Measurement of Quality of Life after Total Parathyroidectomy in Patients with Secondary Hyperparathyroidism and End Stage Renal Disease.

BACKGROUND: Surgery is the definitive treatment of secondary hyperparathyroidism (2HPT) and end stage renal disease patients. The aim of this study to assess the impact of surgery on the evolution of quality of life (QoL) in patients with 2HPT, and to identify the variables that influence this evolution. METHODS: A series of 85 consecutive unselected patients underwent total parathyroidectomy for 2HPT in our clinic. QoL was measured using the Short-Form Health Survey(SF-36) and alleviation of symptoms was documented using an outcome tool (PAS score), based on visual analog scales, preoperatively, postoperatively and at 6 months. RESULTS: Preoperatively, patients had lower SF-36 scores than the general population in all 8 individual and 2 component summary scales, with significant decrease in the physical health scales(p 0.0001). Patients improved in all ten scales at 6 months follow-up, most significant being: Body Pain (45.02‚+-5.52 vs 33.12‚+-8.82, p 0.0001), Role-physical (41.00‚+-7.43 vs 33.46‚+-8.54, p 0.0001), Physical functioning (40.06 ‚+-7.77 vs 33.36 ‚+-10.84, p 0.0001). PAS Scores decreased from preoperatory levels of 569.99 ‚+- 136.45 to 372.20 ‚+- 104.62 at 7 days after surgery and furthermore at 292.64 ‚+- 85.16 at 6 months follow-up (p 0.0001). CONCLUSIONS: We found no correlation between preoparatory PTH or Calcium levels and clinical symptoms. Parathyroidectomy clearly alleviates symptomatology and improves QoL in 2HPT patients, with durable effect at 6 months.

The place of thoracic abdominal ultrasound influencing survival of patients in traumatic cardiac arrest imminence.

Severe trauma has become the most frequent cause of death in industrialized countries and, for this reason, the fastness of a diagnostic approach and the precocity of the proper treatment are both essential and best influenced by the trauma team collaboration and the existence of a specific algorithm in which each specialist has a definite place and role. In the first stage time of a proposed specific algorithm, the vital stage, which covers the primary survey, the trauma team has not more than 5 min. (ideally) to complete airway, breathing, circulation lesions with vital potential. The ultrasound exam is placed in this stage, which is nothing more than a completion of the primary survey maneuvers, which are exclusively clinical. Two groups of patients were compared in our study; one which was named A, represented by severe traumatized patients admitted between January 2003 and December 2006 and the other one which was named B, with severe traumatized patients admitted between January 2007 and December 2012. The second group was treated by using the modified algorithm. Although the differences were not statistically significant because of the small number of survivors, the modified algorithm was evidently superior in patients with and without cardiac arrest. If we take into account that 48 of the 261 patients survived a cardiac arrest event (although only 9 of them were discharged), the advantages of this type of algorithm are even more obvious. In lot A, 21 patients survived a cardiac arrest, of whom only 4 were discharged. Performing an ultrasound examination during the first step of the algorithm used in the study is essential regardless of trauma causes, particularly hypovolemia. For both groups of patients with and without cardiac arrest, the percentage of patients who received ultrasound increased in the group that received a modified algorithm.

Surgical Attitude in Patients with Secondary Hyperparathyroidism Undergoing Dialysis.

BACKGROUND: Secondary hyperparathyroidism (SHPT), develops, more or less in all the patients with chronic kidney disease. The pathology is even more severe as it intervenes in a suffering patient in whom the chronic kidney disease frequently associates severe comorbidities. General mortality is higher than in general population. The failure of the medical therapy is an indication for parathyroidectomy. METHODS: The study analyzed 200 patients with SHPT and chronic kidney disease, admitted in the clinic from October 2011 until January 2015.In this period, 179 (89.5 %) total-parathyroidectomies have been performed a long with 14 (7%) subtotal parathyroidectomies. Also 7 (3.5%) surgical interventions were incomplete. RESULTS: Overall mortality was 1% (2 patients) and postoperative specific morbidity 3.5% -4 local hemorrhagic complications and 3 cases of dysphonia have been encountered (12% if we include the reinterventions for recurrent hyperparathyroidism - 17 patients). CONCLUSIONS: Total parathyroidectomy is encumbered by a reduced number of postoperative complications and the risk of recurrent disease in almost nonexistent. The disadvantages of this surgical approach are the tendency of immediate postoperative hypocalcemia and long therm substitution with calcium and vitamine D.

