Search

Background With the current aging of the world's population, diagnosis of primary hyperparathyroidism is being reported in increasingly older patients, with the associated functional symptomatology exacerbating the vicissitudes of age. This retrospective study was designed to establish functional improvements in older patients following parathyroid adenomectomy under local anesthesia as outpatient surgery. Materials and methods Data were collected from 53 patients aged 80 years or older who underwent a minimally invasive parathyroid adenomectomy. All patients underwent a preoperative ultrasound, scintigraphy, and were monitored for the effectiveness of the procedure according to intra- and postdosage of parathyroid hormone (PTH) at 5 min, 2 h and 4 h. Results Mean preoperative serum calcium level was 2.8 mmol/L (112 mg/L) and mean PTH was 180 pg/ml. Thirty-eight patients were operated under local anesthesia using minimally invasive surgery and 18 patients were operated under general anesthesia. In 26 cases, the procedure was planned on an outpatient basis but could only be carried out in 21 patients. Fifty-one patients had normal serum calcium and PTH levels during the immediate postoperative period. Two patients were reoperated under general anesthesia, since immediate postoperative PTH did not return to normal. Four patients died due to reasons unrelated to hyperparathyroidism. Five patients were lost to follow-up six months to two years postsurgery. Of the 44 patients (83%) with long-term monitoring for PTH, none had recurrence of biological hyperparathyroidism. Excluding the three asymptomatic patients, 38 of the 41 symptomatic patients (93%) with long-term follow-up were considering themselves as “improved” or “strongly improved” after the intervention, notably with respect to fatigue, muscle and bone pain. Two patients (4.9%) reported no difference and one patient (2.4%) said her condition had worsened and regretted having undergone surgery. Conclusion In patients 80 years or older, minimally invasive surgery as an outpatient under local anesthesia offered an excellent risk/benefit ratio given its many advantages: simplicity, speed, absence of general anesthesia, ease of monitoring, direct voice control intraoperatively, very low morbidity, effectiveness in treating primary hyperparathyroidism in more than 95% of first intention patients, and the possibility of immediate or delayed recovery in the event of multiglandular disease going unnoticed.

Resume Les diagnostics apparemment simples ne sont pas toujours les plus faciles. Ainsi, nous avons retrace l’incroyable parcours qui fut necessaire pour admettre le concept d’appendicite et les modalites de son traitement chirurgical. Apres une longue periode preparatoire qui recouvre les xvi e et xvii e siecles, Francois Melier fut le premier, en 1837, qui relia la lesion anatomique, le diagnostic clinique et le traitement chirurgical. Durant le xix e siecle, le diagnostic et la pratique chirurgicale se developperent d’abord aux Etats-Unis, puis en France apres l’episode fâcheux de Leon Gambetta. Marquee initialement d’une morbidite lourde (20 %), le pronostic vital fut transforme par l’association de l’antibiotherapie apparue au cours de la seconde guerre mondiale et la morbidite fut alors abaissee a 2 %. Enfin, depuis une vingtaine d’annees, la videochirurgie a permis un traitement chirurgical mini-invasif. Ira-t-on plus loin dans cette evolution therapeutique en traitant medicalement ? Cependant, l’appendicite reste encore une maladie grave et imprevisible chez les enfants et chez les patients immunodeprimes. Il est permis de poser la question au debut du xxi e siecle ou l’on decrit a nouveau la typhlite, cette fois-ci plus credible…

The profi le of primary hyperparathyroidism (PHPT) changed profoundly over the course of the twentieth century. The highly symptomatic forms reported in the 1960s have progressively been replaced by forms with few symptoms and in some cases totally asymptomatic forms.

Objective: To retrospectively evaluate the feasibility of thoracoscopic removal of mediastinal parathyroids. Summary Background Data: Mediastinal exploration to resect ectopic parathyroid(s) is needed in approximately 2% of cases in hyperparathyroidism. Recent advances in thoracoscopic surgery allow for a minimally invasive treatment. Methods: From 1999 through 2007, 13 patients affected by primary hyperparathyroidism (11 females, mean age 60 years, range: 22–88) underwent thoracoscopic removal of mediastinal parathyroids. Scintigraphy produced positive results in 11 of 13 cases, computed tomography scan in 9 of 10, parathyroid hormone venous sampling in 10 of 10 patients, and magnetic resonance imaging in 5 of 7. Right thoracoscopic access was used in 9 patients, left in 4. Postoperative outcome was analyzed. Results: Thoracoscopy enabled retrieval of mediastinal parathyroids in 10 of 13 (78%) cases. Mean operating time was 92 minutes (range: 50–240). One procedure (8%) was converted. No perioperative deaths/major complications occurred. Mild complications occurred in 2 of 13 (15%) patients (pneumothorax/pneumonia, transient recurrent nerve palsy). Mean hospital stay was 4.7 days (range: 2–15). At a mean follow-up of 73 months (range: 16–105), parathyroid hormone and calcium venous concentrations were high in 3 patients. Unsuccessful procedures were related to doubtful or non–concordant preoperative localization. Conclusions: The thoracoscopic approach for mediastinal parathyroidectomy is feasible and safe. An accurate preoperative work-up should be standardized to avoid useless procedures. In case of negative preoperative localization of the abnormal gland, thoracoscopy should not be adopted as a diagnostic tool.

