Przełom hiperkalcemiczny z powodu pierwotnej nadczynności przytarczyc — przegląd piśmiennictwa i opis przypadku

Hypercalcaemic crisis is an uncommon and potentially life-threatening manifestation of primary hyperparathyroidism, and it is associated with rapid deterioration of the central nervous system, and cardiac, gastrointestinal, and renal function. We present the case of a 76 year-old man in a sudden coma due to hypercalcaemic crisis as a first manifestation of primary hyperparathyroidism. At first, the patient was treated conservatively, his mental status gradually improved in the next three days. On the ninth day after the initiation of therapy, a minimally invasive radio-guided parathyroidectomy was performed. Histologically, the tumour consisted of densely arranged chief cells immunohistochemically positive for PTH antigens, suggesting adenoma. Calcaemia level and PTH were normalised in the immediate postoperative period. A systematic review was performed by consulting PubMed MEDLINE for publications from 1958 to 2011. This review found a total of 499 reported cases of hypercalcaemic crisis due to primary hyperparathyroidism. Manifestations are neurological alterations, and cardiac, renal and gastrointestinal dysfunctions associated with markedly elevated serum calcium and parathyroid hormone levels. The most frequent histology is the parathyroid adenoma. In untreated cases, mortality is 100%. Despite advances in its management, the mortality rate is still 93.5% in patients treated only conservatively. Medical therapy followed by expeditious parathyroidectomy should be considered as the treatment of choice for patients affected by hypercalcaemic crisis due to a primary hyperparathyroidism. (Endokrynol Pol 2012; 63 (6): 494–502)Przełom hiperkalcemiczny jest rzadkim choć potencjalnie zagrażającym życiu objawem pierwotnej nadczynności przytarczyc i jest skojarzony z gwałtownym pogorszeniem funkcji ośrodkowego układu nerwowego, serca, przewodu pokarmowego i funkcji nerek. W pracy zaprezentowano przypadek 76-letniego mężczyzny, u którego pierwszym objawem pierwotnej nadczynności przytarczyc był przełom hiperkalemiczny w postaci nagłej śpiączki. Na początku pacjent był leczony zachowawczo i jego stan psychiczny zaczął ulegać stopniowej poprawie w ciągu pierwszych 3 dni. Dziewiątego dnia terapii wykonano u niego mini inwazyjny zabieg usunięcia przytarczyc pod kontrolą RTG. Histologicznie guz składał się z gęsto ułożonych dużych komórek pozytywnych badaniem imunohistologiczno-chemicznym dla antygenów PTH, sugerując gruczolak. Stężenie wapnia i PTH znormalizowano w bezpośrednim okresie pooperacyjnym. Dokonano systematycznego przeglądu publikacji PubMed MEDLINE w latach 1958–2011. Przegląd zawiera łącznie 499 odnotowanych przypadków przełomu hiperkalcemicznego jako objawu pierwotnej nadczynności przytarczyc. Przejawy to zmiany neurologiczne, dysfunkcja nerek, przewodu pokarmowego i serca związanych ze znacznie podwyższonym stężeniem wapnia i parathormonu w surowicy. W badaniu histologicznym najczęściej diagnozowany jest gruczolak przytarczycowy. W przypadkach nieleczonych odnotowuje się 100-procentową śmiertelność. Mimo postępów w leczeniu, przy terapii tylko zachowawczej, śmiertelność jest nadal wysoka — 93,5%. Leczenie zachowawcze plus szybkie usuniecie przytarczyc powinny być uważane za leczenie z wyboru u pacjentów dotkniętych przełomem hiperkalcemicznym z powodu pierwotnej nadczynności przytarczyc. (Endokrynol Pol 2012; 63 (6): 494–502

Substernal oxyphil parathyroid adenoma producing PTHrP with hypercalcemia and normal PTH level

