[Gallbladder metastasis of clear cell renal carcinoma]. / Metástasis de carcinoma renal de células claras en la vesícula biliar.

Clear cell renal cell carcinoma (ccRCC) is an uncommon malignant neoplasm that accounts for 3% of all malignant tumors in adults. This tumor exhibits a high tendency to develop synchronous or metachronous metastases in different anatomical sites. Although gallbladder metastasis from ccRCC is extremely rare, sporadic cases have been reported in the medical literature. We present the case of a 78-year-old woman with a history of undifferentiated nasopharyngeal carcinoma, basal cell carcinoma, and ccRCC in the right kidney. She underwent radical nephrectomy. Histopathological analysis confirmed the diagnosis of ccRCC without vascular or ureteral invasion. Two years later, during follow-up, a nodular lesion was detected in the gallbladder through computed tomography. Despite the absence of symptoms, surgical resection was decided. Laparoscopic cholecystectomy was performed without complications. Histopathological examination confirmed the presence of ccRCC metastasis in the gallbladder. The patient had a favorable outcome and is currently under follow-up without recurrence. Gallbladder metastasis from ccRCC is extremely rare, but surgeons should consider this possibility in patients with a history of ccRCC. Preoperative differential diagnosis between primary gallbladder carcinoma and ccRCC metastasis can be challenging and is often confirmed through histopathological examination. Complete surgical resection is the best treatment option to achieve disease-free survival.

El carcinoma renal de células claras (CRCC) es una neoplasia maligna poco común que representa el 3% de todos los tumores malignos en adultos. Este tumor presenta una alta tendencia a desarrollar metástasis sincrónicas o metacrónicas en diferentes sitios anatómicos. Aunque la metástasis en la vesícula biliar por CRCC es extremadamente rara, se han reportado casos esporádicos en la literatura médica. Presentamos el caso de una mujer de 78 años con antecedentes de carcinoma indiferenciado de cavum, carcinoma basocelular y CRCC en riñón derecho. Se sometió a nefrectomía radical. El análisis histopatológico confirmó el diagnóstico de CRCC sin invasión vascular ni ureteral. Dos años después, durante el seguimiento, se detectó una lesión nodular en la vesícula biliar mediante tomografía computarizada. A pesar de la ausencia de síntomas, se decidió la resección quirúrgica. Se realizó colecistectomía laparoscópica sin complicaciones. El examen histopatológico confirmó la presencia de metástasis de CRCC en la vesícula biliar. La paciente evolucionó favorablemente encontrándose en seguimiento sin recurrencia. La metástasis vesicular por CRCC es extremadamente rara, pero los cirujanos deben considerarla en pacientes con antecedentes de CRCC. El diagnóstico diferencial prequirúrgico entre el carcinoma primario de vesícula biliar y la metástasis de CRCC puede ser desafiante y, a menudo, se confirma mediante el examen histopatológico. La resección quirúrgica completa parece ser la mejor opción de tratamiento para lograr una supervivencia libre de enfermedad.

Metástasis de carcinoma renal de células claras en la vesícula biliar / Gallbladder metastasis of clear cell renal carcinoma

Resumen El carcinoma renal de células claras (CRCC) es una neoplasia maligna poco común que representa el 3% de todos los tumores malignos en adultos. Este tumor presenta una alta tendencia a desarrollar metástasis sincrónicas o metacrónicas en diferentes sitios anató micos. Aunque la metástasis en la vesícula biliar por CRCC es extremadamente rara, se han reportado casos esporádicos en la literatura médica. Presentamos el caso de una mujer de 78 años con antecedentes de carcinoma indiferenciado de cavum, carcinoma basocelular y CRCC en riñón derecho. Se sometió a nefrectomía radical. El análisis histopatológico confirmó el diagnóstico de CRCC sin invasión vascular ni ureteral. Dos años después, du rante el seguimiento, se detectó una lesión nodular en la vesícula biliar mediante tomografía computarizada. A pesar de la ausencia de síntomas, se decidió la resección quirúrgica. Se realizó colecistectomía laparoscópica sin complicaciones. El examen histopatológico confirmó la presencia de metástasis de CRCC en la vesícula biliar. La paciente evolucionó favorablemente encontrándose en seguimiento sin recurrencia. La metástasis vesicular por CRCC es extremadamente rara, pero los cirujanos deben considerarla en pacientes con antecedentes de CRCC. El diagnóstico diferencial prequirúrgico entre el carcinoma primario de vesícula biliar y la metástasis de CRCC puede ser desafiante y, a menudo, se confirma mediante el examen histopatológi co. La resección quirúrgica completa parece ser la mejor opción de tratamiento para lograr una supervivencia libre de enfermedad.

