Stavros Gourgiotis

Inadvertent parathyroidectomy during thyroid surgery: the incidence of a complication of thyroidectomy

Background and aimsIncidental parathyroidectomy is a complication of thyroid surgery. The aim of this report is to explore the incidence, risk factors, and clinical relevance of inadvertent parathyroidectomy during thyroidectomy.Materials and methodsPatients who underwent thyroidectomy between January 1998 and June 2005 were evaluated. Pathology reports were reviewed for the presence of parathyroid tissue in the thyroidectomy specimens. Information regarding diagnosis, operative details, and postoperative hypocalcemia were collected.ResultsThree hundred and fifteen thyroid procedures were performed: 163 total thyroidectomies, 124 near-total thyroidectomies, and 28 lobectomies. The findings were benign in 240 and malignant in 75 cases. Incidental parathyroidectomy was found in 68 (21.6%) cases: 58 were benign and 10 were malignant. One and two parathyroids were accidentally removed in 46 and 22 patients, respectively. Parathyroid tissue was found in intrathyroidal (33%) and extracapsular (27%) sites. Total/near-total thyroidectomy was not associated with increased risk of incidental parathyroidectomy (P=0.646), and there was no association of inadvertent parathyroidectomy with postoperative hypocalcemia (P=0.859). Thyroid malignancy was associated with decreased incidence of incidental parathyroidectomy (P=0.047).ConclusionInadvertent parathyroidectomy, although not uncommon, is not associated with postoperative hypocalcemia. The type of surgical procedure does not increase the risk of incidental parathyroidectomy, while thyroid malignancy may reduce the incidence of inadvertent parathyroidectomy.

Acute Gastric Volvulus: Diagnosis and Management over 10 Years

Background/Aims: Gastric volvulus is a rare, potentially life-threatening condition, which is difficult to diagnose. This study represents a series of patients with acute gastric volvulus. Methods: All patients presenting with acute gastric volvulus over a 10-year period were reviewed. Results: Twenty-one patients with a median age of 66 years were identified. Acute gastric volvulus was secondary to a paraesophageal hiatus hernia in 16 patients. The major symptoms were abdominal pain, vomiting and upper gastrointestinal bleeding/anemia. The most useful investigations were barium studies and upper gastrointestinal endoscopy. Treatment was open surgery in all patients. There were no major complications and no deaths. Median hospitalization was 8 days. Conclusion: Acute gastric volvulus is a rare condition which requires a high index of suspicion for diagnosis, which is usually based on imaging studies. The treatment is immediate surgery. Volvulus can be treated successfully by open surgery with minimal morbidity and short hospitalization.

The significance of neutrophil/lymphocyte ratio as a possible marker of underlying papillary microcarcinomas in thyroidal goiters: a pilot study

BACKGROUND Preoperatively elevated neutrophil/lymphocyte ratio (NLR) is a negative prognostic factor of survival in various types of cancers. A retrospective study was conducted to examine if preoperative elevation of NLR is associated with higher risk for incidental papillary thyroid microcarcinoma (PTMC). METHODS The study sample consisted of 26 patients with benign goiters, 31 patients with incidental PTMC, 26 patients preoperatively diagnosed with thyroid cancer, and 26 healthy controls. NLRs were compared regarding thyroidal pathology. RESULTS The mean preoperative NLR was significantly elevated in patients with PTMC and thyroid cancer. In addition, the third and fourth quartiles of NLR included only patients with either PTMC or thyroid cancer. No significant differences in NLR occurred between patients with multifocal and unifocal PTMC. CONCLUSIONS NLRs were significantly elevated in patients with incidental PTMC and thyroid cancer. The findings of this pilot study indicate that NLR should be considered an easily accessible biomarker for detecting incidental PTCM; nevertheless, further studies are required to confirm these preliminary results.

Diagnostic evaluation and management of patients with rectus sheath hematoma. A retrospective study

INTRODUCTION Rectus sheath hematoma (RSH) is an uncommon cause of acute abdominal pain. It may mimic a wide variety of intraabdominal disorders thus frequently leading to delay in treatment, increased morbidity or even in an unnecessary surgery. PATIENTS AND METHODS This is a retrospective study of 10 patients with RSH who were treated in our department over a five-year period. There were 6 (60%) men and 4 (40%) women ranging in age from 38 to 86 years, with a mean age of 57.1 years. RESULTS The most common clinical presentation was a palpable abdominal mass associated with abdominal pain. Computed tomography (CT) established the diagnosis in 100% of the cases. 4 patients had type I hematoma, 3 had type II hematoma and 3 had type III hematoma. Anticoagulation therapy was the most common predisposing factor. Conservative treatment was effective in 90% of the cases and in all cases of spontaneous RSHs in patients under anticoagulation therapy. One patient, who developed a very severe RSH following an abdominal injection of low-molecular-weight heparin (LMWH), underwent surgery. All patients with type III hematoma required blood transfusion. CONCLUSIONS RSH should be considered in the differential diagnosis of the elderly patients under anticoagulation therapy presenting with acute abdominal pain and a palpable mass. CT is the diagnostic modality of choice. Conservative treatment is feasible in most cases. Early diagnosis is mandatory in order to avoid morbidity or unnecessary surgery. In order to prevent a traumatic RSH, trocar insertion under direct vision during laparoscopic surgery and careful attention in the abdominal administration of LMWH are essential.

