[Oesophageal endoscopic ultrasound in the accurate location of primary hyperparathyroidism (HPT)]. / Valor de la ecoendoscopia transesofágica en el diagnóstico de localización en el hiperparatiroidismo primario.

AIM: Our aim was to estimate the usefulness of oesophageal endoscopic ultrasound in the accurate location of recurrent or persistent primary hyperparathyroidism (HPT). MATERIAL AND METHOD: A total of 352 patients with primary hyperparathyroidism were operated on over the last seven years. A preoperative parathyroid 99Tc- sestamibi gammagraphy and an intraoperative PTH determination were performed routinely. Only 5 patients (1.4%) had localization problems: three with persistent HPT after parathyroid extirpation, one recurrent HPT and one HPT after a right hemithyroidectomy. An oesophageal endoscopic ultrasound was carried out before any new exploratory neck surgery in order to find the definitive location. RESULTS: The endoscopic ultrasound showed a clear image of adenoma with an accurate location in four patients. No tumour was present in one patient. All five patients were operated on. The exact location was confirmed in the four patients with positive endoscopic ultrasound images. The fifth surgical exploration revealed a parathyreosis. All five patients had a favourable post-operative period, with no nerve lesions or morbidity associated with the endoscopic ultrasound. CONCLUSIONS: Oesophageal endoscopic ultrasound is a very useful diagnostic tool in HPT patients with location problems, particularly in cases having anatomical changes due to previous surgery. It is a procedure that helps the surgeon to make a more selective and efficient exploration of parathyroid glands.

The pattern of the descent of PTH measured by intraoperative monitoring of intact-PTH in surgery for renal hyperparathyroidism.

BACKGROUND: In the setting of total parathyroidectomy and autotransplantation surgery (TPTxAS) treatment for secondary hyperparathyroidism (SHPT) we evaluated whether intraoperative parathyroid hormone (iPTH) monitoring is an useful tool as a reference for total parathyroid removal. DESIGN: Prospective open single value measurement efficacy study of one intraoperative (i.o.) diagnostic monitoring method (iPTH) on a cohort of surgical patients. PATIENTS: All patients (n = 35) undergoing TP and SCTx at the Department of Surgery, Donostia Hospital from January 2002 to December 2006. MAIN OUTCOME MEASURES: Serum levels of iPTH during surgery and prediction time of the of descent of PTH levels (measured in the clinic, at admission day and intra-operatively during induction of anesthesia, and every 5 and 10 minutes after removal of adenoma and 24 hours thereafter) were analyzed. RESULTS: iPTH levels dropped clearly at ten minutes in all 35 patients and were non-measurable at 24 hours. iPTH decreased from pathological (1302.24 + 424.9 pg/ml) to half (50%) the values at the third intra-operative determination - minute 10 - (614.8 ± 196.62) and was undetectable at 24 hours. CONCLUSIONS: Intra-operative measurement of iPTH is useful in the prediction of complete removal of all parathyroid tissue prior to autotransplantation thus avoiding persistence because of incomplete surgery.

Effect of liver resection on the progression and growth of rhabdomyosarcoma metastases in a rat model.

BACKGROUND/AIMS: To analyze the effect of liver resection on the progression of liver metastases in a rhabdomyosarcoma rat model. METHODS: Liver metastases were induced by intrasplenic injection of S4MH rhabdomyosarcoma cells in WAG/RijCrl rats. In a first experiment, rats were sequentially sacrificed until day 30 following tumor cell inoculation to establish the optimal day to evaluate liver and lung metastases. A second group of rats were hepatectomized or laparotomized 10 d after tumor inoculation, and on day 21 they were sacrificed to determine the size and number of liver and lung metastases. Also, in vitro proliferation rates of tumor cells in the presence of fetal calf serum or hepatectomized or laparotomized rat serum were assessed. RESULTS: Individual metastases could be optimally determined on day 21. In hepatectomized animals liver metastases reached greater size and their number was significantly increased (28.7 versus 9.3, P < 0.05). Moreover, the number of lung tumor foci in this group nearly doubled that in the control group (99.2 versus 28.5, P < 0.05). In vitro studies showed that hepatectomized rat serum increased cell proliferation when compared with laparotomized rat serum (2.0-fold) or fetal calf serum (1.4-fold). CONCLUSIONS: This tumor model shows the tumor-enhancing effect derived from hepatic resection, and may be useful to assess preventive therapeutic strategies.

