Pheochromocytoma: a changing perspective and current concepts

This article aims to review current concepts in diagnosing and managing pheochromocytoma and paraganglioma (PPGL). Personalized genetic testing is vital, as 40-60% of tumors are linked to a known mutation. Tumor DNA should be sampled first. Next-generation sequencing is the best and most cost-effective choice and also helps with the expansion of current knowledge. Recent advancements have also led to the increased incorporation of regulatory RNA, metabolome markers, and the NETest in PPGL workup. PPGL presentation is highly volatile and nonspecific due to its multifactorial etiology. Symptoms mainly derive from catecholamine (CMN) excess or mass effect, primarily affecting the cardiovascular system. However, paroxysmal nature, hypertension, and the classic triad are no longer perceived as telltale signs. Identifying high-risk subjects and diagnosing patients at the correct time by using appropriate personalized methods are essential. Free plasma/urine catecholamine metabolites must be first-line examinations using liquid chromatography with tandem mass spectrometry as the gold standard analytical method. Reference intervals should be personalized according to demographics and comorbidity. The same applies to result interpretation. Threefold increase from the upper limit is highly suggestive of PPGL. Computed tomography (CT) is preferred for pheochromocytoma due to better cost-effectiveness and spatial resolution. Unenhanced attenuation of >10HU in non-contrast CT is indicative. The choice of extra-adrenal tumor imaging is based on location. Functional imaging with positron emission tomography/computed tomography and radionuclide administration improves diagnostic accuracy, especially in extra-adrenal/malignant or familial cases. Surgery is the mainstay treatment when feasible. Preoperative α-adrenergic blockade reduces surgical morbidity. Aggressive metastatic PPGL benefits from systemic chemotherapy, while milder cases can be managed with radionuclides. Short-term postoperative follow-up evaluates the adequacy of resection. Long-term follow-up assesses the risk of recurrence or metastasis. Asymptomatic carriers and their families can benefit from surveillance, with intervals depending on the specific gene mutation. Trials primarily focusing on targeted therapy and radionuclides are currently active. A multidisciplinary approach, correct timing, and personalization are key for successful PPGL management.

Non-stenting treatment versus endoscopic stent placement in staple line leaks after laparoscopic sleeve gastrectomy

PURPOSE

Presentation of results of non-stenting treatment versus endoscopic stenting placement in gastric staple leaks after laparoscopic sleeve gastrectomy (LSG).

METHODS

Between January 2007 and August 2020, 1371 eligible patients underwent LSG. After gastric leak detection, patients were classified into treatment groups A (endoscopic stent placement) and B (non-stenting management). Overall hospital stay, the time to complete gastric leak resolution and the incidence of further operative management constituted the main outcome measures. Statistical analysis included descriptive statistics and linear regression tests as needed.

RESULTS

A total of 27 patients (19 F/8 M, median age: 44.8 years (range: 36-58) with median preoperative BMI: 43.5 kg/m² (range: 37.0-48.7)) presented with gastric staple line leak (1.9%) - mean detection day 5.8 postop (range: 1-12). Eight patients enrolled in group A and 19 patients in group B. The mean hospital stay for group A was 41.2 days (range: 24-60) versus 15 days (range: 12-18) for group B (p < 0.001). Complete leakage resolution was observed at mean 42.4 days (range 25-60) for group A and 34.5 days (range: 28-40) for group B patients, (p = 0.025). Only 2 group A patients accomplished complete leak resolution without additional intervention. Five group A patients (62.5%) versus 4 group B patients (21.1%) needed operative intervention during the treatment course (p = 0.037).

CONCLUSIONS

Conservative, non-stenting treatment of staple line leaks after LSG is feasible and is associated with superior results in terms of hospital say and leak resolution in comparison to endoscopic stenting.