Technical Factors Involved in Parathyroid Surgery.

We aimed to investigate the frequency of ectopic and supernumerary parathyroid glands in our series of renal hyperparathyroidism. From October 2011 to November 2014, 202 patients with chronic renal failure and advanced SHPT nonresponsive to medical therapy were hospitalized in the General Surgery Department of the Carol Davila Nephrology Hospital. These patients underwent a number of 188 (93%) total parathyroidectomies and a number of 14 patients (7%) subtotal parathyroidectomies. Of these 202 patients, reoperation was carried out for 14 patients (7%) in which we identified ectopic and supernumerary parathyroid glands. Operative details and pathology results were prospectively collected and reviewed after we obtained informed consent for data and pictures use. In 188 patients (93% cases), four or more parathyroid glands were removed at the first operation. In 14 cases (7%) high PTH level persisted after the initial operation. In 22 of them (11%), supernumerary glands were found at the first operation and in 6 of them (3%) at the second operation. We conclude that extensive cervical exploration in addition with preoperative imaging tests, parathyroid ultrasound; scintigraphy with Tc will reduce secondary hyperparathyroidism surgery.

Study regarding the survival of patients suffering a traumatic cardiac arrest.

Severe trauma is the most frequent cause of death in young people, in civilized countries with major social and vital costs. The speed of diagnostic decision making and the precocity of treatment approaches are both essential and depend on the specialists' colaboration. The present study aims to emphasize the actual situation of medical interventions in case of cardiorespiratory arrest due to trauma. 1387 patients who suffered a cardio respiratory arrest both traumatic and non-traumatic were included in order to point out the place of traumatic arrest. Resuscitation of such patients is considered useless and resource consumer by many trauma practitioners who are reporting survival rates of 0%-3.5%. As the determinant of lesions, trauma etiology was as it follows car accidents - 43%, high falls - 30%, suicidal attempts - 3%, domestic violence - 3%, other causes - 21%. Hypovolemia remains the major cause of cardiac arrest and death and that is why the efforts of emergency providers (trauma team) must be oriented towards "hidden death" in order to avoid it. This condition could be revealed and solved easier with minimal diagnostic and therapeutic maneuvers in the emergency department.

The Role of Collagen Metabolism in the Formation and Relapse of Incisional Hernia.

Despite the continuous development of synthetic prosthetic meshes and their wide use, recurrent incisional hernias still appear in 5 to 20% of cases, with a linear incidence curve over the years, suggesting a multifactorial process rather than a simple failing technical repair as the underlying cause. Recent molecular biological research provide increasing evidence of connective tissue alterations such as a defective wound healing with impaired scarring process in patients with incisional hernia. Although there are some promising results, at present, in-depth understanding of the pathophysiological mechanisms and of the role that collagens play in the development and recurrence of incisional hernia is rather scarce. The aim of this systematic review is to summarize and evaluate the biochemical mechanisms involved in incisional hernia formation and recurrence, with a primary focus on collagen I to III ratio. Also, the consequences for surgical practice are discussed.

Traumatic cardiac arrest in the emergency department - Overview upon primary causes.

