Successful Endovascular Microembolization for Post-Traumatic High-Flow Priapism: A Case Report.

BACKGROUND High-flow (non-ischemic) priapism is a rare urological condition usually related to blind trauma to the penis or perineum causing an arterial-lacunar fistula. It can be treated conservatively, but in some cases when conservative treatment fails, the interventional approach is indicated. In the past, only surgical treatment was available, which was associated with a significant risk of complications. Endovascular techniques use a novel approach and offer clinical benefits for the patient. CASE REPORT A 51-year-old man was admitted to the hospital after referral from the urology department with high-flow priapism related to blunt trauma. Angio-computed tomography showed extravasation of contrast medium to the corpus cavernosum, and angiography revealed a fistula between the distal segment of the left internal pudendal artery and corpora cavernosa. A successful endovascular microembolization of the arterial-lacunar fistula with the use of microcoils was performed. The postprocedural period was uneventful and the patient was discharged. Despite incomplete angiographic follow-up at 6 months, the initial symptoms were fully resolved with the absence of any erectile dysfunction and no recurrence of priapism occurred. CONCLUSIONS Post-traumatic high-flow priapism can be safely and effectively treated by endovascular means. Microembolization has proven to be successful and beneficial to preserve sexual functions.

Treatment Algorithm of Peripancreatic Arteries Aneurysm Coexisting with Coeliac Artery Lesion: Single Institution Experience.

INTRODUCTION: True aneurysms of peripancreatic arterial arcades (PAAAs) coexisting with celiac axis lesion are often asymptomatic. However, they may rupture regardless of their size and cause life-threatening hypovolemia. No treatment guidelines exist to date. We present a series of 21 patients and our management algorithm. MATERIAL AND METHODS: For ruptured aneurysms we preformed endovascular embolization. Further treatment was dependent on patient's condition and control studies. In case of unruptured aneurysms, we assessed collateral circulation between superior mesenteric artery and celiac axis in angio-CT. If there was a pathway free from aneurysms, endovascular approach was chosen. Otherwise, surgical or combined treatment was favored. RESULTS: Endovascular treatment was performed in 14 patients with no complications. Follow-up studies revealed incomplete occlusion of the aneurysms in two cases. Surgical or combined treatment was performed in 7 patients with three serious perioperative complications. They were managed conservatively in two cases and surgically in one. Follow-up studies showed aneurismal dilatation and stenosis of a renohepatic by-pass in one case. CONCLUSION: We present our management algorithm of PAAAs. Our results support the leading role of endovascular treatment. We present its limitations favoring surgical or combined treatment. All patients should be carefully followed.

Parathyroid transplantation in thyroid surgery.

Permanent hypoparathyroidism following thyroid surgery is rare. Its prevalence is reported to be below 1-2% if surgery is performed by experienced thyroid surgeons. Parathyroid identification and preservation in situ with good vascular supply is the mainstay of safe thyroid surgery. However, if the parathyroid glands are damaged, autotransplantation should be undertaken to preserve their function. Parathyroid transplantation can be considered in three distinct modes of application: (I) fresh parathyroid tissue autotransplantation during thyroidectomy in order to reduce the risk of permanent hypoparathyroidism; (II) cryopreserved parathyroid tissue autotransplantation in patients with permanent hypoparathyroidism; (III) parathyroid allotransplantation in patients with permanent hypoparathyroidism when cryopreserved parathyroid tissue is not available for grafting. Nowadays, allotransplantation of cultured parathyroid cells without immunosuppression should be taken into consideration in selected patients as an alternative to calcium and vitamin D3 supplementation in management of permanent hypoparathyroidism. This paper is aimed to provide a review of current status of various parathyroid transplantation techniques in thyroid surgery.

Aneurysms of Peripancreatic Arterial Arcades Coexisting with Celiac Trunk Stenosis or Occlusion: Single Institution Experience.

Introduction. True aneurysms of peripancreatic arterial arcades (PAAAs) are rare. Most of them coexist with celiac axis stenosis/occlusion due to median arcuate ligament (MAL) compression or atherosclerosis. The aim of this study was to evaluate the cause of celiac axis lesion and characterize the anatomy of the aneurysms. These findings may have important management implications. Material and Methods. A retrospective analysis of 15 patients with true PAAAs was performed. The diagnosis was established by contrast-enhanced CT, using a 64-MDCT scanner. We evaluated the most probable cause of celiac axis lesion. Aneurysms were characterized by their number, location, size, and morphology. Location of the aneurysms was classified either as pancreaticoduodenal arteries (PDA) or as dorsal pancreatic arteries (DPA) as they may represent different collateral pathways between superior mesenteric artery and celiac trunk. Results. A total of 32 true PAAAs were identified. Celiac trunk was occluded in 12 patients and critically narrowed in 3 patients. Celiac axis lesion was categorized as secondary to MAL compression in 14 cases and due to atherosclerosis in 1 case. The most common location of the aneurysms was inferior pancreaticoduodenal arteries. Only in 1 case aneurysms involved both PDA and DPA. Conclusions. Coexistence of PAAAs with celiac axis compression as well as involvement of either PDAs or DPAs has important therapeutic implications. The uninvolved collateral pathway may be sufficient to preserve effective circulation in celiac trunk branches in case of resection or embolization of the aneurysms. However, further studies are crucial to confirm our findings.

