George H. Sakorafas

Incidental parathyroidectomy during thyroid surgery: an underappreciated complication of thyroidectomy.

The aim of this study was to investigate the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery. Prospective analysis of data in patients following thyroidectomy, specifically regarding the presence of parathyroid parenchyma in the thyroidectomy specimens, the underlying thyroid pathology, and the presence of postoperative hypocalcemia (biochemical/clinical). The clinical records of 158 patients who underwent thyroid surgery during a 2-year period were reviewed. Pathology reports were carefully reviewed for the nature of the underlying thyroid disease, the presence, number, and size of incidentally resected parathyroid gland(s), their location, and possible parathyroid pathology. Serum calcium levels were measured preoperatively, on the day of surgery, and on postoperative days 1, 2, and 7 or even later as needed. Two groups of patients were studied: a group with incidental parathyroidectomy following thyroidectomy (group A) and a group without incidental parathyroidectomy after thyroidectomy (group B). Total/near-total thyroidectomy was the procedure of choice and was performed in 154 patients; total lobectomy and contralateral subtotal lobectomy was performed in the other 4 patients. Elective central neck lymph node dissection was performed in four patients with neck lymphadenopathy. Inadvertently removed parathyroid tissue was found in 28 cases (17.7 %); in 6 of these patients (21%) the parathyroid tissue was intrathyroidal. The percentage of women in group A was significantly higher than in group B (93% vs. 58.5%, P = 0.0002). There was no statistically significant difference between the two groups (A and B) regarding the preoperative (presumed) diagnosis, the histologic diagnosis of thyroid disease (benign versus malignant), the type/extent of surgery, or the presence of thyroiditis. Biochemical and clinical hypocalcemia was observed in 6 (21%) and 2 (7%) patients in group A, respectively, and in 30 (23%) and 8 (6%) patients of group B, respectively. There was no statistically significant difference regarding the occurrence of postoperative hypocalcemia (clinical/biochemical) between the two groups (P = 0.33). Incidental parathyroidectomy is not uncommon following thyroidectomy and in a significant percentage of cases it may be due to the intrathyroidal location of the parathyroid glands. Incidental parathyroidectomy was not found to be associated with postoperative hypocalcemia (biochemical/clinical). Incidental parathyroidectomy may be considered as a potentially preventable but clinically minor complication of thyroid surgery.

Can somatostatin prevent post‐ERCP pancreatitis? Results of a randomized controlled trial

Background:  Acute pancreatitis is the most common complication of endoscopic retrogade cholangiopancreatography (ERCP), occurring in 1–10% of patients. Several substances have been used, with negative results, in an attempt to prevent this complication.

Microscopic papillary thyroid cancer as an incidental finding in patients treated surgically for presumably benign thyroid disease

BACKGROUND Papillary thyroid microcarcinoma (PTMC) is a relatively common entity in the general population. AIM To present our experience with papillary thyroid microcarcinoma of the thyroid as an incidental finding in patients treated surgically for presumably benign thyroid disease. SETTINGS AND DESIGN Histology reports of patients treated surgically with a preoperative diagnosis of benign thyroid disease were reviewed to identify patients with PTMC. Patients with a preoperative diagnosis of thyroid cancer were excluded from this study. MATERIALS AND METHODS The files of 380 patients who underwent surgery for presumably benign thyroid disease in our hospital from 1990 to 2002 were reviewed. Data regarding patients demographics, pathology findings, management and outcomes, were retrieved. STATISTICAL ANALYSIS USED The findings are expressed as absolute numbers and as percentages (with reference to the total number of patients of this study). RESULTS Twenty-seven patients with PTMC diagnosed incidentally following thyroid surgery for presumably benign thyroid disease (27/380 or 7.1%) (multinodular goiter = 20 patients, follicular adenoma = 6 patients, diffuse hyperplasia of the thyroid = 1 patient) are presented. Mean diameter of PTMC was 4.4 mm. In 11 patients (40.7%) the tumor was multifocal and in about half of them tumor foci were found in both thyroid lobes. In two patients the tumor infiltrated the thyroid capsule. Total/near-total thyroidectomy was performed in all these patients (in three as completion thyroidectomy). All patients received suppression therapy and 20 of them underwent adjuvant radioiodine therapy. Follow-up (mean 4.56 years, range 1-12 years) was completed in 25 patients; all these patients were alive and disease-free. CONCLUSIONS PTMC is not an uncommon incidental finding after surgery for presumably benign thyroid disease (7.1% in our series). The possibility of an underlying PTMC should be taken into account in the management of patients with nodular thyroid disease; total/near total thyroidectomy should be considered, at least in selected patients with presumably benign nodular thyroid disease.