RATIONALE: Trauma is the leading cause of death for patients aged less than 40 years. Trauma patients with cardiac arrest have low survival rates, the resuscitation being often considered futile and consumptive of medical and human resources. OBJECTIVE: The aim of this study is to describe the main characteristics in cases of patients critically traumatized, who were admitted in our emergency department. METHODS AND RESULTS: The study is based on a retrospective analysis of cases of major trauma admitted in an Emergency Department between 2004 and 2008. There were 201 cases of critically traumatized patients, who received cardiopulmonary resuscitation. The patients were aged between 16 and 79, mostly men (67.16%), with a range of ISS between 30 and 75. Regarding the type of mechanism that produced the injury we noted a predominance of blunt trauma (87,2% of cases) and hypovolemia as a direct cause that led to the cardiac arrest. The first monitored rhythm was non-shockable for over 90% of the cases. In our group, 4 patients were discharged alive (2% of all cardiac arrest cases). The mechanism of cardiac arrest for those 4 cases were hypoxia through massive facial trauma in one case and tension pneumothorax through severe thoracic trauma in three cases. DISCUSSION: Given the low survival figures, all the efforts that could be achieved by an emergency team in the face of severe trauma had to be oriented towards the maintaining of the vital functions or, when needed, towards restoring life in order to enrich the operation theatre for the definitive care.

Efficacy of cetuximab in metastatic colon cancer - case report.

In recent years, targeted therapies have proved effective in the treatment of colon cancer, but even in these conditions,metastatic disease is generally considered incurable.Cetuximab is approved for the treatment of advanced colorectal cancer patients with KRAS wild-type, in order to increase survival and hinder progression of the disease. We report a case of a 55 year-old woman, diagnosed with stenosing sigmoid cancer and liver metastases, which underwent multimodal treatment: palliative surgery -Hartmann segmental colectomy, and adjuvant chemotherapy -second line monotherapy with cetuximab, according to standard protocols. After 6 months of XELOX chemotherapy,during which she showed progression of metastatic disease, she was switched to monotherapy with cetuximab, with favorable outcome. Comparing relevant literature, in which complete response to treatment with cetuximab is obtained in low percentages ( 3%) after 3 months of treatment with cetuximab the patient shows clinical and paraclinical complete response and increased quality of life. Proper selection of patients with metastatic colon cancer for treatment with anti-EGFR therapy may lead to prolonged survival and time to progression.

Translating clinical research of Molecular Biology into a personalized, multidisciplinary approach of colorectal cancer patients.

Although multimodal treatment has brought important benefit, there is still great heterogeneity regarding the indication and response to chemotherapy in Stage II and III, and individual variations related to both overall survival and toxicity of new therapies in metastatic disease or tumor relapse. Recent research in molecular biology led to the development of a large scale of genetic biomarkers, but their clinical use is not concordant with the high expectations. The Aim of this review is to identify and discuss the molecular markers with proven clinical applicability as prognostic and/or predictive factors in CRC and also to establish a feasible algorithm of molecular testing, as routine practice, in the personalized, multidisciplinary approach of colorectal cancer patients in our country. Despite the revolution that occurred in the field of molecular marker research, only Serum CEA, Immunohistochemical analysis of mismatch repair proteins and PCR testing for KRAS and BRAF mutations have confirmed their clinical utility in the management of colorectal cancer. Their implementation in the current practice should partially resolve some of the controversies related to this heterogenic pathology, in matters of prognosis in different TNM stages, stage II patient risk stratification, diagnosis of hereditary CRC and likelihood of benefit from anti EGFR therapy in metastatic disease. The proposed algorithms of molecular testing are very useful but still imperfect and require further validation and constant optimization.

Predictors for in-hospital mortality and need for clinical intervention in upper GI bleeding: a 5-year observational study.

