Giacomo Pata

Clinical Appraisal of 99mTechnetium-Sestamibi SPECT/CT Compared to Conventional SPECT in Patients with Primary Hyperparathyroidism and Concomitant Nodular Goiter

BACKGROUND Although 99m Technetium-sestamibi scintigraphy with single-photon emission computed tomography (SPECT) and, recently, hybrid SPECT/computed tomography (CT) have been claimed to be the preoperative methods of choice for parathyroid localization in patients with primary hyperparathyroidism (PHPT) and concomitant nodular goiter (NG), they have never been compared in this setting. We aimed at testing the hypothesis that SPECT/CT may be superior to SPECT for parathyroid localization in patients with PHPT and NG. METHODS Thirty-three patients with PHPT and NG (one or more nodular lesions based on cervical ultrasound) who underwent open parathyroidectomy during 2004-2009 were reviewed. All patients had preoperative 99m Tc-sestamibi planar scintigraphy and SPECT (18 patients) or SPECT/CT (15 patients) after cervical ultrasound. Sensitivity, specificity, and positive predictive value (PPV) (for both correct neck side and quadrant identification) were calculated for the two procedures through comparison with intraoperative findings. In addition, operative times were assessed if the surgery was only for PHPT and not for the six patients who also had thyroidectomy. RESULTS The sensitivity of SPECT/CT for correctly identifying the neck side containing an abnormal parathyroid was 93.7% versus 80% for SPECT (p = 0.21, not significant [ns]). The specificity and PPV for this attribute were 92.9% and 93.7%, respectively, for SPECT/CT versus 87.5% and 88.9%, respectively, for SPECT (p = 0.75 and 0.8, ns). SPECT/CT showed higher sensitivity than SPECT (87.5% vs. 55.6%; p = 0.0001) and higher PPV (87.5% vs. 62.5%; p = 0.0022) for correctly identifying the neck quadrant affected by PHPT. The specificity for this was 95.5% for SPECT/CT versus 88.5% for SPECT (p = 0.26, ns). Mean operative time was shorter after SPECT/CT than after SPECT (38 vs. 56 minutes; p = 0.034). One of the patients having SPECT/CT had double adenomas, and two had ectopic parathyroid glands, all of which were recognized preoperatively by this technique. Two of the patients having SPECT had double adenomas, and two had ectopic glands, none of which were recognized preoperatively. No patient had persistent or recurrent PHPT. CONCLUSIONS SPECT/CT is superior to SPECT for preoperative imaging of patients with PHPT and NG. We recommend the routine use of SPECT/CT for work-up of all such patients, particularly if minimally invasive parathyroid surgery is planned.

Biliopancreatic diversion with transient gastroplasty and duodenal switch: Long-term results of a multicentric study

BACKGROUND Over the years, several modifications of the Scopinaro biliopancreatic diversion (BPD) have been proposed. This retrospective study reported the results of 15 years of follow-up after open BPD coupled with a type of transient gastroplasty (TG) and duodenal switch (DS), termed BPD-TG with DS. METHODS Data were analyzed for 874 patients operated on between January 1993 and May 2010 in 3 different surgical departments. RESULTS The median preoperative body mass index (BMI) was 52 kg/m² (range, 35-63). Comorbidities present were hypertension (57%), hypercholesterolemia (87%), hypertriglyceridemia (53%), type 2 diabetes (35%), and obstructive sleep apnea syndrome (OSAS; 9%). The mean follow-up was 11.9 ± 3.1 years. The median BMI decreased to 33.9 after 1 year from bariatric surgery, 31.1 after 2-5 years, 30.9 after 5-10 years, and 31.2 kg/m² after 10-15 years. Overall, 67% of diabetic patients were able to stop insulin and 97% were able to stop oral hypoglycemic drugs within 1 year. Blood pressure, triglyceride levels, and cholesterol levels became normal in >96% of patients within 1 year. OSAS was resolved within 8 months in all cases. One year postoperatively, but absent thereafter, we observed severe hypoalbuminemia (serum albumin <3 g/dL) in 1.7% of patients and severe iron-deficiency anemia in 1.9%. Incisional hernias were recorded in 30% and anastomotic ulcers in 2.4% of cases. Mortality was null. CONCLUSION Our results suggest considering BPD-TG with DS as a viable bariatric operation, with its excellent long-term outcome in terms of weight loss, improvement of obesity-related diseases, and quality of life.

