Diagnostic, therapeutic and health-care management protocol in thyroid surgery: a position statement of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB).

PURPOSE: The diagnostic, therapeutic and health-care management protocol (Protocollo Gestionale Diagnostico-Terapeutico-Assistenziale, PDTA) by the Association of the Italian Endocrine Surgery Units (U.E.C. CLUB) aims to help treat the patient in a topical, rational way that can be shared by health-care professionals. METHODS: This fourth consensus conference involved: a selected group of experts in the preliminary phase; all members, via e-mail, in the elaboration phase; all the participants of the XI National Congress of the U.E.C. CLUB held in Naples in the final phase. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up. RESULTS: A clear and concise style was adopted to illustrate the reasons and scientific rationales behind behaviors and to provide health-care professionals with a guide as complete as possible on who, when, how and why to act. The protocol is meant to help the surgeon to treat the patient in a topical, rational way that can be shared by health-care professionals, but without influencing in any way the physician-patient relationship, which is based on trust and clinical judgment in each individual case. CONCLUSIONS: The PDTA in thyroid surgery approved by the fourth consensus conference (June 2015) is the official PDTA of U.E.C. CLUB.

Acute hyperparathyroidism: our experience with 36 cases.

OBJECTIVES: Acute hypercalcemia is a serious condition and represents a physician-surgical emergency: the difficulty in setting a precise diagnosis is due to several possibilities that can cause the condition. It is our purpose to critically evaluate the most actual schemes of treatment and the conditions that could favour the appearance of a hypercalcemic acute crisis. MATERIALS AND METHODS: A retrospective study was performed considering 1321 patients (638 primary HPT, 683 secondary or tertiary HPT) operated from 1975 to December 2002 for Primary, Secondary and Tertiary HPT. RESULTS: It should be noticed that out of 638 cases of Primary HPT this syndrome was present in 35 patients (Ca higher than 15 mg/dl): if you compare these cases with the hyperparathyroid population with calcium less than 15 mg/dl it is possible to observe that a double adenoma or a carcinoma were more frequently found in acute HPT, as the cystic appearance of the lesion. The weight of the adenoma and the PTH assay are strictly correlated with the appearance of this syndrome. The mortality rate is also higher (2.8% to 0.1%) than in the hyperparathyroid patient who underwent parathyroidectomy without hypercalcemic crisis. CONCLUSION: These characteristics suggest that an early operation is mandatory in the patients in whom such a possibility could be expected, before serious involvement of the cardiovascular, renal or neuromuscular system. We can point out the rarity of this syndrome in Secondary and Tertiary HPT: just one case in Secondary out of 683 patients operated on from 1975 until December 2002.

[Surgical treatment of secondary and tertiary hyperparathyroidism]. / Il trattamento chirurgico dell'iperparatiroidismo secondario e terziario.

AIMS: To determine whether, in secondary and tertiary hyperparathyroidism (HPT), quick parathyroid hormone (PTH) assay can be used to prevent persistent or recurrent HPT. Another point was to determine, considering the PTH decrease, the cut-off point at which the operation could be considered well performed. METHODS: A retrospective study was performed evaluating all cases operated on since 1975 until 2002, 679 patients, and particularly the analysis of two groups of patients that underwent surgical treatment for secondary and tertiary HPT in the period 1995-2002. In the first group, (January 1995-October 1999) 207 (167 HPT II and 40 HPT III) neck explorations were performed without the aid of quick PTH assay; in the second group (November 1999-December 2002), 192 (153 HPT II and 39 HPT III) patients were operated on with blood samples for quick PTH. RESULTS: In the first group the percentage of success for secondary HPT was 93.8 versus 96.2 of the second group and 91.7 versus 94.2 for tertiary HPT. In reoperations the percentage of success was 72.7 in the first group and 87.5 in the second one. CONCLUSIONS: There are no substantial differences in persistences or recurrences between subtotal or total parathyroidectomy (PTx) with autotransplantation (AT). The choice of the gland to be left in the neck or transplanted in the forearm and the modalities of doing so are very important, considering the macroscopical and histological aspects. Intraoperative PTH monitoring is a useful aid during the first cervical exploration for secondary and tertiary HPT to prevent the development of persistent or recurrent HPT. The cut-off point for secondary HPT is 70% (in difficult cases with more than 2 assays, 75%) and for tertiary HPT 50% and 70% respectively.

Secondary and tertiary hyperparathyroidism: causes of recurrent disease after 446 parathyroidectomies.

