Intraoperative parathyroid hormone levels dynamics of cured patients with impaired renal function following parathyroidectomy for primary hyperparathyroidism.

BACKGROUND: Intraoperative parathyroid hormones have been used to establish operative success in patients with primary hyperparathyroidism. This study's aim was to assess the impact of estimated glomerular filtration rate and serum creatinine levels on the fulfillment of >50% drop and normalization of intraoperative parathyroid hormone levels. METHODS: Patients successfully treated for primary hyperparathyroidism were analyzed. The samples for parathyroid hormone were collected at baseline, 5-, 10-, and 30-minutes postexcision. The patients were classified as follows: (1) estimated glomerular filtration rate >60 mL/min, (2) estimated glomerular filtration rate <60 mL/min and serum creatinine levels <1.2 mg/dL, and (3) estimated glomerular filtration rate <60 mL/min and serum creatinine levels >1.2 mg/dL. Comparative analysis of patients achieving the >50% parathyroid hormone drop criterion and normalization of intraoperative parathyroid hormone was performed. RESULTS: One hundred-fourteen patients were distributed as follows: 88 patients (77.2%), 14 (12.3%), and 12 (10.5%) for groups 1, 2 and 3, respectively. No difference between groups in the proportion of patients fulfilling the >50% parathyroid hormone drop criterion was found. An abnormally elevated intraoperative parathyroid hormone level at 30-minute postexcision was observed in 0, 14.3, and 16.6% in groups 1, 2, and 3, respectively (P ≤ .0001). CONCLUSION: In the study, >50% parathyroid hormone drop criterion was equally achieved despite normal or reduced estimated glomerular filtration rate. When serum creatinine levels increased >1.2 mg/dL and estimated glomerular filtration rate declined <60 mL/min, the likelihood of reaching normal intraoperative parathyroid hormone levels postexcision was significantly lower.

Spontaneous mediastinal emphysema in a non-intubated patient with COVID-19 related pneumonia: a case report.

Spontaneous mediastinal emphysema (ME) is a rare clinical entity often associated with sudden changes in intrathoracic pressures. The presumed pathophysiological mechanism is diffuse alveolar injury leading to alveolar rupture and air leak. Inflammatory alterations installed over the airway following SARS-CoV-2 infection may reduce its distensibility and compliance conferring an increased risk of developing the complication, even in the absence of mechanical ventilation. However, the exact mechanism by which ME occurs in SARS-CoV-2 pneumonia is unknown. We report a case of a 58-year-old man that presented to the emergency department with dyspnea, subcutaneous emphysema of the neck and high clinical suspicion of COVID-19 infection. There was no smoking history and no lung comorbidities. The patient was admitted into a monitored unit and received management accordingly (having never required mechanical intubation). During chest radiological evaluation ME was found and ultimately resolved with noninvasive maneuvers. We want to emphasize the importance of this adverse event despite their non-smoking history and the exclusion of positive pressure ventilation. Given the recent increase in the number of patients with COVID-19 related pneumonia, the presence of pneumomediastinum in patients with COVID-19 infection should alert the clinician to monitor the patients carefully for possible worsening of disease, especially when lung lesions are severe.

Total esophageal replacement by transmediastinal transposition of the stomach in a gastrointestinal stromal tumor of the thoracic esophagus: a rare surgical case report.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the digestive tract. A rare site of localization of these tumors is the esophagus. Evidence-based consensus regarding the type of surgery for patients with esophageal GIST remains unclear. CLINICAL CASE: A female without history of diseases experienced dysphagia, weight loss (6 kg) and malaise. Computed tomography revealed thickening of the esophagus. During the endoscopic ultrasonography a localized lesion was observed in the esophagus that depended on the muscularis propria. We opted to treat with an esophagectomy with replacement by transmediastinal transposition of the stomach. Patient recovered well from the surgery and she was discharged home in stable condition in post-operative day seven. At 6 months she has no symptoms. CONCLUSION: This case illustrates the clinical presentation of an esophageal GIST which represents only 1% of all sites where GISTs have been reported; open surgery was successfully performed with minimal morbidity, complete resolution of symptoms and improvement of the patient's quality of life. Esophagectomy with replacement by transmediastinal transposition of the stomach should be performed when the center has experience to do so with minimal morbidity and mortality.

ANTECEDENTES: Los tumores del estroma gastrointestinal (GIST) son las lesiones malignas mesenquimales más comunes del tracto digestivo. Un sitio raro de localización de estos tumores es el esófago. A la fecha actual no hay un consenso claro basado en evidencia científica con respecto al tipo de cirugía a realizar en pacientes con GIST en esta localización inusual. CASO CLÍNICO: Una mujer previamente sana presentó disfagia, pérdida de peso (6 kg) y malestar general. La tomografía computarizada reveló un engrosamiento del esófago y en la ultrasonografía endoscópica se observó una lesión localizada en el esófago dependiente de la muscular propia. Se optó por realizar esofagectomía con reemplazo mediante transposición transmediastinal del estómago. La paciente se recuperó bien de la cirugía y fue dada de alta en condición estable en el séptimo día del posoperatorio. A los 6 meses, se encuentra asintomática. CONCLUSIÓN: Este caso ilustra la presentación clínica de un GIST esofágico que representa solo el 1% de todos los sitios reportados. La cirugía se realizó con éxito, con morbilidad mínima, resolución completa de los síntomas y mejoría de la calidad de vida de la paciente. La esofagectomía con reemplazo mediante transposición transmediastinal del estómago (comúnmente llamado ascenso gástrico) debe realizarse cuando el centro tiene experiencia para hacerlo con morbilidad y mortalidad mínimas.