Primary angiosarcoma of the Pancreas - A case Report and review of the literature.

BACKGROUND: Angiosarcomas are malignant neoplasms that originate from endothelial cells. The symptoms exhibit a non-specific nature, and achieving a preoperative diagnosis is frequently challenging. They are seldom encountered in the abdomen, and their occurrence in the pancreas is even rarer. METHODS: Here we document a 67-year-old man with pancreatic angiosarcoma and analyse the literature to outline the clinicopathologic characteristics of this rare phenomenon. RESULTS: This patient with family history of pancreas cancer presented with abdominal pain, and the CT-scan revealed a 4 cm mass at the neck of the pancreas but CA19-9 was normal. Radiologic findings were unusual for ordinary pancreas cancer. Fine-needle aspiration biopsy through endoscopic ultrasound revealed "undifferentiated malignant cells for which the diagnosis of "carcinoma" was favoured. Total pancreatectomy, splenectomy and portal vein reconstruction were performed and epithelioid angiosarcoma were diagnosed. Despite an uneventful postoperative period, discharge on postoperative day 8 without any complications, as well as diligent post-discharge clinical care, the patient died 65 days postoperatively, attributed to the presence of extensive metastasis. A comprehensive literature search has identified a limited number of documented cases of primary pancreatic angiosarcoma, with only ten cases reported to date. CONCLUSIONS: Pancreatic angiosarcomas are very rare and prone to misdiagnosis. The formation of a more demarcated but high-grade tumour with necrosis is a feature that distinguishes angiosarcomas from ordinary carcinomas of this organ. Pathologic diagnosis is also highly challenging closely resembling undifferentiated carcinomas. Angiosarcomas are highly aggressive when they occur in the pancreas. Prompt diagnosis at an early stage is crucial as surgery with curative intent serves as the primary treatment approach.

Surgery with curative intent is the mainstay treatment for pancreatic angiosarcoma when diagnosed at an early stage.Oncological treatment options should be taken into consideration according to the follow-up data.Why does this paper matter?This article is important in that it is the most comprehensive review of the literature on pancreatic angiosarcoma, which is a very rare pathology, from the perspective of radiology, pathology and surgery.

Cardiac involvement of primary hyperoxaluria accompanied by non-compaction cardiomyopathy and patent ductus arteriosus.

Primary hyperoxaluria is a rare hereditary metabolic disorder resulting in accumulation of calcium oxalate in visceral organs, including the heart. We report a 19-year-old male with non- compaction cardiomyopathy combined with patent ductus arteriosus awaiting combined liver-kidney transplantation for primary hyperoxaluria. After surgical closure of the patent ductus arteriosus, the patient underwent a successful renal and subsequent liver transplantation. The presence of hypertrophic cardiomyopathy in hyperoxaluria patients has been reported before, but this is the first report of non-compaction myocardium with patent ductus arteriosus in a patient with primary hyperoxaluria. At the third month after combined liver and renal transplantation, improvement in cardiac functions were observed. Primary hyperoxaluria is a clinical entity to be taken into consideration in differential diagnosis of hypertrophied myocardium with high myocardial echocardiographic intensity. In cases of hyperoxaluria, additional congenital abnormalities may complicate the clinical picture.

Controversial issues in biliary pancreatitis: when should we perform MRCP and ERCP?

OBJECTIVES: The majority of bile duct stones (BDS) that cause acute biliary pancreatitis (ABP) pass spontaneously into the duodenum. If not passed, they worsen the prognosis or cause recurrence. Therefore, they must be treated. The purpose of this study was to assess the number and timing of spontaneous passage of BDS using magnetic resonance cholangiopancreatography (MRCP) and to determine the effect of this approach on endoscopic retrograde cholangiopancreatography (ERCP). METHODS: Sixty patients diagnosed with ABP were evaluated prospectively. MRCP was performed between the 1st and 4th days of an acute attack in all the patients. A control MRCP was performed after 7 days in patients with MRCP-identified choledocholithiasis. Patients in whom BDS were visible on imaging or who showed no decrease in bilirubin or cholestasis enzymes underwent ERCP. RESULTS: MRCP revealed choledocholithiasis in 20 (33%) of the 60 patients. In the control MRCP imaging, choledocholithiasis was detected in 16 of 20 (80% of those who had stone initially) patients. ERCP was performed in these patients and in 2 patients who did not have BDS on the control MRCP but whose bilirubin values and cholestatic enzyme levels had not decreased. ERCP verified choledocholithiasis in 16 of the 18 patients. The positive predictive value of MRCP was 93.7% (15/16). CONCLUSIONS: MRCP performed in the second week in ABP patients with a nonworsening prognosis and a suspicion of choledocholithiasis will give more specific results. This will avoid unnecessary ERCP and the potential morbidity and mortality that can develop with this invasive procedure.

