M.J. Montoya

Utility of fine‐needle aspiration for diagnosis of carcinoma associated with multinodular goitre

background  Fine‐needle aspiration (FNA) is a useful method for evaluating a solitary thyroid nodule; however, this is not an agreed method for a multinodular goitre (MNG). The aim of this study was to assess the utility of preoperative FNA for detecting malignancy in MNG.

Surgical treatment of multinodular goiter in young patients

The objectives of this study were to analyse the results of surgical treatment of multinodular goiter (MG) in a population with under 30 yr of age; (2) to determine the incidence and evolution of related thyroid carcinomas; and (3) to evaluate the rate of relapse. Eighty-one patients operated for MG and under 30 yr of age were analyzed. The control group used consisted of 510 patients between 30 and 60 yr of age, operated on for MG. Cervical surgery for thyroidectomy was performed in all patients. The main outcome measures were postoperative morbidity and mortality; related thyroid carcinoma (number, type and evolution); remission of symptoms; and relapse of goiter. There were neither cases of hypoparathyroidism nor definitive recurrent lesions. In patients with symptoms, there was total remission of these. Although more than half were treated on suspicion of malignancy, only 9% were related to a carcinoma and most were papillary microcarcinomas. The average follow-up was 124±68 mo. Of the 48 patients with partial surgery, 40% had relapse (n=19). After 5 yr, the rates of relapse were 11% for the Dunhill technique, 20% for bilateral subtotal thyroidectomy, 17% for hemithyroidectomy, and 50% for unilateral subtotal hemithyroidectomy. These rates increased by 25%, 50%, 44%, and 60% respectively, after 10 yr, and up to 33%, 50%, 62%, and 70% after 15 yr; 89% of the cases of relapse were operated on—there were two hypoparathyroidisms and two recurrent lesions, one of the cases of recurrent lesion becoming definitive. MG in young people is mainly treated because of the suspicion of malignancy, although this occurs in less than 10% of cases. Surgery can be carried out with a low rate of morbidity, although the results are only definitive with total thyroidectomy, with a high level of relapse when partial techniques are used given that these are patients with long life expectancy.

Acute lower gastrointestinal hemorrhages in geriatric patients.

Age is a risk factor in acute lower gastrointestinal hemorrhages (LGIH). The objectives here were to analyze: (1) diagnostic and therapeutic handling, (2) related morbidity and mortality, (3) the indications for surgery, and (4) the evolution of acute LGIH in patients ≥80 years. Forty-three patients ≥80 years with acute LGIH were reviewed retrospectively. In 86% (n = 37) related co-morbidities were found, in 9% (n = 4) there had been prior colorectal surgery, 19% (n = 8) were antiaggregated, and 7% (n = 3) were anticoagulated. One hundred thirty-two cases of acute LGIH in patients < 80 years were used as a control group. Student’s t test and the chi-square test were applied. On arrival at the emergency ward 11 cases (26%) had hemodynamic instability and 8 of these were stabilized using conservative measures. In 39 cases an endoscopy was performed, allowing for an etiological diagnosis in 59% (n = 23) of cases, above all in those carried out in an urgent or semiurgent way. The arteriography permitted an etiological diagnosis in two of the four cases in which it was carried out. In seven patients (16%) urgent surgery was indicated: three were hemorrhoidectomies, three were subtotal colectomies, and one was a resection of the small intestine. The morbidity rate was 10% (n = 4) in the patients who were not treated and 14% (n = 1) in those treated, with a mortality rate of 8% (n = 3) and 14% (n = 1), respectively. The rate of relapse of bleeding after discharge from hospital was 42% (n = 18), with nine of these needing to be readmitted into hospital. In comparison with the control group, they present a different bleeding etiology (diverticulosis as opposed to the benign anal–rectal and small intestinal pathology in the younger population; P = 0.017), surgery is indicated with less frequency (9 versus 33%; P = 0.007), and there is a higher relapse rate (42 versus 26%; P = 0.045). Acute LGIH in geriatric patients relents in most cases with the use of conservative measures, although there is a high percentage of related morbidity and mortality, and of relapse of bleeding.

