José Antonio Amondarain

Intraoperative Monitoring of Intact PTH in Surgery for Renal Hyperparathyroidism as an Indicator of Complete Parathyroid Removal

In the setting of total parathyroidectomy and autotransplantation surgery (TPT × AS) as treatment for secondary hyperparathyroidism (SHPT), we evaluated whether intraoperative parathyroid hormone (iPTH) monitoring is useful as a reference for total parathyroid removal. We conducted a prospective, open, single value measurement efficacy study of the intraoperative (i.o.) diagnostic monitoring of iPTH in a cohort of surgical patients. All patients (n = 25) underwent TPT × AS at the Department of Surgery, Donostia Hospital from January 2002 to October 2004. The primary outcome measures were kinetics of serum levels of iPTH during surgery and prediction time of the of descent of PTH levels (measured in the clinic on the day of admission and intraoperatively during induction of anesthesia, every 5 and 10 minutes after removal of the adenoma, and again 24 hours thereafter). iPTH levels returned to normal in all 25 patients, decreasing from pathological levels at the beginning of the operation (1302.24 + 424.9 pg/ml) to half (50%) values at the third intraoperative determination, minute 10 (614.8 ± 196.62), becoming undetectable at 24 hours. Frozen sections were conclusive for parathyroid tissue (20.56 + 10.3 minutes after removal). Intraoperative measurement of iPTH is useful in the prediction complete removal of all parathyroid tissue prior to autotransplantation, thus avoiding persistence of disease because of incomplete surgery.

Parathyroid Subcutaneous Pre-sternal Transplantation after Parathyroidectomy for Renal Hyperparathyroidism. Long-term Graft Function

BackgroundIn the setting of total parathyroidectomy (TPT) and parathyroid transplantation (PTx) for renal hyperparathyroidism (RHP), we evaluated long-term parathyroid graft function after subcutaneous pre-sternal transplantation (SCPTx). Because parathyroid glands are surrounded by fatty tissue, we postulated that results of subcutaneous implantation of parathyroid tissue after total parathyroidectomy for renal hyperparathyroidism could be at least as successful as intramuscular grafting, but without its complicationsPatients and MethodsThe study, a prospective open efficacy study of postoperative (po) diagnostic monitoring of intact parathyroid hormone (iPTH) on a cohort of surgical patients, was conducted within a university hospital with a dialysis unit. Thirty five patients (19 women and 16 men) operated on for renal hyperparathyroidism underwent TPT and SCPTx for RHP at the Department of General Surgery and the Department of Nephrology. Donostia Hospital. San Sebastián. Gipuzkoa. Spain, from January 2002 to December 2005. Follow-up ranges from 6 months to 42 months (median: 15.4 months). The main outcome measure was evaluation of graft function by measurement of iPTH plasma level, based on serum levels of iPTH before operation and 24 h and 1, 3, 5, 15, 30, 60, 100, and 150 weeks after surgeryResultsAverage preoperative iPTH values were 1,341.52 + 367.78 pg/ml (mean ± SD) (range: 493–2,180). After TPT and PSCTx, iPTH levels became undetectable in all patients at 24 h. A level of 50 pg/ml was established as the criterion of adequate parathyroid graft function. Values obtained at the various time intervals were as follows: 14.14 + 7.73 1 pg/ml (mean ± SD) (range: 6–36) after 1 week, 53 + 77.33 pg/ml (mean ± SD) (range: 35–74) after 5 weeks, 62.95 + 20.93 pg/ml (mean ± SD) (range: 11–89) after 15 weeks, 77.54 + 18.84 pg/ml (mean ± SD) (range: 24.6–104.2) after 30 weeks, 109.29 + 50.22 pg/ml (mean ± SD) (range: 54–327) after 60 weeks, 134.21 + 128.64 pg/ml (mean ± SD) (range: 43–712) after 100 weeks, and 122.84 + 117.54 pg/ml (mean ± SD) (range: 68–723) after 150 weeks. Prevalence of hypoparathyroidism (intact parathyroid hormone serum level < 20 pg/ml with a normal or low serum calcium concentration) was 2/35 (5.71%) by week 60 and recovered by week 100. Graft-related recurrence was 2.85% (1/35).ConclusionsSubcutaneous pre-sternal transplantation (SCPTx) after TPT and PTx for secondary (RHP) is an adequate method to replace muscular forearm parathyroid transplantation and avoid its complications. Functioning results of total parathyroidectomy and presternal subcutaneous grafting compare favorably with the published data on other surgical techniques proposed for the treatment of renal hyperparathyroidism. Results of long-term follow-up exceed previously reported results.

Esplenosis: una entidad infradiagnosticada

Resumen Introduccion La esplenosis es una entidad observada ocasionalmente y probablemente infradiagnosticada. Material y metodos Se ha realizado un analisis retrospectivo de 303 esplectomias de indicacion variada: 112 traumaticas, 134 por procesos hematologicos, 43 por cirugia resectiva, nueve por parasitosis y/o infecciones y nueve por otras causas. Resultados Se determino la existencia de tejido esplenico funcional en 14 ocasiones. En 9 casos fue confirmada la existencia de tejido esplenico implantado mediante laparotomia debido a los sintomas producidos. Conclusiones La esplenosis es una entidad a considerar en el seguimiento a largo plazo de pacientes esplenectomizados y sintomaticos.

