The utility of intraoperative PTH dosage in primary hyperparathyroidism based on preoperative diagnosis and surgical choice.

BACKGROUND: The aim of this study was to evaluate the impact of the intraoperative PTH (ioPTH) monitoring in the success of parathyroidectomy based on the concordant or indeterminate preoperative imaging studies of localization and the performed surgical choices. METHODS: Fourthy-seven patients who received parathyroidectomy operations were divided in four groups: concordance of the imaging and ioPTH, concordance of the imaging and no ioPTH, indeterminate imaging and ioPTH and indeterminate imaging and no ioPTH. RESULTS: Overall, patients in whom ioPTH monitoring was not performed were healed in 89.47% of cases, while the percentage of recovery in patients receiving ioPTH was 85.71%. There were no differences in the changes in strategy or in the cure rates with the use of ioPTH. CONCLUSIONS: No significant differences were found, independently from the preoperative imaging agreement, in either the cure rate or in the change of intraoperative strategy using the ioPTH dosage.

Extracorporeal versus intracorporeal anastomosis after laparoscopic right colectomy for cancer: a case-control study.

BACKGROUND: The purpose of this study was to compare the short-term outcome (3 months) of laparoscopic right colectomy, between intra- and extracorporeal anastomosis techniques. METHODS: This study was designed as a case-controlled study from a prospective colorectal cancer database. Forty consecutive patients who underwent laparoscopic right hemicolectomy with intracorporeal anastomosis (totally laparoscopic colectomy, TLC) for adenocarcinoma, with the exception of T4 lesions and metastasis, were compared with 40 patients who underwent laparoscopic right hemicolectomy with extracorporeal anastomosis (laparoscopic-assisted colectomy, LAC). Controls were matched for stage, age, and gender via a statistically generated selection of all laparoscopic right hemicolectomies performed between October 2006 and August 2009. RESULTS: In terms of operating time (median 150 min), histopathological results, surgical site complications (5% for LAC and 2.5% for TLC), nonsurgical site complications (2.5% for LAC and 5% for TLC), hospitalization (median 5 days), there were no differences between the groups (p > 0.05). Incision length was significantly shorter for TLC (p < 0.05), but no differences were observed for postoperative use of analgesics. There were six postoperative cases of vomiting with reinsertion of nasogastric tube in the LAC group and only one case in the TLC group (p < 0.05). CONCLUSIONS: TLC seems feasible and safe, it does not significantly affect the length of surgery, and it guarantees maintenance of radical oncological standards. Furthermore, it significantly improves cosmesis and patient comfort postoperatively, reducing the rates of emesis, which leads to higher rates of early regular diet tolerance.

In Vitro Control of Genes Critical for Parathyroid Embryogenesis by Extracellular Calcium.

BACKGROUND: The expression of the parathyroid transcription factors, encoded by the genes GATA3, GCM2, and MAFB, persists after parathyroid morphogenesis. This suggests a role of these genes in the regulatory program that governs parathyroid function in the adult. Indeed, these 3 genes form a transcriptional cascade able to activate PTH gene expression. MATERIALS AND METHODS: Adult adenoma parathyroid tissues were put in primary cell culture to evaluate the messenger ribonucleic acid (mRNA) expression of the PTH gene, of the genes involved in the calcium regulatory signaling pathway (CaSR, GNA11, and AP2S1), and of the 3 genes (GATA3, GCM2, and MAFB) involved in the parathyroid morphogenesis in the presence of different extracellular calcium concentrations from 0.1 mM to 3.0 mM. AIM: The aim of the study was to investigate whether different extracellular calcium conditions could control the expression of transcription factors critical for parathyroid embryogenesis. RESULTS: The results of the experiments showed that the mRNA expression of GATA3, GCM2, and MAFB genes follows the same response as the PTH gene to extracellular calcium concentrations, with the highest expression at low calcium (0.1 mM) and the lowest at high calcium (3.0 mM). Conversely, the genes involved in the calcium signaling in the parathyroid cells showed a variable response to the extracellular calcium concentrations, with the CaSR and GNA11 genes exhibiting a sensitivity to low calcium concentrations. CONCLUSIONS: These findings indicate that transcription factors recognized for their role in parathyroid embryogenesis show a response to extracellular calcium later in adulthood that parallels the behavior of the PTH gene.