Lymphoepithelial cysts are rare lesions of the thyroid, with exceptional bilateral presentation. We report the case of a 62-year-old woman presenting with a multinodular goiter, without associated clinical or biological abnormality. Histological examination demonstrated multiple cysts lined by squamous or respiratory-type epithelium, associated with a dense lymphoid infiltrate. Chronic thyroiditis and numerous solid cell nests were also observed in the adjacent parenchyma. We briefly discuss differential diagnosis and current hypothesis concerning the pathogenesis of these peculiar lesions.

Resume La definition de l’hyperparathyroidie primaire (HPT1) est une hypersecretion de PTH inadaptee a la calcemie et son diagnostic est biologique reposant sur un dosage plasmatique concomitant de PTH et de calcium. L’apport de la biologie dans l’HPT1 est primordial au niveau diagnostic, en bilan de base ou en test dynamique sous charge calcique pour les cas limites a PTH et/ou calcium plasmatiques subnormaux, pour un diagnostic differentiel avec les autres causes d’elevation de PTH. Le dosage des formes bioactive et inactive de la PTH permettrait d’evaluer leur equilibre en reponse a une regulation fine au niveau des organes cibles en fonction des besoins physiologiques. La PTH apporte des informations complementaires aux donnees morphologiques de l’imagerie parathyroidienne : par la determination du contenu hormonal sur la ponction d’un nodule repere a l’echographie confirmant la nature tissulaire en accord avec la cytologie, et par le catheterisme veineux etage realise en radiologie vasculaire avec dosage immediat de PTH permettant de dresser une cartographie de PTH a la recherche d’une zone de secretion maximale qui peut etre associee a un foyer repere par echographie et scintigraphie prealables, ou scanner ou IRM, et fournissant ainsi une « imagerie biologique ». L’association imagerie-biologie constitue une methode efficace pour localiser le secteur de presence de l’adenome parathyroidien et surtout pour prouver l’importance de l’hypersecretion. L’apport de la PTH a la chirurgie est essentiel pour prouver l’efficacite du geste operatoire et decider rapidement des suites en cas d’echec grâce au dosage per-operatoire. Le controle postoperatoire du couple PTH-Ca juge de la pertinence de l’ajustement therapeutique eventuel et doit etre assure a longue echeance.

Biology of primary hyperparathyroidism: Selective venous sampling The diagnosis of primary hyperparathyroidism (PHP) is chemical: high level of Parathormone (PTH) in conjunction with hypercalcaemia. In borderline cases with sub-normal plasma PTH and calcium, an oral calcium load test could allow a differential diagnosis from other causes of high PTH. Imaging is required only for PHP. Selective venous sampling can help in localizing a parathyroid adenoma in difficult cases by PTH cartography in the following situations: imaging in favour of an ectopic mediastinal gland or a deep cervical adenoma, persistent or recurrent PHP after first failed surgery with negative neck exploration or unsatisfactory in case of another hypersecreting gland, PHP well diagnosed with indeterminate imaging, symptomatic PHP with normal PTH and negative imaging. Venous blood sampling performed in a vascular radiological department with a quick PTH assay can reveal an area of maximum secretion potentially linked to a nodule localized by previous ultrasound coupled to scintigraphy, giving thus a “biological imaging” study. The association of imaging and biology is an efficient procedure enabling localization of an area of abnormal PTH secretion and characterization of the level of PTH secretion. The area with the highest gradient of PTH concentration can help to protocol CT and MR examination.