<p>Abstract</p> <p>Background</p> <p>Parathyroid adenoma is the most common cause of primary hyperparathyroidism. Preoperative serum calcium and intact-parathyroid hormone levels are the most useful diagnostic parameters that allow differentiating primary hyperparathyroidism from non-parathyroid-dependent hypercalcemia. Parathyroidectomy is the definitive treatment for primary hyperparathyroidism. Approximately 5% of patients who underwent parathyroidectomy present with persistent or recurrent hyperparathyroidism due to ectopic localization of the adenoma. Functioning oxyphil parathyroid adenoma is an uncommon histological form, seldom causing primary hyperparathyroidism. Parathyroid adenoma with hypercalcemia exhibiting normal parathyroid hormone level is rare. An incidence of 5% to 33% has been documented in the literature; no etiologic explanation has been given. In 1987, parathyroid-hormone-related peptide was isolated as a causative factor of humeral hypercalcemia of malignancy. The presence of parathyroid-hormone-related peptide in parathyroid tissue under normal and pathological conditions has been described in the literature; however, its role in causing hyperparathyroidism has not yet been defined.</p> <p>Case presentation</p> <p>We present a case of persistent hypercalcemia with a normal level of intact-parathyroid hormone due to a substernal parathyroid adenoma, treated with radioguided parathyroidectomy. The final histological diagnosis was oxyphil adenoma, positive for parathyroid-hormone-related peptide antigens.</p> <p>Conclusion</p> <p>In clinical practice, this atypical biochemical presentation of primary hyperparathyroidism should be considered in the differential diagnosis of hypercalcemia. The parathyroid-hormone-related peptide should be considered not only in the presence of malignancy.</p

Prepectoral breast reconstruction: an ideal approach to bilateral risk-reducing mastectomy

Background: Bilateral risk-reducing mastectomy (BRRM) has increased its popularity in the last years because of its aim to minimise the chances of developing breast cancer in high-risk patients. Women undergoing this procedure must be considered highly demanding patients given the need to combine aesthetical, functional and preventive desires. This study aims to present the authors’ experience in performing BRRM followed by single-stage prepectoral reconstruction (PPBR) with implant completely covered by acellular dermal matrix (ADM) and to report indications, surgical techniques, functional and aesthetic results. Methods: A single-centre prospective data collection was carried out from January 2017 to January 2021 of patients at high risk of developing breast cancer undergoing BRRM and immediate PPBR with ADM. Patients were subdivided into two groups according to the breast shape: Group A had small and medium size breasts and Group B had large and ptotic breasts. Oncological and surgical outcomes were collected. Satisfaction with reconstruction and related quality of life were evaluated through the BREAST-Q questionnaire. Results: A total of twenty-three patients met the inclusion criteria. Seventeen patients were included in group A and six patients in group B. Average follow-up was 18.4 months. Minor complications occurred in four breasts: one seroma, one hematoma and two cases of wound dehiscence. Capsular contracture was not observed. All patients were satisfed with the fnal result according to the post-operative BREAST-Q questionnaire. Conclusions: Immediate prepectoral breast reconstruction could represent the ideal reconstruction option after BRRM and should be offered to all women that fulfl the inclusion criteria

Minimally invasive laparoscopic and robot-assisted emergency treatment of strangulated giant hiatal hernias: report of five cases and literature review

Background Giant hiatal hernia (GHH) is a condition where one-third of the stomach migrates into the thorax. Nowadays, laparoscopic treatment gives excellent postoperative outcomes. Strangulated GHH is rare, and its emergent repair is associated with significant morbidity and mortality rates. We report a series of five cases of strangulated GHH treated by a minimally invasive laparoscopic and robot-assisted approach, together with a systematic review of the literature. Methods During 10 years (December 2009–December 2019), 31 patients affected by GHH were treated by robot-assisted or conventional laparoscopic surgical approach. Among them, five cases were treated in an emergency setting. We performed a PubMed MEDLINE search about the minimally invasive emergent treatment of GHH, selecting 18 articles for review. Results The five cases were male patients with a mean age of 70 ± 18 years. All patients referred to the emergency service complaining of severe abdominal and thoracic pain, nausea and vomiting. CT scan and endoscopy were the main diagnostic tools. All patients showed stable hemodynamic conditions so that they could undergo a minimally invasive attempt. The surgical approach was robotic-assisted in three patients (60%) and laparoscopic in two (40%). Patients reported no complications or recurrences. Conclusion Reviewing current literature, no general recommendations are available about the emergent treatment of strangulated hiatal hernia. Acute mechanical outlet obstruction, ischemia of gastric wall or perforation and severe bleeding are the reasons for an emergent surgical indication. In stable conditions, a minimally invasive approach is often feasible. Moreover, the robot-assisted approach, allowing a stable 3D view and using articulated instruments, represents a reasonable option in challenging situations

