Laparoscopic fixation of volvulus by extra-peritonealization: a case series.

BACKGROUND: Volvulus is one of the leading causes of colonic obstruction with a high recurrence rate following endoscopic decompression. Although colonic resection remains the treatment of choice, it is often associated with significant morbidity and mortality, especially in elderly patients. Colonic fixation with extra-peritonealization has been suggested as an alternative to colonic resection. The aim of this study was to evaluate the surgical outcomes of patients with colonic volvulus in our initial experience with this procedure. METHODS: A retrospective analysis of a prospectively maintained database of all patients who underwent colonic extra-peritonealization for volvulus between January 2016 and April 2021 in Sheba medical center (Ramat-Gan, Israel) was performed. Patients' demographics, clinical, peri-operative and post-operative data were recorded and analyzed. RESULTS: One hundred and thirty nine patients were admitted due to acute colonic volvulus, 48 of whom were treated surgically. Eleven patients underwent extra-peritonealization of the sigmiod or cecum during the study period. Mean age was 64.5 years. Six patients (54.55%) were males. Seven patients (63.63%) presented with sigmoid volvulus and 4 (36.36%) with cecal volvulus. Median American Society of Anesthesiologists (ASA) class was 3 (range 2-4). One patient (9.09%) was required urgent surgery. The majority of patients was operated on using a laparoscopic approach (10 patients, 90.9%). Median length of stay was 3 days (range 1-6 days) and no post-operative complications or readmissions within 30 days after surgery were recorded. Median length of follow-up was 283 days (range 21-777 days). During the follow-up period, three patients (27.27%) presented with recurrent volvulus and required an additional surgical intervention with colonic resection. Of the patients with volvulus recurrence, one patient (9.09%) required an urgent surgical intervention. CONCLUSIONS: Extra-peritonealization of colonic volvulus is feasible and safe. Although recurrence rates are fairly high, the low morbidity associated with the procedure makes it an appealing alternative to colonic resection, especially in patients with high risk for post-operative complications.

The efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome: a systematic review and meta-analysis.

BACKGROUND: Sacral neuromodulation (SNM) has become one of the main treatment options in patients with fecal incontinence. The aim of this study was to determine the efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome (LARS). METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search was conducted using the Pubmed, Embase, Ovid, and Cochrane databases, restricted to the English language and to articles published from 2000 to November 2018. RESULTS: A total of 434 articles on the efficacy of SNM in the treatment of LARS were retrieved, and 13 studies were included in the final analysis, with a total of 114 patients treated with SNM for LARS The overall success rate excluding study heterogeneity was 83.30% [95% CI (71.33-95.25%)]. Improvement in anal continence was seen in several clinical and functional parameters, including the Wexner Score [10.78 points, 95% CI (8.55-13.02), p < 0.0001], manometric maximum resting pressure [mean improvement of 6.37 mm/Hg, 95% CI (2.67-10.07), p = 0.0007], maximum squeeze pressure [mean improvement of 17.99 mm/Hg, 95% CI (17.42-18.56), p < 0.0001] and maximum tolerated volume [mean improvement of 22.74 ml, 95% CI (10.65-34.83), p = 0.0002]. Quality of life questionnaires also demonstrated significant improvement in patients' quality of life, but were reported only in a small group of included patients. CONCLUSIONS: SNM significantly improves symptoms and quality of life in patients suffering from fecal incontinence following low anterior resection.

Reversal of Hartmann's procedure: still a complicated operation.

Hartmann's procedure, colonic resection with an end colostomy and rectal closure, is used in a variety of surgical emergencies. It is a common surgical procedure that is often practiced in patients with colonic obstruction and colonic perforation, resolving the acute clinical situation in the majority of cases. Reversal of Hartmann's procedure with restoration of bowel continuity occurs in a significantly low percentage of patients. There are several reasons contributing to the fact that many patients remain with a permanent colostomy following Hartmann's procedure. These include factors related to the patients' clinical status but also to the significant difficulty and morbidity related to the surgical reversal of Hartmann's procedure. The aim of this study was to review the factors related to the fairly low percentage of patients undergoing Hartmann's reversal as well as surgical techniques that could help surgeons restore intestinal continuity following Hartmann's procedure and deal with the postoperative outcomes.

