Yatsuka Hibi

Reoperation for renal hyperparathyroidism

Abstract Reoperation for secondary hyperparathyroidism (HPT) due to uremia (2HPT) may be required among patients with persistent renal failure if not all parathyroid glands are removed at the initial operation. Between March 1981 and July 2001, altogether 1110 patients underwent total parathyroidectomy with forearm autograft for advanced 2HPT in our department. In this study, we evaluated the clinical features of patients who required reoperation and classified them into persistent HPT [the lowest intact parathyroid (PTH) level after initial operation remained higher than 60 pg/ml] and recurrent HPT (the lowest intact PTH level was normalized after surgery but reelevated became high enough to require reoperation). Removal of residual glands was indicated in 30 (2.7%) cases for persistent or recurrent HPT. All remaining glands were detected by preoperative imaging diagnoses. In 44 (4.0%) patients persistent HPT was recognized and in 15 of them (1.4% of all cases) reoperation was required. In 11 cases, the responsible glands were supernumerary ones removed from the mediastinum. In 4 cases, the glands were resected from the neck. In 15 cases (1.4%), reoperation was performed for recurrent HPT when residual glands were left either in the neck or in the thymic tongue. In all but one case, the missed glands were supernumerary. This study reveals that it is often difficult to avoid persistent HPT induced by mediastinal supernumerary glands and recurrent HPT caused by small glands left in the neck. Our findings indicate that patients with uremia should be closely followed considering the possibility that persistent or recurrent HPT may occur after parathyroidectomy.

Expression of Vascular Endothelial Growth Factor and Presence of Angiovascular Cells in Tissues from Different Thyroid Disorders

BackgroundVascular endothelial growth factor (VEGF) is involved in tumor angiogenesis and other pathophysiological processes.Materials and methodsWe studied the localization of VEGF in human thyroid tissues to clarify its involvement in proliferative processes in a variety of thyroid disorders. Immunohistochemical analysis using purified rabbit polyclonal anti-human VEGF or anti-human CD34 antibody and a streptavidin–biotin peroxidase complex detection system was performed on 58 tissue specimens from 53 patients with different thyroid disorders and 5 normal thyroid glands.ResultsVascular endothelial growth factor was not detected in normal thyroid follicular cells. However, some thyroid tumor cells expressed VEGF in the cytoplasm (papillary carcinoma, 10/18; follicular carcinoma, 1/3; medullary carcinoma, 2/2; follicular adenoma, 3/11; adenomatous goiter, 2/4). In benign follicular adenoma and adenomatous goiter, weak expression of VEGF was found in small areas of the tumor, whereas in malignant thyroid tumors, it was strongly expressed in many cells. However, VEGF was not expressed in anaplastic carcinoma, malignant lymphoma, or Graves’ disease. Angiovascular cells stained with CD34 antibody in tissues from different thyroid disorders reflected statistically significant differences in papillary carcinoma, follicular adenoma, and Graves’ disease compared with normal thyroids, and such cells showed a trend toward increases in medullary carcinoma and adenomatous goiter. In contrast, low vascularity was observed in anaplastic carcinoma, malignant lymphoma, and follicular carcinoma.ConclusionsBecause VEGF probably functions as a hypoxia-inducible angiogenic factor, overexpression of this mediator, concomitant with hypervascularity, may be induced more strongly in malignant thyroid tumors, which need more oxygen to proliferate, than in benign follicular tumors. However, neither VEGF nor CD34 was expressed in anaplastic thyroid carcinoma, which is an extremely poorly differentiated malignant tumor. CD34 but not VEGF was expressed in the hyperplastic thyroid tissues of Graves’ disease composed of nontransformed cells. Thus, the expression of VEGF concomitant with CD34 is suggested to reflect both the transformation and differentiation state of malignant tumors.

Mesh Plug Repair for a Small Incisional Hernia in a Cirrhotic Patient with Ascites:Report of a Case

We report herein the case of a patient with severe liver ascites due to cirrhosis in whom a small incisional hernia on a midline incision was successfully treated by a mesh plug repair, a method most commonly employed for groin hernia repair. The hernia sac was dissected and inverted into the abdominal cavity by the mesh plug under epidural anesthesia. The patient’s recovery was quick and relatively painless, and there has been no recurrence after 1 year of followup. This case report demonstrates that the method of mesh plug repair may be appropriate for small incisional hernias as well as groin hernias, performed under epidural anesthesia.