Emergency total thyroidectomy due to non traumatic disease. Experience of a surgical unit and literature review

<p>Abstract</p> <p>Background</p> <p>Acute respiratory failure due to thyroid compression or invasion of the tracheal lumen is a surgical emergency requiring urgent management. The aim of this paper is to describe a series of six patients treated successfully in the emergency setting with total thyroidectomy due to ingravescent dyspnoea and asphyxia, as well as review related data reported in literature.</p> <p>Methods</p> <p>During 2005-2010, of 919 patients treated by total thyroidectomy at our Academic Hospital, 6 (0.7%; 4 females and 2 men, mean age: 68.7 years, range 42-81 years) were treated in emergency. All the emergency operations were performed for life-threatening respiratory distress. The clinical picture at admission, clinical features, type of surgery, outcomes and complications are described. Mean duration of surgery was 146 minutes (range: 53-260).</p> <p>Results</p> <p>In 3/6 (50%) a manubriotomy was necessary due to the extension of the mass into the upper mediastinum. In all cases total thyroidectomy was performed. In one case (16.7%) a parathyroid gland transplantation and in another one (16.7%) a tracheotomy was necessary due to a condition of tracheomalacia. Mean post-operative hospital stay was 6.5 days (range: 2-10 days). Histology revealed malignancy in 4/6 cases (66.7%), showing 3 primitive, and 1 secondary tumors. Morbidity consisted of 1 transient recurrent laryngeal palsy, 3 transient postoperative hypoparathyroidism, and 4 pleural effusions, treated by medical therapy in 3 and by drains in one. There was no mortality.</p> <p>Conclusion</p> <p>On the basis of our experience and of literature review, we strongly advocate elective surgery for patients with thyroid disease at the first signs of tracheal compression. When an acute airway distress appears, an emergency life-threatening total thyroidectomy is recommended in a high-volume centre.</p

Role of prophylactic central compartment lymph node dissection in clinically N0 differentiated thyroid cancer patients: Analysis of risk factors and review of modern trends

In the last years, especially thanks to a large diffusion of ultrasound-guided FNBs, a surprising increased incidence of differentiated thyroid cancer (DTC), "small" tumors and microcarcinomas have been reported in the international series. This led endocrinologists and surgeons to search for "tailored" and "less aggressive" therapeutic protocols avoiding risky morbidity and useless "overtreatment". Considering the most recent guidelines of referral endocrine societies, we analyzed the role of routine or so-called prophylactic central compartment lymph node dissection (RCLD), also considering its benefits and risks. Literature data showed that the debate is still open and the surgeons are divided between proponents and opponents of its use. Even if lymph node metastases are commonly observed, and in up to 90 % of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is subject to intensive research and the best indications of lymph node dissection are still controversial. Identification of prognostic factors for central compartment metastases could assist surgeons in determining whether to perform RLCD. Considering available evidence, a general agreement to definitely reserve RCLD to "high-risk" cases was observed. More clinical researches, in order to identify risk factors of meaningful predictive power and prospective long-term randomized trials, should be useful to validate this selective approach

Diagnostic, therapeutic and health-care management protocol in thyroid surgery: a position statement of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB)

PURPOSE: The diagnostic, therapeutic and health-care management protocol (Protocollo Gestionale Diagnostico-Terapeutico-Assistenziale, PDTA) by the Association of the Italian Endocrine Surgery Units (U.E.C. CLUB) aims to help treat the patient in a topical, rational way that can be shared by health-care professionals. METHODS: This fourth consensus conference involved: a selected group of experts in the preliminary phase; all members, via e-mail, in the elaboration phase; all the participants of the XI National Congress of the U.E.C. CLUB held in Naples in the final phase. The following were examined: diagnostic pathway and clinical evaluation; mode of admission and waiting time; therapeutic pathway (patient preparation for surgery, surgical treatment, postoperative management, management of major complications); hospital discharge and patient information; outpatient care and follow-up. RESULTS: A clear and concise style was adopted to illustrate the reasons and scientific rationales behind behaviors and to provide health-care professionals with a guide as complete as possible on who, when, how and why to act. The protocol is meant to help the surgeon to treat the patient in a topical, rational way that can be shared by health-care professionals, but without influencing in any way the physician-patient relationship, which is based on trust and clinical judgment in each individual case. CONCLUSIONS: The PDTA in thyroid surgery approved by the fourth consensus conference (June 2015) is the official PDTA of U.E.C. CLUB