Peritoneal adhesions as a cause of mechanical small bowel obstruction based on own experience.

UNLABELLED: Bowel obstruction is a condition which has been known for many years. As time goes by, the problem is still often encountered at surgical emergency rooms. More than 20% of emergency surgical interventions are performed because of symptoms of digestive tract obstruction with the disease mostly situated in the small bowel. Rates of causative factors of the disease have changed over recent years and there have been increasingly more cases of small bowel obstruction caused by peritoneal adhesions, i.e., adhesive small bowel obstruction (ASBO). The aim of the study to analyse the reasons and incidence of adhesive small bowel obstruction during two periods of time (1990-1995 and 2005-2010). MATERIAL AND METHODS: We performed a retrospective analysis of medical records of patients hospitalized at the 1st Department of General Surgery and Surgical Oncology of the Provincial Polyclinic Hospital in Plock between 1990 and 1995. The outcomes were compared with another period of 2005-2010. RESULTS: We found that the incidence of adhesive small bowel obstruction increased from 58 cases in the first period to 215 cases in the second one, and the outcomes improved. The proportion of patients who underwent surgery diminished from 38% to 13%. The mean hospitalization time shortened and was 11.3 days and 6.95 days during 1990-1995 and 2005-2010 periods of time, respectively. In the first group, patients who had a surgery were hospitalized for 17.8 days and those who were treated conservatively for 8.08 days. In the second group, the mean hospital stay decreased to 15.6 days and 5.7 days in the case of surgical and conservative treatment, respectively. The age of onset declined from 56.63 years in the first period to 52.54 years in the other one. CONCLUSIONS: Analysed data show an increasing number of patients with adhesive small bowel obstruction. The highest risk of the disease was associated with operations on the large bowel and gynaecological procedures.

The current status of intraoperative iPTH assay in surgery for primary hyperparathyroidism.

Intraoperative intact parathyroid hormone (iPTH) monitoring has been accepted by many centers specializing in parathyroid surgery as a useful adjunct during surgery for primary hyperparathyroidism. This method can be utilized in three discreet modes of application: (I) to guide surgical decisions during parathyroidectomy in one of the following clinical contexts: (i) to confirm complete removal of all hyperfunctioning parathyroid tissue, which allows for termination of surgery with confidence that the hyperparathyroid state has been successfully corrected; (ii) to identify patients with additional hyperfunctioning parathyroid tissue following the incomplete removal of diseased parathyroid/s, which necessitates extended neck exploration in order to minimize the risk of operative failure; (II) to differentiate parathyroid from non-parathyroid tissue by iPTH measurement in the fine-needle aspiration washout; (III) to lateralize the side of the neck harboring hyperfunctioning parathyroid tissue by determination of jugular venous gradient in patients with negative or discordant preoperative imaging studies, in order to increase the number of patients eligible for unilateral neck exploration. There are many advantages of minimally invasive parathyroidectomy guided by intraoperative iPTH monitoring, including focused dissection in order to remove the image-indexed parathyroid adenoma with a similar or even higher operative success rate, lower prevalence of complications and shorter operative time when compared to conventional bilateral neck exploration. However, to achieve such excellent results, the surgeon needs to be aware of hormone dynamics during parathyroidectomy and carefully choose the protocol and interpretation criteria that best fit the individual practice. Understanding the nuances of intraoperative iPTH monitoring allows the surgeon for achieving intraoperative confidence in predicting operative success and preventing failure in cases of unsuspected multiglandular disease, while safely limiting neck exploration in the majority of patients with sporadic primary hyperparathyroidism. Thus, parathyroidectomy guided by intraoperative iPTH monitoring for the management of sporadic primary hyperparathyroidism is an ideal option for the treatment of this disease entity. However, the cost-benefit aspects of the standard application of this method still remain a matter of controversy.

Total thyroidectomy is associated with increased prevalence of permanent hypoparathyroidism.

