Boletin.96.1 Ene-Feb. - Asociacion Medica de Puerto Rico

BOLETÍN
ASOCIACIÓN MÉDICA DE PUERTO RICO
2 JUNTA DE DIRECTORES / JUNTA EDITORA
• MENSAJE DEL PRESIDENTE Y PORTADA
3 DR. RAMÓN EMETERIO BETANCES
Por: Eduardo Rodríguez Vázquez, MD;
7 EDITORIAL
• ARTÍCULOS ORIGINALES • ORIGINAL ARTICLES
8 PUERTO RICO EXPERIENCE WITH PLUGS IN
THE TREATMENT OF ANAL FISTULAS
By: Ignacio Echenique, MD; Juan R. Mella, MS; Francisco Rosado, MD;
Ignacio A. Echenique, MS, Maria T. Mella, MS. and Gerardo Quevedo, MD.
13 EXPERIENCE WITH HAND ASSISTED
LAPAROSCOPIC SURGERY OF THE COLON
By: Ramón K. Sotomayor, MD. and Bolivar Arboleda, MD.
20 COMPARISON BETWEEN OPEN AND LAPAROSCOPIC
APPENDECTOMY IN NON-COMPLICATED APPENDICITIS
By: Aura F. Delgado Cifuentes, BS and Ramón K. Sotomayor, MD.
27 MINIMALLY INVASIVE PARATHYROIDECTOMY
AS TREATMENT FOR PRIMARY HYPERPARATHYROIDISM
By: By: Laureano A. Giraldez-Rodriguez, MD.
and Laureano J. Giraldez-Casasnovas, MD.
34 PARATHYROID SURGERY WITHOUT INSTANT PTH
OR RADIOGUIDED SESTAMIBI SCAN
By: E. Vázquez-Quintana, MD. FACS. and D.E. Vázquez-Torres, MD.
39 SURVEY OF CARDIAC RHYTHM MANAGEMENT
AND DEVICE IMPLANT PATTERNS IN PUERTO RICO:
ANALYSIS OF 13,854 CARDIAC IMPLANTS
By: Juan M. Aranda, MD; FACC; Miguel Girod, MS; Eng; Fernando Ochoa,
Miguel Abreu, MD; FACC; José J. Rivera, MD; FACC; Juan C. Sotomonte, MD;
Angel Rodríguez, MD; Daniel Arzola, M.D; Raúl Jiménez, MD; FACC.
and Juan M. Aranda Jr; MD; FACC.
PORTADA
Dr. Ramón Emeterio Betances
Página 3
CONTENIDO
• ARTÍCULO DE REPASO • REVIEW ARTICLE
50 HISTORY OF PARATHYROID SURGERY IN PUERTO RICO
By: Enrique Vázquez-Quintana, MD.
61 28TH F.L. RAFFUCCI RESEARCH FORUM ABSTRACTS
66 CME CREDITS
• INFORME DE CASOS • CASE REPORTS
70 DISTAL FRAGMENTED PORT CATHETER:
CASE REPORT AND REVIEW OF LITERATURE
By: Norman E. Colón-Casasnovas and Humberto Lugo-Vicente
76 HERMANSKY PUDLAK SYNDROME:
AN UNUSUAL FORM OF PROCTO-COLITIS
By: Ignacio Echenique, MD; José M. García González, MD;
Ignacio A. Echenique, MS; Natalio J. Izquierdo, MD; Juan R. Mella, MA;
Eligio Barasorda, MD; María T. Mella, MS. and Siegfried Figueroa-Boilo, MD.
81 LAPAROSCOPIC NEPHRECTOMY WITH LAPAROSCOPICALLY
ASSISTED TRANSVAGINAL EXTRACTION OF INTACT KIDNEY
By: Alfonso Serrano-Ysern, MD; Alvin López, MD; Freddie Méndez, MD;
Lianette Perez, MD. and Jaime Acosta, MD.
86 CALENDARIO DE ACTIVIDADES MÉDICAS
87 SOLICITUD PRELIMINAR DE MEMBRESÍA AMPR
EL IMPRESO DE ESTA EDICIÓN DEL BOLETÍN
HA SIDO POSIBLE POR
UN AUSPICIO EDUCATIVO DE:
TRIPLE S, PUERTO RICO
BOLETÍN • Asociación Médica de Puerto Rico
Ave. Fernández Juncos Núm. 1305
PO Box 9387 • San Juan, Puerto Rico 00908-9387
Tel.: 787-721-6969 • Fax: 787-724-5208
e-mail: asocmed@coqui.net
web page: asociacionmedicapr.com
Catalogado en Cumulative Index e Index Medicus.
Listed in Cumulative Index and Index Medicus. No. ISSN - 0004-4849
Diseño Gráfico y Emplanaje por:
PubliArt • 787-273-0160
e-mail: publiart@prtc.net
Impreso en Colombia por: D’vinni
Vol. 100 • Núm. 1 • Enero-Marzo 2008

2
JUNTA DE DIRECTORES
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
ASOCIACIÓN MÉDICA DE PUERTO RICO • 2008
Eduardo Rodríguez Vázquez, MD
Presidente
Ricardo Marrero Santiago, MD
Presidente Saliente
Verónica Rodríguez, MD
Secretaria
Raúl Castellanos Bran, MD
Tesorero
Hilda Ocasio Maldonado, MD
Vicepresidente AMPR
Rolance Chavier Roper, MD
Vicepresidente AMPR
Raúl A. Yordán Rivera, MD
Vicepresidente AMPR
Arturo Arché Matta, MD
Pres. Cámara de Delegados
José I. Iglesias, MD
Vicepresidente Cámara Delegados
Rafael Fernández Feliberti
Delegado Alterno AMA
Eladio Santos Aponte, MD
Delegado Aterno AMA
Wanda Vélez Andujar, MD
Delegado Alterno AMA
José Gerena Díaz
Presidente Distrito Este
Gustavo Cedeño Quintero MD
Presidente Distrito Noreste
Wanda Velez Andujar
Presidenta Distrito Sur
Mildred Arché Matta
Presidenta Distrito Central
Verónica Rodriguez MD
Presidenta Consejo de Educación Médica Continuada
Ismael Toro Grajales MD
Presidente Consejo Etico-Judicial
Alejandro Medina Vilar
Presidente Consejo Relaciones Públicas y Servicios Públicos
Jorge Velez Soto MD
Presidente Consejo Servicios Médicos
Eladio Santos Aponte MD
Presidente Consejo Salud Pública y Bienestar Social
Natalio Debs Elias MD
Presidente Consejo Politica Pública y Legislación
Emilio Arce Ortíz, MD
Presidente Comité Asesor Presidente
Ilia E. Zayas Ortíz, MD
Presidenta Instituto Educación Médica
PRESIDENTES
SECCI0NES DE ESPECIALIDAD
ANESTESIOLOGÍA
Carlos Estrada Gutiérrez, MD
CIRUGÍA GENERAL
José García Troncoso, MD
CIRUGÍA ORTOPÉDICA
Kenneth Cintrón, MD
CIRUGÍA ESTÉTICA Y RECONSTRUCTIVA
Natalio Debs Elías, MD
CIRUGÍA TORACICA Y CARDIOVASCULAR
José O’neill Rivera, MD
CIRUGÍA DE LA MANO
José Santiago Figueroa, MD
DERMATOLOGÍA
Luis J. Ortíz Espinosa, MD
ENDOCRINOLOGÍA
Eladio Santos Aponte, MD
MEDICINA DE FAMILIA
Marina Almenas, MD
MEDICINA FÍSICA Y REHABILITACIÓN
Miguel Berrios, MD
MEDICINA INTERNA
Ramón A. Suárez Villamil
MEDICINA PREVENTIVA Y SALUD PÚBLICA
Roberto Rosso Quevedo, MD
OFTALMOLOGÍA
Emilio Arce López, MD
OTORRINOLARINGOLOGÍA
Charles Juarbe
SIQUIATRÍA
Pedro Colberg, MD
NEUROCIRUGÍA
Edwin Lugo Piazza, MD
UROLOGÍA
Pedro Piquer Merino, MD
MEDICINA DE EMERGENCIA
Pablo Laureano Martí, MD
JUNTA EDITORA
Humberto Lugo Vicente, MD
Presidente
Luis Izquierdo Mora, MD
Melvin Bonilla Félix, MD
Carlos González Oppenheimer, MD
Eduardo Santiago Delpin, MD
Francisco Joglar Pesquera, MD
Yocasta Brugal, MD
Juan Aranda Ramírez, MD
Francisco J. Muñiz Vázquez, MD
Walter Frontera, MD
Mario R. García Palmieri, MD
Raúl Armstrong Mayoral, MD
José Ginel Rodríguez, MD
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Este número del Boletín por primera vez
en los 105 años de historia del mismo, le llegará
al universo de los médicos de Puerto Rico. Esto
es: a todos los médicos con licencia, a todos los
estudiantes de medicina de nuestras cuatro escuelas
y a todos los Internos y Residentes, total una tirada
de 12,000 ejemplares.
Es por esto que hoy, quien mejor que el Dr.
Ramón Emeterio Betances para engalanar la
portada de nuestro Boletín. El Dr. Betances ha
permanecido en el olvido colectivo por muchos
años y como bien expresó el Dr. Francisco
Manrique Cabrera, “aún se percibe el silencio
oficial con que siempre se acoge a Betances”. Sin
embargo es necesario traerlo a nuestra vida como
ejemplo de un ser excepcional, en todas las fases
de su existir. Hay que hacer excepción de algunos
estudiosos que han trabajado para revivir a
Betances a fin de dar a conocer toda su obra en
Puerto Rico y otros países. Entre éstos hay que
mencionar a:
1. Luis Bonafoux, escritor y periodista, quien
recopiló mucha información sobre
Betances, fue su amigo y se destacó en el
extranjero, especialmente en España y
Francia.
2. Dra. Ada Suárez Díaz, ya fallecida
catedrática universitaria, quien dedicó su
vida a investigar y publicar las obras del
prócer y a quien su hijo y mi amigo, el
Licenciado Gilberto Concepción Suárez,
suele llamar “la eterna novia de Betances”.
Vol. 100 • Núm. 1 • Enero-Marzo 2008
Mensaje del Presidente y Portada
Message from the President and Cover
DR. RAMÓN EMETERIO BETANCES
3
Por: Eduardo Rodríguez Vázquez, MD
Presidente, Asociación Médica de Puerto Rico
3. Los Doctores Félix Ojeda Reyes
puertorriqueño, Paul Estrade (Francés)
profesor Emérito de la Universidad de París,
quienes han dedicado años a recopilar,
destacar y publicar la vida y obra de Betances.
Su interés les ha llevado a varios países:
Cuba, Santo Domingo, Francia, España,
Estado Unidos y otros en la búsqueda de
información documental sobre nuestro
patriota. Han continuado la labor titánica de
mantener viva su figura revisando archivos,
bibliotecas y rescatando documentos,
manuscritos, epistolarios y fotografías a fin
de darlas a conocer.
Estos esfuerzos han culminado en la
publicación de una serie de libros, los cuales
cubren toda la vida de Betances, desde diferentes
ópticas: familia, estudios, profesión, trabajo, labor
política, profesional y muchos otros aspectos.
Entre estos: La Manigua en París, El Anciano
Maravilloso, El Desterrado de París. Ya se han
empezado a publicar las obras completas de
Betances, siendo el primer volumen su labor
como médico y científico, el cual me honro en
prologar. Todos estos esfuerzos han llevado a
Betances más allá de nuestros mares,
eslabonándolo a figuras de la talla de José Marti,
Simón Bolívar, San Martín y otros gigantes de
nuestra América. Sus gestiones pronto verán el
fruto en una estatua de Betances en Nueva York,
Central Park South y avenida las Américas entre
las estatuas de Bolívar y Martí.

