Compliance with recommendations on surgery for primary hyperparathyroidism-from guidelines to real practice: results from an Iberian survey.

PURPOSE: Knowledge about compliance with recommendations derived from the positional statement of the European Society of Endocrine Surgeons on modern techniques in primary hyperparathyroidism surgery and the Third International Workshop on management of asymptomatic primary hyperparathyroidism is scarce. Our purpose was to check it on a bi-national basis and determine whether management differences may have impact on surgical outcomes. METHODS: An online survey including questions about indications, preoperative workup, surgical approach, intraoperative adjuncts, and outcomes was sent to institutions affiliated to the endocrine surgery divisions of the National Surgical Societies from Spain and Portugal. A descriptive evaluation of the responses was performed. Finally, we assessed the correlation between the different types of management with the achievement of optimal results, defined as a cure rate equal or greater than the median of all interviewed institutions. RESULTS: Fifty-seven hospitals (41 Spanish, 16 Portuguese) answered the survey. First-ordered imaging tests were neck ultrasound and sestamibi scan. Facing negative or non-concordant results, 44 % of surgeons ordered additional tests before first-time surgery, and 84 % before reoperations. When indicated, selective parathyroidectomy was an acceptable option for 95 % of institutions as first-time surgery and for 51 % in reoperations. Intraoperative parathormone measurements were used by 92 % of departments. The surgical outcomes were good in most institutions (median cure rate 97 %) and were influenced mostly by the presence of an endocrine surgery unit in the surgical department (p = 0.038). CONCLUSIONS: Practice of Iberian endocrine surgeons is consistent with current recommendations on surgery for primary hyperparathyroidism, with variability in some areas.

Are the minimally invasive techniques the new gold standard in thymus surgery for myasthenia gravis? Experience of a reference single-site in VATS thymectomy.

The thymus is the primary lymphoid organ responsible for the maturation and proliferation of T lymphocytes. During the first years of our lives, the activation and inactivation of T lymphocytes occur within the thymus, facilitating the correct maturation of central immunity. Alterations in the positive and negative selection of T lymphocytes have been studied as the possible origins of autoimmune diseases, with Myasthenia Gravis (MG) being the most representative example. Structural alterations in the thymus appear to be involved in the initial autoimmune response observed in MG, leading to the consideration of thymectomy as part of the treatment for the disease. However, the role of thymectomy in MG has been a subject of controversy for many years. Several publications raised doubts about the lack of evidence justifying thymectomy's role in MG until 2016 when a randomized study comparing thymectomy via sternotomy plus prednisone versus prednisone alone was published in the New England Journal of Medicine (NEJM). The results clearly favored the group of patients who underwent surgery, showing improvements in symptoms, reduced corticosteroid requirements, and fewer recurrences over 3 years of follow-up. In recent years, the emergence of less invasive surgical techniques has made video-assisted or robotic-assisted thoracoscopic (VATS/RATS) thymectomy more common, replacing the traditional sternotomy approach. Despite the increasing use of VATS, it has not been validated as a technique with lower morbidity compared to sternotomy in the treatment of MG. The results of the 2016 trial highlighted the benefits of thymectomy, but all the patients underwent surgery via sternotomy. Our hypothesis is that VATS thymectomy is a technique with lower morbidity, reduced postoperative pain, and shorter postoperative hospital stays than sternotomy. Additionally, VATS offers better clinical improvement in patients with MG. The primary objective of this study is to validate the VATS technique as the preferred approach for thymectomy. Furthermore, we aim to analyze the impact of VATS thymectomy on symptoms and corticosteroid dosage in patients with MG, identifying factors that may predict a better response to surgery.

Surgical and oncological results after surgical treatment of patients diagnosed with sarcoma liver metastases.