Abstract Clear cell renal cell carcinoma (ccRCC) is an uncom mon malignant neoplasm that accounts for 3% of all malignant tumors in adults. This tumor exhibits a high tendency to develop synchronous or metachronous me tastases in different anatomical sites. Although gallblad der metastasis from ccRCC is extremely rare, sporadic cases have been reported in the medical literature. We present the case of a 78-year-old woman with a history of undifferentiated nasopharyngeal carcinoma, basal cell carcinoma, and ccRCC in the right kidney. She un derwent radical nephrectomy. Histopathological analysis confirmed the diagnosis of ccRCC without vascular or ureteral invasion. Two years later, during follow-up, a nodular lesion was detected in the gallbladder through computed tomography. Despite the absence of symp toms, surgical resection was decided. Laparoscopic cho lecystectomy was performed without complications. Histopathological examination confirmed the presence of ccRCC metastasis in the gallbladder. The patient had a favorable outcome and is currently under follow-up without recurrence. Gallbladder metastasis from ccRCC is extremely rare, but surgeons should consider this possibility in patients with a history of ccRCC. Preoperative differential diagno sis between primary gallbladder carcinoma and ccRCC metastasis can be challenging and is often confirmed through histopathological examination. Complete sur gical resection is the best treatment option to achieve disease-free survival.

Recurrent Papillary Thyroid Carcinoma to the Cervical Lymph Nodes: Outcomes of Compartment-Oriented Lymph Node Resection.

INTRODUCTION: Recurrence of papillary thyroid carcinoma after initial treatment is challenging. Surgical reintervention is recommended, but cure after surgery in uncertain and surgical morbidity may be high. This study evaluates the effect of compartment-oriented lymph node dissection (LND) on clinical and biochemical cure rate as well as the related complications. PATIENTS AND METHODS: All patients who underwent LND for recurrent papillary thyroid carcinoma between 2000 and 2015 were included. Demography, the extent of the initial surgery, usage of 131I, the pattern of recurrence, diagnosis, details of the surgical reintervention, histological findings, surgical morbidity, and clinical and biochemical outcomes were analyzed. RESULTS: There were 11 (12.7%) males and 75 (87.2%) females with a mean age of 42.8 ± 14.6 years. Seventy-seven patients had undergone total thyroidectomy and in 67 (77.9%) some type of LN resection. In 76 (88.3%), 131I was administered after the initial surgery. We localized suspicious lymph nodes by US in all patients, and metastases were documented before surgery by FNA in 63. Seven (8.13%) patients underwent central LND, 63 (73.2%) lateral LND and 16 (18.6%) both, central and lateral LND. Major complications occurred in 6 patients (6.9%). Sixty-two (72.0%) patients received 131I after surgery. A second surgical re-exploration was performed in 30 (34.8%) patients, and 7 patients required 3 or more additional LND. In a mean follow-up of 59.4 ± 39 months, 51 (59.3%) patients are clinically, radiologically and biochemically free of disease. CONCLUSIONS: In this series, compartment-oriented lymph node resection of recurrent papillary thyroid carcinoma leads to a final clinical and biochemical disease-free status of 59.3% with 6.9% of major complications.

Development of an Interactive Outcome Estimation Tool for Laparoscopic Roux-en-Y Gastric Bypass in Mexico Based on a Cohort of 1002 Patients.