BACKGROUND: Thyroid disorders are very common in adults. Despite advances in conservative management, surgery remains a treatment modality of choice in many cases. The mortality and morbidity of thyroidectomy are low, but long-term postoperative hypoparathyroidism (HPT) remains a prominent complication of the procedure. The aim of this study was to assess the incidence of permanent HPT and identify the risk factors for this complication in a cohort of post-thyroidectomy patients followed at a District Endocrine Clinic. MATERIAL AND METHODS: This was a retrospective analysis of 401 patients followed up at a Regional/District Endocrine Clinic, who had undergone thyroid surgery in the years 1993-2011. The percentage of patients with permanent (>12 months) HPT was the primary endpoint of the study. The statistically analyzed data of patients with permanent HPT versus the remaining patients free from postoperative complications included their demographic data, indications for surgical treatment of their thyroid disorder, and extent of the thyroid resection. The risk factors for postoperative hypoparathyroidism were assessed using logistic regression analysis. RESULTS: Permanent HPT following surgery on the thyroid gland occurred in 8.5% of the patients. It was more frequent following total thyroidectomy (20.2%) than near-total thyroidectomy (6.7%) or subtotal thyroidectomy (4.2%); p<0.0001. A multivariate statistical regression analysis demonstrated that primary total thyroidectomy was a significant risk factor for permanent HPT (OR 6.5; 95% CI: 2.9-14.4; p<0.0001). CONCLUSIONS: Total thyroidectomy was associated with increased prevalence of permanent hypoparathyroidism when compared to less extensive thyroid resection modes in patients with benign thyroid diseases.

Reoperations for persistent or recurrent primary hyperparathyroidism: results of a retrospective cohort study at a tertiary referral center.

BACKGROUND: Parathyroid reoperations are challenging and achieving a cure requires multidisciplinary treatment team cooperation. The aims of this study were to summarize our experience in revision surgery for persistent (pHPT) or recurrent primary hyperparathyroidism (rHPT) and to explore factors underlying failure to cure at initial surgery. MATERIAL AND METHODS: This was a retrospective cohort study of patients who underwent reoperations for pHPT or rHPT at a tertiary referral center. The database of parathyroid surgery was searched for eligible patients (treated in the years 2000-2012). The primary outcome was the cure rate. All the patients were followed-up for at least 12 months postoperatively. Factors underlying failure to cure at initial surgery were reviewed based on hospital records. RESULTS: The study group comprised 88 patients (69 women, 19 men) operated on for persistent (n=57) or recurrent disease (n=31), who underwent 98 reoperations, including 26 (2.4%) patients first operated on at our institution, and 72 (81.8%) patients operated on elsewhere, but referred for revision surgery. A long-term cure was achieved in 83/88 patients (94.3%). The mean post-reoperation follow-up was 91.7 (12-176) months. Missed hyperfunctioning parathyroid gland was found on reoperation in eutopic position in 49 (55.5%) patients, and in ectopic position in 39 (44.3%) patients, including 20 (22.7%) cases of cervical ectopy and 19 (21.6%) cases of mediastinal ectopy. CONCLUSIONS: Multidisciplinary treatment team cooperation at a tertiary referral center, consisting of an accurate preoperative localization, expertise in parathyroid re-explorations, and correct use of intraoperative adjuncts, contribute to the high success rate of parathyroid reoperations.

Utility of the laparoscopic approach to surgical treatment of acute appendicitis in a single surgical unit.

INTRODUCTION: Acute appendicitis (AA) is one of the most common reasons for emergency surgery within the abdominal cavity in Poland. AIM: To compare outcomes of surgical treatment of AA using both classical (OA) and laparoscopic methods (LA). MATERIAL AND METHODS: Retrospective analysis of 299 patients (157 men and 142 women) operated on in 2008-2011 due to AA. The following comparisons between LA and OA were done: mean operative time, mean hospital stay after surgery, conversion rate, proportion of LA to OA in successive years. RESULTS: Laparoscopic appendectomy was performed in 170 (56.9%) patients (74 men and 96 women), whereas OA was done in 89 (29.8%) patients (44 men and 45 women). In 13.4% of patients (24 men and 16 women) conversion from LA to OA was done. Mean operating time was 53.4 ±16.1 min (range: 25-100 min) for LA, and 55.4 ±20.2 min (range: 20-140 min) for OA; p = 0.64. Mean hospital stay after LA was 4.0 ±1.2 days (range: 2-9 days), while it was 6.0 ±4.2 days (range: 2-28 days) after OA; p < 0.001. Laparoscopic appendectomy was 24.1% of all appendectomies performed in the year 2008, 54.1% in the year 2009, and in consecutive years 71.7% in 2010 and 65.6% in 2011. CONCLUSIONS: Laparoscopic appendectomy method did not require longer surgery times and entailed shorter hospital stays as compared with OA. In our opinion, LA should be the preferred approach in surgical treatment of AA in adults.