4
El Dr. Ramón Emeterio Betances fue uno de
esos pocos hombres que pudieron combinar en
su vida la excelencia como, estudiante, médico,
patriota, amigo, benefactor, líder, creador,
abolicionista, valiente ante la adversidad, pujante
ante la injusticia, desobediente ante las
imposiciones de crueldad; no dobló nunca la
cabeza, ni se amilanó.
Lucho abiertamente de frente contra la tiranía
de los que ostentaban el poder y a pesar de toda
su acción, nunca abandonó su profesión de
médico, la cual llevó hasta los menesterosos. En
esas actividades altruistas desarrolló su existir.
Betances viene a la vida en un momento histórico
trascendental, el siglo XIX, cuando Europa y la
América Latina convulsionaban buscando avenidas
de libertad personal y universal. La rebelión de las
colonias norteamericanas contra Inglaterra y la
revolución Francesa de 1789 fueron provocadas
por esta ansia de libertad personal y comunitaria.
Toda esta rebelión de los sojuzgados provocó la
liberación de las colonias españolas en América y
la libertad que gesta Bolívar, de cinco naciones:
Chile, Colombia, Venezuela, Perú y Bolivia.
En Puerto Rico, la situación colonial a
principios del siglo XIX, era insostenible ante la
amenaza de las guerras de Independencia en
América, España emite la Real Cédula de Gracias
del 1815, a fin de aumentar la población blanca
con extranjeros monárquicos y leales a la corona
Española, debían además, profesar la fé católica.
Llegaron a Puerto Rico, corsos, franceses,
italianos, alemanes, eslavos y de otros países. A
la par que emite esta disposición, impone otra real
orden para impedir que los estudiantes
puertorriqueños y cubanos asistan a universidades
europeas, no españolas y a universidades
norteamericanas. Esta prohibición, que dura
hasta la década del 1830, logra su propósito y
no es hasta 1835 que el primer puertorriqueño,
el Dr. Pedro Gerónimo Goyco y Sabanetas, se
graduó de la Facultad de Medicina en la
Universidad de París.
A partir de este momento, hay un movimiento
sostenido de decenas de jóvenes puertorriqueños
que acuden a Europa especialmente Francia y
Alemania, a iniciar sus estudios universitarios. En-
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
tre estos, se encuentran los Hermanos José Marcial
y Francisco Mariano Quiñónes, Santiago Porrata
Doria, José Maria Arroyo y Juan Secchi (graduados
de medicina en París), Gabriel Adolfo Ruiz de
Heidelberg (1850), Agustín Stahl de Wurzburgo
(1864) y otros. Entre ellos va el joven Betances.
Betances llega a Tolosa a la edad de diez años,
habiendo muerto su madre, su padre Don Felipe,
lo envía bajo la tutela de Jacques Prevost, un
farmacéutico francés, quien casó con una
caborrojeña. Al llegar Prevost a Puerto Rico, la subdelegación
de farmacia no convalidó su título, por
lo que tuvo que regresar a su país. Siendo gran
amigo de Don Felipe, éste delega en Prevost, la
educación de su hijo. Betances se gradúa con dos
bachilleratos, uno en letras y otro en ciencias,
requisitos indispensables para entrar a la facultad
de medicina. Obtiene luego su Doctorado en
Medicina y cirugía de la Universidad de París (1855).
En esta universidad se relaciona con condiscípulos
destacados de la talla de Charcot, Labbe y Lorain.
Tiene además una facultad extraordinaria de
profesores sobresalientes, reconocidos en la
profesión de medicina, dentro y fuera de Francia
como: Trosseau, Nelaton, Brocca y Cruveilhier. Uno
de sus profesores en Oftalmología, viéndolo operar
una catarata comentó: “No hay nadie como los
americanos del sur que tengan esa habilidad innata”.
Betances regresa a Puerto Rico en el 1856
trayendo los aires de libertad que incorporó en
Francia. Enfrenta un régimen absolutista, opresor,
que promulga la sujeción y la esclavitud humana.
Es entonces cuando se rebela y se torna en un adalid
por la libertad de su patria en un defensor de las
injusticias y en “el Abolicionista”. No Abandona
nunca su carrera de médico, prestó sus servicios al
pueblo de Mayagüez, quien lo bautizó como “el
Médico de los Pobres”, durante la epidemia de
cólera. Su interés en las enfermedades fue tal que
“modificó con éxito el tratamiento para la dispepsia,
disentería, fiebre tifoidea y tétano”. Fundó la Clínica
San Antonio en Mayagüez, donde realizaba trabajos
clínicos y de investigación a la par que atendía a
sus pacientes fuera de ésta, aún a los indigentes en
los hogares. En 1860 adoptó el tratamiento para
la pulmonía, el que después fue utilizado, luego de
los descubrimientos de Pasteur.
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Su trabajo sobre la osqueotomía, para tratar la
elefantiasis, fue presentado ante la Academia de
Cirugía de París y estimado como uno de los más
sobresalientes de su época. Además de esto, no
abandonó su lucha por la independencia de Puerto
Rico y por la liberación de los esclavos. Fue
deportado en varias ocasiones; en 1870 se instala
en París definitivamente hasta su muerte en 1898.
Por su participación destacada en la diplomacia
antillana fue condecorado por el Gobierno Francés
con la cruz de Gran Caballero de la Legión de
Honor.
La evaluación de la actividad médica y científica
de Betances puede dividirse en tres períodos, a
partir del 1855, cuando presenta su tesis doctoral
sobre el aborto.
1. El primer periodo, 1855-64 se destaca por
la escasez de sus publicaciones debido a la
censura gubernamental del pensamiento
escrito en Puerto Rico y por la ausencia de
facilidades para ello. Durante este período
Betances se envuelve de lleno en la práctica
de la medicina y se inicia en sus luchas
patrióticas y en la Abolición de la esclavitud
que culmina en 1873.
2. 1864-1887 Betances publica un solo artículo
sobre osqueotomía ante la sociedad de cirugía
de París desborda toda su energía en
actividades políticas relacionadas con el Grito
de Lares la abolición de la esclavitud y la
independencia en Puerto Rico. En el 1869,
se va al exilio definitivamente. Hemos
encontrado un solo artículo sobre
oftalmología en 1873. Participa de lleno en
las luchas patrióticas y se dedica a la practica
de la medicina en París.
3. 1887-1898 en adelante. Comienza a
publicar activamente numerosos artículos
sobre temas de medicina y científicos en
Francia, España, Santo Domingo y Puerto
Rico hasta su muerte en 1898.
El Dr. Betances publicó trabajos sobre:
Oftalmología, Parasitología, Salud Pública, Viruelas,
Vacunas, Medicina Preventiva, Trabajos sobre la
leche, Ginecología, Urología, Técnicas Quirúrgicas,
El cólera, entre otras. Esta visión multidisciplinaria
de la vida de Betances es lo que hemos perdido a
Vol. 100 • Núm. 1 • Enero-Marzo 2008
través de los años. Hoy el médico es solo médico,
el dentista es dentista, el enfermero es enfermero,
el maestro es maestro. El profesional practica “eso
que sabe”. Así, el cuadro general de la profesión se
convierte en lo específico. Betances y su siglo nos
dio una cátedra distinta, fueron los hombres del siglo
XIX, los que acuden a Europa a estudiar, ciencias
naturales, los que transformaron a Puerto Rico,
añadiendo el elemento de estas ciencias, cambiaron
nuestro destino. Román Baldioroty de Castro y José
Julián Acosta se licenciaron en física y matemáticas
en España y Francia. Al regresar a Puerto Rico,
Baldorioty enseño desde Historia Natural hasta
Náutica y Acosta, Agricultura hasta su muerte.
La idea de la educación en nuestros días es a
veces, una enseñanza simplista de estudios culturales
que “desarrollan la sensibilidad y la espiritualidad
del alumno”. Debemos estudiar todo aquello que
pertenece al intelecto abstracto, al estudio de las
corrientes del pensamiento que han regido al
universo, a la difusión de la cultura clásica y la de
personas bien preparadas que posean un
conocimiento amplio de los múltiples estudios del
ser humano. Muchos de los próceres de ese siglo
Betances, Agustín Stahl, Pedro Gerónimo Goyco,
Salvador Carbonell, José Francisco Basora, José
Gualberto Padilla, Manuel Alonso, Manuel Zeno
Gandía, Cayetano Coll y Toste, Martín Corchado y
muchos otros, fueron a Europa a estudiar medicina
y no otra profesión.
La formación de nuestros principales
abolicionistas, Betances, Basora, Acosta, Quiñónes
era científica, exceptuando a Segundo Ruiz Belvis.
Todos estuvieron influenciados por la Francia de
los altos principios revolucionarios. La historia que
se nos ha enseñado ha omitido la verdadera historia
de las ciencias en nuestra cultura. Se nos ha limitado
solo a aprender una historia política, económica y
social.
Nuestra educación actual es cómoda, discursiva,
a base de conferencias y de lecturas. Se nos habla
mucho de lo que pensaron o dijeron otros, antes
que nosotros. Y no es que esto esté mal, pero
debemos contribuir con nuestro pensamiento y
análisis, a fin de lograr una crítica positiva a lo que
se hace, contribuyendo con “lo que podemos
hacer”. ¿ Dónde están los nuevos Betances, los
5

6
Stahl, los Acosta, los Baldorioty de Castro que
contribuirán al conocimiento general y específico?
Y más aún ¿los que protestarán y combatirán los
estatutos injustos y las malas decisiones?
Ellos fueron los que se apartaron de los
aplausos del momento, para descifrar los misterios
de la naturaleza, las enfermedades y los problemas
de la sociedad. El hombre de ciencias, el médico,
el maestro y otros proponían soluciones para
beneficio de sus congéneres. La producción del
hombre de ciencias era constante y sin interés
monetario alguno. Se vivía para saber y ayudar.
Ese siglo XIX continuador de “La Ilustración”
despertó un gran estímulo, para innovar, inventar,
para vivir una vida intensa, ayudando a su mundo
a ser uno mejor. Existió entonces una intensidad
del esfuerzo humano para modificar lo que estaba
mal y buscar nuevas soluciones. El hombre de ese
siglo actuaba con devoción, para servir a su país.
Era un hombre culto, que entendía la necesidad
de proveer medios adecuados para realizar los
trabajos de investigación necesarios, para dotar a
los estudiantes. Fueron hombres de una clara
visión, quienes convencidos de la necesidad de
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
nuevos horizontes dejaron sentir sus opiniones, en
momentos de rebeldía hacia lo impuesto y así
lograron cambios en muchísimas esferas de las vidas
de las gentes.
Son estos hombres un reto para nosotros. En
un país tan lleno de todo tipo de problemas como
el nuestro ¿Qué hacemos? ¿Qué podemos hacer
además de ejercer nuestro trabajo en las horas
impuestas? ¿Qué es lo que podemos añadir en
nuestra vida cotidiana para ayudar a resolver los
problemas que cada día se tornan peor, por nuestra
indiferencia a participar en la vida de nuestro Puerto
Rico? Por tanto, yo les exhorto a que se involucren
con mayor intensidad en los grupos, sociedades y
asociaciones que intentan mejorar nuestro entorno.
Que contribuyan con sus conocimientos y
actividades a inventar nuevas avenidas y proyectos
que redunden en el bienestar de nuestro pueblo. Si
todos damos de nuestro tiempo, en corregir todo
aquello que puede mejorarse, nuestro Puerto Rico
podría atenuar o resolver los múltiples problemas
que nos avasallan.
Solo así podríamos disfrutar del bienestar y la
paz que tanto necesitamos.
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Almost 105 years has passed since a group of
renowned physicians founded a Medical Scientific
Journal in Puerto Rico under the shelter of the Puerto
Rico Medical Association. This same Journal now
known as ‘Boletin’ surpassed the tutelage of the
National Library of Medicine in 1966 and became
our first Medline source in Puerto Rico. Since then
the struggles of time has placed our heritage in
danger on several occasions. Thanks to the
abnegated and unselfish work of a group of
publishing board members, some who actually still
prevails in their position, the ‘Boletin’ has continued
to survive as one of the two Medline source of Puerto
Rico for our research writers. We are honored to
push the golden pages of time a little longer.
This first 2008 issue deals with clinical research
work originating from our recent 58 th Annual Meeting
of the American College of Surgeons - Puerto
Rico Chapter celebrated in February 2008 at La
Concha Hotel, San Juan, Puerto Rico. The original
and case reports published encompass residents
and young surgeons writing their experience and
results with the new technological advances of
minimal invasive surgical procedures.
The Puerto Rico Medical Association and his
president, Dr. Eduardo Rodriguez, have made an
enormous effort to bring, free of charge, the
Internal Medicine Residency, Damas Hospital – Ponce School of Medicine Teaching Consortium, Ponce, Puerto Rico.
Vol. 100 • Núm. 1 • Enero-Marzo 2008
7
EDITORIAL
Humberto Lugo-Vicente MD, FACS, FAAP
Editor-in-Chief, “Boletin” Asociación Medica de Puerto Rico
‘Boletin’ to all of our physician medical community,
medical students and residents to encourage them
to see themselves publishing the new trends of our
future medicine.
We are also very happy to include a very
important review article on the history of parathyroid
surgery in Puerto Rico, vis a vis the worldwide
history, from our renowned professor and endocrine
surgeon, Dr. Enrique Vázquez-Quintana. A lecture
included as the main speaker of the 28 th Raffucci
Surgical Research Forum.
Finally, the abstracts presented during the 28 th
Raffucci Forum are included also in this issue as a
token of appreciation to the many hours of research
each and every student, resident and surgeon has
devoted to their presentation.
CME credits can be obtained after studying the
three articles on parathyroid surgery included in this
issue.
Sincerely,
Humberto Lugo-Vicente MD, FACS, FAAP

8
Artículos Originales • Original Articles
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
PUERTO RICO EXPERIENCE WITH PLUGS IN THE
TREATMENT OF ANAL FISTULAS
By: Ignacio Echenique MD.*, Juan R. Mella MS**, Francisco Rosado MD.*, Ignacio A. Echenique MS §,
Maria T. Mella MS § and Gerardo Quevedo MD. ¥
ABSTRACT
Background: Anorectal fistula is a common
problem that affects quality of life. Main objective
of therapy has been to eradicate the fistula tract
while preserving fecal continence. Latest good results
for anal fistula treatment have been an anal
fistula plug. This study was undertaken to determine
if these results could be reproduced in Puerto Rico.
Method: From January 2003 to January 2008,
two experienced colorectal surgeons performed this
new operation in 23 consecutive patients. A multivariable
analysis was undertaken including age, sex,
location of the fistula, previous surgeries, Seton
placement before the insertion of the plug, continence
pre and post operation, as well as close follow
up. No patient with inflammatory bowel disease
was included.
Results: We had a good result or healing of the
fistula in 14 of 23 patients for a success rate of 60%.
We had a subgroup of patients who did slightly better
and had a healing rate of 66% compared to the 60%
of the whole group. It appears to be a trend in favor of
the Seton group but is not statically significant. We
had 9 failures of 23 patients or 39%. Suppuration
was noticed in three patients and all three had failures
of the plug with recurrences.
Conclusions: This new operation is another
alternative to add to our armamentarium but we
need to search for an operation that decreases the
incidence of recurrences we had in our study while
maintaining function of the sphincters.
Key words: plug, fistula-in-ano, surgery
Anorectal fistulas are a common problem that
results in a reduced quality of life as well as physical
and emotional grief. They usually present with
chronic drainage and a pustule-like lesion in the
perianal region that can lead to pain during defecation.
The main objective of surgical therapy is to
eradicate the fistula tract while preserving fecal continence.
Depending on the location and type of fistula,
management of anal fistulas can be quite challenging
despite several treatment options. Those
with low transsphincteric or superficial fistulas can
be treated by primary fistulotomy with low risk of
incontinence. However, this procedure cannot be
performed without risk in the case of mid or high
fistulas. Subsequently, other options have been developed
since the advent of the primary fistulotomy,
albeit without much success, high recurrence rates,
and/or relatively high complication rates.
Advancement flap procedures have been rela-
From the * Department of Surgery, Auxilio Mutuo Hospital, Rio Piedras, PR, ** Boston University, Medical School, Boston, MA, § Jefferson’s
Medical School Philadelphia, PA, and ¥ Department of Surgery HIMA-San Pablo, Bayamon, PR.
Address reprints to: Ignacio Echenique MD - Office 218, Torre Auxilio Mutuo, 715 Ave. Ponce de Leon, Rio Piedras, PR, 00918. E-mail
Poster presented during the 58 th Annual Meeting American College of Surgeons, Puerto Rico Chapter, February 22, 2008,
La Concha Hotel, San Juan, PR.
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
tively successful in treating anal fistulas with closure
rates as high as 75% (1). This procedure is
technically difficult but has an incontinence rate
between zero and 12.5% (2). The use of a Seton
(Latin seta, a bristle) is a temporizing measure, as it
is intended to drain and promote fibrosis while is
not curative. The use of fibrin glue has a success
between 50-70% (3). A major disadvantage of the
use of glue in management of anal fistulas is the
tendency to become dislodged and eventually extruded
from the secondary opening of fistula tract,
thus resulting in failure of the tract closure. A more
recent therapeutic measure is an anal fistula plug
made of lyophilized porcine intestinal submucosa.
Recent studies using this plug have been promising.
Champagne et al. have achieved a success rate
of 83% using this new anal fistula plug (3, 4).
Essentially, the fistula plug is an extracellular
matrix that is harvested from porcine small intestinal
submucosa (5, 6). This biomaterial provides a
scaffold for which it allows adequate strength for
tissue support and permits host cells to reconstruct
related tissues. It acts as a “substitute dermis” that
already possesses several of the factors required for
wound healing and may result in improvement of a
healing injury as in the case of a fistulous tract (7).
Given the high success rate described in the literature
for treatment of anal fistula using the anal fistula
plug, this clinical study was undertaken to determine if
these results could be reproduced in Puerto Rico.
METHOD
A retrospective analysis based on the personal
experience of two colorectal surgeons using a new
operation for anal fistulas between 2006 and 2008
encompass this study. Results and complications
from this surgical procedure for management of anal
fistulas using an anal fistula plug (Surgisis, Cook
Surgical, Inc.) were evaluated (see Figure 1).
A total of 23 patients were operated during
this period. Factors examined were age, sex, previous
surgery and continence. Other factors studied
such as presence of a complex fistula, multiple
external openings, complications, recurrences
and if re-operation was necessary were
also evaluated. Length of the fistula was defined
as short, mid or long fistulas according to
Vol. 100 • Núm. 1 • Enero-Marzo 2008
Figure 1: Anal fistula plug
Godsall’s rule. All patients enrolled had moderate
or deep transsphincteric fistula. Complex fistulas
were not excluded. Preoperative evaluation
consisted of exclusion of Crohn’s disease,
Endorectal Sonogram and MRI when indicated.
No infections were apparent at the time of anal
fistula plug treatment. In patients that presented
with an abscess we waited three months after the
placement of a Seton and placement of the fistula
plug.
Patients underwent preoperative mechanical
bowel preparation and prophylactic antibiotics were
given. Spinal anesthesia was used and patients
placed were in jackknife position. We used the standard
technique (6), irrigating the fistula with hydrogen
peroxide, without enlarging the internal opening
or curettage of the track. Identification of the
internal opening was done after gentle probing
when a Seton was not present. Placement of the
plug, snug in the track and suturing of the plug to
the internal sphincter with a figure of eight absorbable
suture, with closure of the internal opening
and coverage of the plug was performed. Externally,
excess plug was excised and a simple absorbable
suture was used to fix the plug to the skin ensuring
that the skin would remain open for adequate
drainage. Stool softeners, rest and decreased physical
activity, prevention of constipation or straining
were encouraged in the postoperative period.
9

