Long-term outcomes following “presumed” total parathyroidectomy for secondary hyperparathyroidism of chronic kidney disease

Aim. The most efficacious surgical treatment for renal hyperparathyroidism is still subject of research. Considering its low incidence rate of long-term relapse, “presumed” total parathyroidectomy without autotrasplantation (TP) may be indicated for secondary hyperparathyroidism (2HPT) in patients with chronic kidney disease (CKD), not eligible for kidney transplantation. The aim of this study was to analyse the TP long-term results in 2HPT haemodialysis (HD) patients. Method. Between January 2004 and October 2009, 25 2HPT HD patients, not eligible for kidney transplantation, underwent TP of at least four parathyroid glands. Clinical status and intact parathyroid hormone (iPTH) serum levels were assessed intraoperatively and during a 36-month follow-up. Results. TP improved the typical clinical symptoms and a significant reduction of iPTH serum levels was achieved in each patient. Aparathyroidism was never observed; in case of severe postoperative hypocalcemia, hypocalcemic seizures were never reported and the long-term recurrence rate was 8%. Only one patient received a kidney transplantation. Postoperative cardiovascular events (hypertension, peripheral artery disease, arrhythmia, coronary or cerebrovascular disease) were observed in 32% of cases and mortality rate was 16%. Conclusions. Considering its low long-term relapse rate and the absence of postoperative aparathyroidism, TP may still be considered the treatment of choice in patients with aggressive forms of 2HPT or of advanced dialytic vintage, with no access to renal transplantation. In case of postoperative hypoparathyroidism, hypocalcaemia can be effectively managed by medical treatment.

Colorectal retained foreign bodies per anum introduced. Three years retrospective study at Emergency Surgery Unit

Colorectal foreign bodies per anum introduced are not exceptional. They can be classified as high-lying or low-lying, depending on their location relative to the recto-sigmoid junction. High-lying rectal foreign bodies sometimes require surgery; low-lying ones are often palpable by digital examination and can removed at bedside. No reliable data exist regarding the frequency of inserted rectal foreign bodies and the literature is largely anecdotal. We review our experience on patients almost all males and heterosexual with retained colorectal foreign bodies and their outcome in Surgical Emergency Unit of a Southern Italy University hospital.

Pancreatic pseudocyst: case report and short literature review

We report a case of pancreatic pseudocyst secondary to acute necrotizing pancreatitis treated with open cystogastrostomy. Following a literature review, we stress the enormous benefits offered by modern diagnostic techniques, and especially imaging techniques, for the diagnosis and monitoring of this disease. Treatment should be delayed for at least six weeks, following which the drainage by open surgery offers the best results and lowest morbidity and mortality, followed by laparoscopy and endoscopy, indicated in particular cases and in patients where open surgery is contraindicated.

Colonic lipomas. Three surgical techniques for three different clinical cases

Colonic lipomas larger than 2 cm in diameter are likely to be symptomatic. In some cases a complication is the first clinical sign. Massive lower intestinal bleeding or obstruction, acute bleeding, prolapse or perforation or, rarely, acute intussusception with intestinal obstruction require urgent surgery. Diagnosis is often made following colonoscopy, which can also have a therapeutic role. Imaging procedures such as CT has a secondary role. Patients with small asymptomatic colonic lipomas need regular follow up. For larger (diameter > 2 cm) and/or symptomatic lipomas, resection should be considered, although the choice between endoscopic or surgical resection remains controversial. We believe that even lipomas > 2 cm can safely be removed by endoscopic resection. If surgery is indicated, we consider laparoscopy to be the ideal approach in all patients for whom minimally invasive surgery is not contraindicated.

