Measurement of Quality of Life after Total Parathyroidectomy in Patients with Secondary Hyperparathyroidism and End Stage Renal Disease.

BACKGROUND: Surgery is the definitive treatment of secondary hyperparathyroidism (2HPT) and end stage renal disease patients. The aim of this study to assess the impact of surgery on the evolution of quality of life (QoL) in patients with 2HPT, and to identify the variables that influence this evolution. METHODS: A series of 85 consecutive unselected patients underwent total parathyroidectomy for 2HPT in our clinic. QoL was measured using the Short-Form Health Survey(SF-36) and alleviation of symptoms was documented using an outcome tool (PAS score), based on visual analog scales, preoperatively, postoperatively and at 6 months. RESULTS: Preoperatively, patients had lower SF-36 scores than the general population in all 8 individual and 2 component summary scales, with significant decrease in the physical health scales(p 0.0001). Patients improved in all ten scales at 6 months follow-up, most significant being: Body Pain (45.02‚+-5.52 vs 33.12‚+-8.82, p 0.0001), Role-physical (41.00‚+-7.43 vs 33.46‚+-8.54, p 0.0001), Physical functioning (40.06 ‚+-7.77 vs 33.36 ‚+-10.84, p 0.0001). PAS Scores decreased from preoperatory levels of 569.99 ‚+- 136.45 to 372.20 ‚+- 104.62 at 7 days after surgery and furthermore at 292.64 ‚+- 85.16 at 6 months follow-up (p 0.0001). CONCLUSIONS: We found no correlation between preoparatory PTH or Calcium levels and clinical symptoms. Parathyroidectomy clearly alleviates symptomatology and improves QoL in 2HPT patients, with durable effect at 6 months.

Surgical Attitude in Patients with Secondary Hyperparathyroidism Undergoing Dialysis.

BACKGROUND: Secondary hyperparathyroidism (SHPT), develops, more or less in all the patients with chronic kidney disease. The pathology is even more severe as it intervenes in a suffering patient in whom the chronic kidney disease frequently associates severe comorbidities. General mortality is higher than in general population. The failure of the medical therapy is an indication for parathyroidectomy. METHODS: The study analyzed 200 patients with SHPT and chronic kidney disease, admitted in the clinic from October 2011 until January 2015.In this period, 179 (89.5 %) total-parathyroidectomies have been performed a long with 14 (7%) subtotal parathyroidectomies. Also 7 (3.5%) surgical interventions were incomplete. RESULTS: Overall mortality was 1% (2 patients) and postoperative specific morbidity 3.5% -4 local hemorrhagic complications and 3 cases of dysphonia have been encountered (12% if we include the reinterventions for recurrent hyperparathyroidism - 17 patients). CONCLUSIONS: Total parathyroidectomy is encumbered by a reduced number of postoperative complications and the risk of recurrent disease in almost nonexistent. The disadvantages of this surgical approach are the tendency of immediate postoperative hypocalcemia and long therm substitution with calcium and vitamine D.

The Role of Collagen Metabolism in the Formation and Relapse of Incisional Hernia.

Despite the continuous development of synthetic prosthetic meshes and their wide use, recurrent incisional hernias still appear in 5 to 20% of cases, with a linear incidence curve over the years, suggesting a multifactorial process rather than a simple failing technical repair as the underlying cause. Recent molecular biological research provide increasing evidence of connective tissue alterations such as a defective wound healing with impaired scarring process in patients with incisional hernia. Although there are some promising results, at present, in-depth understanding of the pathophysiological mechanisms and of the role that collagens play in the development and recurrence of incisional hernia is rather scarce. The aim of this systematic review is to summarize and evaluate the biochemical mechanisms involved in incisional hernia formation and recurrence, with a primary focus on collagen I to III ratio. Also, the consequences for surgical practice are discussed.

Translating clinical research of Molecular Biology into a personalized, multidisciplinary approach of colorectal cancer patients.

Although multimodal treatment has brought important benefit, there is still great heterogeneity regarding the indication and response to chemotherapy in Stage II and III, and individual variations related to both overall survival and toxicity of new therapies in metastatic disease or tumor relapse. Recent research in molecular biology led to the development of a large scale of genetic biomarkers, but their clinical use is not concordant with the high expectations. The Aim of this review is to identify and discuss the molecular markers with proven clinical applicability as prognostic and/or predictive factors in CRC and also to establish a feasible algorithm of molecular testing, as routine practice, in the personalized, multidisciplinary approach of colorectal cancer patients in our country. Despite the revolution that occurred in the field of molecular marker research, only Serum CEA, Immunohistochemical analysis of mismatch repair proteins and PCR testing for KRAS and BRAF mutations have confirmed their clinical utility in the management of colorectal cancer. Their implementation in the current practice should partially resolve some of the controversies related to this heterogenic pathology, in matters of prognosis in different TNM stages, stage II patient risk stratification, diagnosis of hereditary CRC and likelihood of benefit from anti EGFR therapy in metastatic disease. The proposed algorithms of molecular testing are very useful but still imperfect and require further validation and constant optimization.