BACKGROUND: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is one of the most commonly performed bariatric procedures. Considering significant differences between populations around the world, surgical outcomes may vary widely. The aim of the study was to develop an educational patient-specific interactive application that may estimate the potential outcomes of LRYGB in the Mexican population. METHODS: A database with 76 different variables from 1002 patients who underwent LRYGB at two Mexican Institutions between 1992 and 2014 and had a minimum of 6-month follow-up was analyzed. Descriptive and inferential statistics, as well as a multivariate regression analysis, were performed for the primary analysis. Results were based on four statistical models obtained from the cohort outcomes. A tool was designed to provide estimates of absolute weight loss (AWL) and resolution of four major comorbidities: type 2 diabetes (T2D), high blood pressure (HBP), hypercholesterolemia, and the obstructive syndrome of sleep apnea (OSAS). RESULTS: There were 353 males (35.2%) and 649 females (64.8%) with a mean age of 41.9 ± 12.1 years and a mean preoperative BMI of 45.3 ± 7.9 kg/m2. Mean AWL at 2 years was 39.02 ± 12.7 kg. Mean accumulative percentage of resolution for T2D, HBP, and dyslipidemias at the same time period was 78%, 66.2%, and 84.7%, respectively. Based on these results, the educational tool was developed. CONCLUSIONS: We were able to develop an interactive estimation application to provide a population-based guidance for potential outcomes of LRYGB. This might be useful not only for health professionals but also for patients interested in learning potential outcomes in specific circumstances.

Correction to: Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands.

In the original version of the article, the last three column headings in Table 3 were mislabeled. The original article has been corrected. Following is the corrected table.

Hypoparathyroidism After Total Thyroidectomy: Importance of the Intraoperative Management of the Parathyroid Glands.

BACKGROUND: Total thyroidectomy is the most common surgical procedure for the treatment of thyroid diseases. Postoperative hypocalcemia/hypoparathyroidism is the most frequent complication after total thyroidectomy. The aim of this study was to evaluate the rate of postoperative hypocalcemia and permanent hypoparathyroidism after total thyroidectomy in order to identify potential risk factors and to evaluate the impact of parathyroid autotransplantation. PATIENTS AND METHODS: We performed a retrospective analysis of 1018 patients who underwent total thyroidectomy at our institution between 2000 and 2016. Medical records were reviewed to analyze patient features, clinical presentation, management and postoperative complications. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. Statistical significance was set at p ≤ 0.05. RESULTS: Mean ± SD age was 46.79 ± 15.9 years; 112 (11.7%) were males and 844 (88.3%) females. A total of 642 (67.2%) patients underwent surgery for malignant disease. The rate of postoperative hypocalcemia, transient, protracted and permanent hypoparathyroidism was 32.8%, 14.43%, 18.4% and 3.9%, respectively. Permanent hypoparathyroidism was significantly associated with the number of parathyroid glands remaining in situ (4 glands: 2.5%, 3 glands: 3.8%, 1-2 glands: 13.3%; p ˂ 0.0001) [OR for 1-2 glands in situ = 5.32, CI 95% 2.61-10.82]. Other risk factors related to permanent hypoparathyroidism were obesity (OR 3.56, CI 95% 1.79-7.07), concomitant level VI lymph node dissection (OR 3.04, CI 95% 1.46-6.37) and incidental parathyroidectomy without autotransplantation (OR 3.6, CI 95% 1.85-7.02). CONCLUSIONS: Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia (30.4%) and permanent postoperative hypoparathyroidism (2.79%).

Differences in Body Composition in Patients with Obesity 1 Year After Roux-En-Y Gastric Bypass: Successful Vs. Unsuccessful Weight Loss.

AIM: The aim of this study is to compare the differences in body composition in patients with obesity with successful weight loss (SWL) and unsuccessful (USWL) 1 year after Roux-en-Y gastric bypass (RYGB). METHODS: We included 36 women and 22 men. After stratifying patients according with SWL (defined as ≥ 50% of excess weight loss), fat-free mass (FFM) and fat mass (FM) trajectories were analyzed in each group. RESULTS: The %FM in SWL women (78%) was lower than USWL (36 vs. 44, p < 0.001). The %FM in SWL men (77%) was lower than USWL (27 vs. 38, p < 0.05). A lower %FM before surgery increased the probability of success (p < 0.05). CONCLUSIONS: SWL patients have a lower %FM, and those with lower pre-surgical %FM are more likely to have SWL 1 year after RYGB.

Continuous intraoperative neural monitoring in thyroid surgery: a Mexican experience.