Ocular traumatology in children. A retrospective study

Obiective. This study assesses the descriptive epidemiology of children with eye injuries presenting to the Emergency Department of a non exclusive Paediatric University Hospital - First Division of Ophthalmology of “Sapienza” University of Rome - over a period of 12 years. Study Design. A retrospective long term study of 12 years. Participants. All paediatric patients (up to 14 years of age) presenting with ocular injuries and hospitalized. Methods. It was analyzed the incidence of the ocular trauma among males and females. The situation in which the trauma occurred, type of trauma (contusive or perforating), the presence of endo-bulbar foreign bodies, visual acuity outcome. Results. There were 203 patients who presented to the Emergency Department in the period examined. Contusive traumas were 130 (90 males, 40 females). The perforating trauma were 73 (63 males, 10 females). The presence of an endo-bulbar foreign body was registered in 10 patients. A detailed analysis of the causes of the trauma is therefore provided. We evidence that males were almost exclusively involved in sport traumas (60 males versus 2 females), and in second instance accidental trauma is almost equally divided between two genders. Conclusions. Our retrospective study presents the paediatric cases of a non exclusive Paediatric University Hospital where 3% of ocular traumas requiring hospitalization were in children. Therefore our data could be useful in order to bring about the necessary preventive measures to minimize paediatric eye injuries.

How new imaging techniques can aid in defining the cardiovascular profile of the high-risk patient

Cardiovascular prevention has been developed in the last eight years producing an ever increasing amount of data requiring frequent updating. Studies using angiography to determine change in coronary obstruction have indicated progression, stabilization, or regression of coronary lesions associated with changes in plasma lipids and lipoproteins. Moreover, the guidelines on arterial hypertension published in 2007 listed the risk factors affecting prognosis but even by 2009 an update modified not only the list of risks, but even the philosophy behind the thought process which introduced as essential element in the prognosis of hypertension the ascertained existence of a damaged organ. Thus, the documentation of atherosclerotic vascular disease (plaques) and the quantification of its extension in the arterial tree became a determinant in the definition of cardiovascular risk. Magnetic Resonance (MRI) and coronary computed tomography (coro CT) applied to the heart and large vessels are the most promising methods.

The lipid- and lipoprotein- [LDL-Lp(a)] apheresis techniques. Updating

Therapeutic plasmapheresis allows the extracorporeal removal of plasmatic lipoproteins (Lipid-apheresis) (LA). It can be non selective (non specific), semi - selective or selective low density lipoprotein-lipoprotein(a) (specific [LDL- Lp(a)] apheresis) (Lipoprotein apheresis, LDLa). The LDL removal rate is a perfect parameter to assess the system efficiency. Plasma-Exchange (PEX) cannot be considered either specific nor, selective. In PEX the whole blood is separated into plasma and its corpuscular components usually through centrifugation or rather filtration. The corpuscular components mixed with albumin solution plus saline (NaCl 0.9%) solution at 20%-25%, are then reinfused to the patient, to substitute the plasma formerly removed. PEX eliminates atherogenic lipoproteins, but also other essential plasma proteins, such as albumin, immunoglobulins, and hemocoagulatory mediators. Cascade filtration (CF) is a method based on plasma separation and removal of plasma proteins through double filtration. During the CF two hollow–fiber filters with pores of different diameter are used to eliminate the plasma components of different weight and molecular diameter. A CF system uses a first polypropylene filter with 0.55 µm diameter pores and a second one of diacetate of cellulose with 0.02 µm pores. The first filter separates the whole blood, and the plasma is then perfused through a second filter which allows the recovery of molecules with a diameter lower than 0.02 µm, and the removal of molecules larger in diameter as apoB100–containing lipoproteins. Since both albumin and immunoglobulins are not removed, or to a negligible extent, plasma-expanders, substitution fluids, and in particular albumin, as occurs in PEX are not needed. CF however, is characterized by lower selectivity since removes also high density lipoprotein (HDL) particles which have an antiatherogenic activity. In the 80’s, a variation of Lipid-apheresis has been developed which allows the LDL-cholesterol (LDLC) (-61%) and Lp(a) (-60%) removal from plasma through processing 3 liters of filtered plasma by means of lipid-specific thermofiltration, LDL immunoadsorption, heparin-induced LDL precipitation, LDL adsorption through dextran sulphate. More recently (90’s) the DALI®, and the Liposorber D® hemoperfusion systems, effective for apoB100- containing lipoproteins removal have been developed. All the above mentioned systems are established LDL-apheresis techniques referable to the generic definition of LDLa. However, this last definition cannot describe in an appropriate manner the removal of another highly atherogenic lipoprotein particle: the Lp(a). Thus it would be better to refer the above mentioned techniques to the wider scientific and technical concept of lipoprotein apheresis. Lipid apheresis - Lipoprotein apheresis - LDL-apheresis - Severe Dyslipidemia.