[Mucocele of the appendix]. / Mucoceles apendiculares.

INTRODUCTION: Mucoceles of the appendix are infrequent entities and are found in only 0.25% of all appendectomies and 8% of all appendicular tumors. MATERIAL AND METHODS: We describe 27 cases of mucocele of the appendix treated at Donostia Hospital between January 1978 and December 2006. RESULTS: The mean age of the patients was 54.4 +/- 21.7 years (range: 17-88). Of the 27 patients, 15 (55.5%) were males and 12 (44.5%) were females. Emergency surgery was performed in 17 patients (62.9%). Mucoceles were identified as operative findings during surgery for other reasons in seven patients (25.9%). Three patients (11.1%) underwent surgery because of a diagnosis of abdominal tumor. The main reason for emergency surgery was lower right abdominal pain in 14 patients (82.2%), intestinal obstruction in one (5.8%), a diagnosis of endometriosis in one (5.8%) and a diagnosis of pyosalpinx in one (5.8%). Three patients underwent surgery due to pseudomyxoma peritonei after 24, 36 and 41 months' follow-up. The third patient is asymptomatic after peritonectomy and a follow-up of 78 months. We found an overall incidence of 11 cases (40.7%) presenting with synchronous or metachronous neoplasms from other locations. CONCLUSIONS: We recommend monitoring of all patients with mucocele of the appendix, because these masses can sometimes be associated with neoplasms in other locations and there is a risk of pseudomyxoma peritonei even after a long follow-up.

[Nodular lymphoid hyperplasia of the liver. Pseudolymphoma]. / Hiperplasia nodular reactiva linfoidea hepática. Seudolinfoma.

UNLABELLED: We present a rare pathological entity of the liver and review the literature. CASE REPORT: a 33-year-old asymptomatic woman showed a space-occupying lesion on liver segment VI, which was detected incidentally on ultrasound examination performed for a gynecological disorder. Computed tomography and magnetic resonance imaging of the liver confirmed a 3-cm lesion in segment VI. Segmentectomy of segment VI was performed. Pathological diagnosis was nodular lymphoid hyperplasia of the liver. Nodular lymphoid hyperplasia or pseudo-lymphoma is a highly uncommon disease that usually develops in cirrhotic liver. Our patient was free of liver disease.

[Expression of proteins associated with multidrug resistance and resistance to chemotherapy in lung cancer]. / Expresión de proteínas relacionadas con resistencia a múltiples fármacos y resistencia a la quimioterapia en el cáncer de pulmón.

OBJECTIVE: Membrane transporters are proteins that play a crucial role in resistance to chemotherapy. The aim of this study was to assess the influence of membrane transporter protein expression on chemotherapeutic response. MATERIAL AND METHODS: One hundred and forty seven samples of tumor tissue were collected from 143 patients; 35 samples were obtained by bronchoscopy and 112 were surgical specimens. A total of 101 samples from 99 patients were adequate for study. Cryopreserved samples were subjected to immunohistochemical analysis to detect 3 proteins associated with multidrug resistance: P-glycoprotein (Pgp), multidrug-resistance-associated protein 1 (MRP1), and lung resistance protein (LRP). RESULTS: In 16 cases none of the proteins were expressed. A single protein was expressed in 32 (3 Pgp, 11 MRP1, and 18 LRP); 2 in 34 cases (24 Pgp and LRP; 5 MRP1 and Pgp; 5 MRP1 and LRP); and all 3 in 17 cases. No significant relationship was found between age and the expression of Pgp (P=.74), MRP1 (P=.95), or LRP (P=.26). Nor were there significant differences in number (P=.72) or type of coexpressed proteins (P=.39) by sex, by tumor stage (number, P=.55; type, P=.21), or by tumor grade (number, P=.59; type, P=.51). There was a highly significant trend toward coexpression of Pgp and LRP (P< .01) but not of Pgp and MRP1 (P=.18) or MRP1 and LRP (P=.26). MRP1 was expressed less often in adenocarcinoma. LRP was expressed less often in squamous cell carcinoma than in adenocarcinoma and undifferentiated large cell carcinoma. Coexpression of Pgp, MRP1, and LRP was observed most often in squamous cell carcinoma. CONCLUSIONS: Proteins associated with multidrug resistance are commonly expressed in lung cancer. Of the 3 proteins studied, LRP was the one most often found. Coexpression of more than 1 of the proteins was found in a considerable percentage of patients. Pgp was mainly found to be coexpressed with LRP. Pgp expression and the number of coexpressed proteins seemed to have a negative impact on response to chemotherapy.