Laparoscopic Fixation for Torsion of Transplanted Kidney: A Case Report.

BACKGROUND: Kidney graft torsion and subsequent acute kidney injury is a rare yet potentially devastating complication of intraperitoneal kidney transplant. We report a case of this elusive diagnosis and describe kidney salvage by using laparoscopic fixation. CASE REPORT: A 49-year-old male patient presented with multiple episodes of anuric acute kidney injury 16 months after an uneventful combined orthotopic liver and kidney transplantation. After a thorough investigation, a diagnosis of kidney torsion was made, and the patient was urgently operated. Upon surgery, a complete torsion of a viable kidney was found. Laparoscopic fixation was achieved by using an absorbable mesh "pocket." The patient has experienced no similar episodes in the subsequent year. CONCLUSIONS: Nephrologists and surgeons should be aware of this rare complication. Prompt diagnosis and operative repair are crucial to save the graft. Prophylactic nephropexy should be considered in all intraperitoneal transplantations.

Colonoscopy after the first episode of acute diverticulitis: challenging management paradigms.

BACKGROUND: Colonoscopy is commonly recommended after the first episode of acute diverticulitis to exclude colorectal neoplasia. Recent data have challenged this paradigm due to insufficient diagnostic yield. The aim of this study was to assess whether colonoscopy after the first episode of acute diverticulitis is needed to exclude colorectal neoplasia. METHODS: We performed a retrospective cohort analysis of medical records of patients admitted for the first episode of acute diverticulitis between January 2008 and December 2012. Ambulatory colonoscopy was routinely recommended at discharge. Clinical follow-up and telephone surveys were used for data collection. RESULTS: Four hundred and twenty-five patients with a mean age of 62.6 years (range 21-98 years) were admitted during the 5-year period. Three hundred and ten (72.9 %) patients underwent colonoscopy at median time of 3.2 months after discharge. Five patients (1.6 %) of the 310 available for evaluation had malignant findings in colonoscopy. Of those, one patient had rectal carcinoma away from the inflamed site and one had colonic lymphoma. None of the 95 patients <50 years of age was found to have adenocarcinoma of the colon. CONCLUSIONS: Cancer is rarely detected in colonoscopy following the first episode of acute diverticulitis. These results question this indication for colonoscopy, especially in patients under 50.

Laparoscopic cholecystostomy tube-guided hepatotomy and cholecystolithotomy: alternative strategy for treatment of severe chronic cholecystitis.

Laparoscopic cholecystectomy can be a challenging procedure in gallbladders with chronic disease. We describe a patient with chronic cholecystitis and difficult visualisation of the gallbladder at surgery who underwent laparoscopic hepatotomy along the drainage tube of the cholecystostomy. In this way, the gallbladder was identified to avoid non-visualisation of ductal anatomy. This exceptional solution should be added to the surgical options if anatomical recognition is difficult and complete removal of the gallbladder is too risky.

Regional lymph node status after neoadjuvant chemoradiation of rectal cancer producing a complete or near complete rectal wall response.

AIM: Transanal excision of the tumour site after complete response to chemoradiotherapy can determine the rectal wall response to treatment. This study was designed to assess whether the absence of tumour in the rectal wall corresponds to the absence of tumour in the mesorectum (true pathological complete response). METHOD: A retrospective review identified patients who underwent preoperative chemoradiation therapy for advanced mid and low rectal cancer followed by routine pre-planned radical surgery with total mesorectal excision. Patients in whom the pathology specimen showed no residual tumour in the rectal wall (ypT0) or a ypT1 lesion were assessed for tumour involvement in the mesorectum. RESULTS: Seventy-eight patients who underwent pelvic chemoradiation followed by radical surgery were reviewed. The rectal wall tumour disappeared in eight (ypT0). Of these, residual tumour was found in the mesorectum (ypT0N1) in one (12%) patient. Eleven patients were found to have ypT1 residual tumour. Of these, two (18%) had a final post-surgical staging of ypT1N1. CONCLUSION: Complete rectal wall tumour eradication was achieved in 10% of the patients, and downstaging to ypT1 was achieved in 14%. In 15% (12% in ypT0 and 18% in ypT1) of these patients, residual tumour cells were evident in the mesorectum. This would probably have rendered these patients with residual disease had a nonradical approach of transanal excision of the original tumour site been employed. Caution should be taken when considering the avoidance of radical surgery.

