Antonietta Palazzo

Impact of parathyroidectomy on cardiovascular outcomes and survival in chronic hemodialysis patients with secondary hyperparathyroidism. A retrospective study of 50 cases prior to the calcimimetics era

BackgroundIn chronic hemodialysis patients with secondary hyperparathyroidism, pathological modifications of bone and mineral metabolism increase the risk of cardiovascular morbidity and mortality. Parathyroidectomy, reducing the incidence of cardiovascular events, may improve outcomes; however, its effects on long-term survival are still subject of active research.We compared, in hemodialysis patients, the results of parathyroidectomy, in terms of cardiovascular outcomes and mortality, with those present in patients following medical treatment only, prior to the diffusion of calcimimetics.MethodsFrom January 2004 to December 2006, 30 hemodialysis patients, affected by severe and unresponsive secondary hyperparathyroidism, underwent parathyroidectomy - 15 total parathyroidectomy and 15 total parathyroidectomy + subcutaneous autoimplantation. During a 5-year follow-up, patients did not receive a renal transplantation and were evaluated for biochemical modifications and major cardiovascular events - death, cardiovascular accidents, myocardial infarction and peripheral vascular disease. Results were compared with those obtained in a control group of 20 hemodialysis patients, affected by secondary hyperparathyroidism, and refusing surgical treatment, and following medical treatment only.ResultsThe groups were comparable in terms of age, gender, dialysis vintage, and comorbidities. Postoperative cardiovascular events were observed in 18/30 - 54% - surgical patients and in 4/20 - 20%- medical patients, with a mortality rate respectively of 23.3% in the surgical group vs. 15% in the control group. Parathyroidectomy was not associated with a reduced risk of cardiovascular morbidity and survival rate was unaffected by surgical treatment.ConclusionsIn secondary hyperparathyroidism hemodialysis patients affected by severe cardiovascular disease, surgery did not modify cardiovascular morbidity and mortality rates. Therefore, in secondary hyperparathyroidism hemodialysis patients, resistant to medical treatment, only an early indication to calcimimetics, or surgery, in the initial stage of chronic kidney disease - mineral bone disorders, may offer a higher long-term survival. Further studies will be useful to clarify the role of secondary hyperparathyroidism in determining unfavorable cardiovascular outcomes and mortality in hemodialysis population.

Total parathyroidectomy without autotransplantation in the surgical treatment of secondary hyperparathyroidism of chronic kidney disease

Background: Subtotal parathyroidectomy (SP) and total parathyroidectomy (TP) with autotransplantation (TPai) are the most commonly adopted operations for the treatment of secondary hyperparathyroidism (2HPT). TP without autotransplantation had previously been confined to patients with advanced dialytic vintage, not eligible for kidney transplantation. Over the years, the procedure has gained more widespread use, but there is no precise knowledge on the immediate and long-term effects. Methods: The authors analyzed the immediate and long-term results of TP without autotransplantation, that is after the systematic removal of at least four glands in 20 patients operated for 2HPT, which were compared with results from TPai in an equal number of cases. Results: An improvement of the typical clinical symptoms was found in every patient undergoing surgery, and a significant reduction in intact PTH (iPTH) serum levels was achieved. Immediate normalization of iPTH level was observed in 11/20 TP cases, hypoparathyroidism in 4/20 and persistent HPT in 5/20 cases. One year of follow-up showed a slight increase in hypoparathyroidism, with 1/20 (5%) recurrence of the disease. One-year TPai results showed a similar percentage of euparathyroidism, as well as a higher long-term recurrence rate (4/20, 20%), although values do not reach statistical significance. Conclusions: TP may still be considered the operation of choice in patients with aggressive forms of 2HPT or of advanced dialytic vintage, with no access to renal transplantation, because of its low recurrence rate (5%). Post-operative aparathyroidism is rare, while hypoparathyroidism and hypocalcemia can be well controled by medical treatment.

Preoperative workup in the assessment of adrenal incidentalomas: outcome from 282 consecutive laparoscopic adrenalectomies

BackgroundTo confirm the efficacy of preoperative workup, the authors analyse the results of a multicentre study in a surgical series of patients diagnosed with an adrenal incidentaloma.MethodsThe retrospective review of a prospectively collected database was conducted. The data was obtained by six surgical units operating in the Campania Region, Italy. Five-hundred and six (506) adrenalectomies performed between 1993 and 2011 on 498 patients were analysed. Final histology in patients with a preoperative diagnosis of incidentaloma and studied according to guidelines (230/282 patients group A) was compared with final histology coming from patients presenting the same preoperative diagnosis but studied not according to guidelines (52/282 patients group B).ResultsIn group A preoperative diagnosis was confirmed at final histology in 76/81 (93.8%) cases of subclinical functioning lesions presenting as an incidentaloma. The preoperative detection of pheochromocytoma and primary adrenocortical cancer (ACC) reached 91.6% and 84.6% respectively. In group B conversion rate to open surgery was higher than in group A (p = 0.02). One pheochromocytoma was missed at preoperative diagnosis whereas one ACC smaller than 4 centimetres (cm) and coming from an incidental lesion was discovered. In both groups a significant association between increasing dimensions of incidentaloma and cancer has been observed (p = 0.001).ConclusionsThis surgical series confirm the high efficacy of suggested guidelines. A significant preoperative detection rate of adrenal lesions presenting as incidentaloma is observed. The unnecessary number of adrenalectomies performed in understudied patients, causing higher morbidity, was not associated to a higher detection rate of primary adrenocortical cancer.