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Pre-operative ultrasound for breast tumour measurements: is there potential for mismanagement?

The pre-operative size of breast tumour is the most important factor in determining feasibility of breast conserving surgery in operable breast cancer. Currently there is no consensus on the most accurate modality to measure tumour size. A prospective study of consecutive and unselected symptomatic patients with invasive breast cancer who had primary surgery between January 2006 and December 2007 was conducted. Patients with multi-focal and multi-centric tumours were excluded. The aim of this study was to find the correlation between histological size of invasive breast cancer and pre-operative tumour size as measured by ultrasound. Over this two year period, data for 192 patients was analysed for this study. The mean tumour diameter on ultrasound and histology was 19.5mm and 29mm respectively. The difference between the means in the two modalities was found to be statistically significant (P<0.001).Ultrasound underestimates the true size of breast tumours as determined histologically. Inaccurate tumour size measurements may result in re-operations to achieve adequate margins.

Two cases of right atrial myxoma in redo patients. A mere coincidence?

We describe two cases of right atrial myxoma in redo patients who had previously undergone to coronary artery by-pass grafting (CABGs) and mitral valve replacement respectively. Both of patients experienced effort dyspnea and were assessed by trans-thoracic echocardiography, revealing the right atrial masses. They were operated on for myxoma resection and postoperative course was uneventful. Our report deals with the interesting topic of the location of benign masses that are usually more common in the left atrium. Should we hypothesize that the right atrial manipulation during the previous surgery induces the onset of the right atrial mass? It is an interesting matter to debate.

Actual status of preoperative diagnosis of thyroid cancer in Albania

Introduction. Thyroid cancer is the most common endocrine malignancy and accounts for almost 1% of human cancer. It is well known that the majority of cases occur in women in the middle decades of life. Thyroid cancer is a relatively rare disease; on the other hand clinically apparent thyroid nodules are present in 4-7% of the adult population. Most thyroid nodules are not malignant, with reported malignancy rates from 3-12%. It is important for the surgeon to know beforehand the diagnosis of malignancy, in order to perform a more radical operation on the thyroid gland. Patients and Methods. In our study we have analyzed the preoperative clinical data of 84 patients operated in the First Clinic of General Surgery, UHC “Mother Theresa” in Tirana; all with a positive histopathologic diagnosis of thyroid cancer. The data comprised age, sex, age distribution, blood group, time-lapse from the first endocrinologic visit, clinical examination, signs and symptoms, imaging, functional tests, preoperative FNA, admission diagnosis, associated diseases and preoperative treatment. Results. From the study emerged that only 9,3% of these patients were diagnosed preoperatively as thyroid cancer. Another related problem is the low percentage of preoperative FNA – only 22%. Among the signs and symptoms related to thyroid cancer we found that 40 and 33% of these patient presented dyspnea and dysphagia, respectively. The physical examination revealed apparent nodular growth of the thyroid gland in 81% and nodular hard consistency in 79% of cases. The proper endocrinologist consultation lacked in 23% of cases. Conclusion. In our opinion, close collaboration between endocrinologists and surgeons in a multidisciplinary frame is the key to correct preoperative thyroid cancer diagnosis and optimal treatment.

Parotid gland oncocytoma in HCV-positive patient with non-Hodgkin's lymphoma. Case report

We report a case of parotid gland oncocytoma in a patient with chronic infection from hepatitis C virus (HCV) and associated non-Hodgkin's lymphoma and xerophthalmia. Our case confirms the triple tropism of the HCV: hepatotropism, lymphotropism and sialotropism.