Bowel obstruction in recurrent gynecologic malignancies: defining who will benefit from surgical intervention.

AIM: To define factors that could help select, in a cohort of gynecologic cancer patients with malignant gastro-intestinal obstruction, those most likely to benefit from palliative surgery. METHODS: In this retrospective study of patients with malignant gastro-intestinal obstruction who underwent palliative surgery in our institute over 7 years, outcome measures were oral intake, chemotherapy, and 30-day, 60-day and overall survival. Based on Cox proportional-hazards regression models and Kaplan-Meier curves with log-rank tests, a prognostic score was developed to identify those most likely to benefit from surgery. RESULTS: Sixty-eight palliative surgeries were performed in 62 patients with ovarian (69.1%), primary-peritoneal (8.8%), cervical (11.8%) or uterine (10.3%) malignancies. Procedures were colostomy (26.5%), ileostomy (39.7%), colonic stent (1.5%), gastrostomy (7.3%), gastroenterostomy (5.9%) and bypass/resection and anastomosis (19.1%). Eighteen patients died prior to discharge, within 3-81 days (median 25 days). The 30-day and 60-day mortality rates were 14.7% and 29.4%, respectively. Postoperative oral-intake and chemotherapy rates were 65% and 53%, respectively, with albumin level identified on multivariate analysis as the only significant predictor of both. Median postoperative survival was 106 days (3-1342). Bypass/resection and anastomosis was associated with improved survival. Ascites below 2 L, younger age, ovarian primary tumor, and higher blood albumin correlated with longer postoperative survival. A prognostic index based on these factors was found to identify patients with increased 30-day and 60-day mortality. CONCLUSIONS: Our proposed prognostic index, based on age, primary tumor, albumin and ascites, might help select those gynecological cancer patients most likely to benefit from palliative surgery.

Laparoscopic colectomy for transverse colon carcinoma.

BACKGROUND: Laparoscopic resection of transverse colon carcinoma is technically demanding and was excluded from most of the large trials of laparoscopic colectomy. The aim of this study was to assess the safety, feasibility, and outcome of laparoscopic resection of carcinoma of the transverse colon. METHODS: A retrospective review was performed to identify patients who underwent laparoscopic resection of transverse colon carcinoma. These patients were compared to patients who had laparoscopic resection for right and sigmoid colon carcinoma. In addition, they were compared to a historical series of patients who underwent open resection for transverse colon cancer. RESULTS: A total of 22 patients underwent laparoscopic resection for transverse colon carcinoma. Sixty-eight patients operated for right colon cancer and 64 operated for sigmoid colon cancer served as comparison groups. Twenty-four patients were identified for the historical open group. Intraoperative complications occurred in 4.5% of patients with transverse colon cancer compared to 5.9% (P = 1.0) and 7.8% (P = 1.0) of patients with right and sigmoid colon cancer, respectively. The early postoperative complication rate was 45, 50 (P = 1.0), and 37.5% (P = 0.22) in the three groups, respectively. Conversion was required in 1 (5%) patient in the laparoscopic transverse colon group. The conversion rate and late complications were not significantly different in the three groups. There was no significant difference in the number of lymph nodes harvested in the laparoscopic and open groups. Operative time was significantly longer in the laparoscopic transverse colectomy group when compared to all other groups (P = 0.001, 0.008, and <0.001 compared to right, sigmoid, and open transverse colectomy, respectively). CONCLUSIONS: The results of laparoscopic colon resection for transverse colon carcinoma are comparable to the results of laparoscopic resection of right or sigmoid colon cancer and open resection of transverse colon carcinoma. These results suggest that laparoscopic resection of transverse colon carcinoma is safe and feasible.

