Successful minimally invasive surgery for primary hyperparathyroidism: influence of preoperative imaging and intraoperative parathyroid hormone levels.

PURPOSE: Adenoma is the main parathyroid disorder leading to primary hyperparathyroidism (PHP). Minimally invasive parathyroidectomy (MIP) is recognized as a valid procedure for adenoma-related PHP. It requires precise preoperative localization combining Tc-99m-MIBI (methoxy-isobutyl-isonitrile) scintigraphy and single-photon emission computed tomography (SPECT) with x-ray computed tomography (CT) and intraoperative confirmation of successful excision by change in intact parathormone (iPTH) levels. The study aim was to assess the surgery success in relation to these two parameters. METHODS: All patients operated on for PHP from 2005 to mid-2014 at our institution were retrospectively reviewed. MIP was performed in case of precise preoperative adenoma localization on scintigraphy, absence of past cervical surgery, and absence of concomitant thyroid resection necessity. In these patients, iPTH levels were monitored intraoperatively. Confirmation criteria for iPTH values were a return to normal level or a decrease >50 % of basal iPTH level. RESULTS: There were 197 PHP operations during the study period: 118 MIP and 79 bilateral neck explorations (BNEs). The MIP success rate was 95 % (112/118) with a preoperative MIBI scan ± CT accurate in 94 % (111/118) of the patients and with correct iPTH in 90 % (106/118) of the cases. Among the 12 iPTH levels that did not meet the confirmation criteria, 10 returned to normal range by postoperative day 2. Treatment failure appeared in three patients (one BNE, two MIPs). CONCLUSIONS: Tc-99m-MIBI dual-phase scintigraphy with SPECT/CT is the key examination for functional and morphological parathyroid adenoma localization. If preoperative scintigraphy is obvious and intraoperative assessment is clear, one could possibly safely omit iPTH, as it may lead to unnecessary BNE in primary PHP.

Robotic-Assisted Surgery Improves the Quality of Total Mesorectal Excision for Rectal Cancer Compared to Laparoscopy: Results of a Case-Controlled Analysis.

BACKGROUND: The use of a robotic surgical system is claimed to allow precise traction and counter-traction, especially in a narrow pelvis. Whether this translates to improvement of the quality of the resected specimen is not yet clear. The aim of the study was to compare the quality of the TME and the short-term oncological outcome between robotic and laparoscopic rectal cancer resections. METHODS: 20 consecutive robotic TME performed in a single institution for rectal cancer (Rob group) were matched 1:2 to 40 laparoscopic resections (Lap group) for gender, body mass index (BMI), and distance from anal verge on rigid proctoscopy. The quality of TME was assessed by 2 blinded and independent pathologists and reported according to international standardized guidelines. RESULTS: Both samples were well matched for gender, BMI (median 25.9 vs. 24.2 kg/m(2), p = 0.24), and level of the tumor (4.1 vs. 4.8 cm, p = 0.20). The quality of the TME was better in the Robotic group (complete TME: 95 vs. 55 %; p = 0.0003, nearly complete TME 5 vs. 37 %; p = 0.04, incomplete TME 0 vs. 8 %, p = 0.09). A trend for lower positive circumferential margin was observed in the Robotic group (10 vs. 25 %, p = 0.1). CONCLUSIONS: These results suggest that robotic-assisted surgery improves the quality of TME for rectal cancer. Whether this translates to better oncological outcome needs to be further investigated.

Risk factors for colorectal cancer in subjects with family history of the disease.

The relationship between lifestyle factors, past medical conditions, daily meal frequency, diet and the risk of 'familial' colorectal cancer has been analysed using data from a case-control study conducted in northern Italy. A total of 1584 colorectal cancer patients and 2879 control subjects were admitted to a network of hospitals in the Greater Milan area and the Pordenone province. The subjects included for analysis were the 112 cases and the 108 control subjects who reported a family history of colorectal cancer in first-degree relatives. Colorectal cancer cases and control subjects with family history were similarly distributed according to sex, age, marital status, years of schooling and social class. Familial colorectal cancer was associated with meal frequency, medical history of diabetes (relative risk, RR = 4.6) and cholelithiasis (RR = 5.2). Significant positive trends of increasing risk with more frequent consumption were observed for pasta (RR = 2.5, for the highest vs the lowest intake tertile), pastries (RR = 2.4), red meat (RR = 2.9), canned meat (RR = 1.9), cheese (RR = 3.5) and butter (RR = 1.9). Significant inverse associations and trends in risk were observed for consumption of poultry (RR = 0.4), tomatoes (RR = 0.2), peppers (RR = 0.3) and lettuce (RR = 0.3). Significant inverse trends in risk with increasing consumption for beta-carotene and ascorbic acid were observed (RR = 0.5 and 0.4 respectively, highest vs lowest intake tertile). These results suggest that risk factors for subjects with a family history of colorectal cancer in first-degree relatives are not appreciably different from recognized risk factors of the disease in the general population.