Resume De nos jours, l’association d’une technicite performante a une faible morbidite a permis l’emergence d’une chirurgie preventive qui integrerait la chirurgie moderne de l’hyperparathyroidie. Œuvrant en ce sens, les 2500 patients operes depuis 30 ans dans le service de chirurgie viscerale de l’hopital Cochin a Paris ont permis de parvenir a la conception actuelle que nous avons du traitement chirurgical de l’hyperparathyroidie primaire en particulier avec le developpement de la chirurgie mini-invasive sous anesthesie locale. A ce sujet, le role promotionnel tenu, depuis 30 ans, par notre institution encourage l’approfondissement d’une reflexion basee sur l’experience acquise et les lectures faites pendant cette periode. Enfin, le travail accompli doit etre fondu dans le recit d’une aventure beaucoup plus riche qui debuta au xix e siecle. Nous vous proposons d’en retracer egalement les grandes lignes pour mieux comprendre les principes qui regissent aujourd’hui la chirurgie des glandes parathyroides.

Resume Objectif L'hydroxyzine est administree en preoperatoire comme premedication anxiolytique. Nous avons etudie l'effet d'une premedication par l'hydroxyzine sur les variations du BIS observees au cours de l'induction de l'anesthesie generale realisee avec de l'etomidate seul. Patients et methodes Soixante-sept patients ASA I–II ont recu apres tirage au sort 1,5 mg/kg d'hydroxyzine par voie orale ou un placebo 90 minutes avant l'induction de l'anesthesie generale realisee avec 0,3 mg/kg d'etomidate intraveineux. Le BIS a ete enregistre. Le temps de decroissance du BIS a 50 et de disparition du reflexe ciliaire, les variations de la pression arterielle et de la frequence cardiaque, la frequence des myoclonies et leur degre ont ete enregistres et compares entre le groupe hydroxyzine et le groupe placebo. Resultats Le temps [mediane (extremes) (secondes)] de decroissance du BIS a 50 [100 (21–266) versus 113 (30–510), p = 0,1] et de disparition du reflexe ciliaire [83 (21–210) versus 97 (30–300), p = 0,1] ; la frequence des myoclonies [(oui/non) (9/26 versus 4/28, p = 0,2)] et le degre des myoclonies (p = 0,3) ; l'evolution de la pression arterielle moyenne et de la frequence cardiaque (p = 0,3) ont ete similaires dans les groupes hydroxyzine et placebo. Conclusion L'hydroxyzine administree par voie orale selon une dose rapportee au poids n'a pas modifie les variations du BIS associees a l'administration intraveineuse de 0,3 mg/kg d'etomidate seul.

Objectives: To examine the cost-effectiveness of strategies for management of primary asymptomatic hyperparathyroidism: surgical strategies and medical follow-up versus surgery. Design: We used a Markov state-transition decision-analytic model for an hypothetical cohort of 55-year-old women to compare with a lifetime horizon costs and effectiveness of bilateral neck exploration (BNE), unilateral neck exploration (UNE), video-assisted parathyroidectomy (VAP) and lifelong medical follow-up shifting for either BNE or UNE in case of disease progression. Methods: Data on localization tests, complications and treatment efficacies were derived from a systematic review of the literature. Outcomes were expressed as quality-adjusted life years (QALY). Costs (€2002) discounted at 3% yearly were estimated from the health care system perspective. Results: In the base-case analysis, VAP strategy (VAPS) was the most effective and BNE strategy (BNES) was the least costly. UNE strategy (UNES) had an incremental cost-effectiveness ratio of €2688/QALY versus BNES and VAPS of €17 250/QALY in comparison with UNES. Surgical management was more effective than medical follow-up with acceptable incremental cost-effectiveness ratios. VAPS became less effective than UNES over 71 years. Differences between UNES and VAPS were sensitive to success and complication rates, quality-of-life weights and procedural costs. Medical follow-up strategies became the most effective if quality-of-life weight for this condition was higher than 0.99. Conclusions: Surgery is more effective than medical follow-up at a reasonable cost and can be preferred except in patients choosing medical follow-up. Minimally invasive surgery is cost-effective compared to the traditional surgical approach.

OBJECTIVE: To present first-line thoracic surgery made possible by localization studies in three patients with ectopic parathyroid adenomas. DESIGN AND METHODS: Three patients with ectopic parathyroid tissue in the mediastinum were examined by ultrasound, technetium-99m sestamibi scintigraphy, computed tomography (CT), and venous catheterization with measurement of parathyroid hormone. Without previous cervical exploration, video-assisted thoracic surgery (VATS) was used in all cases to avoid the need for thoracic open surgical procedures. RESULTS AND CONCLUSIONS: The mediastinal parathyroid glands were all detected at scintigraphy, and CT and venous catheterization were helpful in anatomic and functioning characterization. All pathologic glands were successfully resected, with only one minor complication. VATS can safely remove a deep mediastinal parathyroid adenoma and avoid more aggressive open approaches. In an experienced referral center, systematic and sophisticated imaging studies may accurately identify and localize rare ectopic parathyroid adenomas, and avoid cervical surgery.