A retrospective case-controlled study of video-assisted versus open minimally invasive parathyroidectomy.

INTRODUCTION: Minimally invasive parathyroidectomy (MIP) with intraoperative parathyroid hormone assay (IOPTH) has successfully replaced conventional neck exploration in most patients with primary hyperparathyroidism (pHPT) and preoperatively localized parathyroid adenoma. AIM: To compare outcomes of video-assisted MIP (MIVAP) to open MIP (OMIP). MATERIAL AND METHODS: A retrospective case-controlled study of 455 patients with sporadic pHPT undergoing MIP with IOPTH at our institution in 2003-2012 was undertaken. The primary outcome measure was postoperative pain. Secondary outcome measures were: duration of surgery, recurrent laryngeal nerve (RLN) identification rate, conversion rate, length of hospital stay, cure rate, patients' satisfaction with cosmetic outcome, morbidity, costs, and diagnostic accuracy of IOPTH. RESULTS: Of 455 patients with pHPT and a solitary parathyroid adenoma on preoperative imaging, 151 underwent MIVAP and 304 had OMIP. The following outcomes were favourable for MIVAP vs. OMIP: lower pain intensity during 24 h postoperatively (p < 0.001), lower analgesia request rate (p < 0.001), lower analgesics consumption (p < 0.001), higher recurrent laryngeal nerve identification rate (p < 0.001), shorter scar length (p < 0.001), and better cosmetic satisfaction at 1 month (p = 0.013) and at 6 months (p = 0.024) after surgery. However, MIVAP vs. OMIP had longer duration of surgery (p < 0.001), and was more expensive (p < 0.001). No differences were noted in the conversion rate, length of hospital stay, and morbidity. CONCLUSIONS: Both MIVAP and OMIP approaches were equally safe and effective. However, the outcomes of MIVAP operations were superior to OMIP in terms of lesser postoperative pain, lower analgesics consumption, and better cosmetic satisfaction resulting from a smaller scar.

Xenotransplantation of human cultured parathyroid progenitor cells into mouse peritoneum does not induce rejection reaction.

INTRODUCTION: Parathyroid progenitor cells devoid of immunogenic antigens were used for human allotransplantation. Although there were many potential reasons for the expiry of transplant activity in humans, we decided to exclude a subclinical form of rejection reaction, and test the rejection reaction in an animal model. MATERIAL AND METHODS: Experiments were carried out on 40 conventional male mice in their third month of life. The animals were housed in groups of 10 per cage in 4 cages with fitted water dispensers and fed a conventional diet based on standard pellet food. They were divided into four groups of 10 animals each, three experimental groups and one control group. Identified progenitor cells were stored in a cell bank. After testing the phenotype, viability, and absence of immunogenic properties, the cells were transplanted into mouse peritoneum cavity. RESULTS: Animals were observed for 9 weeks. At 9 weeks of observation, the mean serum PTH concentration in the experimental groups was 2.0-2.5 pg/ml, while in the control group it did not exceed 1.5 pg/ml. The immunohistochemical assays demonstrated that millions of viable cells with a phenotype identical to the endocrine cells had survived in the peritoneum. Histologic specimens from different internal organs stained for PTH revealed positive cells labelled with anti-PTH Ab in the intestinal lamina, brain, liver, and spleen. CONCLUSIONS: In the present paper we have demonstrated that xenotransplantation may be used as a model for an explanation of the immunogenic properties of cells generated from postnatal organs for regenerative therapy.

Generation and identification of thymic epithelial progenitor cells pTEC by in-vitro processing of human thymic fragments for allotransplantation.

The procedure of generation and identification of stromal progenitor cells derived from human thymic fragments (PL patent 378431) has been described in this article. Our aim was to prepare material for transplantation in elderly people. The method is based on in-vitro processing of thymic fragments to get rid of all immunogenic elements of lymphocytes, endothelial cells, macrophages, and fibroblasts. In the thymic culture process, this organ dies out in the incubation medium and epithelial cells emerge out of the organ. After about 4 weeks from the start of the culture, the population of various developmental forms of epithelial cells was generated, namely CK AE1/AE3+, SDF-1 alpha+ and a weak expression of FGF+ S-100+. Finally, we obtained approximately 3 million cells as a monolayer. The progenitor cells were experimentally transplanted into a 72-year-old volunteer in order to prove that they do not induce neither a local nor a systemic rejection response.

