Hypercalcemic Crisis Due to a Giant Intrathyroidal Parathyroid Adenoma, with Postsurgical Severe Hypocalcemia and Hungry Bone Syndrome: A Case Report.

BACKGROUND: Parathyroid adenoma is the most common cause of hypercalcemia and rarely leads to a hypercalcemic crisis, which is an unusual endocrine emergency that requires timely surgical excision. CASE PRESENTATION: A 67-year-old male was admitted to the ER of the Euroclinic Hospital, Athens, Greece, because of elevated calcium levels and a palpable right-sided neck mass, which were accompanied by symptoms of nausea, drowsiness, and weakness for six months that increased prior to our evaluation. A gradual creatinine elevation and decreasing mental state were observed as well. The initial laboratory investigation identified severely elevated serum calcium (3.6 mmol/L) levels consistent with a hypercalcemic crisis (HC) and parathyroid hormone PTH (47.6 pmol/L) due to primary hyperparathyroidism. Neck ultrasonography (USG) identified a large, well-shaped cystic mass in the right thyroid lobe. With a serum calcium concentration of 19.5 mg/dL and a PTH of 225.3 pmol/L, the patient underwent partial parathyroidectomy and total thyroidectomy, which decreased serum calcium and PTH to 2.5 mmol/L and 1.93 pmol/L, respectively. Histology revealed a giant intrathyroidal cystic parathyroid adenoma, which was responsible for the hypercalcemic crisis. Postoperatively, the patient developed severe biochemical and clinical hypocalcemia, with calcium concentrations as low as 1.65 mmol/L, consistent with hungry bone syndrome (HBS), which was treated with high doses of intravenous calcium gluconate and oral alfacalcidol, and a slow recovery of serum calcium. After discharge, parathyroid function recovered, and symptomatology resolved entirely in more than one month. DISCUSSION/CONCLUSIONS: We present a case involving an exceptionally large intrathyroidal parathyroid adenoma that is characterized by clinical manifestations that mimic malignancy. The identification and treatment of such tumors is challenging and requires careful preoperative evaluation and postoperative care for the risk of hungry bone syndrome.

Elevated Preoperative TPO Ab Titers Decrease Risk for DTC in a Linear Fashion: A Retrospective Analysis of 1635 Cases.

CONTEXT: For some, chronic lymphocytic thyroiditis (Hashimoto thyroiditis) is an important risk factor for differentiated thyroid cancer (DTC). Surgical cohort studies even suggested a potential role for thyroid peroxidase antibodies (TPO-Abs) on that risk. OBJECTIVE: Our clinical observations argued against that possibility. We designed the present study to evaluate the relationship of TPO-Abs and DTC in a large patient population. METHODS: We recruited individuals who underwent thyroidectomies at 4 different clinical sites (USA: 1 clinic, 2000-2013, and Greece: 3 clinics, 2007-2021). We gathered data on TPO-Abs titers measured with commercially available chemiluminescence immunoassays, and reviewed patients' data including surgical pathology. TPO-Abs of 34 IU/mL or greater was deemed positive (TPO+) and TPO-Abs less than 34 IU/mL was deemed negative (TPO-). Odds ratios (OR) for DTC were calculated with the Fisher exact test and P less than .05 was deemed significant. RESULTS: We reviewed data from 8461 consecutive thyroid surgery cases. TPO-Abs titers were available for 1635 individuals: DTC n = 716 (43.8%), benign pathology n = 919 (56.2%), TPO+ n = 540 (33.0%), and TPO- n = 1095 (67.0%). DTC was found at a lower frequency in TPO+ (198/540, 36.7%) compared to TPO- (518/1095, 47.3%) patients, OR 0.64 (0.52-0.80; P < .0001). Rising TPO-Abs titers conferred protection against DTC in a linear fashion: TPO-Abs less than 10 IU/mL: 59.3%, TPO-Abs less than 34 IU/mL: 47.4%, TPO-Abs 34 to 100 IU/mL: 42.6%, TPO-Abs 100 to 500 IU/mL: 32.0%, TPO-Abs greater than 1000 IU/mL: 19.4%; P less than .0001. CONCLUSION: Higher TPO-Ab titers appear protective against DTC in our large multicenter cohort of patients who underwent thyroidectomies. Rising preoperative TPO-Abs titers conferred linearly increasing protection against DTC.