Minimally invasive approach to colorectal surgery.

While the development of laparoscopic surgery over the last two decades was amazingly fast, its adoption was neither uniform nor universal. Some procedures, like laparoscopic cholecystectomy, rapidly became the standard of care throughout the surgical community. Laparoscopy for colorectal surgery gained much less acceptance. Factors such as technical complexity, cost, duration of surgery and concerns about oncologic safety influenced the hesitancy in performing this surgery, and it took the surgical community more than a decade to admit that the laparoscopic option is legitimate: it is safe, and it provides the patients with the advantages of minimally invasive surgery, without any surgical or oncologic compromise. This slow process of maturation had a significant advantage, as it allowed this kind of surgery to be thoroughly investigated. Its acceptance is now well based on multitude of data, available from many basic science and clinical studies. Not many procedures in the daily surgical practice are as evidence-based as is laparoscopic colon surgery. The aim of this review was to describe some general aspects of laparoscopic colorectal surgery, and examine the data supporting its use in different procedures for various pathologies, both benign and malignant.

Laparoscopically assisted reversal of Hartmann's procedure.

BACKGROUND: Restoration of bowel continuity after Hartmann's procedure is a major surgical procedure associated with substantial morbidity and occasional mortality. The authors review their experience with laparoscopically assisted reversal of Hartmann's procedure (LARH) to assess difficulties and potential advantages associated with this procedure. METHODS: A retrospective chart review of a prospectively entered database was performed to identify patients who underwent LARH over a period of 7 years. Data regarding demographic and clinical characteristics, surgical details, and postoperative course were reviewed. Specifically, age, gender, diagnosis at initial operation, American Society of Anesthesiology (ASA) score, comorbidities, operative time, conversion, surgical team, complications, postoperative bowel movements, and hospital stay were assessed. All surgeries were performed by six experienced laparoscopic surgeons. RESULTS: A total of 27 patients, 17 men and 10 women, with mean ages of 58.1 and 62.9 years, respectively, underwent LARH. The procedure was laparoscopically completed for 23 patients. Conversion to laparotomy was required for four patients (14.8%) because of dense adhesions after the initial Hartmann's procedure in three patients and rectal perforation in one patient. The median operative time was 226 min, and the median hospital stay was 6 days. The overall morbidity rate was 33% (9 patients), attributable to colostomy site infection in 5 of the 9 patients. One patient required reoperation because of intraabdominal bleeding. No anastomotic leaks or intraabdominal abscesses were recorded. There was no operative mortality. CONCLUSIONS: Laparoscopically assisted reversal of Hartmann's procedure is technically challenging and time consuming. However, in the hands of experienced laparoscopic surgeons, it is safe and associated with a reasonably low conversion rate. Furthermore, the relatively low morbidity rate, short hospital stay, and earlier return of bowel function may be beneficial to patients.

Endoscopic sphincterotomy and temporary internal stenting for bile leaks following complex hepatic trauma.

BACKGROUND: Biliary leak secondary to blunt or penetrating hepatic trauma and damage to the intrahepatic biliary tree remains a challenging problem. The role and safety of endoscopic retrograde cholangiopancreatography (ERCP) and stenting in this setting were studied. METHODS: All trauma victims who developed a bile leak secondary to hepatic trauma were included. Bile leak was defined as the appearance of bile in a surgical wound or intra-abdominal drain after surgery, following percutaneous drainage of a perihepatic bile collection, or evidence of a leak on hepatobiliary scintigraphy. ERCP was performed within 24 h of diagnosis and included biliary sphincterotomy and internal stenting. Recovery was defined as cessation of leakage. RESULTS: Between 1996 and 2004, six patients with penetrating injuries and five with blunt abdominal injuries were treated according to the study protocol. Eight underwent surgery to control bleeding or for additional intra-abdominal injuries. All bile leaks resolved completely within 10 days of ERCP. One patient died from pulmonary sepsis; ten recovered without hepatobiliary sequelae. CONCLUSION: ERCP, biliary sphincterotomy and temporary internal stenting, together with percutaneous drainage of intra-abdominal or intrahepatic bile collections, represent a safe and effective strategy for the management of bile leaks following both blunt and penetrating hepatic trauma.