Pushing the boundaries: circumferential endoscopic submucosal dissection in distal duodenum.

Video 1Pushing the boundaries: circumferential endoscopic submucosal dissection in distal duodenum (7.58 seconds).

A Post-International Gastrointestinal Cancers' Conference (IGICC) Position Statements.

Hepatocellular carcinoma (HCC), the most prevalent liver tumor, is usually linked with chronic liver diseases, particularly cirrhosis. As per the 2020 statistics, this cancer ranks 6th in the list of most common cancers worldwide and is the third primary source of cancer-related deaths. Asia holds the record for the highest occurrence of HCC. HCC is found three times more frequently in men than in women. The primary risk factors for HCC include chronic viral infections, excessive alcohol intake, steatotic liver disease conditions, as well as genetic and family predispositions. Roughly 40-50% of patients are identified in the late stages of the disease. Recently, there have been significant advancements in the treatment methods for advanced HCC. The selection of treatment for HCC hinges on the stage of the disease and the patient's medical status. Factors such as pre-existing liver conditions, etiology, portal hypertension, and portal vein thrombosis need critical evaluation, monitoring, and appropriate treatment. Depending on the patient and the characteristics of the disease, liver resection, ablation, or transplantation may be deemed potentially curative. For inoperable lesions, arterially directed therapy might be an option, or systemic treatment might be deemed more suitable. In specific cases, the recommendation might extend to external beam radiation therapy. For all individuals, a comprehensive, multidisciplinary approach should be adopted when considering HCC treatment options. The main treatment strategies for advanced HCC patients are typically combination treatments such as immunotherapy and anti-VEGFR inhibitor, or a combination of immunotherapy and immunotherapy where appropriate, as a first-line treatment. Furthermore, some TKIs and immune checkpoint inhibitors may be used as single agents in cases where patients are not fit for the combination therapies. As second-line treatments, some treatment agents have been reported and can be considered.

Intra-ampullary Papillary Tubular Neoplasm (IAPN): Clinicopathologic Analysis of 72 Cases Highlights the Distinctive Characteristics of a Poorly Recognized Entity.

The guidelines recently recognized the intra-ampullary papillary tubular neoplasm (IAPN) as a distinct tumor entity. However, the data on IAPN and its distinction from other ampullary tumors remain limited. A detailed clinicopathologic analysis of 72 previously unpublished IAPNs was performed. The patients were: male/female=1.8; mean age=67 years (range: 42 to 86 y); mean size=2.3 cm. Gross-microscopic correlation was crucial. From the duodenal perspective, the ampulla was typically raised symmetrically, with a patulous orifice, and was otherwise covered by stretched normal duodenal mucosa. However, in 6 cases, the protrusion of the intra-ampullary tumor to the duodenal surface gave the impression of an "ampullary-duodenal tumor," with the accurate diagnosis of IAPN established only by microscopic correlation illustrating the abrupt ending of the lesion at the edge of the ampulla. Microscopically, the preinvasive component often revealed mixed phenotypes (44.4% predominantly nonintestinal). The invasion was common (94%), typically small (mean=1.2 cm), primarily pancreatobiliary-type (75%), and showed aggressive features (lymphovascular invasion in 66%, perineural invasion in 41%, high budding in 30%). In 6 cases, the preinvasive component was pure intestinal, but the invasive component was pancreatobiliary. LN metastasis was identified in 42% (32% in those with ≤1 cm invasion). The prognosis was significantly better than ampullary-ductal carcinomas (median: 69 vs. 41 months; 3-year: 68% vs. 55%; and 5-year: 51% vs. 35%, P =0.047). In conclusion, unlike ampullary-duodenal carcinomas, IAPNs are often (44.4%) predominantly nonintestinal and commonly (94%) invasive, displaying aggressive features and LN metastasis even when minimally invasive, all of which render them less amenable to ampullectomy. However, their prognosis is still better than that of the "ampullary-ductal" carcinomas, with which IAPNs are currently grouped in CAP protocols (while IAPNs are kindreds of intraductal tumors of the pancreatobiliary tract, the latter represents the ampullary counterpart of pancreatic adenocarcinoma/cholangiocarcinoma).