Background: Two opioid regimens, computer-simulated to provide optimal general anesthesia in combination with propofol, were compared using clinical criteria. Methods: Fifty patients undergoing thyroid surgery were blindly, prospectively and randomly allocated to receive either (a) i.v. remifentanil (1.5 µg kg−1, followed by 0.2 µg kg−1 min−1) or (b) i.v. sufentanil (0.2 µg kg−1 followed by 0.2 µg kg−1 h−1). Remifentanil infusion was stopped at the last skin suture. Sufentanil infusion was stopped 30 min before the end of surgery. Intravenous propofol was titrated to keep BIS at 50±5. Remifentanil and sufentanil groups were compared with regards to (a) propofol delivery, (b) hemodynamic and recovery variables, and (c) effect-site propofol levels during a steady-state period for effect-site remifentanil and sufentanil levels. P

AIM OF THE STUDY The goal of this retrospective study was to recognize the incidence of adrenal tumors called incidentalomas, that are in fact symptomatic or hormone secreting tumors, to assess if the diagnostic criteria proposed in the literature are reliable for adrenal tumors found incidentally. PATIENTS AND METHOD The records concerned 147 patients operated between April 1981 and December 2000 for an adrenal mass measuring 3 cm in diameter and larger on CT scan. Clinical and laboratory findings as well as hormone levels and imaging examinations (CT Scan, IRM, scintigraphy) were correlated with operative findings and results of histologic examinations. One hundred and three patients were operated by a traditional approach and forty four by videoendoscopic techniques. RESULTS In 41 patients (28%), the tumors had to be classified as false incidentalomas (group 1) postoperatively. In 106 patients (72%), the nature of tumor was non definite. In this group 2, there were ten malignant tumors, two pheochromocytomas and 94 benign lesions. Age of patient, size of tumor, increase in size over time and radiological appearance represent criteria that are not reliable to separate malignant from benign tumors. CONCLUSIONS Tumors of indeterminated and non specific nature only should be classified as incidentalomas. Imaging techniques as well as other criteria of malignancy cannot be relied upon to separate benign from malignant tumors. The risk even small of cancer or pheochromocytoma leads us to recommend excision of tumors > or = 3 cm in radiological diameter. The videoendoscopic approach is a good alternative to open operation in centers with this special expertise.

Background: Conventional parathyroidectomy involves a bilateral neck exploration with the patient under general anesthesia with a thorough search for all parathyroid tissue. The purpose of this study was to assess the efficacy and safety of unilateral neck exploration under local anesthesia in patients with asymptomatic primary hyperparathyroidism (first-degree hyperparathyroidism). Methods: Of 679 patients who underwent parathyroidectomy for first-degree hyperparathyroidism from July 1989 to June 1997, 230 asymptomatic patients underwent unilateral neck exploration under local anesthesia. Selection criteria for this approach included the successful identification of a solitary parathyroid adenoma on preoperative imaging, no thyroid disease, and no family history of multiple endocrine neoplasia. Intact parathyroid hormone levels were monitored during the operation. Results: Total serum calcium levels were normal in 220 patients (96%) 3 to 6 months after surgery. Ten patients (4%) experienced persistent hypercalcemia, 8 of whom had multiple gland disease and 2 of whom had false-positive imaging. Two of these patients underwent bilateral neck exploration under general anesthesia and were cured, although 8 patients remained asymptomatic and were followed up nonoperatively. The mean operating time was 30 minutes (range, 12-65 minutes). There were two complications (0.87%) including one wound hematoma and one transient recurrent laryngeal nerve palsy. Conclusions: Unilateral neck exploration under local anesthesia is an efficacious and safe approach to the treatment of first-degree hyperparathyroidism and should be considered in all patients with asymptomatic disease. (Surgery 1999:126:1004-10.)

Parathyroid incidentaloma is not a well-known entity. The aim of this study was to show its incidence and to discuss its management.This was a prospective study analyzing cases of enlarged parathyroid glands discovered during thyroid surgery. The records of patients with parathyroid incidentaloma were reviewed. We also reviewed all cases of primary hyperparathyroidism (HPTPs) operated during the same period for comparison.Three cases of enlarged parathyroid were found. No clinical or biochemical features led us to suspect hyperparathyroidism before surgery, but a macroscopically enlarged parathyroid gland was discovered during the dissection and was removed in all three patients.Enlarged parathyroid glands discovered at the time of surgery may represent an early pathological stage responsible for overt primary hyperparathyroidism. In absence of major risk for recurrent nerve palsy, we recommend removal of any enlarged parathyroid discovered during neck surgery in order to avoid the risks of future surgical procedures, preserving in the same time at least one normal parathyroid gland.