10
Figure 2: Fistula plug results
RESULTS
We reviewed the data obtained from the medical
records of patients since the first operation three years
ago with a mean follow up of ten months; the shortest
follow up was five months. The condition was more
common in men than women; 62% compared with
38% respectively. The left anterior area was the most
common location, two long fistulas, two complexes
and 1 horseshoe fistula.
Continence was not affected in any of our patients.
In one case the plug had dissolved and in another, the
plug was dislodged. There were no reported cases of
bleeding, allergic reactions or medical complications.
A total of 23 patients were operated. Eighteen of
23 had a Seton in place before plug surgery was done.
The most common operation before the plug was
drainage of abscess and Seton placement. Other operations
included two procedures for hemorrhoids.
Three patients had no surgery prior to the development
of the anal fistula.
Good results: We had good result or healing
of the fistula in 14 of 23 patients for a success rate
of 60% (see Figure 2). Of the 23 total patients, 18
had drainage of an abscesses and placement of
Seton with at least three months between the Seton
placement and the insertion of the plug. Of
the18 patients that had a Seton, 12 (66%) healed.
This was not statistically significant (p = 0.26). Of
the 14 patients with healing of the fistula, 12 (86%)
of the patients had a Seton in place before the placement
of the plug. Secretions of the external opening
were not a factor in predicting who would heal
or fail. However, it may take some time before a
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Figure 3: Total healing group
final outcome can be determined.
Failures: We had 9 failures of 23 patients or
39%. Of these five patients had no Seton placed
before the placement of the fistula plug and 3 of
them failed (60%) and required a re-operation due
to abscess formation. Suppuration was noticed in
3 patients and all three had failures of the plug with
recurrences (see Figure 3).
DISCUSSION
Challenges of treating anal fistulas are prevention
of recurrence and preservation of anal sphincter function.
Since medieval times treatment of anal fistulas
has been a challenge. Surgical techniques have improved
significantly but still many times we must perform
drainage, what John of Arderne did in London
in 1307 (8). Herman and Desfosses recognized the
presence of glands in the submucosa and the internal
sphincter in 1880, commonly believed to be the origin
of the infections causing abscesses that developed
into fistulas (9).
Closure of the primary opening with an absorbable
suture plus the use of a biologic anal fistula plug is
another alternative for treating anorectal fistulas with
little risk of incontinence.
A review of the literature available described a
success rate between 60 to 80% (5, 6, 7). Our experience
with the 23 patients is 60% but we noted a subgroup
of patients who did slightly better when a previous
Seton was in place and a long fistulous tract (> 3
cm) was not found .
There were complications from this procedure.
Three patients required re-operation and placement
of a Seton for treatment of abscesses. Leaving the
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
external opening for drainage is an important factor
as we noticed accumulation of secretions in this
area that were resolved by widening of the external
opening and oral antibiotics. An abscess developed
exclusively in case of definite failures. Secretions
alone did not correlate with recurrence of the fistulas.
It is important to prevent premature closure of
the external opening as this could lead to formation
of an abscess with failure of the plug and recurrence.
It is also important not to have significant
purulent drainage during at least three months
between drainage of an abscess with Seton placement
before the insertion of the plug.
Basic principles of surgery such as “Do No Harm”
and “Simpler is Better” should be in our minds when
we go into the operative room. If we can obtain a low
recurrence rate with preservation of the sphincter function,
then we have achieved these important principles.
We continue to explore different alternatives and in
the process add new surgical techniques. All surgical
techniques mentioned have a role but we must still
search for a way to decrease the incidence of recurrences
we had in our study.
This new operation is not risk free and it appears
that there may be a benefit to having previous placement
of a Seton before the insertion of the fistula plug.
In this study a subgroup of patients who did slightly
better and had a healing rate of 66% compared to the
60% of the whole group. It appears to be a trend in
favor of the Seton group but is not statically significant
(p = 0.28 NS). This group had a Seton in place
before placement of the fistula plug. This small benefit
could be due to a better-defined fistula track and less
purulent material. The non-seton group in our study
was too small to conclude that all patients should have
a Seton before the insertion of a plug. Further studies
should address this issue. Secretions of the external
opening occurred in some cases and did not correlate
with recurrences. Abscess formation, a fistula with long
track (> 3cm) and dislodging of the plug, were important
factors in the recurrence group. This new technique
with the use of a fistula plug is here to stay and
Vol. 100 • Núm. 1 • Enero-Marzo 2008
11
we must continue to evaluate the results obtained so
we can do better patients selection of those that could
benefit from this new operation.
RESUMEN
Las fístulas anales son una condición muy frecuente
que afecta la calidad de vida de los que la padecen. El
objetivo principal del tratamiento de las fístulas anorectales
ha sido el erradicar el tracto fistuloso y a la
misma vez preservar la continencia fecal. Recientemente
se han reportado buenos resultados en el tratamiento
de fístulas anales con el uso de un tapón para
fístulas (‘anal fistula plug’). Este estudio se llevó a cabo
para determinar si estos buenos resultados se podían
reproducir en Puerto Rico.
Desde enero 2003 a enero 2008, dos cirujanos
colorectales llevaron a cabo esta nueva operación
en 23 pacientes consecutivos. Se hizo un análisis
multifactorial incluyendo sexo, edad, localización
de la fístula, cirugías previas, presencia de
Seton previo a la inserción del tapón, continencia
antes y después de la operación y un seguimiento
bien cercano. Ningún paciente con enfermedad
inflamatoria del intestino fue incluido.
Se obtuvo un buen resultado o cicatrización de la
fístula en 14 de 23 pacientes para un resultado satisfactorio
de 60%. Tuvimos un subgrupo de pacientes
con un Seton previo que les fue levemente mejor con
cicatrización de la fístula en un 66% comparado con
60% del grupo total. Este beneficio leve no fue
estadísticamente significativo pero sugiere una tendencia
a ser favorecido el tener un Seton previamente a la
inserción del “Plug”. La operación no funcionó en 9
de 23 pacientes o 39%. Supuración se notó en tres
pacientes y los tres fallaron en cerrar la fístula con el
“Plug” con recurrencias.
Esta nueva operación es otra alternativa para sumarse
a las alternativas quirúrgicas pero aun tenemos
que encontrar una operación que disminuya la incidencia
de recurrencias que encontramos en nuestro estudio
y a la misma vez mantenga la función del esfínter.

12
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
REFERENCES
1. Lewis P, Bartolo DC. Treatment of trans-sphincteric fistulae by full thickness anorectal advancement flaps. Br J Surg 1990; 77: 1187–9.
2. Williams, J. G., Farrands, P. A., Williams, A. B., Taylor, B. A., Lunniss, P. J., Sagar, P. M., Varma, J. S. & George, B. D.The Treatment
of Anal Fistula: ACPGBI Position Statement.Colorectal Disease 9 (s4), 18-50.
3. Eric K. Johnson, Janette U. Gaw, David N. Armstrong,Efficacy of Anal Fistula Plug vs. Fibrin Glue in Closure of Anorectal Fistulas, DCR:
vol 49,no. 3 March,2006.
4. Champagne, Bradley J. (2006) Efficacy of Anal Fistula Plug in Closure of Cryptoglandular Fistulas: Long-Term Follow-Up. Diseases of the
Colon & Rectum
5. Maluf-Filho F, Ishioka S, Moura E, Berti L, Sakai P, Garrido A, Gama-Rodrigues J. Fistulae with an acellular matrix. Abstract presented at
the Digestive Disease Week® 2004.
6. Robb BW, Nussbaum MN, Vogler SA, Sklow B. Early experience using porcine small intestinal submucosa to repair fistulas-in-ano. 2004
Annual Meeting of the American Society of Colon & Rectal Surgeons.
7. (2007) The surgisis® AFP anal fistula plug: report of a consensus conference. Colorectal Disease 0(0)
8. John of Arderne, GLASGOW UNIVERSITY LIBRARY SPECIAL COLLECTIONS DEPARTMENT, England http://special.lib.gla.ac.uk
9. Hermann G, Desfosses L. Sur la muquese de la region cloacale du rectum. Comptes end Acad des Sci 1880; 90: 1301–2.
ANUNCIO PÚBLICO • AMPR
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
ABSTRACT
Background: Hand assisted laparoscopic
colectomy (HALS) has been shown to have the advantages
of laparoscopic colectomy in terms of pain,
recovery and length of hospital stay. Studies have
shown similar outcomes in laparoscopic colectomy
as in open surgery. There is a learning curve to
HALS, the operative time is longer, and it is more
difficult than open surgery and requires specialized
equipment. In this report we present our initial
experience over a 2.5 year period using HALS for
colon surgery for diverticulosis, polyps and colon
cancer.
Methods: A retrospective review of office and
hospital charts of patients undergoing HALS colectomy
from June 2005 to January 2008 was performed
at HIMA-San Pablo Hospital. Demographics,
outcomes data including operative time, conversion
rate to open surgery, reasons for conversion,
time to start feedings, and length of stay were
collected as well as staging and number of nodes
for cancer patients. Complications are discussed
along with comments pertinent to the experience
of two surgeons going through the learning curves
of LC and HALS colectomy.
Results: A total of 65 patients underwent attempted
hand assisted laparoscopic colon resection.
There were 33 males and 32 females between the
ages of 26 and 87. Thirty-one patients underwent
surgery for diverticulosis; 8 for pre-malignant le-
Vol. 100 • Núm. 1 • Enero-Marzo 2008
13
Artículos Originales • Original Articles
EXPERIENCE WITH HAND ASSISTED
LAPAROSCOPIC SURGERY OF THE COLON
By: Ramón K. Sotomayor, MD.* and Bolivar Arboleda, MD.*
sions (large polyps or polyps with high grade dysplasia),
and 26 for colon cancer. Mean operative
time was 195 minutes (120 to 300); mean length
of stay was six days (range 4-14 days). Conversion
rate was (13.8 %) overall; 21 % during the first year
and 10.8 % after the first year. 5 (7.5 %) of the
patients in which HALS colon resection was completed
had complications with prolonged length of
stay. Patients without complication had an average
length of stay of 4.5 days. The average number of
lymph nodes was 14.8 (range 7-24); average length
of specimens for diverticulosis was 17cm. Complications
included postoperative bleeding in three
patients who required early reoperation, prolonged
ileus and small bowel obstruction in two patients.
One patient developed a pelvic collection requiring
a drain, and one patient had a wound infection requiring
re-admission and antibiotics. No patient required
colostomy due to a complication. There were
no operative deaths.
Conclusion: HALS colectomy is a safe and
feasible alternative to open colectomy in a
community hospital setting with proper expertise
and equipment. Patients will benefit from faster
recovery time and decreased length of stay in the
hospital. Oncologic results are similar to open
surgery. Operative times are longer than with
open surgery and the operations are difficult to
learn and master.
* From the Department of Surgery Hospital Interamericano de Medicina Avanzada, Caguas, Puerto Rico. Address reprint requests to: Ramon K.
Sotomayor, MD - 300 La Sierra Ave. Aptdo. 61 San Juan, PR 00926. E-mail: ksotomayor@msn.com. Poster Presented at the 58th Annual
Meeting of the Puerto Rico Chapter of the American College of Surgeons Feb 21, 2008, La Concha Hotel, San Juan, Puerto Rico.