Pancreatic surgery in elderly patients: results of 329 consecutive patients during 10 years.

Introduction: There is a progressive shift from a younger population to an older population throughout the world. With the population age shift, surgeons will be more encountered with older patient profiles. We aim to determine age-related risk factors of pancreatic cancer surgery and the effect of patient age on outcomes after pancreatic surgery. Materials and methods: A retrospective review was conducted with data obtained from consecutive 329 patients whose pancreatic surgery was performed by a single senior surgeon between January 2011 and December 2020. Patients were divided into three groups based on age: patients younger than 65 years old, between 65 and 74 years old, and older than 74 years old. Demographics and postoperative outcomes of the patients were evaluated and compared between these age groups. Results: The distribution of a total of 329 patients into the groups was 168 patients (51.06%) in Group 1 (age <65 years old), 93 patients (28.26%) in Group 2 (age ≥65 and <75 years old), and 68 patients (20.66%) in Group 3 (age ≥75 years old). The overall postoperative complications were statistically significantly higher in Group 3 than in Group 1 and Group 2 (p = 0.013). The comprehensive complication index of the patients in each group was 23.1 ± 6.8, 20.4 ± 8.1, and 20.5 + 6.9, respectively (p = 0.33). Fisher's exact test indicated a significant difference in morbidity in patients with ASA 3-4 (p = 0.023). In-hospital or 90-day mortality was observed in two patients (0.62%), one from Group 2 and one from Group 3. The 3-year survival rates for each group were 65.4%, 58.8%, and 56.8%, respectively (p = 0.038). Conclusion: Our data demonstrate that comorbidity, ASA score, and the possibility of achieving a curative resection do have significantly more impact than age alone.

Effects of the Largest Metastatic Lymph Node Size on the Outcomes of Patients who Underwent Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma.

Objectives: Prognostic importance of metastatic lymph nodes in pancreatic cancer is always garnered attention due to dismal prognosis, with some quantitative factors drawing attention for significantly predicting outcomes. Size is one of the easy approach morphological characteristics of the lymph node, and data for effect of largest metastatic lymph node (LMLN) size on survival outcomes are lacking in pancreatic cancer. We aim to evaluate the effect of LMLN size on the prognosis of patients with pancreatic ductal adenocarcinoma (PDAC). Methods: This retrospective study evaluates the effect of LMLN size on survival outcomes by grouping the patients who were surgically treated for PDAC, according to their lymph node stage and calculated cutoff value for LMLN size, between February 2015 and May 2020. Results: In the study cohort of 131 patients, the mean age was 63.9±10.8 years and 77 patients were female. Ninety-nine of the patients had pN1, 32 had pN2 stage disease. The optimal cutoff point of LMLN size for predicting the prognosis was calculated as 7.5 mm (sensitivity = 81% and specificity = 81%). 34 (34.3%) of pN1 and 7 (21.9%) of pN2-staged patients had lymph node smaller than 7.5 mm. Three-year survival was significantly longer for patients whose LMLN size was <7.5 mm (56.2-18.2%, p<0.001). Whereas, the patients with LMLN size <7.5 mm had statistically significant longer median survival rate in the subgroup of patients with pN1 lymph node stage, no significant difference in median survival rates was observed between subgroups of pN2 patients (p=0.237). Conclusion: The present study demonstrated that the LMLN size was one of the potential predictors of survival in patients with PDAC.

Use of smooth muscle plasty after intersphincteric rectal resection to replace a partially resected internal anal sphincter: long-term follow-up.