Little evidence for association between the TGFBR1*6A variant and colorectal cancer: a family-based association study on non-syndromic family members from Australia and Spain.

Genome-wide linkage studies have identified the 9q22 chromosomal region as linked with colorectal cancer (CRC) predisposition. A candidate gene in this region is transforming growth factor beta receptor 1 (TGFBR1). Investigation of TGFBR1 has focused on the common genetic variant rs11466445, a short exonic deletion of nine base pairs which results in truncation of a stretch of nine alanine residues to six alanine residues in the gene product. While the six alanine (*6A) allele has been reported to be associated with increased risk of CRC in some population based study groups this association remains the subject of robust debate. To date, reports have been limited to population-based case-control association studies, or case-control studies of CRC families selecting one affected individual per family. No study has yet taken advantage of all the genetic information provided by multiplex CRC families. Methods: We have tested for an association between rs11466445 and risk of CRC using several family-based statistical tests in a new study group comprising members of non-syndromic high risk CRC families sourced from three familial cancer centres, two in Australia and one in Spain. Results: We report a finding of a nominally significant result using the pedigree-based association test approach (PBAT; p = 0.028), while other family-based tests were non-significant, but with a p-value < 0.10 in each instance. These other tests included the Generalised Disequilibrium Test (GDT; p = 0.085), parent of origin GDT Generalised Disequilibrium Test (GDT-PO; p = 0.081) and empirical Family-Based Association Test (FBAT; p = 0.096, additive model). Related-person case-control testing using the 'More Powerful' Quasi-Likelihood Score Test did not provide any evidence for association (M-QL5; p = 0.41). Conclusions: After conservatively taking into account considerations for multiple hypothesis testing, we find little evidence for an association between the TGFBR1*6A allele and CRC risk in these families. The weak support for an increase in risk in CRC predisposed families is in agreement with recent meta-analyses of case-control studies, which estimate only a modest increase in sporadic CRC risk among 6*A allele carriers.

Copy number variations of colorectal cancer by whole exome sequencing data

Colorectal cancer (CRC) is the third most common cancer and the fourth leading cause of cancer death worldwide. About 85% of the cases of CRC are known to have chromosomal instability, an allelic imbalance at several chromosomal loci, and chromosome amplification and translocation. The aim of this study is to determine the recurrent copy number variant (CNV) regions present in stage II of CRC through whole exome sequencing, a rapidly developing targeted next-generation sequencing (NGS) technology that provides an accurate alternative approach for accessing genomic variations. 42 normal-tumor paired samples were sequenced by Illumina Genome Analyzer. Data was analyzed with Varscan2 and segmentation was performed with R package R-GADA. Summary of the segments across all samples was performed and the result was overlapped with DEG data of the same samples from a previous study in the group1. Major and more recurrent segments of CNV were: gain of chromosome 7pq(13%), 13q(31%) and 20q(75%) and loss of 8p(25%), 17p(23%), and 18pq(27%). This results are coincident with the known literature of CNV in CRC or other cancers, but our methodology should be validated by array comparative genomic hybridisation (aCGH) profiling, which is currently the gold standard for genetic diagnosis of CNV.

Intestinal microbiota in the adenoma progression to colorectal cancer: a cross-sectional study

Background: Colorectal cancer is a major health problem worldwide and many efforts have been done to delineate risk factors and develop screening strategies to reduce its incidence and mortality. Colorectal adenomas have been clearly considered preneoplastic lesions due to their potential malignant transformation via the adenoma-carcinoma sequence. Over the last years, intestinal microbiota has been studied in several diseases and it has been hypothesized that colonic microbiota could influence colorectal cancer pathogenesisObjective: The goal of this study is to analyse whether there is an association between the fecal microbiota profiling and the presence and progression of colorectal adenomas, detected in population undergoing colonoscopy, to better understand the role of intestinal microbiota in colorectal carcinogenesisDesign: A cross-sectional study in the Gastroenterology Department at Hospital Universitari Doctor Josep Trueta in Girona, in a period of time of two yearsParticipants: General population undergoing screening or diagnostic colonoscopy in the Digestive Endoscopy UnitOutcomes: Identification and characterization of intestinal microbiota in stool samples from healthy patients and patients with low and high risk colorectal adenomas

