Mid-Term and Long-Term Impact of Permanent Hypoparathyroidism After Total Thyroidectomy.

BACKGROUND: Permanent hypoparathyroidism (PH) is the most frequent long-term complication after total thyroidectomy. PH is related to many short-term and long-term complications, including clinical manifestations of hypocalcemia, hypercalcemia due to overtreatment, hyperphosphatemia, gastrointestinal, neuropsychiatric symptoms, decrease in renal function and infectious complications. The aim of this study was to identify the most frequent effects of PH and its associated risk factors. METHODS: We performed a retrospective analysis of a single institutional series of patients who developed PH after total thyroidectomy between 2000 and 2016. PH was defined as hypoparathormonemia (≤12 pg/mL) or the need for calcium/vitamin D supplementation to achieve normal calcium levels for more than 12 months. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. RESULTS: Thirty-nine patients fulfilled the criteria for PH. Mean ± SD age was 46.26 ± 13.4 years; 6 (15.4%) were males and 33 (84.6%) females. Mean follow-up was 6.13 ± 3.25 years. Mean calcium carbonate supplementation doses per day were 18.95 ± 17.5 g and 21.4 ± 19.3 g at 1 year and last follow-up, respectively. Hypocalcemic crisis was the most common complication (66.7%), followed by neuropsychiatric (38.5%) and gastrointestinal symptoms (33.3%). Ten patients showed a decrease in renal function (eGFR drop ≥25%) and 4 developed chronic kidney disease. The amount of calcium supplementation was the most relevant related risk factor. CONCLUSIONS: PH is associated with multiple complications, including renal function impairment, gastrointestinal, neuropsychiatric and infectious complications. Lower calcium supplementation doses are related to lower complications rates.

The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism.

Importance: Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades. Objective: To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy. Evidence Review: A multidisciplinary panel used PubMed to review the medical literature from January 1, 1985, to July 1, 2015. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Findings: Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hour urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation for vitamin D deficiency. Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy. Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. Patients with nonlocalizing imaging remain surgical candidates. Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. The possibility of multigland disease should be routinely considered. Both focused, image-guided surgery (minimally invasive parathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoring via a reliable protocol is recommended. Minimally invasive parathyroidectomy is not routinely recommended for known or suspected multigland disease. Ex vivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. Clinically relevant thyroid disease should be assessed preoperatively and managed during parathyroidectomy. Devascularized normal parathyroid tissue should be autotransplanted. Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up to assess for cure defined as eucalcemia at more than 6 months. Calcium supplementation may be indicated postoperatively. Familial pHPT, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special consideration and expertise. Conclusions and Relevance: Evidence-based recommendations were created to assist clinicians in the optimal treatment of patients with pHPT.

Anemia after Roux-en-Y gastric bypass. How feasible to eliminate the risk by proper supplementation?

BACKGROUND: Anemia after Roux-en-Y gastric bypass (RYGB) has been reported in 5 to 64 % of patients. Since absorption of specific elements is reduced, proper supplementation is mandatory. The aim of this study was to investigate the frequency of anemia, its causes, and the related deficiencies during the 1st postoperative year after RYGB. METHODS: A retrospective review of our prospectively collected database was performed. A total of 486 patients who underwent RYGB in a 5-year period and completed at least 1-year follow-up were included. Daily supplements as suggested by the AACE/TOS/ASMBS guidelines were routinely prescribed. Blood count, iron profile, folic acid, and B12 measurements 1 year after surgery were reviewed. RESULTS: One hundred ninety-five males and 291 females were included, with a mean age of 39.9 ± 11.6 years and a mean body mass index (BMI) of 42.4 ± 6.3 kg/m(2). Anemia 1 year after surgery was found in 19 patients (4 %), 6 males and 13 females. In seven women, it was related to iron deficiency. Two additional women had iron deficiency combined with low vitamin B12. Anemia was secondary to inflammation in two and indeterminate in two. In the six males, the cause of anemia was inflammation in three and indeterminate in three. Abnormal bleeding was found in five of these patients. CONCLUSIONS: Frequency of anemia 1 year after RYGB in our population was low (4 %). Anemia non-attributable to malabsorption was frequently present (n = 9/19). Iron deficiency was found exclusively in women. The most common non-malabsorptive types of anemia were inflammation and dysfunctional uterine bleeding.

Selection of electrical algorithms to treat obesity with intermittent vagal block using an implantable medical device.

BACKGROUND: A laparoscopically implantable electrical device that intermittently blocks both vagi near the esophagogastric junction led to significant excess weight loss (EWL) in an initial clinical trial in obese patients. The study objective was to optimize therapy algorithms and determine the EWL achieved with a second-generation device at university hospitals in Australia, Norway, and Switzerland. METHODS: Data acquired during the initial clinical trial were analyzed and subsequently used to select alternative electrical algorithms. In the second trial, vagal blocking using one selected therapy algorithm was initiated 2 weeks after implanting the second-generation device. The patients were followed up for 6 months to assess the EWL and safety, including adverse events. RESULTS: In the initial clinical trial, vagal blocking algorithm durations of 90-150 s were associated with greater EWL compared with either shorter or longer algorithm durations (P<.01). The second trial enrolled 27 patients (mean body mass index 39.3+/-.8 kg/m2) to evaluate a 120-s blocking algorithm. At 6 months, greater EWL was achieved (22.7%+/-3.1%, n=24) compared with the initial study and first-generation device (14.2%+/-2.2%, n=29, P=.03). In both trials, an association was found between the number of 90-150-s algorithms delivered daily and greater EWL (P=.03). No deaths, unanticipated device-related adverse events, or medically serious adverse events were associated with the device. CONCLUSION: This second-generation vagal blocking device, using a therapy algorithm of 120-s duration, resulted in a clinically acceptable safety profile and significantly greater EWL compared with the first-generation device delivering a wider range of therapy algorithm durations.

Prevalence of iron, folate, and vitamin B12 deficiency anemia after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: One of the most common bariatric operations is the laparoscopic Roux-en-Y gastric bypass (LRYGBP) in which the gastric capacity is restricted and the absorption by the small intestine is reduced. The objective of this study was to evaluate the incidence of iron, folate, and vitamin B12 deficiency anemia in patients undergoing LRYGBP. PATIENTS AND METHODS: Clinical records of 30 patients who underwent LRYGBP between July 2003 and January 2005 and had a minimum follow up of 24 months at our outpatient clinic were included. Multivitamin supplementation was prescribed to all patients. The complete blood cell count, plasma iron, total iron-binding capacity, transferrin saturation, serum folate, and cobalamin levels before surgery, 6 months, 1, 2, and 3 years after the surgery were analyzed. RESULTS: There were 25 women (83.4%) and five men (16.6%) with ages from 21 to 56 years. Before surgery, two patients (6.6%) presented ferropenic anemia. Iron deficiency was seen in 40 and 54.5% 2 and 3 years after surgery, respectively. Cobalamin deficiency was observed in 33.3% at 2 years and in 27.2% at 3 years. At 2-year follow-up, 46.6% of the patients had already developed anemia and 63.6% at 3 years. Folate deficiency was not observed in any patient. CONCLUSION: Our routine scheme of vitamin supplementation is not sufficient to prevent iron and vitamin B12 deficiencies in most patients.

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

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