FIRST DAY SERUM CALCIUM AND PARATHYROID HORMONE LEVELS AS PREDICTIVE FACTORS FOR SAFE DISCHARGE AFTER THYROIDECTOMY.

CONTEXT: Permanent hypocalcemia is a rare but significant complication of thyroid surgery. OBJECTIVE: The aim of this study was to identify predictive factors of hypocalcemia and hypoparathyroidism after thyroidectomy. DESIGN: Study included 134 total patients submitted to thyroidectomy from two endocrine units (January 2015 - August 2016). METHODS: We measured total serum calcium (sCa) and intact PTH (iPTH) on postoperative day one and 1 month after surgery. RESULTS: 118 patients were women with F/M ratio of 7.3/1 and a mean age of 51.8 years. 64 patients were included in group A (iPTH <12 pg/mL) and 70 patients in group B (iPTH >12 pg/mL). sCa and hypocalcemia symptoms were correlated with iPTH, measured 24 hours after surgery. The cut-off value was for sCa 8.05 mg/dL with a sensitivity of 85.29% and a specificity of 88.0% and for iPTH 11.2 pg/mL, with a sensitivity of 82.3% and a specificity of 71.0%. SCa (< 8.05 mg/dL) was a predictive factor with a 99 (IC95%:12.86-761.58) and iPTH (<11.2 pg/mL) with a 10.77 higher risk (CI95%: 3.83-30.30) to be associated with symptoms. CONCLUSION: SCa and iPTH represent good predictive factors of early and safe hospital discharge and can predict the risk of prolonged and permanent hypoparathyroidism.

INCIDENTAL PARATHYROIDECTOMY DURING THYROID SURGERY - RISK, PREVENTION AND CONTROVERSIES; AN EVIDENCE-BASED REVIEW.

BACKGROUND: Postoperative hypocalcemia after thyroid surgery has a high prevalence ( 16-55% in different series). Incidental parathyroidectomy (IP) is a less discussed complication of thyroidectomy with consequences not properly defined. The aim of our study was to find incidence, risk factors and how to prevent IP. METHODS: Extensive search of English literature publications via PubMed was performed and 73 papers from 1980 to 2017 were analysed using the GRADE system/classification, quality of evidence was classified as "strong" when the result is highly unlikely to change existing recommendation and "weak" when opposite. RESULTS: Incidence of IP is 3.7-24.9%, while prevalence of permanent hypoparathyroidism is less frequent 6-12%. Direct relation between IP and hypoparathyroidism/hypocalcemia remains controversial. Female patients, ectopic parathyroids, small thyroids, Graves', malignancy, redo surgeries and total thyroidectomy favour IP. Routine visualization of parathyroids, new hemostatic devices, magnifying instruments and fluorescence can prevent incidental removal of parathyroids. Incidence of IP during videoassisted or robotic thyroidectomies was similar to open procedures. High volume, experienced and younger surgeons have lower complication rates (including hypoparathyroidism). CONCLUSIONS: Incidental parathyroidectomy is more frequent than we might have expected. It should be avoided and parathyroid glands should be kept in situ. Majority of studies are retrospective (low degree of evidence according to previous mentioned GRADE classification) and further meta-analysis or randomized control studies are welcome in order to define the impact of incidental removal of parathyroids on postoperative outcome.

A COMPARATIVE ANALYSIS OF THE INITIAL EAST EUROPEAN CENTER EXPERIENCE WITH A WESTERN HIGH-VOLUME CENTER FOR OPEN MINIMALLY INVASIVE PARATHYROIDECTOMY (OMIP) AS TREATMENT OF PRIMARY HYPERPARATHYROIDISM.

