Is intraoperative parathyroid hormone assay mandatory for the success of targeted parathyroidectomy?

BACKGROUND: Minimally invasive parathyroidectomy has become the first surgical option for patients with primary hyperparathyroidism (HPT) in many places. Preoperative localization studies are mandatory, and the use of a quick parathyroid hormone (PTH) assay is highly recommended. The aim of this study was to analyze our initial series of targeted parathyroidectomies. STUDY DESIGN: In a 2-year period, 50 patients underwent unilateral neck exploration for HPT under local anesthesia and light sedation. After biochemical diagnosis, a technetium 99m sestamibi scan was performed on all patients, and cervical ultrasonography was obtained in some patients. Frozen section analysis was used to confirm parathyroid tissue in all patients. There was no biochemical intraoperative evaluation of PTH. Demographics, surgical details, results, and complications were analyzed. RESULTS: There were 35 women and 15 men, with a mean age of 56 years (range 23 to 85 years). Mean preoperative calcium was 11.4 mg/dL (range 10.0 to 14.8 mg/dL), and PTH was 342 pg/mL (range 105 to 2,231 pg/mL). Mean surgical time was 52 minutes (range 30 to 100 minutes), and mean hospital stay was 2 days (range 1 to 7 days). Mean parathyroid weight was 1,000 mg (range 117 to 17,000 mg). Sestamibi scan correctly localized the abnormal gland in 47 patients (94%). There was one postoperative complication (bleeding); two patients required contralateral exploration, and persistent hypercalcemia developed in one that required surgical reintervention. After a mean followup of 12 months (range 3 to 25 months), all patients were normocalcemic. CONCLUSIONS: Targeted parathyroidectomy is safe and effective. Despite the fact that quick intraoperative PTH assay was not used, the cure rate was 98%.

Laparoscopic Roux-en-Y gastric bypass for morbid obesity: results of our learning curve in 100 consecutive patients.

BACKGROUND: Morbid obesity requires life-long treatment, and bariatric surgery provides the best results. Among the bariatric procedures, laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been considered to be superior. However, it requires advanced laparoscopic skills and a learning curve. We analyzed our results in an initial series of 100 patients. METHODS: Data of 100 consecutive patients who underwent LRYGBP for morbid obesity in a 2.5-year period were prospectively collected and analyzed with emphasis on results and complications. RESULTS: Mean age was 31+/-5 years. There were 63 woman and 37 men. Preoperative BMI was 50+/-9 kg/m(2). 33 patients were considered super-obese (BMI>50). Mean operative time was 3.8 +/- 0.7 hours. Two patients required conversion to open surgery. Mean hospital stay was 6 days. Complications occurred in 10 patients. Mortality rate was 2%. Excess body weight loss was as follows: 33 +/- 8% at 3 months (n=92), 47 +/- 2% at 6 months (n=82), 62 +/- 4% at 1 year (n= 70), 66 +/- 5% at 18 months (n= 63) and 67 +/- 8% at 2 years (n= 35). There was significant improvement in several co-morbid conditions, such as diabetes and hypertension. CONCLUSION: LRYGBP is a reproducible technique. It requires the combination of bariatric and laparoscopic expertise.

Quality of life in bariatric surgery.

BACKGROUND: Bariatric surgery is the treatment of choice for morbid obesity. Since bariatric operations alter gastrointestinal anatomy, they may induce symptoms that have a negative impact on quality of life (QOL). The aim of this study was to prospectively analyze QOL after bariatric surgery. METHODS: The QOL index questionnaire (GIQLI) was applied to 45 surgically treated morbidly obese patients (15 vertical banded gastroplasty, 15 Roux-en-Y gastric bypass (RYGBP), and 15 distal RYGBP) and to 15 non-operated morbidly obese controls. Follow-up was of 1-year minimum. The GIQLI evaluates physical and mental well-being, digestion and bowel habits. RESULTS: Physical and mental well-being as well as the overall QOL were significantly higher in the operated patients. There were no significant differences in digestion and bowel habits between the groups. Differences in QOL were not related to the type of surgical procedure. CONCLUSION: Overall QOL was significantly better in operated than in non-operated patients. There is no negative impact of bariatric surgery on QOL related to GI symptoms.