14
Key words: hand assisted, laparoscopy,
colon, surgery
In June 2005 the first cases of Hand Assisted
Laparoscopic colon resections were performed. The
two surgeons participating in this work were experienced
with basic and advanced laparoscopic procedures
namely cholecystectomies, appendectomies,
Nissen fundoplications and ventral hernias. In this presentation
we were able to review 65 hospital charts of
patients who underwent hand assisted laparoscopic
surgery. The results and outcomes are discussed in
the following tables; operative time, length of stay,
conversion rate to open surgery, and complications.
We also looked at the stage of the patients, the number
of lymph nodes obtained in the specimens and the
length of the specimens in patients who had colon
resection for diverticular disease.
In general, hand assisted laparoscopic resections
were performed using one of the commercially available
hand assist devices Lap Disc (Ethicon) or Gelport
(Applied Medical), are extremely useful as they allow
use as a “hand port” or as a working port by supporting
a trocar by which the camera or instruments can
be passed. Hand assist devices allow the use of tactile
sensation during laparoscopic surgery, and allow easier
atraumatic retraction of the bowel (1, 2). Colon resections
are more difficult than other laparoscopic procedures,
as the surgeon needs access to more than one
quadrant of the abdomen. By facilitating exposure,
hand devices make laparoscopic colon surgery easier
(3). The hand assist device also protects the wound
during the retrieval of the specimen and for construction
of extracorporeal anastomosis. Disadvantages of
hand assisted surgery include the hand getting in the
way in initial cases and the fact that the hand is a
rather large “instrument”. Hand fatigue is also an issue,
but hand assist devices are very useful because
they may be used as a trocar to pass instruments and
perform a fully laparoscopic operation and have been
found to preserve the features of minimally invasive
rugby procedures in terms of postoperative pain, recovery
and oncologic outcome (4).
In this presentation we intend to document what
we have learned in our initial cases and the problems
and pitfalls associated to starting a minimally
invasive colon surgery program.
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Technique for Hand Assisted Laparoscopic
Colon Resections
The technique for hand assisted laparoscopic
colon resections according to the center, but most
authorities agree on proper positioning of the patient,
and careful planning of the trocar positions
and the hand port, in order to maximize its benefits
in facilitating the operations (1, 2, 3).
We performed segmental resections following
what we found has worked in our center. All cases
were electively admitted. In general, standard bowel
preparation, antibiotic and deep venous thrombosis
with pneumatic compression devices or low
molecular weight heparin was utilized. Small cancers
and polyps were marked prior to surgery. General
endotracheal anesthesia was used. Five and 12
mm trocars, 0 degree and 30 degree, 5 and 10mm
lenses and two monitors were routinely used. For
division of vessels, monopolar cautery, harmonic
scalpel (Ethicon) or LigaSure (Coviden), endoscopic
staplers and endoloops were used.
For left colon cases, the patients were placed
in the semi-lithotomy position, lighted ureteral catheters
were placed and the hand assist device was
usually placed in the left lower quadrant. Routine
mobilization of the splenic flexure was performed,
anastomosis was intracorporeal with a circular stapling
device and sigmoidoscopy and insufflation test
was done on all cases.
Right colon resections were done in the supine
position with the hand assist device in the right lower
quadrant, vessels were divided intracorporeally and
the anastomosis extracorporeal. Patients were usually
monitored in the intermediate unit overnight.
Nasogastric tubes were used on discretion of the
surgeon. Diet was started when passing flatus, and
discharge after regular bowel movement.
RESULTS
Table 1 shows the demographics of the patients
undergoing hand assisted laparoscopic colon
resection. Ages ranged from 27 to 87 years old.
48 % underwent surgery for diverticular disease,
40 % for colon cancer and 12 % for polyps or high
grade dysplasia. 24 patients (37%) had segmental
resections of the right colon with ileo-transverse
colon anastomosis, 38 patients (58%) had segmental
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Table 1- Demographic data of patients undergoing hand
assisted laparoscopic colectomy*
total patients
no. patients
65
Gender 33 females/32 males
Ages
Diagnosis
26 years to 87 years mean- 63years
- diverticulosis 31 (48 %)
-colon cancer 26 (40 %)
-polyps/dysplasia
Procedures
8 (12 %)
- HALS right colectomy 24 (37 %) 2 pt-lap chol w hals rt col
-HALS left colectomy 38(58 %) 5 pt lapp appy w hals lt colon
-HALS transverse colon
-other
3( 5 % )
*all patients in which laparoscopic resection was attempted or started
are included.
resection of the left colon with an intracorporeal
low pelvic anastomosis. Two patients had
laparoscopic cholecystectomies during colon
resection and five patients appendectomies.
Mean operative time was 195 minutes, ranging
from 120 to 300 minutes (Table 2). Overall,
nine patients (13.8%) required conversion to open
surgery. Diet was started on average of three days
(Range 2 to 7 days). Five patients (7.6%) had complications
requiring prolonged length of stay; overall
length of stay was six days. In patients without a
complication, length of stay was 4.5 days. Three
patients required re-operation in the post-operative
period (4.6 %), and six patients required readmissions
for other reasons.
Table 3 shows the rates and reasons for conversion
to open surgery. During the first year, 21 % of
the patients required conversion to open surgery, while
during the second year only five out of 46 patients
(10.8 %), required conversion. Right colon resections
had an 8.3 % rate of conversion while left colon resections
had an 18.3% rate of conversion to open
surgery. Reasons for conversion were bleeding, large
tumor, one splenic laceration and severe adhesions
from diverticular disease.
Complications are listed on Table 4. Three patients
were reoperated during the first 24 hours;
two due to intraabdominal bleeding, and one due
to anastomotic bleeding. Two patients were found
Vol. 100 • Núm. 1 • Enero-Marzo 2008
Table 2- Immediate outcome of HALS colon resection
Operative time ( minutes)
mean 195 range 120-300
Conversion to open 4/26
days to start diet (days) 3.36 2-7days
complications with prolonged los 5
length of stay (total) 6 days 4-14 days
length of stay (w out compication) 4.5 days 4-7days
reoperation 2
15
with symptomatic anemia in the post op period,
and were transfused without need for surgery. Two
patients had prolonged ileus; one had documented
small bowel obstruction which resolved with
nasogastric suction. One patient had fever and a
pelvic collection which was drained in the
interventional radiology suite. There were two superficial
wound infections and one deep wound infection
which required re admission, drainage and
antibiotics, which was quite difficult to treat due to
infection running between the planes of the flank
musculature. One patient required admission to the
intensive care unit due to acute respiratory insufficiency
and resolved in 48 hours. There was no need
for diverting stomas as a complication and no
perioperative deaths.
Pathological data is listed in Table 5. The colon
cancer specimens had an average of 14.8 nodes, and
ranged from 7 to 34. The length of the diverticulosis
cases averaged 17cm, range from 12 to 28cm.
DISCUSSION
Our patients were evenly distributed in terms
of diagnosis with 47% diverticular disease, 38%
for cancer and 12% for polyps or dysplasia.
Operative times in this series ranged from 2 to 4
hours, with an average of three hours in most
cases. We found left colons usually took longer,
namely because of inflammatory conditions
related to past episodes of inflammation. This is
usually the case in most series (3).
The conversion rate to open surgery is an
important issue in laparoscopic surgery. HALS
colon surgery has been found to have a lower
conversion rate than “pure” laparoscopic
approach; and in fact some critics have pointed
out that HALS is really open surgery. The fact is

16
Table 3- Rates and Reasons for Conversion to Open Surgery
no. of patients ( %) comments
Total conversions 9 / 61 (14 %)
during 1st year 4 / 19 (21 %)
After 1st year
HALS Right
5/46 (10.8 %)
Hemicolectomy
HALS Left
2/24 (8.3 %) 1 intraop bleeding
1 large tumor
ureter position unclear
Colectomy w Low 7/38 ( 18.4 %) 1 splenic
Pelvic Anastomosis laceration-splenorraphy
1 inability to mobilize splenic flexure
5 severe adhesions
due to diverticular disease
HALS Transverse
colectomy 0/3
that hand assist devices allow either combination
of pure laparoscopic surgery or the surgeon can
switch to a hand assisted technique as is
necessary (4). Sometimes in our initial cases we
felt that the hand would obstruct the field of view,
and hand fatigue was an issue which we have
learned to deal with. At the present time we
approach most cases laparoscopically and use
hand assistance freely for certain difficult parts
of the operation.
The conversion rate was 13.8% overall; but
we broke this down to the conversions in the first
year which were 21% and 10.8% after one year
performing the procedures.
We take this as an expected welcome event, as
it shows progress in developing new techniques.
One conversion was due to a splenic capsule tear,
one due to a very large tumor invading the abdominal
wall, one due to bleeding, and the remainder
due to inflammatory adhesions. We expect our
conversion rate to further decrease with time. One
interesting observation regarding conversions was
the difference in conversion rates between right colon
(8.3 %) and left hemicolectomy (18.4 %). We
attribute this to the difficulty in dealing with
inflammatory adhesions and the need to mobilize
the splenic flexure for proper tension free anastomosis.
In the initial experience we have found this
part of the operation to be particularly difficult.
Major complications were the need to re –
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Table 4- Complications of HALS Colon Resections
no. comments/ outcome
reoperation due to bleeding 3
drop in hgb requiring
2 mesentery, 1 anastomosis
transfusion without surgery 2
outcome
two U PRBC transfused, no adverse
prolonged ileus
suction
2 delayed gastric emtpying-nasogastric
small bowel obstruction
Infections
1 nasogastric suction
intraabdominal/ pelvic 1 pelvic drain, CT guided, antibiotics
urinary 1 re- admission, antibiotics
wound 3 1 re-admit, drain, antibiotics
pulmonary
need for diverting stomas
1 icu stay 48 hr
Carciac, thromboembolic 0
Deaths 0
Table 5- Number of lymph nodes and length of specimens
mean range
Colon cancer specimens *
number of lymph nodes
Diverticulosis
14.8 7 to 34
length of specimen** 17cm 12 to 28 cm
* includes patients with polyps and high grade dysplasia
** specimen length measured by pathology lab
operate on three patients due to bleeding. Two
were due to bleeding from the mesentery of the
colon; and one had an anastomotic bleed which
required re- suturing of the anastomosis 24 hours
after initial surgery. Although this is a pertinent
risk in open surgery, we have learned to divide
large vessels intracorporeally with electrosurgical
instruments and staplers this has decreased. One
important technical point is to release the tension
on the tissues when dividing the vessels.
We had two patients in which the hemoglobin
level dropped in the post op period, due to
symptomatic anemia, both were transfused and
observed and none required surgery. This is a
complication which again relates to the level of
familiarity with the instruments and the technique
and should decrease with experience.
The time to start diet was relatively short as well
as the length of stay, although we have been extremely
conservative in starting diet and discharging patients.
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Patients without complications usually started diet on
the 3 rd postop day, and could be discharged on day
four. Several patients had prolonged ileus, small bowel
obstruction and one had a leak which required a drain
and a prolonged stay. Other complications were relatively
minor; two superficial wound infections. There
was one rather difficult wound infection in the lap disc
incision, which we attributed to misplacement of the
lap disc with some enteric spillage into the wound.
The wound was drained and treated and resolved, but
this shows that proper positioning of the lap disc is
essential to avoid this complication (3).
There was one pulmonary complication requiring
a 48 hour stay in the ICU, no cardiac complications,
no deaths and no need for diverting stomas
as a complication of surgery.
In terms of oncologic outcome we looked at
the number of lymph nodes in the specimen. It is
recommended by SAGES and the Society of
Colorectal Surgeons (SCRS) to perform at least
twenty cases of benign disease or non curable colon
cancer before performing surgery for colon cancer.
We have tried to follow these guidelines as much
as possible as there is still many unanswered questions
regarding oncologic outcome (5,6). Lymph
node count averaged 14.8 nodes; ranging from 7
to 34. In general, most of the cases had more than
12 nodes but we did observe that earlier cases
tended to have less than 12. Again, we feel that
this in an issue that has to do with experience and
familiarity with the procedure and the instruments
and definitely recommend that hospitals and
credentialing committees follow these guidelines, in
order to have safe, high quality surgery.
CONCLUSIONS
We have found hand assisted laparoscopic colon
surgery to be a viable, safe alternative to traditional
open surgery in a community hospital setting
with the procedure having an excellent patient
acceptance. Time to start oral feedings and length
of stay in the hospital is shortened. HALS procedures
can be performed with an adequate level of
safety with a low level of complications. Conversions
to open surgery are to be expected in the
initial experience and left colon cases due to past
episodes of diverticulitis appear more difficult than
Vol. 100 • Núm. 1 • Enero-Marzo 2008
17
right colon resections, but it is expected that as surgeons
progress and expertise improves, conversions
to open surgery and complications due to bleeding
should decrease. Cancer resections can be performed
using HALS techniques, but surgeons need
to have experience with benign disease in order to
have adequate outcomes in colon cancer surgery.
Due to the difficulties and the time needed to learning
laparoscopic surgery, it is not clear to us whether HALS
can be applied and utilized by the majority of surgeons.
RESUMEN
Introducción: La cirugía de colon
laparoscópica asistida con la mano (CLAM) ha
demostrado tener la ventajas de la colectomía
laparoscópica (CL) en términos de dolor, recuperación
y estadía en el hospital. Estudios han
demostrado resultados similares en cirugía
laparoscópica que en cirugía abierta para
resecciones del colon. La cirugía laparoscópica
asistida con la mano tiene su curva de aprendizaje,
el tiempo de cirugía es mayor, es más difícil
que la cirugía abierta y requiere equipo especializado.
En este informe presentamos nuestra
experiencia inicial durante un periodo de 2.5
años utilizando CLAM del colon para
diverticulosis, pólipos y carcinoma del colon.
Materiales y Métodos: Se revisaron los
expedientes de clínica y hospital de todos los
pacientes al que se les practicó CLAM del colon
durante los periodos de Junio del 2005 a enero
del 2008 en el Hospital HIMA San Pablo-
Caguas. Se obtuvo información demográfica,
resultados incluyendo tiempo de operación, tasas
de conversión a cirugía abierta, razones para
conversión, tiempo para comenzar alimentación,
estadía en el hospital, al igual que información
de estadio de cáncer y el número de nódulos
linfáticos obtenidos en los especimenes. Se discuten
las complicaciones con comentarios pertinentes
a la experiencia de dos cirujanos con las
técnicas de CL y CLAM.
Resultados: Se comenzaron 65 resecciones
del colon utilizando CLAM. Hubo 33 hombres y
32 mujeres entre las edades de 26 y 87 años.
Hubo 31 casos de diverticulosis; 8 por condiciones
pre-malignas(pólipos grandes o pólipos

18
con displasia de alto grado) y 26 para carcinoma
del colon. El tiempo promedio de cirugía fue de
195 minutos(120 a 300 min.); estadía promedio
fue de 6 días (4 a 14 días). La tasa de conversión
para todos los casos fue de 13.8 %. 21
% durante el primer año y 10.8 % durante el
segundo año. 5 pacientes (7.5 %) tuvieron complicaciones
requiriendo una estadía prolongada.
Los pacientes sin complicaciones tuvieron una
estadía promedio de 4.5 días. El número promedio
de nódulos linfáticos fue 14.8 (7 a 24; el
tamaño promedio de especimenes en
diverticulosis fue de 17cm. Complicaciones fueron
sangrado en tres pacientes que requirieron
re-intervención, íleo prolongado y obstrucción
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
intestinal en dos pacientes. Una paciente tuvo
una colección pélvica que requirió drenaje, y uno
tuvo una infección de herida requiriendo admisión,
drenaje y antibióticos. Ningún paciente requirió
una ostomía por una complicación y no
hubo muertes perioperatorias.
Conclusión: La cirugía de colon
laparoscópica asistida con la mano es una alternativa
segura y viable a cirugía abierta en un
hospital con el equipo y la experiencia apropiada.
Los pacientes se benefician de tiempo de
recuperación más rápido y con corta estadía en
el hospital. Los resultados oncológicos son similares
a cirugía abierta. El tiempo de cirugía es
mayor y son operaciones difíciles de aprender.
REFERENCES
1. Ballanthyne, GH, et al, Hand Assisted Colectomy: Evolution to a Clinically useful Technique. Dis Colon
Rectum 2004: 47: 753-765
2. Loungnarath, R, Fleshman, J. Hand Assisted Laparoscopic Colectomy Techniques. Seminars in Laparoscopic
Surgery, Volume 8, 2001. pp 220-229.
3. Darzi, A. Hand Assisted Laparoscopic Colorectal Surgery . Seminars in Laparoscopic Surgery, Volume 8,
Number 2(june)2001:pp 153-150
4. Targarona, EM et al. Prospective Trial comparIng conventional Laparoscopic Colectomy with Hand Assisted
Colectomy Surg Endos (2002) 16:234-239
5. A Comparison of Open and Laparoscopically Assisted and Open Colectomy for Colon Cancer. N Eng J Med
2004; 350:2050-92069
6. Position Statement of the Society of Colon and Rectal Surgeons (ASCRS) on Laparoscopic Colectomy for
Curable Colon Cancer. Endorsed by the Society of American Gastrointestinal Endoscopic Surgeons(SAGES)
Vol. 100 • Núm. 1 • Enero-Marzo 2008

