Algorithm for early discharge after total thyroidectomy using PTH to predict hypocalcemia: prospective study.

PURPOSE: Hypocalcemia is the most common complication after total thyroidectomy. The aim of this study was to determine whether postoperative parathyroid hormone (PTH) levels predict hypocalcemia in order to design an algorithm for early discharge. METHODS: We present a prospective study including patients who underwent total thyroidectomy. Hypocalcemia was defined as serum ionized calcium < 1.09 mmol/L or clinical evidence of hypocalcemia. PTH measurement was performed preoperatively and at 1, 3, and 6 h postoperatively. The percent decline of preoperative values was calculated for each time point. RESULTS: One hundred and six patients were included. Thirty-six (33.9%) patients presented hypocalcemia. A 50% decline in PTH levels at 3 h postoperatively showed the highest sensitivity and specificity to predict hypocalcemia (91 and 73%, respectively). No patients with a decrease <35% developed hypocalcemia (100% sensitivity), and all patients with a decrease >80% had hypocalcemia (100% specificity). CONCLUSIONS: PTH determination at 3 h postoperatively is a reliable predictor of hypocalcemia. According to the proposed algorithm, patients with less than 80% drop in PTH levels can be safely discharged the day of the surgery.

Predictive factors for conversion in laparoscopic colorectal surgery.

BACKGROUND: Although laparoscopic colon and rectal surgery can be safely performed in the hands of well-trained surgeons, criteria for patient selection should be further developed in order to decrease the conversion rate. The main objective of this study was to identify predictive factors for conversion of laparoscopic colorectal surgery to an open procedure based on statistical analysis. METHODS: A retrospective survey was performed using data collected from 400 patients who underwent laparoscopic colorectal surgery between March 2000 and December 2006. As potential predictive factors for conversion, we considered demographic characteristics, surgery-related variables and disease-related variables. Univariable analysis was performed to identify individual predictive risk factors for conversion. Factors with p values below 0.05 were included in a regression model. RESULTS: Conversion to open surgery was required in 51 patients (12.7%). Age (>65 years) was the only independent predictive demographic factor (OR=2.3; 95% CI, 1.25-4.46). Low anterior resection (OR=3.9; 95% CI, 1.64-9-18) and complicated diverticulitis (OR=3.9; 95% CI, 1.64-9.18) were also predictive factors. The only predictive factor evidenced in the multivariate analysis was complicated diverticulitis (OR=159.99; 95% CI, 41.02-624.02). Indications for conversion were: adhesions in 53% of the patients, technical problems in 18%, bleeding in 1%, and other indications for the remaining 28%. CONCLUSION: Complicated diverticulitis or cancer of the rectum treated by low anterior resection have higher probabilities of conversion.

Long-term assessment of fecal incontinence after lateral internal sphincterotomy.

BACKGROUND: Lateral internal sphincterotomy (LIS) can cause fecal incontinence. The aim of this study was to evaluate this sequelae after long-term follow-up of patients treated by LIS and to identify possible associated factors. METHODS: Data were retrospectively collected for patients with chronic anal fissure who had LIS between 1994 and 1997. Continence was assessed according to the incontinence score (IS) obtained by medical record review and telephone questionnaire. Statistical analysis was performed using by Student's t test for qualitative variables and chi-square test for qualitative variables. RESULTS: All 68 patients evaluated had healed after fissure surgery. None of these patients had preoperative fecal incontinence neither recurrence at the time of follow-up. At a mean follow-up of 66.6 months (range, 30-84 months), 7 patients (10.2%) were incontinent (mean IS=8.2; range, 5-16) and none had recovered continence at the time of follow-up. There was no significant difference between patients with and without fecal incontinence relative to gender age, hemorrhoidectomy combined with LIS, or vaginal delivery. CONCLUSIONS: Incontinence due to LIS does not recover after long-term follow-up and appears to be an independent cause of fecal incontinence.