Alpha-adrenergic receptor (alpha(2 A )) is colocalized in basal forebrain cholinergic neurons: a light and electron microscopic double immunolabeling study.

A variety of data suggest that noradrenaline and acetylcholine may interact in the basal forebrain, however no morphological studies have addressed whether indeed cholinergic neurons express adrenergic receptors. We have investigated the presence of alpha-adrenergic receptor subtype alpha2A-AR in cholinergic neurons of the basal forebrain. Cholinergic neurons were identified with an antibody against choline acetyltransferase and the receptor with a polyclonal antibody raised against a 47 amino acid fragment of the third intracellular loop of the alpha2A-AR. For double labeling at the light microscopic level the Ni-DAB/DAB technique was used, and for electron microscopy an immunoperoxidase/immunogold method was applied. We detected the alpha2A-AR protein in cholinergic as well as in non-cholinergic neurons. Almost half of all cholinergic neurons contained this adrenergic receptor. Double-labeled neurons were distributed throughout the rostro-caudal extent of the basal forebrain cholinergic continuum, including the medial septum, vertical and horizontal diagonal band nuclei, pallidal regions, substantia innominata and the internal capsule. Non-cholinergic neurons that expressed the alpha2A-AR outnumbered cholinergic/alpha2A-AR neurons by several factors. Electron microscopy confirmed the presence of alpha2A-AR in cholinergic neurons in the medial septum, vertical and horizontal diagonal band nuclei. Gold particles (10 nm) indicative of alpha2A-AR were diffusely distributed in the cytoplasm and accumulated in cytoplasmic areas near the Golgi complex and cysterns of the endoplasmic reticulum and were associated with the cellular membranes at synaptic and non-synaptic locations. Since many of the alpha2A-AR+/non-cholinergic neurons we detected are likely to be GABAergic cells, our data support the hypothesis that noradrenaline may act via basal forebrain cholinergic and non-cholinergic neurons to influence cortical activity.

Laparoscopic management of surgical complications after a recent laparotomy.

BACKGROUND: The use of laparoscopy in the scarred abdomen is now well established. However, recent laparotomy and the presence of a fresh abdominal wound usually preclude laparoscopic intervention. Thus, early postlaparotomy complications, which mandate surgical interventions, are usually treated by a second laparotomy. We report our experience with the use of laparoscopy for the treatment of postoperative complications, after open abdominal procedures. METHODS: Fourteen patients were operated for a variety of conditions, and postoperative complications, such as bowel obstruction, intraabdominal infection, or anastomotic insufficiency, were handled laparoscopically. RESULTS: Eleven patients recovered from the acute condition. One patient died from sepsis, one retroperitoneal abscess was missed and later drained percutaneously, and one conversion to open surgery was necessary because of adhesions and lack of working space. CONCLUSIONS: We conclude that a recent laparotomy is not a contraindication for laparoscopic management of acute abdominal conditions. Postlaparotomy complications can be successfully treated by laparoscopy. Avoiding the reopening of the abdominal wound and a second laparotomy may reduce the additional surgical trauma, and thus result in easier recovery.

The impact of a resident's seniority on operative time and length of hospital stay for laparoscopic appendectomy: outcomes used to measure the resident's laparoscopic skills.