Allotransplantation of cultured parathyroid progenitor cells without immunosuppression: clinical results.

BACKGROUND: Hypoparathyroidism is a well-known consequence of extensive thyroid and parathyroid surgery. Allotransplantation of cultured parathyroid cells can be considered as an alternative to vitamin D3 and calcium supplementation in treatment of hypoparathyroidism. We present the long-term allotransplant activity in 85 patients who had undergone cellular allotransplantation for surgical hypoparathyroidism. Also, a modified technique to prepare parathyroid explants is described for obtaining a new nonimmunogenic cell population. METHODS: From March 1990 to December 2004, 85 patients underwent 116 allotransplantations of cultured parathyroid cells. Mean recipient age was 46.2+/-11.1 years. Donors were selected from patients undergoing parathyroidectomy for secondary and tertiary hyperparathyroidism. RESULTS: After 6 weeks of cultivation and freezing, the parathyroid cells decreased their normal human leukocyte antigen (HLA) class I ABC expression and were free of HLA class II positive cells. The viability of cultured cells was 95.15+/-2.94%. Eighty-five patients underwent primary allotransplantation. Of these, 25 patients subsequently underwent a repeat procedure. In six cases, the parathyroid cells were obtained from the same donor and in 19 cases from a different donor. For all patients, the mean cellular allograft survival was 6.35+/-13.08 months. In 64 patients (55.1%), the allografts retained their endocrine function for more than 2 months. CONCLUSIONS: The present study has shown that in some patients parathyroid cell allotransplantation may be considered a method of treatment for permanent hypoparathyroidism after thyroid surgery. Graft function and/or survival did not depend on the baseline viability or secretory activity of cultured cells used for transplantation.

The calcium-sensing receptor and vitamin D receptor expression in tertiary hyperparathyroidism.

The parathormone (PTH) production is controlled by calcium and vitamin D, which interact with the calcium-sensing receptor (CaSR) and vitamin D receptor (VDR), respectively. All of these elements control calcium homeostasis, which is crucial for many physiological processes. Thus, impairment of the upstream component of this system, e.g. a decrease of CaSR and/or VDR, could result in hyperparathyroidism (HPTH). Therefore, the aim of this study was to assess the expression of CaSR and VDR in a tertiary form of HPTH (T-HPTH). The study involved 19 T-HPTH patients qualified for parathyroidectomy and 21 control parathyroids harvested from multi-organ cadaver donors. The small fragments of harvested glands were homogenized and used for Western blot analysis, whereas the remaining tissues underwent routine hematoxylin-eosin staining or immunostaining for CaSR and VDR. Among 64 T-HPTH parathyroids, 58 revealed the morphology of benign hyperplasia, 2 were identified as adenoma and 4 were classified as normal; some glands displayed a mixed histological phenotype. Western blot analysis revealed a decrease of CaSR and VDR in hyperplasia and adenoma-derived samples. However, no correlation between the types of hyperplasia and receptor expression was observed. On the other hand, microscopic analysis of CaSR- and VDR-immunostained sections revealed a highly differentiated and significantly decreased mean expression of both receptors, which correlated with parathyroid histology. The reason behind the impaired expression of CaSR and VDR in T-HPTH is unclear. It presumably results from constant parathyroid stimulation at the stage of S-HPTH, followed by further development of polyclonal autonomy. However, the verification of this thesis requires further study.

ESTIV questionnaire on the acquisition and use of primary human cells and tissue in toxicology.

The ability to use human cells and tissues in toxicology research and testing has the benefit that it obviates the need to undertake species extrapolation when assessing human hazard. However, obtaining and using human cells and tissues is logistically difficult, ethically complex and is a potential source of infections to those coming into contact with human cell material. The issue is also controversial, with the recent EU legislation draft on tissue engineering, and also due to some instances of human material being obtained and used without informed consent. There are also varying regulations and attitudes relating to the use of human cells and tissues throughout Member States of the EU, and there is a need for harmonisation. The European Society of Toxicology in Vitro (ESTIV) Executive Board and the European Network of Human Research Tissue Banks (ENRTB) have conducted a survey to ascertain the extent to which human cells and tissues are used by its members, how these are obtained, what local regulations are in force, how the material is used, and the advantages and disadvantages experienced by members in using such material, as opposed to cell lines. The results obtained have been compared with the results from a previous survey conducted in 2000. It is hoped that this information will help to facilitate the process of acquiring and using human cells and tissues in a safe and effective way to promote the use of non-animal approaches for investigating the mechanisms of toxicity, and for predicting the toxic hazard of substances.