Diagnostic values of ultrasound and the Modified Alvarado Scoring System in acute appendicitis

BACKGROUND: Making the diagnosis of acute appendicitis is difficult, and is important for preventing perforation of the appendix and negative appendectomy results. Ultrasound and clinical scoring systems are very helpful in making the diagnosis. Ultrasound is non-invasive, available and cost-effective, and can accomplish more than CT scans. However, there is no certainty about its effect on the clinical outcomes of patients, and it is operator dependent. Counting the neutrophils as a parameter of the Alvarado Scale is not routine in many laboratories, so we decided to evaluate the diagnostic value of the Modified Alvarado Scaling System (MASS) by omitting the neutrophil count and ultrasonography. METHODS: After ethical approval of methodology in Tehran University of Medical Sciences ethical committee, we collected the data. During 9 months, 75 patients with right lower quadrant pain were enrolled in the study, and underwent abdominal ultrasonography and appendectomy, with pathological evaluation of the appendix. The MASS score was calculated for these patients and compared with pathology results. RESULTS: Fifty-five male and 20 female patients were assessed. Of these patients 89.3% had acute appendicitis. The sensitivity, specificity, PPV, NPV and accuracy rate of ultrasonography was 71.2%, 83.3%, 97.4%, 25% and 72.4%, respectively. By taking a cutoff point of 7 for the MASS score, a sensitivity of 65.7%, specificity of 37.5%, PPV of 89.8%, NPV of 11.5% and accuracy of 62.7% were calculated. Using the cutoff point of 6, a sensitivity of 85.1%, specificity of 25%, PPV of 90.5%, NPV of 16.7% and accuracy of 78.7% were obtained. CONCLUSION: Ultrasound provides reliable findings for helping to diagnose acute appendicitis in our hospital. A cutoff point of 6 for the MASS score will yield more sensitivity and a better diagnosis of appendicitis, though with an increase in negative appendectomy

Comparison of Methoxyisobutylisonitrile Scintigraphy and Ultrasonography in Preoperative Localization of Secondary Hyperparathyroidism

Background: In patients with secondary hyperparathyroidism, the four glands are not uniformly enlarged; therefore, preoperative localization is difficult in comparison with primary hyperparathyroidism. The aim of this study was to compare the usefulness of 99mTc-sestamibi scintigraphy versus ultrasonography in the preoperative assessment of patients with secondary hyperparathyroidism.Methods: Between October 2008 and March 2012, 25 uremic patients with secondary hyperparathyroidism underwent 99mTc-sestamibi scintigraphy and high resolution ultrasonography before total or subtotal parathyroidectomy. We measured plasma concentration of intact parathyroid hormone (PTH), calcium, phosphorus, and alkaline phosphatase (ALP) before parathyroidectomy.Results: Sensitivity and positive predictive value (PPV), respectively, were 47.3% and 97.8% for MIBI scintigraphy, and 69.5% and 96.9% for ultrasonography. The sensitivity of combined techniques was 84.2%. There was a positive correlation between the parathyroid glands’ weight and serum calcium level, and positive MIBI scintigraphy and ultrasonography results. However, there was no correlation between the preoperative serum PTH, phosphorus, alkaline phosphatase (ALP), dialysis duration, and parathyroid glands’ weight.Conclusions: Ultrasonography is a reliable non-invasive localization tool. It has greater sensitivity in localizing parathyroid glands in secondary hyperparathyroidism than scintigraphy

Outcome of Common Bile Duct Exploration without Intraoperative Cholangiography: a Case Series and Review of Literature