Preoperative predictors of sternotomy need in mediastinal goiter management

The objective of this study was to identify the preoperative risk factors for patients in need of a sternotomy in the management of mediastinal goiters in order to provide better preoperative planning and patient consent.

Peri-operative complications and hematologic improvement after first-line splenectomy for splenic marginal zone lymphoma

Giacomo Pata, Enrico Damiani, Michele Bartoli, Stefano Solari, Antonella Anastasia, Chiara Pagani, Alessandra Tucci & Fulvio Ragni Department of Medical & Surgical Sciences, 2nd Division of General Surgery, Brescia Civic Hospital, Brescia, Italy, Department of Medical & Surgical Sciences, 2nd Division of General Surgery, University of Brescia School of Medicine, Brescia, Italy, Division of Hematology, Brescia Civic Hospital, Brescia, Italy, and Division of Hematology, University of Brescia School of Medicine, Brescia, Italy

Perivascular epithelioid cell tumor located retroperitoneally with pulmonary lymphangioleiomyomatosis: report of a case.

Perivascular epithelioid cell neoplasms, also known as “PEComas”, are unusual mesenchymal tumors, exhibiting perivascular epithelioid cell differentiation and characterized by a mixed myogenic and melanocytic phenotype. “PEComas not otherwise specified” (PEComas-NOS) are especially rare; consequently, there are no published large series, but only case reports. These tumors are rarely located retroperitoneally, with only about 15 such cases reported. We report a case of pulmonary diffuse lymphangioleiomyomatosis with large retroperitoneal PEComa-NOS in a 66-year-old woman. Treatment consisted only of tumor resection, without additional adjuvant therapy. We emphasize the importance of correct immunohistochemistry diagnosis, initiation of recommended treatment, and surveillance of this unique family of tumors.

Hereditary multiple exostoses and juvenile colon carcinoma: A case with a common genetic background?

A case of obstructing colon cancer is described in a 31‐year‐old patient affected by hereditary multiple exostoses. The association of these two rare conditions, which has never been described previously, and their early onset prompt us to discuss the clinical and genetic elements of a potential common pathogenic scenario. J. Surg. Oncol. 2009;100:520–522.

Iatrogenic rectovaginal fistula repair by trans-perineal approach and pubo-coccygeus muscle interposition

INTRODUCTION Rectovaginal fistula (RVF) is a rare but debilitating complication of a variety of pelvic surgical procedures. PRESENTATION OF CASE We report the case of a 45-year-old female who underwent the STARR (Stapled Trans Anal Rectal Resection) procedure, that was complicated by a 30mm rectovaginal fistula (RVF). We successfully repaired the fistula by trans-perineal approach and pubo-coccygeus muscle interposition. Seven months later we can confirm the complete fistula healing and good patients quality of life. We carefully describe our technique showing the advantages over alternative suturing, flap reconstruction or resection procedures. DISCUSSION This technique is fairly easy to perform and conservative. The pubo-coccygeus muscle is quickly recognizable during the dissection of the recto-vaginal space and the tension-free approximation of this muscle by single sutures represents an easy way of replacement of the recto-vaginal septum. CONCLUSION In our experience the use of pubo-coccygeus muscle interposition is an effective technique for rectovaginal space reconstruction and it should be considered as a viable solution for RVF repair.

Still a role for surgery as first-line therapy of splenic marginal zone lymphoma? RESULTS of a prospective observational study.