Intraoperative continuous neural monitoring (C-IONM) during thyroid surgery has been recognized as a useful tool to identify and confirm recurrent laryngeal nerve integrity. The aim of the present study is to analyze electromyographic features and thresholds for normal vocal fold function in our initial experience with C-IONM in thyroid surgery. C-IONM was utilized in 57 patients who underwent thyroid surgery between July 2012 and December 2015. EMG parameters were analyzed looking for potential predictors of postoperative vocal fold dismotility. There were 54 females (94.7%) and 3 males (5.3%) with a mean age of 46.7 ± 11.6 years. C-IONM was successfully registered in 89 of 107 nerves at risk (83.1%). Mean basal amplitude was 727.31 ± 471.25 µV and mean final amplitude was 650.27 ± 526.87 µV (P = 0.095, CI 95% 13.83-167.91). Mean basal latency was 5.23 ± 1.42 mS and mean final latency was 5.18 ± 1.50 mS (P = 0.594, CI 95% 0.39-0.24). Four patients had transient postoperative vocal fold paresis. None of these four patients had loss of signal (LOS), three had transient decrease in amplitude, and one had a normal registry throughout the operation. C-IONM is a useful tool to identify patients in whom intraoperative RLN is at risk during surgery. Final amplitude above 500 µV and no LOS is associated with RLN integrity and normal postoperative vocal fold function.

Clinical impact of a 6-week preoperative very low calorie diet on body weight and liver size in morbidly obese patients.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) may be a technically challenging surgical technique when features such as thick abdominal wall and increased liver volume are present. Very low calorie diets in the form of liquid meal replacements given 6 weeks prior to surgery have proven to decrease liver volume. The aim of our study was to assess the effect of a 6-week preoperative low calorie/regular diet on liver volume and body weight in morbidly obese patients. METHODS: A pilot study was carried out in 20 morbidly obese patients with an 800-kcal diet for 6 weeks. They were followed weekly to ensure proper compliance. CT scan was used for determining liver volume every 2 weeks in order to assess the impact of the diet. Baseline values were taken as controls for every patient as tied measures. Statistical analysis was suitable to variable scaling and performed using SPSS v. 20.0. Parametric and non-parametric test for tied measures were done. Any p value lesser than 0.05 or 5% was considered as statistically significant. RESULTS: Twenty patients adhered to the diet intervention for 6 weeks prior to LRYGB. Median ± SD age was 34.5 ± 11.5 years and 17 were female (85%). Heart rate and blood pressure did not vary across the study. Initial median ± SD BMI was 46.02 ± 5.29 kg/m2 (range 38.7-54.8). Repeated and tied measurements across the 6 weeks of treatment within individuals resulted statistically significant for reducing BMI (p < 0.0001). CT scan assessed liver volume initially as a control and in weeks 2, 4 and 6. Parametric and non-parametric assessment for multiple measurements also showed statistical significance among these values (p < 0.0001). Diet tolerability was additionally evaluated with a questionnaire showing more than 80% of acceptability with discrete rates of nausea (15%) and diarrhoea (15%). CONCLUSIONS: Based on our results, we demonstrated that a very low calorie diet with home ingredients is capable for effectively reducing body weight and liver size in morbidly obese patients. This relatively short intervention (4 to 6 weeks) was accomplished in all our patients with a high frequency of compliance and a low rate of secondary effects.

[Primary adrenal malignacies]. / Tumores suprarrenales malignos primarios.

BACKGROUND: Primary adrenal malignancies are rare and have a dismal prognosis. We report our experience in both adrenocortical carcinomas and malignant pheochromocytomas who received medical care at our Institution between 1994 and 2009. MATERIAL AND METHODS: The data bases of hospital discharges, surgery and pathology were reviewed looking for patients with diagnosis of primary adrenal malignant tumors. Clinical presentation, laboratory and image characteristics, surgical details, histopathology findings and outcome were analyzed. RESULTS: A total of eight patients were identified, two men and six women with a mean age of 48.1 +/- 15.7 years (31-80). Six patients presented with adrenocortical carcinomas and two had malignant pheochromocytomas. Of the six cortical tumors four were functioning. Five were stage II, two were stage III and one was stage IV. All patients underwent surgery as initial treatment. Six patients underwent open and two, laparoscopic adrenalectomy. Three patients received adjuvant chemotherapy. In a mean follow up of 32 +/- 27 months, only three patients with stage II were alive and free of the disease. CONCLUSIONS: As in other series, primary adrenal carcinoma in our population proved to be a rare endocrine neoplasm with poor prognosis despite complete surgical resection. Treatment at initial stages provides better outcome.

