Dynamics of PTH levels in the development of post-operative hypoparathyroidism.

BACKGROUND: Post-operative hypoparathyroidism is the most frequent complication after total thyroidectomy. The identification of preoperative predictors could be helpful to identify patients at risk. This study aimed to evaluate the potential influence of preoperative PTH levels and their perioperative dynamics as a predictor of transient, protracted, and permanent post-operative hypoparathyroidism. METHODS: A prospective, observational study that includes 100 patients who underwent total thyroidectomy between September 2018 and September 2020. RESULTS: Transient hypoparathyroidism was present in 42% (42/100) of patients, 11% (11/100) developed protracted hypoparathyroidism, and 5% (5/100) permanent hypoparathyroidism. Patients who presented protracted hypoparathyroidism had higher preoperative PTH levels. The protracted and permanent hypoparathyroidism rate was higher in groups with greater preoperative PTH [0% group 1 (<40 pg/mL) vs. 5.7% group 2 (40-70 pg/mL) vs. 21.6% group 3 (>70 pg/mL); p = 0.03] and (0 vs. 8.3 vs. 20%; p = 0.442), respectively. The rate of protracted and permanent hypoparathyroidism was higher in patients with PTH at 24 h lower than 6.6 pg/mL and whose percentage of PTH decline was higher than 90%. The rate of transient hypoparathyroidism was higher in patients who showed a PTH decline rate of more than 60%. The percentage of PTH increase one week after surgery in patients with permanent hypoparathyroidism was significantly lower. CONCLUSION: The prevalence of protracted hypoparathyroidism was higher in groups with higher preoperative PTH levels. PTH levels 24 h after surgery lower than 6.6 pg/mL and a decline of more than 90% predict protracted and permanent hypoparathyroidism. The percentage of PTH increase a week after surgery could predict permanent hypoparathyroidism.

Patients who presented protracted and permanent hypoparathyroidism had higher preoperative PTH levels.Patients in groups with higher preoperative PTH levels showed higher rates of protracted and permanent hypoparathyroidism.The percentage of PTH variance one week after surgery in patients with permanent hypoparathyroidism was significantly lower and could predict permanent hypoparathyroidism.

Medullary colorectal carcinoma. Do we really know it?

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Medullary colorectal carcinoma. Do we really know it?

Medullary carcinoma (MC) is a recently described subtype of mismatch repair deficient (MMRd) colorectal carcinoma (CRC) which, despite being poorly differentiated by traditional morphological criteria, has been reported to have a good prognosis. By the moment, there is a handful reports about its clinical and pathological features, without agreement between results obtained.

Luschka Duct Leak: An Unexpected Cause of Choleperitoneum After Liver Transplant.

The anatomic variabilities in ducts of Luschka put patients at risk during hepatobiliary surgery. Clinically relevant bile leakage is the cause of 0.4% to 1.2% of complications of cholecystectomies, with almost one-third of complications caused by an inadvertent injury to the duct of Luschka. However, bile leakage from a duct of Luschka after liver transplant is rare, and only one previously published report has been found. Here, we report a case of a 67-year-old male patient who underwent liver transplant for cirrhosis due to hepatitis C virus infection. After transplant, the patient had a choleperitoneum caused by bile leakage from a duct of Luschka. The donor surgery had been performed by surgeons from another institution, and they had also performed the previous cholecystectomy. Fifteen days after surgery, a cholangiography showed bile leakage near the anastomosis. A new intervention was decided. After confirmation of the integrity of the anastomosis, methylene blue was injected through the Kehr's tube, which escaped from a duct of Luschka. The duct was closed, and an intraoperative cholangiography confirmed that the biliary tree was intact. After this intervention, a new bile leakage was observed, resulting in an endoscopic retrograde cholangiopancreatography scan and sphincterotomy. The Kehr's tube was kept open until leak resolution. Although unusual after liver transplant, this complication should be considered in cases of bile leakage. The ducts of Luschka are difficult to see during cholecystectomy in the graft due to perivesicular edema.

Management of Esophageal Perforation: 28-Year Experience in a Major Referral Center.

Esophageal perforation constitutes a surgical emergency. Despite its gravity, no single strategy has been described as sufficient to deal with most situations to date. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 28-year period, to characterize optimal treatment options in this severe disease. A retrospective clinical review of all patients treated for esophageal perforation at Ramón y Cajal Hospital between January 1987 and December 2015 was performed (n = 57). Iatrogenic injury was the most frequent cause of esophageal perforation (n = 32). Abdominal esophagus was the main location (23 patients; 40.4%). Eight patients (14%) were managed with antibiotics and parenteral nutrition. In seven patients (12.3%), an endoscopic stent was implanted. Surgical therapy was performed in 38 patients (66.7%). Morbidity and 90-day mortality rates were 61.4 and 28 per cent, respectively. Five patients were reoperated (8.8%). Median hospital stay was 23.5 days. The mortality rate was higher among patients with spontaneous and tumoral perforation (54.5 and 100%; P = 0.009), delayed diagnosis (>24 hours; P = 0.0001), and abdominal/thoracic location (37.5%; P = 0.05). No statistical differences were found between surgical and conservative/endoscopic management (31% vs 20%; P = 0.205) although hospital staying was longer in surgical group (36.30 days vs 15.63 days; P = 0.029). Esophageal perforation was associated with high morbidity and mortality rates. Global outcomes depend on etiology, site of perforation, and delay in diagnosis. An individualized approach for each patient should be chosen to prevent septic complications of this potentially fatal disease.