Open tension free repair of inguinal hernias; the Lichtenstein technique.

BackgroundRecurrences have been a significant problem following hernia repair. Prosthetic materials have been increasingly used in hernia repair to prevent recurrences. Their use has been associated with several advantages, such as less postoperative pain, rapid recovery, low recurrence rates.MethodsIn this retrospective study, 540 tension-free inguinal hernia repairs were performed between August 1994 and December 1999 in 510 patients, using a polypropylene mesh (Lichtenstein technique). The main outcome measure was early and late morbidity and especially recurrence.ResultsInguinal hernia was indirect in 55 % of cases (297 patients), direct in 30 % (162 patients) and of the pantaloon (mixed) type in 15 % (81 patients). Mean patient age was 53.7 years (range, 18 – 85). Follow-up was completed in 407 patients (80 %) by clinical examination or phone call. The median follow-up period was 3.8 years (range, 1 – 6 years). Seroma and hematoma formation requiring drainage was observed in 6 and 2 patients, respectively, while transient testicular swelling occurred in 5 patients. We have not observed acute infection or abscess formation related to the presence of the foreign body (mesh). In two patients, however, a delayed rejection of the mesh occurred 10 months and 4 years following surgery. There was one recurrence of the hernia (in one of these patients with late mesh rejection) (recurrence rate = 0.2 %). Postoperative neuralgia was observed in 5 patients (1 %).ConclusionLichtenstein tension-free mesh inguinal hernia repair is a simple, safe, comfortable, effective method, with extremely low early and late morbidity and remarkably low recurrence rate and therefore it is our preferred method for hernia repair since 1994.

Molecular Biology of Pancreatic Cancer Potential Clinical Implications

The development of cancer involves the accumulation of genetic changes. Over the past decade there has a been spectacular advance in the knowledge of the genetic basis of cancer, mainly as a result of the rapid progression of molecular technology. Pancreatic cancer is one of the most lethal cancers. Conventional therapeutic approaches have not had much impact on the course of this aggressive neoplasm. Knowledge of the molecular biology of pancreatic cancer has grown rapidly. Genetic alterations in pancreatic cancer include oncogene mutations (most commonly K-ras mutations), and tumour suppressor gene alterations (mainly p53, pl6, DCC, etc.). These advances have potential implications for the management of this deadly disease. Identification of a hereditary genetic predisposition to pancreatic cancer has led to the formation of pancreatic cancer registries around the world, with voluntary screening of patients and siblings for the hereditary genetic defect. Asymptomatic population screening remains unrealistic, but the recognition of subpopulations at increased risk from pancreatic cancer, along with novel and sensitive detection techniques, means that targeted population screening is a step closer. Intensive research is performed in specialist laboratories to improve the diagnostic approach in patients with pancreatic cancer. The use of such molecular diagnostic methods is likely to expand. Molecular biology may also have a great impact on the treatment of pancreatic cancer, and many therapeutic approaches are being evaluated in clinical trials, including gene replacement therapy, genetic prodrug activation therapy, antisense immunology and peptide technology. The ‘molecular age’ has the promise of delivering still better results. This review summarises recent data relating to the molecular biology of pancreatic cancer, with emphasis on features that may be of clinical significance for diagnosis and/or therapy.