OBJECTIVE: To compare results of treatment of primary hyperparathyroidism (PHPT) in two teaching hospitals (eastern and western Europe) and to establish conclusions regarding quality of surgery for PHPT in Romania. METHODS: We reviewed two prospectively collected databases of patients submitted to open minimally invasive parathyroidectomy (OMIP) for symptomatic PHPT in two centers from Romania and the United Kingdom (UK). We included patients with biochemically proven PHPT and positive pre-operative localization studies. We excluded patients with negative localization studies, suspected multiglandular disease, concomitant thyroid disorders and chronic renal failure. RESULTS: 60 patients were included, 27 in group A (Romanian cohort) and 33 in group B (UK cohort). We noted significant differences between groups in pre-operative serum calcium and phosphorus levels (p<0.5). There were no differences between groups regarding the presence of symptoms; in group A we had significantly more patients with renal calculi history (p=0.02), digestive symptoms (p=0.006) and osteitis fibrosa cystica (p=0.01). Two patients from the UK group had lithium associated hyperparathyroidism and 2 patients had genetic disease. Intraoperative parathyroid hormone measurement (ioPTH) was available only for group B and frozen sections were selectively used in both groups. Both the adenoma size and weights were significantly higher in group A. The median operative time was significantly longer in Romanian group (p=0.001); in this group we noted the single conversion to traditional cervicotomy (3.7%) from all studied patients. In group A we noted two patients (7.4%) with failed parathyroidectomy and persistent PHPT; the cure rate was 92.5% for Romanian group and 97% for the UK group. CONCLUSIONS: OMIP can be performed safe with a high cure rate in "small" volume endocrine centres with results comparable to western experienced endocrine centres. Romanian patients presented with more severe PHPT with more frequent end-organ damage, due probably to late diagnosis.

Minilaparotomy as surgical approach for aortoiliac occlusive disease -- single center initial experience.

PURPOSE: The purpose of this study was to emphasize the benefits and indications of performing minilaparotomy as surgical approach for occlusive aortoiliac disease. MATERIAL AND METHOD: From January 2011 to July 2012, a total of 23 patients (19 men and 4 women), with a median age of 60 years (range 49-75) diagnosed with aortoiliac occlusive disease(n=22) or abdominal aneurysm (n=1), were included in a retrospective non-randomized clinical study. Among these patients 11 underwent aortic bypass procedure by minila parotomy approach (ML group) and 12 patients by standard laparotomy(SL group). Demographic and clinical data, operative data, postoperative recovery data and complications were analysed according to these two groups of patients. Follow-up consisted of clinical examination and duplex scanning at 1, 3,6 and 12 months postoperatively. RESULTS: There were no significant differences between the minilaparotomy and standard laparotomy control groups concerning clinical and demographical data. Two surgical conversions to standard laparotomy were necessary (18.18%) in the ML group due to technical difficulties. The mean operative time was shorter in the ML group (124 ± 22 minutes) and the mean aortic clamping time was similar between the two groups.Major differences between the two lots were observed postoperatively;mean blood loss was more important in the SL group (550 ml) than in the ML group (350 ml) (statistical significance p=0.001, Student test). Patients who have undergone standard laparotomy required more fluids (10000 Â+-2000 ml) in comparison to the other group (6000 ± 1000 ml) p value=0.0001, while the duration of nasogastric suction and period before resuming a liquid diet was both shorter in the ML group (1.1 ± 0.5 days) than those from the SL group (2.5 ± 0.6 days) p value=0.001. The period spent in the ICU was significantly shorter for the ML lot of patients and the median hospitalization time was 5.6 days for patients in ML group,whereas in the SL group the median hospitalization time was 8.9 days (Student test - p value 0.01). We had no 30-day mortality in any of the groups included in the study. One patient from the ML group was readmitted in postoperative day 43 and re-operated on for a prosthetic limb graft thrombosis.Two patients were lost to follow-up and the mean follow-up was 9 ± 1.5 months. CONCLUSIONS: Minilaparotomy as surgical approach for aortic diseases is a feasible, safe procedure on selected patients.

Topical applications of 5-fluorouracil in the medical treatment of cholesteatoma of the middle ear.

Recent studies have demonstrated that aural cholesteatoma features intense DNA turnover in the germinative layer of the matrix and an immune response in the wall of the cyst, which trigger a chain reaction. 5-Fluorouracil, an antimetabolitic agent that is also effective topically, was applied to the cyst wall in the initial cholesteatoma, in relapsing cholesteatoma (even transtympanically) and in large exudative cavities resulting from attico-antrectomy: in all cases, it inhibited the formation of keratin and reduced the mucous hypersecretion. These results have persisted even after 12 months of suspending treatment.