Potential additional effect of omentectomy on metabolic syndrome, acute-phase reactants, and inflammatory mediators in grade III obese patients undergoing laparoscopic Roux-en-Y gastric bypass: a randomized trial.

OBJECTIVE: To assess the additional effect of sudden visceral fat reduction by omentectomy on metabolic syndrome, acute-phase reactants, and inflammatory mediators in patients with grade III obesity (G-III O) undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). RESEARCH DESIGN AND METHODS: Twenty-two patients were randomized into two groups, LRYGB alone or with omentectomy. Levels of interleukin-6, C-reactive protein, tumor necrosis factor-alpha, leptin, adiponectin, glucose, total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides, as well as clinical characteristics, were evaluated before surgery and at 1, 3, 6, and 12 months after surgery. Results were compared between groups. RESULTS: Baseline characteristics were comparable in both groups. Mean operative time was significantly higher in the group of patients who underwent omentectomy (P < 0.001). Median weight of the omentum was 795 +/- 341 g. In one patient, a duodenal perforation occurred at the time of omentectomy. BMI, blood pressure, glucose, total cholesterol, LDL, and triglycerides significantly improved in both groups at 1, 3, 6, and 12 months of follow-up when compared with basal values. However, there were no consistent statistically significant differences among the groups in terms of metabolic syndrome components, acute-phase reactants, and inflammatory mediators. CONCLUSIONS: Omentectomy does not have an ancillary short-term significant impact on the components of metabolic syndrome and does not induce important changes in the inflammatory mediators in patients undergoing LRYGB. Operative time is more prolonged when omentectomy is performed.

Pancreatic insulinoma: a surgical experience.

BACKGROUND: Small size, high benignity rate, and sporadic nature make insulinomas suitable for laparoscopic resection. On the other hand, occult location or multicentricity mandate open surgery. This study was designed to analyze a series of patients who had pancreatic insulinomas and underwent initial treatment at our institution. METHODS: Clinical records of the 34 patients with pancreatic insulinomas who underwent surgical resection between 1995 and 2007 were reviewed. Main variables for analysis were cure of the disease and surgical complications. RESULTS: There were 20 women and 14 men with a mean age of 40 +/- 13 years. Mean size of the tumors was 2.2 +/- 1 cm. Laparoscopic resection was completed in 14 of 21 patients. Most tumors that were resected by laparoscopy were solitary, benign, and located in the body and tail of the pancreas. Open surgery was selected for 13 patients, including 7 sporadic (5 in the head), 4 related to the MEN syndrome, and 2 malignant tumors. Surgical morbidity occurred in 23 patients. The most common complication was pancreatic fistula (3/13 in open, 4/14 in laparoscopic, and 6/7 in conversions). One patient in the open group died 15 days after surgery from massive PTE. Postoperative normoglycemia was achieved in all patients and persisted for a follow-up period of 4 +/- 3.7 years. CONCLUSIONS: Most insulinomas in our series were small and benign. Tumors that were located in the body and tail were more often amenable for laparoscopic resection. The cure rate was very high. Pancreatic fistula was the most frequent complication.

Maximal weight loss after banded and unbanded laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) leads to significant weight loss and correction of co-morbidities in most patients. Banded LRYGB was designed to enhance weight loss and avoid weight regain. METHODS: A randomized controlled pilot trial was designed to comparatively analyze the results and complications of banded (6.5 cm) and unbanded LRYGB. The present study was an interim analysis focused on morbidity, mortality, and maximal weight loss. RESULTS: The 60 patients were divided into 2 groups. Group 1 underwent unbanded LRYGB (n = 30) and group 2 underwent banded LRYGB (n = 30). No differences were found between the 2 groups in terms of age, gender, body mass index, or operative time. No significant differences were found in the percentage of excess weight loss and body mass index at 6, 12, and 24 months between the 2 groups. The frequency of complications was similar in both groups; 1 patient required band removal because of stenosis at the level of the mesh. CONCLUSION: The weight loss pattern in both groups was similar at 1 and 2 years postoperatively. Proper assessment of weight maintenance and late weight regain will require longer follow-up.