INTRODUCTION: The presence of liver metastases in sarcomatous tumors is associated with poor prognosis. However, in selected patients, surgical resection has been suggested as a tool to improve survival rates. The aim of our study is to describe postoperative and oncological outcomes after liver resection. METHODS: A retrospective unicentric study was conducted including patients diagnosed with hepatic metastases from soft tissue sarcoma who underwent hepatic resection between 2003-2019. The inclusion criteria were the presence of resectable disease, including synchronic and metachronic lesions. The presence of extra-hepatic controlled disease was not considered unresectable. RESULTS: Nineteen patients underwent liver resection for liver metastasis of 7 different sarcomatous subtypes. Median age was 58-years. Liver metastases were diagnosed a median 25 months after primary tumor diagnosis. Six patients (32%) suffered of synchronic metastases and 12 (63%) were affected of extrahepatic disease. Major hepatectomy was done in 5 (26 %) patients, 8 (42%) minor complications were described. Median follow-up was 33 months. Survival analysis was performed independently for, GIST tumors and non-GIST sarcomas. One, three and five-year survival rate was 100%, 85.7% and 42.9% in non-GIST sarcomas, while Five and ten-year survival rate was 100% and 40% in GIST, respectively. CONCLUSION: Surgical approach of liver metastases of sarcomatous tumors seems to be useful in order to improve survival in selected patients, while been associated to low complications rate. In our cohort, extrahepatic disease rate is high in comparison with series published before, nevertheless survival is comparable. These results support performing surgical resection in selected patients with stable extrahepatic disease.

Identification of Occult Adenomas in Primary Hyperparathyroidism With 18F-fluorocholine PET/CT. / Identificación de adenomas ocultos en hiperparatiroidismo primario con PET-TC 18F-fluorocolina.

INTRODUCTION: Single parathyroid adenomas are the most common cause of primary hyperparathyroidism (PHP) in our population. Parathyroidectomy is still the only potentially curative treatment and requires preoperative localization imaging studies to perform selective surgery. In patients with negative results on conventional tests, PET/CT has demonstrated higher sensitivity rates. METHODS: A prospective cohort study was designed, including 34 patients diagnosed with PHP between 2017 and 2019, candidates for surgery with negative preoperative localization tests with scintigraphy and MIBI SPECT/CT. All patients underwent PET/CT with 18F-Fluorocholine. The clinical, biochemical and postoperative outcome results were compared with a control group of 30 patients with positive standard tests. RESULTS: Hyperfunctional parathyroid tissue was detected in 85% of the patients that had undergone choline PET/CT. The selective resection of the adenoma identified in these patients achieved curative criteria in 87% of the cases without undergoing bilateral cervical surgical exploration. The preoperative levels of PTH, calcemia and gland weight were significantly lower in this group compared to the control group. No differences were identified in cure criteria or approach between the 2groups. CONCLUSION: In our study, choline PET/CT showed higher detection rates compared to the gold standard. The increase provides the opportunity to perform unilateral selected adenoma resection, especially in patients with smaller adenomas associated with lower calcemia and PTH levels and patients with previous cervical surgery.

Diagnostic accuracy of ultrasound and fine-needle aspiration in the study of thyroid nodule and multinodular goitre.

OBJECTIVE: Ultrasonography and cytology obtained by fine-needle aspiration are part of the basic study of the thyroid nodule. Although they are not diagnostic in every case, they are cost-effective methods that inform surgical treatment and its extent. The purpose of this study was to evaluate the accuracy of ultrasonography associated with fine-needle aspiration to predict malignancy in nodular thyroid pathology. DESIGN AND PATIENTS: We collected prospective data from patients undergoing thyroidectomy by single nodule or multinodular goitre between 2006 and 2016. A total of 417 patients were included. Ultrasounds were classified as suspected of malignancy if they had 2 or more of the following characteristics: hypoechogenicity, microcalcifications, intranodular central hypervascularization, irregular margins and poorly defined edges. MEASUREMENTS: Ultrasound and fine-needle aspiration accuracy. RESULTS: In the postoperative study, 40% presented malignant pathology. 33% of patients with nonsuspicious ultrasound and 73% of those with suspicious ultrasound had malignant disease. Among patients with single nodule and suspicious ultrasound, the malignancy rate reached 80%. As for cytology, 100% of Bethesda VI patients, 88% of V, 63% of IV, 31% of III and 12% of II were found to have carcinoma. The combination of the 2 tests showed a high predictive value, particularly in cases of Bethesda IV cytology. CONCLUSIONS: Thyroid cytology provides high predictive value of the presence of carcinoma. The predictive value of ultrasound is also high, mainly in the study of isolated nodules. The combination of the 2 tests results in increased diagnostic accuracy.

