Secondary hyperparathyroidism: diagnosis of site of recurrence

Persistent or recurrent hyperparathyroidism after total parathyroidectomy with forearm implant may be caused by hyperplastic grafted tissue, residual parathyroid tissue left in the neck or the presence of a supernumerary gland not found during surgery. A correct assessment of graft function is needed to localize the source of hormone excess and to avoid an unnecessary neck reoperation in cases of graft dependent hyperparathyroidism. In 12 patients with relapsing hyperparathyroidism after total parathyroidectomy with forearm implant, total ischemic blockade of the arm bearing the parathyroid graft produced a "transitory implantectomy" with a significant reduction of serum levels of intact PTH in those with graft hyperfunction. In 6 patients with proved supernumerary glands, total ischemia of the graft was not followed by significant changes in intact PTH. Hyperparathyroidism was reversed after surgical resection of the parathyroid implants in the 6 patients with positive responses to the ischemic maneuver. A repeat neck reoperation removing cervical or mediastinal supernumerary glands was followed by control of recurrent hyperparathyroidism in the 6 patients with a negative response to the ischemic blockade. Total ischemic blockade of the arm bearing the parathyroid graft is a valuable method for a correct assessment of graft function after total parathyroidectomy with forearm autotransplantation.

Pancreas transplantation: 50 years of experience

In December 1966, the first pancreas transplant ever was performed at the University of Minnesota. R. Lillehei and W. Kelly, transplanted a kidney and a pancreas in a diabetic patient on dialysis, getting function of both organs. Since then, the technical and immunological advances in this transplant have resulted in graft and patient survival results as the rest of the abdominal solid organ transplants. The balance of these 50 years is that more than 50,000 diabetic patients have been transplanted in more than 200 centers around the world. In our country the first transplant was performed 34 years ago in Barcelona and now 12 centers perform about 100 transplants per year. Although advances in diabetes control have been very important, pancreas transplantation continues to be the only method that allows normalization of the carbohydrates metabolism to improve the quality of life and, above all, to increase the survival of these patients.

Surgical treatment of persistent hyperinsulinemic hypoglycemia (PHH) (insulinoma and nesidioblastosis)

BACKGROUND

The persistent hyperinsulinemic hypoglycemia is characterized by clinical symptoms that occur when the blood glucose levels drop below the normal range. Two pathological situations cause this clinical problem: The presence of a tumor of the pancreas secreting excessive amounts of insulin, known as insulinoma, and congenital beta-cell hyperplasia in the pancreas in children and noninsulinoma pancreatogenic hypoglycemia syndrome in adults.

PATIENTS AND METHODS

Clinical characteristic and surgical outcome of a group of 20 patients operated on for this hypoglycemic syndrome; 18 for insulinoma and two for nesidioblastosis in children was studied.

RESULTS

eight of the insulinomas were in the head of the pancreas, two in the body, and the remaining eight in the tail. The surgical technique was enucleation in nine cases, local resection in one case because of suspicious malignancy, and distal pancreatectomy in eight cases. Both children with nesidioblastosis underwent 85% pancreatectomy with splenic preservation. There was no mortality in the study, but three patients developed a low-volume pancreatic fistula after head enucleation.

CONCLUSIONS

Negative results in diagnostic localization together with the small size of the insulinoma represent a poor combination for successful surgery. The intraoperative ultrasonography is the method of choice for the identification of the tumor, as it is able to identify nonpalpable lesions.

Surgical accreditation in liver transplantation

Almost 25 years since the first liver transplantation was performed in Spain, 25 groups support the activities of >1000 transplantations a year. Despite such a significant number, it is necessary to initiate mechanisms of accreditation for programs and surgeons. Professional competence in medical care is defined as "the aptitude of the professionals for integrating and applying the knowledge, skills, and attitudes associated with the good practices of their profession." Accreditation is the process by which a professional or a training specialist achieves or satisfies a level of competence and quality. Certification consists of the recognition of an institution where a person has completed a process of accreditation. The Division of Transplantation was formed in 2007 from the Section of Surgery of the Union Europeëne des Medecins Spécialistes (UEMS) and the European Board of Surgery (EBS). The Division operates in close collaboration with the European Society of Organ Transplantation (ESOT). The main objective of the Division is to guarantee the best standard of care in organ transplantation in Europe by ensuring that training in transplantation surgery is maintained at the highest level. Certification can be obtained for the following separate modules: multi-organ retrieval, kidney transplantation, pancreas transplantation, and liver transplantation. The Diploma of the European Board of Surgery Qualification (Transplantation) is obtained by passing Part I (Eligibility) and Part II (Examination). A candidate can be accredited for one or more modules. To obtain accreditation for the liver transplantation module, it is mandatory to obtain accreditation in module 1 as well. The UEMS, through its Medical Committees, offers the opportunity to provide the first steps toward accreditation of training in liver transplantation.

[Pancreas transplant in Spain: better late than...]

Pancreas transplant is the only method that enables diabetic patients to have a normal carbohydrate metabolism in the long-term. Its application in selected patients has shown to have patient survival rates, at one year of the graft, similar to those transplanted with other solid organs, such as kidney, heart, liver, etc. The indications are currently well established, with combined pancreas-kidney transplant being the most common, followed by pancreas transplant after a functioning kidney transplant and isolated pancreas transplant in pre-uraemic patients. In 2005, in Spain, under the auspices of the National Transplant Organisation (ONT), a consensus meeting was held with the scientific societies involved in this type of transplant, to standardise its indications and highlight its benefits in order to optimise the results of this transplant in our country. The most important conclusions of this consensus meeting are discussed in this short article.