20
Artículos Originales • Original Articles
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
COMPARISON BETWEEN OPEN AND LAPAROSCOPIC
APPENDECTOMY IN NON-COMPLICATED APPENDICITIS
By: Aura F. Delgado Cifuentes, BS* and Ramón K. Sotomayor, MD.**
ABSTRACT
Background/Objective: An extensive web
search failed to provide studies from Puerto Rico
regarding whether open (OA) or laparoscopic
appendectomy (LA) should be performed for noncomplicated
appendicitis. Our goal is to compare
these techniques in terms of time at operating
room (OR), length of surgery, hospital stay, pain
medication requirements, in-hospital
complications and readmissions.
Methods: 126 patients (64 OA; 62 LA) with
non-complicated appendicitis were studied
retrospectively. Data obtained: demographics,
CT-Scan use, surgery and operating room time,
days in hospital, complications, diet
commencement, pain medications doses,
pathology and readmission.
Results: Difference was found in total time
at OR (80.1± 29 minutes OA; 105.7± 22.6 LA)
and in surgery length (41± 28 OA; 48± 16 LA),
but not in hospital stay (2.1 days OA; 2.2 LA)
nor in in-hospital complication rate. Negative
appendectomy rate was 24% LA vs. 3% OA.
Readmission rate was higher in OA with 5%
wound infection rate.
Conclusion: Techniques are similar in mean
hospital stay, in-hospital complications, and pain
medication requirements. LA had a higher
negative appendectomy rate but of these patients
five had surgical diagnosis of acute appendicitis
and after appendectomy, signs and symptoms
resolved; and two patients had interval
appendectomies. As these patients were cured,
the real negative appendectomy rate is 13%, similar
to the historically accepted 16%. The other
eight patients had an adequate diagnosis. We are
concerned OA negative appendectomy rate is
only 3%; we wonder if surgeons are waiting too
long to operate patients. Readmission was higher
in OA (wound infection rate of 5%). Although it
takes more time in the OR, LA is as safe as OA,
has a low rate of complications and lower
readmission rate.
Key words: appendectomy, acute
appendicitis, laparoscopy
Appendectomy is the most common abdominal
surgery performed on an emergency basis 2 .
Since its introduction in the 1980’s, there has
been the controversy of whether the practice of
laparoscopic appendectomy (LA) compares or is
better than open appendectomy (OA). Contrary
to laparoscopic cholecystectomy which is
accepted as the standard of care to remove the
* From Universidad Central del Caribe, Bayamón, Puerto Rico, and ** Department of Surgery, HIMA-San Pablo Group, Caguas, PR. Address
reprints: Ramón K. Sotomayor, MD - 300 Avenida La Sierra, Apartado 61, San Juan, PR 00926. E-mail: . Presented at
the 58 th ACS Meeting Puerto Rico Chapter: February 21-23, 2008.
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
gallbladder, LA is not widely accepted by most
surgeons who remain skeptical of replacing the
relatively straightforward OA 3 . This is because
no definitive data shows the superiority of
laparoscopy for treating appendicitis and the
existence of contradictory evidence regarding this
issue.
Several studies report advantages of
laparoscopic over open appendectomy; others
claim there is no difference between the two, and
other state OA is better. In the past, randomized
trials were performed in order to determine if
there was an advantage to LA when compared
to OA. Frazee, et al. (1994) concluded that
patients who underwent LA had a shorter
duration of analgesic use and returned to full
activities sooner, reason they stated the
procedure of choice should be LA 4 .
On the other hand, in another randomized
study in 1995, Martin and his colleagues 5 found
LA was comparable to OA in terms of
complications, hospital stay, cost, return to normal
activities and work, but there was a greater
operative time. They concluded LA does not
confer any significant benefit over the OA for
routine appendectomies. A prospective
randomized double blind study 6 on 2005
concluded LA does not confer significant
advantage over OA outcomes, except for quality
of life scores, reason they recommend the choice
of the procedure should be based on surgeon’s
or patient’s preference.
One of the largest studies available, a meta
analysis performed in 2004 using a database of
43,757 patients who underwent appendectomy
for acute appendicitis, showed LA was associated
with shorter median length of hospital stay, lower
rate of infection, fewer gastrointestinal and
overall complications, and a higher rate of routine
discharge. 7 They concluded that laparoscopic
appendectomy had several advantages over open
appendectomy and should be performed.
Several studies have been performed but no
general consensus has been reached. An
extensive web search failed to provide published
studies that used data regarding the comparison
of these two approaches from hospitals in Puer-
Vol. 100 • Núm. 1 • Enero-Marzo 2008
21
to Rico. The goal of this study is to determine if
any of the two approaches, OA or LA, is more
beneficial for patients or if they are similar in
terms of total time in the operating room (OR),
length of surgery and of hospital stay, starting
diet, requirement of pain medications, in-hospital
complications and readmission rate.
MATERIAL & METHODS
A retrospective chart review of 126 patients
was performed of patients who underwent noncomplicated
appendectomies during February
2005 to June 2007 at HIMA San Pablo Group,
an acute care tertiary hospital in Caguas, PR.
Data was gathered from 64 cases of OA and 62
cases of LA. Exclusion criteria included patients
with perforation at the time of the procedure
confirmed by pathologic findings. Data obtained
included age of patient, sex, height, weight,
previous abdominal surgeries, CT-Scan used and
interpretation, time of surgery, number of days
in hospital, starting diet, use of pain medications,
in-hospital complications, final pathologic
findings and readmission to hospital.
OA was usually performed through a musclesplitting
incision in the right lower quadrant. LA
general steps included: preparing the patient with
general endo-tracheal anesthesia, placement of
foley catheter and nasogastric tube, then
placement of three ports (usually one 10mm port
and two 5mm ports). After full dissection of
appendix its base was ligated using PDS Endoloops
or stapler. It was divided, resected and then
retrieved using an Endo-bag.
Length of hospital stay was defined as the
difference in days since surgery day to discharge
home day. Total time at OR was defined as the
total time since patient entered the OR until
patient left the room. Total time of surgery was
defined as the total time from the first incision
to full closing of wound. The amount of pain
medications was described as the doses of pain
medications received after discharged from
recovery room until the discharge from hospital.
We used SPSS version 10.0 to perform our
statistical analysis that included Chi-square and
t-tests. A p < 0.05 was statistically significant.

22
RESULTS
A total of 126 patients, 64 OA and 62 LA,
were studied. Demographics were similar for both
groups (Table 1). Mean age for OA was 28±15 years
(range 2-68) and 30± 15 years (range 6-67) for LA.
Male to female ratio was similar for both groups
and within groups (1:0.68OA; 1:1.1LA). Mean
basal metabolic index (BMI) was also similar as OA
patients had an average BMI of 26± 7 and LA had
28± 6. There was no difference in previous abdominal
surgeries incidence as 22% of the patients in
the OA group had previous abdominal surgeries vs.
18% of LA patients. No difference was found
(p=0.14) in the frequency of CT scan use (70%OA
vs. 57%LA).
Difference was found in total time at OR
(p=0.008). OA had an average length of surgery of
80.1± 29 min. vs.105.7± 22.6 min. in LA. This is
an average 25 minute difference between the procedures.
Also we found a significant difference
(p=0.001) of 7 minutes in length of surgery as the
OA group had an average of 41± 28 vs. 48± 16 in
the LA group (Graph 1).
There was no difference (p=0.5) in mean hospital
stay (days). OA had an average of 2.14± 1.4
days of hospital stay vs. 2.19± 1 days in LA. Most
patients in both groups were discharged home
in the first 2 days after surgery. There was also
no difference in pain medication requirements
(p=0.3) and most patients required 1 or 2 doses
of pain medications after leaving recovery room.
Most patients in OA group started on clear liquids
diet (63%) while most patients in LA started
on full liquids diet (58%), but this seem to be related
to surgeon’s preference.
Total in-hospital complication rate was similar
(p=0.5) for both groups being fever the most com-
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
mon (17/21 OA and 18/21 LA). Other complications
in the OA group included one patient with
coffee ground vomiting and severe hiccups, one with
diarrhea, and one with persistent pain after eating.
On the other hand, in the LA group there was
one patient with blood loss anemia who was discharged
with no events, one with urinary retention
and one with diarrhea.
There were 15 cases (24%) of negative pathologies
in the LA group vs. 2 cases (3%) in the OA
group (Table 2). Historically this rate should be
around 16% 1 . Considering that there four patients
had surgical diagnosis of acute appendicitis, two
with interval appendectomies, and one with appendiceal
adhesions with fecalith, the real negative
appendectomy rate for the LA group is 13% (N=8)
that is similar to the expected rate.
Readmission rate was higher in OA with 71.4%
of all readmissions (5/7) with 2 cases of intestinal
obstruction and 3 cases of wound infection (5% of
patients) (Graph 2). One of the patients with intestinal
obstruction in the OA group was treated conservatively
with naso-gastric suction and IV fluids
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
but the other one required exploratory laparotomy
with enterolysis and enterorraphy. One of the readmissions
for the LA group included one patient
with abdominal swelling who was treated conservatively
and was discharged with no events and one
patient who presented one week after surgery with
intestinal obstruction and required re-exploration
with enterectomy and was discharged with no long
term adverse events.
DISCUSSION
There was difference in total time in the OR
and time of Surgery as we found an average OR
time of 80.1 min. OA vs. 105.7 min. in the LA
group. This is an average of 25 additional minutes
Vol. 100 • Núm. 1 • Enero-Marzo 2008
23
for the LA group that can be expected as there is
more instrumentation and preparation for
laparoscopic procedures. On the other hand, we
question the clinical relevance of the difference in
surgery time as we found an average of 48 minutes
OA vs. 41 minutes LA, and there’s an average difference
of only 7 minutes between the procedures.
Open and laparoscopic appendectomies are
similar in terms of mean hospital stay, in-hospital
complications, and pain medication requirements.
Contrary to other series that have reported up to
one day less of hospital stay 1, 7, 8, 9 , we did not found
such a difference between both techniques. We had
one LA patient with blood loss anemia as a complication.
This was a patient with a difficult retrocecal
appendix with final pathology of acute gangrenous
appendicitis. He was found to have hemoglobin
of 8g/dl the second post operative day. Patient
was discharged home with a hospital stay of
six days without need of blood transfusions or any
negative outcomes.
Negative appendectomy rate was higher in the
LA group and it was higher than the rate published
in other series as we had 24%. But we have to consider
that we had five patients with surgical diagnosis
of acute appendicitis who after appendectomy
the leukocytosis, abdominal pain, and other symptoms
resolved completely suggesting diagnosis could
have been early acute appendicitis or mesenteric
adenitis. Other two patients had interval appendectomies
and were discharged with no events. Taking

24
into account that these 7 patients had excellent recovery
after the appendectomy, the real negative
appendectomy rate is 13% (N=8) that is similar to
the historically accepted rate of 16% 1 . The other
eight patients with pre-op diagnosis of acute appendicitis
left OR with an adequate diagnosis as
laparoscopy allow an adequate exploration of the
abdominal cavity. The negative appendectomy rate
for the OA group was 3%. Published series quote
ranges between 0% to 35.5% with an average of
16% of negative appendec-tomies 1 . Flum (2001,
2002) 10, 11 states that classically, this rate of negative
appendectomies has been accepted by the clinical
community because the frequency of appendiceal
perforation is considered by many to be inversely
linked to the rate of negative appendectomies and
it has been suggested that a higher than zero (10%-
15%) rate of unnecessary appendectomy must be
tolerated to assure a low threshold for operation,
such that diagnostic delays that might result in perforation
are avoided. Frazee (1994) 4 states that as
the diagnostic accuracy increases so does the risk
of perforation. Another issue could be that surgeons
want to make sure diagnosis is accurate before submitting
the patient to an open procedure which is
usually made through a small Rocky-Davis incision
that makes difficult to explore other organs. Sometimes
when a surgeon encounters a negative appendix,
extension of the incision is necessary.
Other series have reported up to a 7% of intraabdominal
abscess rate after LA 1, 7 . In contrast to
this, no intra-abdominal abscesses were reported
in this series. We attribute this to the management
of appendiceal stump. Appendiceal stump was almost
routinely managed with polydioxanone endoloops,
two at the base and one distally. In several
cases of thickened base of appendix it was divided
flush with the cecum using the endoscopic stapler.
Leakage after this was negative in our patients and
is reflected in the negative intra-abdominal abscess
rate. In addition to that, no patients were admitted
with stump appendicitis. Also, we did not found
patients who had to convert to open procedure.
The readmission rate was lower in the LA
group. The wound infection rate for the OA was
higher than that of the LA group as 5% of OA patients
had a wound infection (3/64) that required
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
readmission vs. 0% in LA group. This is because
no contamination of incision is made while retrieving
the specimen from the abdomen in the LA procedure
vs. the contamination that occurs with OA.
These three patients were drained at the emergency
room or bedside and treated with intravenous antibiotics.
One complication after LA includes the case
of a patient with multiple previous abdominal surgeries
who develop bowel obstruction one week
after surgery for which readmission with re-exploration
and enterectomy was necessary. Patient was
discharged with no adverse long term outcomes.
Two patients had bowel obstruction after OA and
were readmitted. One was treated with nasogastric
tube suction and IV fluids while the other one required
exploratory laparotomy with enterolysis and
enterorraphy. Both were discharged with no long
term negative outcomes.
Study limitations include the fact that most of
the appendectomies were performed using the open
approach making it necessary to gather records
dated from 2005. Another limitation is the sample
size, as a small sample will yield a greater statistical
error. Also a retrospective study depends on the
accuracy of medical record information and how
well documented it is. In addition to that, most
wound infections are seen in the private office and
are not documented in the same medical record.
Another limitation is the fact that we could not evaluate
other aspects after surgery such as quality of
life in terms of time required to return to normal
daily activities or to work.
Although it takes more time in the operating
room, LA is equally as safe as OA; it also has a low
rate of complications and has a significantly lower
readmission rate. LA is still underrepresented (e.g.
11% of all appendectomies in 2005) and more cases
are required in order to compare both techniques
with more precision. There are other parameters
not measured in this study such as time required by
patients to return to normal activities and work or
complications treated as outpatients that could help
differentiate the outcomes of these procedures.
Further studies including these data and a greater
sample are needed in order to determine which
procedure favors patients the most.
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Acknowledgements:
The authors thank Professor Iris Parrilla for
contribution in statistical analysis and HIMA hospital
record room personal for their help.
Resumen
Introducción/Objetivo: Una bús-queda
extensa en Internet demostró que no existen
estudios de Puerto Rico comparando apendectomía
abierta (AA) y apendectomía laparoscópica para el
tratamiento de apendicitis aguda. Nuestra meta es
comparar estas dos técnicas en términos de tiempo
en la sala de operaciones, tiempo de cirugía, estadía
en el hospital, requerimientos de analgésicos,
compli-caciones y re- admisiones al hospital.
Métodos: Se revisaron expedientes de 126
pacientes con diagnóstico de apendicitis aguda. Se
recopiló información demográfica, uso de
tomografía com-putarizada (CT), tiempo de cirugía,
tiempo total en la sala de operaciones, tiempo para
empezar dieta, uso de analgésicos, patología y tasas
de re admisión.
Resultados: Se encontró una diferencia en el
tiempo total en sala de operaciones (80.1 ± 29
minutos AA; 105.7 ± 22.6 AL) y en el tiempo de
cirugía (41 ± 28 minutos AA; 48 ± 16 min. AL),
pero no en el tiempo de estadía en el hospital (2.1
días AA; 2.2 AL), ni hubo diferencia en la tasa de
Vol. 100 • Núm. 1 • Enero-Marzo 2008
25
complicaciones durante la estadía en el hospital.
La tasa de apendectomía negativa fue de 24 % en
apendectomía laparoscópica vs. 3% en
apendectomía abierta. Las readmisiones fueron
mayores en apendectomía abierta que en casos
laparoscópicos al igual que la tasa de infecciones
de herida.
Conclusiones: Las técnicas son similares en
términos de estadía en el hospital, complicaciones
y requerimientos de analgésicos. AL tuvo una tasa
más alta de apendectomías negativas pero cinco de
estos pacientes tuvieron un diagnóstico quirúrgico
de apendicitis y sus síntomas y signos resolvieron
luego de apendectomías. Excluyendo estos cinco
casos, la tasa real de apéndices negativas es de 13
%, similar la tasa histórica de alrededor de 16 %.
En los demás pacientes de apendectomías
laparoscópicas que resultaron negativas (8) se
obtuvo un diagnóstico certero y adecuado durante
la cirugía. Es preocupante la tasa de apendectomías
negativas en apendectomías abiertas de solo 3 %;
lo cual trae la pregunta de si se está esperando
demasiado tiempo para operar. Las readmisiones e
infecciones de herida fueron más altas en
apendectomías abiertas. Aunque el tiempo de
cirugía es más largo en cirugía laparoscópica, AL
es una operación segura con baja probabilidad de
complicaciones y re admisión al hospital.
REFERENCES
1. Hung, S. Appendectomy. In Souba, W., Fink, M. ACS Surgery. 2005 Ed., New York, WebMD, 2005:656-664.
2. Paulson, Erik, Kalady, M., Pappas, T.: “Suspected Appendicitis”. New England Journal of Medicine. 2003; 348; 3:236-243.
3. Aziz, O., Athanasiou, T., Tekkis, P., et al.: “Laparoscopic versus Open Appendectomy in Children, a meta-analysis”. Annals of Surgery.
2006; 243:17-27.
4. Frazee, R., Roberts, J., Symmonds, R., et al.: “A Prospective Randomized Trial Comparing Open versus Laparoscopic Appendectomy”.
Annals of Surgery. 1994; 219:725-731.
5. Martin, L., Puente, I., Sosa, J., et al.: “Open versus Laparoscopic Appendectomy”. Annals of Surgery. 1995; 222:256-262.
6. Katkhouda, N., Mason, R., Towfigh, S., et al.: “Laparoscopic versus Open Appendectomy, a prospective randomized double-blind
study”. Annals of Surgery. 2005; 242:439-450.
7. Guller, U., Hervey, S., Purves, H., et al.: “Laparoscopic Versus Open Appendectomy, Outcomes Comparison Based on a Large
Administrative database”. Annals of Surgery. 2004; 239:43-52.
8. Long, K., Bannon, M., Zietlow, S., et al.: “A prospective randomized comparison of laparoscopic appendectomy with open appendectomy”.
Surgery. 2001; 129:390-400.
9. Nguyen, NT, Zainabadi, K., Mavandadi, S., et al.: “Trends in utilization and outcomes of laparoscopic versus open appendectomy”.
American Journal of Surgery. 2004; 188(6):813-820.
10. Flum DR, Koepsell T. The clinical and economic correlates of misdiagnosed appendicitis: nationwide analysis. Arch Surg.2002; 137 :799
–804.
11. Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? A population-based analysis.
JAMA.2001; 286 :1748 –1753.