Nelson's syndrome after bilateral adrenalectomy for Cushing's disease.

BACKGROUND: Presentation and outcome of Nelson's syndrome after bilateral adrenalectomy is variable. METHODS: Clinical records of 39 patients who underwent bilateral adrenalectomy for primary or recurrent Cushing's disease during a 15-year period were analyzed for frequency and evolution of Nelson's syndrome. RESULTS: The study included 32 females and 7 males with a mean age of 31 years; 20 patients had a hypophysectomy as the initial procedure, and 19 had an adrenalectomy. Of the group, 17 patients received prophylactic radiation therapy to the pituitary gland. A total of 11 patients, none of whom had received prophylactic radiation therapy, developed Nelson's syndrome (determined by skin hyperpigmentation, elevated serum ACTH levels, and enlargement of a previous pituitary tumor or development of a new tumor in patients with no previous pituitary abnormality) over a mean follow-up period of 53 months. Treatment for Nelson's syndrome included valproic acid, radiation therapy, and hypophysectomy as monotherapy or combined therapy. Of the remaining 28 patients, 10 (7 without prophylactic radio therapy) developed skin hyperpigmentation and increased ACTH levels without a tumor. CONCLUSIONS: Nelson's syndrome is a frequent complication after bilateral adrenalectomy in the absence of prophylactic radiotherapy (28%). The syndrome can be successfully controlled by medical treatment and or radiotherapy; patients rarely require hypophysectomy.

Is intraoperative parathyroid hormone assay mandatory for the success of targeted parathyroidectomy?

BACKGROUND: Minimally invasive parathyroidectomy has become the first surgical option for patients with primary hyperparathyroidism (HPT) in many places. Preoperative localization studies are mandatory, and the use of a quick parathyroid hormone (PTH) assay is highly recommended. The aim of this study was to analyze our initial series of targeted parathyroidectomies. STUDY DESIGN: In a 2-year period, 50 patients underwent unilateral neck exploration for HPT under local anesthesia and light sedation. After biochemical diagnosis, a technetium 99m sestamibi scan was performed on all patients, and cervical ultrasonography was obtained in some patients. Frozen section analysis was used to confirm parathyroid tissue in all patients. There was no biochemical intraoperative evaluation of PTH. Demographics, surgical details, results, and complications were analyzed. RESULTS: There were 35 women and 15 men, with a mean age of 56 years (range 23 to 85 years). Mean preoperative calcium was 11.4 mg/dL (range 10.0 to 14.8 mg/dL), and PTH was 342 pg/mL (range 105 to 2,231 pg/mL). Mean surgical time was 52 minutes (range 30 to 100 minutes), and mean hospital stay was 2 days (range 1 to 7 days). Mean parathyroid weight was 1,000 mg (range 117 to 17,000 mg). Sestamibi scan correctly localized the abnormal gland in 47 patients (94%). There was one postoperative complication (bleeding); two patients required contralateral exploration, and persistent hypercalcemia developed in one that required surgical reintervention. After a mean followup of 12 months (range 3 to 25 months), all patients were normocalcemic. CONCLUSIONS: Targeted parathyroidectomy is safe and effective. Despite the fact that quick intraoperative PTH assay was not used, the cure rate was 98%.

Differential RNA expression profile by cDNA microarray in sporadic primary hyperparathyroidism (pHPT): primary parathyroid hyperplasia versus adenoma.