Medullary thyroid carcinoma in children: current state of the art and future perspectives

Medullary thyroid carcinoma (MTC) is a distinct type of malignant thyroid tumor in cell origin, biological behavior, and natural history. It accounts for 1.6% of all thyroid cancers and presents either sporadically or as a hereditary disease, the latter occurring as a part of multiple endocrine neoplasia (MEN) 2A and MEN2B syndromes or as a familial MTC disease with no other manifestations. The gene responsible for the hereditary form is the rearranged during transfection (RET) gene, a proto-oncogene located to human chromosome 10. Most pediatric MTC cases have been discovered after genetic testing investigations, leading to the concept of prophylactic surgery in presymptomatic patients. Therefore, the genetic status of the child, along with serum calcitonin levels and ultrasonographic findings, determine the appropriate age for prophylactic surgical intervention. Nevertheless, a diagnosis at an early stage of MTC warrants total thyroidectomy and central lymph node dissection with the addition of lateral/contralateral lymph node dissection depending on the tumor size, ultrasonographic evidence of neck disease, or calcitonin levels. Conversely, locally advanced/unresectable or metastatic MTC is primarily treated with multikinase inhibitors, while more specific RET inhibitors are being tested in clinical trials with promising results.

Calcitonin: current concepts and differential diagnosis

Calcitonin (CT) is most effectively produced by the parafollicular cells of the thyroid gland. It acts through the calcitonin receptor (CTR), a seven-transmembrane class II G-protein-coupled receptor linked to multiple signal transduction pathways with its main secretagogues being calcium and gastrin. It is clinically used mostly in the diagnosis and follow-up of medullary thyroid carcinoma (MTC). Hypercalcitoninemia can be attributed to primary (e.g. CT-secreting tumor) or secondary (e.g. due to hypercalcemia) overproduction, underexcretion (e.g. renal insufficiency), drug reaction (e.g. β-blockers), or false-positive results. In clinical practice, elevated basal calcitonin (bCT) is indicative, but not pathognomonic, of MTC. Current literature leans toward an age as well as gender-specific cutoff approach. bCT >100 pg/ml has up to 100% positive prognostic value (PPV) for MTC, whereas bCT between 8 and 100 pg/ml for adult males and 6 and 80 pg/ml for adult females should be possibly further investigated with stimulation calcitonin (sCT) tests. Calcium is showing similar efficacy with pentagastrin (Pg) sCT; however, the real value of these provocative tests has been disputed given the availability of new, highly sensitive CT immunoassays. Anyhow, evidence concludes that sCT <2 times bCT may not be suggestive of MTC, in which case, thyroid in addition to whole body workup based on clinical evaluation is further warranted. Moreover, measurement of basal and stimulated procalcitonin has been proposed as an emerging concept in this clinical scenario. Measuring bCT levels in patients with thyroid nodules as a screening tool for MTC remains another controversial topic. It has been well established, though, that bCT levels raise the sensitivity of FNAB (Fine Needle Aspiration Biopsy) and correlate with disease progression both pre- and postoperatively in this situation. There have been numerous reports about extrathyroidal neoplasms that express CT. Pancreatic, laryngeal, and lung neuroendocrine neoplasms (NENs) are most frequently associated with hypercalcitoninemia, but CT production has also been described in various other neoplasms such as duodenal, esophageal, cutaneous, and paranasal NENs as well as prostate, colon, breast, and lung non-NENs. This review outlines the current biosynthetic and physiology concepts about CT and presents up-to-date information regarding the differential diagnosis of its elevation in various clinical situations.

Long-standing hypercalcemia in a 78-years old woman

A 78 years-old woman was found with worsening hypercalcemia, osteopenia and memory loss during the past 2 years. Multiple, repeated imaging studies failed to reveal the etiology of the primary hyperparathyroidism. Bilateral neck exploration revealed a 4.5 × 2.3 cm right superior parathyroid adenoma in an ectopic position.

Large adrenal tumor in a 76-year-old man

Among various adrenal tumors, metastatic ones are the most common. PET/CT scanning facilitates early detection. Occurrence of isolated and synchronous metastasis is very rare and poses serious diagnostic and therapeutic challenges.

ENSAT registry-based randomized clinical trials for adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is an orphan disease lacking effective systemic treatment options. The low incidence of the disease and high cost of clinical trials are major obstacles in the search for improved treatment strategies. As a novel approach, registry-based clinical trials have been introduced in clinical research, so allowing for significant cost reduction, but without compromising scientific benefit. Herein, we describe how the European Network for the Study of Adrenal Tumours (ENSAT) could transform its current registry into one fit for a clinical trial infrastructure. The rationale to perform randomized registry-based trials in ACC is outlined including an analysis of relevant limitations and challenges. We summarize a survey on this concept among ENSAT members who expressed a strong interest in the concept and rated its scientific potential as high. Legal aspects, including ethical approval of registry-based randomization were identified as potential obstacles. Finally, we describe three potential randomized registry-based clinical trials in an adjuvant setting and for advanced disease with a high potential to be executed within the framework of an advanced ENSAT registry. Thus we, therefore, provide the basis for future registry-based trials for ACC patients. This could ultimately provide proof-of-principle of how to perform more effective randomized trials for an orphan disease.

