Persistent hypercalcitoninemia in patients with medullary thyroid cancer: a therapeutic approach based on selective venous sampling for calcitonin.

BACKGROUND: Persistent or recurrent medullary thyroid carcinoma (MTC) can be cured by microdissection of residual metastatic lymph nodes in the neck. Selective venous sampling can be used for localization. The aim of this study is to prospectively analyze our results with a therapeutic approach based on venous sampling, in patients with hyperthyrocalcitoninemia after thyroidectomy for MTC. METHODS: Selective venous sampling for determination of stimulated calcitonin was obtained in all patients after performing a complete laboratory and imaging workup. Patients with a gradient between the suprahepatic vein and the superior vena cava underwent unilateral or bilateral extensive lymph node dissection. We used the gradient between the right and left jugular veins to decide which side of the neck to operate. Calcitonin levels were obtained after surgery and a pentagastrin test was performed one year later if basal levels remained normal. RESULTS: Mean age of the five women with a neck gradient in the selective venous sampling who underwent neck exploration was 45 years. In all patients metastatic lymph nodes were found at the site suggested by the study. Mean positive/resected lymph nodes were 5/20. Postoperative basal and stimulated levels of calcitonin became normal in two patients at one year of follow up. CONCLUSION: Selective venous sampling is useful to localize recurrent MTC.

Diseases and problems secondary to massive obesity.

Morbid obesity is a health hazard. It carries several health risks and decreases life expectancy. Individuals with morbid obesity may develop one or more complications. These are mainly cardiovascular, metabolic, respiratory, gastrointestinal, renal, genitourinary and gynaecological. Patients with morbid obesity also have a high surgical risk. This review analyses the most common complications of morbidly obese patients and their changes after surgically induced weight loss.

Laparoscopic versus open splenectomy for immune thrombocytopenic purpura.

BACKGROUND: Laparoscopic splenectomy (LS) has been proposed as a substitute to open splenectomy (OS) in the treatment of immune thrombocytopenic purpura (ITP). The aim of this study was to compare two cohorts of patients with ITP who underwent OS or LS. PATIENTS AND METHODS: From February 1990 to January 1997, 27 patients underwent OS and 22 LS. Perioperative characteristics, outcomes, and complications were comparatively analyzed. RESULTS: Mean age was 38 years (+/- 16) in the OS group, and 39 (+/- 16) in the LS group; the male: female ratio was 1:2 in both groups. Median preoperative platelet count was 16 x 10(9)/L (range 2 to 186 x 10(9)/L) in the OS group, and 50 x 10(9)/L (2 to 241 x 10(9)/L) in the LS group. Mean operative time was 2.7 hours (+/- 0.7) for OS, and 4.5 hours (+/- 1) for LS (P <0.0001). Two conversions to laparotomy occurred in the LS group. A total of 14 complications occurred in 10 patients of the OS group; 8 complications occurred in 6 patients of the LS group. Two patients died in the OS group and 1 in the LS group. Mean postoperative discharge was 6 days (3 to 44) in the OS group and 4 days (2 to 11) in the LS group (P <0.02). Response rates were similar in both groups. CONCLUSIONS: Laparoscopic splenectomy is comparable to OS in terms of efficacy and safety, and it is associated with a shorter hospital stay.

[Laparoscopic splenectomy in autoimmune thrombocytopenic purpura]. / Esplenectomía laparoscópica en púrpura trombocitopénica autoinmune.

OBJECTIVE: To describe the perioperative characteristics, complications and outcome of the first 22 patients who underwent laparoscopic splenectomy for refractary/recurrent ITP in our institution. MATERIAL AND METHODS: Clinical and biochemical characteristics, spleen size, indication for surgery, operative time, blood requirements, complications and outcome of 22 patients who underwent laparoscopic splenectomy between 1994 and 1997 were prospectively recorded. Their mean age was 40 +/- 15 (+/- SD), 15 females and 7 males. RESULTS: The preoperative platelet count was 56 thousand +/- 58.7/uL, average spleen size 10.5 +/- 2 cm. The surgical time averaged 4.5 +/- 1 hours; accessory spleens were removed from two patients. Conversion to the open procedure was necessary in two cases. Complete response was achieved in 59%, partial response in 27%, and no response in 14% (none of these due to missed accessory spleens). Six patients developed complications. One of them died two days after surgery. The mean postoperative stay was 4.7 +/- 2.6 days. CONCLUSIONS: The results of laparoscopic splenectomy were similar to our previous results with the open approach. The laparoscopic technique took longer in our hands but the postoperative stay was shorter.

[Endocrine tumors of the pancreas]. / Tumores endocrinos del páncreas.

BACKGROUND: Endocrine tumors of the pancreas arise from pancreatic and duodenal neuroendocrine cells. OBJECTIVE: To review clinical features, diagnosis and treatment of endocrine tumors of pancreas, as well as our experience at the Instituto Nacional de la Nutrición "Salvador Zubirán" (INNSZ). RESULTS: Endocrine tumors of pancreas are slow growing tumors. The most frequent tumors are insulinoma, gastrinoma and non-functioning tumors. Clinical picture of functioning tumors is determined by the action of the secreting hormone, and the diagnosis is established once high levels of the tumor secretin peptide are demonstrated. In order to localize the tumor and to search for metastasis, several imaging studies have been used. In general, image studies have demonstrated poor sensitivity in finding the primary lesion. Recently, dynamic studies have shown their ability to regionalize the peptide increase. Endoscopic and intraoperative ultrasound have shown promising results. Surgical resection is the only curative treatment, resection of hepatic metastasis can even improve survival. In the INNSZ, 38 patients with endocrine tumors of the pancreas have received initial treatment in a 32-year period. The most common neoplasia is the insulinoma, followed by non-functioning tumors and gastrinoma. Most insulinomas were benign, where as the malignancy rate of non-functioning. CONCLUSIONS: Endocrine tumors of the pancreas are rare lesions, with a variety of clinical pictures related to the hormone produced. Localizing studies are generally poor. Favorable outcome meaning cure of benign lesions or long survival despite the presence of malignancy occur in most patients.