Hernias de Morgagni. Presentación de una serie de casos tratados en la era prelaparoscópica

Resumen Material y metodo Revision de hernias de Morgagni intervenidas en tres hospitales entre los anos 1980 y 2000. Resultados Se recogieron 28 casos, y la proporcion varones/mujeres era de 12/16. La edad media fue para los varones de 45 ± 13,2 (rango: 7-83) y para las mujeres de 51 ± 16,4 (rango: 18-85) anos. Los hallazgos fueron casuales en 13 casos y sintomaticos en 15 ocasiones: cuadros digestivos inespecificos (n = 8), respiratorios (n = 5) y cardiacos (n = 2). Siete casos fueron intervenidos por via toracica. En 19 ocasiones el abordaje fue abdominal y en dos, mediante laparoscopia. Se han observado 6 recidivas (21,4%). Conclusiones Las hernias de Morgagni son poco frecuentes. Existe riesgo elevado de recidiva tras el tratamiento tradicional. La mayoria se trataron de forma electiva y por abordaje abdominal.

The pattern of the descent of PTH measured by intraoperative monitoring of intact-PTH in surgery for renal hyperparathyroidism

BackgroundIn the setting of total parathyroidectomy and autotransplantation surgery (TPTxAS) treatment for secondary hyperparathyroidism (SHPT) we evaluated whether intraoperative parathyroid hormone (iPTH) monitoring is an useful tool as a reference for total parathyroid removal.DesignProspective open single value measurement efficacy study of one intraoperative (i.o.) diagnostic monitoring method (iPTH) on a cohort of surgical patients.PatientsAll patients (n = 35) undergoing TP and SCTx at the Department of Surgery, Donostia Hospital from January 2002 to December 2006.Main outcome measuresSerum levels of iPTH during surgery and prediction time of the of descent of PTH levels (measured in the clinic, at admission day and intra-operatively during induction of anesthesia, and every 5 and 10 minutes after removal of adenoma and 24 hours thereafter) were analyzed.ResultsiPTH levels dropped clearly at ten minutes in all 35 patients and were non-measurable at 24 hours. iPTH decreased from pathological (1302.24 + 424.9 pg/ml) to half (50%) the values at the third intra-operative determination — minute 10 − (614.8 ± 196.62) and was undetectable at 24 hours.ConclusionsIntra-operative measurement of iPTH is useful in the prediction of complete removal of all parathyroid tissue prior to autotransplantation thus avoiding persistence because of incomplete surgery.

Carcinoma epidermoide sobre sinus pilonidal

Introduction: Malignant degeneration of pilonidal sinus is a rare complication observed mainly in recurrent chronic cases of the disease, associated to a very bad prognosis. Material and methods: We have reviewed 367 patients with simple and complicated pilonidal cysts. We found 3 cases (0.81%) of epidermoid carcinoma. Conclusions: Pilonidal sinus epidermoid carcinoma is an infrequent disease predicting for very poor outcome.

Función paratiroidea en el autotrasplante paratiroideo subcutáneo preesternal en el hiperparatiroidismo secundario

Resumen Introduccion Se ha estudiado la funcion del tejido paratiroideo trasplantado subcutaneamente. Pacientes y metodo Se ha estudiado a 13 pacientes sobre una poblacion en dialisis total de 187 (6,95%) pacientes. Se realizo paratiroidectomia total y autotrasplante subcutaneo preesternal. Resultados Descendio el valor de hormona paratiroidea a las 24 h en todos los casos. Se observan concentraciones valorables de hormona paratiroidea a partir de la quinta semana postransplante en todos los casos. Conclusiones El trasplante paratiroideo subcutaneo preesternal es una alternativa valida y funcional en el tratamiento del hiperparatiroidismo secundario.

La imagen del mes

Paciente de 63 años sin antecedentes que acude a urgencias por dolor en hipocondrio derecho. A la exploración presenta taquicardia e insuficiencia respiratoria. En la analı́tica destaca bilirrubina total 6.3 mg/dL a expensas de la directa, GGT 717 U/L y PCR de 15.62 mg/dL. Presenta TC abdominal compatible con coledocolitiasis, sin signos sugestivos de colecistitis aguda. Con diagnóstico de colangitis se inicia antibioterapia y se realiza CPRE con papilotomı́a y colocación de prótesis biliar. Al 4 8 dı́a inicia nuevo cuadro de dolor objetivándose área de celulitis desde la región periumbilical hasta el epigastrio (fig. 1). Se solicita nueva TC (fig. 2) que muestra oclusión y engrosamiento de la vena umbilical, permaneciendo permeable el eje venoso espleno-porto-mesentérico. Se inicia tratamiento anticoagulante, sin precisar drenaje quirú rgico al no presentar absceso a dicho nivel, y por tanto con bajo riesgo de peritonitis generalizada. A los 10 dı́as se retira la prótesis biliar y posteriormente se realiza la colecistectomı́a laparoscópica. c i r e s p . 2 0 1 8 ; 9 6 ( 5 ) : 3 0 2