Influence of common clinical variables on intraoperative parathyroid hormone monitoring during surgery for primary hyperparathyroidism.

BACKGROUND: Intraoperative monitoring of parathyroid hormone (IOPTH) is a reliable method of predicting the cure of primary hyperparathyroidism (PHPT). The aim of this study is to assess whether common clinical variables (CCV) frequently encountered in patients with PHPT may affect the magnitude of PTH drop or the likelihood of patients meeting the intraoperative cure criterion. DESIGN: Patients who were surgically cured from PHPT caused by single gland disease (SGD) and had full IOPTH protocol (4 measurements) were stratified according to age, gland weight, renal function, vitamin D status and severity of hypercalcemia. The percentage of IOPTH drop and the frequency of patients who had true positive IOPTH test results were compared among groups. RESULTS: 762 patients had surgery for PHPT, of whom 746 were (98%) cured. Of these 746 patients, 511 who had SGD and a full IOPTH protocol were included in this study. The median IOPTH drop was significantly higher among younger patients, those with severe hypercalcaemia at 5, 10, 15 min after gland excision, giant glands (at 5-min only), patients with vitamin D deficiency (at 10, 15 min), and those with normal renal function (at 15 min only). The likelihood of the patients meeting the intraoperative cure criterion was not significantly affected among the groups except in patients with mild hypercalcaemia, who were significantly less likely to have 50% IOPTH drop than those with severe hypercalcaemia at all time points. The frequency of mildly hypercalcaemic patients who met cure criterion was significantly improved by extending measurement to 15 min. CONCLUSIONS: IOPTH monitoring has the ability to mitigate the variability of IOPTH kinetics associated with most clinical variables. Mildly hypercalcemic patients in particular may benefit from waiting for 15-min measurement before any surgical decision is made.

Axially vascularized bone substitutes: a systematic review of literature and presentation of a novel model.

INTRODUCTION: The creation of axially vascularized bone substitutes (AVBS) has been successfully demonstrated in several animal models. One prototypical indication is bone replacement in patients with previously irradiated defect sites, such as in the mandibular region. The downside of current clinical practice, when free fibular or scapular grafts are used, is the creation of significant donor site morbidity. METHODS: Based on our previous experiments, we extended the creation of an arterio-venous loop to generate vascularized bone substitutes to a new defect model in the goat mandibula. In this report, we review the literature regarding different models for axially vascularized bone substitutes and present a novel model demonstrating the feasibility of combining this model with synthetic porous scaffold materials and biological tissue adhesives to grow cells and tissue. RESULTS: We were able to show the principal possibility to generate axially vascularized bony substitutes in vivo in goat mandibular defects harnessing the regenerative capacity of the living organism and completely avoiding donor site morbidity. CONCLUSION: From our findings, we conclude that this novel model may well offer new perspectives for orthopedic and traumatic bone defects that might benefit from the reduction of donor site morbidity.

Fungating thyroid cancer: a complex clinical scenario.

BACKGROUND: Most research reporting the management of advanced thyroid cancer focuses on major aerodigestive system or vessel involvement. In the present study, we investigated patients with locally advanced thyroid cancers who presented with malignant skin infiltration. The term fungating thyroid cancer (fTC) has been used to describe such a condition. METHODS: The study was based on prospective collection of clinical, laboratory, imaging, and pathological data of all patients admitted to the head and neck and endocrine surgery unit, Main University Hospital, Alexandria School of Medicine, during the period April 2005-March 2011. RESULTS: Eleven patients were referred with fTC, eight of whom had undergone subtotal thyroidectomy for an undiagnosed well-differentiated thyroid cancer (DTC) in another institution. The final pathological diagnosis showed (DTC, n = 3), poorly differentiated thyroid cancer (n = 5), anaplastic cancer (n = 2), and medullary thyroid cancer (n = 1). Extensive resections and reconstruction using flaps (pectoralis major, n = 6; deltopectoral, n = 1; sternocleidomastoid, n = 1) were undertaken. Complete tumor clearance (R0) was achieved in one patient and the others had microscopic (R1, n = 6) or macroscopic (R2, n = 1) residual disease. The three patients who did not undergo operation died within one month of presentation. The latest review of the eight patients who did undergo operation ranged from 3 to 6 months, but their survival remains unknown as access for follow-up was limited.

Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery.

BACKGROUND: Perineal wound complications may occur after visceral pelvic surgery. We reviewed our experience to determine indications for immediate tissue transfer (TT) to prevent complications. METHODS: Hospital records and computerized data were reviewed on 175 perineal repairs in 156 patients treated at The University of Texas M.D. Anderson Cancer Center for tumors involving the alimentary tract (135 of 175), genitourinary tract (15 of 175), perineum (19 of 175), or sacrum (6 of 175). Patients had either resection of only the colorectum and anus (APR) (46 of 175) or multivisceral resection (MVR) (129 of 175), and the perineal wound was closed by using TT (108 of 175) or primary closure (PC) (67 of 175) on the basis of the surgeon's judgment. Complications were compared between PC and TT groups. RESULTS: Complications occurred in 57% (100 of 175). There was no significant difference overall in PC and TT procedures or in the APR subgroup. There were significantly fewer complications for TT patients in the MVR subgroup (P =.0001). There were significantly fewer complications for TT patients with prior irradiation in both APR (P =.01) and MVR (P =.007) subgroups. CONCLUSIONS: Immediate TT for perineal wound closure is associated with fewer healing complications than PC in a subset of patients with multivisceral resection or prior radiotherapy. Surgical planning in these cases should consider immediate soft tissue reconstruction.