AIM Assessment of hematologic improvement, survival and peri-operative morbidity after first-line splenectomy for splenic marginal zone lymphoma (SMZL). METHODS Forty-three patients undergoing open splenectomy were prospectively analyzed. Perioperative clinical course, overall and progression-free survival (OS-PFS) were evaluated. Risk factors analyzed were gender, age, ASA-grade, ECOG performance status, presence of B-symptoms, body mass index, steroidal treatment, serum albumin concentration, IIL-score, operative time, spleen size and weight. RESULTS The median follow-up was 31 months (IQR 15-76; range 24-154). Anemia and thrombocytopenia resolved in 80% of patients at 6 months; in 60% at 2 years. The 5-year and 10-year PFS were 35% and 13% respectively, with a median of 35 months (shorter in patients with ECOG performance status ≥2 and B-symptoms). Nineteen cases (44.2%) had a progression of disease within 2 years. Of these, 14 (32.6%) received adjuvant chemotherapy (mainly R-FC or R-CVP). Progression was attributed to high-grade B lymphoma in 7 (16.3%) patients. The median time between diagnosis and progression to aggressive lymphoma was 25.5 months (range 18.8-81.8). The median time to next treatment was 83.5 months (95% CI 49-118). The 5-year and 10-year OS were 75% and 53% respectively. Mortality was due to disease progression and histological transformation in high-grade B lymphoma in 50% of cases, myelodisplastic syndrome in 15%, recurrence of hemolytic anemia in 15%, Hodgkin lymphoma in 7% and to infections (mainly pulmonary) in the remaining 13% of cases. Post-operative morbidity was 2.3% (1 patient with grade-3 complication). Overall grade ≥2 complication rate was 32.5% (mainly hemorrhagic and pulmonary complications). Spleen weight was the only independent risk factor for morbidity. Mortality was nil. CONCLUSION Splenectomy is safe and effective as regards cytopenia resolution and OS, although disease progression is frequently observed at follow-up. Such results are strictly linked to accurate pre- and post-operative clinical management and optimal anesthesiologic approach.

“Upstream” Chronic Pancreatitis: An Unusual Sequela of Pancreatic Trauma: Reply

I am pleased to see open discussion on the nonoperative management (NoM) of blunt pancreatic trauma with Wirsung disruption, where the letter by Mercantini et al. [1] represents the first contribution on grade IV pancreatic lesions and on the possible delayed evolution of ductal leakage when managed conservatively. The term ‘‘upstream’’ chronic pancreatitis has been coined to describe an unusual sequela of the main pancreatic duct (MPD) lesion, which occurs several months after apparent recovery from the effects of the original trauma. In these patients, progressive fibrosis at the site of injury to the Wirsung results in stricture of the duct, with proximal dilatation and chronic obstructive pancreatitis in the segment of the pancreas drained by the obstructed duct. It is an important reminder that this condition, although rare, does exist and that it may need proper treatment when it occurs. A thorough search of the literature reveals fewer than 15 reported cases on this issue [2–7]. Interestingly, all the cases reported to date underwent surgical management (pancreatoenteric drainage or distal pancreatectomy). One explanation for the relative lack of cases might be that some patients are asymptomatic and therefore undiagnosed. In fact, in the case of acute and complete duct obstruction, the obliterated part of the gland will atrophy within a couple of weeks and become ‘‘silent’’ after the initial symptomatic period. In our series [8], complete obstruction of the MPD was responsible for atrophy of the pancreatic tail and upstream Wirsung dilatation in one patient (diagnosed using contrast-enhanced CT and MR pancreatography 15 months after recovery), whereas the pancreas downstream of the structure was functionally and anatomically normal. This patient experienced recurrent episodes of slight abdominal pain which were managed with analgesic therapy without hospitalization and decreased with time. In the remaining cohort of patients, a progressive upstream pancreatic fibrosis was observed at each CT evaluation, without any clinical symptoms. The development of atrophy of the exocrine parenchyma with fibrosis in the gland with an obstructed duct is a wellknown phenomenon. It leads to the progressive disappearance of the diseased part of the gland. This probably explains the progressive fading out of the recurrent attacks of pain with apparent healing, as reported for our patient. Indeed, with the proximal part of the gland functioning normally, no exocrine or endocrine insufficiency should be observed. This spontaneous and favorable evolution must be kept in mind when surgical treatment is discussed. One patient in the series reported by Laugier et al. [4] underwent a left pancreatectomy and died postoperatively. This type of operation carries a fairly high risk because the diseased left part of the gland is tightly bound to the surrounding organs, especially the blood vessels. In our series [8], the spontaneous disappearance of the symptoms in the patient with upstream MPD dilatation was observed in 1 year without any late recurrence. Therefore, I feel confident in affirming that if the pain is not too severe or too frequent, the best management policy is to wait for spontaneous healing. The contribution of Mercantini et al. [1] is worthwhile as it first explores the sustainability of NoM of grade IV pancreatic injury while drawing our attention to the rare complication of MPD fracture which, if properly managed, can be completely cured. G. Pata (&) Department of Medical and Surgical Sciences, First Division of General Surgery, University of Brescia, Viale Europa 11, 25123 Brescia, Italy e-mail: giacomopata@alice.it