Early parathyroid hormone (PTH) level as a predictor of post-surgical hypoparathyroidism

INTRODUCTION

Post-operative hypocalcemia and postoperative persistent hypoparathyroidism remain the most common complications after thyroidectomy. Many approaches have been developed to prevent them, but actually, a common protocol is not yet individuated.

MATERIALS AND METHODS

We retrospectively analyzed the results of a prospectively collected database. We dosed PTH preoperatively and 4 h after surgery (PTH_4); calcium was evaluated preoperatively, on the first (I_POD) and on the second postoperative day (II_POD). Hypocalcemia was defined when calcium <8 mg/dl. PTH_4 and I_POD calcium serum levels are identified to predict postoperative hypocalcemia.

RESULTS

Three hundred and forty-eight patients were enrolled, 37 patients resulted as hypocalcemic on I_POD and 41 on the II_POD. PTH_4 is related to I_POD (p < 0.001, r = 0.45) and II_POD (p < 0.001, r = 0.44) calcemia. PTH_4-cut-off predicting I_POD hypocalcemia was 10.50 pg/ml (sensitivity: 78.7%, specificity: 72.7%). A PTH_4 value of 11.5 pg/ml is able to predict hypocalcemia during II_POD (sensitivity: 76.5%, specificity: 69.2%). We set up a combined test to predict II_POD hypocalcemia, using PTH_4 and I_POD calcium (sensitivity: 77.8%, specificity: 89.9%).

CONCLUSION

This research shows the association between PTH_4 and postoperative hypocalcemia. The PTH_4 cut-off to predict I_POD-hypocalcemia was 10.5 pg/ml. We analyzed the calcemia trend during the postoperative period and we realized a combined test using PTH_4 and I_POD-calcemia. This test improves the accuracy of the previous test. Further studies, in particular multicentric, with a larger sample are necessary to validate the combined model.

Solitary fibrous tumor of the thyroid: report of three cases with a focus on cytological features and histological clues for malignancy

Solitary fibrous tumor is a mesenchymal tumor of intermediate malignant potential characterized by a recurrent NAB2::STAT6 fusion and STAT6 nuclear expression. Primary thyroid solitary fibrous tumor is relatively uncommon, with 45 cases described in the English literature to date. Although its histologic features are characteristic, its diagnosis in the thyroid can be problematic, especially in small biopsies or cytology specimens. We herein present three new cases of thyroid solitary fibrous tumor, one of which is malignant, with new insights on the morphological spectrum and malignant potential of this tumor. We additionally provide a review of the literature with a focus on the clues and challenges of a preoperative cytological diagnosis of this tumor, which can nowadays be supported by STAT6 nuclear expression, when appropriately suspected.

Timing of cholecystectomy in acute biliary pancreatitis: is it still reasonable to wait?

BACKGROUND

Acute gallstone-related pancreatitis is a potentially life-threatening condition, and its adequate therapy is represented by cholecystectomy. The aim of this study was to analyze the best surgical strategy, and the optimal timing.

METHODS

All cases of acute pancreatitis of biliary origin occurred between January 2007 and December 2013 in Gradenigo Hospital (Turin, Italy) undergone to a surgical procedure, were reviewed. Patients were divided in two groups, based on the timing of cholecystectomy, and compared.

RESULTS

Out of 2233 cholecystectomies performed in the mentioned time interval, we have identified 79 patients that fulfill the selection criteria. 24 patients were treated with an index-stay procedure, while 55 with a delayed approach. Length of stay was significantly lower in patients that underwent to an early laparoscopic cholecystectomy (9 vs. 13 days, P=0.003), while no differences were found in terms of length of intervention, intraoperative complications, postoperative stay and mortality. Patients treated with delayed surgery had a 28.6% recurrence rate of acute pancreatitis, with an odds ratio of 10.28 (P=0.02).

CONCLUSIONS

Early laparoscopic cholecystectomy should be performed in suitable patients in the index admission, reducing overall risks, avoiding or at least minimizing recurrencies, and rationalizing the scarce economic resources.

The new approach to the rectal cancer: 'down-to-up' double endolaparoscopic pelvic access. Preliminary evaluation of outcomes

Laparoscopic access in low anterior rectal resection is widely adopted, performing an 'up-to-down' dissection. The aim of this study is to present and analyze the outcomes of a novel surgical 'down-to-up' total mesorectal excision technique that could obviate to the well-known issues of the standard treatment. 18 suitable patients underwent double endolaparoscopic pelvic access (DEPA) 'down-to-up' technique. DEPA TME was completed in all patients, with intact mesorectum. Mean operative time was 365 min (range 280-510 min). The morbidity rate was 22%, including three radiologically detected leakage (grade A) and one pelvic abscess, requiring only a conservative management. Mortality rate at 30 and 90 days was 0%. Resection margins were negative in all patients. A median of 11 nodes (range 5-19) was retrieved per specimen. Mean length of hospital stay was 9 days (range 7-19 days). Patients were followed for an average of 14 months (range 0-42 months), with no recurrence. Despite exiguous patient's sample in this pilot study, transanal endoscopic TME with laparoscopic assistance seems to be feasible and safe, and is a promising alternative to open and laparoscopic TME. However, a conspicuous functional and oncologic long-term evaluation is required, before the widespread adoption could be recommended.