Manejo quirúrgico de carcinoma de paratiroides: a propósito de un caso / Surgical management of parathyroid carcinoma: a case report

Resumen Introducción: A pesar de que el carcinoma de paratiroides es uno de los cánceres menos frecuentes del mundo, es importante tenerlo en cuenta al plantear el diagnóstico diferencial del hiperparatiroidismo primario, ya que su diagnóstico temprano tiene repercusiones en el tratamiento y el pronóstico vital del paciente. Caso Clínico: A continuación, se expone un caso clínico de un paciente con sintomatología abigarrada de hiperfunción paratiroidea que, dada la sospecha clínica de carcinoma de paratiroides y la no infiltración de estructuras adyacentes, fue tratado con una paratiroidectomía. Conclusión: Esta cirugía supone una menor morbilidad, sin suponer un detrimento para la supervivencia global del paciente.

Introduction: Parathyroid carcinoma should be taken into consideration among the differential diagnosis of primary hyperparathyroidism, even though it is one of the less common malignant tumours in the world, because an early diagnosis is essential for the treatment and the prognosis of the patient. Case Report: We present the case of a patient whose symptoms were compatible with hyperfunction of parathyroid gland. Due to the malignant disease suspicion and the non-invasion of adjacent tissue, he was treated with a parathyroidectomy. Conclusión: This type of treatment supposes a lower morbidity without decrease in overall survival, according to bibliography.

Resultados obtenidos tras el tratamiento quirúrgico de los pacientes con metástasis hepáticas de sarcomas / Surgical and oncological results after surgical treatment of patients diagnosed with sarcoma liver metastases

Introducción: La presencia de metástasis hepáticas en pacientes con sarcomas se asocia a peor pronóstico, aunque en casos seleccionados la resección de dichas metástasis se ha propuesto para aumentar la supervivencia. El objetivo de este estudio es describir la evolución postoperatoria y los resultados oncológicos tras la resección hepática. Métodos: Se presenta un estudio retrospectivo unicéntrico. Se incluyen pacientes diagnosticados de metástasis hepáticas de sarcoma intervenidos quirúrgicamente entre 2003-2019. Los criterios de inclusión fueron la presencia de enfermedad resecable, la presencia de enfermedad extrahepática controlada no se consideró criterio de irresecabilidad. Resultados: Diecinueve pacientes se sometieron a resección hepática de 7 tipos distintos de estirpes sarcomatosas. La mediana de edad fue de 58 años. Las metástasis se diagnosticaron 25 meses de mediana tras el primario, 6 (32%) presentaron lesiones sincrónicas y 12 (63%) estaban afectos de enfermedad extrahepática. Se realizó hepatectomía mayor en 5 (26%) pacientes; se describieron 8 (42%) complicaciones menores. La mediana de seguimiento fue de 33 meses. El análisis de supervivencia se realizó estratificando en 2 grupos, la supervivencia fue del 100%, 85,7% y del 42,9% al año, a los 3 años y a los 5 años, en los no-GIST, y del 100% y del 40% a los 5 y 10 años en los GIST. Conclusiones: El abordaje quirúrgico de las metástasis hepáticas de sarcoma parece aumentar la supervivencia en pacientes seleccionados, asociando pocas complicaciones. En nuestra serie, la tasa de enfermedad extrahepática es elevada en comparación con series previas, no obstante la supervivencia es equiparable. Dichos resultados apoyan la resección hepática en pacientes con enfermedad extrahepática estable. (AU)

Introduction: The presence of liver metastases in sarcomatous tumors is associated with poor prognosis. However, in selected patients, surgical resection has been suggested as a tool to improve survival rates. The aim of our study is to describe postoperative and oncological outcomes after liver resection. Methods: A retrospective unicentric study was conducted including patients diagnosed with hepatic metastases from soft tissue sarcoma who underwent hepatic resection between 2003 and 2019. The inclusion criteria were the presence of resectable disease, including synchronic and metachronic lesions. The presence of extra-hepatic controlled disease was not considered unresectable. Results: Nineteen patients underwent liver resection for liver metastasis of 7 different sarcomatous subtypes. Median age was 58-yo. Liver metastases were diagnosed a median 25 months after primary tumor diagnosis. Six patients (32%) suffered of synchronic metastases and 12 (63%) were affected of extrahepatic disease. Major hepatectomy was done in 5 (26%) patients, 8 (42%) minor complications were described. Median follow-up was 33 months. Survival analysis was performed independently for, GIST tumors and non-GIST sarcomas. One, three and five-year survival rate was 100%, 85.7% and 42.9% in non-GIST sarcomas, while five and ten-year survival rate was 100% and 40% in GIST, respectively. Conclusions: Surgical approach of liver metastases of sarcomatous tumors seems to be useful in order to improve survival in selected patients, while associated to be of low complications rate. In our cohort, extrahepatic disease rate is high in comparison with series published before, nevertheless survival is comparable. These results support performing surgical resection in selected patients with stable extrahepatic disease. (AU)