PURPOSE: Patients with very low rectal cancer were treated by intersphincteric rectal resection employing partial internal anal sphincter resection. They then underwent smooth muscle plasty to restore internal anal sphincter function. We assessed the functional and oncological outcomes. PATIENTS AND METHODS: Patients were selected if their biopsies revealed well-differentiated or moderately well-differentiated very low rectal tumors with distal tumor margins that permitted preservation of part of the internal anal sphincter. Functional results after closing the loop ileostomy were assessed by use of a standardized questionnaire. Continence was evaluated by use of the Kirwan score. RESULTS: Forty-seven patients with T2 to T3 very low rectal carcinomas underwent intersphincteric rectal resection and smooth muscle plasty that extended into the anal canal. All received neoadjuvant treatment. Postoperative morbidity was 38.3%. There were 46 R0 resections based on frozen section analysis; one patient achieved an R0 resection after reexcision of a positive distal margin on the frozen section. The median follow-up period was 67.2 months. One patient had local recurrence. The five-year overall and disease-free survival rates were 85% and 82%, respectively. Six months, one year, and two years after intersphincteric rectal resection, 80%, 87%, and 89%, respectively, had good continence (Kirwan I and II). Evacuation difficulty was detected in two patients with colonic S-pouches. CONCLUSION: Providing neodjuvant treatment and preserving at least half of the functional internal anal sphincter mass produces acceptable oncological and functional outcomes in patients undergoing intersphincteric rectal resection for very low rectal cancer. However, whether smooth muscle plasty further improves postoperative continence should be tested by further studies.

Management of pilonidal sinus disease with oblique excision and bilateral gluteus maximus fascia advancing flap: result of 278 patients.

PURPOSE: Excision followed by natal cleft depth reduction should be performed, with no leftover midline scar tissue, to prevent recurrence of pilonidal sinus, which is the main problem in the treatment of this disease. We investigated the potential advantages of this advancing flap technique, which we developed. METHOD: An S-type incision together with a bilateral gluteus maximus fascia advancing flap was applied on 278 (89 percent) patients, who did not have extensive gluteal involvement, of the 312 patients who had pilonidal sinus disease, between January 1997 and January 2007. No drainage was performed on any patient. RESULTS: All patients were discharged within 24 hours. Total complication rate was 7.2 percent and recurrence rate was 0.7 percent. The mean time off from work was 12 +/- 2 days (range, 10 to 22). The mean follow-up period was 66 +/- 32 months (range, 12 to 120). CONCLUSION: We suggest that this surgical procedure may successfully be applied to a large majority of the patients. It does not lead to unnecessary excision of healthy tissue because of its significantly simpler nature compared with the full-layer flap technique and its S-type incision, it does not create a midline scar tissue, and it is able to flatten the gluteal sulcus.

Comparison of laparoscopic versus open liver tumor resection: a case-controlled study.

BACKGROUND: Although there are data in the literature about the safety and efficacy of laparoscopic liver resections, there are not many studies comparing laparoscopic versus open approaches in a case-matched design. The purpose of this study is to compare the perioperative outcome of laparoscopic versus open liver resections from a single institution. METHODS: Thirty-one patients underwent laparoscopic liver resection between April 1997 and August 2007, with a prospective laparoscopic program started in April 2006 (n=25). This group of patients was compared with 43 consecutive patients undergoing open resection who were matched by size of the lesion (5 cm or less for malignant and 8 cm or less for benign), anatomical location (segments 2, 3, 4b, 5, 6), and type of resection (wedge resection, segmentectomy, partial liver resection). Data were obtained from medical records as well as from a prospective database. Statistical analysis was performed using t-test and chi-square. All data are expressed as mean +/- standard error on the mean (SEM). RESULTS: Mean age in the laparoscopic group was 57.6+/-2.7 years versus 61.9+/-2.3 years in the open group (p=0.2). There were more women in the laparoscopic group [74% females (n=23) and 26% males (n=8)] versus in the open group [40% females (n=17) and 60% males (n=26)] (p=0.003). There were more patients with malignant lesions in the open group (73%) versus in the laparoscopic group (45%) (p=0.01). Eight patients underwent partial and 23 patients segmental/wedge liver resection in the laparoscopic group versus 15 patients who underwent partial and 28 patients segmental/wedge liver resection in the open group (p=0.7). Mean tumor size was 3.9+/-0.4 cm in the laparoscopic group versus 4.2+/-0.3 cm in the open group (p=0.5). Ten (32%) out of 31 cases in the laparoscopic group were hand-assisted. Inflow occlusion was used in 1 case (3%) in the laparoscopic group versus 16 (37.2%) in the open group. Mean operating time was 201+/-15 min for the laparoscopic group and 172+/-12 min for the open group (p=0.1). Mean estimated blood loss during the procedure was 122.5+/-45.4 cc for the laparoscopic group and 299.6+/-33.6 cc for the open group (p=0.002). Surgical margin was similar for malignant cases in both groups. Mean hospital stay was 3.2+/-1.0 days for the laparoscopic group and 6.8+/-0.7 days for the open group (p=0.004). The incidence of postoperative complications was 13% (n=4) in the laparoscopic and 16% (n=7) in the open group (p=0.7). CONCLUSION: This study shows that, with a longer operative time, the laparoscopic approach, despite the learning curve, offers advantages regarding operative blood loss, postoperative analgesic requirement, time to regular diet, hospital stay, and overall cost compared with the open approach for minor liver resections.

