Laparoscopic adrenalectomy, a safe procedure for pheochromocytoma. A retrospective review of clinical series

BACKGROUND

Minimally invasive adrenalectomy for pheochromocytoma (PCC) is a complex surgical procedure especially because of the haemodynamic instability due to the excessive secretion of cathecolamines, which may result in a considerable risk of conversion and complications.

AIM

By a multicentric retrospective study, the authors reported the results of laparoscopic adrenalectomies in patients operated for adrenal pheochromocytomas with the aim of investigating the role of the laparoscopic approach in managing adrenal disease.

METHODS

Sixty patients, preoperatively treated with a selective alpha1-blocker, underwent 61 laparoscopic adrenalectomies for PCC smaller or larger than 6 cm - group A (≤6 cm), group B (>6 cm). We compared the two groups of patients analyzing haemodynamic instability, operative time, conversion rate, incidence of complications, length of hospital stay and medium and long-term outcomes.

RESULTS

In 23 cases tumor was >6 cm in diameter. Average operative time was 165 min, with a 5% conversion rate. There was no mortality and morbidity rate was 8.3%. Intraoperative hypertensive crises were registered in 15% of patients, whereas 5/60 patients had hypotensive crises. After comparing the two groups of patients, no statistically significant differences in terms of haemodynamic instability, operative time, conversion rate, morbidity and length of hospital stay were observed.

CONCLUSIONS

As a surgical treatment of pheochromocytomas, laparoscopic adrenalectomy is an effective and safe approach, in selected cases even for PCCs >6 cm in diameter, although patients with such large tumors may have a higher conversion rate and more intraoperative hypertensive crises. Preoperative selective adrenergic blockade does not prevent intraoperative hypertensive crises, but by facilitating the pharmacological management of the perioperative haemodynamic instability, may avoid the onset of major adverse cardiovascular complications.

Partial response to cinacalcet treatment in a patient with secondary hyperparathyroidism undergoing hemodialysis: a case report

INTRODUCTION

In the treatment of secondary hyperparathyroidism of chronic kidney disease, calcimimetics - allosteric modulators of the calcium-sensing receptor - inhibit glandular hyperplasia and significantly reduce circulating parathyroid hormone levels. They have a major impact on the management of secondary hyperparathyroidism.

CASE PRESENTATION

We present the clinical case of a 41-year-old Caucasian man undergoing chronic hemodialysis, who had a parathyroidectomy to treat severe secondary hyperparathyroidism resistant to cinacalcet treatment. Preoperatively, 24 months after high-dose cinacalcet hydrochloride, we observed a persistently elevated intact parathyroid hormone serum level, and detected clear parathyroid gland hyperplasia regression on ultrasound. We performed a three-gland parathyroidectomy, which was assumed to be total, associated with a hemithyroidectomy. Our patient then entered a hypoparathyroid state. A histopathological examination showed that the removed parathyroid glands were of small size, with a total weight of 1g, associated with a multifocal small papillary thyroid cancer.

CONCLUSION

In the management of secondary hyperparathyroidism, cinacalcet hydrochloride effectively reduces total parathyroid gland hyperplasia. However, a persisting elevated intact parathyroid hormone serum level may be observed, demonstrating that reduced parathyroid hyperplastic tissue may still be associated with severe secondary hyperparathyroidism. Even if calcimimetics are very effective in secondary hyperparathyroidism treatment, further studies are necessary for a better understanding of their actions.

Long-term outcomes following "presumed" total parathyroidectomy for secondary hyperparathyroidism of chronic kidney disease

AIM

The most efficacious surgical treatment for renal hyperparathyroidism is still subject of research. Considering its low incidence rate of long-term relapse, "presumed" total parathyroidectomy without autotrasplantation (TP) may be indicated for secondary hyperparathyroidism (2HPT) in patients with chronic kidney disease (CKD), not eligible for kidney transplantation. The aim of this study was to analyse the TP long-term results in 2HPT haemodialysis (HD) patients.

METHOD

Between January 2004 and October 2009, 25 2HPT HD patients, not eligible for kidney transplantation, underwent TP of at least four parathyroid glands. Clinical status and intact parathyroid hormone (iPTH) serum levels were assessed intraoperatively and during a 36-month follow-up.

RESULTS

TP improved the typical clinical symptoms and a significant reduction of iPTH serum levels was achieved in each patient. Aparathyroidism was never observed; in case of severe postoperative hypocalcemia, hypocalcemic seizures were never reported and the long-term recurrence rate was 8%. Only one patient received a kidney transplantation. Postoperative cardiovascular events (hypertension, peripheral artery disease, arrhythmia, coronary or cerebrovascular disease) were observed in 32% of cases and mortality rate was 16%.