BACKGROUND: Laparoscopic appendectomy (LA) frequently is performed by residents during calls. This study aimed at evaluating residents' surgical skills using parameters of operating time, length of hospital stay (LOS), and conversion rate in correlation with the operating team's level of seniority. In addition, this study compared the operating time for LA with that for open appendectomy performed by the same teams, and identified deterministic factors that have an impact on such parameters. METHODS: All records of patients undergoing appendectomy performed by residents alone during a 32-month period were reviewed retrospectively. Eight residents were assigned to two levels of seniority: juniors 3 years (S). Operating time and LOS were compared between the three surgical teams, namely, J/J, J/S, and S/J as operating and assistant surgeons, respectively. Operating time, conversion rates, and LOS were compared for the same team combinations. RESULTS: Residents alone performed 341 (151 laparoscopic and 190 open) appendectomies during on-call hours. Four of the residents had been 3 years or less in residency (J), and four had been in residency more than 3 years (S). The overall mean operating time was 1.33 +/- 0.48 h for LA and 1.2 +/- 0.5 h for open appendectomy (p = 0.016). The operating time correlated with the level of training for both LA (J/J, 1.6 +/- 0.38 h; J/S, 1.41 +/- 0.37 h; S/J, 1. 25 +/- 0.4 h; p = 0.03, ANOVA) and open appendectomy (J/J, 1.53 +/- 0.89 h; J/S, 1.4 +/- 0.63 h; S/J, 0.86 +/- 0.45 h; p = 0.023, ANOVA). The mean LOS was 2.9 +/- 3.1 days for open appendectomy and 2.1 +/- 2.8 days for LA (p = 0.065), and was not different after operation by any of the teams (J/J, J/S, S/J) for either the open or the laparoscopic procedure. CONCLUSIONS: There is a distinct difference in the surgical skills of residents according to level of seniority, as primarily reflected by operating time. Laparoscopic appendectomy requires longer time to perform in a teaching setting, but the most deterministic factor that dictates operating time is the composition of the surgical team rather than the laparoscopic approach.

Laparoscopic distal pancreatectomy.

BACKGROUND: Advanced laparoscopic techniques have been adapted to various surgical pathologies, including pancreatic tumors, with the potential benefits of attenuated surgical trauma, faster recovery, and improved cosmesis. Laparoscopic pancreatic surgery is technically demanding, and thus has not yet gained widespread acceptance. The aim of this study was to review our preliminary experience with laparoscopic distal pancreatectomy for benign and malignant pancreatic pathologies. METHODS: A retrospective chart review of consecutive patients with benign and malignant pancreatic tumors who underwent laparoscopic distal pancreatectomy in a university-affiliated department of surgery between 1997 and 2003 was performed. Data relative to demographic and clinical characteristics, indications for surgery, surgical procedure, and postoperative course were recorded. RESULTS: Laparoscopic distal pancreatectomy was attempted for 12 patients with benign (n = 8) and malignant (n = 4) pancreatic tumors and successfully completed laparoscopically in 75%, of these cases. Six early postoperative complications (two abscesses, two instances of diabetes mellitus, two pancreatic leaks) developed in three patients. The spleen was successfully preserved in 58% of the cases. CONCLUSIONS: This preliminary experience suggests that laparoscopic distal pancreatectomy is a feasible and safe procedure with a morbidity rate comparable with that for the conventional open procedure. However, laparoscopic surgery for malignant pancreatic tumors remains controversial. Larger series with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the treatment of pancreatic pathologies.

Receptor heteromerization in adenosine A2A receptor signaling: relevance for striatal function and Parkinson's disease.