Intense Testing and Use of Vitamin D Supplements Leads to Slow Improvement in Vitamin D Adequacy Rates: A Cross-Sectional Analysis of Real-World Data.

BACKGROUND: Vitamin D testing (VDT) and supplement use (VDS) are on the rise, but most patients remain deficient (<30 ng/mL-VDD). We designed the present real-world study to assess this paradox. METHODS: We reviewed data from all patients visiting our clinics between 2014 and 2022. We estimated the rate of patients with vitamin D adequacy (≥30 ng/mL) (VDA) by year and month of testing, the dose of VDS (low (≤1200 IU/day), medium (1201-3000 I/day) and high dose (>3000 IU/day)), intake duration (short-term (<12 months) and long-term use (≥12 months)), and timing of use (current use, former use, no use). RESULTS: We enrolled n = 6912 subjects with vitamin D measurements: n = 5195 females (75.2%), age 44.0 ± 16.8 years, BMI 27.9 ± 6.5 kg/m2; never users: n = 5553 (80.3%), former users: n = 533 (7.7%), current users: n = 826 (12.0%). Current use of VDS was higher in females. VDT rose from 42.1% in 2014 to 92.7% in 2022, and VDA rose from 14.8% to 25.5% for the same time. VDA was found overall in n = 1511 (21.9%); Never users: n = 864 (15.6%), Former users: n = 123 (23.2%); and Current users: n = 370 (44.8%). The maximal VDA (67.9%) was found in subjects using high-dose VDS in the long term. CONCLUSIONS: Despite the significant rise in VDT and VDS use, VDA was found in a minority of patients. Prolonged use of high-dose supplements produces modest improvements in VDA.

De novo purely prostatic large-cell neuroendocrine carcinoma with thyroid and adrenal metastases.

Summary: Large-cell neuroendocrine carcinoma (LCNEC) is a rare neuroendocrine prostatic malignancy. It usually arises after androgen deprivation therapy (ADT), while de novo cases are even more infrequent, with only six cases described. The patient was a 78-year-old man with no history of ADT who presented with cervical lymphadenopathy. Diagnostic approaches included PET/CT, MRI, CT scans, ultrasonography, biopsies, and cytological and immunohistochemical evaluations. Results showed a poorly differentiated carcinoma in the thyroid gland accompanied by cervical lymph node enlargement. Thyroid surgery revealed LCNEC metastasis to the thyroid gland. Additional metastases were identified in both the adrenal glands. Despite appropriate treatment, the patient died of the disease. De novo LCNEC of the prostate is a rare, highly aggressive tumor with a poor prognosis. It is resistant to most therapeutic agents, has a high metastatic potential, and is usually diagnosed at an advanced stage. Further studies are required to characterize this tumor. Learning points: De novo LCNECs of the prostate gland can metastasize almost anywhere in the body, including the thyroid and adrenal glands. LCNECs of the prostate are usually associated with androgen-depriving therapy, but de novo cases are also notable and should be accounted for. Further studies are required to fully understand and treat LCNECs more effectively.

Large, Slowly Growing, Benign Thyroid Nodules Frequently Coexist With Synchronous Thyroid Cancers.

CONTEXT: Thyroid nodules' size should not be the sole criterion for thyroidectomy; however, many patients undergo surgery for large or slowly growing nodules. OBJECTIVE: We evaluated risk for clinically significant thyroid cancer in patients with large or slowly growing nodules. METHODS: We reviewed data from 2 prospectively collected databases of patients undergoing thyroidectomies in tertiary referral centers in the USA and Greece over 14 consecutive years. We collected data on the preoperative surgical indication, FNA cytology, and surgical pathology. We included subjects operated solely for large or growing thyroid nodules, without any known or presumed thyroid cancer or high risk for malignancy, family history of thyroid cancer, or prior radiation exposure. RESULTS: We reviewed 5523 consecutive cases (USA: 2711; Greece: 2812). After excluding 3059 subjects, we included 2464 subjects in the present analysis. Overall, 533 thyroid cancers were identified (21.3%): 372 (69.8%) microcarcinomas (<1 cm) and 161 (30.2%) macrocarcinomas (≥1 cm). The histology was consistent with papillary cancer (n = 503), follicular cancer (n = 12), Hürthle cell cancer (n = 9), medullary cancer (n = 5), and mixed histology cancers n = 4. Only 47 (1.9%) of our subjects had any form of thyroid cancer in the nodule that originally led to surgery. The cancers were multifocal in 165 subjects; had extrathyroidal extension in 61, capsular invasion in 80, lymph node involvement in 35, and bone metastasis in 2 subjects. CONCLUSION: The risk of synchronous, clinically important thyroid cancers is small, but not null in patients with large or slow growing thyroid nodules. Therefore, more precise preoperative evaluation is needed to separate the patients who would clearly benefit from thyroid surgery from the vast majority of those who do not need to be operated.