Reliability of intraoperative ultrasound in margin status assessment in women undergoing breast conserving surgery

Background: Effective treatment for breast cancer requires accurate preoperative planning, developing and implementing a consistent definition of margin clearance, and using tools that provide detailed real-time intraoperative information on margin status. Intraoperative ultrasound (IOUS) may fulfil these requirements and may offer few advantages that other preoperative localization and intraoperative margin assessment techniques may notPurpose: The goal of the present work is to determine how accurate the intraoperative ultrasound should be to acquire complete surgical excision with negative histological margins in patients undergoing Breast Conservative SurgeryDesign: A diagnostic test study with a cross-sectional design carried out in a tertiary referral hospital in Girona within a Breast Pathology UnitParticipants: Women diagnosed with breast cancer undergoing a Breast Conservative Surgery in the Breast Pathology Unit at Hospital Universitari de Girona Dr. Josep Trueta

Graft materials in oral surgery: revision

Oral implantology is a common procedure in dentistry, especially for fully or partially edentulous patients. The implants must be placed in the best location from both the aesthetic and functional point of view. Because of this it is increasingly more frequent to resort to regeneration techniques that use substitutes of the bone itself, in order to be able to insert the implants in the most appropriate location. Material and Methodology: A review was performed on the literature from the last ten years based on the following search limitations: "graft materials', 'allograft', 'xenograft', 'autologous graft" and 'dentistry". Results: 241 works were obtained that after reading their respective summaries, they were reduced to 38, and 9 previous works were included in order to summarize the concepts. Discussion: Autologous grafts are the 'gold standard' of the bone regeneration. They have obvious advantages, but they also have drawbacks. This is why allogeneic and xenogeneic tissues are used. The former because of their clear similarity with the recipient's tissue and the latter due to their wide availability. Given that these grafts also have drawbacks, the industry has developed synthetic materials that have properties similar to those of human bone tissue. However, as of today, the ideal material to substitute human bone has not yet been found. In recent years the tendency has been to combine these synthetic materials with the patient's own bone, which is extracted during drilling in implant placement, with bone marrow aspiration, or with bone morphogenetic proteins. Thus the intention is to equip these substances with the osteogenic capacity. Conclusions: There is currently no ideal graft material, with the exception of those materials that come directly from the patient. We hope that in the coming years we will have products that will allow us to perform rehabilitations with better results and provide a better quality of life for our patients, especially those who have more complex situations to resolve, like the patients that are operated on for head and neck cancer

Cognitively Empowering Internet-Based Patient Education for Ambulatory Orthopaedic Surgery Patients