BACKGROUND: Upper GI bleeding (UGIB) is a potentially life threatening gastrointestinal emergency whose effective management depends on early risk stratification. METHODS: We retrospectively studied 151 patients admitted to our unit with UGIB between 1st January 2007 and 31st December 2011 and in whom we calculated the clinical and complete Rockall, the Glasgow-Blatchford and modified Glasgow-Blatchford risk scores. We performed an analysis of the predictive value of these scores for in-hospital mortality and need for clinical intervention. RESULTS: Of the 151 patients enrolled, 68.87% were male, and the mean age was 59.48 years. One in three patients had a history of chronic liver disease and one in eight had a previous episode of UGIB. Clinically, 58.3% of the patients presented with melena, 18.5% with hematemesis and 23.1% with both hematemesis and melena. 22% of cases were variceal hemorrhages and the other non-variceal. 16 patients died during hospitalization. The prognostic accuracy of all four scores for in-hospital death and need for clinical intervention was good, the complete Rockall score having the best performance (AUROC 0.849 and 0.653 respectively). CONCLUSIONS: The Rockall and Blatchford scores were good predictors of mortality and need for clinical intervention in our study. The good predictive performance of these scores highlight the need for their use in day-to-day practice to select patients with likelihood of poor clinical outcome.

Microsatellite instability in the management of stage II colorectal patients.

BACKGROUND: Up-to-date it is unclear whether stage II colorectal cancer patients should receive adjuvant chemotherapy.The presence of high risk features (T4, CEA 5 ng dl, less than 12 lymph nodes examined) is an indication for Oxaliplatin based treatment. In their absence, there is no consensus, 5 Fluorouracil regimens, or observation only being equally recommended by oncologists. Microsatellite instability is associated with good prognosis in stage II colorectal cancer and also with poor response to 5 Fluorouracil and should be used as a predictive marker. METHODS: We performed a prospective descriptive study on 115 consecutive patients who received surgical resection for colorectal cancer in our clinic during 2011 and 2012 using a risk stratification algorithm based on TNM staging, clinico pathologic and molecular markers. RESULTS: From the 44 stage II colorectal cancer patients, 10 cases were classified as high risk, in 26 cases we performed Immunohistochemical analysis that identified 8 patients with low risk microsatellite instability phenotype, with no indication for adjuvant chemotherapy; 26 intermediate risk patients received 5-FluoroUracil regimens. CONCLUSION: We believe that microsatellite instability testing provides a useful tool in the goal of better characterizing patients with stage II colorectal cancer in matters of risk of recurrence and likelihood of benefit from chemotherapy.

Surgical utility of the Lanz classification of median nerve ramification.

The authors comment on the Lanz classification of the median nerve ramification at wrist level. The authors outline the importance of having very good knowledge of this classification for hand surgeons, plastic surgeons and neurosurgeons, in order to prevent iatrogenic lesions of the median nerve branches at wrist level. The regional anatomy is of utmost importance for carpal tunnel syndrome surgery, especially the mini-invasive and endoscopic techniques.

Molecular factors of failure in incisional hernia surgery.

Incisional hernias occur as frequent as they did 20 years ago even if we use modern technologies in terms of suture. Sutures techniques, either primary repair or applied after failure of primary repair are characterized by high rates of recurrence. Using the hernia mesh has become mandatory in repairing of all types of hernias - inguinal, ventral or incisional. Implantation of the mesh is a relatively well-coded surgical procedure. But surgery is only the first step in the process of healing. Implantation starts a strong response with haematological mechanisms: protein absorption, complement activation, coagulation, platelet activation, neutrophil activation and tissue mechanisms: proliferation, adhesion, fibrosis. Recurrence rates are consistently lower when replacement meshes are used and a variety of meshes have been developed for this purpose. How the mesh is embedded by the human body and how the biomechanical limits of the abdominal wall are restored is still a subject of debate for surgeons. Histopathological studies and progress in design and materials are the only keys to solve this problem. Also pathological studies should determine the right material for personalized repair according to each patient's biology. This paper attempts to analyze the molecular failure factors in incisional hernia surgery, different from errors in surgery procedures. Complications can be avoided or reduced by an appropriate selection of the type of place in a particular case, and by performing a meticulous technique. Incisional hernias are considered at this moment a biological progressive phenomenon, and not only a strictly technical one, a "simple hole in the abdominal wall" that has to be firmly sutured.