Papillary thyroid carcinoma micro-deposits in cervical lymph nodes without intra-thyroid malignancy: A comment in consideration of the latest American Thyroid Association guidelines.

Differentiated thyroid cancer (DTC) represents the vast majority of all thyroid cancers, with the papillary variant being the most common. According to the previous 2009 American Thyroid Association (ATA) guidelines, papillary thyroid microcarcinoma (PTMC; ≤1 cm in diameter) exhibiting cervical lymph node metastasis corresponded to an intermediate-risk group for recurrence or metastasis. However, the latest 2015 ATA guidelines advocate that a patient with PTMC is low-risk if there are ≤5 regional node micrometastases. This means that therapeutic radioactive iodine (RAI) is not required. The current study reports a rare case of a patient who underwent total thyroidectomy due to multi-nodular goiter where the pathologic specimen exhibited two PTMC foci in regional lymph nodes, but no primary cancer was identified in the thyroid despite thorough examination of the thyroid parenchyma. The etiology of such results is unknown and it was hypothesized that it may be the consequence of insufficient pathologic examination or due to the regression of a primary PTMC in the thyroid. Moreover, the risk-stratification of cases with intra-lymph node PTMC without any evidence of primary cancer in the thyroid is not considered in the ATA recommendations. The aim of the current report was to elucidate the risk-stratification of this rare occurrence and to reconsider the possible etiologies. By extrapolating the latest ATA recommendations concerning a patient with a known primary PTMC and ≤5 metastatic micro-foci (thus the only difference between cases being the absence of a primary tumor), it was concluded that the patient should be considered low-risk. As a consequence, RAI therapy should be deemed as unnecessary despite the presence of lymph node microfoci. Moreover, it was proposed that cervical lymph node PTMC with no evidence of a primary tumor in the thyroid could be the consequence of normal thyroid tissue micro-deposit progression to cancer within the lymph node, which is a rare benign entity.

The diagnostic and predictive accuracy of thyroglobulin to TSH ratio and TSH to thyroglobulin ratio in detecting differentiated thyroid carcinoma in normothyroid patients with thyroid nodules: A retrospective cohort study and systematic review of the literature.

The purpose of the present study is to examine the diagnostic and predictive accuracy of the thyroglobulin (Tg) to thyroid stimulating hormone (TSH) and TSH/Tg ratios in normothyroid patients with differentiated thyroid cancer (DTC). We conducted a retrospective cohort study evaluating the diagnostic accuracy of the serum Tg/TSH and TSH/Tg ratios in normothyroid patients with thyroid nodules. We also systematically searched the international literature using the Medline, Cochrane's CENTRAL, Scopus, Clinicaltrials.gov, EMBASE, and Google Scholar databases for evidence concerning the diagnostic and predictive accuracy of these ratios. Overall, 374 patients were identified in our cohort study of whom 240 were treated for benign disease and 134 were treated for DTC. Significant differences were noted in the Tg/TSH and TSH/Tg values among cases with malignant and benign disease (P=0.020). However, the diagnostic ROC curve did not confirm these results (Tg/TSH=0.572 and TSH/Tg=0.428). After searching the international literature, we identified 8 studies. The majority of the included data reported significant differences among patients with benign/malignant disease and those with successful iodine therapy compared to those with disease relapse. However, the clinical relevance was clearer among studies that investigated the usefulness of these ratios in predicting recurrent disease. The findings of our study support that the Tg/TSH ratio increases in patients with DTC and can, thus, become useful in the future as a predictive marker of ablative 131I therapy success. However, given the significant variability of Tg its diagnostic accuracy remains to date minimal; thus, the actual cut-off value that can be used to discriminate cancer cases from benign disease has not been determined yet.

Mucosa-Associated Lymphoid Tissue Lymphoma of the Thyroid Gland: A Systematic Review of the Literature.

