Diagnosis and treatment of primary thyroid lymphoma from a surgical perspective: a multi-institutional study.

PURPOSE: Surgery of primary thyroid lymphoma (PTL) has been mostly limited to diagnostic work-up. This study aimed to further study its potential role. METHODS: This was a retrospective study from a multi-institutional registry of PTL patients. Clinical, diagnostic work-up (fine needle aspiration, FNA; core needle biopsy, CoreNB), contribution of surgery (open surgical biopsy, OpenSB; thyroidectomy), histology subtype, and outcome data were evaluated. RESULTS: Some 54 patients were studied. Diagnostic work-up included FNA in 47 patients, CoreNB in 11, and OpenSB in 21. CoreNB yielded the best sensitivity (90.9%). Thyroidectomy was performed in 14 patients with other diagnosis (incidental PTL), in 4 for diagnosis and in 4 for elective treatment of PTL. Incidental PTL was associated with not performed FNA nor CoreNB (OR 52.5; P = 0.008), mucosa-associated lymphoid tissue (MALT) subtype (OR 24.3; P = 0.012), and Hashimoto's thyroiditis (OR 11.1; P = 0.032). Lymphoma-related death (10 cases) mostly occurred within the first year after diagnosis and was associated with diffuse large B-cell (DLBC) subtype (OR 10.3; P = 0.018) and older patients (OR 1.08 for every 1-year increase; P = 0.010). There was a trend towards lower mortality rate in patients receiving thyroidectomy (2/22 versus 8/32, P = 0.172). CONCLUSION: Incidental PTL accounts for most of thyroid surgery cases and are associated with incomplete diagnostic work-up, Hashimoto's thyroiditis and MALT subtype. CoreNB appears to be the best tool for diagnosis. Most of PTL deaths occurred during the first year after diagnosis and mostly related to systemic treatment. Age and DLBC subtype are poor prognostic factors.

Risk-adjusted treatment selection and outcome of patients with acute cholecystitis.

PURPOSE: Age and comorbidities increase the surgical risk for patients with acute cholecystitis and impact on the initial treatment selection. The aim of this article is the implementation of objective risk criteria that may be used to select the most appropriate treatment. METHODS: We carried out a prospective cohort study of all patients who were admitted to the hospital with a diagnosis of acute cholecystitis during 2014. They were initially allocated to three different treatment groups according to cholecystitis grade, number of days from clinical onset, and surgical risk scores as follows: immediate surgery by sepsis (EmergS), early surgery (EarlyS), or medical treatment group (MedT). Differences in the outcomes between the treatment groups were evaluated using bivariate and logistic regression analyses. RESULTS: A total of 149 patients were admitted; 44 % were >80 years old and 40 % were American Society of Anesthesiologists (ASA) > II. The mortality rate of the series was 0 % in EarlyS, 17 % in MedT, and 19 % in EmergS. The mortality rate was significantly associated with a higher degree of cholecystitis, age, and worse score values in risk scales and Charlson index. Logistic regression identified that the only independent predictors of death at the time of admission were the degree of cholecystitis (OR 2.87, p = 0.018) and the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM) score (OR 1.14, p = 0.001). CONCLUSION: The evaluation for the initial treatment in acute cholecystitis should include a systematic determination of the degree of cholecystitis and a surgical risk assessment. Tokyo guideline recommendations should be reviewed.

Caso 1: Solución del caso 1. Paraganglioma del órgano de Zuckerkandl / Case 1: Solution to case 1. Paraganglioma of the organ of Zuckerkandl

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Solución del caso 1. Paraganglioma del órgano de Zuckerkandl / Solution to case 1. Paraganglioma of the organ of Zuckerkandl

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Fluid and sodium problems in perioperative feeding: what further studies need to be done?

Total parenteral nutrition may induce harmful water and sodium retention. Few efforts have been made to elucidate the mechanisms of this deleterious response to total parenteral nutrition. In this review we discuss the different factors involved in its pathophysiology and possible changes in total parenteral nutrition regimes in order to modulate such a response: reduction of the proportion of non-protein calories given as glucose, restriction of water and sodium, and the possible benefits of pharmaceutical nutritional therapy with glutamine and growth hormone.

Sequential changes in the metabolic response in critically injured patients during the first 25 days after blunt trauma.

BACKGROUND: Understanding the changes in energy expenditure and body composition is essential for the optimal management of the critically injured, yet these changes have not been quantified within the current context of trauma care. METHODS: Ten critically injured patients (median Injury Severity Score = 35) had measurements of energy expenditure and body composition as soon as they were hemodynamically stable and then every 5 days for 21 days. RESULTS: Resting energy expenditure rose to 55% above predicted and remained elevated throughout the study period. Total energy expenditure was 1.32 X resting energy expenditure. Body fat was oxidized when energy intake was insufficient (r=-0.830, p<0.02). Body water changes closely paralleled body weight changes and were largely accounted for by changes in extracellular water. Over the 21-day study period, there was a loss of 1.62 kg (16%) of total body protein (p<0.0002), of which 1.09 kg (67%) came from skeletal muscle. Intracellular potassium was low (133 +/- 3 mmol/L, p<0.02) but did not deteriorate further after hemodynamic stability had been reached. CONCLUSIONS: These results show that the period of hypermetabolism lasts longer and the protein loss is greater in critically injured patients than previously thought. Most, but not all, the protein is lost from muscle. Fat loss can be prevented and cell composition preserved once hemodynamic stability is achieved.