Diverticulopexia asociada a miotomía del cricofaríngeo en el tratamiento del divertículo de Zenker. Presentación de 21 casos

Resumen Introduccion El diverticulo de Zenker consiste en la herniacion de la mucosa esofagica a traves del triangulo de Killian. En la actualidad persiste la controversia sobre que tecnica quirurgica se debe realizar en el tratamiento del diverticulo de Zenker, la diverticulopexia o la diverticulectomia y si es necesario o no asociar una miotomia del cricofaringeo. El objetivo de este trabajo es analizar de forma retrospectiva los resultados clinicos y radiologicos obtenidos en un grupo de 21 pacientes intervenidos por diverticulo de Zenker. Pacientes y metodos Entre 1985 y 2001, 21 pacientes diagnosticados de diverticulo de Zenker fueron intervenidos en nuestro servicio de cirugia, se realizo una miotomia del cricofaringeo en todos ellos, y se asocio una diverticulopexia en 19 casos y una diverticulectomia en otro paciente. Resultados El diagnostico se realizo, en todos los casos, amediante transito esofagico baritado, que mostro la presencia del diverticulo con un tamano mediano de 4 cm. El estudio manometrico se realizo en 14 pacientes, se aprecio una asinergia faringoesfinteriana en 3 casos, y el estudio cricofaringeo fue normal en el resto. Ademas, se objetivaron cuatro casos de trastorno motor esofagico primario. Tras la intervencion quirurgica, ningun paciente fallecio a consecuencia de la misma, y presentaron complicaciones 4 pacientes. Tras una mediana de seguimiento de 5,5 anos (rango, 1-16), los resultados clinicos fueron excelentes en 19 pacientes y buenos en 2. Desde el punto de vista radiologico, no se observo ningun caso de recidiva del diverticulo, ni de malignizacion del saco herniario. Conclusiones Segun nuestra experiencia, la diverticulopexia asociada a la miotomia del cricofaringeo es una buena opcion quirurgica en el tratamiento del diverticulo de Zenker.

El personal médico ante la donación hepática de vivo. Estudio de opinión en un hospital español con programa de trasplante hepático de donante vivo