Superior mesenteric venous thrombosis as a first manifestation of Antithrombin III deficiency in the postoperative course of laparoscopic sleeve gastrectomy: a case study of 2 patients from 1211 bariatric patients

Superior mesenteric venous thrombosis (SMVT) following laparoscopic sleeve gastrectomy (LSG) is a rare, potentially life-threatening complication, which presents either isolated, or as a part of portal/mesenteric/splenic vein thrombosis. Distinction between them possibly confers an important clinical and prognostic value. Antithrombin III (ATIII) deficiency causes an hypercoagulable state which predisposes to SMVT. We report the clinical presentation and treatment of two patients among 1211 LSGs (incidence = 0.165%) that presented with isolated SMVT and ATIII deficiency in an Academic Bariatric Center. Both patients had an unremarkable past medical history; none was smoker or had a previously known thrombophillic condition/thrombotic episode. Mean time of presentation was 15.5 days after LSG. Despite aggressive resuscitative and anticoagulation measures, surgical intervention was deemed necessary. No mortalities were encountered. Coagulation tests revealed ATIII deficiency in both patients.

Intravascular B-large cell lymphoma: an unexpected diagnosis of an incidental adrenal mass

Adrenal incidentalomas originally defined as tumors discovered serendipitously in the course of diagnostic evaluation or follow-up of unrelated disorders, may occasionally pose serious diagnostic challenges. Intravascular large B-cell lymphoma (IVLBCL) may be a rare example of such a case. We present an IVLBCL confined to the adrenal gland in a 52-year-old man focusing on its diagnostic and therapeutic aspects. On endocrine work up, the tumor was hormonally inactive and exhibited inconclusive imaging characteristics without signs of locoregional spread. After a left laparoscopic adrenalectomy, histologic sections revealed the presence of tumor cells inside dilated, thin-walled vascular spaces. Immunohistochemical stains confirmed the diagnosis of IVLBCL. The patient was then referred to a Hematology Unit for further staging and treatment and received six cycles of R-CHOP. Despite the fact that IVLBCL carries a dismal prognosis our patient remains alive and in complete remission 6 years after the initial diagnosis.

Carney Syndrome Presented as a Pathological Spine Fracture in a 35-Year-Old Male

Patient: Male, 35

Final Diagnosis: Carney syndrome

Symptoms: Pain at the spine

Medication: —

Clinical Procedure: Retroperitoneal adrenalectomy

Specialty: Surgery

Classic Primary Hyperparathyroidism Versus Normocalcemic and Normohormonal Variants: Do They Really Differ?

BACKGROUND

Normocalcemic (NCpHPT) and normohormonal (NHpHPT) variants have been recognized primary hyperparathyroidism entities that pose serious challenges. We sought to define the differences among them in a series of surgically treated patients.

PATIENTS AND METHODS

Between 2011 and 2015, 149 patients were enrolled into three groups: CpHPT (Ca > 10.2 mg/dL, PTH > 65 pg/mL), NCpHPT (normal Ca, PTH > 65 pg/mL) and NHpHPT (Ca > 10.2 mg/dL, normal PTH). Descriptive statistics and inter-group differences were computed, whereas multiple logistic/linear regression tests were used for further analysis.

RESULTS

Of these patients 125 were female and 24 male, mean age 56.3 years (range 8-83). A total of 115 (77.2%) patients presented with CpHPT, 23 (15.4%) with NCpHPT and 11 (7.4%) with NHpHPT. MGD was found in 25 (16.8%) patients and SGD in 124 (83.2%); multivariate analysis failed to reveal statistically significant association of MGD with any pHPT variant (CpHPT 16.5% vs NCpHPT 21.7% vs NHpHPT 9.1%, p = 0.726). Conversely, NCpHPT patients exhibited statistically significant smaller adenoma weight (p = 0.023). Moreover, U/S in these patients had smaller positive predictive value (p = 0.278), whereas concordance between U/S and MIBI was also lower (p = 0.669). The utility of MIBI and U/S differed significantly (p < 0.001); more frequent use of U/S was observed for all groups. However, their predictive values did not differ significantly (p = 0.832).