Incidental cancer in patients surgically treated for benign thyroid disease. Our experience at a single institution

Increased incidence of incidental cancer in patients operated for benign thyroid disease has been reported. We report our experience about incidental thyroid cancer (ITC) in order to better characterize this nosologic entity. Between 2001 and 2009 a total of 568 patients underwent surgery for benign thyroid disease. Patients with preoperative cytology undetermined or positive for malignancy were excluded. The most frequent indication for surgery was multinodular or diffuse nontoxic goiter. We performed total thyroidectomy in 499 cases and emithyroidectomy in 69 cases. Final histology revealed ITC in 53 patients (9.3%): 44 had papillary carcinoma (20 classic variant and 24 follicular variant), 4 follicular carcinoma, 4 medullary carcinoma and 1 primitive thyroid paraganglioma. The preoperative diagnosis was multinodular or diffuse goiter in 45 cases of ITC and uninodular goiter in 8 cases. We performed total thyroidectomy in 46 case, emithyroidectomy in 4 patients with past history of lobectomy, emithyroidectomy in 3 patients with following radicalization and central neck dissection. In 14 patients the tumor was multifocal and in 12 of these patients the tumor foci were bilateral. The lesion was a microcarcinoma in 34 cases. Mean diameter of the ITC was 1.14 cm. We retrospectively reconsidered the results of preoperative ultrasound examinations in relation to the exact position of the tumor in the specimens and we found a statistically significant association between echogenicity and papillary histotype. Twenty-six patients were followed up at our Hospital. The mean follow-up period was 38.2 months. A relapse was observed in 3/26 patients. Incidental thyroid cancer in patients operated for benign disease has its own surgical and oncological relevance. A correct preoperative assessment, with a careful selection of nodules for fine-needle aspiration cytology on the basis of ultrasound pattern, could better address the choice of surgical procedure. The non irrelevant incidence of incidental thyroid cancer, the eventuality of multifocality and bilaterality and the possible occurrence of relapse, support that total thyroidectomy without residuum is a valuable option for treating benign thyroid conditions such as multinodular goitre. When an incidental cancer is diagnosed after emithyroidectomy, a radicalization with central neck dissection could be considered. We suggest that natural history of papillary microtumors and the correct surgical approach for these lesions could be better defined with a more extensive use of “Porto proposal” criteria. Incidental thyroid cancer, Papillary microcarcinoma, Papillary microtumors, Total thyroidectomy.

Diagnosis of intra-abdominal injuries can be challenging in multitrauma patients with associated injuries. Our experience and review of the literature

ntroduction. Trauma is the most common cause of death and disability among patients during the first four decades of life. Abdominal trauma is reported to be the 3rd most common injured region. Clinical examination may be unreliable in the evaluation of these patients especially in the presence of associated injuries. Therefore the use of diagnostic tools is essential in the management of the injured patient with abdominal trauma and additional injuries. Patients and Methods. During 1 year period from December 2010 to November 2011 we recorded the patients that presented to the emergency department of our hospital and were found to suffer from intra-abdominal injuries. These patients were divided in two groups depending on whether they had additional comorbid injuries or not. Several parameters were recorded and compared between the two groups, such as mechanism of injury, general status and hemodynamic stability of the patient on presentation, physical examination, use of imaging modalities and concomitant findings, need for surgical intervention and mortality rates. Furthermore the discrepancy between physical findings and final diagnosis after the use of diagnostic adjuncts is reported. Results. We recorded 31 patients with abdominal trauma. 13 (42%) patients were found to suffer from abdominal trauma and associated injuries (Group I), whereas 18 (58%) presented with abdominal trauma alone (Group II). The patients of the first group presented hemodynamic instability in 38% of cases while the patients of the second in 22% of cases. Reduced consciousness was present in 38% in group I versus 17% in group II. Signs of abdominal injury during clinical examination were present in only 15% in group I versus 72% in group II that represented a remarkable difference between the two groups. Conservative treatment was possible in 15% of patients with additional injuries and in 22% of patients with abdominal injury alone. In group I there were two deaths whereas in group II all patients survived. Conclusion. In patients with abdominal trauma, associated injuries seem to add to the severity of injury and indicate a worse prognosis. Clinical examination is unreliable and misleading in the majority of these patients and the use of diagnostic tools cannot be overemphasized.