Predictors for in-hospital mortality and need for clinical intervention in upper GI bleeding: a 5-year observational study.

BACKGROUND: Upper GI bleeding (UGIB) is a potentially life threatening gastrointestinal emergency whose effective management depends on early risk stratification. METHODS: We retrospectively studied 151 patients admitted to our unit with UGIB between 1st January 2007 and 31st December 2011 and in whom we calculated the clinical and complete Rockall, the Glasgow-Blatchford and modified Glasgow-Blatchford risk scores. We performed an analysis of the predictive value of these scores for in-hospital mortality and need for clinical intervention. RESULTS: Of the 151 patients enrolled, 68.87% were male, and the mean age was 59.48 years. One in three patients had a history of chronic liver disease and one in eight had a previous episode of UGIB. Clinically, 58.3% of the patients presented with melena, 18.5% with hematemesis and 23.1% with both hematemesis and melena. 22% of cases were variceal hemorrhages and the other non-variceal. 16 patients died during hospitalization. The prognostic accuracy of all four scores for in-hospital death and need for clinical intervention was good, the complete Rockall score having the best performance (AUROC 0.849 and 0.653 respectively). CONCLUSIONS: The Rockall and Blatchford scores were good predictors of mortality and need for clinical intervention in our study. The good predictive performance of these scores highlight the need for their use in day-to-day practice to select patients with likelihood of poor clinical outcome.

Microsatellite instability in the management of stage II colorectal patients.

BACKGROUND: Up-to-date it is unclear whether stage II colorectal cancer patients should receive adjuvant chemotherapy.The presence of high risk features (T4, CEA 5 ng dl, less than 12 lymph nodes examined) is an indication for Oxaliplatin based treatment. In their absence, there is no consensus, 5 Fluorouracil regimens, or observation only being equally recommended by oncologists. Microsatellite instability is associated with good prognosis in stage II colorectal cancer and also with poor response to 5 Fluorouracil and should be used as a predictive marker. METHODS: We performed a prospective descriptive study on 115 consecutive patients who received surgical resection for colorectal cancer in our clinic during 2011 and 2012 using a risk stratification algorithm based on TNM staging, clinico pathologic and molecular markers. RESULTS: From the 44 stage II colorectal cancer patients, 10 cases were classified as high risk, in 26 cases we performed Immunohistochemical analysis that identified 8 patients with low risk microsatellite instability phenotype, with no indication for adjuvant chemotherapy; 26 intermediate risk patients received 5-FluoroUracil regimens. CONCLUSION: We believe that microsatellite instability testing provides a useful tool in the goal of better characterizing patients with stage II colorectal cancer in matters of risk of recurrence and likelihood of benefit from chemotherapy.

Molecular factors of failure in incisional hernia surgery.

Incisional hernias occur as frequent as they did 20 years ago even if we use modern technologies in terms of suture. Sutures techniques, either primary repair or applied after failure of primary repair are characterized by high rates of recurrence. Using the hernia mesh has become mandatory in repairing of all types of hernias - inguinal, ventral or incisional. Implantation of the mesh is a relatively well-coded surgical procedure. But surgery is only the first step in the process of healing. Implantation starts a strong response with haematological mechanisms: protein absorption, complement activation, coagulation, platelet activation, neutrophil activation and tissue mechanisms: proliferation, adhesion, fibrosis. Recurrence rates are consistently lower when replacement meshes are used and a variety of meshes have been developed for this purpose. How the mesh is embedded by the human body and how the biomechanical limits of the abdominal wall are restored is still a subject of debate for surgeons. Histopathological studies and progress in design and materials are the only keys to solve this problem. Also pathological studies should determine the right material for personalized repair according to each patient's biology. This paper attempts to analyze the molecular failure factors in incisional hernia surgery, different from errors in surgery procedures. Complications can be avoided or reduced by an appropriate selection of the type of place in a particular case, and by performing a meticulous technique. Incisional hernias are considered at this moment a biological progressive phenomenon, and not only a strictly technical one, a "simple hole in the abdominal wall" that has to be firmly sutured.

Septic remnants, a crucial factor in the outcome of suppurated pancreatitis.