CONCLUSIONS

NCpHPT is more similar than different to CpHPT. NCpHPT constitutes the most challenging entity: it is associated with smaller adenoma weight, whereas U/S exhibited lower positive predictive value and lower concordance rate with MIBI. A trend for higher MGD presence in this group of patients was observed, though without statistical significance.

Thyroid paraganglioma: a case series of a rare head and neck tumor

Thyroid paragangliomas are rare neuroendocrine tumors. We present two cases analyzing their clinical presentation and pathology findings. A 44-year-old woman presented with a 33 mm left thyroid lobe mass. A 27-year-old male presented with a 27-mm right thyroid lobe mass and a FNA biopsy suggesting a follicular thyroid tumor. Both patients underwent total thyroidectomy. Vigorous bleeding was noted on the first case. Histologic sections revealed encapsulated tumors, whereas immunochemical stains were positive for chromogranin A, synaptophysin and NSE and negative for thyroglobulin, calcitonin, CEA and S-100. After an 18- and 12-month follow-up, respectively, both patients have no signs of local recurrence or distant metastasis. Preoperative diagnosis of thyroid paragangliomas was never attained in this series. Immunohistochemistry is mandatory for proper differential diagnosis. For the surgeon, the operation is technically demanding mainly due to the increased vascularity and friability of the tumor.

Posterior retroperitoneoscopic versus laparoscopic adrenalectomy in sporadic and MENIIA pheochromocytomas

INTRODUCTION

Retroperitoneal adrenalectomy (PRA) comprises an alternative approach in the management of adrenal tumors that has been set as the treatment of choice in our Institution. We assess the impact of PRA the management of hereditary and sporadic pheochromocytomas comparing its outcomes to the laparoscopic technique, in a case-controlled setting.

PATIENTS AND METHODS

From May 2008 to January 2013, 17 patients [5 males and 12 females, mean age: 51 yrs (range 26-73)] with pheochromocytomas underwent PRA. Demographics, tumor characteristics, operative time, complications, hospital stay, and postoperative pain (based on VAS score at days 1 and 3) were compared to 17 selected laparoscopic patient controls [7 males and 10 females, mean age 49 yrs (range 25-64)].

RESULTS

17 patients, 11 with the sporadic form and 6 with MENIIA associated pheochromocytomas, comprised the retroperitoneoscopic group. 19 pheochromocytomas with a mean size 3.7 cm (range 1.7-7.0) at a mean operative time: 105.6 min (range 60-180) were accordingly excised. In the laparoscopic group, 13 patients had sporadic pheochromocytomas, whereas 4 patients had MENIIA syndrome. Mean tumor size of the laparoscopic series was 5.1 cm (range 1.7-8.5) at a mean operative time of 137 min (range 75-195). No mortality or conversions were encountered in both groups. No blood transfusions were needed. Mean visual analog scale pain scores were significantly lower for the retroperitoneoscopic group both on days 1 and 3 [0.94 (0-3) vs 4.15 (3-6), p < 0.001 and 0.06 (0-1) vs 3.5 (2-6) p < 0.001] respectively. Mean hospital stay for the patients of the retroperitoneoscopic group was significantly better than the laparoscopic group [(2.1 ± 0.24 days vs 40 ± 0.70 days) p < 0.001].

CONCLUSIONS

Retroperitoneoscopic adrenalectomy is associated with excellent clinical results in the management of sporadic and hereditary pheochromocytomas. Moreover, it appears to be superior to the laparoscopic approach, because it is faster and affords the patient with less pain and shorter hospital stay.

Adrenal cortical oncocytoma mimicking pheochromocytoma

OBJECTIVE

Adrenal tumors present with clinical features and signs unique to their specific hormonal hypersecretion. However, there have been cases in which the clinical expression has been in conflict with the histologic features of the tumor. In this communication we report an unusual clinical presentation of an adrenal cortical tumor with histologic features of an oncocytoma that clinically mimicked a pheochromocytoma.

