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Objective: Although there has been contrasting evidence for a causative role of parathyroid hormone (PTH) in sleep disorders in patients on maintenance hemodialysis, a recent study disclosed the possibility that this role might exist at least in patients requiring parathyroidectomy because of failure of medical therapy. The present study was devised to assess a possible difference in sleep disorders of patients on hemodialysis needing parathyroidectomy and those in whom medical therapy controlled hyperparathyroidism. Design and Patients: To this end, a group of 22 patients requiring parathyroidectomy were studied by means of a sleep questionnaire, along with a group of 44 patients matched for age, gender, body weight, and duration of dialytic treatment. Results: Patients requiring parathyroidectomy slept fewer hours (P < .001), had a higher prevalence of sleep disorders (P < .001), and were more often insomniac (P < .001). Conclusions: This study indicates that patients on hemodialysis requiring parathyroidectomy for intractable hyperparathyroidism comprise a good model for investigating the causative role of PTH on disordered sleep, and that these patients have very poor sleep. These data support recent findings on the prevalence of sleep disorders in dialyzed patients with insuppressible hyperparathyroidism. © 2008 National Kidney Foundation, Inc.

BACKGROUND/AIMS: Laparoscopic cholecystectomy is characterized by a higher incidence of iatrogenic biliary lesions. The Authors evaluate the role of hepaticojejunostomy in the treatment of iatrogenic biliary lesions following laparoscopic cholecystectomy in 51 patients observed in the Campania region, Italy from 1991 to 2003. METHODOLOGY: The Authors report the data of a retrospective multicentric study of 51 patients -39 women (76.47%), 12 men (13.53%)-reoperated on for major biliary lesions following laparoscopic cholecystectomy. Hepaticojejunostomy in 20 cases (39.21%) and T-Tube plasty in 20 cases (39.21%) were performed. RESULTS: The mean follow-up was 25.01 months. The mean hospital stay was 25.7 days. 1/51 patients (1.9%) died from intraoperative incontrollable hemorrhage while cumulative postoperative mortality was 9.8% (5/51 patients). Therapeutic success rate of hepaticojejunostomy was 70% with a T-Tube plasty success rate of 65%. 9/51 patients (17.64%) were reoperated while in 4/51 (7.84%) a biliary stent was positioned. In 1/51 patients (1.9%) a biliary cirrhosis and in 3/51 (5.7%) a bioumoral cholestasis was observed. CONCLUSIONS: Laparoscopic cholecystectomy causes a higher incidence of iatrogenic biliary lesions. Hepaticojejunostomy gives better long-term results and lower morbidity compared to T-Tube plasty. Management of septic complications in patients with iatrogenic biliary lesions represents the first therapeutic step.

There are scanty data available on alexithymia in patients with end-stage renal disease, which point to an independent association with depression and social support. This study was devised to investigate the prevalence of alexithymia and sleep disorders in patients maintenance hemodialysis with insuppressible secondary hyperparathyroidism, who need parathyroidectomy (PTX), because previous data from our laboratories as well as those of others showed that this patient-group are the worst sleepers among hemodialysis patients with end-stage renal disease. A total of 40 patients needing PTX were enrolled and studied before the surgery. As for the control group, 80 patients on maintenance hemodialysis not needing PTX were enrolled. We measured alexithymia with the Toronto Alexithymia Score (TAS-20), sleep disorders with the Pittsburgh Sleep Quality Index (PSQI), and depression with Beck Depression Inventory (BDI), intact parathyroid hormone (iPTH), calcium, phosphate, use of antihypertensives, systolic and diastolic blood pressure, hemoglobin concentration, and albumin concentration. Patients needing PTX in comparison with those not needing PTX had significantly higher iPTH, calcium, and phosphate; they also had significantly higher systolic and diastolic blood pressure. They were more significantly alexithymic (P < .001), had more severe sleep disorders (P < .001), and were more depressed (P < .043). In multivariate analysis, BDI correlated significantly with iPTH concentration (r = 0.505, P < .001). A reduction of TAS-20 occurred after PTX which correlated with the number of patients on antihypertensive drugs, PSQI, BDI, hemoglobin concentration in the univariate and multivariate analysis. When TAS-20 and PSQI were adjusted for BDI (using analysis of variance) there was still a significant difference of TAS-20 and PSQI between patients needing PTX and not needing PTX (P < .001). This study confirms the high prevalence of sleep disorders in patients with unsuppressed secondary hyperparathyroidism and discloses a high prevalence of Alexithymia which is ameliorated by PTX. However, the correlation of Alexithymia with sleep disorders does not depend on depression.