BACKGROUND: Differential diagnosis between adenoma and hyperplasia in primary hyperparathyroidism (pHPT) remains a dilemma. The aim of this study was to assess differences in transcriptional genomic expression profiles between sporadic (nonfamilial) parathyroid hyperplasia (SPH), adenoma, and normal tissue. METHODS: Parathyroid tissue from 12 patients with parathyroid adenoma, 3 with SPH, and 2 with normal glands was selected for analysis. Histopathology was reviewed in all cases, and all patients with adenomas presented normocalcemia for a minimum of 6 months after one gland resection. Hybridizations were performed in a microarray containing 19,968 human cDNA clones including contiguous replicates. Direct comparisons were performed with reverse labeling for every different pooled sample entity. Expression levels were analyzed using the SAM, SMA, LIMMA, Cluster, and PAM packages in the R environment for statistical computing. RESULTS: There were significant statistical differences between SPH and adenomas. In the direct comparison, a total of 200 genes showed differential expression (P < 0.03): 61 genes were upregulated (> 1.65-fold increase) and 139 were downregulated (> 1.58-fold decrease) with a B value > 4.68 (99.08% probability of real differential expression). When SPH was compared to normal parathyroid tissue, 50 genes were differentially expressed: 42 were upregulated (> 1.89) and 8 were downregulated (> 1.7) with a B > 4.26 (98.6% probability of real differential expression). At least 17 genes were differentially expressed and able to discriminate SPH from adenoma or normal tissue. Upregulated genes were related to apoptosis inhibition, cell proliferation, transcriptional activity and cell adhesion, among other activities. Downregulated genes were mainly related to ion channel activity, lipopolysaccharides, prostaglandin-d synthase, and integral membrane proteins. CONCLUSIONS: Our data suggest that SPH and adenoma have a singular molecular signature that, theoretically, could be used for the differential diagnosis of these entities and normal parathyroid tissue.

Localization of parathyroid adenomas by (99m)Tc-sestamibi scanning: upper neck versus lower neck lesions.

OBJECTIVE: To assess the diagnostic properties of (99m)Tc-sestamibi scanning (dual-phase technique) in patients with primary hyperparathyroidism and to establish the overall efficacy of this imaging technique for localization of an adenoma. METHODS: The medical records of all 131 patients who underwent parathyroid scanning in a tertiary care center between January 1997 and December 2002 were reviewed. The surgical findings were used as the "gold standard" for the diagnosis of parathyroid pathologic conditions. RESULTS: Primary hyperparathyroidism was diagnosed in 87 of the 131 patients (66.4%); of these, 76 underwent surgical treatment. In 44 patients, sestamibi scanning was also done for conditions other than primary hyperparathyroidism. (99m)Tc-sestamibi scanning had a sensitivity of 79.1%, a specificity of 86.7%, a positive predictive value of 88.3%, a false-positive rate of 11.6%, and a false-negative rate of 23.3% for the diagnosis of parathyroid adenoma. Despite the apparent high sensitivity of this scanning technique, only 58.2% of the adenomas were found intra-operatively at the location predicted by the scan. Lesions in the upper neck area were missed more frequently by sestamibi scanning than were those in the lower neck area (13 of 32 versus 1 of 35, respectively) (P<0.05). CONCLUSION: Preoperative localization of parathyroid adenomas with use of (99m)Tc-sestamibi scanning showed a limited capacity to reveal their precise location. Thus, such scans must be complemented with other studies, such as intraoperative ultrasonography and rapid parathyroid hormone assay, to ensure a successful excision if a limited surgical procedure is planned.

[Laparoscopic surgery of pancreas]. / Cirugía laparoscópica de páncreas.

UNLABELLED: In pancreatic diseases, laparoscopic surgery is used to drain fluid collections in infected pancreatic necrosis, abscesses and pseudocysts, for cancer staging, to resect both benign and malignant tumors and for palliative procedures as well. In patients with intractable pain, percutaneous or surgical celiac plexus block can be performed, celiac ganglion alcoholization and torachoscopic splacnicectomy can be done. The laparoscopic approach for staging, allows us to identify very small peritoneal or hepatic metastasis, local invasion or deep hepatic metastasis. The lack of tactile sensation is a disadvantage in the laparoscopic procedures for both staging and resection; which can be compensated utilizing laparoscopic ultrasound. The laparoscopic pancreatic approach for resection is useful to treat neuroendocrine tumors, chronic pancreatitis and cystic neoplasm allowing preservation of the splenic vessels and the spleen. The insulinoma is a treatable laparoscopic tumor given its unique characteristics. The preoperative diagnosis is made by image studies like ultrasound, CAT scans, angiography studies, MRI, endoscopic ultrasound and calcium stimulation test. There are three surgical options: enucleation, distal pancreatectomy with or without preserving the spleen. The most important complication is the pancreatic fistula. CONCLUSIONS: The laparoscopic approach in pancreatic surgery is a feasible and safe one, although, its superiority over the classic open approach has not been demonstrated yet.