[Pancreatic islets transplantation in the treatment of diabetes mellitus: present and future]

Diabetes treatment with insulin does no prevent the development of secondary complications. For this reason, treatments other than conventional ones are needed, which could bring about an <> metabolic regulation. This can only be done by transplanting insulin producing tissue, such as vascularised pancreas transplantation, which is an already consolidated clinical procedure these days, or by islets transplantation, which is still a procedure in the clinical research phase. This has the same metabolic objectives as the vascularised transplant, but without the risks of major abdominal surgery, since the islets are implanted in the liver with minimal surgery or using interventionist radiology by means of a catheter. A clinical trial (Edmonton Protocol) was published in the year 2000, which improved the results after islet transplantation by obtaining normoglycaemia periods of more than one year in a consecutive patient series with type 1 diabetes and without using corticoids. This protocol has been endorsed in other centre in different trials. Although the initial results were good, the progress of these patients has shown that many islets transplantations do not manage to maintain insulin-independence indefinitely.

Multiorgan retrieval and preservation of the thoracic and abdominal organs in Maastricht III donors

This editorial describes the indications and technical aspects of the simultaneous retrieval of thoracic and abdominal organs in Maastricht III donors as well as the preservation of such organs until their implantation.

Complications during multiorgan retrieval and pancreas preservation

In pancreas transplantation, complications can arise at each step of the process, from the initial selection of donors and recipients through the surgical technique itself and the post-operative period, when lifelong immunosuppression is required. In the early steps, careful retrieval and preservation of the pancreas are crucial for the viability of the organ and ultimate success of the transplant. The pancreas is a low-flow gland, making it highly sensitive to transplantation conditions and presenting risk of pancreatitis due to periods of ischemia. The two groups of donors - after brain death (DBD) or after cardiac arrest (DCD) - require different strategies of retrieval and preservation to avoid or reduce the risk of complications developing during and after the transplantation. For DBD donor transplantation, multiorgan retrieval and cold preservation is the conventional technique. Asystole donor (DCD) transplantation, in contrast, can benefit from the newest technologies, such as hypothermic and especially normothermic preservation machines (referred to as NECMO), to optimize organ preservation. The latter has led to an increase in the pool of donors by facilitating recuperation of organs for transplantation that would have been discarded otherwise.

SEVE project (Surgical Expertise Validity Evaluation) risk adjusted quality by standard data

The SEVE project (Surgical Expertise Validity Evaluation) is a collaborative effort of the AEC (Spanish Association of Surgeons) and the Section of Surgery of the European Union of Medical Specialists (UEMS) that aims to develop a model and an on line application that can be used to evaluate surgical complications. The aim is to identify the optimal results that can be obtained in each intervention, in order to present them as a reference for our usual practice (benchmarking).

[Minimally invasive surgery of thyroids and parathyroids]

The term minimally invasive surgery of thyroids and parathyroids encompasses a series of therapeutic procedures aimed at solving the endocrinal pathology responsible for the disease, with limited surgical aggression and aesthetic results and postoperative comfort on a par with the conventional approach. Its application has become possible with the development of new methods of imaging and instruments that make it possible to carry out dissection in very limited spaces. Unlike classical surgery of thyroids and parathyroids, where surgical technique has broad possibilities of application, in the cerviscopic approach the indications are more limited and a relationship is established with the characteristics of each patient. With respect to thyroidal pathology, the size of the nodule constitutes the main limiting factor, since in sizes above 3 cm the benefits of the procedure are not so apparent. However, greater potential is available in parathyroidal surgery given that the adenoma responsible for the disease is frequently found in anatomical positions that are very accessible for this type of procedure. Thus, in patients with an absence of associated thyroidal pathology, with a unilateral pathology based on the information of the sestamibi scan and preferably in lower localisations, the cervicoscopic approach can meet the requirements of efficiency, postoperative comfort and short hospital stay.

Successful transplantation of canine islets of Langerhans after 24 hours cold-storage

Utilizing the intrasplenic canine islet autograft model, it was possible to examine the effect of cold-storage of pancreatic tissue, both prior to and following dispersion, on functional outcome. A control group of dogs receiving freshly prepared autografts (n = 8) obtained durable euglycaemia in 75% of cases; the mean K value at two weeks being -1.70 (Standard Deviation (sd) = 0.06). In the first experimental group, animals (n = 8) were transplanted following 24 hours of whole pancreas cold-storage in silica gel fractionated plasma (SGF) using intraductal perfusion prior to preservation. None of these animals obtained euglycaemia; the transplanted material having a significantly reduced insulin content compared with controls (p = 0.0006). In the second experimental group, animals (n = 6) were transplanted following 24 hours of dispersed pancreatic tissue storage in SGF. This resulted in an 83% incidence of durable euglycaemia; the mean K value at two weeks being -1.60 (sd = 0.3). The glucose decay curve improved with time in this group and at three months the mean K value was -2.00 (sd = 0.38); this value being significantly superior to that of the control animals (K = -1.34, sd = 0.34, p less than 0.05). We conclude that while storage of the whole pancreas prior to islet isolation remains problematic, it is possible to reliably preserve dispersed pancreatic tissue for 24 hours by simple cold-storage, as assessed by the functional outcome of intrasplenic autografting in the dog model. These findings have important clinical implications.