DESIGN

A 49-year old man was referred to our Unit due to type B aortic dissection and a mass of the left adrenal gland. Computed tomography and magnetic resonance imaging confirmed the presence of aortic dissection extending from the left subclavian artery to both iliac arteries and also revealed a 6 cm tumor on the left adrenal gland. Preoperative endocrine evaluation showed a near tenfold increase of urinary vanillylmandelic acid (VMA) and metanephrine values.

RESULTS

Transperitoneal laparoscopic adrenalectomy was successfully performed. The adrenal tumor proved to be an adrenal cortical neoplasm with histologic features of oncocytoma.

CONCLUSION

Although the case of an adrenal cortical adenoma clinically mimicking a pheochromocytoma has been described in the literature, to the best of our knowledge, there has been no previous report of an adrenal cortical neoplasm with predominant features of oncocytoma.

Adrenal ganglioneuromas: incidentalomas with misleading clinical and imaging features

BACKGROUND

Ganglioneuromas are benign neoplasms of the neural crest, occurring rarely in the adrenal glands. This study presents our experience regarding diagnostic and therapeutic management of these neoplasms and a review of the relevant literature.

METHODS

Among 150 patients with of incidentalomas, we had 7 primary ganglioneuromas. Their clinical, imaging, and operative data were collected retrospectively, and the literature was reviewed using MEDLINE. There were 4 females and 3 males, with mean age of 50 years (range, 39-64). All neoplasms were discovered incidentally with ultrasonography and were evaluated subsequently with computed tomography (CT). One patient was studied further with (131)I-MIBG due to asymptomatic increased in urine vanillylmandelic acid, and 1 patient with history of breast cancer underwent additional FDG-PET/CT.

RESULTS

All but 2 patients were asymptomatic. Two patients complained of epigastric pain and hypertension, respectively. The preoperative mean size on CT was 6.8 cm, whereas the postoperative true mean histologic size was 7.7 cm. Both patients who were evaluated with radionuclide studies had false positive results, suggestive of pheochromocytoma and adrenal metastasis, respectively. Three patients underwent open adrenalectomy due to preoperative suspicion of carcinoma, and the remaining 4 underwent laparoscopic anterior adrenalectomy. Histologically, all 7 neoplasms were completely differentiated, mature ganglioneuromas. We had no mortality or significant morbidity. No recurrence occurred during a mean follow-up of 6 years (range, 1-18).

CONCLUSION

Adrenal ganglioneuromas are rare incidentalomas that can mimic primary or secondary adrenal malignancies as well as pheochromocytomas. Despite their usually large size, resection via laparoscopic approach is safe and effective.

Laparoscopic sleeve gastrectomy in morbidly obese patients. Technique and short term results

OBJECTIVE

To evaluate the efficacy of Laparoscopic Sleeve Gastrectomy (LSG) as a definitive procedure for morbidly obese patients.

DESIGN

This constitutes a prospective study carried out in a tertiary care private hospital and included 15 morbidly obese patients who underwent LSG. The operation was performed through two 12 mm and two 5 mm ports, using the Endo-GIA stapler to create a lesser curve gastric tube over a 36-Fr bougie.

RESULTS

Operative time, complication rates, hospital length of stay, Body Mass Index (BMI), % of Excess Weight Loss (EWL) and appetite were evaluated. There were six females and nine males, aged (mean+/-SD) 40.5+/-10.5 yrs and preoperative BMI 47.8+/-7.5 kg/m2. The operative time was 147.7+/-43.2 min. There was one conversion to open surgery and one gastric leak with haemorrhage that led to gastric tube stenosis, ultimately requiring revision surgery. All patients, except these two, were discharged on the 2nd postoperative day after an upper GI series and the initiation of a clear liquid diet. At the follow-up (7.5+/-4.4 months post operatively), the % EWL was 35.7+/-10.1. Eight patients who received regular postoperative dietician counselling at follow-up did better than the others who did not (% EWL 40.4+/-3.8 vs 30.2+/-4.1, respectively). All patients reported significant loss of appetite.

CONCLUSIONS

Although the number of patients is relatively small, the data of this study indicate that laparoscopic sleeve gastrectomy is effective in weight reduction, being an acceptable surgical option for morbidly obese patients. A higher number of patients and longer follow-up period will be necessary to evaluate long-term efficacy.