[Surgical approach of the functional post-partial gastrectomy syndromes]. / La chirurgia delle sindromi funzionali dopo gastrectomia parziale.

AIM OF THE STUDY: Post-gastrectomy syndromes (PGS) are iatrogenic conditions which may arise from partial gastrectomies, independently from their indications (cancer or ulcer) and the reconstruction technique (Billroth I, Billroth II or Roux-en-Y). They are usually less frequent in patients with a Roux-en-Y reconstruction, but also this technique does not surely prevent SPG. Recently, some new technique have been proposed in order to prevent the PGS. Most of them are based upon a less extensive resection of the viscus, replaced by application of simple stapler mediated interruptions (the so called "uncut" technique). We aimed to verify whether such less invasive technique were also able to exert a therapeutic role for various type of PGS with the same efficiency of the traditional ri-resection techniques, which are known to generally have a major morbidity impact. MATERIAL AND METHODS: Nineteen patients, 12 male and 7 female, aged between 44 and 67 years, have been operated since 1985 up to 2004. All of them had an overt SPG (2 with efferent loop syndrome, 10 with gastro-esophageal biliary reflux, 3 with an afferent loop disease and, finally, 4 with a late dumping disease. The series has been divided into two groups depending on the type of surgical technique we chose for the correction of their SPG: "high surgery" patients (HS), operated with Roux re-resection and TADE, "low surgery" (LS) patients treated with "uncut" techniques and or Braun/GEA anastomosis. Both group were comparatively analyzed for the surgical outcome using an Eckhauser and a Visick scale. RESULTS: Out of the 11 patients of the first group 8 had a Roux ri-resection and 3 a TADE, whereas subjects from the second group underwent in four cases to a Braun/uncut afferent loop closer, which was associated to a GEA in the remnant ones. In both group there was no mortality rate, whereas only one subjects from the HS group had a post-operative complication. Either the Visick and the Eckauser score was better in the LS group. DISCUSSION: Data collected show that SPG, even if represented an heterogeneous group of clinical conditions, can be generally treated following a surgical procedure as conservative as possible. Such conclusion may open further views in the laparoscopic management of SPG.

Adrenal incidentaloma: the influence of a decision-making algorithm on the short-term outcome of laparoscopy.

BACKGROUND: At the present time, the precise indications for laparoscopic surgery of adrenal incidentaloma (AI) have yet to be completely clarified. The most controversial issue is the role of laparoscopy in the treatment of potentially malignant and large adrenal masses. Trying to address these questions, we retrospectively examined a group of patients with AIs. MATERIALS AND METHODS: Forty-two patients with AIs who were laparoscopically treated since 1995 were enrolled in this study. The patients were divided into two groups: the 27 patients of the immediate surgery (IS) group were operated on immediately, whereas the 15 subjects in the delayed surgery (DS) group needed further evaluations and/or a follow-up period before surgery. Surgical timing for both groups was decided according to a widely accepted decision-making algorithm. Many outcome parameters of laparoscopy (operative time, blood loss, conversion rate, time to liquid and solid food nutrition, drainage removal, resumption of normal bowel habits, and average hospital stay) were analyzed in the two groups. The subjects had AIs of various sizes and different histotypes. RESULTS: Patients in the DS group had a higher risk for malignancy. The definitive pathology revealed a malignant biology in 26.6% of DS vs. 0% of IS cases. No difference in the outcome parameters of laparoscopy was observed between the two groups or among pathologically different AIs. A significant correlation was found between the operative time and the size of the AI (r=0.836, P<0.001, linear regression test). CONCLUSION: Our study shows that laparoscopy is feasible and safe for AIs, regardless of the preoperative probability of malignancy. The size of the AI was the only determinant for choosing a laparotomy. Further long-term studies are necessary to confirm the laparoscopic efficacy in terms of oncologic safety.

A systematic review and meta-analysis of total thyroidectomy versus bilateral subtotal thyroidectomy for Graves' disease.