Predictors of hypocalcemia occurring after a total/near total thyroidectomy.

PURPOSE: The aim of this study was to identify the predictors of early postoperative hypocalcemia after a total/near total thyroidectomy in order to select patients for prompt treatment to prevent symptomatic hypocalcemia. METHODS: Patients with hypocalcemia within 24 h of surgery were identified as Group I and normocalcemic patients as Group II. The perioperative serum total calcium (tCa, ionized calcium (iCa) and intact parathormone (iPTH) were measured perioperatively. Skin closure (SC) was accepted as the reference time point. Data are expressed as the mean +/- SEM. RESULTS: The study included 73 patients. Hypocalcemia (Group I) was detected in 40 patients (54%) within the first 24 h postoperatively. Symptomatic hypocalcemia was detected in 40% of the patients in Group I. Intact parathormone values at 10 min of SC were significantly lower in Group I (P = 0.001). IPTH measurement at 10 min of SC showing a >/=30% decrease had a 92.3% sensitivity and 92.6% specificity in predicting hypocalcemia after a total/near total thyroidectomy. The postoperative day 15 mean tCa, iCa, and iPTH values were similar in both groups of patients. The mean iPTH level was 16.79 +/- 2.5 pg/dl at 10 min after SC in patients who developed symptomatic hypocalcemia. CONCLUSIONS: Intact parathormone measurement 10 min after SC is helpful to predict early postoperative hypocalcemia. An IPTH decrease >/=30% at this time point estimates the risk of postoperative hypocalcemia.

Tempol reduces bacterial translocation after ischemia/reperfusion injury in a rat model of superior mesenteric artery occlusion.

PURPOSE: We investigated whether Tempol, a water-soluble antioxidant, prevents the harmful effects of superior mesenteric ischemia/reperfusion on intestinal tissues in rats. METHODS: The rats were divided into three groups of 10. In group 1, the superior mesenteric artery (SMA) was isolated but not occluded, and in groups 2 and 3 the superior mesenteric artery was occluded for 60 min. After that, the clamp was removed and reperfusion began. In group 3, 5 min before the start of reperfusion, a bolus dose of 30 mg/kg Tempol was administered intravenously and continued at a dose of 30 mg/kg for 60 min. All animals were euthanized after 24 h and tissue samples were collected for analysis. RESULTS: There was a significant increase in myeloperoxidase activity, malondialdehyde levels, and the incidence of bacterial translocation in group 2, with a decrease in glutathione levels. These parameters were found to be normalized in group 3. The intestinal mucosal injury score in group 2 was significantly higher than those in groups 1 and 3. CONCLUSION: Tempol prevents bacterial translocation while precluding the harmful effects of ischemia/reperfusion injury on intestinal tissues in a rat model of superior mesenteric artery occlusion.

Evaluation of gadolinium pre-treatment with or without splenectomy in the setting of renal ischemia reperfusion injury in rats.