Bilateral Laparoscopic Transperitoneal Adrenalectomy in Three Children

BACKGROUND

This study focuses on the clinical presentation, surgical technique, and results of bilateral laparoscopic adrenalectomy in three girls aged 6, 13, and 14.

MATERIALS AND METHODS

This retrospective study included two girls with bilateral tumors (pheochromocytomas in one case, recurrent leiomyosarcomas in the other case) and a girl with micronodular hyperplasia associated with Cushing's syndrome.

RESULTS

Six transperitoneal laparoscopic adrenalectomies were performed with no conversions. The average operative time was 137 minutes (range 125-148); the mean estimated blood loss was 75 mL; the mean size of the adrenal lesions was 8 cm (range, 0.5-9); and the mean length of hospital stay was 3 days (range, 2-4). Resolution of clinical and biochemical parameters of adrenal hyperfunction was accomplished in the patients with adrenocortical hyperplasia and pheochromocytoma. No tumor recurrence has been so far found in the case of the leiomyosarcomas.

CONCLUSION

Bilateral laparoscopic adrenalectomy can be performed safely and effectively with a shorter hospital stay, minimal blood loss, and excellent functional outcome in the pediatric population.

Surgical management of adrenal myelolipoma: a series of 10 patients and review of the literature

AIM

Adrenal myelolipomas have been conventionally described as asymptomatic tumors that are easily diagnosed and can be managed conservatively. The purpose of this study is to evaluate the role of surgery in the management of these lesions.

METHODS

The clinical presentation, the operative treatment and histopathological features of 10 patients with myelolipoma over a 13-year period in a tertiary care Center are presented.

RESULTS

Eight patients (80%) were symptomatic: 7 patients presented with non-specific abdominal pain, whereas 1 patient presented urgently due to intraperitoneal hemorrhage. Investiga-tion of concurrent medical conditions revealed hypertension (7 patients), diabetes mellitus (2 patients), obesity (4 patients) and nephrolithiasis (1 patient). Seven patients underwent adrenalectomy by open approach (4 through the anterior and 3 through the posterior route) and 3 by laparoscopic method. There was no postoperative morbidity and mortality and all patients are currently symptom free.

CONCLUSIONS

Although myelolipomas are considered as innocent benign growths, they may present with acute clinical symptoms. Surgical therapy is a safe and definitive treatment option for both symptomatic and ''asymptomatic'' lesions providing definitive diagnosis and alleviating the patients' symptoms along with the emotional burden due to tumor presence.

Bile duct injuries associated with laparoscopic and open cholecystectomy: an 11-year experience in one institute

PURPOSE

Bile duct injury (BDI) represents the most serious complication of laparoscopic cholecystectomy (LC). The aim of this retrospective single-institution study was to evaluate the real incidence of BDI during laparoscopic and open cholecystectomy (OC) in a tertiary academic center in Athens, Greece.

METHODS

Between January 1991 and December 2001, 3637 patients underwent cholecystectomy in our department; as LC in 2079 patients (LC group) and as OC in 1558 patients (OC group). All the LCs were performed or supervised by five staff surgeons and all the OCs were performed or supervised by another five staff surgeons.

RESULTS

There were 13 BDIs associated with LC (0.62%) and 6 associated with OC (0.38%) (P = 0.317). There was one death associated with BDI after LC. Only two (15.4%) of the BDIs associated with LC occurred within the proposed learning curve limit of 50 LCs per individual surgeon.

CONCLUSION

Laparoscopic cholecystectomy is safe and is not associated with a higher incidence of BDI than OC. Moreover, we did not find that the learning curve for LC affected BDI occurrence.

Laparoscopic management of complicated appendicitis

BACKGROUND

Complicated appendicitis is associated with a significant risk of postoperative morbidity, making the value of the minimally invasive approach controversial.

METHODS

From January 2000 to October 2004, 42 patients with complicated appendicitis were categorized into 3 groups: Group 1--perforation, Group 2-abscess formation, and Group 3--generalized peritonitis. The conversion rate, the operative time, the mean hospital stay, the postoperative abdominal and wound infections, the return to oral intake, and the late obstructive complications were analyzed in relation to clinicopathological subgroupings.