Open versus laparoscopic vertical banded gastroplasty: a randomized controlled double blind trial.

BACKGROUND: Vertical banded gastroplasty (VBG) is a frequently used surgical procedure for the treatment of morbid obesity. It can be done open (OVBG) or laparoscopic (LVBG). The aim of this double-blind randomized clinical trial was to compare the postoperative outcome and 1-year follow-up of 2 cohorts of patients who underwent either OVBG or LVBG. PATIENTS AND METHODS: 30 patients with morbid obesity were randomized into 2 groups (14 OVBG and 16 LVBG). Pain intensity, analgesic requirements, respiratory function, and physical activity were blindly analyzed during the first 3 postoperative days. Complications, weight loss, and cosmetic results after 1 year follow-up were evaluated. RESULTS: Both groups were highly comparable before surgery. Surgical time was longer in the laparoscopic procedure. Patients in this group required less analgesics during the first postoperative day. There was an earlier recovery in the expiratory and inspiratory forces, as well as faster recovery of physical activities in patients who underwent LVBG. Postoperative complications were more frequent in the open group. Excess body weight loss after 1 year was similar in both groups. Cosmetic results were significantly better in the laparoscopic group. CONCLUSIONS: LVBG had advantages over the open procedure in terms of analgesic requirements, respiratory function, postoperative recovery, and cosmetic results.

Impact of surgically-induced weight loss on respiratory function: a prospective analysis.

BACKGROUND: Morbid obesity (MO) causes several degrees of respiratory impairment that may resolve after weight reduction. The aims of the present study were to investigate the frequency of respiratory impairment in a selected cohort of morbidly obese patients with BMI 40-50 kg/m(2) with no respiratory symptoms and to evaluate the impact of surgically-induced weight loss on respiratory function. METHODS: Prospective analysis of respiratory impairment was conducted before surgery and 1 year after surgery in a cohort of patients with MO who underwent vertical banded gastroplasty (VBG). 30 consecutive patients with MO who underwent VBG (14 open and 16 laparoscopic) in a 1-year period were studied. Respiratory function tests, arterial blood gases and hemoglobin were obtained in all patients before and 1 year after VBG. RESULTS: Results were analyzed using the Wilcoxon signed-rank test and Spearman for variables without normal distribution. Mean age was 35+/-8 years; there were 3 males and 27 females. BMI was 44+/-4 kg/m(2) before surgery and 32+/-4 kg/m(2) at 1-year follow-up. By respiratory function tests, the diagnosis of obstructive disease was made before surgery in 4 patients and a restrictive disorder was identified in 4 additional patients. Evidence of pulmonary disease was absent in all patients 1 year after surgery. Forced vital capacity, inspiratory and expiratory forces, tidal volume, SaO(2), and PaCO(2) significantly improved after weight reduction. CONCLUSION: Surgically-induced weight loss significantly improves pulmonary function.

Surgical treatment of recurrent differentiated thyroid carcinoma.

OBJECTIVE: To describe our experience of treating recurrent thyroid carcinoma. DESIGN: Retrospective study of casenotes. SETTING: Teaching hospital, Mexico. SUBJECTS: 20 patients who developed recurrences of 273 who presented with well-differentiated thyroid carcinoma between 1991 and 1999. MAIN OUTCOME MEASURES: Presentation, management, morbidity, and mortality. RESULTS: There were 18 men and 2 women, median age 51 years (range 28-75). 13 were treated initially by total thyroidectomy and 7 with less than total resection. 16 were given ablative doses of 311I. The median time between initial resection and recurrence was 3 years (range 1-6). The sites of recurrence were cervical lymph nodes (n = 12), thyroid bed (n = 3), or both (n = 5). During a median of 3 years 10 patients were free of disease and 2 had died. CONCLUSIONS: Well-differentiated thyroid cancer usually recurs in the cervical lymph nodes. Further resection offers a high cure rate.

Correlation between radiologic and pathologic dimensions of adrenal masses.