Background: Open or laparoscopic surgical exploration of common bile duct (CBD) is performed when endoscopic approaches fail to extract CBD stones. Intraoperative cholangiography (IOC) through T-tube is performed in order to reduce the rate of retained stones. The aim of this study was to evaluate results of CBD exploration without IOC through T-tube and reviewing existing literature.Methods: A retrospective medical chart review of 392 patients who underwent surgical CBD exploration was performed. All patients had proven CBD stones and had previously undergone failed attempts of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES). T-tube insertion or biliary-enteric anastomosis was performed after open CBD exploration with regard to patient’s presentation and CBD diameter. IOC was not performed after T-tube insertion and cholangiography was postponed until 7th postoperative day. Postoperative retained stone and their management were reviewed.Results: Of 392 patients with CBD explorations, T-tube was placed in 215 (54.8%) including 66 (30.7%) emergent biliary drainage and 149 (69.3%) elective operations. A number of 177 of 392 (45.2%) patients underwent biliaryenteric anastomosis. In 6 of 215 patients (2.8%) with T-tube placement, retained CBD stones were detected by T-tube cholangiography during postoperative period. All of them were treated successfully by ERCP.Conclusions: T-tube placement without IOC is accompanied by a low rate of retained stone. Omitting IOC may decrease the operation time which is especially important in emergent cases. Retained stones following CBD exploration and T-tube placement can be treated successfully using ERCP

Adenoma Weight and Biochemical Parameters in Primary Hyperparathyroidism

Background: Primary hyperparathyroidism is autonomous production of parathyroid hormone. After removal of adenoma, one of the surgeons concern is postoperative hypocalcaemia. There is no precise method to determine if patients have hypocalcaemia postoperatively. The purpose of this study was to determine the relation between parathyroid adenoma weights, postoperative serum calcium and serum biochemical parameters in patients with primary hyperparathyroidism. Methods: In a prospective study, eighty patients with single parathyroid adenoma were enrolled. Preoperative serum levels of calcium, phosphate, PTH, as well as Postoperative serum calcium and weight of adenomas were recorded. The level of significance was set to be p < 0.05. Results: There was no significant correlation between postoperative serum calcium, parathyroid adenoma weight (r= -0.17, p= 0.1), and parathyroid hormone level (r = -0.11, p = 0.3). However, a weak correlation between postoperative and preoperative serum calcium levels (r = 0.23, p = 0.03) was observed. Moreover, Serum calcium decline after adenoma resection was statistically correlated with adenoma weight (r = 0.36, p= 0.001), preoperative serum calcium (r = 0.92, p= 0.0007), PTH (r= 0.54, p= 0.0005) and ALP levels (r = 0.3, p= 0.006). Conclusion: Although preoperative serum markers and adenoma weight are unreliable in predicting postoperative serum calcium level, it is possible to estimate postoperative calcium decline by considering adenoma weight and preoperative serum biochemical parameters

Parathyroid Adenoma Localization

Abstract Background: Bilateral neck exploration is the gold standard for parathyroid adenoma localization in primary hyperparathyroidism. But surgeons do not have adequate experience for accurate surgical exploration and new methods are developed for surgery like unilateral exploration and minimally invasive surgery, thus, preoperative localization could reduces time and stress in surgical performance. Method: 80 patients with documented primary hyperparathyroidism and with raised serum calcium and parathyroid hormone (PTH) were selected. The results of ultrasonographic localization for each patient were compared with findings of surgery and 99m technetium sestamibi scintigraphy. Also variables such as preoperative serum calcium, PTH level and adenoma weight were compared between patients who had localized and nonlocalized adenoma with ultrasonography or Sestamibi scan. The data was compared with student’s t-test. Results: In a prospective diagnostic tests’ accuracy, 80 patients with primary hyperparathyroidism were enrolled. Ultrasonography images detected enlarged parathyroid glands in 61 of 80 patients (76.3%) with sensitivity of 83.5% and positive predictive value (PPV) of 89.7%. Sestamibi scintigraphy detected adenoma in 63 patients (78.8%) with sensitivity of 85% and PPV of 91.3%. There was no significant deference between ultrasonography and scintigraphy in localization of adenomas. Both ultrasonography and scintigraphy used for determining localization, and they located 73 adenomas (91.3%) with sensitivity of 97.3% and PPV of 93.5%. Conclusion: Ultrasonography as an accurate method for localization of enlarged parathyroid glands in primary hyperparathyroidism, is comparable in overall utility with sestamibi scintigraphy. This study suggests a strategy for initial testing with one method, followed by the alternate imaging test if the first test happen to be negative