OBJECTIVE: Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type of the thyroid gland is a rare indolent malignant disease encountered in approximately 0.5% of patients with Hashimoto thyroiditis (HT). The purpose of the present systematic review was to accumulate the current evidence in the field. STUDY DESIGN: We searched the Medline, Scopus, EMBASE, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials CENTRAL databases from inception to May 2018. Statistical analysis was performed with SPSS version 22.0. RESULTS: Fourteen case series and 20 case reports were finally included in the present systematic review. Analysis of the patient data included in the published case reports suggested that the age at diagnosis of MALT lymphoma does no differ among males and females (64 [52.5-73] vs. 67 [60.5-72] years, p = 0.442). HT was detected in 60% of patients, whereas coexisting carcinoma was evident in 17% of cases. The incidence of HT and thyroid cancer was comparable among males and females (p = 0.474 and p > 0.999, respectively). Among all patients included in the present systematic review there were two disease relapses and two deaths attributed to the disease. CONCLUSION: MALT lymphoma of the thyroid gland is a rare malignancy with an indolent course. The scarce data available in the literature preclude safe conclusions concerning the mode of treatment and follow-up of these patients. However, the combination of minimally invasive surgery and adjuvant therapy seems feasible. Moreover, an extended follow-up period is recommended.

Higher TSH Is Not Associated With Thyroid Cancer Risk in the Presence of Thyroid Autoimmunity.

BACKGROUND: Higher-but-within-normal thyrotropin (thyroid-stimulating hormone, TSH) is associated with higher risk for differentiated thyroid cancer (DTC) in surgical series. Our recent clinical observations suggest that this is not the case in the presence of autoimmune thyroid disease (AITD). We designed the present study to clarify this controversy. METHODS: We analyzed our prospectively collected database of patients referred for thyroid surgery at 2 tertiary care referral centers in Greece and the United States. We collected data for preoperative TSH, postoperative pathology, and thyroid peroxidase (TPO) antibodies titers. Subjects were subdivided into 2 groups, those with AITD (i.e., lymphocytic thyroiditis) and non-AITD. We excluded subjects with Graves disease, abnormal TSH (< 0.40 or > 4.50 mIU/mL), or recent use of levothyroxine. We compared the serum TSH among different groups using the Mann-Whitney test. RESULTS: A total of 3973 subjects were screened; 1357 met exclusion criteria. After all exclusions, data from 1731 non-AITD subjects and 329 AITD subjects were included in the analysis. AITD subjects had higher TSH than non-AITD subjects (2.09 vs 1.48; P < 0.0001). TSH values were higher in DTC compared with benign histology only in non-AITD subjects (1.65 vs 1.40; P < 0.0001). Progressively higher TSH was associated with higher incidence of DTC only in non-AITD subjects (P < 0.0001). In AITD subjects, TSH was similar between groups with or without DTC (2.02 vs 2.14; P = 0.21). CONCLUSIONS: TSH concentrations are not associated with the risk of developing DTC in the presence of thyroid autoimmunity, even though this seems to be the case for all other patients.

Incidentally Discovered Papillary Thyroid Microcarcinomas Are More Frequently Found in Patients with Chronic Lymphocytic Thyroiditis Than with Multinodular Goiter or Graves' Disease.

Background: Incidental finding of differentiated thyroid microcarcinomas (DTMc) in patients undergoing thyroid surgery for benign indications has become increasingly common. Even though carcinogenesis might relate to the background disease of the gland, the incidence of DTMc in the setting of various thyroid disorders remains unclear. We designed the present study to address this question. Materials and Methods: We reviewed data from two prospectively collected databases of consecutive patients undergoing thyroid surgery in two high-volume tertiary care referral centers, one in the United States (A) and the other one in Greece (B) over 18 years. We collected data on the preoperative surgical indication, fine-needle aspiration (FNA) cytology, and surgical pathology. We excluded subjects operated for thyroid cancer or with high risk for malignancy (FNA suspicious for thyroid cancer, follicular neoplasm, suspicious for follicular neoplasm, follicular lesion of undetermined significance/atypia of undetermined significance, or preoperative features of malignancy) and those with postsurgical pathology consistent with papillary thyroid cancer (PTC) ≥1 cm in largest diameter. We divided our subjects based on pathology data into those with chronic lymphocytic thyroiditis (CLT), Graves' disease (GD), or multinodular goiter (MNG). Results: We reviewed 6096 cases of thyroid surgery (A: 2711, B: 3385). We included 3909 subjects in the analysis. Overall, 569 (14.6%) PTC subjects were identified (A: 221/2003 [11%], B: 348/1906 [18.3%], odds ratios [OR] = 0.56, p < 0.0001). CLT was present in 617 subjects; PTC sonographic was present in 143 subjects (23.2%) (A: 79/404 [19.6%], B: 64/213 [30%], OR = 0.56, p = 0.003). GD was present in 359 subjects; PTC was present in 37 subjects (10.3%) (A: 12/197 [6.1%], B: 25/162 [15.4%], OR = 0.36, p = 0.004). MNG was present in 2933 subjects; PTC was present in 389 subjects (13.3%) (A: 130/1402 [9.3%], B: 259/1531 [16.9%], OR = 0.50, p < 0.0001). The incidence of PTC was significantly higher in CLT compared with MNG (OR = 1.75, p < 0.0001) or GD (OR = 2.25, p < 0.0001) but not in MNG compared with GD (OR = 1.29, p > 0.05). Conclusions: Incidentally discovered PTC are more commonly identified in surgical specimens from subjects with CLT compared with patients with MNG, while patients with GD present with a lower incidence compared with both groups. These data support previously published findings that euthyroid Hashimoto thyroiditis favors carcinogenesis, while GD may have a protective role.