Randomized clinical trial comparing survival after D1 or D2 gastrectomy for gastric cancer

BACKGROUND

It is still unclear whether D2 lymphadenectomy improves the survival of patients with gastric cancer and should therefore be performed routinely or selectively. The aim of this multicentre randomized trial was to compare D2 and D1 lymphadenectomy in the treatment of gastric cancer.

METHODS

Between June 1998 and December 2006, patients with gastric adenocarcinoma were assigned randomly to either D1 or D2 gastrectomy. Intraoperative randomization was implemented centrally by telephone. Primary outcome was overall survival; secondary endpoints were disease-specific survival, morbidity and postoperative mortality.

RESULTS

A total of 267 eligible patients were allocated to either D1 (133 patients) or D2 (134) resection. Morbidity (12.0 versus 17.9 per cent respectively; P = 0.183) and operative mortality (3.0 versus 2.2 per cent; P = 0.725) rates did not differ significantly between the groups. Median follow-up was 8.8 (range 4.5-13.1) years for surviving patients and 2.4 (0.2-11.9) years for those who died, and was not different in the two treatment arms. There was no difference in the overall 5-year survival rate (66.5 versus 64.2 per cent for D1 and D2 lymphadenectomy respectively; P = 0.695). Subgroup analyses showed a 5-year disease-specific survival benefit for patients with pathological tumour (pT) 1 disease in the D1 group (98 per cent versus 83 per cent for the D2 group; P = 0.015), and for patients with pT2-4 status and positive lymph nodes in the D2 group (59 per cent versus 38 per cent for the D1 group; P = 0.055).

CONCLUSION

No difference was found in overall 5-year survival between D1 and D2 resection. Subgroup analyses suggest that D2 lymphadenectomy may be a better choice in patients with advanced disease and lymph node metastases.

REGISTRATION NUMBER

ISRCTN11154654 (http://www.controlled-trials.com).

Lymph-nodal ratio in gastric cancer staging system

AIM

Many studies have indicated that lymph node metastases and the depth of invasion of the primary tumor are the most reliable prognostic factors for patients with radically resected gastric cancer. Recently the ratio between metastatic and examined lymph nodes (n ratio) has been proposed as a new prognostic indicator. The aim of this study was to evaluate the prognostic value of n ratio in patients with gastric cancer.

METHODS

We retrospectively reviewed the data of 399 patients who had undergone radical resection for gastric carcinoma.

RESULTS

N ratio was significantly greater in patients with large and undifferentiated tumors. Moreover, it was significantly related to both the number and location of lymph node metastases. Survival curves showed that n ratio was strictly related to patients' survival. Multivariate analysis confirmed that it was an important independent prognostic indicator.

CONCLUSION

N ratio is useful to better evaluate the status of lymph node metastases in patients with gastric cancer submitted to radical surgery. Moreover it is a very important independent prognostic factor for gastric cancer.

[Treatment of functional diseases after rectum anal surgery: effectiveness of rehabilitation of the pelvic pavement]

AIM

Anorectal dysfunction is routinely treated at the Center for Pelvic Floor Rehabilitation, San Giovanni University Hospital, Turin, Italy. Of a total of 147 patients treated between April 2007 and May 2008, 44 (30%) received pelvic floor rehabilitation following anorectal surgery. With this study we wanted to evaluate the response of patients with constipation and/or fecal incontinence to postsurgical pelvic floor rehabilitation designed to regain full or partial anorectal function and so improve their quality of life.

MATERIAL AND METHODS

The study population was 44 patients, subdivided into 3 groups. One group (n=25) consisted of patients with fecal incontinence, which was further split into two subgroups: subgroup A (n=10) with direct involvement of the anal sphincter at surgery and subgroup B (n=15) without sphincter involvement. The second group (n=12) included patients with constipation. The third group (n=7) included patients with constipation and incontinence; this group was further split into 2 subgroups: those in which constipation (n=5) and those in which incontinence (n=2) was predominant. Pre- and postrehabilitation anorectal function was compared using two types of assessment: 1) clinical evaluation with the Wexner incontinence scale and 2) diagnostic evaluation with anorectal manometry in patients with fecal incontinence (plus transanal sonography to determine anatomic damage in the subgroups in which the sphincter had been involved) and defecography in those with constipation (plus transit radiography to exclude intestinal colic-associated constipation).

RESULTS

The number of patients classified as having severe incontinence decreased from 8 to 1 (-87.5%), those with moderate incontinence decreased from 8 to 4 (-50%); 20 out of 25 patients presented with mild dysfunction at the end of the rehabilitation program. No difference in response to treatment was found between the two subgroups of patients with fecal incontinence nor among those with constipation. Of those with predominant constipation, none were classified as having severe dysfunction; the number of those with moderate dysfunction decreased from 13 to 7 (-54%).

CONCLUSIONS

The study results show that, when sufficiently motivated, patients with fecal incontinence and constipation following anorectal surgery respond positively to pelvic floor rehabilitation.