CONCLUSIONS

Considering its low long-term relapse rate and the absence of postoperative aparathyroidism, TP may still be considered the treatment of choice in patients with aggressive forms of 2HPT or of advanced dialytic vintage, with no access to renal transplantation. In case of postoperative hypoparathyroidism, hypocalcaemia can be effectively managed by medical treatment.

Surgical treatment of papillary thyroid carcinoma without lymph nodal involvement

BACKGROUND

In the treatment of differentiated thyroid cancer (DTC), in absence of enlarged lymph nodes, the role of routine central lymph node dissection (RCLD) remains controversial. The aim of this study is to analyze data resulting from total thyroidectomy (TT) not combined with RCLD in the treatment of DTC.

METHODS

We retrospectively evaluated the clinical records of 80 patients treated between January 1996 and December 2003 with TT without RCLND, in absence of suspected enlarged lymph nodes at preoperative ultrasonography and intraoperatively during neck exploration. In this series, 75 patients (93.7%) underwent radioiodine (RAI) ablation, followed by Thyroid Stimulating Hormone (TSH) suppression therapy. In case of locoregional lymph nodal recurrence, a central (VI) and ipsilateral (III-IV) selective lymph node dissection was performed.

RESULTS

Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and unilateral temporary vocal fold paralysis were respectively 2.55% and 2.55%. Locoregional recurrence, with positive cervical lymph nodes, after a 10.3 ± 4.7 years mean follow-up was observed in 3 patients (3.75%). They were submitted to a central (VI) and ipsilateral (III-IV) selective neck dissection without significant complications.

CONCLUSIONS

In our series, TT not combined with RCLD was associated to a low locoregional recurrence rate, even if the lack of a control group treated with RCLD does not allow any generalized assumption. RCLD may be indicated in high risk patients, in whom lymph nodal recurrence is more frequent. More prospective randomized studies are needed to better define the role of RCLD and postoperative radioiodine ablation.

An approach to urticaria in the elderly patients

The guidelines for the management of urticaria in adults and children have been published in outstanding position papers. By contrast, the onset of urticaria in the elderly has not yet had a clear definition. In order to approach diagnosis and treatment in a population of elderly patients, we have performed an epidemiological study on a population of elderly people observed in the Immuno Allergology Unit in Bari University Hospital. The patients underwent skin prick test for food allergy and laboratory and instrumental tests. From the data it resulted that 49% of cases have had urticaria because of adverse drug reactions (ADRs), 16% of cases were positive to food, while in 21% of cases systemic and metabolic diseases (SMDs) have been diagnosed. If we consider the young controls, urticaria for ADR was present in 48% of cases; however, in 28% it was possible to make the diagnosis of food allergy, 12% cases had a SMD. Our results show that the main cause of urticaria in the elderly is related to drug assumption because of the high number of drugs taken, followed by internal pathologies correlated to the typical immune and metabolic changes of the elderly. Furthermore, from the observation of our data it was possible to give guidelines for the treatment of urticaria in geriatric age.

Hemoperitoneum caused by the rupture of a giant ovarian teratoma in a 9-year-old female. Case report and literature review

The Authors report the case of a 9-year-old girl suffering from acute abdominal pain, combined with mild anaemia (Hb 10.9 g/dL), leukocytosis (24.3 x 10(3) cells/dL), and a large palpable mass in the upper left quadrant. The child underwent an appendectomy 20 days before the admission to our Department. The operation performed in urgency, as well as the removal of a bulky mass situated in the left flank and the right ovary whence it arose, made it clear that abdominal signs and symptoms were caused by the twisting and rupturing of a neoformation, that would hence cause an impressive hemoperitoneum. The histopathologic examination showed a three-germ layer mature mixed teratoma. Clinical, radiologic and biochemical test (alpha-FP, beta-hcG) performed in a postoperative 2 months follow-up revealed no residual disease.

