marginal donors and marginal recipients very carefully and more data is needed to prove its safety and cost effectiveness. At our center, long-term patient and graft survival have been acceptable (86% and 73%, respectively, at 5 years). We will continue to use SPK transplantation as the procedure of choice for excellent candidates. We may need to change our philosophy to use living-related kidney transplants followed by a sequential pancreas transplant to overcome some of the shortage of pancreatic organs. The issue of primary enteric drainage has not been addressed in this report due to our success with bladder drainage. Despite the lower threshold for enteric conversion, about 10% of our patients are converted.