Bax and Bcl-2 protein expression in gastric precancerous lesions: immunohistochemical study.

Background and Aims:  Bcl‐2 protein prolongs cell survival in the face of classical apoptotic stimuli, and is considered to be a suppressor of apoptosis. Bax plays a key role in apoptosis by accelerating cell death after an apoptotic stimulus. The aim of our study was to determine the roles of the Bax proapoptotic gene and the Bcl‐2 antiapoptotic gene in the carcinogenesis of gastric cancer.

Paget's disease of the breast: a clinical perspective.

Abstract.Pagets disease of the breast is a rare disorder of the nipple–areola complex often associated with an underlying in situ or invasive carcinoma. Eczematoid changes of the nipple–areola complex and persistent soreness or itching should raise suspicion of this disease. The histogenesis of Pagets disease of the breast continues to be debated and is important when considering treatment options. The epidermotropic theory suggests that Pagets cells are ductal carcinoma cells that have migrated from an underlying carcinoma of the breast parenchyma to the epidermis of the nipple. The in situ transformation theory has been proposed to explain the development of this disorder in patients in whom an underlying mammary carcinoma is not found or when there is an underlying carcinoma anatomically remote from the nipple-areola complex. Pagets cells are believed to arise as malignant cells in the epidermis of the nipple independent from any other pathologic process within the breast parenchyma. The current standard treatment of biopsy-proven Pagets disease involves mastectomy, although some studies have proposed the use of breast conservation therapy for patients in whom an underlying breast cancer cannot be located. We propose a treatment algorithm for patients presenting with Pagets disease of the breast.

Budd-Chiari syndrome and portal vein thrombosis due to right atrial myxoma

Budd-Chiari syndrome is a rare disorder characterized by hepatic venous outflow obstruction. Atrial myxomas account for 35% to 50% of primary cardiac tumors and are usually located in the left atrium. We describe a patient who presented with hepatic inferior vena cava and portal vein thrombosis due to a large myxoma of the right atrium. After the successful removal of the tumor, ascites resolved completely. We conclude that right atrial myxoma is a rare but potentially curable cause of Budd-Chiari syndrome.

Combined carcinoid‐adenocarcinoma tumour of the anal canal

The concurrence of carcinoid admixed with adenocarcinoma in the gastrointestinal tract is an unusual phenomenon that has been reported in the oesophagus, stomach, small intestine, appendix, colon and rectum. These mixed or ‘composite’ tumours seem to be derived from a multipotential stem cell capable of bidirectional differentiation and have a worse prognosis than ordinary adenocarcinoma. Chromogranin‐A staining has increased the diagnostic yield for detecting these tumours and provides information for perioperative management and long‐term prognosis. We describe a patient who presented to our department due to painful defecation. Sigmoidoscopy demonstrated a mass in the anal canal. Histology revealed that the tumour was a mixed carcinoid‐adenocarcinoma neoplasm. To our knowledge, this is the first report in the English literature of a composite tumour of the anal canal.

Occult breast cancer: a challenge from a surgical perspective

Patients with occult breast cancer pose a challenging diagnostic and therapeutic problem. High-quality mammography is required to decrease the false-negative rates. A number of other imaging methods have been proposed in the diagnostic evaluation of these women, including breast ultrasonography, color Doppler ultrasonography, breast magnetic resonance imaging (MRI), positron emission tomography (PET), and scintimammography. Among them, MRI may be particularly helpful, since it has a high sensitivity and may enable preoperative localization of the primary, thus allowing the surgeon to perform a breast conserving procedure. Treatment options include surgery, radiotherapy and watchful waiting (followed by mastectomy when a breast tumor is detected). Systemic therapy is usually required in the management of these patients.