[Coleman lipofilling: experience of an Italian group and review of the literature]

Although the first operation of reconstructive breast surgery dates back to the end of the nineteenth century, it was only in the last decade of the twentieth century that lipofilling became widely adopted in the management of diseases of the breast. The Coleman technique involves taking a sample of fat from the regions of the body where it is largely present (abdomen, trochanter region, groin, knee), followed by centrifugation and the grafting of the fat cells thus purified. In 1987 the American Society of Plastic and Reconstructive Surgery banned the diffusion of this procedure because it was considered of little benefit for both aesthetic and oncological purposes. From January 2005 to May 2007, 17 patients underwent lipofilling according to the Coleman technique at the Operative Unit of General Surgery of the "San Giuseppe Moscati" Hospital in Avellino. Previously, 15 (88%) of the 17 women had received reconstructive breast surgery with a prosthesis after a Madden total mastectomy. As regards the other 2 patients, when admitted to hospital, one (5.9%) presented a pectum excavatum and the other (5.9%) a congenital depression of the temporal bone. No important complications were observed in the postoperative course. At a distance of 6 and 12 months after the injection, follow-up monitoring revealed that the loss of substance in the grafted adipose tissue was about 53%. In conclusion, reconstructive breast surgery should always be attempted after radical surgery. The multidisciplinary cooperation of radiologists, surgeons, anatomical pathologists and psychologists, in our opinion, avoids the danger of poor aesthetic results and the risk of underestimating a possible tumour relapse.

[Prognostic and therapeutic value of D2 lymphadenectomy in the treatment of gastric cancer: experience of an Italian team]

Recently, the incidence of gastric cancer and the related percentage of mortality have been decreasing world-wide, especially in the industrialised countries. Surgery has commonly been opted for as primary treatment of this disease. However, the optimal extent of surgical intervention is still debated. Japanese surgeons have been the pioneers of perigastric and celiac tripod lymphadenectomies in an attempt to improve long-term survival and the postoperative disease-free period. In recent years, D2 resection has been compared with D1 resection, which consists in excision of the stomach along with its locoregional nodes. From March 2002 to January 2007, 70 interventions for gastric cancer were performed at the VII Division of General Surgery of the Second University of Naples. All patients underwent excision of the lymph nodes from stations 1 to 6 (D1) combined with excision of stations 7 to 12 (D2). In 32 cases (45.7%) there were no metastatic lymph nodes (NO), in 28 patients (40%) 1 to 6 nodes proved metastatic (N1), and in 10 cases (14.3%) from 7 to 15 nodes were metastasised (N2). The incidence of metastatic lymph nodes was 54.3% and the prevalence 13.6%. Metastatic lymph nodes were found mostly in T3 (15/24) and T4 (14/20) stage tumours rather than in T1 (3/12) and T2 (6/14) neoplasms. Two patients (2.86%) died within 60 days of the intervention. The overall postoperative morbidity and mortality rates were 21.43% and 2.86%, respectively. D2 gastrectomies without pancreatic resections present distinct advantages in terms of long-term survival and are associated with postoperative morbidity and mortality rates which are similar to those obtained after D1 node resection.

Effects of high and low ligation on survival in patients operated for colorectal cancer

In spite of numerous studies on the subject, it is still unclear whether or not high ligation of the inferior mesenteric artery (at about 1 cm from its origin) improves the 5-year survival rate in patients operated on for colorectal cancer in comparison to low ligation (ligation below the origin of the left colic artery). From February 2000 to November 2001 40 patients with cancer of the colic segment between the descending sigmoid junction and the low rectum underwent surgical colorectal resection and low ligation of the inferior mesenteric artery. At the end of 5 years of observation we report a survival rate of 70% which is not very far from the value reported in the literature. In our study, the incidence of lymph-node metastases, inexistent in patients with T1 grading increases with the increase in the TNM T grading but does not depend on the location of the cancer. In our patients age below 65 years was a negative prognostic indicator because colorectal tumours in patients of that age are associated with a higher incidence of lymph-node metastases. On the basis of the data we obtained, it is also evident that the 5-year survival rate decreases in proportion to the increase in the distance of the lymph-node metastases from the mesenteric margin of the colon. In conclusion, in the treatment of cancers located between the descending sigmoid junction and the low rectum, we prefer to execute a low ligation of the inferior mesenteric artery because it exposes the patient to a lower risk of intra- and postoperative complications and also because several authors have demonstrated that high ligation with removal of lymph nodes at the origin of the artery for colorectal cancer does not improve the 5-year survival rate.