Septic remnants, a crucial factor in the outcome of suppurated pancreatitis.

Scheduled reinterventions, or dictated by necessity in order to drain the septic foci occupy an important place in the surgery of the pancreatic suppurations. Approximately 50% of the operated patients require one or more reinterventions, in order to accomplish the debridement and evacuation of the necrotic-suppurative remnants. The authors reanalyze the retroperitoneal space as a center of the necrotic-suppurative processes, emphasizing over the insufficiency of the approach of the retroperitoneum only through the omental bursa. The anatomical considerations infirm the belief according to which the approach of the omental bursa would be the primary gesture of retroperitoneal access. The pancreas and the surrounding atmosphere are hosted within the anterior an posterior pararenal space. In order to avoid septic remnants it is insisted on six access pathways to the pararenal space. These ways of approach are dictated according to topography of the suppurated necrosis. Post surgical evolutional future of the patient is directly dependent on the presence or absence of the remnants after the first surgical intervention. Evidently, the remnants will be present where the debridement and evacuation of the sepsis didn't take place- meaning all the dependencies of the pararenal space. The large, multiple drainage, closed or opened, with or without continuous lavage, can not correct the septic omissions. Partial and incomplete debridements must not be based on the corrections through the scheduled reinterventions.

Rives technique, a gold standard for incisional hernias -- our experience.

Incisional hernias are a real problem in abdominal surgery and occur in up to 18% of patients undergoing surgery. Simple sutures or so-called anatomical processes lead to recurrence in up to 50% of cases. Performance of an alloplastic procedure decreases relapse rate to 10%, down from 12%. Popularized in Europe by Rives and Stoppa, the sublay mesh repair technique has proven very effective, with low recurrence rates (0% -23%) and minimal complications. In our clinic we have been using this technique for about 10 years, adding some changes that we consider beneficial to the further evolution of the patient and especially to obtaining a strong abdominal wall, equally functional in terms of bio-mechanics. During the study period, we recorded a total of 45 patients with abdominal incisional hernias operated by this technique. All patients were operated on by the same surgical team. No patients required surgical reintervention. Our results show that the Rives-Stoppa technique is an effective method for repairing incisional hernias. Complications and recurrence rates are comparable with the results of other techniques.

Intraoperative cholangiography still a current investigation.

Laparoscopic cholecystectomy is the standard treatment for patients requiring gallbladder removal. Although the advantages of the laparoscopic technique are widely accepted, the introduction of this technique has doubled the rate of iatrogenic lesions of extrahepatic bile ducts. Research methods for biliary tree also evolved, but intraoperative cholangiography, the traditional exploring method used for the biliary tree in classic cholecystectomy remains a valuable investigation in the laparoscopic technique. We performed a retrospective study on a group of patients who underwent cholecystectomy (laparoscopic or classic). Of these, intraoperative cholangiography was performed on a total of 108 patients. Patients who underwent cholangiography motivated by preoperative investigations were excluded from the group and the study operates on patients in whom the decision to perform cholangiography was taken during surgery (45 cases). We have analyzed the criteria that led to the motivation investigation (dilated cystic duct, suspected biliary duct stones, suspicion of iatrogenic biliary injury) results and subsequent therapeutic conduct. The results showed that in 90% of the patients, the suspected diagnosis was confirmed by cholangiography (10 cases with normal cholangiography aspect, oddita 9 cases, 11 cases with bile duct stones, 2 cases with biliary tumor and 13 cases of iatrogenic biliary injury). In conclusion, the decision to perform intraoperative cholangiography proved salutary, the suspected diagnosis was confirmed and the course of treatment was adjusted accordingly.

Acute pancreatitis: the onset digestive manifestation, in a patient with adult T-cell leukemia/lymphoma.