Scheduled reinterventions, or dictated by necessity in order to drain the septic foci occupy an important place in the surgery of the pancreatic suppurations. Approximately 50% of the operated patients require one or more reinterventions, in order to accomplish the debridement and evacuation of the necrotic-suppurative remnants. The authors reanalyze the retroperitoneal space as a center of the necrotic-suppurative processes, emphasizing over the insufficiency of the approach of the retroperitoneum only through the omental bursa. The anatomical considerations infirm the belief according to which the approach of the omental bursa would be the primary gesture of retroperitoneal access. The pancreas and the surrounding atmosphere are hosted within the anterior an posterior pararenal space. In order to avoid septic remnants it is insisted on six access pathways to the pararenal space. These ways of approach are dictated according to topography of the suppurated necrosis. Post surgical evolutional future of the patient is directly dependent on the presence or absence of the remnants after the first surgical intervention. Evidently, the remnants will be present where the debridement and evacuation of the sepsis didn't take place- meaning all the dependencies of the pararenal space. The large, multiple drainage, closed or opened, with or without continuous lavage, can not correct the septic omissions. Partial and incomplete debridements must not be based on the corrections through the scheduled reinterventions.

Rives technique, a gold standard for incisional hernias -- our experience.

Incisional hernias are a real problem in abdominal surgery and occur in up to 18% of patients undergoing surgery. Simple sutures or so-called anatomical processes lead to recurrence in up to 50% of cases. Performance of an alloplastic procedure decreases relapse rate to 10%, down from 12%. Popularized in Europe by Rives and Stoppa, the sublay mesh repair technique has proven very effective, with low recurrence rates (0% -23%) and minimal complications. In our clinic we have been using this technique for about 10 years, adding some changes that we consider beneficial to the further evolution of the patient and especially to obtaining a strong abdominal wall, equally functional in terms of bio-mechanics. During the study period, we recorded a total of 45 patients with abdominal incisional hernias operated by this technique. All patients were operated on by the same surgical team. No patients required surgical reintervention. Our results show that the Rives-Stoppa technique is an effective method for repairing incisional hernias. Complications and recurrence rates are comparable with the results of other techniques.

The role of imaging evidence in pancreatic suppurations.

The authors wish to propose an interpretation protocol of the imaging dedicated to the pancreatic suppurations that appear in acute necrotising pancreatitis. Analyzing the data from the literature regarding the extension mode of the pancreatic suppurations, it promotes the idea according to which the surgeon must himself utilize and interpret the offered imaging. Using well known anatomical references, highlighted on the CT and MRI images and reconstructions, the surgeon is able to appreciate more accurately, on the basis of evidence, the references and limits of the suppurative collections. Thus, it is obtained a more precise topographic map of the suppurative areas and so it proposes the necessity of reporting to precisely named retroperitoneal spaces, that are part of the pararenal bilateral area. Hence it is identified the lumenal, parenchymal and vascular anatomical marks, which permit the exact anatomical reference of the retroperitoneal spaces interested by the pathological process. In this way, it creates the possibility of aimed surgical approach, with the selection of the ways of access towards the suppurative zones in order to avoid septic omissions. Finally, the authors propose the imaging reference to 13 retroperitoneal areas, areas that are contained under the name of pararenal space.

Present and future tense in operable rectal cancer.

In the last three decades it has been repeatedly insisted on the total mesorectal excision (TME), as being the key for pelvic recurrence. The authors have focused upon issues still "questionable", that invite reflection, having as a starting point now become the classic precepts of RJ Heald. The authors stop mainly on defining points that justify the complex therapeutical approach of rectal cancer. There are discussed some issues still subject to controversy: the extent of regional extirpation, critical points of surgical risk, the attitude towards the protection of genito-urinary innervation. In this purpose surgical considerations are presented on: the anatomy of the rectum and mesorectum, TME and its limits, on dissemination issues and pathology tumor grading, pelvic relapse and the place of adjuvant therapy. Complication rate is also analyzed and the quality of life of patients undergoing TME. Finally conclusions are advanced, some of them having the capacity to provide topics for future study and debate.

Prognostic factors in colorectal cancer evolution.

BACKGROUND: This paper tries to evaluate prognostic value of various pre and post-operative colorectal cancer markers. MATERIALS AND METHODS: In the study conducted in our clinic over a period of five years we tried to emphasize the biological factors of prognostic value in colorectal cancer, and to demonstrate the important role of these factors in predicting survival, but also of early relapse or, in some cases, resistance to chemotherapy. Most important component of these factors remains molecular tumor markers. RESULTS: Of the markers of tumor load increased preoperative serum levels of carcinoembryonic antigen (CEA) means increased risk of neoplastic recurrence and reducing survival expectancy. Aneuploidy tumor cells would have the same importance. CONCLUSIONS: Although for their study modern and expensive techniques are necessary, molecular tumor markers have an increasingly role appreciated by researchers both in estimating the risk of relapse and neoplastic dissemination and the response rate to adjuvant treatment. It is estimated that the study of molecular/genetic profile of colorectal tumors in the future will dictate therapeutic decisions ahead.