Surgical therapy of goiter plunged in the mediastinum. Considerations regarding our experience with 165 patients

Thyroid goiter is called plunged when, starting from the cervical region, it grows in the anterior-superior mediastinum to a depth of more than 2 cm. The highest frequency (48.44%) is evident in the age range from 60 to 70. From February 2002 to August 2005, performed 133 (80.6%) near total thyroidectomies, 26 total thyroidectomies (15.7%), 4 lobectomies (2.4%) and 2 (1.2%) totalisations of recurrences for plunged goiter in the 7th Division of General Surgery of the Second University of Naples. The goiters were classified using Lamke and Ferrante's topographical classification, which distinguishes between prevascular and retrovascular cervico-mediastinal goiters depending on the position assumed by the part plunged in the mediastinum in relation to the vascular layer of the epiaortic trunks. Retrovascular goiters are further subdivided into: pre-tracheal, laterovisceral and retrovisceral goiters depending on the relation to the trachea, oesophagus and epiaortic trunks. Among the patients who underwent near total thyroidectomy, there were 3 cases of permanent hypocalcaemia, 7 (7.2%) of temporary hypocalcaemia and only 1 (0.6%) monolateral temporary recurrent nerve lesion. Among those who underwent total thyroidectomy there was 1 case (0.6%) of temporary hypocalcaemia, and 1 (0.6%) of permanent hypocalcaemia. Postoperatively we also observed 3 cases (1.8%) of haemorrhage and 3 (1.8%) transfers to intensive care for respiratory insufficiency; 1 of these patients died 25 days after the operation. Ligature of the inferior and superior thyroid artery near the thyroid capsule protects the vascularisation of the parathyroid glands as well as the recurrent nerve and its division branches.

[Surgical treatment of Basedow's disease: our experience with 424 operations]

From February 2002 to December 2005, 424 operations for thyroid disease were performed in our institute. Twenty-two patients were suffering from Basedow's disease, 14 female and 8 male, mean age 36 years (range: 23 to 53 years). In each patient the diagnosis of Basedow's disease was made according to common clinical and laboratory criteria, by evaluation of the thyroid hormones, TSH and TRAB. Before operation all patients were rendered euthyroid with antithyroid drug treatment. Fourteen total thyroidectomies (64%) and 8 near-total thyroidectomies (36%) were performed. Postoperative thyroid function status was evaluated before, 3-4 weeks after the operation and then 3, 6,12 and 24 months postoperatively. The patients were classified as euthyroid (FT3-FT4 and TSH normal), hypothyroid (FT3 and/or FT4 reduced and TSH increased), or hyperthyroid (FT3-FT4 increased). In expert hands, surgical treatment appears to be capable of curing the hyperthyroidism of Basedow's disease effectively, with a very low and largely acceptable risk of complications. Among the different types of surgery, total thyroidectomy and near-total thyroidectomy are equally appropriate to ensure there is no risk of recurrence of hyperthyroidism.

[Diagnostic and therapeutic guidelines for entero-cutaneous fistulas. Personal experience and literature review]

The entero-cutaneous fistulas (ECF) are abnormal communications between intestine and abdominal skin. They can occur spontaneously, or after an injury or a surgical procedure. They are associated with a high rate of morbidity and mortality. Spontaneous fistulas can mainly occur in patients affected by cancer, inflammatory bowel disease, diverticulitis, appendicitis, as a result of radiotherapy or injuries. Surgical procedures, carried out in case of neoplastic diseases, inflammatory bowel disease, adhesions removal, represent the primary cause in the development of a postoperative fistulas. Malnourishment, poor general conditions of the patient, high output fistula along with anatomical site of development, and the presence of abscesses, represent the negative factors influencing the spontaneous healing of fistulas. The experience reported here is about three ECF cases occurred after surgery and treated only with medical therapy. The first case is a woman in good general conditions who underwent surgery to remove a recurrent retroperitoneal myxoid liposarcoma situated in the right lower quadrant. The patient had never undergone surgery for an intestinal resection. The other two patients analyzed were affected by sepsis and metabolic unbalance and had developed a fistula after colonic resection. Fluids and electrolytes adjustments and sepsis management have preceded any other kind of therapy. Continuous infusion with somatostatin, fast, proton pump inhibitors and loperamide have been taken up to decrease secretions and intestinal motility. Total parenteral nutrition has been essential to recover nutritional status and improve patients' general conditions. In order to heal and protect peri-fistula skin we have used sterile washing solutions, absorbable ionic exchange resin, silver and polyurethanes based medications and colostomy bags adhesive systems. Since surgical treatment of ECF is associated with high rates of morbidity and mortality, conservative treatment should always be taken into consideration. When conservative treatment fails, delayed surgical intervention has been related to a higher rate of success. The purpose of this study is to describe diagnostic and therapeutic guidelines to general surgeons, like ourselves, whenever they have to deal with ECF cases.