Sleeping disorders are very common in patients with chronic kidney disease on dialysis (CKD5D) and are an emerging risk factor able to predict mortality. Parathyroid hormone (PTH) although considered a pivotal uremic toxin has rarely been associated with sleep disorders in uremia. In a study from our laboratory PTH concentrations failed to distinguish patients with sleep disorders from those without. In a study performed by Chou et al a 97% prevalence of insomnia was found in patients undergoing hemodialysis requiring parathyroidectomy. Surgery reduced PTH and increased sleeping hours within 3 months. The aim of this study was to study the effects of parathyroidectomy on the sleep disorders of insomniacs on maintenance hemodialysis. The study was performed in 16 insomniac patients on maintenance hemodialysis who successfully underwent surgery with autotransplantation of autologous parathyroid tissue (40 mg) under the skin of the forearm. Patients (5 F and 11 M) were studied from 1 month before surgery to 1 year after. Sleep disorders were assessed by means of a 27-item questionnaire--Sleep Disorder questionnaire (SDQ)--that identified sleeping disorders according to Diagnostic and Statistical Manual of Mental Disorders - IV Edition (DSM-IV) criteria. The Charlson Comorbidity Index (CCI) was also measured along with systolic and diastolic blood pressure, Hb, PTH, Ca, P. A 95.5% prevalence of sleep disorders was found pre operatively. Patients slept 4.90+/-1.2 hours, Ca averaged 10.09+/-0.54 mg/dL, Phosphate 5.5+/-1.93, CCI 9.8+/-1.1, PTH 1498+/-498 ng/mL. After 1 year follow-up 2 out 16 patients had normal sleep, 6 out 16 patients had subclinical sleep disorders and 8 remained insomniacs (p=0.008, Mc Nemar Test for paired data, insomniacs vs. no disturbance + subclinical disorders). Sleeping hours increased up to 6.0+/-1.24 (p

BACKGROUND: Secondary hyperparathyroidism (HPTs) in patients with chronic renal failure is related to a reduction of absorption of calcium with hyperplasia of main cells and an increase of PTH levels: this often leads to complications in dialysis. METHODS: Data from 10 patients (mean age 55 years) with HPTs who underwent total parathyroidectomy from November 1999 to November 2001 were retrospectively collected. Surgical indications included: persistent hypercalcemia, bone fractures, fatigue, joint pain and itching. Median preoperative PTH level was 800 pg/ml. Presurgical work-up included: serum PTH, calcium and alkaline phospha-tases. Thyroid ultrasound and scintigraphy, 99Tc sestamibi scintigraphy, CBM, FNB were also performed. In 5 patients 2 hours prior to the operation 2 MCu of sestamibi 99Tc had been injected. Patients underwent cervical exploration radioguided in 5 cases under general anesthesia. The operation consisted in the removal of all glands with subcutaneous forearm implant in 4 cases. PTH dosage at starting time of operation (time 0) was performed; it was repeated after the removal of each parathyroid gland and postoperatively on days 1 and 3 and then every month for 6 months. RESULTS: Twenty-four hours postoperatively 9 patients showed a great reduction of PTH levels with improved symptoms already on day 1 postoperative. In the patient with persistent HPT an autoimplant had been performed. CONCLUSIONS: Secondary HPT still shows unclear aspects. Parathyroidectomy determines an immediate improvement in symptoms. In all observed patients PTH was significantly reduced, serum calcium returned to normal and in any case hypoparathyroidism was detected.

An higher incidence rate of iatrogenic bile duct injuries is reported in cholecystectomy performed with the laparoscopy than with the laparotomy approach. The aim of this study was to provide a multicentre report on surgical treatment and the outcome of biliary complications during and following laparoscopic cholecystectomy. A questionnaire was mailed to all surgeons with experience in laparoscopic cholecystectomy in the Campania region. Data were collected from January 1991 to December 2003. Each patient was requested to indicate age, gender, associated diseases, site and type of lesion, surgical experience, diagnosis, treatment and complications. Twenty-six surgeons answered the questionnaire. Fifty-one patients (36 F/15 M; mean age: 42.5 +/- 11.9, range 13-91 years) with bile duct injuries following laparoscopic cholecystectomy were reported. The most frequent lesions were main bile duct partial or total transection. The intraoperative mortality rate was 1/51 (1.9%) due to a complex biliary and vascular injury. The postoperative mortality rate of revision surgery was 5/50 (10%). T-tube positioning (n = 20) and Roux-en-Y hepato-jejunostomy (n = 20) were the procedures most frequently performed. The complication rate in patients treated with the T-tube was significantly higher than in those treated with hepatico-jejunostomy. Surgical treatment of biliary injuries following laparoscopic cholecystectomy was characterized by unusually high mortality and morbidity for a non-neoplastic disease. Roux-en-Y hepato-jejunostomy remains the procedure of choice for these injuries.