[Evaluation of parathyroid function in presternal subcutaneous grafting after total parathyroidectomy for renal hyperparathyroidism]. / Evaluación de la función paratiroidea en el injerto subcutáneo preesternal tras paratiroidectomía total en el hiperparatiroidismo renal.

INTRODUCTION: In the setting of total parathyroidectomy (TPT) and parathyroid transplantation (PTx) for renal hyperparathyroidism (RHP), we evaluated long-term parathyroid graft function after subcutaneous presternal transplantation (SCPTx). HYPOTHESIS: Parathyroid glands are surrounded by fatty tissue. Therefore, we postulated that subcutaneous implantation of parathyroid tissue after TPT for RHP could be at least as effective as intramuscular grafting and would avoid the complications of the latter technique. MATERIAL AND METHOD: We performed a study in a university hospital and its dialysis unit. DESIGN: Prospective open efficacy study of a postoperative diagnostic monitoring method of intact parathyroid hormone (iPTH) in a cohort of surgical patients without loss to follow-up. PATIENTS AND INTERVENTIONS: Thirty-five patients (19 women and 16 men) underwent TPT and SCPTx for RHP at the Department of General Surgery and Department of Nephrology, Donostia Hospital, San Sebastián, Gipuzkoa, Spain, from January 2002 to December 2005. Follow-up ranged from 6 to 42 months (mean, 15.4 months). Graft function was evaluated by measurement of plasma iPTH levels before surgery and 24 hours and 1, 3, 5, 15, 30, 60, 100 and 150 weeks after surgery. Reference values for PTH in our laboratory were 20-65 pg/mL. RESULTS: The mean preoperative iPTH values were 1245 +/- 367.9 pg/mL (mean +/- SD) (range, 493-2160). After TPT and SCPTx, iPTH levels became undetectable in all patients at 24 hours. A value of 50 pg/mL was established as the criterion for adequate parathyroid graft function. The following values were obtained: 15.54 +/- 10.61 pg/mL (mean +/- SD) (range, 6-44) after 1 week, 57.2 +/- 1.9 pg/mL (mean +/- SD) (range, 43-74) after 5 weeks, 64.21 +/- 9.73 pg/mL (mean +/- SD) (range, 11.3-89) after 15 weeks, 75.12 +/- 9.05 pg/mL (mean +/- SD) (range, 24.6-104.2) after 30 weeks, 101.63 +/- 19.85 pg/mL (mean +/- SD) (range, 65-143) after 60 weeks, 121.63 +/- 27.85 pg/mL (mean +/- SD) (range, 62-179) after 100 weeks, 63 +/- 19.85 pg/mL (mean +/- SD) (range, 68-723) after 150 weeks and 102 +/- 18.65 pg/mL (mean +/- SD) (range, 68-113) after 200 weeks. The prevalence of hypoparathyroidism (serum iPTH level of < 20 pg/mL with a normal or low serum calcium concentration) was 2 out of 35 patients (5.71%) by week 60, with recovery of normal values by week 100. Graft-related recurrence occurred in one out of 35 patients (2.85%). CONCLUSIONS: SCPTx after TPT and PTx for secondary RHP is an adequate method to replace muscular forearm parathyroid transplantation and avoid its complications. The functional results of TPT and SCPTx compare favorably with published data on other surgical techniques proposed for the treatment of RHP. Long-term follow-up of this series is currently being performed.