Why does laparoscopic common bile duct exploration fail?

Laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis carries an overall ductal clearance rate of between 85% and 95%. We present our single institute experience with LCBDE. Between July 1999 and July 2003, 60 patients (42 females, 18 males; median age, 59.5 years) with proven choledocholithiasis underwent LCBDE for common bile duct (CBD) clearance. The method failed to clear the CBD in six patients, resulting in a 90% overall success rate. Conversion to a conventional open approach (n = 1), hand-assisted LCBDE (n = 1), T-tube placement followed by multiple postoperative endoscopic retrograde cholangiopancreatography (ERCP; n = 2), and endobiliary stent placement followed by single successful postoperative ERCP in each case (n = 2) were chosen as treatment options when the laparoscopic method failed to clear the CBD. LCBDE is a feasible and safe method of managing CBD stones. Impacted stones at the lower end of the CBD or in the ampulla of Vater represent the most likely factors leading to failure of LCBDE. Laparoscopic endobiliary stent placement followed by postoperative ERCP represents the most attractive alternative in these difficult cases of impacted stones.

Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis.

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n=20), whereas 24 patients underwent an operation later on and constitute the delay group (n=24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, avoiding preoperative ERCP, can be safely performed during the same admission, after the improvement of symptoms and local inflammation. Postoperative ERCP should be selectively used in patients in whom the single-stage method failed to resolve the problem.

Cost-effective method for laparoscopic choledochotomy.

BACKGROUND: Recent reports have noted that postoperative complications following open or laparoscopic choledochotomy for common bile duct (CBD) exploration are mainly related to the T-tube presence, and that there has been no trend of decrease in the laparoscopic era. Laparoscopic endobiliary stent placement with primary closure of the CBD has been proposed as a safe and effective alternative to T-tube placement. METHODS: Between January 1999 and January 2003, 53 consecutive patients suffering from proven choledocholithiasis underwent laparoscopic common bile exploration (LCBDE) via choledochotomy. In the early period, a T-tube was placed at the end of the procedure (group A, n = 32) while, from June 2001 onwards, laparoscopic biliary stent placement and primary CBD closure were chosen as the drainage method (group B, n = 21). RESULTS: Six patients developed T-tube-related complications postoperatively. Univariate analysis revealed statistically significant lower morbidity rate and shorter postoperative hospital stay for the stent group. Although not statistically significant, a median saving of 780 UK pounds per patient was observed in the stent group. CONCLUSION: Biliary endoprosthesis placement following laparoscopic choledochotomy avoids the well-known complications of a T-tube, leading to a shorter postoperative hospital stay. The method is safe and effective and it should also be considered as cost-effective compared to T-tube placement. Further studies are required in order to document cost-effectiveness of the method.

Limitations of fluoroscopic intraoperative cholangiography in cases suggestive of choledocholithiasis.