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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
ANUNCIO PÚBLICO • AMPR
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Vol. 100 • Núm. 1 • Enero-Marzo 2008
27
Artículos Originales • Original Articles
MINIMALLY INVASIVE PARATHYROIDECTOMY AS
TREATMENT FOR PRIMARY HYPERPARATHYROIDISM
ABSTRACT
Background: Current techniques for
management of primary hyperpara-thyroidism
(pHPT) rely on preoperative localization studies in
order to perform a direct exploration of the neck.
This case series reports the results of minimally
invasive parathyroidectomy (MIP) performed in
twenty-two consecutive pHPT patients with
suspected parathyroid adenoma.
Methods: All patients with symptomatic pHPT
and or aberrant biochemical markers underwent preoperative
evaluation including calcium and
parathyroid hormone (PTH) serum levels, and a Tc-
99 Sestamibi (MIBI) scintigraphy scan. The day of
surgery Tc-99 MIBI was administered intravenously
to localize diseased parathyroid glands. Within the
next two hours after administration of IV contrast a
gamma radiation detection device was applied over
the neck to detect areas of prominent radiation
gradient that served as landmarks during surgery.
All removed tissue was again tested with the gamma
radiation probe and sent for frozen sections to
confirm parathyroid gland tissue. Serum calcium
levels were measured immediately after surgery, 24
hours, and 3 days later at an outpatient visit.
Results: Twenty-two patients with symptomatic
hypercalcemia (6 M, 16 F), mean age of 63 years
(Range 35 to 87), completed pre-operative
Sestamibi scintigraphy and follow up evaluations.
Mean pre-operative calcium and PTH levels were
By: Laureano A. Giraldez-Rodriguez, MD.* and Laureano J. Giraldez-Casasnovas, MD.**
11.3 mg/dL and 194.2 pg/mL, respectively. Preoperative
Sestamibi scintigraphy were negative in
four (18%) and positive in 18 (82%) patients.
Parathyroid adenoma was confirmed by frozen sections
in all patients. The mean operative time was
approximately 32 minutes except in 3 cases which
required combined surgical procedures. There were
no intra-operative complications while minor wound
swelling was the only postoperative complication
reported. All patients exhibited decreased serum
calcium levels with resolution of symptoms within a
week, and resumed a normal lifestyle.
Conclusions: MIP using preoperative Tc-99
MIBI scan is an excellent and safe treatment for
patients in pHPT patients with a suspected
parathyroid adenoma. In our experience this
technique avoids the potential complications of
extensive neck exploration, reduces operative time,
and has a high patient acceptance.
Key words: minimally, invasive, parathyroidectomy,
primary hyperpara-thyroidism
The standard treatment for patients with hypercalcemia
due to primary hyperpara-thyroidism
(pHPT) is surgical removal through bilateral exploration
of the neck. Current techniques for surgical
manage-ment of primary pHPT rely on preoperative
localization studies in order to perform a direct
*PGY-1 Resident, Department of Otolaryngology & Head and Neck Surgery, University of Puerto Rico School of Medicine; Rio Piedras, Puerto
Rico, and ** Head and Neck Surgeon, Hospital Auxilio Mutuo, San Juan, Puerto Rico. Address Reprints to: Laureano A. Giraldez Rodriguez, MD,
B5 Calle Tabonuco, Ste 216 PMB 299 Guaynabo, PR 00968. Email:laureano_giraldez@hotmail.com. Poster presented at the 58th Annual Meeting
of the American College of Surgeons, Puerto Rico Chapter, February 22, 2008, La Concha Hotel, San Juan, Puerto Rico.

28
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Figure 1: Transverse Neck Incision showing the
parathyroid adenoma Figure 2: Gamma Radiation detection device.
exploration of the neck. This case series reports
the results of minimally invasive parathyroidectomy
(MIP) performed in twenty-two consecutive pHPT
patients with suspected parathyroid adenoma using a
gamma radiation detection device (see Fig. 1).
MATERIAL AND METHODS
Twenty-two patients were operated between 2005
and 2007 using the minimally invasive technique. The
pre-operative work up included calcium and
parathyroid hormone (PTH) levels, as well as Sestamibi
scintigraphy scan on all patients. The day of surgery
the patient was first sent to the nuclear medicine
department were a dose of preoperative Technetium-
99m Sestamibi 30 millicurie injection was administered
intravenously. The patient was then operated within
two hours of the injection.
All patients were given general anesthesia
except for one patient who was given intravenous
sedation and the area of the adenoma was explored
using local anesthesia.
A pg/mL (gamma probe) was applied directly
to the neck before surgery to detect the exact area
where the radiation gradient was more prominent.
This identified the approximate location of the
adenoma. A 2 to 2.5 cm incision was made at the
midline in the anterior lower neck (Image 2). The
sub-platysmal plane was developed and a midline
dissection approach was used to reach the thyroid
isthmus. The thyroid isthmus and the gland were
identified. The gamma probe was inserted through
the neck incision and the area of highest radiation
gradient was sought again. The exploration for the
parathyroid adenoma was done until identification
was obtained with visual confirmation. In the
process, the recurrent laryngeal nerve was identified.
The vascular pedicle of the adenoma was controlled
with Surgi-Clips and the diseased gland removed.
The gamma probe was applied to the removed glandular
tissue on the operating room instrument table
to confirm the high radiation gradient. A frozen
section was performed on all removed glands and
it was confirmed to be parathyroid tissue. The
surgical wound was closed in layers in the usual
manner. Post-operative calcium levels were taken
at the recovery room and twice thereafter in a
twenty four-hour period. Calcium levels were
repeated at the first post-operative outpatient visit
three days later in all patients. Our reported value
of post-operative calcium corresponds to the first
serum calcium sample taken after surgery.
RESULTS
Twenty-two patients were chosen for the case
series based on the minimally invasive surgical technique
chosen. Six were male (27%) and 16 were
female (83%). The mean age for the patients was
62.3 years and the range was 35 to 87 years. Mean
age for males was 61.5 years old and for females
was 62.6 years old. Mean laboratory values were
the following: pre-operative serum calcium levels
were 11.3 mg/dL (Normal value 8.5 mg/dL – 10.3
mg/dL); pre-operative serum PTH 194.2 (Normal
value: 10-60 pg/ml); post-operative serum calcium
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
levels 8.68 mg/dL (Normal value: 8.5 mg/dL – 10.3
mg/dL). (Table 1)
The most common presenting symptom for all
patients was hypertension, followed by musculoskeletal
pain, nephrolithiasis and osteoporosis.
The twenty-two patients were submitted to the
same procedure. Pre-operative Sestamibi Tc-99
scintigraphy was done in 100% of the patients. The
scan was negative in 4 patients (18%) and positive
in 18 patients (82%).
In the present series all patients were operated
under general anesthesia, except one who was operated
under IV sedation and local anesthesia. The
average operating time was 32 minutes, with operative
length ranging from 16 to 60 minutes. Intra-operative
usage of the Sestamibi Technetium-
99 gamma probe was used in all patients for localization
of the parathyroid adenoma with success. A
more than double increase from the baseline of the
gradient shown in the probe monitor was used as
the standard to imply the presence of the adenoma
at that site. Frozen section pathology revealed the
presence of parathyroid tissue in all 22 patients.
Table 1: General Patient Data
Serum Post-Op Surgery
Sestamibi PTH Pre-Op Ca (24hr) Time
Sex Age Scan (pg/mL) Ca (mg/dl) (mg/dL) (min)
M 42 Positive 629 13.2 8.4 45
M 58 Negative 347 12.2 9.2 20
M 87 Positive 102 11.7 8.7 45
F 78 Positive 527 12.5 8.4 20
M 35 Negative 112 12.5 8.5 25
F 66 Positive 275 10 9 25
M 71 Positive 150 10.2 7.7 40
F 38 Positive 128 10.7 8.5 20
F 75 Positive 142 10.8 7.5 40
F 67 Positive 109 10.8 9 23
F 40 Positive 85 12 9.3 40
F 72 Negative 99 10.7 9.8 60
F 50 Negative 110 11 8.2 17
F 73 Positive 191 10.5 7.6 22
F 54 Positive 284 13 9.2 27
M 76 Positive 158 11.1 9.4 60
F 88 Positive 88 11.1 9.5 20
F 72 Positive 151 10.4 8.6 25
F 43 Positive 82 11.3 8.6 25
F 67 Positive 156 11.2 7.6 60
F 61 Positive 174 10.7 8.9 20
F 58 Positive 174 11.3 9.5 16
Vol. 100 • Núm. 1 • Enero-Marzo 2008
29
There were three cases of concomitant surgery. The
first was combined with a hemi-thyroidectomy; the
second was combined with a thyroidectomy as well
due to the fact that the adenoma was found embedded
inside the thyroid tissue. The third patient also
had a Zenker diverticulum’s that was excised. In this
particular patient the incision had to be extended
to encompass the resection of the other pathology.
Multiglandular disease was encountered in two out
of twenty two patients (9%). The procedure included
the other side of the neck in both of these patients.
The presence of multi-glandular disease had been
confirmed on the Sestamibi scintigraphy done preoperatively
in both cases. All the patients in the
study returned to normal serum calcium levels in
the first twenty-four hours after surgery. There were
some sporadic cases of symptomatic hypo-calcemia
that were managed immediately. These episodes
were most common on the second to third postoperative
day when the patient was discharged from
the hospital. The most common symptoms of postoperative
hypocalcemia were perioral, peripheral
extremity paresthesias and dizziness. All patients
were observed in the hospital for a period of twentyfour
hours and were discharged home the next day.
There was one exception, the patient operated
under IV sedation and local anesthesia was sent
home the same day of surgery after being observed
in the recovery ward for two hours. Average hospital
stay was one day. Symptoms and signs of hypercalcemia
improved immediately and to the last
follow-up visit there have been no patients with recurrence
of hypercalcemia.
DISCUSSION
Twenty-two patients underwent parathyroidectomy
because it was indicated based on their symptoms
or due to aberrant biochemical parameters.
The 2002 NIH Consensus Conference on Hyperparathyroidism
Recommendations for Surgery established
the following indications for parathyroidectomy:
1) Typical bone, renal, gastrointestinal, or
neuromuscular symptom; life-threatening hypercalcemia.
2) Calcium level > 11.2-12.0 mg/dL (> 2.9-
3.0 mmol/L). 3) Urine calcium level > 400 mg/d
(10 mmol/d); renal stones. 4) BMD 2 SD’s