The size of adrenal tumors has been shown to be a good predictor of malignancy. There is still some controversy about the concordance between radiologic and real pathologic measurements. The aim of this study is to determine the correlation between direct and corrected radiologic computed tomography scan dimensions and the measurements of the resected specimen. A total of 41 adrenal tumors were included. Direct and corrected measurements of the largest diameter were contrasted with the pathologic dimensions. The Linos formula was used for the corrected measurements. Proper statistics were used considering a two-tailed significance level of 0.05. The intraclass correlations using direct and corrected measurements were 0.89 [95% confidence interval (95%CI) 0.81-0.94, p = 0.00001) and 0.90 (95%CI 0.82-0.95, p = 0.00001), respectively. The bivariate analysis using Pearson's correlation between two-dimensional group variables showed r = 0.82 (p < 0.0001) when direct and pathologic measurements were compared and r = 0.83 (p < 0.0001) when the corrected values were compared with the real dimensions. In this study, we demonstrate good correlation between radiologic and pathologic measurements of adrenal tumors. The Linos formula turned out to be significantly more accurate than direct radiologic measurements when means of the groups were compared, whereas when individual correlations were determined the two were similar. The Linos formula and radiologic measurements can be used to determine the proper management of adrenal incidentalomas in individual patients.

La adrenalectomía laparoscópica en una institución mexicana / Laparoscopic adrenalectomy in mexican institution

Objetivo. Analizar las características y resultados de la adrenalectomía laparoscópica en una institución mexicana. Métodos. Se analizaron las características clínicas, transoperatorias, complicaciones y evolución de los 29 pacientes a quienes se les realizó adrenalectomía laparoscópica por vía lateral transperitoneal entre febrero de 1995 y enero de 1998. Resultados. La edad promedio fue de 34 ñ 11 años, seis del género masculino y 23 del femenino. El diagnóstico más frecuente fue hiperplasia en pacientes con enfermedad de Cushing recurrente, seguido por adenomas funcionales y feocromocitomas. Se practicaron 17 adrenalectomías unilaterales y 12 bilaterales. El tiempo operatorio de resección de cada glándula fue de 2.5 ñ 1 horas. Hubicaron dos conversiones a laparotomía. Dos pacientes desarrollaron complicaciones: una infección de herida y una hipoglucemia posoperatoria. El paciente que desarrolló la hipoglucemia falleció a los 18 días de hemorragia masiva de tuvo digestivo alto. La estancia hospitalaria promedio fue de 5 días. A un promedio de seguimiento de 1 año se ha documentado una sola recurrecia, en un paciente con feocromocitoma. Conclusiones. La adrenalectomía laparoscópica mostró ser una alternativa segura para el tratamiento de diversas enfermedades suprarrenales. Esta técnica favoreció una recuperación rápida

Tratamiento quirúrgico de bocio multinodular en el Instituto Nacional de la Nutrición Salvador Zubirán / Surgical treatment of multinodular goiter at the Instituto Nacional de la Nutricion Salvador Zubiran

Antecedentes. La resección quirúrgica es la primera opción en el manejo de las lesiones obstructivas o con sospecha de malignidad en el bocio multinodular (BMN). La magnitud de la resección y la necesidad de supresión hormonal postoperatoria son aún aspectos de debate. Objetivo. Analizar los resultados terapéuticos de 101 pacientes intervenidos quirúrgicamente por BMN entre 1980 y 1995. Material y métodos. Se revisaron los expedientes clínicos de los pacientes con énfasis en la indicación quirúrgica, tipo de resección, diagnóstico definitivo, complicaciones y evolución. El seguimiento promedio fue de tres años (0.5-12). Resultados. Diez pacientes fueron varones y 91 mujeres, con edad promedio de 46 años. En 60 pacientes la cirugía se indicó por sospecha de malignidad, en 33 por obstrucción y en 8 por razones cosméticas. Se efectuaron 30 lobectomías, 55 tiroidectomías subtotales bilaterales y 16 totales; 83 pacientes recibieron, además, tratamiento hormonal postoperatoria. El diagnóstico definitivo fue de bocio multinodular en 89 pacientes y cáncer en 12. En el grupo con enfermedad benigna hubieron tres recurrencias asintomáticas (con hemitiroidectomía y tratamiento hormonal supresivo). Conclusión. La tiroidectomía subtotal mostró ser el mejor procedimiento para el manejo del BMN ya que en nuestro estudio no se acompañó de recurrencia y su frecuencia de complicaciones fue del 2 por ciento