OBJECTIVE: To determine, in a series of patients with secondary and tertiary parathyroid hyperplasia, whether the type of parathyroidectomy (subtotal, total with autotransplantation, or total), the histologic pattern of the parathyroid tissue, or the proliferative index, as determined by Ki-67 analysis, could predispose patients to recurrent hyperparathyroidism. SUMMARY BACKGROUND DATA: Recurrent hyperparathyroidism appears in 10--70% of the patients undergoing surgery for secondary or tertiary hyperparathyroidism. The incidence could be related to the type of operation (Rothmund) but also depends on the histologic pattern of the glands removed (Niederle). METHODS: The retrospective investigation was performed on 446 patients undergoing parathyroid surgery. They were also studied in relation to the possibility of renal transplantation. In this population, two homogeneous groups were subsequently identified (23 patients with clear signs of recurrence and 27 patients apparently cured); they were studied from the histologic and immunohistochemical point of view using antibody to Ki-67 antigen. RESULTS: Subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy produced similar results when considering the regression of osteodystrophy, pruritus, and ectopic calcification. As one could anticipate, total parathyroidectomy increased the incidence of hypoparathyroidism. The percentage of recurrence was 5% to 8% after subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy, and only after incomplete parathyroidectomy did this percentage climb to 34.7%. In the recurrence group, the nodular form was more common and the proliferative fraction detected by Ki-67 was 1.9%; it was 0.81% in the control group. CONCLUSIONS: Because more radical procedures were not more effective, the authors favor a less radical procedure such as subtotal parathyroidectomy. Histologic patterns and proliferative fraction could be useful indices of a recurrence, and these patients should be watched closely after surgery.

Intraoperative decay profile of intact (1-84) parathyroid hormone in surgery for renal hyperparathyroidism--a consecutive series of 80 patients.

BACKGROUND: The utility of intraoperative parathyroid hormone (PTH) monitoring is unclear in the surgical management of renal hyperparathyroidism. Our goal was to define the normal pattern of decay during operation for renal hyperparathyroidism by using the rapid intact (1-84) parathyroid hormone (PTH) assay. METHODS: Eighty consecutive patients underwent neck exploration for renal hyperparathyroidism. Intact PTH levels were monitored with a rapid immunochemiluminometric assay. Samples were assayed at the induction of anesthesia, after dissection before resection, and 20 and 40 minutes after resection. Follow-up ranged from 3 to 24 months. RESULTS: Twenty minutes after resection, PTH levels remained many-fold supranormal. Seventy-seven patients (96%) were cured. Of these, 75 patients (94%) had PTH decay of more than 50% from the preoperative level; 74 (99%) were cured. Only 1 of 3 patients (33%) in whom the PTH level decreased less than 40% from the preoperative level was cured. Two patients had intermediate values and both were cured. CONCLUSIONS: The intraoperative decay of PTH during operation for renal hyperparathyroidism is slower than for patients with normal renal function. However, 20 minutes after resection, a decline to less than 50% of the preoperative level predicts cure, while a level greater than 60% predicts failure.

Optimizing efficacy of quick parathyroid hormone determination in the operating theater.

The usefulness of intraoperative parathyroid hormone (PTH) monitoring has been extensively documented in primary hyperparathyroidism (HPT), whereas few data have been published on its use in reoperations or in secondary and tertiary HPT. We report our initial experience with a rapid (12 min response) PTH immunochemiluminometric assay performed in the operating room during surgery in 12 patients with primary HPT, 16 end-stage renal disease patients with secondary HPT and five kidney transplanted subjects with tertiary HPT. Blood samples were taken at baseline, within 10 min after resection and subsequently at various intervals whenever needed. The mean PTH levels before and after parathyroidectomy were 230.5 pg/mL (range 69-842) and 47.3 pg/mL (range 5-184), respectively, in primary HPT, 855.0 pg/mL (416-1655) and 202.2 pg/mL (53-440) in secondary HPT, and 205.6 pg/mL (116-301) and 45.4 pg/mL (18-97) in tertiary HPT. All patients but one had a significant percentage decline from pre-excision values (mean 76.9%, 76.0%, and 76.1% in primary, secondary and tertiary HPT, respectively). While a reduction of more than 50% was observed in 30 out of 33 patients after the first intraoperative sampling, additional measurements were performed in 10 cases. On-site PTH monitoring with this user-friendly and reliable system has proved helpful in targeting PTH tests to give the surgeon a rapid and accurate assessment of the intervention. The development of optimal PTH sequence strategies with decision-focused analytical and clinical limits will improve the efficacy of "point-of-care" PTH assay and resource utilization.

[Venous ulcers of the lower limbs in the aged. Indications for bandages]. / Le ulcere venose degli arti inferiori negli anziani. Indicazioni al bendaggio.

BACKGROUND: There are many causes of ulcer of the lower limb. In the elderly, venous ulcers and arteriosclerosis often coexist; for this reason pressure bandages might be contraindicated for the risk of precipitating a potentially critical arterial flow. In this work, the conditions which allow a safely treatment with pressure bandage in the elderly are evaluated. MATERIAL AND METHOD: Eleven self-sufficient elderly, with venous ulcerations to one leg only, and ankle pressure/omeral pressure between 0.92 and 0.86 were treated with elastic bandaging of the leg. RESULTS: All patients completed the treatment, with healing of the ulcer obtained in 3-8 months time. So far none of them relapsed. CONCLUSIONS: In the elderly, in selected cases, when Pc/Po > 0.86, pressure bandages can be safely applied to heal the ulcer, without running the risk of endangering arterial circulation.