Recently evidence has been presented that adenosine A2A and dopamine D2 receptors form functional heteromeric receptor complexes as demonstrated in human neuroblastoma cells and mouse fibroblast Ltk- cells. These A2A/D2 heteromeric receptor complexes undergo coaggregation, cointernalization, and codesensitization on D2 or A2A receptor agonist treatments and especially after combined agonist treatment. It is hypothesized that the A2A/D2 receptor heteromer represents the molecular basis for the antagonistic A2A/D2 receptor interactions demonstrated at the biochemical and behavioral levels. Functional heteromeric complexes between A2A and metabotropic glutamate 5 receptors (mGluR5) have also recently been demonstrated in HEK-293 cells and rat striatal membrane preparations. The A2A/mGluR5 receptor heteromer may account for the synergism found after combined agonist treatments demonstrated in different in vitro and in vivo models. D2, A2A, and mGluR5 receptors are found together in the dendritic spines of the striatopallidal GABA neurons. Therefore, possible D2/A2A/mGluR5 multimeric receptor complexes and the receptor interactions within them may have a major role in controlling the dorsal and ventral striatopallidal GABA neurons involved in Parkinson's disease and in schizophrenia and drug addiction, respectively.

140 consecutive cases of minimally invasive, radio-guided parathyroidectomy: lessons learned and long-term results.

BACKGROUND: The advent of highly accurate parathyroid imaging and the ever-increasing trend towards minimally invasive procedures have changed considerably the surgical approach to the patient with primary hyperparathyroidism (PHPT) caused by a single parathyroid adenoma. This study analyzes the short- and longer-term results of 140 patients who underwent minimally invasive, radio-guided parathyroidectomy. METHODS: Demographic, clinical, and pre-operative imaging data, operative findings, and short- and long-term results of 140 consecutive patients operated within a 20 months period (8/1999-4/2002), were prospectively entered into a database. Immediate pre-operative sestamibi scintigraphy with skin marking of focal adenoma uptake were followed by intraoperative hand-held gamma probe for the removal of the parathyroid adenoma by unilateral minimal access surgery. Preoperative and surgical data were analyzed and correlated to outcomes, measured by success or failure to cure PHPT, associated morbidity and mortality, predictive value of localizing studies, and postoperative laboratory results in the immediate as well as long-term period. RESULTS: 140 patients, mean age: 55.1 +/- 14.1 years (range 19-88 years), female to male ratio 94:46 with PHPT proven by concomitantly elevated serum calcium and parathormone (PTH) levels, with a single adenoma identified by sestamibi single photon emission tomography (SPECT) scintigraphy and high-resolution sonography, underwent minimally invasive, radio-guided parathyroidectomy. Mean serum levels of preoperative calcium, phosphorus, and PTH were 11.6 +/- 0.8 mg/dL (range 9.1-14), 3.0 +/- 0.3 mg/dL, and 147.1 +/- 94.3 pg/mL (range 68-784), respectively. Overall, in 3 out of 140 patients (2.1%), focused, minimally invasive surgery failed to identify and remove the adenoma. Positive predictive value when both localizing modalities concurred was 99.2%. Positive predictive value of SPECT scan alone was 97.2%. Overall success rate was 97.8% (137/140). 24 hours postoperative mean serum calcium was 9.2 +/- 0.8 mg/dL and at 6 months mean serum calcium, phosphorus, and PTH were 9.4 +/- 1.06 mg/dL, 3.2 +/- 0.8 mg/dL, and 32.1 +/- 11.9 pg/mL, respectively (p = 0.0001). There was no mortality. In 2 patients (1.4%) there was transient vocal cord paresis and there were 8 instances of clinically significant hypocalcemia. In 3 cases (2.1%), a second adenoma manifested itself 9-14 months following surgery and was removed by minimal access procedure. CONCLUSIONS: Minimally invasive, radio-guided focused parathyroidectomy for a single adenoma is safe and effective in curing hyperparathyroidism with a 97% success rate. A second adenoma occurring in less than 3% may be successfully treated with a second minimal access operation. The combined positive predictive value of concurring sestamibi SPECT scintigraphy and sonography of 99.2% may increase success rate, and thus implementing this technique in patients with concurring sonography and scintigraphy may be advocated.

Rectal salami.

We present the case of a 63-year-old man who had inserted a salami into his anal canal for sexual stimulation--the commonest reason for inserting foreign bodies--and who subsequently required a laparotomy for its removal. This common surgical problem requires a thorough medical history, an examination and the use of radiographs for management. Current techniques for removal of such objects are discussed.