Josefina C. Farra

Submucosal fibrin glue injection for closure of recurrent tracheoesophageal fistula

We describe a new endoscopic technique for closure of recurrent tracheoesophageal fistula in which fibrin glue is injected into the submucosa of the lateral walls of the fistula until the lumen is occluded. This technique eliminates the possibility of the fibrin glue plug becoming dislodged and aspirated. In addition, our technique is simpler and safer in that it does not require diathermy or laser coagulation to deepithelialize the tract, and thereby eliminates the potential for injury to the esophagus and trachea.

Successful parathyroidectomy guided by intraoperative parathyroid hormone monitoring for primary hyperparathyroidism is preserved in mild and moderate renal insufficiency

Background. The effect of altered parathyroid hormone metabolism in renal insufficiency on intraoperative parathyroid hormone monitoring during parathyroidectomy is not well known. This study evaluates operative outcomes in patients undergoing parathyroidectomy guided by intraoperative parathyroid hormone monitoring for primary hyperparathyroidism with mild and moderate renal insufficiency. Methods. A retrospective review of prospectively collected data in 604 patients with sporadic primary hyperparathyroidism undergoing parathyroidectomy guided by intraoperative parathyroid hormone monitoring was performed. Patients were stratified by stage of chronic kidney disease (CKD); those with overt secondary hyperparathyroidism (CKD stages IV and V) were excluded. Rates of bilateral neck exploration, multiglandular disease, and long‐term operative outcomes, including success, failure, and recurrence were compared. Results. Of the 604 patients, 38% (230/604) had normal renal function or stage I CKD, 44% (268/604) had stage II CKD, and 18% (106/604) had stage III CKD. Overall, there were no differences in the rates of bilateral neck exploration or multiglandular disease or in rates of operative success, failure, or recurrence in patients with normal renal function and stages I to III CKD. Conclusion. Parathyroidectomy guided by intraoperative parathyroid hormone monitoring is performed with high operative success uniformly in primary hyperparathyroidism patients with mild and moderate renal insufficiency with outcomes similar to those with normal renal function.

Stricter ioPTH criterion for successful parathyroidectomy in stage III CKD patients with primary hyperparathyroidism

Background: The effects of underlying renal insufficiency on intraoperative parathormone monitoring during parathyroidectomy (PTX) for primary hyperparathyroidism remain unclear. This study evaluates operative outcomes in patients undergoing parathyroidectomy using classic or stricter >50% intraoperative parathormone decrease criterion for primary hyperparathyroidism with mild or moderate renal insufficiency. Methods: A retrospective review of prospectively collected data in 577 patients undergoing parathyroidectomy guided by intraoperative parathormone monitoring for primary hyperparathyroidism was performed. Patients were stratified by stages I to III of chronic kidney disease; those with overt secondary hyperparathyroidism (chronic kidney disease stages IV and V) were excluded. Patients were further subdivided into subgroups based on the classic criterion of a >50% intraoperative parathormone decrease and a stricter criterion of a >50% intraoperative parathormone decrease e to a normal range (<65 pg/mL). Long‐term operative outcomes were compared across the 3 chronic kidney disease groups. Results: Of 577 patients, 38% (221) had normal renal function or stage I chronic kidney disease, 44% (251) had stage II chronic kidney disease, and 18% (105) had stage III chronic kidney disease. In stages I and II chronic kidney disease patients, there were no differences in operative success, failure, recurrence, bilateral neck exploration, and multiglandular disease between classic and stricter criterion groups. In contrast, in stage III chronic kidney disease patients, operative success was greater using the stricter intraoperative parathormone criterion than the classic intraoperative parathormone criterion (100% vs 92%, respectively, P < .05). No other outcome differences were identified between classic and stricter intraoperative parathormone criterion subgroups in stage III chronic kidney disease patients. Conclusion: In patients with primary hyperparathyroidism and concurrent stage III chronic kidney disease, a stricter criterion of a >50% intraoperative parathormone decrease to a normal range should be used for successful parathyroidectomy.

Intraoperative PTH spikes during parathyroidectomy may be associated with multiglandular disease

Background The importance of intraoperative parathormone “spikes” during parathyroidectomy remains unclear. This study compared patients with and without intraoperative parathormone spikes during parathyroidectomy using the criterion of a > 50% parathormone and determined the effect of intraoperative parathormone spikes on operative outcome. Methods We performed a retrospective review of prospectively collected data on 683 patients who underwent parathyroidectomy guided by intraoperative parathormone monitoring. An intraoperative parathormone “spike value” was calculated by subtracting the preincision intraoperative parathormone value from the pre‐excision intraoperative parathormone value (SV = PE − PI). An intraoperative parathormone spike was defined as having a positive spike value ≥9 pg/mL (≥10th percentile of all spike values). Results Of 683 patients, 224 (33%) had intraoperative parathormone spikes and a greater rate of multiglandular disease (8% vs. 3%, P < 0.05) and bilateral neck exploration (10% vs. 5%, P < 0.05) compared with patients without intraoperative parathormone spikes. Overall, there were no differences between parathyroidectomy patients with and without intraoperative parathormone spikes in terms of operative success (98.2% vs. 98.0%), failure (1.8% vs. 2.0%), or recurrence rates (0.4% vs. 1.3%). Conclusions Although the presence of intraoperative parathormone spikes may increase suspicion for multiglandular disease, the ability of intraoperative parathormone monitoring to predict operative success after parathyroidectomy is not affected by spikes.

Small Bowel Neuroendocrine Tumors

Small bowel neuroendocrine tumors (NETs) are the most common neoplasm of the small intestine, and their incidence has increased in the past four decades. A majority of patients have metastatic disease at the time of diagnosis. Biochemical and imaging studies are important in the diagnostic workup and surveillance of small bowel NETs. Surgical resection of the primary tumor with regional lymph nodes and resection of metastatic lesions when possible is the only hope for cure and only possible in about 20 % of cases. In patients with unresectable metastasis, ablative/cytoreductive techniques exist which can achieve tumor control. Patients with systemic disease may be treated with somatostatin analogues as well as new emerging modalities such as peptide-receptor radiotherapy. Advancements in the treatment of metastatic lesions with ablative techniques and targeted medical therapy have improved survival.