CQ3. What Is the Frequency (Probability of Cancer Before Examination) of Thyroid Cancer

The thyroid is an accessible organ near the body’s surface which can easily be palpated during a routine physical examination or “ningen dock,” added as a simple adjunct to a sonogram of the breast or picked up by a CT, MRI or PET scan. Thyroid cancer also tends to progress slowly and many latent cancers are discovered in post-mortem pathology.

The Safety and Efficacy of Surgery for Primary Hyperparathyroidism without Intraoperative Parathyroid Hormone Measurement in Japan

Introduction: Primary hyperparathyroidism (PHP) is a curable disease because most patients have only one adenoma and can fully recover after adenoma removal at the location determined by preoperative imaging. However, many Japanese surgeons believe that intraoperative intact PTH measurement (IOPM) is essential to the surgery. Hence, many general surgeons in Japan are unable to perform surgeries for PHP in their local hospitals and must refer the patients to urban high volume centers that have introduced IOPM, even though they are experienced in general surgery and the surgery for PHP is technically simple and related to general surgery. So, we analyzed the relationship of surgical outcomes, with and without IOPM. Method: Between January 2007 and December 2016, 183 consecutive patients with PHP underwent surgery in our institution. We performed the surgery between 2007 and 2012 without IOPM, and starting from 2013 we performed the surgery with IOPM. We compared and evaluated the cure rate and surgical complications between patients who underwent unilateral neck exploration without IOPM with clear preoperative localization of the affected adenoma, and those who underwent any surgery with IOPM. Result: There was no significant difference in cure rate between the two groups and there were no surgical complication in either group. Conclusion: In cases where preoperative imaging is able to clearly localize the affected adenoma and an experienced general or endocrine surgeon performs the surgery, there is no significant difference in overall cure rate and surgical complications with or without IOPM. Though many hospitals in Japan currently do not perform IOPM routinely, our study may encourage many general surgeons to perform the surgery without IOPM.

Inferior Vena Cava Syndrome Caused by Port Site Hemorrhage as a Complication of Laparoscopic Adrenalectomy

Inferior vena cava (IVC) syndrome results from obstruction of the IVC. Occlusion of the IVC caused by external pressure is a well-recognized complication of malignancy; meanwhile, benign causes of IVC obstruction are not frequently encountered without deep vein thrombosis. There have been a few reports of benign external compression of the IVC. We here show a rare and unique case of benign IVC syndrome in a 47-year-old woman, which was caused by hemorrhage as a complication of laparoscopic adrenalectomy on postoperative day 1. She had undergone laparoscopic adrenalectomy, performed successfully for primary aldosteronism, but she lost consciousness for about 10 seconds on postoperative day 1. After emergency medical care, her sinus rhythm and stable hemodynamic status were restored. At that time, computed tomography showed retroperitoneal hematoma caused by port site bleeding with the IVC compressed excessively, and we considered that drastic IVC syndrome may have occurred. Hemostatics and complete rest im...

CQ9. What Are the Sensitivity and Specificity of Ultrasonography, CT, MRI, Laryngoscopy, and Bronchoscopy in the Preoperative Evaluation of Thyroid Cancer Invasion to the Trachea, Esophagus, and the Recurrent Laryngeal Nerve?

Ultrasonography, CT, MRI, endoscopic ultrasonography, bronchoscopy, and larygoscopy are among the possible diagnostic tools in the preoperative evaluation of invasion to the trachea, esophagus, and the recurrent nerve.

CQ14. Do Cystic Nodules Decrease in Volume by Aspiration and Drainage of Content Fluid and Percutaneous Ethanol Injection Therapy

Thyroid nodule is detected in 4–7% of the general population and 15–25% of nodules are cystic [1]. TSH suppression therapy by administering T4 is not effective. Before the 1980s, cystic nodules were treated surgically if aspiration and drainage of fluid could not reduce their volumes. However, in the 1990s, an increasing number of PEIT treatments were reported. Ethanol directly makes tissue necrotic by coagulation of proteins and secondarily destroys tissue by forming thrombi in microscopic blood vessels.

CQ10. How Is the Natural History of Nodules Diagnosed as Benign (Growth and Reduction Rates)

Surgical treatment and TSH suppression therapy by administering thyroid hormone are adopted as therapies for benign thyroid nodules, but it is also important to understand their natural histories for therapeutic choice.

Column 6. Diagnosis of Anaplastic Carcinoma

Since anaplastic thyroid carcinoma has an extremely dire prognosis, multimodality therapy is performed. The diagnosis can be divided into two stages: “qualitative diagnosis” during which suspicion of anaplastic carcinoma is confirmed and definitive diagnosis is made and “quantitative diagnosis” during which strategies are established for multimodality therapy [1].