UNLABELLED: Acute pancreatitis is a common complication, which occurs with patients suffering from vesicular biliary lithiasis or chronic alcoholism. Hypercalcemia may determine acute pancreatitis, its causes being multiple: primary or secondary hyperparathyroidism, metabolic diseases of the bone, metastatic bone neoplasm, as well as lymphoproliferative syndromes caused by the HTLV-1 virus-adult T-cell leukemia/lymphoma (ATLL). ATLL is a malignant and aggressive lymphoproliferation with the T-cell, associated with the infection caused by the HTLV-1 retrovirus. Organomegaly, cutaneous conditions, and hypercalcemia represent the main characteristics of the disease. From a hematologic point of view, we can notice the atypical lymphocytes (also known as flower cells, due to the shape of their nucleus), with a distinct CD4+ CD25+ phenotype. There have been reported few cases of patients who showed acute pancreatitis in the onset of the disease. We will describe the case of a patient whose diagnosis has not been an easy one, as it showed multiple complications from a very early stage. CONCLUSIONS: The atypical onset of ATLL with acute pancreatitis is rarely reported. Its etiology seems to be hypercalcemia but pancreatic infiltration with ATLL cells cannot be ruled out. An attentive investigation of the peripheral blood sample and flow-cytometric tests of peripheral and medullar blood smear are very important for diagnosis. The patient showed from the very beginning severe neurological manifestations which developed to a coma. Causes could have been metabolic as well as CNS infiltration (as shown by the CT examination).

The role of imaging evidence in pancreatic suppurations.

The authors wish to propose an interpretation protocol of the imaging dedicated to the pancreatic suppurations that appear in acute necrotising pancreatitis. Analyzing the data from the literature regarding the extension mode of the pancreatic suppurations, it promotes the idea according to which the surgeon must himself utilize and interpret the offered imaging. Using well known anatomical references, highlighted on the CT and MRI images and reconstructions, the surgeon is able to appreciate more accurately, on the basis of evidence, the references and limits of the suppurative collections. Thus, it is obtained a more precise topographic map of the suppurative areas and so it proposes the necessity of reporting to precisely named retroperitoneal spaces, that are part of the pararenal bilateral area. Hence it is identified the lumenal, parenchymal and vascular anatomical marks, which permit the exact anatomical reference of the retroperitoneal spaces interested by the pathological process. In this way, it creates the possibility of aimed surgical approach, with the selection of the ways of access towards the suppurative zones in order to avoid septic omissions. Finally, the authors propose the imaging reference to 13 retroperitoneal areas, areas that are contained under the name of pararenal space.

Spinal involvement with spinal cord compression syndrome in hematological diseases.

UNLABELLED: Primary spinal involvement in hematological diseases is rare. PURPOSE: The purpose of this article is studying diagnostic and treatment strategies in patients with spinal cord primary hematologic tumors causing spinal cord compression syndrome. PATIENTS AND METHODS: We report two cases with spinal cord primary hematologic tumors causing spinal cord compression syndrome. One patient had a diffuse large B-cell non-Hodgkin's lymphoma located in the thoracic spine and the second patient had a plasmocytic plasmacytoma located in the thoraco-lumbar spine. RESULTS: Both patients underwent surgery, with resection of the intracanalar tumor and spinal cord decompression and adjuvant systemic and intrathecal chemotherapy. Neurological outcome was favorable with partial remission of spinal cord compression syndrome. Finally, patients developed secondary dissemination and succumbed due to progression of the hematological disease. CONCLUSIONS: Clinical onset and radiographic evaluation is uncharacteristic in early stages. Spinal MRI is mandatory in cases with rebel pain, unresponsive to conservative treatment. Surgery is indicated in all patients with spinal cord compression syndrome. Early diagnosis is associated with better prognosis. Recommended treatment is surgical resection and systemic and intrathecal chemotherapy adapted to histological form of each tumor. In selected cases, if indicated radiotherapy can also be associated.