Parathyroid Retrospective Analysis of Neoplasms Incidence (pTRANI Study): An Italian Multicenter Study on Parathyroid Carcinoma and Atypical Parathyroid Tumour

Background: Parathyroid cancer (PC) is a rare sporadic or hereditary malignancy whose histologic features were redefined with the 2022 WHO classification. A total of 24 Italian institutions designed this multicenter study to specify PC incidence, describe its clinical, functional, and imaging characteristics and improve its differentiation from the atypical parathyroid tumour (APT). Methods: All relevant information was collected about PC and APT patients treated between 2009 and 2021. Results: Among 8361 parathyroidectomies, 351 patients (mean age 59.0 ± 14.5; F = 210, 59.8%) were divided into the APT (n = 226, 2.8%) and PC group (n = 125, 1.5%). PC showed significantly higher rates (p &lt; 0.05) of bone involvement, abdominal, and neurological symptoms than APT (48.8% vs. 35.0%, 17.6% vs. 7.1%, 13.6% vs. 5.3%, respectively). Ultrasound (US) diameter &gt;3 cm (30.9% vs. 19.3%, p = 0.049) was significantly more common in the PC. A significantly higher frequency of local recurrences was observed in the PC (8.0% vs. 2.7%, p = 0.022). Mortality due to consequences of cancer or uncontrolled hyperparathyroidism was 3.3%. Conclusions: Symptomatic hyperparathyroidism, high PTH and albumin-corrected serum calcium values, and a US diameter &gt;3 cm may be considered features differentiating PC from APT. 2022 WHO criteria did not impact the diagnosis

Anorectal emergencies: WSES-AAST guidelines.

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process

Emergency surgery for splenic flexure cancer: results of the SFC Study Group database.

BACKGROUND: The effectiveness of surgical treatment for splenic flexure carcinomas (SFCs) in emergency settings remains unexplored. This study aims to compare the perioperative and long-term outcomes of different alternatives for emergency SFC resection. METHOD: This multicenter retrospective study was based on the SFC Study Group database. For the present analysis, SFC patients were selected if they had received emergency surgical resection with curative intent between 2000 and 2018. Extended right colectomy (ERC), left colectomy (LC), and segmental left colectomy (SLC) were evaluated and compared. RESULTS: The study sample was composed of 90 SFC patients who underwent emergency ERC (n = 55, 61.1%), LC (n = 18, 20%), or SLC (n = 17, 18.9%). Bowel obstruction was the most frequent indication for surgery (n = 75, 83.3%), and an open approach was chosen in 81.1% of the patients. A higher incidence of postoperative complications was observed in the ERC group (70.9%) than in the LC (44.4%) and SLC groups (47.1%), with a significant procedure-related difference for severe postoperative complications (Dindo-Clavien ≥ III; adjusted odds ratio for ERC vs. LC:7.23; 95% CI 1.51-34.66; p = 0.013). Anastomotic leakage occurred in 8 (11.2%) patients, with no differences between the groups (p = 0.902). R0 resection was achieved in 98.9% of the procedures, and ≥ 12 lymph nodes were retrieved in 92.2% of patients. Overall and disease-free survival rates at 5 years were similar between the groups and were significantly associated with stage pT4 and the presence of synchronous metastases. CONCLUSION: In the emergency setting, ERC and open surgery are the most frequently performed procedures. ERC is associated with increased odds of severe postoperative complications when compared to more conservative SFC resections. Nonetheless, all the alternatives seem to provide similar pathologic and long-term outcomes, supporting the oncological safety of more conservative resections for emergency SFCs