Laparoscopic adrenalectomy: lessons learned from an initial series of 100 patients.

BACKGROUND: Laparoscopic adrenalectomy is considered the gold standard for the surgical treatment of adrenal disorders in most centers. This study analyzes the authors' experience using the lateral intraperitoneal approach with the first 100 patients. In addition to analyzing the authors' experience, this article aims to contrast it with some published series as an internal quality control. METHODS: In a 10-year period, 138 laparoscopic adrenalectomies were performed for 100 patients. Demographics, surgical results, complications, and long-term outcomes were analyzed. RESULTS: The participants comprised 69 women and 31 men with a mean age of 37 years. The procedures included 24 right, 38 left, and 38 bilateral adrenalectomies. The indications for surgery were Cushing's disease for 33 patients, pheochromocytoma (4 bilateral) for 23 patients, Cushing's syndrome for 18 patients, Conn's syndrome for 16 patients, and incidentaloma for 10 patients. Five procedures were converted to open surgery. Two patients with pheochromocytoma required intraoperative blood transfusion. The mean operative time was 174 min for unilateral adrenalectomies and 302 min for the bilateral procedures. The mean hospital stay was 5 days. Surgical morbidity included an abdominal wall hematoma, a small pneumothorax, and intraabominal bleeding in one patient that required reexploration. There were three operative mortalities not related to the technique. The long-term results showed control of hypercortisolism in all the patients with Cushing's disease and 82% of the patients with pheochromocytoma. Most of the patients with Conn's syndrome (91.4%) became normotensive after surgery. CONCLUSIONS: Laparoscopic adrenalectomy is safe and effective. The complications are mild, and mortality is related more to the patient's condition than to the surgical technique.

Open vs. laparoscopic vertical banded gastroplasty: a case control study with a 1-year follow-up.

BACKGROUND: Vertical Banded Gastroplasty (VBG) is one of the most common bariatric operations. It can be performed by open or laparoscopic methods. The purpose of this study was to analyze and compare the 1-year results of 40 patients who underwent laparoscopic (20) and open (20). METHODS: The initial 20 patients undergoing Laparoscopic VBG and the initial 20 patients in whom an Open VBG were performed in our Institution were comparatively evaluated. Demography, surgical details, complications, and 1-year weight loss were analyzed. RESULTS: Both groups were highly comparable in terms of age, sex and body mass index. Laparoscopic VBG was a more prolonged procedure (median 4 hr) than the open VBG (median 3 hr). On the other hand, hospital stay was significantly shorter in the laparoscopic procedure (median 10 days for the open and 6 days for the laparoscopic). One year weight loss and complications were similar in both groups. CONCLUSIONS: Laparoscopic VBG is a safe procedure for the treatment of morbid obesity. This initial series shows comparable results.

Laparoscopic versus open adrenalectomy in Cushing's syndrome and disease.

BACKGROUND: Adrenalectomy in Cushing's syndrome and disease involves particular risks and complications. The aim of the study was to compare the open posterior and the flank laparoscopic approaches in this group of patients. METHODS: Forty patients who underwent unilateral or bilateral adrenalectomy for hypercortisolism between 1991 and 1999 were studied. Patients were divided as follows: adenoma--5 laparoscopic and 6 open; hyperplasia--17 laparoscopic and 12 open. Demographics, surgical details, outcome, and complications were comparatively analyzed. RESULTS: Patients undergoing laparoscopic or open adrenalectomy were comparable in terms of age, sex distribution, body mass index, respiratory status, and anesthetic risk. Operative time was longer in the laparoscopic group. One patient in the laparoscopic group died of upper gastrointestinal tract bleeding on postoperative day 17. Two patients in the open group and one in the laparoscopic group experienced postoperative complications. Cure of the disease occurred in all patients. Mild abdominal wall pain developed in one patient in each group. No abdominal wall weakness was identified in either group. CONCLUSIONS: Cure rate and operative and long-term morbidity were similar for laparoscopic and open adrenalectomies in this series. However, it is important to emphasize that late complications in our patients who underwent the posterior open procedure were rather infrequent.

Prospective biochemical and scintigraphic evaluation of autografted normal parathyroid glands in patients undergoing thyroid operations.