The first 50 cases of primary hyperparathyroidism treated by an endocrine surgery team

Antecedentes. El hiperparatiroidismo primario (HPT) es una enfermedad frecuente cuyo tratamiento quirúrgico es efectivo. En nuestro hospital han ocurrido cambios en la estrategia quirúrgica de HPT: desde 1991 todos los enfermos son atendidos en un servicio de cirugía endocrina. Objetivo. Evaluar los resultados del tratamiento quirúrgico en los primeros 50 pacientes vistos en dicho servicio. Métodos. Se recabaron prospectivamante las características clínicas, estudios de laboratorio, hallazgos transoperatorios, complicaciones y evolución postoperatoria de 50 pacientes con HPT intervenidos de julio de 1991 a marzo de 1994. Resultados. La edad promedio de los enfermos fue de 53 años, 10 fueron del sexo masculino y 40 del femenino. Se indentificó un adenoma como responsable de la enfermedad en 43 pacientes, cinco cursaron con hiperplasia, en uno se demostró un adenoma doble y en uno más un adenoma en una glándula supernumeraria. Se logró curación de la enfermedad en el 96 por ciento de los enfermos después de un procedimiento quirúrgico y en el 100 por ciento después de reexploración quirúrgica durante la misma hospitalización. Conclusión. Nuestros resultados apoyan el empleo del tratamiento quirúrgico en HPT

Pain relief in chronic pancreatitis by pancreatico-jejunostomy. An institutional experience

Effective pain control in chronic pancreatitis can be accomplished by pancreatic resection or decompression. Pancreatico-jejunostomy (PJ) has been reported to be effective for relieving pain in 70-80 perecnet, of cases. The present study analyses the authors's long term results with PJ in the treatment of pancreatic pain. From 1963 to 1993, 49 patients with chronic pancreatitis underwent PJ for uncotrollable pain. General and radiologic characteristics, intraoperative findings and outcome were ana-lyzed. Mean age was 35 ñ 13 years, 34 were male and 15 female. Alcoholic etiology was documented in 23 patients. Multiple pancreatic calcifications were found in 33 patients. Pancreatic biopsy confirmed chronica pancreatitis in all patients. There was one operative mortality, 12 minor, and 4 major complications. In a mean follow-up of 6.5 years, 98 perecent of the total group was found to be free of pain. Pancreatic function remained stable in most patients. PJ is an excellent procedure for pain control that allows stable pancreatic function

Comportamiento clínico de adenomas foliculares mayores de 5 cm / Clinical course of follicular adenomas greater than 5 cm

Introducción. Se ha sugerido que el tamaño de los tumores foliculares y su tiempo de evolución podrían ser de utilidad para predecir el diagnóstico de malignidad. Objetivo. El objetivo del presente estudio fue evaluar el comportamiento clínico de 35 ade4nomas foliculares = 5 cm tratados mediante cirugía para enfermedad benigna en un periodo de 23 años. Sede. Instituto Nacional de la Nutrición. México. Pacientes y métodos. Del total de pacientes llevados a cirugía por enfermedad benigna, en nuestro hospital, se seleccionaron aquellos con tumores iguales o superiores a 5 cm. Se revisaron sus características general, estudio histológico y su evolución a largo plazo en busca de recidiva o metástasis. Se empleo prueba t de Student para el análisis estadístico. Resultados. Se encontraron 30 mujres y 5 hombres con una edad promedio de 41.6 ñ 14.3 años. Treinta y dos tumores fueron sólidos y 3 mostraron un patrón mixto. El diámetro promedio de las lesiones fue de 6.8 ñ 1.4 cm. Se realizó lobectomía unilateral en 27 pacientes y tiroidectomía subtotal en 8. Se estableció el diagnóstico de adenoma folicular en todos los pacientes, revisando en promedio 6 ñ 3 laminillas. En un seguimiento promedio de 15.3 ñ 7.04 años, no hubo evidencia de recurrencia local o metástasis a distancia en ninguno de los pacientes. Se comparó el tiempo de evolución de los pacientes con el de un grupo de 25 enfermos con carcinoma folicular sin encontrar diferencias significativas. Conclusión. Ni el tamaño del tumor ni su tiempo de evolución son marcadores útiles para predecir malignidad