We diagnosed transient left ventricular apical wall motion abnormalities after surgery in a patient presenting with a clinical and electrocardiographic picture of acute myocardial infarction in the absence of significant coronary disease. These angiographic, clinical, and electrocardiographic features satisfied the criteria of the recently described tako-tsubo-like left ventricular dysfunction.

Background Etomidate-associated hypnosis has only been studied using standard clinical criteria and raw EEG variables. We conducted a BIS-based investigation of etomidate induction of general anaesthesia. Methods Thirty hydroxyzine-premedicated ASA I patients were randomly allocated to receive etomidate 0.2, 0.3, or 0.4 mg kg−1 intravenously over 30 s. The BIS was continuously recorded. A tourniquet was placed on a lower limb to record purposeful movements and myoclonia. Tracheal intubation was facilitated using rocuronium 0.6 mg kg−1 when the BIS value was 50. The times to disappearance of the eyelash reflex, to a decrease in the BIS to 50, and to tracheal intubation were compared. The BIS values 30 s following tracheal intubation, and mean arterial pressure (MAP) and heart rate (HR) at all time points were also recorded. Results The BIS value decreased to 50 for tracheal intubation with no purposeful movement in all but one patient in the 0.2 mg kg−1 group. There was no difference between the etomidate groups (0.2, 0.3, and 0.4 mg kg−1) in regards to time to loss of the eyelash reflex (103 (67), 65 (34), 116 (86) s, P=0.2), or to a decrease in BIS to 50 (135 (81), 82 (36), 150 (84) s, P=0.1). Also, the BIS value 30 s after intubation (41 (10), 37 (4), 37 (4), P=0.4), and plasma etomidate concentrations (161 [29–998], 308 [111–730], 310 [90–869] ng ml−1, P=0.2) did not differ between groups. The time to loss of the eyelash reflex was 12–140 s shorter than the time to a decrease in BIS to 50 in three patients in each group who received etomidate 0.2 and 0.4 mg kg−1, and in four patients who received 0.3 mg kg−1. No awareness was recorded. MAP and HR increases following tracheal intubation were comparable between groups. Conclusions Etomidate induction doses do not predict the time for BIS to decrease to 50 as this variable varies markedly following three etomidate dose regimen.

Villin is an actin-binding protein found in a few normal adult epithelia, namely epithelial cells in the digestive and urogenital tracts. Moreover, villin production is maintained in malignant cells. We assumed that cell lysis and necrosis of solid tumors producing villin might result in villin release into blood. We analyzed the villin content of sera from 788 patients and controls using an enzyme-linked immunosorbent assay. Patients and controls were classified into healthy donors, patients with benign diseases of the gastrointestinal tract, patients with colorectal cancers, and patients with malignant nondigestive diseases. In the panel of sera analyzed, the sensitivity of the assay for colorectal cancers was 50.5%, and its overall specificity for malignant digestive tumors was 94.5%. Results were statistically analyzed comparing each group of sera with each other. We conclude that the presence of villin is indicative of a pathological state in the gastrointestinal tract (P less than 0.001). Finally, we followed villin levels after tumor resections (60 patients). We found that the villin level in sera remains low in remissions but is raised in recurrences. We suggest that the villin assay may have clinical utility as a diagnostic adjunct for adenocarcinoma of the gastrointestinal tract. It may also have some value in monitoring patients with advancing colorectal carcinomas after resection of these tumors.

Placement of a transvenous vena cava filter has became a common way to control recurrent pulmonary embolism. However few studies have been reported on the diameter of the infrarenal inferior vena cava (IIVC) where the device is usually placed. This study based upon 100 cavographies has showed the calculated average diameter of IIVC was 20.9 mm (range 12–27 mm) in its middle part and 21.3 mm (range 10–31 mm) in its terminal end. The calculated average IIVC length was 96 mm (range 80.3–142 mm). There was no statistical correlation between caval size and age, sex, height, weight and corporeal area. There was a statistical difference of left renal vein location between patients presenting with lumbar arthrosis and those without. We discuss different methods to measure IIVC in particular tomodensitometry. CT scans reviewed in our department show that the largest diameter of IIVC is not in a frontal plane and that the width seen on cavography is the projection of the largest diameter on the film. Therefore, the range of the real caval diameters is greater than indicated above.