The effects of tobacco smoking on the incidence and risk of intraoperative and postoperative complications in adults

INTRODUCTION Despite the warnings of health hazards of cigarette smoking, still one third of the population in industrial countries smoke. This review was conducted with the aim of exploring the effects of preoperative tobacco smoking on the risk of intra- and postoperative complications and to identify the value of preoperative smoking cessation. METHODS The databases that were searched included The Cochrane Library Database, Medline, and EMBASE. Articles were also identified through a general internet search using the Google search engine. The incidence or risk of different types of intra- and postoperative complications were used as outcome measures. RESULTS Tobacco smoking has a negative effect on surgical outcome, as has been found to be a risk factor for the development of complications during and after many types of surgery, even in the absence of chronic lung disease. Furthermore, the long-term health hazards of smoking reduce health-related quality of life and premature death. CONCLUSION It is widely documented that stopping smoking before surgery has substantial health benefits in the longer term and should be recommended to every smoker in order for them to gain maximum benefit from their treatment. However, identification of the optimal period of preoperative smoking cessation on postoperative complications cannot be determined.

Breast cancer associated with type 1 neurofibromatosis

The association between breast cancer and type 1 neurofibromatosis (NF1) is a rare clinical entity. We herein present the case of a 59-year-old woman, with typical clinical manifestations of NF1, who presented with a painless lump in her right breast, which she had first noticed 8 months earlier. Clinical examination and diagnostic workup were suggestive of a breast carcinoma, and a modified radical mastectomy was performed. Histopathological examination revealed a poorly differentiated invasive ductal breast carcinoma and multiple neurofibromas. The pathological staging was pT2N1a according to TNM/UICC. Delayed presentation of the patient was the result of her mistakenly identifying the breast tumor as a manifestation of NF1 neurofibromatosis.

Diagnosis and Surgical Management of Spontaneous Hepatic Rupture Associated with HELLP Syndrome

Spontaneous hepatic rupture with hemoperitoneum is an uncommon but devastating complication of hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Although the syndrome has been considered a variant of preeclampsia/eclampsia, its pathogenesis is not completely understood. Hepatic rupture increases the perinatal and maternal morbidity and mortality. This report describes 3 cases of extensive spontaneous hepatic rupture in pregnant women with HELLP syndrome. Early diagnosis and adequate tertiary management of this rare but life-threatening condition reduce the high maternal and newborn mortality.

Synchronous early gastric cancer and gastrointestinal stromal tumor in the stomach of a patient with idiopathic thrombocytopenic purpura

The synchronous occurrence of gastrointestinal stromal tumour (GIST) in the stomach and early gastric cancer is uncommon, with only a few previous reports. In particular, the collision of GIST and early gastric cancer in a patient with idiopathic thrombocytopenic purpura (ITP) has never been reported. We present the case of a 78‐year‐old male patient with ITP who was diagnosed with a synchronous development of GIST and early gastric cancer of the stomach. He underwent an elective subtotal gastrectomy with splenectomy. We discuss whether the development of GIST in the stomach in concert with early gastric cancer is an incidental coexistence or involve the same carcinogenic agents. Furthermore, it is not known whether or not such a situation is connected with ITP. To our knowledge this is the second report of a small GIST concomitant with an early gastric cancer and the first one in a patient with ITP.

Neuroprotective Effects of Erythropoietin in Patients with Severe Closed Brain Injury.

AIM Our research was focused on the neuroprotective function of erythropoietin (Epo) in patients with severe closed traumatic brain injury (TBI). MATERIAL AND METHODS Our model examined the influence of the outcome and neurological recovery in 42 adults with TBI who were admitted to ICU within 6 hours of their injury and were recruited into a randomized controlled study of two groups; only the patients of the intervention group received 10,000 i.u. of Epo for 7 consecutive days. A prognostic model based on CRASH II injury model and outcome was measured by survival and Glasgow Outcome Scale-Extended version (GOS-E) score at 6 months post-injury. RESULTS Six patients (18.7%) died during the first two weeks; 4 of the control group and 2 of the intervention group. A mortality rate of 22.2% and 8.3% for the control and intervention group respectively was observed. A lower rate of good outcome (GOS-E score > 4) at 6 months was mentioned among patients of the control group. CONCLUSION The study provides evidence of lower mortality and better neurological outcome for the patients who received Epo increasing the possibility that Epo therapy could be used in clinical practice, limiting neuronal damage induced by TBI.

Metaplastic Changes in Chronic Cholecystitis: Implications for Early Diagnosis and Surgical Intervention to Prevent the Gallbladder Metaplasia-Dysplasia-Carcinoma Sequence

Background Metaplastic features of the gallbladder epithelium are considered to be the precursors of gallbladder cancer. Considering the possible role of chronic inflammatory changes in the development of these lesions and the rationale for performing an early prophylactic cholecystectomy, we performed a retrospective study to assess the prevalence of gallbladder metaplasia in patients who underwent cholecystectomy due to underlying cholelithiasis. Methods We reviewed the routine histopathology reports of 86 patients with chronic cholecystitis, who underwent elective cholecystectomy, to assess the prevalence of gallbladder metaplasia in the course of chronic cholecystitis. We further attempted to evaluate the existence of any correlations between the presence of the gallbladder metaplasia and the type of lithiasis, as well as the gallbladder wall thickness. Results The overall prevalence of metaplastic features in the resected specimens was 25.6%. Dysplastic changes were more frequent in gallbladder specimens with concurrent metaplasia. Moreover, in presence of metaplastic changes, we observed an increase of the average gallbladder wall thickness. Finally, metaplastic and dysplastic changes were associated with the presence of micro-lithiasis rather than macro-lithiasis. Conclusions Gallbladder metaplastic changes appear to be more frequent in cases of micro-lithiasis and seem to be associated with a chronic thickening of the gallbladder wall. Taking into account the usually sub-clinical course of this group of patients, when compared to patients with macro-lithiasis, further studies are needed to evaluate a possible role of prophylactic cholecystectomy in this population to prevent the long term evolution of these early changes to cancerous lesions.