BACKGROUND: Our aim was to perform a meta-analysis of high-quality published trials, randomized and observational, comparing total thyroidectomy (TT) and bilateral subtotal thyroidectomy (ST) for Graves' disease. METHODS: All studies published from 1970 to August 2012 were identified. All randomized controlled trials (RCTs) were included. Selection of high-quality, nonrandomized comparative studies (NRCTs) was based on a validated tool (Methodological Index for Nonrandomized Studies). Recurrent hyperthyroidism during follow-up, progression of ophthalmopathy, postoperative temporary and permanent hypoparathyroidism, and permanent recurrent laryngeal nerve (RLN) palsy were compared using odds ratios (ORs). RESULTS: Twenty-three studies were included (4 RCTs and 19 NRCTs) compromising 3,242 patients (1,665 TT, 1,577 ST). TT was associated with a decrease in recurrent hyperthyroidism (P < .00001; OR, 0.10; 95% confidence interval [CI], 0.06-0.18), but with an increase in both temporary (P < .00001; OR, 2.70; 95% CI, 2.04-3.56) and permanent hypoparathyroidism (P = .005; OR, 2.91; 95% CI, 1.59-5.32). Progression of ophthalmopathy (P = .76; OR, 0.90; 95% CI, 0.48-1.71) and permanent RLN palsy (P = .82; OR, 0.91; 95% CI, 0.41-2.02) were similar. CONCLUSION: TT offers a better chance of cure of hyperthyroidism than bilateral ST and can be accomplished safely with only a small increase in temporary and permanent hypoparathyroidism.

Dexamethasone prophylaxis before thyroidectomy to reduce postoperative nausea, pain, and vocal dysfunction: a randomized clinical controlled trial.

BACKGROUND: The objective of this 2-arm, double-blind, randomized, controlled study was to assess the effects of a preoperative single dose steroid on postoperative nausea and vomiting (PONV), pain, and vocal function after thyroidectomy for benign disease. METHODS: We randomized 102 patients into 2 groups from January to December 2009: (1) treatment with 8 mg/2 mL of dexamethasone and (2) treatment with 2 mL NaCl 0.9%, both administered intravenously before anesthesia. RESULTS: The severity of nausea and the need for antiemetic drugs were reduced in patients receiving dexamethasone (p = .0001). Dexamethasone patients reported significantly less pain (p = .008); the need for analgesic drugs was lower in the dexamethasone group (p = .048). No differences were noted with regard to subjective voice analysis (p = .693). CONCLUSION: Dexamethasone (8 mg IV) is a safe and effective method to reduce PONV and pain after thyroid resection and should be used routinely.

Expectations and outcomes when moving from open to laparoscopic adrenalectomy: multivariate analysis.

Various authors have suggested that laparoscopic adrenalectomy (LA) leads to better surgical outcomes than open surgery. The debate is still open, however, and indications and limitations of minimally invasive surgery have not been completely established. The objective of our study was to compare surgical outcomes of LA and open adrenalectomy (OA), using multivariate analysis to adjust for potential confounding factors (e.g., size of the lesion, histology). Between 1995 and June 2000 at "Careggi" Hospital in Florence, Italy patients with an indication for adrenalectomy were treated laparoscopically if the lesion was < 10 cm and there was no clinical evidence of malignancy. All 79 patients who underwent LA have been included in this study. Among 152 patients who underwent OA at "La Sapienza" University in Rome, 93 had an adrenal lesion < 10 cm and no clinical evidence of malignancy; they were selected for comparison. Multivariate analysis has been used to analyze the effect of the surgical approach (OA vs. LA) on the surgical outcome, controlling for potential confounders. Multiple logistic regression showed that there is no significant difference in intraoperative outcomes (i.e., surgical time > 2 hours, blood loss > or = 500 ml) between patients operated on through a traditional approach and those who underwent LA. On the other hand, patients operated on laparoscopically have a significantly higher probability than the OA group of experiencing a better recovery from surgery (i.e., require less postoperative analgesics and return to normal activities earlier). The results of the present study show that, although LA does not add much benefit in terms of expected intraoperative outcomes, it dramatically speeds patients' recovery from surgery. The two approaches are complementary and should both be integrated into the technical background of all endocrine surgeons.