INTRODUCTION: This study aims to investigate gadolinium chloride (Gd) pre-treatment with/without splenectomy (Splx) in the setting of renal ischemia/reperfusion (IR) injury in rats. MATERIALS AND METHODS: Under anesthesia, male Wistar albino rats with or without splenectomized (Splx) were right nephrectomized and subjected to 45 min of renal pedicle occlusion followed by 3 h of reperfusion. Gadolinium chloride (10 mg kg(-1)) or saline was administered 24 hours prior to ischemia via penile vein. Right nephrectomy and intravenous saline administration was performed in the control group. At the end of the reperfusion period, following decapitation, kidney samples were taken for histological examination or determination of renal malondialdehyde (MDA) and glutathione (GSH) levels and myeloperoxidase (MPO) and Na(+)-K(+) ATPase activities. Creatinine, blood urea nitrogen (BUN), lactate dehydrogenase (LDH), TNF-alpha, and IL-1 beta were assayed in the serum samples. RESULTS: Ischemia/reperfusion caused significant increases in the serum TNF-alpha, IL-1 beta, BUN, creatinine, AST, ALT, LDH, and tissue MDA levels and MPO activity, while either Gd pre-treatment or Splx decreased these parameters significantly. On the other hand, IR induced a decrease in the tissue GSH, and Na(+)-K(+) ATPase activity was restored by both gadolinium and Splx. Furthermore, histopathological alterations induced by IR were also reversed. CONCLUSION: The extent of renal IR injury depends on the pro-inflammatory cytokine response. Gd pre-treatment decreases macrophage-derived cytokine secretion and thereby effectively limits the extent of renal IR injury in rats similar to Splx. Further studies needed to define an optimal way of decreasing macrophage-derived cytokine release due to the clinical limitations of Gd.

Early vs. delayed closure of temporary covering ileostomy: a prospective study.

BACKGROUND/AIMS: Temporary loop ileostomies constructed to protect distal anastomoses are generally closed at 8 to 12 weeks, a period long enough to encounter stoma-related complications, which reduces the quality of life. Early closure may be considered to overcome these adverse effects. This prospective study was designed to investigate the reliability of early closure of loop ileostomies. METHODOLOGY: Fifty consecutive patients were sequentially distributed either to group A (delayed closure) or group B (early closure). Anastomotic integrity was examined before closure in all patients. RESULTS: There were 25 patients in each group who were comparable in terms of age, sex, comorbid conditions, primary pathology, and tumor stage. Early closure was achieved in 88% (n=22) of the patients in group B. Stoma-related complications were significantly greater in group A patients (44% vs. 16%) (p<0.05) while the complications following closure were similar in both groups (16% vs. 8%) (p>0.05). CONCLUSIONS: Early closure during the same hospital admission produces less stoma-related complications with similar accomplishment as the late closure. Early closure of temporary ileostomy is recommended in suitable patients without anastomotic complications.

Serum D-dimer as a prognostic marker in patients undergoing radiofrequency ablation of colorectal liver metastasis.

BACKGROUND: Although traditionally used for coagulation disorders, there has been a recent interest in serum D-dimer as a tumor marker. The aim of this prospective study is to determine its value as a tumor marker in patients with colorectal liver metastasis. PATIENTS AND METHODS: Between January 2000 and October 2007, 242 patients undergoing laparoscopic radiofrequency ablation (RFA) of colorectal liver metastasis were evaluated prospectively. The relationship of D-dimer levels to pre-ablation parameters, recurrence, and survival was prospectively assessed. All data are expressed as mean ± SEM. RESULTS: Preoperative D-dimer levels correlated with liver tumor volume (p = .04) and CEA (p = .003). D-dimer levels increased by a mean of 11.4 ± 1.5 folds after RFA on POD#7 and returned to preoperative values in three months. The rate of the elevation of D-dimer values after RFA was related to tumor volume ablated. The median overall survival was six months for patients with preoperative D-dimer > 1,000 ng/ml vs. 32 months for patients with D-dimer < 1,000 ng/ml (p = .02). On multivariate analysis preoperative serum D-dimer was an independent predictor of overall survival along with CEA and liver tumor burden. CONCLUSION: Serum D-dimer levels reflect liver tumor burden and independently predict survival in patients with colorectal liver metastasis undergoing RFA.

Myoglobinuria after laparoscopic radiofrequency ablation of liver tumors.