BACKGROUND: Parathyroid autotransplantation has been widely used in thyroid operations. Few studies have assessed the function of the autotransplanted glands. The aim of this study was to evaluate the success rate, pattern of biochemical function, and scintigraphic appearance of parathyroid autografts in patients undergoing thyroid operations. METHODS: Twelve patients in whom 1 parathyroid gland was removed during thyroid operation were included. Glands were fragmented and autografted into individual pockets in the brachioradialis muscle of the nondominant forearm. Parathyroid hormone levels were measured in both arms the day of autotransplantation and 2 weeks and 1, 2, 3, and 6 months after operation. Serum calcium levels were also measured at each interval. Sestamibi scanning was performed 6 months after operation in 7 patients. RESULTS: All patients were women with a mean age of 50 +/- 15 years. Serum calcium levels were normal during follow-up. A gradient of parathyroid hormone level of 1.5 or greater between the autotransplanted and nontransplanted arm was found in 10 patients. Isotope uptake at the site of the parathyroid autotransplant was demonstrated in the 7 patients evaluated. CONCLUSIONS: Biochemical function of autotransplanted normal parathyroid tissue was documented in 83% of the patients. Sestamibi scintiscans were able to identify the autotransplanted tissue.

Pain relief in chronic pancreatitis by pancreatico-jejunostomy. An institutional experience.

Effective pain control in chronic pancreatitis can be accomplished by pancreatic resection or decompression. Pancreatico-jejunostomy (PJ) has been reported to be effective for relieving pain in 70-80% of cases. The present study analyzes the authors' long-term results with PJ in the treatment of pancreatic pain. From 1963 to 1993, 49 patients with chronic pancreatitis underwent PJ for uncontrollable pain. General and radiologic characteristics, intraoperative findings and outcome were analyzed. Mean age was 35 +/- 13 years, 34 were male and 15 female. Alcoholic etiology was documented in 23 patients. Multiple pancreatic calcifications were found in 33 patients. Pancreatic biopsy confirmed chronic pancreatitis in all patients. There was one operative mortality, 12 minor, and 4 major complications. In a mean follow-up of 6.5 years, 98% of the total group was found to be free of pain. Pancreatic function remained stable in most patients. PJ is an excellent procedure for pain control that allows stable pancreatic function.

Laparoscopic approach to fever of unknown origin.

BACKGROUND: Fever of unknown origin (FUO) is difficult to diagnose. Laparotomy is needed to establish the etiologic diagnosis in some patients. The aim of this study was to analyze the feasibility, safety, and success rate of a protocolized laparoscopy in patients with FUO. METHODS: An extensive clinical evaluation was performed before surgery. Laparoscopy included inspection of the abdominal cavity, wedge and tru-cut liver biopsies, lymph node biopsy, splenectomy, and bone marrow biopsy. Histologic analysis, permanent section analysis, and cultures were obtained. RESULTS: The study involved 15 patients with a mean age of 43.6 +/- 14.5 years. The mean operative time was 122 +/- 60 min. Minor complications occurred in 9% of the patients. One patient bled after surgery and underwent reoperation. There was no operative mortality. An etiologic diagnosis was made in 66% of the patients, and laparoscopy helped to rule out intraabdominal pathology in four additional patients, giving a total success rate of 93%. CONCLUSION: Protocolized laparoscopy in patients with FUO is safe, feasible, and accurate.

Histologic diagnosis of primary hyperparathyroidism: a concordance analysis between three pathologists.

Primary hyperparathyroidism (HPT) is caused by a parathyroid adenoma, hyperplasia or carcinoma. Difficulties for the histologic diagnosis of abnormal parathyroid tissue are widely recognized. The aim of the study was to evaluate the reproducibility of the morphologic criteria through a concordance study among three pathologists. Representative slides of 40 patients with biochemically primary HPT stained with hematoxylin and eosin were blindly reviewed by three pathologists. Each pathologist established the diagnosis of adenoma or hyperplasia and assessed the presence of fat cells, a rim of normal tissue, a fibrous capsule, the number of cellular types, the lobular pattern, and the characteristics of the blood vessel's wall. A concordance analysis was then performed. Mean age of the group was 55 +/- 14 yr, 7 were males and 33 females. The concordance analysis among the three pathologists for the differential diagnosis between adenoma and hyperplasia, showed a Kappa index of 0.5. Kappa index for the presence of fat cells was 0.56, for the presence of a rim of normal tissue 0.47, and for the number of cellular types 0.29. The concordance for the differential diagnosis between parathyroid adenoma and hyperplasia in this study was low.

[Clinical characteristics and course of severe hypercalcemia caused by primary hyperparathyroidism in surgically treated patients]. / Características clínicas y evolución de la hipercalcemia grave por hiperparatiroidismo primario en pacientes intervenidos quirúrgicamente.

AIM: To describe presentation, diagnosis, management and outcome of severe hypercalcemia due to primary hyperparathyroidism in a series of patients. METHODS: Clinical characteristics, presentation, diagnosis, acute preoperative medical management, surgical findings and strategy, short outcome and complications of a cohort of 21 patients with primary hyperparathyroidism (HPT) and severe hypercalcemia (serum calcium > or = 14 mg/dL) were analyzed. This group was selected from a total of 118 patients who underwent surgery for HPT in the time period. RESULTS: Mean age was 47 +/- 17 years-old and the male:female ratio was 4:17. A total of 95% of patients presented one or more symptoms related to hypercalcemia while 62% had an abnormal EKG and 76% also had radiological abnormalities. All patients received intense hydration often associated to diuretics. Uniglandular disease was found in 13 patients, multiglandular involvement was identified in 4 and parathyroid carcinoma was documented in other 4. Normalization of the calcemia was achieved in all patients with benign disease. CONCLUSIONS: Severe hypercalcemia was relatively frequent in our patients with HPT. Most patients were symptomatic and presented radiological or cardiac abnormalities. Surgical normalization of the calcemia was achieved in all patients with benign disease.