A new model of intraabdominal abscess: usefulness for hydrosaline metabolism studies in parenteral nutrition associated with sepsis.

The present study was set up to develop a new model of intraabdominal abscess (IAA) useful for hydrosaline metabolism studies based on the ligation of the appendix (AL) and wrapping of the appendix tip with omentum. Two experiments were designed: (1) to characterize the model and (2) to investigate extracellular volume (ECV) changes during parenteral nutrition (PN). Four groups of rabbits were studied at 3 (3DA) and 7 days (7DA) after AL or sham operation. PN was given for 6 days to two groups of septic rabbits: high volume HV) and low volume (LV) groups received 100 and 70 ml/kg.day of water with 7 and 0 meq/day of ClNa, respectively. Serum albumin (SA), ECV, and weight, water and sodium balances were determined. In 3DA, weight loss, reduced spontaneous intake, negative water balance, and reduction in SA were noted. Low SA, higher weight loss, and reduced intake were still observed in 7DA. SA correlated with ECV (r2 = 0.61, P = 0.003) in 7DA. Positive nitrogen balance was achieved during PN. The HV group had higher water and sodium balances than LV. In the HV group only, SA negatively correlated with sodium balance and with ECV at the end of PN (r2 = 0.87, P = 0.0007 and r2 = 0.9, P = 0.0001). The impact on hydrosaline metabolism of IAA in this model resembles that of moderate sepsis in humans. SA decrease appears to have two major components: escape around the inflammatory area and dilution. ECV expansion after PN is influenced by the initial SA concentration.

Body composition studies in intensive care patients: comparison of methods of measuring total body water.

Changes in total body water (TBW) were monitored in 12 critically-ill intensive care patients using four independent methods. Over the 10-day study period TBW measured by tritium dilution changed from 51.3 ± 2.5 (SEM) kg to 43.6 ± 2.3 kg, an average loss of 7.7 ± 0.8 kg. A six-compartment model of the body incorporating measurements of protein by in vivo neutron activation analysis and fat and bone mineral by dual-energy X-ray absorptiometry was used to determine TBW by difference from body weight. The 10-day change in TBW measured by this approach was 8.4 ± 0.9 kg which correlated well with the tritium dilution changes (r=0.84, P<0.01, SEE=1.83 kg). The changes measured by single frequency and multi-frequency bio- electrical impedance analysis were not significantly different from the tritium results (9.7 ± 1.3 and 8.2 ± 0.8 kg. respectively) although the prediction errors were high for both methods (SEE=3.29 and 2.72 kg, respectively) with correlations that were statistically significant for the single frequency approach but not for the multi-frequency approach (r=0.71, P<0.01 and r=0.45, ns, respectively). The high prediction errors render these impedance techniques inappropriate, at the present time, for monitoring total water changes in individual intensive care patients.

A new method for the estimation of the components of energy expenditure in patients with major trauma.

The management of critically ill patients would be better understood if the total energy expenditure (TEE) and its components are known. To quantify the different components of energy expenditure in patients with major trauma, we used a technique combining measurements of body composition and oxygen consumption. We determined changes in body weight, total body water, total body protein, total body potassium, total body fat, and bone mineral content every 5 days over a 10-day period in a group of nine multiply injured patients. Resting energy expenditure was measured by indirect calorimetry (REEm), and a predicted value was obtained from total body potassium (REEp). TEE was assessed by adding the total calorie intake to the changes in body energy stores, and the activity energy expenditure (AEE) was calculated by subtracting REEm from TEE. Mean daily values for REEm, REEp, TEE, and AEE were 2,236 +/- 140, 1,683 +/- 82, 3,029 +/- 276, and 793 +/- 213 kcal/day, respectively, over the 10-day study period. Although not statistically significant, the mean AEE was four times smaller for the first 5 days of study than for the second 5 days (298 +/- 400 vs. 1,254 +/- 588 kcal/day). The technique of combining indirect calorimetry and body composition measurements offers a new approach to evaluate energy expenditure and a new way to study metabolic disorders and therapeutic strategies in critically ill patients.

Acute postoperative diverticulitis.

Acute diverticulitis following surgery is a severe condition reported previously only after heart surgery. Four cases of diverticulitis in the early postoperative period are presented, three of them after non-cardiac procedures (tracheostomy, inguinal hernia repair and laminectomy). Advanced age, administration of morphine, treatment with steroids, postoperative constipation and intestinal mucosal ischaemia are discussed as possible aetiological factors leading to diverticular perforation. Although the diagnosis is often difficult, early treatment offers the best chance of survival.