BACKGROUND: There are scant data in the literature about myoglobinuria after radiofrequency ablation (RFA) of liver tumors. The aim of this study is to analyze the incidence and identify the risk factors involved in this complication after RFA. PATIENTS AND METHODS: An initial case of myoglobinuria and acute kidney injury (AKI) during laparoscopic liver RFA after 10 years of the liver ablation program led to the design of this study. Prospective data were collected on 41 consecutive patients undergoing laparoscopic RFA at our institution over a 9-month period. Urine myoglobin, serum creatinine kinase, and serum creatinine levels were obtained preablation and postablation. Variables were compared between patients to identify possible risk factors that might be related to this rare complication. Data are expressed as mean +/- standard error of the mean. RESULTS: Two patients were excluded from the study due to preoperative myoglobinuria of unknown etiology. Of the remaining 39 patients, three developed dark urine with significant myoglobinuria on postoperative day 1. Two of these patients had carcinoid liver metastases; the remaining patient had a metastatic colorectal lesion. The number of tumors ablated in these patients was 14, 11, and 3 vs. 2.4 +/- 0.4 in the rest of the patients. Cumulative tumor volume was larger in the group of patients that developed the complication vs. those who did not (127.9 +/- 59.5 vs. 48 +/- 3 cm(3)). Two grounding pads were used in the three patients that had a complication vs. four pads in the rest of the patients. Dark urine was identified promptly intraoperatively and treated aggressively. All of these patients required intensive care unit (ICU) admission and had a prolonged hospital stay. Marked elevation of transaminases and creatinine kinase as well as a drop in hematocrit and platelet count was observed in patients with myoglobinuria. In our retrospective review of 706 patients that underwent liver RFA in the past 10 years, we detected 27 patients (3.8%) with ten or more lesions (11.9 +/- 0.4). None of these patients had significant elevation of serum creatinine postoperatively. In the whole series of 706 patients, 22 (3.2%) were found to have elevated creatinine after liver RFA, with return to baseline in all but seven patients in follow-up. CONCLUSION: Myoglobinuria after liver RFA is a rare but potentially devastating complication that may lead to AKI with significant morbidity and prolonged hospital stay. Patients with large tumor volumes requiring longer ablation times need to be monitored closely for the development of this complication. The fact that this was not observed in other patients with similar tumor characteristics suggests that individual patient-related factors might play an important role.

Evaluation of intraoperative parathormone measurement for predicting successful surgery in patients undergoing subtotal/total parathyroidectomy due to secondary hyperparathyroidism.

OBJECTIVES/BACKGROUND: The aim of this study is to investigate the predictive value of intraoperative parathormone measurement addressing successful surgical resection in patients with secondary hyperparathyroidism. METHODS: The study included 42 consecutive patients operated on between May 2006 and July 2008. Patients were grouped according to successful surgery (Group 1, n = 36) and persistent postoperative hyperparathyroidism (Group 2, n = 6). Serum phosphorus (P), total calcium (tCa), ionized calcium (iCa), intact parathormone (iPTH), and alkaline phosphatase (ALP) were drawn preoperatively and intraoperatively upon 15 minutes after completion of resection (iPTH(15)). The rate of decrease of pith detected by iPTH(15) compared to preoperative values was calculated (iPTH(%)). RESULTS: Preoperative P, tCa, iCa, iPTH, and ALP were comparable. Subtotal parathyroidectomy (sPx) (n = 27) and total parathyroidectomy with autotransplantation (tPx) (n = 15) were performed. Mean iPTH(15) value, iPTH(%) rates were 145.9 +/- 12.3 pg/mL, % 91.6 +/- 0.7, and 522.5 +/- 85.4 pg/mL, % 75.1 +/- 2.0 (P = ,001) in Groups 1 and 2, respectively. Mean serum tCa and iCa at POD#1 in Group 1 were 7.6 +/- 0.1 mg/dL, 0.910 +/- 0.4 mmol/L, and Group 2 were 8.3 +/- 0.3 mg/dL, 1.050 +/- 0.4 mmol/L (P < .05), respectively. ALP levels were similar. CONCLUSION: iPTH(15) value and iPTH(%) rate accurately predicts the completeness of resection in secondary hyperparathyroidism. The rate of decrease in serum iPTH detected intraoperatively compared to preoperative baseline levels exceeding 90% in sPx, 95% in tPx, accurately predicts the success of surgery. Postoperative normocalcemia without calcium replacement would raise a suspicion about completeness of surgical resection.