Parathyroid subcutaneous pre-sternal transplantation after parathyroidectomy for renal hyperparathyroidism. Long-term graft function.

BACKGROUND: In the setting of total parathyroidectomy (TPT) and parathyroid transplantation (PTx) for renal hyperparathyroidism (RHP), we evaluated long-term parathyroid graft function after subcutaneous pre-sternal transplantation (SCPTx). Because parathyroid glands are surrounded by fatty tissue, we postulated that results of subcutaneous implantation of parathyroid tissue after total parathyroidectomy for renal hyperparathyroidism could be at least as successful as intramuscular grafting, but without its complications. PATIENTS AND METHODS: The study, a prospective open efficacy study of postoperative (po) diagnostic monitoring of intact parathyroid hormone (iPTH) on a cohort of surgical patients, was conducted within a university hospital with a dialysis unit. Thirty five patients (19 women and 16 men) operated on for renal hyperparathyroidism underwent TPT and SCPTx for RHP at the Department of General Surgery and the Department of Nephrology. Donostia Hospital. San Sebastián. Gipuzkoa. Spain, from January 2002 to December 2005. Follow-up ranges from 6 months to 42 months (median: 15.4 months). The main outcome measure was evaluation of graft function by measurement of iPTH plasma level, based on serum levels of iPTH before operation and 24 h and 1, 3, 5, 15, 30, 60, 100, and 150 weeks after surgery. RESULTS: Average preoperative iPTH values were 1,341.52 + 367.78 pg/ml (mean +/- SD) (range: 493-2,180). After TPT and PSCTx, iPTH levels became undetectable in all patients at 24 h. A level of 50 pg/ml was established as the criterion of adequate parathyroid graft function. Values obtained at the various time intervals were as follows: 14.14 + 7.73 1 pg/ml (mean +/- SD) (range: 6-36) after 1 week, 53 + 77.33 pg/ml (mean +/- SD) (range: 35-74) after 5 weeks, 62.95 + 20.93 pg/ml (mean +/- SD) (range: 11-89) after 15 weeks, 77.54 + 18.84 pg/ml (mean +/- SD) (range: 24.6-104.2) after 30 weeks, 109.29 + 50.22 pg/ml (mean +/- SD) (range: 54-327) after 60 weeks, 134.21 + 128.64 pg/ml (mean +/- SD) (range: 43-712) after 100 weeks, and 122.84 + 117.54 pg/ml (mean +/- SD) (range: 68-723) after 150 weeks. Prevalence of hypoparathyroidism (intact parathyroid hormone serum level < 20 pg/ml with a normal or low serum calcium concentration) was 2/35 (5.71%) by week 60 and recovered by week 100. Graft-related recurrence was 2.85% (1/35). CONCLUSIONS: Subcutaneous pre-sternal transplantation (SCPTx) after TPT and PTx for secondary (RHP) is an adequate method to replace muscular forearm parathyroid transplantation and avoid its complications. Functioning results of total parathyroidectomy and presternal subcutaneous grafting compare favorably with the published data on other surgical techniques proposed for the treatment of renal hyperparathyroidism. Results of long-term follow-up exceed previously reported results.

[Adenosquamous and squamous carcinoma of the gallbladder]. / Carcinoma adenoescamoso y epidermoide de la vesícula biliar.

INTRODUCTION: Squamous and adenosquamous carcinomas of the gallbladder have poor prognosis. Because these tumors are silent in the initial stage, they are generally diagnosed in advanced stages. MATERIAL AND METHOD: We performed a retrospective observational study of five patients with squamous or adenosquamous carcinoma of the gallbladder. There were two women and three men with a mean age of 71 years (range, 68-75). All patients showed abdominal pain, nausea, vomiting, and weight lost (4-8 kg). One patient presented with acute cholecystitis. None of the patients had jaundice and all had gallstone disease. RESULTS: Surgery was performed in all patients. Extended cholecystectomy was performed in three patients, cholecystectomy and bile drainage in one patient, and colonic bypass and cholecystectomy in the remaining patient. Pathologic analysis revealed epidermoid carcinoma in two patients and adenosquamous carcinoma in three patients. Two patients were treated with adjuvant chemotherapy. All died within 6 months of surgery. CONCLUSIONS: In both histological types of gallbladder carcinoma, treatment depends on the grade of local and regional invasion and tumor spread at diagnosis.