Complicaciones de la tiroidectomía total / Complications of total Thyroidectomy

La tiroidectoimía total es realizada con relativa frecuencia para el tratamiento tanto de patología maligna como en casos específicos de patología benigna de la glándula tiroides. La cifra de complicaciones varía en las distintas series publicadas. El objetivo de este trabajo es determinar las características y el porcentaje de complicaciones postoperatorias de la tiroidectomía total....La tiroidectomía total, realizada por cirujanos entrenados en la especialidad, es un procedimiento seguro y con una morbilidad aceptable

Complicaciones de la tiroidectomía total / Complications of total Thyroidectomy

La tiroidectoimía total es realizada con relativa frecuencia para el tratamiento tanto de patología maligna como en casos específicos de patología benigna de la glándula tiroides. La cifra de complicaciones varía en las distintas series publicadas. El objetivo de este trabajo es determinar las características y el porcentaje de complicaciones postoperatorias de la tiroidectomía total....La tiroidectomía total, realizada por cirujanos entrenados en la especialidad, es un procedimiento seguro y con una morbilidad aceptable

Alterations in the retinoblastoma pathway of cell cycle control in parathyroid tumors.

Mutations in proto-oncogenes and tumor suppressor genes have been associated with tumor development and/or progression in many neoplasms. It has been reported that parathyroid tumors have deletions affecting the retinoblastoma gene (RB), and overexpression of cyclin D1 (Cyc D1). The aim of the present study was to evaluate the alterations in the components of the pRB pathway in parathyroid adenomas and parathyroid aggressive tumors, including patterns of expression of pRB, Cyc D1, and p16/INK4A. Paired normal and tumor DNA from 6 parathyroid adenomas and 5 aggressive tumors were analyzed for loss of heterozygosity (LOH) at the RB locus. The expression of pRB, Cyc D1 and p16 was studied in 4 adenomas and 5 aggressive tumors. RB LOH was found in 1 of 6 adenomas, and in 1 of 2 informative aggressive tumors. Immunohistochemical analysis revealed undetectable pRB in 4 of 5 aggressive tumors and presence of pRB in all adenomas. Conversely, Cyc D1 expression was found in 3 of 4 aggressive tumors, but was undetectable in the adenomas. Expression of p16 was identified only in one aggressive tumor. Thus, alterations in the pRB pathway seem to prevail in the aggressive form of parathyroid neoplasms. Our results warrant further investigation of these cell cycle regulators in order to determine their potential role as tumor markers in parathyroid tumors.

[Tc-99-sestamibi scan in the preoperative localization of abnormal hyperfunctioning parathyroid glands]. / Uso del Tc-99m-sestamibi en la localización preoperatoria de paratiroides anormales hiperfuncionantes.

Hyperparathyroidism is a relatively frequent condition mostly due to a solitary parathyroid adenoma. Although it has been claimed that surgical exploration is the best way to visualize the abnormal parathyroid gland, several imaging techniques have been proposed to localize it in order to simplify and shorten the surgical procedure. Echography, thalium-technetium scintigraphy, computerized tomography and nuclear magnetic resonance have shown a mean sensitivity of 75% which can be increased to about 90% by combining 2 or more of these procedures. In this study, we evaluated the utility of Tc-99m-sestamibi scintigraphy in 13 patients with hyperparathyroidism (11 primary, 2 secondary). High resolution neck echography was carried out in all of the cases. Cervical scans were obtained 10-15 min and 3 hours after giving an i.v. injection of 25 mCi Tc-99m-sestamibi in all the patients; suppression studies with combined 131-I were also done. Positive scans were obtained in 11 out of the 13 patients. Abnormal parathyroid glands were found and surgically excised in all the cases (10 adenomas, 1 carcinoma, 2 hyperplasias). Echographic localization had a sensitivity of only 33.3%. On the contrary, Tc-99m-sestamibi showed a sensitivity of 56% for the whole group, increasing to 82% in the 11 patients with primary hyperparathyroidism whereas the positive predictive value was of 91% and 90%, respectively. We conclude that Tc-99m-sestamibi is a very useful tool in localizing abnormal parathyroid glands and should be the first choice before reoperation after surgical failure or before the first parathyroid surgery whenever it is desired to shorten the surgical and anesthetic duration.

Chinese flap in head and neck surgery.