30
nine clearance > 30%. 6) Age < 50 years old. 7)
Patient request. 8) Calcium level > 1 mg/dL (0.25
mol/L) above normal for each laboratory. 9) Bone Mass
Density T score < 2.5 at any sites (This last corresponds
to the WHO definition of osteoporosis.) (1)
The standard treatment for patients with
primary hypercalcemia due to parathyroid
adenomas is surgical removal through bilateral
exploration of the neck. In the past seventeen years
of this single surgeon experience the approach for
removal of parathyroid adenomas has significantly
evolved. The success of bilateral neck exploration
without the aid of localizing techniques has been
well documented in the literature with rate of almost
95% cure since the early eighties in some series (2,
3). This was the standard procedure used for many
years since the beginning of this practice. Yet, we
sought to find ways to render the procedure less
morbid in light of the fact that surgical intrusion of
the whole neck is utilized for finding a single
adenoma in the majority of cases. Hence, a less
invasive procedure had to be developed for the
benefit of the patient. Set aside, the incidence of
multiglandular disease documented in the literature
and in various case series is around 10 to 20% (4,
5). In our experience the presence of multiglandular
disease (9%) was comparable to what has been
reported before.
The advent of intraoperative methylene blue
injection to aid in the direct visualization of
parathyroid adenomas changed our perspectives on
the necessity of bilateral neck explorations. The
procedure consisted on injecting a discrete dose of
methylene blue (amount) prior to operation. Unilateral
neck exploration would be done and the
presence of adenoma was confirmed when the
adenoma was directly visualized by its bluish
appearance. We began using this method during
the mid to late 1990’s. Nonetheless, intraoperative
usage of methylene blue decreased the oxygen
saturation of the patient intraoperatively. Although,
this effect was known to be false –methylene blue
absorbs light at 666 nm, whereas the pulse oximeter
sensor absorbs light at 660 nm to 910 nm, causing
an interference with the sensor and it appears the
patient is desaturating- it still was a controversial
practice from our point of view (6). We ceased usage
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
of methylene blue in 2001 and began seeking
alternatives for intraoperative localization that would
be cost effective for the patient and at the same
time would minimize intraoperative and
postoperative risks.
Between 2001 and late 2004 this group
mainly relied on Sestamibi scintigraphy for the
localization of suspected parathyroid adenomas.
If a scintigraphy was positive then the surgeon
proceeded to operate in the area where the hot
spot was evident on the film. Bilateral neck explorations
were solely indicated for patients
whose scintigraphy was inconclusive or negative,
but the patient still had signs and symptoms of
primary hyperparathyroidism and abnormal laboratory
parameters (hyper-calcemia, hypophosphatemia
and elevated serum PTH levels).
We introduced the use of the gamma probe
combined with Sestamibi scintigraphy to our
practice in the beginning of the year 2005. This
technique, which was documented in the literature
since 1995, had various advantages. It reduced the
surgical incision of the anterior neck by 50%. Before
this we would use a five to 7 cm incision for bilateral
and unilateral neck explorations, because there
was always a question of what the extent of the
surgery would be. The next benefit it added was
the decrease in operating time for this type of
surgery, which meant less time under anesthesia.
Likewise, there was a reduction in the morbidity of
the surgery. Access to the diseased gland was
directed to a specific point in the presence of uniglandular
or multiglandular disease. All these variables
led inevitably to decreased length of hospital
stay that in turn translates to greater costeffectiveness
for the patient and the hospital. These
factors are stressed in various documented series
(8, 9). The cure rate for our method has been 100%
using this technique comparable to other series that
have reported 98%, 97.8% and 96%, and that have
a significantly higher number of patients (5, 10, 11).
The only docu-mented adverse effect of Sestamibi
in the literature is the development of erythema
multiforme in one patient (12).
The introduction of this method also set the stage
for the usage of local anesthesia and IV sedation in
the excision of a neck adenoma. This method for
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
anesthesia has gained wide acceptance in the United
States since the late 1990’s. The Mayo Clinic group,
for example, reported 263 patients between 1998 and
2004 who underwent parathyroidectomy with IV
sedation and local anesthesia (1). In early 2008 we
performed the first case of parathy-roidectomy with
IV sedation and local anesthesia in Puerto Rico. The
patient was discharged home on the same day of
surgery after being monitored for two hours in the
recovery room.
There are two current trends in the effective
localization and removal of parathyroid adenomas. The
first one is the technique we use with our patients,
which involves radio-guided localization of the diseased
gland. Yet, there is a new movement towards the use
of intraoperative parathyroid hormone measurements.
This technique consists of doing the same
preoperative workup as for the patients mentioned
above, targeting the adenoma with preoperative
imaging, removing the diseased gland and obtaining
an intraoperative serum intact PTH measurement
(iPTH). A decrease of 50% from the initial serum
PTH concentration means the success of the
surgery. Therefore, there is objective confirmation
during the surgery that the parathyroid gland has
been removed. There is current controversy as to
whether one procedure is more effective than the
other. Although, we already have the necessary tools
for intraoperative PTH measurement during surgery
we have not used them. There are two primary
reasons for this. In view of our success rate with
the gamma probe, even in the presence of multiglandular
disease, we do not believe that the patient
will necessarily benefit from intraoperative PTH
monitoring. Second, there is the problem of the
added cost of intraoperative intact PTH testing to
our patients. In one series using the gamma probe
method translated in an average savings of $4,000
US dollars compared to other procedures (9).
Minimally invasive parathyroidectomy using the
gamma probe is an excellent and safe treatment
for patients with primary hyperparathyroidism and
suspected adenoma. This technique avoids the
morbidity of bilateral neck exploration, reduces
operative time, and has a high patient acceptance.
The initial success that we have had has led us to
use it as a standard for parathyroidectomies.
Vol. 100 • Núm. 1 • Enero-Marzo 2008
31
RESUMEN
Las técnicas de manejo actual para el manejo
de hiperparatiroidismo primario dependen de
estudios de localización preoperatorio para llevar
a cabo una cirugía exploratoria del cuello.
Esta serie de casos informa los resultados de
paratiroidectomia minimamente invasiva utilizada
en veintidós pacientes con hiperparatiroidismo
primario y sospecha de adenoma.
Todos los pacientes con hiperpara-tiroidismo
sintomático o laboratorios en sangre alterados se
les practicaron una evaluación preoperatorio que
incluía niveles de calcio, hormona paratiroidea y
una cintigrafía de Tc-99 Sestamibi. El día de la cirugía
se administro una cantidad del contraste Tc-
99 Sestamibi para localizar la glándula enferma
intra-operatoriamente. En el periodo inmediato de
la inyección un aparato para detectar radiación
gamma se aplicó al cuello anterior para determinar
el área de radiación más prominente hacia donde
seria dirigida la cirugía. Todo tejido removido durante
la cirugía seria probado nuevamente con el
detector a ver si este tejido resultaba en un gradiente
mayor que aquello detectado en el cuello. A todos
los pacientes se les hizo histología congelada inmediata
para confirmar que el tejido removido fuera
glandular. Los niveles de calcio en suero fueron
medidos a las 24 horas y tres días después en una
visita a la oficina.
Veintidós pacientes con hipercalcemia
sintomática con una edad media de 63 años (entre
las edades de 35 a 87 años) se sometieron a
cintigrafía preoperatoria y laboratorios. El calcio
y la PTH promedio antes de operarse fueron
de 11.3 mg/dL y 194.2 pg/mL respectivamente.
En cuatro pacientes (18%) la cintigrafía fue
negativa y en dieciocho pacientes fue (82%) fue
positiva. El adenoma de paratiroides fue confirmado
con histología inmediata en todos los pacientes.
El tiempo operatorio promedio fue de
32 minutos excepto en tres pacientes en los que
se llevo a cabo otro procedimiento simultáneamente
(hemitiroi-dectomia, etc.). No hubo complicaciones
intra-operatorias. Todos los pacientes
exhibieron una disminución de los niveles de
calcio inmediatamente al igual que resolución de
los síntomas asociados al adenoma.

32
La paratirodectomia minimamente invasiva usando
el aparato de captación de radiación para localizar
la glándula es una alternativa excelente y segura en el
tratamiento quirúrgico de hiperparatiroidismo prima-
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
rio. En nuestra experiencia esta técnica evita la necesidad
de tener que explorar el cuello para localizar un
adenoma, disminuye el tiempo intraoperatorio y tiene
muy buena aceptación por el paciente.
REFERENCES
1. Grant CS, Thompson G. Primary hyperparathyroidism surgical management since the introduction of the minimally invasive
parathyroidectomy. Mayo Clinic Experience Arch. Surg. 2005; 140: 472-479
2. Van Heerden JA, Grant CS Surgical treatment of primary hyperparathyroidism: an institutional perspective. World J Surg. 1991; 15:
688-692
3. Kaplan EL, Yashiro T Salti G. Primary Hyperparathyroidism in the 1990s Ann Surg. 1992; 215:300-317
4. Nussbaum SR, Thompson AR, Hutcheson KA, et al. Intraoperative measurement of parathyroid hormone in the surgical management of
hyperparathyroidism. Surgery 1988; 104:1121-1127
5. Gil-Cardenas A, Gamino R, et al. Is intraoperative parathyroid hormone assay mandatory for the success of targeted parathyroidecomty?
J Am Coll Surg Vol. 204, No.2, February 2007
6. Pinero A, Illana J, Effect of Oximetry on Dyes Used for Sentinel Lymph Node Biopsy Arch Surg. 2004; 139:1204-1207
7. Martinez DA, King DR, et al. Intraoperative identification of parathyroid gland pathology: a new approach. J Pediatr Surg. 1995;
30(9):1306-9.
8. Goldstein RE, Blevins L, et al. Effect of minimally invasive radioguided parathyroidectomy on efficacy, length-of-stay, and costs in the
management of primary hyperparathyroidism. Ann Surg. 2000; 231(5):732-42
9. Hutchinson JR, Yandell DW, et al. Three-year financial analysis of radio-guided parathyroidectomy. Am Surg. 2004; 70(12):1112-5.
10. Caudle AS, Brier SE, et al. Experienced radio-guided surgery teams can successfully perform minimally invasive radio-guided
parathyroidectomy without intraoperative parathyroid hormone assays. Am Surg. 2006; 72(9): 785-9.
11. Shabtai M, Benhaim M, et al. 140 consecutive cases of minimally invasive, radio-guided parathyroidectomy, lessons learned and longterm
results. Surg Endosc. 2003; 17(5):688-91.
12. Thomson LE, Allman KC Eryhtema multiforme reaction to sestamibi. J Nucl Med 2001; 42(3): 534
Hazte socio de
la Asociación Médica de Puerto Rico
Ayudanos a mejorar el escenario
médico hospitalario en Puerto Rico
Vol. 100 • Núm. 1 • Enero-Marzo 2008

34
Artículos Originales • Original Articles
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
PARATHYROID SURGERY WITHOUT INSTANT PTH
OR RADIOGUIDED SESTAMIBI SCAN
By: E. Vázquez-Quintana, MD; FACS. and D.E. Vázquez-Torres, MD*
Abstract
Background: Radioguided Sestamibi scan and
instant PTH (iPTH) are being used in minimally
invasive parathyroid surgery (MIP). Experienced
surgeons cure over 90-95% of the patients with
primary hyperparathyroidism.
Purpose/Method: To study the surgical results
in treating hyperparathyroidism in a for profit
community hospital lacking both iPTH and
radioguided Sestamibi scan, we reviewed the
patients operated from November 1, 2005 to
October 31, 2006.
Results: The study comprised 56 patients: 52
with primary hyper-parathyroidism, three with
secondary hyperparathyroidism and one with
tertiary hyperparathyroidism. The only localizing
test utilized pre-operatively was the Sestamibi Scan.
PTH was measured immediately before and after
surgery but the results was received seven to ten
days later. The affected glands were removed in all
patients. Fifty of 52 (96%) of the patients with
primary hyperparathyroidism, the three patients
with secondary hyper-parathyroidism and the
patient with tertiary hyperparathyroidism are
normocalcemic with normal PTH levels. Two
patients have persistent mild hypercalcemia.
Associated conditions were three papillary carcinoma
of the thyroid, three multinodular goiter, four
had a single thyroid nodule, one had an adrenal
tumor and three were reoperations.
Conclusion: Parathyroid surgery can be done
safely and effectively in community hospitals without
the utilization of radioguided Sestamibi scan and
iPTH measurement.
Key words: parathyroid, surgery, instant PTH,
Sestamibi scan
Historically, it has been known that experienced
head and neck surgeons cure 90-95% of patients
with primary hyperparathyroidism at the time of
initial operation. Initially, there were no localizing
tests to aid the surgeon to identify the diseased
glands. The patients were referred by the endocrinologist
who made the diagnosis by excluding other
diseases producing hypercalcemia. The PTH test
was not available and all four parathyroid glands
had to be identified intraoperatively. Eventually,
sonography, CT scan, MRI and thallium-technetium
substraction scans were introduced. None of these
studies were found to be superior to the results already
obtained surgically. The best localizing test,
the Sestamibi parathyroid scan, was introduced in
1992. 1 SPECT (Single Proton Emission Computerized
Tomography), a variant of the Sestamibi scan,
has also been used.
In recent years, the use of radioguided Sestamibi
scan during the operation and instant PTH (iPTH)
sampling have been utilized for Minimally Invasive
* From the Department of Surgery, Pavia Hospital, San Juan, PR. Address Reprints: E. Vazquez Quintana, MD - Pavía Street, Suite 301, San Juan,
P. R. 00909. E-mail
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Table 1: Types of Hyperparathyroidism
Total number of patients 56
Primary hyperparathyroidism 52
Single Adenoma 51
Two Adenomas 1
Secondary hyperparathyroidism 3
Tertiary hyperparathyroidism 1
Parathyroid (MIP) surgery. 2 The radioguided
Sestamibi Scan is recommended to localize the affected
parathyroid gland and the iPTH is used to
reassure the surgeon that the operation is already
completed and no additional exploration is needed.
Some authors claim that the use of iPTH improves
the success rate of surgery in hyperparathyroidism.
3,4 Other groups have questioned the use
of iPTH measure-ments in the decision making process
during the operation. 5,6 But the availability of
these two latter techniques is not ubiquitous in all
hospitals. Challenging the need to use these two
modalities we conducted the present study.
METHODS
All patients operated for hyperpara-thyroidism
from November 1, 2005 to October 31, 2006 in a
private for profit community hospital comprise the
study group. A total of 56 patients had surgery
during that period of time. Frozen section was used
in all patients to confirm the removal of parathyroid
tissue. Samples for calcium, phosphorus and PTHintact
were drawn immediately before surgery and
30 minutes after completion of the operation. It
took from seven to ten days to get the PTH intact
measurements, so the results had no influence on
the decision by the operative surgeon. The only
localizing test utilized preoperatively was the
Sestamibi parathyroid scan.
RESULTS
General anesthesia was used in all patients. A
small 2-3 cm. collar incision was utilized and the
diseased gland was approached. A total of 52
patients had primary hyperparathyroidism, 51 had
a single adenoma, and one had two adenomas. No
patient had parathyroid hyperplasia or carcinoma.
There were three patients with secondary
hyperparathyroidism and one had tertiary
Vol. 100 • Núm. 1 • Enero-Marzo 2008
Table 2: Associated conditions:
Papillary carcinoma of thyroid 3
Multinodular goiter 3
Single thyroid nodule 4
Adrenal tumor 1
Re-operations 3
35
hyperparathyroidism. (See table 1). Another 11
patients had associated conditions; three had
papillary carcinoma of the thyroid, three had
multinodular goiter, four had a single thyroid nodule,
one had an adrenal tumor and three were
reoperations. (See table 2). The average operative
time for the initial operation in patients with primary
hyperpara-thyroidism was 30 minutes. After
removal of the affected gland or glands the PTHintact
decreased to less that 50% of the preoperative
levels in all except four patients. In those patients
the PTH levels ranged from 88 to181 pg/ml.
Nonetheless, the calcium has remained normal in
two. One patient continued with hypercalcemia
although review of the pathology confirmed that
an adenoma of the parathyroid had been removed.
The other patient with a positive Sestamibi scan
removal of the affected gland was interpreted as
normal parathyroid tissue.
All patients with primary hyperparathyroidism,
except three, were discharged on the following day.
Three patients developed hypocalcemia requiring
intravenous calcium replacement. Two of these
patients had severe hyperparathyroidism with
osteopenia and large adenomas, the other also had
a total thyroidectomy for multinodular goiter. The
secondary and tertiary hyperparathyroidism patients
remained hospitalized until the calcium stabilized.
Two patients with primary and one with
secondary hyperparathyroidism were reoperations.
One of these patients had a retrosternal mediastinal
adenoma. The latter was missed by the former
surgeon although it was seen on a Sestamibi
parathyroid scan. (See figure 1).
DISCUSSION
Since the 1960’s, the senior author has gone
through all the stages in the history of parathyroid
surgery. Initially, there were no tests to help in
localizing the parathyroid glands, therefore,