[Diagnosis and treatment of gallbladder and common bile duct stones: our experience]

AIM

The aim of this study was to verify the possibility to identify and treat common bile duct (CBD) stones by means of preoperative magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) with a reduction of postoperative complications.

METHODS

We have carried out a retrospective monocenter analysis of 104 consecutive patients who underwent a laparoscopic or open cholecystectomy performed by a single surgeon at the VII Division of General Surgery, Second University of Naples, between 2002 and 2006. Before the operation, we have performed highly selective studies like MRCP and ERCP to identify and treat CBD stones in patients affected by pancreatitis, jaundice, high liver function tests or in case of common bile duct dilation at the US examination, without intraoperative cholangiography.

RESULTS

Of 104 patients with indication for a cholecystectomy, 22 patients (21.2%) presented high levels of cholestasis tests; 13 patients (12.5%) presented common bile duct dilation at the US examination (>6 mm diameter). Both groups underwent a MRCP which was positive in 8 patients (7.7%), confirming the diagnosis of common bile duct stones. For these reasons we removed CBD stones using preoperative ERCP.

CONCLUSION

Preoperative ERCP and RMCP, without intraoperative cholangiography, is not associated with a significant increase in morbility/mortality associated with CBD stones before surgical treatment.

[The gold standard in the treatment of haemorrhoidal disease. Milligan-Morgan haemorrhoidectomy vs Longo mucoprolapsectomy: comparing techniques]

AIM

Although mucosectomy according to Longo was a real revolution in the treatment of haemorrhoidal disease, Milligan-Morgan haemorrhoidectomy, maintaining the characteristics of a technique which is physiopathologically efficacious and easily performed, is still the procedure of choice in some clinical conditions. The aim of this study was to evaluate which of the two techniques, Milligan-Morgan haemorrhoidectomy and Longo mucoprolapsectomy, could be considered the gold standard in the treatment of haemorrhoidal disease.

METHODS

From March 2002 to October 2006, in the VII Department of General Surgery of SUN, we compared two groups of 26 patients each: one treated with Milligan-Morgan haemorrhoidectomy, the other one with Longo mucoprolapsectomy. Among the patients treated with traditional technique, 16 were suffering from grade III haemorrhoids and prolapse, while the other 10 from grade IV haemorrhoids and prolapse. The group treated with stapler was composed of 10 patients affected by grade III haemorrhoids and prolapse, while the other 16 were patients complaining for grade IV haemorrhoids and prolapse. For both groups of patients the follow-up lasted 12 months; they were controlled at 1 week, 1 month, 6 months and 1 year after the operation.

RESULTS

The level of pain measured with a visual analogue scale (VAS) was always higher in the group treated with traditional technique. In 69% of the patients treated with stapler and in 59% of those treated with open technique there was the first defecation within postoperative day 2. The return to normal activity was earlier in patients who underwent Longo technique. Among the patients treated with traditional technique, 7.7% had postoperative bleeding, 15.4% at the 6-month control, suffered from anal fissure with associated high pressure of anal sphincter and tenesmus and 7.7% showed a recurrence after 1 year. In the group treated with Longo technique, 11.54% of the patients had a postoperative haemorrhage at the 6-month control, 7.7% showed substenosis, 3.84% of the patients felt tenesmus; in 3.84% of the cases a perianal extra-sphincteric fistula was evident. At 1 year control, 11.54% of the patients showed recurrences.

CONCLUSION

The conclusion is drawn that it does not exist any indication for the Longo technique; however, it seems to give the best results in grade III haemorrhoids with prolapse, without sphincteric implications.

Renal oncocytoma: Clinical-pathological study of a singular case

– The authors report their experience of a case of renal oncocytoma and present a literature review.

Conservative surgery of renal cell carcinoma: Our experience

– The authors present their experience with bilateral renal cell carcinoma, as well as an assessment of the tumour for possible conservative surgery with partial mono or bilateral nephrectomy.

Reducing the risks from radon

The U.S. Environmental Protection Agency estimates that residential radon levels in the United States lead to approximately 13,600 lung cancer deaths per year. To address this problem, the Agency has identified three program initiatives that can provide substantial reductions in the public's risks: (1) public information activities that urge the public to test for radon and reduce elevated concentrations in existing homes, (2) new construction standards to reduce radon entry, and (3) radon testing and mitigation during real estate transactions. This paper analyzes the costs and risk reductions that could result from the implementation of these major initiatives, showing how all three elements cost-effectively protect the public's health.