Foregut duplication of the stomach diagnosed by endoscopic ultrasound guided fine-needle aspiration cytology: case report and literature review

Gastric duplication cyst (GDC) with a pseudostratified columnar ciliatedepithelium is an uncommon malformation supposed to originate from a respiratorydiverticulum arising from the ventral foregut. Morphologic appearance of GDCs isvariable, depending on the density of their contents. GDCs are oftenmisdiagnosed as solid masses by imaging techniques, and as a consequence theymay be wrongly overtreated. We report our case of a 56-year-old man with a 5 cmhypoechoic mass of the gastroesophageal junction, incidentally detected bytransabdominal ultrasonography. Neither transabdominal ultrasonography normagnetic resonance clearly outlined the features of the lesion. The patientunderwent endoscopic ultrasound (EUS), which showed a hypoechoic mass arisingfrom the fourth layer of the anterior gastric wall, just below thegastroesophageal junction. According to EUS features, a diagnosis ofgastrointestinal stromal tumor was suggested. EUS-guided fine-needle aspirationcytology revealed a diagnosis of GDC with pseudostratified columnar ciliatedepithelium. We therefore performed an endoscopically-assisted laparoscopicexcision of the cyst.In conclusion, whenever a subepithelial gastric mass is found in the upper partof the gastric wall, a duplication cyst, although rare, should be considered. Inthis case, EUS-guided fine-needle aspiration cytology could provide acytological diagnosis useful to arrange in advance the more adequate surgicaltreatment.

Radiofrequency-Assisted Partial Nephrectomy for Metanephric Adenoma A Case Report and Literature Review

Metanephric adenoma (MA) is a rare benign tumor, diagnosis of which is often carried out after surgical treatment. In case of peripheral lesions, a partial nephrectomy (PN)—either open or laparoscopic may be preferred—and, furthermore, a radiofrequency (RF)-assisted procedure may facilitate adequate hemostasis. In November 2010, the authors performed a RF-assisted PN, according to Habib’s technique, using a 4-needle bipolar device, on a woman affected by a small exophytic MA of the right kidney. Fibrin glue was applied on the cut surface. Postoperative course was uneventful, and discharge was on postoperative day 4. MA is an extremely rare benign tumor with a favorable prognosis. In case of a preoperative cytological diagnosis, a careful follow-up has to be considered. PN represents the standard of care for small exophytic MA, and RF-assisted procedures allow an excellent hemostasis and a rapid conservative resection, with very low morbidity.

Multifocal thoracic chordoma mimicking a paraganglioma.

Chordoma of thoracic vertebras is a very rare locally invasive neoplasm with low grade malignancy arising from embryonic notochordal remnants. Radical surgery remains the cornerstone of the treatment. We describe a case of multifocal T1-T2 chordoma, without bone and disc involvement, incidentally misdiagnosed as a paraganglioma, occurring in a 47-year-old male asymptomatic patient. Neoplasm was radically removed by an endocrine surgeon through a right extended cervicotomy. A preoperative reliable diagnosis of chordoma, as in the reported case, is often difficult. Radical surgery can provide a favorable outcome but, given the high rates of local recurrence of this neoplasm, a strict and careful follow-up is recommended. Although very rare, chordoma should be suggested in the differential diagnosis of the paravertebral cervical masses of unknown origin. Spine surgeon consultation and a FNB should be routinely included in the multidisciplinary preoperative work-up of these neoplasms.

Iatrogenic Bile Duct Injuries Following Laparoscopic Cholecystectomy: Myth or Reality? A Recent Literature Review from 2006 to 2011

At the end of 1980’s, the introduction of mininvasive surgery in clinical practice represented a significant achievement of science and technology research, and laparoscopic cholecystectomy (LC) is nowadays considered a gold standard in the treatment of symptomatic cholelithiasis, according to well known and acknowledged advantages. Although experience is essential to avoiding rates of morbidity in any surgical procedure, in LC the effect of the learning curve does not seem to be the most important factor in minimizing the possibility of iatrogenic bile duct injuries (IBDI) because most of them are related to anatomic misdiagnoses and lapses from basic principles of biliary surgery. IBDI are still a severe complication of biliary surgery, characterized by high morbidity and in some cases significant mortality, often due to the onset of septic complications. They cause a costs rise, related to diagnostic and therapeutic procedures, and they are often associated with distressing litigations, frustrating for surgeons. Factors that may be related to IBDI include certain pitfalls believed to be inherent in the laparoscopic approach: the two-dimensional view and the absence of tactile sensation. However, an analysis of literature until 2005 shows that the “mini-invasive” approach is related to a higher incidence of iatrogenic bile duct injuries (IBDI), both of the main and accessory bile ducts. In 2002 Nuzzo (Nuzzo, 2002), by the means of an Italian survey, proved a three times higher incidence of IBDI than in open cholecystectomy (OC), showing about 300 bile duct injuries out of every 100000 cholecystectomies per year in Italy, pointing out in that country a considerable mortality, in most of cases related to sepsis, with a significant rise of morbidity and healthcare costs ensuing from hospital stay, instrumental investigations, and medium and long-term clinical follow-up. Moreover, IBDI are reported to have late severe aftermath, causing the surgeon frustration and expensive litigation. After accomplishing a learning curve for mini-invasive approach, led by an experienced surgeon, the most significant etiopathogenetic factors of IBDI are the misidentification of the main biliary tree (BT) and wrong manoeuvres to manage bleedings. Treatment of IBDI requires a multidisciplinary approach – namely endoscopy, interventional radiology and surgery – in referral centres,