Tiedollista voimavaraistumista tukeva internet-perustainen ohjaus päiväkirurgisille ortopedisille potilaille Tutkimuksen tarkoituksena oli kehittää tiedollista voimavaraistumista tukeva Internetperustainen potilasohjausohjelma sekä arvioida sitä. Tutkimusprosessi jaettiin kahteen vaiheeseen. Ensimmäisessä vaiheessa luotiin sisältö tiedollista voimavaraistumista tukevalle Internet-perustaiselle ohjaukselle päiväkirurgisia ortopedisia potilaita varten. Toisessa vaiheessa arvioitiin Internet-perustaisen ohjauksen (koeryhmä) hyväksyttävyyttä käyttäjien arvioimana ja ohjauksen tuloksia sekä verrattiin Internet-perustaisen ohjauksen (koeryhmä) tuloksia tiedollisesti voimavaraistumista tukevan sairaanhoitajan välittämään ohjauksen (kontrolliryhmä) tuloksiin. Tutkimuksen tavoitteena oli luoda uusi potilasohjausmuoto joka tarjoaa yksilöllisen, osallistavan ja aikaan ja paikkaan sitomattoman ohjauksen päiväkirurgiseen ortopediseen leikkaukseen tulevalle potilaalle. Tutkimuksen ensimmäisessä vaiheessa käytettiin kuvailevaa ja vertailevaa tutkimusmenetelmää (ennen ja jälkeen testaus). Tutkimukseen osallistui 120 päiväkirurgista ortopedista potilasta joiden tiedon odotuksia ja heille välitettyä tietoa tarkasteltiin. Tutkimuksen ensimmäisen vaiheen tuloksien ja aikaisemman voimavaraistumista käsittävän tiedon perusteella luotiin sisältö tiedollista voimavaraistumista tukevalle Internet-perustaiselle ohjaukselle. Sisältö rakentui voimavaraistavan tiedon kuudesta eri osa-alueesta. Tutkimuksen toisessa vaiheessa käytettiin randomoitua kokeellista tutkimusasetelmaa. Päiväkirurgiseen ortopediseen leikkaukseen tulevat potilaat randomoitiin koeryhmään (n=72) Internetperustaiseen ohjaukseen ja kontrolliryhmään (n=75) sairaanhoitajan välittämään ohjaukseen. Aineisto kerättiin strukturoitujen mittareiden avulla ja tulokset analysoitiin tilastollisesti. Tutkimuksen tulokset osoittavat, että kehitettyä tiedollisesti voimavaraistumista tukevaa Internet-perustaista potilasohjausmenetelmää voidaan suositella käytettäväksi ortopedisten päiväkirurgisten potilaiden ohjauksessa ja potilailla on hyvät mahdollisuudet voimavaraistua tiedollisesti sen avulla. Monipuolista tietoa sisältävä Internet-perustainen ohjaus osoittautui käyttäjien näkökulmasta hyväksyttäväksi. Vaikka Internet ohjauksen hyväksyttävyys koettiin osittain heikommaksi kuin sairaanhoitajan välittämän ohjauksen, potilaat käyttivät nettisivustoa ongelmitta ja arvioivat sen helppokäyttöiseksi. Ohjausmuodolla ei ollut vaikutusta hoidosta aiheutuneisiin kustannuksiin. Sen sijaan kustannuksista organisaatiolle voitiin puolittaa sairaanhoitajan ohjaukseen käyttämä aika Internet-perustaisen ohjauksen avulla. Internet-perustaiseen ohjaukseen osallistuneiden potilaiden tiedon taso ja kokemus tiedon riittävyydestä lisääntyivät ohjauksen jälkeen enemmän kuin sairaanhoitajan välittämään potilasohjaukseen osallistuneiden potilaiden tiedot. Ohjausmuodolla ei ollut vaikutusta potilaiden kokemien tunteiden ja oireiden voimakkuuteen. Yhteenvetona voidaan todeta, että tiedollisesti voimavaraistava Internet-perustaista ohjausta voidaan suositella vaihtoehtoiseksi menetelmäksi sairaanhoitajan välittämälle ohjaukselle päiväkirurgiseen ortopediseen leikkaukseen tuleville potilaille.

Airway surgery for obstructive sleep apnea and partial upper airway obstruction during sleep

This study analyzed the feasibility and efficacy of surgical therapies in patients with sleep-disordered breathing ranging from partial upper airway obstruction during sleep to severe obstructive sleep apnea syndrome. The surgical procedures evaluated were tracheostomy, laser-assisted uvulopalatoplasty (LUPP) and uvulopalatopharyngoplasty (UPPP) with laser or ultrasound scalpel. Obstructive sleep apnea and partial upper airway obstruction during sleep were measured with the static charge-sensitive bed (SCSB) and pulse oximeter. The patients with severe obstructive sleep apnea syndrome were treated with tracheostomy. Palatal surgery was performed only if the upper airway narrowing occurred exclusively at the soft palate level in patients with partial upper airway obstruction during sleep. The ultrasound scalpel technique was compared to laser-assisted UPPP. The efficacy of LUPP to reduce partial upper airway obstruction during sleep was assessed and histology of uvulopalatal specimen was compared to body fat distributional parameters and sleep study findings. Tracheostomy was effective therapy in severe obstructive sleep apnea. Partial upper airway obstruction and arterial oxyhemoglobin desaturation index during sleep decreased significantly after LUPP. The minimal retropalatal airway dimension increased and soft palate collapsibility decreased at the level where the velopharyngeal obstruction had occurred before the surgery. Ultrasound scalpel did not offer any significant benefits over the laser-assisted technique, except fewer postoperative haemorrhage events. The loose connective tissue as a manifestation of edema was the only histological finding showing correlation with partial upper airway obstruction parameters of SCSB. Tracheostomy remains a life-saving therapy and also long-term option when adherence to CPAP fails in patients with obstructive sleep apnea syndrome. LUPP effectively reduces partial upper airway obstruction during sleep provided that obstruction at the other levels than the soft palate and uvula were preoperatively excluded. Technically the ultrasound scalpel or laser surgeries are equal. In patients with partial upper airway obstruction the loose connective tissue is more important than fat accumulation in the soft palate. This supports the hypothesis that edema is a primary trigger for aggravation of upper airway narrowing during sleep at the soft palate level and evolution towards partial or complete upper airway obstruction during sleep.