In the treatment of hemorroidal prolapse, stapled hemorrhoidopexy, according to the Longo's technique, represents an innovative and interesting procedure. The Authors consider own experience in the years 2001-2002, estimating preliminary results in the treatment of 50 patients affected by hemorrhoidal disease classified as III-IV grade, associated with mucosal prolapse, rectocystocele in 5 cases, anal fissures in 6 and hyperplastic polyp in 1. The patients were submitted to mucosal prolapsectomy with mechanical stapler (PPH 01-33 Ethicon), applying haemostatic stitch on suture line, apart from intraoperative bleeding, associated to closed anal sphincterotomy in 6 cases, and resection of anal hyperplasic polyp in 1. In 5 cases of rectocystocele a Burch's culposuspension was associated to a stapled transanal rectal resection (STARR). After 3 and 12 months the Authors performed ano-rectoscopy, anal manometry and defecography. Mean operative time was 45 minutes (range 20'-130') and mean hospital stay was 3 days (range 2-6 days). In the early postoperative course urinary ritention in 4 cases, treated with temporary catheterization in 3 and permanent for 72 hours in 1, was observed. Only 1 patient, was reoperated in day-surgery and with loco-regional anesthesia for residual fibrous hemorroid. Bleeding, severe pain, anal stenosis, impairment of continence were not observed. According to the Literature data, our experience confirm that mucoprolapsectomy represents an innovative, safe, simple and definitive operation in the treatment of hemorrhoids disease. In case of rectal prolapse associated to external fibrous hemorroids, a combined surgical treatment is requested in order to achieve better results.

"Hepatolithiasis is defined as the occurrence of stones proximal to the biliary confluence and represents a prevalent disease in South East Asia being uncommon in Western countries. Biliary sepsis, hepatic abscesses and cholangiocarcinoma are considered potential complications. The Authors describe a case of a 68 years male patient affected by a left massive intrahepatic lithiasis secondary to common duct stones and associated to acute pancreatitis. The patient refused surgery and was submitted to a conservative transhepatic percutaneous treatment. After a complete removal of intrahepatic stones and a positioning of external internal biliary drainage (14F), a laparoscopic cholecistectomy was performed. The MRI control showed a complete resolution of the intrahepatic lithiasis. Conservative transhepatic percutaneous approach to hepatolithiasis represents a safe and effective treatment allowing good medium-long term results. Surgery is recommended in case of severe hepatic fibrosis or atrophy, suspected cholangiocarcinoma or multiple strictures with biliary distorsion. Integrated therapeutical protocols in referral multidisciplinary centers-offers the best long term results."

Fecal incontinence (FI) is associated to elevated costs related to diagnostic work-up, surgical treatment and instrumental follow-up. The real incidence is unknown and prevalence is higher after 45 years with a ratio F:M ratio of 8:1. Frequently FI is due to pelvic damage secondary to obstetric trauma. The Authors analyze surgical treatment results of FI secondary to obstetric trauma evaluating pathogenesis and instrumental diagnostic preoperative work-up. In case of muscular injury, "overlapping" of external sphincter represents the treatment of choice allowing a good medium long term results. In the treatment of patients with more complex injures or after overlapping failures, direct sphincteroplasty are indicated. After multiple surgical failures, or in case of pure neural damage, sacral nerve stimulation, graciloplasty or artificial anal sphincter may be offered by referral centers.

The authors evaluated the role of a laparoscopic approach on a complete resection of an omental cyst. A young female patient (25 years of age) underwent a complete resection of a 12-cm omental cyst via a laparoscopic approach. The patient presented with vomiting, nausea, and pain in the periduodenal area. The lesion was diagnosed via CT and MRI. The authors used four trocars (2 × 10 mm, 2 × 5 mm). After complete resection and aspiration, the cyst was removed in a bag. The postoperative period was uneventful, and the patient was discharged after 48 hours. There was no sign of relapse after 30 months of follow-up. Mesenteric and omental cysts are congenital abdominal lesions. Therefore, a complete resection is mandatory because of the high incidence of relapse. A laparoscopic operation proves a suitable approach because of the advantages of lower costs and comparable results to open surgery.