Identificación de adenomas ocultos en hiperparatiroidismo primario con PET-TC 18F-fluorocolina / Identification of Occult Adenomas in Primary Hyperparathyroidism With 18F-fluorocholine PET/CT

INTRODUCCIÓN: La principal causa de hiperparatiroidismo primario en nuestro medio es el adenoma paratiroideo único. La paratiroidectomía se considera el único tratamiento potencialmente curativo y requiere de estudios de imagen de localización preoperatorios para un abordaje quirúrgico dirigido. En pacientes con negatividad en pruebas convencionales, la PET-TC colina ha demostrado tasas de sensibilidad superiores respecto al gold-standard. MÉTODOS: Se diseñó un estudio de cohortes prospectivo que incluyó a 34 pacientes con diagnóstico de hiperparatiroidismo primario entre 2017 y 2019, candidatos a cirugía con pruebas de imagen con gammagrafía y SPECT-TC MIBI negativas. A todos se les realizó una PET-TC con 18F-fluorocolina. Los resultados se compararon con un grupo control de 30 pacientes con pruebas convencionales positivas intervenidos en el mismo período. RESULTADOS: La PET-TC colina detectó tejido paratiroideo hiperfuncionante en el 85% de los pacientes con gammagrafía previa negativa. Se realizó resección selectiva del adenoma identificado en estos pacientes, con criterio de curación en el 87% de los casos, sin precisar de exploración cervical bilateral. Los niveles de PTH, calcemia y el peso glandular fueron significativamente menores en este grupo con respecto al control. No se identificaron diferencias respecto al criterio de curación ni a la vía de abordaje en ambos grupos. CONCLUSIÓN: En nuestro estudio, la PET-TC colina demostró tasas superiores de detección que permitieron aumentar el número de pacientes candidatos a cirugía dirigida con disminución de la morbilidad quirúrgica, especialmente en grupos con adenomas de menor tamaño asociados a niveles más bajos de calcemia y PTH preoperatorias y en pacientes con cirugías cervicales previas

INTRODUCTION: Single parathyroid adenomas are the most common cause of primary hyperparathyroidism (PHP) in our population. Parathyroidectomy is still the only potentially curative treatment and requires preoperative localization imaging studies to perform selective surgery. In patients with negative results on conventional tests, PET/CT has demonstrated higher sensitivity rates. METHODS: A prospective cohort study was designed, including 34 patients diagnosed with PHP between 2017 and 2019, candidates for surgery with negative preoperative localization tests with scintigraphy and MIBI SPECT/CT. All patients underwent PET/CT with 18F-Fluorocholine. The clinical, biochemical and postoperative outcome results were compared with a control group of 30 patients with positive standard tests. RESULTS: Hyperfunctional parathyroid tissue was detected in 85% of the patients that had undergone choline PET/CT. The selective resection of the adenoma identified in these patients achieved curative criteria in 87% of the cases without undergoing bilateral cervical surgical exploration. The preoperative levels of PTH, calcemia and gland weight were significantly lower in this group compared to the control group. No differences were identified in cure criteria or approach between the 2 groups. CONCLUSION: In our study, choline PET/CT showed higher detection rates compared to the gold standard. The increase provides the opportunity to perform unilateral selected adenoma resection, especially in patients with smaller adenomas associated with lower calcemia and PTH levels and patients with previous cervical surgery

Perforación intestinal por anisakiasis / Ileal perforation due to anisakiasis

La anisakiasis es una parasitosis con un número creciente de casos en nuestro entorno en los últimos años. Manifestada como abdomen agudo, simula otras etiologías y es habitualmente de indicación quirúrgica. Se expone un caso cuya excepcional forma de presentación fue la perforación ileal (AU)