Factors Affecting Cancer Behavior with Special Reference to Lymphatic Vessels, Macrophages, EGFR, and Pim-1 in Colorectal Cancer

Syövän käyttäytymiseen ja ennusteeseen vaikuttavat monet tekijät, muun muassa muutokset syöpäsoluissa sekä kasvainta ympäröivässä mikroympäristössä. Tutkimuksen tavoitteena oli tutkia uusia prediktiivisiä ja prognostisia ennustetekijöitä syöpäsoluissa (EGFR geenikopiomäärä, EGFR, onkogeeni pim-1) sekä syöpäkasvaimen mikroympäristöön kuuluvissa imuteissä (CLEVER-1, podoplaniini), makrofageissa (CD68, CLEVER-1) ja T lymfosyyteissä (CD3) kolorektaalisyövässä. Lisäksi tutkittiin imuteiden molekulaarisia ominaisuuksia tarkemmin (CD73, LYVE-1, podoplaniini) kuten myös lymfosyyttien ja dendriittisolujen liikennöintiä imuteissä. Tutkimustulokset osoittavat että korkea Pim-1 ekspressiotaso, suuri peritumoraalinen CD68+ makrofagimäärä sekä varhaisen vaiheen taudissa suuri CLEVER-1+ peritumoraalinen makrofagimäärä ovat hyvän ennusteen tekijöitä kolorektaalisyövässä. Metastaattisessa taudissa sen sijaan suuri määrä CLEVER-1+ makrofageja, sekä intra- että peritumoraalisesti, liittyy huonoon tautiennusteeseen. EGFR geenikopiomäärä, EGFR proteiinipitoisuuden ohjaaman hopea in situ hybridisaatiomenetelmän avulla määritettynä, ennusti vastetta anti-EGFR hoidolle metastaattisessa kolorektaalisyövässä tarkemmin kuin nykyisin rutiinisti käytössä oleva KRAS määritys. Lisäksi havaittiin että imutiet ovat monimuotoisia imutiemarkkeri ekspressionsa suhteen sekä normaali- että syöpäkudoksissa. CD73 molekyylin funktio imuteissä poikkesi selvästi molekyylin funktiosta verisuonissa. Yhteenvetona voidaan todeta että kolorektaalisyövän ennusteeseen vaikuttavien tekijöiden merkitys vaihtelee taudin levinneisyysasteen sekä imuteiden että makrofagien sijainnin perusteella. Korkea Pim-1 ilmentyminen on yhteydessä hyvään kolorektaalisyöpäennusteeseen. Lisäksi EGFR geenikopiomäärä osoittautui lupaavaksi uudeksi prediktiiviseksi ennustetekijäksi KRAS villintyypin metastaattista kolorektaalisyöpää sairastavilla potilailla.

Descoberta simultânea de carcinomatose disseminada e carcinoma de cólon, após colecistectomia laparoscópica

A particularly rapid and fatal outcome has been noted in cases of malignant soft-tissue metastases occurring after cancer surgery. Abdominal wall metastases occurring in scars after laparotomy for cancer resection show a similar poor outcome. On the other hand, neoplasm seeding at trocar sites after laparoscopy has been reported with an increasing frequency. A case is presented of a 68-years-old woman with metastatic seeding of non-diagnosed colon cancer at the umbilical trocar site used for a laparoscopic cholecystectomy. The gallbladder was extracted through the umbilical incision. Pathological examination confirmed chronic cholecystitis. Eight months latter, the patient was seen with a tender umbilical mass protruded through a 4,5 cm the umbilical incision site. Biopsies of this tissue were taken and histopathological examination showed metastatic adenocarcinoma, probably of a gastrointestinal origin. A colonoscopy performed at the same time revealed a 2-cm lesion at the hepatic flexur which was shown to be a differentiated adenocarcinoma. An 8.0 x 6.0 x 6.0-cm pelvic mass without signs of liver metastases was identified by computerised tomography. Diagnostic laparoscopy showed a diffuse peritoneal carcinomatosis. The pelvis could not be approached, except for simple biopsy, and no surgical procedure was performed. It is presumed that the primary colon cancer existed prior to cholecystectomy. Laparoscopy is the procedure of choice to perform cholecystectomy and fundoplication. It has also been increasingly used to diagnose, resect and perform the staging of malignant tumours. As in any relatively new technique, questions arising about its safety and risk of complications must be extensively studied. Many questions about the specific features of laparoscopy promoting cancer growth remain unanswered.