INTRODUCTION: Mortality on the waiting list for liver transplants is high. Consequently, alternatives such as living donation are being sought. Therefore, one of the aspects that should be improved is the attitude of healthcare professionals toward this type of donation in order to create a favorable climate. The objective of this study was to identify attitudes toward living liver donation among physicians in a hospital with a living donor liver transplant program and to analyze the variables that affect these attitudes. PATIENTS AND METHODS: A random sample stratified by type of service (n = 369) was performed among physicians in the hospital. Attitudes were evaluated using a survey validated in our geographical area. In each service, the head of service, or in their absence, an attending physician, was contacted. This person was given an explanation of the study and was made responsible for distributing the questionnaire in selected work shifts. The questionnaire was completed anonymously and was self-administered. Statistical analysis consisted of chi2 test, Students t-test, and a logistic regression analysis. RESULTS: The survey completion rate was 93% (n = 345). Of those surveyed, 15% (n = 52) were in favor of living liver donation whether related or unrelated. This percentage increased to 85% (n = 292) if donation was related. Of the remainder, 8% (n = 27) did not accept living liver donation and the remaining 7% (n = 26) were undecided. This attitude was associated with only two factors: the respondents belief that he or she might need a transplant in the future (p = 0.003) -90% of those who believed that they might need a transplant at some point in the future were in favor-, and the respondents acceptance (if transplantation were necessary at some point in the future) of a living donated liver from a family member or a friend (p = 0.000). Thus, 96% of those who would be prepared to accept a living organ were in favor. In the multivariate analysis, both variables remained significant: the respondents belief that he or she might need a transplant in the future (odds ratio [OR] = 2.36) and, if this were the case, the respondents acceptance of a living donated liver (OR = 7.11). CONCLUSIONS: Attitudes toward living liver donation among physicians in a hospital with a living donor transplant program were highly favorable. Consequently, these health professionals may be a key element for the promotion of living donation at the present time when this form of donation is being encouraged to avoid mortality on waiting lists.INTRODUCTION Mortality on the waiting list for liver transplants is high. Consequently, alternatives such as living donation are being sought. Therefore, one of the aspects that should be improved is the attitude of healthcare professionals toward this type of donation in order to create a favorable climate. The objective of this study was to identify attitudes toward living liver donation among physicians in a hospital with a living donor liver transplant program and to analyze the variables that affect these attitudes. PATIENTS AND METHODS A random sample stratified by type of service (n = 369) was performed among physicians in the hospital. Attitudes were evaluated using a survey validated in our geographical area. In each service, the head of service, or in their absence, an attending physician, was contacted. This person was given an explanation of the study and was made responsible for distributing the questionnaire in selected work shifts. The questionnaire was completed anonymously and was self-administered. Statistical analysis consisted of chi2 test, Students t-test, and a logistic regression analysis. RESULTS The survey completion rate was 93% (n = 345). Of those surveyed, 15% (n = 52) were in favor of living liver donation whether related or unrelated. This percentage increased to 85% (n = 292) if donation was related. Of the remainder, 8% (n = 27) did not accept living liver donation and the remaining 7% (n = 26) were undecided. This attitude was associated with only two factors: the respondents belief that he or she might need a transplant in the future (p = 0.003) -90% of those who believed that they might need a transplant at some point in the future were in favor-, and the respondents acceptance (if transplantation were necessary at some point in the future) of a living donated liver from a family member or a friend (p = 0.000). Thus, 96% of those who would be prepared to accept a living organ were in favor. In the multivariate analysis, both variables remained significant: the respondents belief that he or she might need a transplant in the future (odds ratio [OR] = 2.36) and, if this were the case, the respondents acceptance of a living donated liver (OR = 7.11). CONCLUSIONS Attitudes toward living liver donation among physicians in a hospital with a living donor transplant program were highly favorable. Consequently, these health professionals may be a key element for the promotion of living donation at the present time when this form of donation is being encouraged to avoid mortality on waiting lists.

Estudio clínico e inmunólogico del xenorrechazo en el xenotrasplante ortotópico de hígado de cerdo a babuino

Resumen Introduccion La experiencia de xenotrasplante hepatico (Xtoh) de cerdo a primate no humano es muy limitada. Nuestros objetivos han sido: a) comprobar si el higado de un cerdo transgenico h-DAF evita el rechazo hiperagudo; b) estudiar las funciones metabolicas del higado porcino tras el Xtoh; y c) analizar el perfil clinico, bioquimico e inmunologico del rechazo vascular agudo retardado. Animales y metodos Se realizaron 6 Xtoh de cerdo a babuino, 4 de cerdos no modificados y dos de cerdos transgenicos para h-DAF. Se llevaron a cabo determinaciones hematologicas, de coagulacion, de xenoanticuerpos y del complemento. En el babuino que sobrevivio 8 dias, se estudiaron durante los mismos las poblaciones linfocitarias y la actividad litica de los linfocitos. Resultados Los valores de xIgG e IgM descendieron drasticamente a los 3 min de la reperfusion, sobre todo del CH50, C3 y C4. En los higados no modificados geneticamente aparecio una coagulacion intravascular diseminada por rechazo hiperagudo, con una supervivencia inferior a 12 h. Con los higados h-DAF, la coagulacion se normalizo, con una supervivencia de 8 y 4 dias, falleciendo ambos por insuficiencia respiratoria, sin rechazo hiperagudo. El babuino que sobrevivio 8 dias presento a las 36 h un rechazo vascular agudo retardado, detectandose una estimulacion de las HLA clase I sobre los linfocitos CD3+ y CD19+, que respondio al tratamiento. Conclusiones El higado transgenico h-DAAF previene el rechazo hiperagudo y mantiene la coagulacion en rangos normales en el babuino. El rechazo vascular agudo provoca el cese en la produccion de bilis y un patron mixto de citolisis y colostasis. Los valores de expresion de HLA clase I en los linfocitos podrian ser utiles para diagnosticarlo.