[Laparoscopic adrenalectomy in a mexican institution]. / La adrenalectomía laparoscópica en una institución mexicana.

AIM: To analyze the general characteristics and outcome of laparoscopic adrenalectomy in our institution. METHODS: The clinical and intraoperative characteristics, complications and outcome of 29 consecutive patients undergoing lateral transperitoneal laparoscopic adrenalectomy between February 1995 and January 1998 were analyzed. RESULTS: Their mean age was 34 +/- 11 years, 6 were males and 23 females. The most common preoperative diagnosis was recurrent Cushing's disease followed by functioning adenomas and pheochromocytomas. There were 17 unilateral and 12 bilateral adrenalectomies. The mean operative time was 2.5 +/- 1 hours for each gland. Two patients were converted to the open technique. There were two complications: a wound infection and a postsurgery hypoglycemia. The hypoglycemic patient also developed massive upper gastrointestinal bleeding 18 days after surgery and died. The mean postoperative hospital stay was 5 days. In a mean follow-up of one year, recurrence of one pheochromocytoma was seen. CONCLUSION: Laparoscopic adrenalectomy was a safe operation that favored early recovery.

The first 50 cases of primary hyperparathyroidism treated by an endocrine surgery team.

BACKGROUND: Primary hyperparathyroidism (HPT) is a common endocrine disease treated very effectively by surgery. There have been changes in the management of parathyroid surgery in our hospital: since 1991, all patients have been treated by a service of endocrine surgery. OBJECTIVE: To analyze the outcome of the first 50 patients treated in the endocrine surgery service. METHODS: A prospective analysis of clinical characteristics, laboratory studies, intraoperative findings, surgical complications and outcome of 50 patients with primary HPT seen between July 1991 and March 1994 was performed. RESULTS: Ten patients were male and 40 female with a mean age of 53 years. A parathyroid adenoma was found in 43 patients, a parathyroid hyperplasia in five, a double adenoma in one and an adenoma in a supernumerary gland in one patient. Surgical cure of the disease was achieved in 96% of the patients after one surgical procedure and in 100% during the same hospital stay after repeat cervical exploration. CONCLUSIONS: Our results support the use of surgical cervical exploration in the treatment of primary HPT.

[Surgical treatment of multinodular goiter at the Instituto Nacional de la Nutrición Salvador Zubirán]. / Tratamiento quirúrgico de bocio multinodular en el Instituto Nacional de la Nutrición Salvador Zubirán.

BACKGROUND: Surgical treatment is the first option for patients with obstructive multinodular goiter. The extent of the resection and the use of postoperative hormonal therapy are, on the other hand, still under debate. OBJECTIVE: To analyze the results of surgical treatment in 101 patient with multinodular goiter seen from 1980 to 1995. MATERIALS AND METHODS: The clinical/pathologic charts of all patients were reviewed with emphasis to the clinical diagnosis, extent of resection, final histology, type and number of complications, and long-term follow-up. The mean follow-up was three years (range 0.5-12). RESULTS: Ten males and 91 females with a mean age of 46 years were included. Surgery was recommended for a nodule suspicious of malignancy in 60 patients, for airway compression in 33, and for cosmetic reasons in eight. Unilateral lobectomy was performed in 30, bilateral subtotal thyroidectomy in 55 and total thyroidectomy in 16. Postoperative hormone therapy was administrated to 83 patients. Surgical complications occurred in six patients. Four developed permanent hypoparathyroidism and two vocal cord paralysis. There was no operative mortality. A final diagnosis of multinodular goiter was established in 89 whereas 12 had cancer. There were three asymptomatic recurrences in the group with benign lesions (they had undergone unilateral lobectomy followed by hormonal therapy). CONCLUSION: Bilateral subtotal thyroidectomy was the best treatment for multinodular goiter in our series. This procedure had few complications and there was no recurrence of the disease.

Cardiac abnormalities associated with morbid obesity.

Morbidly obese patients are at increased risk for structural and functional abnormalities of the heart. This paper summarizes the effects of obesity on the heart, the effect of weight reduction on cardiac function, the impact of coronary artery disease on cardiac cardiomyopathy, and our experience in obesity heart disease at the Instituto Nacional de la Nutrición in Mexico.