Spontaneous retroperitoneal hematoma - our experience with surgical approach

Spontaneous retroperitoneal hematoma is a serious complication of anticoagulation and antiplatelet therapy. Its incidence has increased in recent years due to an increasing number of patients on this treatment. A number of case series have been described in the literature. In the vast majority of cases, the hemodynamically stable patients were treated either conservatively or by selective radiological embolization of the bleeding source. A surgical approach is reported as a last choice in the cases where the conservative therapy fails, radiological intervention is unavailable, in patients with continuous bleeding or in patients who develop abdominal compartment syndrome. In our case report, we present a patient on anticoagulation therapy for deep venous thrombosis complicated by massive retroperitoneal bleeding: surgery was used as the method of first choice and the treatment was successful. Key words: retroperitoneal hematoma bleeding anticoagulation treatment surgery.

[Rare case of a giant parathyroid adenoma]

Currently, primary hyperparathyroidism is the third most common endocrine disorder worldwide. In the last years, though, the numbers of patients with this diagnosis have been clearly increasing. Females are affected more often, and the age of patients is usually over 50 years. The diagnosis is guided by clinical symptoms of the patient and by biochemical and imaging methods results. [1] When parathyroid adenoma is identified as the source of primary hyperparathyroidism, the necessary extent of resection is performed. The present case involved a rapid diagnostic process necessary to stabilize the patient, together with localization of the adenoma for the indicated surgery. Ultrasound-guided exploration found a surprisingly large tumour of the parathyroid gland causing the acute clinical condition with symptoms suggestive of primary hyperparathyroidism with discrete mechanical compression of the upper mediastinum.Key words: critical diagnosis of hyperparathyroidism acute-active parathyroid adenoma extirpation of a huge parathyroid tumour - normalization of the clinical condition.

Self-expandable biodegradable biliary stents in porcine model

BACKGROUND

Treatment or prevention of a benign biliary tree stricture is an unresolved problem. A novel self-expandable biodegradable polydioxanon biliary stent in a porcine model was studied.

MATERIALS AND METHODS

This new stent was used in 23 pigs. Feasibility and safety of surgical stenting, time of biodegradation, and histologic reaction in 2, 8, 13, and 20 wk of a follow-up were studied. All stents were inserted into a common bile duct through a duodenal papilla following small dilatation. After surgical evaluation of abdominal cavities, the pigs were sacrificed to remove common bile ducts with the stents. All bile ducts were assessed by macroscopic and histopathologic examination.

RESULTS

Self-expansion was correct in all cases. Neither bile duct obstruction nor postsurgical complications were observed. Macroscopic evaluation indicated lightening of the stent color in 2 wk, a partial disintegration in 8 wk, and a complete absorption in 13 and 20 wk. Histologic evaluation in general substantiated a mild-to-moderate inflammatory reaction in the lamina propria during the whole follow up and had no clinical consequences. No cholangitis, necrosis, abscess, or excessive fibroplasia was found in a hepatoduodenal ligament.

CONCLUSIONS

Our results suggest that polydioxanon biodegradable self-expanding stents seem to be useful for biliary system implantation, offer a good biocompatibility, and completely degrade within 13 wk.

[The value of intraoperative ultrasonography in parathyroid surgery]

INTRODUCTION

Ultrasound of the neck is a sovereign complementary imaging method suitable for determining morphological changes in thyroidology which uses the so-called B-mode two-dimensional images for the neck area that are complemented by duplex Doppler imaging. Diagnostic verification is performed by sonographists from among radiologists and endocrinologists providing regular outpatient care; the surgeon uses ultrasound for navigation to attain the focus to be operated on. Sonography will provide information on the structure of the thyroid, of the parathyroids, their relationship to the surrounding organs (location, size, relationship to breathing and swallowing pathways). We search for the presence of any pathological abnormalities such as the affection of other organs, tumour invasion into surrounding tissue; it is also important to assess the size and nature of the cervical lymph nodes pretracheally, prelaryngeally, paratracheally, along the vascular plexus and supraclavicularly, where thyroid tumours may form metastases. USG assessment of the regional lymph nodes should not be forgotten before surgical management of thyroid nodules or the parathyroids. Thanks to the introduction of ultrasound as an additional screening method in parathyroid surgery we have gained the opportunity of more precise and successful localisation of pathological parathyroid lesions, which is beneficial for patients with hyperparathyroidism.

MATERIAL AND METHODS

We worked with a group of patients from 2002 to 2010 when we selected 370 prospectively followed patients operated on for endocrine disease of the thyroid and parathyroid glands. The group consisted of 77 men and 293 women. This group was further selected according to the required criteria specified in the text. Since we are focusing on peroperative ultrasound and on the detection and specification of the position of the parathyroid glands for the surgeon, we are concentrating chiefly on pathological parathyroid glands. These are imaged as circumscribed hypoechoic lesions with hyperechoic margin. Ultrasonography is considered both a sovereign standard diagnostic method and a very valuable navigational method used to localise pathological glands. We use a linear as well as a special "hockey stick" probe which has a higher resolution.

RESULTS

For comparison, both detection methods - gamma navigation and ultrasound - are dealt with. We are fully aware of the small number of patients in the selected groups. The results of the statistical analysis show that the use of ultrasound and gamma navigation shortens the overall operation time. More interesting, however, is the indicator of the range of variation, i.e. the difference between the maximum and minimum length of operation. When using one or the other detection method, the variation range is significantly lower and it is apparent that using the gamma-ray or ultrasound navigation system, the detection of the parathyroid gland, particularly when unusually located, is much simpler and thus faster. This finding is also supported by an additional parameter, variance, which expresses the variability of the distribution of values - around the average length of operation.

CONCLUSION

Preoperative and intraoperative detection of hyperactive parathyroid glands is useful for minimizing the extent of surgical intervention, reducing operation time and decreasing the risk of perioperative complications. It is not necessary to use a radionuclide and therefore the method can be used even where there is no nuclear medicine station. It is also possible to detect glands which do not accumulate radionuclides and thus cannot be imaged with MIBI scintigraphy/SPECT CT. Still, an experienced surgeon remains irreplaceable. We dare say that if such a surgeon can make use of the above mentioned auxiliary methods in addition, the rate of success in this field of surgery increases substantially.