Twenty patients underwent resections for head and neck cancer. The reconstructive procedure used was the free forearm flap with microsurgical technique on 22 occasions. The free forearm flap was used in its simple or composite form, with double or manifold islands, with a segment of the radius for mandible reconstruction or with two islands joined solely by the vascular pedicle, constituting what the authors call "tandem flap", with excellent results. The procedure does not replace conventional ones, but the authors believe it should be regarded as one of the choice flaps by surgeons dedicated to this special field.

Estudio experimental en el reemplazo de pared abdominal con Marlex, Dacron, tul de nylon y fascia de bovino. / Experimental study for the replacement of abdominal wall with Marlex, Dacron, nylon mesh and bovine fascia

Se operaron 8 perros reemplazandose 4 sectores de pared abdominal con sendas protesis de Marlex, Dacron, tul de nylon y fascia de bovino. La fascia se comporto como el elemento protesico mejor incorporado y con menor reaccion inflamatoria. El tul de nylon presentaba una reaccion tisular mayor, mas prolongada y con tendencia al rechazo tardio, el Marlex y el Dacron una reaccion intermedia. Este ultimo no se incorporaba al tejido cicatrizal

Linfangiosarcomas postmastectomia. / Post-mastectomy lymphangiosarcomas

Se describen 4 casos de linfagiosarcoma postmastectomia con referencia especial a los aspectos clinicos y patologicos, enfatizando la importancia del diagnostico precoz y urgente tratamiento quirurgico, en razon de su alta malignidad y rapida diseminacion. Se lo observa cada vez con menos frecuencia. Estudios estadisticos indican una incidencia de 7 casos de cada 1.000 pacientes operadas por cancer de la mama. Esta baja incidencia es debida en parte a las medidas actuales de prevencion del linfoedema y tambien porque ahora se opera en estudios mas tempranos. Histologicamente el linfangiosarcoma postmastectomia es un tumor indiferenciado, con gran proliferacion vascular que ha sido algumas veces clasificado como linfangiosarcoma y otras como angiosarcoma. Los muy pocos casos que sobreviven han sido tratados con cirugia radical (amputacion interescapulotoracica). El uso de otras tecnicas mas conservadoras y de la radioterapia han francasado. La quimioterapia recomendada en los ultimos anos no ha probado ser uti

Estudio experimental en el reemplazo de pared abdominal con Marlex, Dacron, tul de nylon y fascia de bovino. / Experimental study for the replacement of abdominal wall with Marlex, Dacron, nylon mesh and bovine fascia

Se operaron 8 perros reemplazandose 4 sectores de pared abdominal con sendas protesis de Marlex, Dacron, tul de nylon y fascia de bovino. La fascia se comporto como el elemento protesico mejor incorporado y con menor reaccion inflamatoria. El tul de nylon presentaba una reaccion tisular mayor, mas prolongada y con tendencia al rechazo tardio, el Marlex y el Dacron una reaccion intermedia. Este ultimo no se incorporaba al tejido cicatrizal

Linfangiosarcomas postmastectomia. / Post-mastectomy lymphangiosarcomas

Se describen 4 casos de linfagiosarcoma postmastectomia con referencia especial a los aspectos clinicos y patologicos, enfatizando la importancia del diagnostico precoz y urgente tratamiento quirurgico, en razon de su alta malignidad y rapida diseminacion. Se lo observa cada vez con menos frecuencia. Estudios estadisticos indican una incidencia de 7 casos de cada 1.000 pacientes operadas por cancer de la mama. Esta baja incidencia es debida en parte a las medidas actuales de prevencion del linfoedema y tambien porque ahora se opera en estudios mas tempranos. Histologicamente el linfangiosarcoma postmastectomia es un tumor indiferenciado, con gran proliferacion vascular que ha sido algumas veces clasificado como linfangiosarcoma y otras como angiosarcoma. Los muy pocos casos que sobreviven han sido tratados con cirugia radical (amputacion interescapulotoracica). El uso de otras tecnicas mas conservadoras y de la radioterapia han francasado. La quimioterapia recomendada en los ultimos anos no ha probado ser uti