[Modifications in intact parathyroid hormone, total serum calcium, and ionized calcium levels in the surgery of primary hyperparathyroidism for single adenoma]. / Modificaciones de paratirina intacta, calcio sérico total y calcio ionizado en la cirugía por hiperparatiroidismo primario por adenoma único.

INTRODUCTION: We evaluated total serum calcium (TSC) and ionized calcium (IC) and their correlation with intraoperative intact parathyroid hormone (iPTH) in the surgery of primary hyperparathyroidism in patients with a single adenoma. MATERIAL AND METHOD: We performed a prospective, blind trial with determination of iPHT, TSC and IC in a cohort of surgical patients (n = 279; 244 were valid for the study) who underwent surgery in the Department of Surgery, Hospital de Cruces, between October 1999 and April 2006. Total calcium, ionic calcium and iPTH were measured in the outpatient department, on admission and intraoperatively (at anesthesia induction and every 5 minutes after surgical excision). RESULTS: Levels of calcium and iPTH were corrected in 234 (95.9%) patients. iPTH decreased from abnormal preoperative values of 294.43 +/- 286.38 pg/ml to 97.89 +/- 121.01 mg/dl (minute 5), 58.58 +/- 58.37 pg/ml (minute 10), 44.62 +/- 54.77 pg/ml (minute 15), and 38.42 +/- 51.72 pg/ml (minute 20). TSC decreased from preoperative values of 10.93 +/- 1.04 mg/dl to 10.2 +/- 0.97 mg/dl (minute 5), 10.17 +/- 1.00 mg/dl (minute 10), 10.12 +/- 0.98 mg/ml (minute 15), and 10.09 +/- 1.03 mg/ml (minute 20). The results for ionized calcium were as follows: 4.90 +/- 0.63 mg/dl at induction, 4.84 +/- 0.61 mg/dl (minute 5), 4.84 +/- 0.66 mg/dl (minute 10), 4.82 +/- 0.63 mg/dl (minute 15), and 4.82 +/- 0.63 mg/dl (minute 20). Frozen samples were conclusive for parathyroid tissue (19.56 +/- 15.3 after excision). CONCLUSIONS: Intraoperative total calcium levels may help to predict adequate elimination of parathyroid tissue in primary hyperparathyroidism when intraoperative iPTH is not available. Ionized calcium levels did not show the same decrease.

Effect of resveratrol on alcohol-induced mortality and liver lesions in mice.

BACKGROUND: Resveratrol is a polyphenol with important antiinflammatory and antioxidant properties. We investigated the effect of resveratrol on alcohol-induced mortality and liver lesions in mice. METHODS: Mice were randomly distributed into four groups (control, resveratrol-treated control, alcohol and resveratrol-treated alcohol). Chronic alcohol intoxication was induced by progressively administering alcohol in drinking water up to 40% v/v. The mice administered resveratrol received 10 mg/ml in drinking water. The animals had free access to standard diet. Blood levels were determined for transaminases, IL-1 and TNF-alpha. A histological evaluation was made of liver damage, and survival among the animals was recorded. RESULTS: Transaminase concentration was significantly higher in the alcohol group than in the rest of the groups (p < 0.05). IL-1 levels were significantly reduced in the alcohol plus resveratrol group compared with the alcohol group (p < 0.05). TNF-alpha was not detected in any group. Histologically, the liver lesions were more severe in the alcohol group, though no significant differences between groups were observed. Mortality in the alcohol group was 78% in the seventh week, versus 22% in the alcohol plus resveratrol group (p < 0.001). All mice in the alcohol group died before the ninth week. CONCLUSION: The results obtained suggest that resveratrol reduces mortality and liver damage in mice.