BACKGROUND: Fluoroscopic intraoperative cholangiography (IOC) has been proposed as a safe and accurate screening method for choledocholithiasis, with a sensitivity and specificity of nearly 100% in selected cases. In the present study we retrospectively reviewed the diagnostic accuracy of IOC in cases highly suggestive of choledocholithiasis. MATERIALS AND METHODS: Between January 1999 and December 2002, 103 patients underwent IOC as an imaging method for common bile duct (CBD) stone detection. We did not routinely perform IOC in all patients who were submitted to laparoscopic cholecystectomy, reserving the method for patients with a high probability of choledocholithiasis, namely patients with a history or the presence of painful obstructive jaundice at the time of referral, patients with a history of mild acute pancreatitis of biliary origin, and patients with abnormalities in their liver biochemistry profile as measured by liver function tests (LFT). RESULTS: The mean rates of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for IOC were 98%, 94%, 94.5%, and 98% for the whole series, respectively. The diagnostic accuracy was 100% in patients with a history of obstructive jaundice or liver biochemical derangement, but was less in patients with a history of biliary pancreatitis. There were 3 false positive cases and 1 case of false negative results, all of which occurred in the subgroup of patients with a history of pancreatitis. CONCLUSION: Selective fluoroscopic IOC is generally feasible and safe, as well as highly accurate (100%) for CBD stone detection in patients with obstructive jaundice or abnormal LFT. The PPV of the method decreases in patients with a history of pancreatitis (75%), while a negative result is highly suggestive of the absence of CBD stones (NPV = 98%). The present study concluded in a higher incidence of false results in patients with a normal size CBD, suggesting that the diagnostic accuracy of IOC is probably related to the size of the CBD rather than the indication for its performance.

Diffuse oesophageal spasm masking achalasia.

Several reports have suggested that esophageal motility disorders may progress from one type to another. A 41-year-old female patient underwent thoracoscopic esophagomyotomy for diffuse esophageal spasm (DOS) with normal resting pressure and complete relaxation of the LOS; findings were confirmed in two preoperative esophageal manometries. Postoperatively, she developed severe dysphagia, and a new esophageal manometry concluded achalasia. She underwent a laparoscopic Heller's myotomy and a posterior (180 degrees) Toupet's fundoplication. Since the second operation, she remains asymptomatic and does not experience any difficulty in swallowing. We concluded that DOS and achalasia might coexist in this case. Through multiple synapses and several nervous roots in the esophageal wall, the inhibitory neurons at the level of LOS were effective before esophagomyotomy and did not show symptoms and manometric findings suggestive for achalasia. Esophagomyotomy, causing disruption of these synapses and lost of inhibitory innervation, finally resulted in symptoms and manometric findings of achalasia.

Pancreaticoduodenectomy for periampullary malignancies: the effect of bile colonization on the postoperative outcome.

OBJECTIVES: The presence of bacteria in the bile of patients undergoing biliary tract surgery has been proposed as associated to an increased incidence of postoperative complications. The present study was designed to determine whether colonization of the bile has an adverse effect in terms of postoperative infectious or noninfectious complications and mortality in a homogenous population of patients suffering from periampullary region malignancies, who all underwent resectional (curative) procedures. MATERIALS AND METHODS: Between January 1997 and December 2002, 115 patients (n = 115) suffering from periampullary region malignancies underwent resectional procedures. Fifty-two of the above patients were referred having undergone preoperative internal biliary drainage. During the operation, bile was routinely isolated from the common bile duct and was sent for culture and sensitivity. Based on the bile culture results, the patients were divided in sterile and colonized group and were retrospectively compared in terms of postoperative outcome and mortality. RESULTS: Of the 115 bile cultures, 67 were colonized with bacteria and 48 were sterile. Postoperatively, 40 patients developed 35 noninfectious and 21 infectious complications. Univariate analysis did not disclose statistically significant differences in overall, noninfectious or infectious morbidity and mortality between the two groups of patients. Although not statistically significant, a higher incidence (22 vs 10%) of postoperative leaks in the colonized group of patients was noticed. Multiple regression analysis disclosed that colonized bile was independently related to the advanced age, preoperative biliary drainage presence, elevated preoperative serum bilirubin levels and low preoperative serum albumin levels but did not predispose to an increased postoperative morbidity, mortality, or reoperation rate. CONCLUSION: The present study did not conclude in any statistically significant differences in the postoperative infectious and noninfectious morbidity as well as mortality, between colonized and sterile groups of patients who underwent resectional procedures for malignancies of the periampullary region. Although internal biliary drainage introduces microorganisms into the biliary tree, this colonization does not increase the risk of either infectious or noninfectious complications or postoperative death. Thus, the likelihood of bacterobilia should not contraindicate the procedure in selected cases.