RESULTS

Conversion was needed in 2 patients (4.8%) due to adenocarcinoma (Group 2) and technical difficulties (Group 1). Mean operative time was 67 minutes (range, 48 to 88), and mean hospital stay was 3.2 days (range, 2 to 5). No postoperative wound infection or intraabdominal abscess was encountered. A clear liquid diet was instituted at the first postoperative 24 hours, and the mean time of flatus passage was 26.5 hours (range, 19 to 31). No statistically significant differences in operative time (P=0.13) and flatus passage (P=0.18) were found among the 3 groups. Two cases of late intestinal obstruction were treated successfully with conservative measures.

CONCLUSIONS

Laparoscopic appendectomy is a safe, feasible treatment option in complicated appendicitis. It is not associated with increased risk of septic postoperative complications including wound infections and intraabdominal abscess formation.

Retroperitoneal perforation of a duodenal diverticulum with colonic necrosis -- report of a case

Primary duodenal diverticula are usually asymptomatic. About 115 perforations have been reported, but none with right colon necrosis. We report a 45-year-old woman, with a five days history of high fever along with epigastric and periumbilical pain. Physical examination revealed right upper and lower quadrant tenderness with peritoneal signs. White blood cell count was 11 500/mm (3) while biochemical and hepatic biology tests were normal. Abdominal radiographs showed no pathologic findings. Ultrasound disclosed fluid in the lower pelvis. Computerized tomography revealed fluid collection in the right hepatorenal space. Intraoperative findings included purulent fluid in the lower pelvis, segmental necrotic changes of the right colon, and a perforated diverticulum on the antimesenteric border of the third part of the duodenum. Surgery consisted of right hemicolectomy and ileo-transverse anastomosis, diverticulectomy, and decompressive lateral duodenostomy at the second duodenal portion. The patient had an uneventful postoperative course. A contrast study from the duodenostomy tube on the 6 (th) postoperative day showed no leakage or obstruction. Duodenostomy tube was removed on the 14 (th) postoperative day. Histology confirmed the diagnosis of a primary duodenal diverticulum.

Laparoscopic management of a ruptured giant epidermoid splenic cyst

BACKGROUND

Epidermoid splenic cysts are uncommon lesions of the spleen. They are known to become symptomatic as a consequence of enlargement, infection, or rupture, the latter being an exceedingly rare complication traditionally treated with open splenectomy. We herein report a unique case of a giant epidermoid splenic cyst that ruptured spontaneously and was successfully treated with the laparoscopic approach.

CONCLUSION

Laparoscopic surgery may be considered an initial treatment option in cases of very large epidermoid cysts even when rupture occurs.

Use of a Diathermy System in Thyroid Surgery

HYPOTHESIS

New hemostatic methods have been widely used in open and laparoscopic surgery. The LigaSure Precise diathermy system (Valleylab, Boulder, Colo) has been recently used in thyroid surgery. We hypothesized that its use could lead to reduced operative time and fewer complications compared with conventional knot tying in total or near-total thyroidectomy.

DESIGN

Prospective case-controlled study.

SETTING

Tertiary care private hospital.

PATIENTS

Eighty patients underwent total or near-total thyroidectomy by 1 surgeon.

INTERVENTIONS

Forty patients underwent thyroidectomy with the conventional knot tying technique and 40 patients with the LigaSure diathermy system.

MAIN OUTCOME MEASURES

Demographics, histopathological diagnosis, operative time, intraoperative blood loss, complications, and cost, using chi2 test and Wilcoxon rank sum test.

RESULTS

The study groups had similar demographic and histopathological characteristics. The mean +/- SD operative time was nonsignificantly reduced in the LigaSure group compared with the conventional knot tying group (84 +/- 6 vs 89 +/- 7 minutes, P = .60). The mean +/- SD intraoperative blood loss was less for the LigaSure group (30 +/- 5 vs 35 +/- 8 mL, P = .36). There was 1 case of transient recurrent laryngeal nerve palsy in the LigaSure group. One patient from this group and 2 patients from the other group exhibited transient hypocalcemia; permanent postoperative hypocalcemia was not encountered in either group. The cost of the LigaSure diathermy system was significantly greater than that of conventional knot tying.

CONCLUSION

Use of the LigaSure in thyroid surgery did not significantly reduce operative time, blood loss, or complication rates compared with conventional knot tying, but it increased operative cost.