36
Figure 1: Sestamibi scan showing a
Retrosternal parathyroid adenoma
exploration and visual identification of all the glands
was required. In an article, “Localization of
Parathyroid Lesions: Blind Study for Surgeons”
published in 1989, 7 the experience of the surgeon
was tested against the use of CT and thallium-
Figure 2: SPECT scan with a marker at the
sternal notch showing the exact location of the
ectopic parathyroid adenoma.
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Table 3: Sestamibi parathyroid scan
Positive 35
Negative 8
Equivocal 9
technetium substraction scans. The senior author
was able to localize the abnormal parathyroid gland
in all 15 hyperparathyroid patients. The CT scan
failed to identify the adenoma in 73% of the cases.
The thallium-technetium substraction scan missed
almost 50% of the diseased glands.
The sensitivity and specificity of the localizing
tests is variable. The best reported results with
Sestamibi parathyroid scans show a sensitivity and
specificity of over 95%. But that is not the
experience in other centers. The test depends on
the number of oxyphil cells of the parathyroid
adenomas. Patients with negative Sestamibi scans
have lower cure rates. 8
The Sestamibi parathyroid scan, the only
localizing test done preoperatively in the present
series, was correct in localizing the affected gland
in 35 of the 52 patients (67.3%). It was completely
negative in eight and equivocal in nine patients (See
Table 3). A SPECT was used with a marker to determine
how low in the retrosternal region the
adenoma was in a patient with persistent
hyperparathyroidism (See figure 2). This gland was
retrieved through the neck incision. Of a total of
52 patients with primary hyperparathyroidism the
affected glands were identified and removed in all
patients at the initial operation, only two patients
remained hypercalcemic, for a success rate of 96%
without the use of radioguided Sestamibi scan or
iPTH measurements.
In Puerto Rico, none of our 52 hospitals have
laboratories capable of doing iPTH. Only a single
institution is using radioguided Sestamibi scans. In
the United States of a total of 5,759 hospitals only
around 92 utilize iPTH testing during parathyroid
operations. 9, 10 The tendency has been to do
specialized tests in a central laboratory.
Quan-Yang Dhu 6 questioned the use of instant
PTH testing to predict cure in Minimally Invasive
Parathyroidectomy. PTH monitoring is less accurate
in multiple glandular disease (double adenomas or
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
hyperplasia). The failure rate for PTH testing is from
2-5%. The test works best when it is less needed.
Peter Stalberg et al 5 have also tested
intraoperative parathyroid hormone measurement
in the decision-making process during minimally
invasive parathyroidectomy. One hundred patients
with positive Sestamibi scans underwent MIP.
Ninety-eight patients were cured by MIP, two
remained hypercalcemic. Nine patients failed to
show a drop in iPTH and they would have been
subjected to a more extensive neck exploration
unnecessarily based on a false negative result.
We have documented that parathyroid surgery can
be done effectively with excellent results in a small for
profit community hospital lacking both iPTH testing
and radioguided Sestamibi parathyroid scans.
RESUMEN
Cintigrafía intraoperatoria radio-guiada por
Sestamibi más el uso instantáneo de niveles de
parathormona (iPTH) se utilizan en el manejo de
cirugía de paratiroides minimamente invasiva. Cirujanos
con experiencia curan 90 a 95% de los
pacientes con hiperparatiroidismo primario.
El propósito de este estudio es reconocer los
resultados quirúrgicos en el manejo de
hiperparatiroidsmo primario en un hospital de co-
Vol. 100 • Núm. 1 • Enero-Marzo 2008
37
munidad que carece de ambos Cintigrafía por
Sestamibi y iPTH revisando los pacientes operados
desde Noviembre 1ero de 2005 a Octubre 31, 2006.
El estudio comprendió 56 pacientes: 52 con
hiperparatiroidismo primario, tres con
hiperparatiroidismo secundario y uno con
hiperparatiroidismo terciario. El único estudio
localizante usado preoperatoria-mente fue una
Cintigrafía con Sestamibi. Niveles de parathormona
se midieron inmediatamente antes y después de la
cirugía, pero los resultados se recibieron siete a diez
días después. La glándula afectada se removió en
todos los pacientes. Cincuenta de 52 (96%) de los
pacientes con hiperparatiroidismo primario, los tres
pacientes de hiperparatiroidismo secundario y el
único paciente con hiperparatiroidsmo terciario
están normocalcemicos con niveles normales de
parathormona (PTH). Dos pacientes persisten con
hipercalcemia leve. Condiciones asociadas incluyen
tres carcinomas papilares del tiroides. Tres bocios
multinodulares, cuatro nódulos sencillos del tiroides,
un tumor adrenal y tres re-operaciones.
Cirugía de las paratiroides se puede hacer de
forma segura y efectiva en hospitales de comunidad
sin la utilización intraoperatoria de Cintigrafía con
Sestamibi o mediciones instantáneas de PTH.
REFERENCES
1. Taillefer R, Boucher Y. Potvin C, Lambert R. Detection and localization of parathyroid adenomas in patients with hyperparathyroidism
using a single radionuclide imaging procedure with technetium-99m-sestamibi (Double-phase study). J Nucl Med 1992;33:1801-1807
2. Chen H, Sokol LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization,
cervical anesthesia, and intraoperative parathyroid hormone assay. Surgery 1999;126:1016-1021
3. Irvin Gl, Solorzano CC, Carneiro DM. Quick intraoperative parathyroid hormone assay: surgical adjunct to allow limited parathyroidectomy,
improve success rate, and predict outcome. World J Surg. 2004; 28:1287-1292
4. Chen H, Pruhs Z, Starling JR, Mack E. Intraoperative parathyroid hormone testing improves cure rates in patients undergoing minimally
invasive parathyroidectomy. Surgery 2005; 138:583-587
5. Stalberg P, Sidhu S, Sywak M, Robinson B, Wildinson M, Delbridge L. Intraoperative Parathyroid Hormone Measurement During
Minimally Invasive Parathyroidectomy: Does it “Value Add” to Decision Making? J Am Coll Surg 2006: 203:1-6
6. Duh QY. What’s new in general surgery: endocrine surgery. J Am Coll Surg 2005;201:746-753
7. Vázquez-Quintana E, Quintana C, Aguiló F, Pagán-Sáez H, Silva F. Localization of Parathyroid Lesions: Blind Study for Surgeons. Bol.
Asoc. Med Puerto Rico 1989: 81:342-344
8. Allendorf J, Kim L, Chabot J, DiGiorgi M, Spanknebel K, LoGerfo P. The Impact of Sestamibi Scanning on the Outcome of Parathyroid
Surgery. J Clin Endo & Met 2003; 88:3015-3018
9. American Hospital Association Statistics-Health Forum Data 2006 edition
10. Hortin GL, Carter AB. Intraoperative Parathyroid Hormone Testing: survey of testing program characteristics. Arch Pathol Lab Med
2002: 126; 1045-9

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Vol. 100 • Núm. 1 • Enero-Marzo 2008
39
Artículos Originales • Original Articles
SURVEY OF CARDIAC RHYTHM MANAGEMENT AND
DEVICE IMPLANT PATTERNS IN PUERTO RICO:
ANALYSIS OF 13,854 CARDIAC IMPLANTS
ABSTRACT
Background: Surveys of cardiac pacing and
implantable cardiovertor defibrillators (ICD) have
been reported since 1969 and 1993 respectively.
Increasing costs of medical technology, budget
constraints and emergent new clinical indications
prompted our committee to conduct the first survey
of cardiac rhythm management and device implant
patterns in Puerto Rico.
Method: Clinical and demographic data were
obtained for all cardiac devices sold and implanted
from 2000 to 2006, through a joint agreement with
official representatives of the 2 largest
manufacturers and distributors of cardiac
pacemakers and ICD in Puerto Rico.
Results: 13,854 cardiac devices were
implanted from 2000 to 2006. The number of
permanent pacemakers (PP) implanted per million
population has varied from 430 in the year 2000
to 482 in the year 2006. A significant greater
number of males received PP than females (P < .05).
Yearly increases in implant rates for cardiac
resynchronization therapy (CRT) and ICD were
observed, mainly due to new emergent clinical
indications, appropriate insurance coverage and
availability of implanting electrophysiologists.
By: Juan M. Aranda, M.D., F.A.C.C. ‡, Miguel Girod, M.S ‡, Eng., Fernando Ochoa ‡,
Miguel Abreu, M.D.*, F.A.C.C., José J. Rivera, M.D., F.A.C.C.** ‡, Juan C. Sotomonte, M.D.** ‡,
Angel Rodríguez, M.D.**, Daniel Arzola, M.D.**, Raúl Jiménez, M.D., F.A.C.C.** ‡,
and Juan M. Aranda, Jr., M.D., F.A.C.C. £
Conclusions: Sales figures from PP and ICD
manufacturers are a reliable system to calculate and
analyze changes in cardiac device implant patterns.
The rate of 482 PP per million population positions
Puerto Rico as the third largest implant market in
North and South America. This finding should be
useful to insurance health providers since 76% of
the implants are performed in patients over 65 years
old. In the year 2006, Puerto Rico was the 10 th
largest implant market in the world with 67 CRT
implanted per million population. A significant
greater number of CRT and ICD were implanted in
males than females. This gender difference has
increased in spite of strict requirements to include
more females in clinical trials and intensive,
educational and awareness efforts conducted among
physicians and patients. A summary of the current
guidelines and clinical indications is provided to
assist the physician in the selection of patients
referred for cardiac rhythm management and
implant procedures.
Key words: cardiac, rhythm, device,
implant, heart
* From the Department of Medicine, University of Puerto Rico, School of Medicine, ** Cardiovascular Center of Puerto Rico, ‡ the Caribbean,
Pavía Heart and Lung Institute in San Juan, PR, and £ University of Florida College of Medicine, Gainesville, Florida. Request reprints to: Juan M.
Aranda, MD, FACC, Hostos # 411, Hato Rey, P.R. 00918.

40
INTRODUCTON
Surveys of permanent cardiac pacing modalities
in the United States have been published every 4 years
since 1969 (1-6). Worldwide information on cardiac
pacemakers and implantable cardiovertor –
defibrillators (ICD) implant patterns have also been
reported since 1973 and 1993 respectively (7-16). The
last world survey presented in the XII World Symposium
of Cardiac Pacing and Electro-physiology in 2003
included Panama and Dominican Republic as the first
countries from Central America and the Caribbean
Region participating in the study (17).
With increasing costs of medical technology and
on going budget constraints, insurance companies,
government health directors, cardiac device manufacturers
and health providers have become increasingly
interested in emergent cardiac device indications,
changes in implant patterns and timely implant
statistics. These factors prompted us to conduct
the first survey on cardiac rhythm modalities
and devices implant patterns in Puerto Rico. The
study was conducted from 2000 through 2006.
MATERIAL AND METHODS
A steering committee was formed in 2004 by
all clinical and interventional electro-physiologists
practicing their sub-specialty in Puerto Rico. As new
electrophysiologists arrived in 2005 and 2006, they
were incorporated in the committee.
The committee developed the guidelines of the
study and selected all the information and
parameters required to start and successfully complete
the study. The objectives were thoroughly
discussed with authorized representatives of the two
main manufacturers and distributors of cardiac
devices in Puerto Rico. After adopting a
professional and ethical policy to protect the
patients privileged information and manufacturer
privileged data, Boston Scientific CRM. (St. Paul,
MN) previously Guidant Corp. and Medtronic Inc.,
(Minneapolis, MN) agreed to participate and
contribute to the survey. An agreement was made
not to discuss or present individual company figures
except in a global form after analysis of the data.
The committee estimated that these 2 companies
provided over 98% of all the implanted devices
during the surveyed period of time.
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
The information requested included the
patient’s age and gender, indication, type of device
implanted, initial mode of pacing, hospitals active
in pacemaker and ICD implants, number of devices
sold per year and complications of the procedures.
The manufacturers provided the information for all
permanent pacemaker systems and ICD devices sold
and implanted in Puerto Rico since 2000.
The information received was entered in a
computerized data base for processing using
Microsoft Office Excel 2003 SP2 for data analysis
and the Statistical Package for the Social Sciences
for Windows version 11.0.1 (SPSS Inc. Chicago,
Illinois) for statistical calcu-lations. The statistical
analysis consisted of calculating means, marginal
percent and percent for various subcategories. Chi
square and / or Fisher’s tests of association and
two-tailed independent t-tests were used to identify
significant differences in patients characteristics,
implants per year and changes in the mode of
pacing. For all tests a p value less than 0.05 was
considered to be statistically significant.
RESULTS
1- Classification of Cardiac Rhythm Modalities
The worldwide survey of cardiac pacing
published in 2001 (17) classified cardiac rhythm
modalities in three distinct categories:
a-Cardiac Devices (permanent pacemakers)
implanted for therapy of slow symptomatic
rhythms (single and dual chamber pacing).
b-Cardiac Devices (implantable cardiovertordefibrillator
or ICD) implanted for therapy of
malignant ventricular arrhythmias or ventricular
fibrillation (one or two leads ICD system).
c-Cardiac Devices implanted for therapy of
heart failure or cardiac resyn-chronization
therapy (CRT) through atrial and
simultaneous biventricular stimulation. This
modality is subdivided into CRT-P (pacing
without ICD) and CRT-D (pacing with ICD).
2- Patterns of Cardiac Rhythm Management
Thirteen thousand, eight hundred and fifty
four (13,854) cardiac devices were implanted
from 2000 to 2006 (Table 1). The total
number of implanted devices has significantly
increased throughout the 6 year period (P <
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Table 1: Total cardiac devices implanted (2000-2006)
*Permanent Pacemaker; **Includes CRT–P and CRT-D
.05). This pattern has been due to the yearly
increases in the number of ICD and CRT
implanted. This is supported by the fact that
the percentage of permanent pacemakers of
the total number of devices implanted per
year decreased from 98% in 2000 to 80%
in 2006 (P < .05), while the % of ICD and
CRT increased from 2% to 20% in the same
period (P < .05). Table 2 highlights the
number of devices implanted per million
population. This allows us to compare our
implant rates with other countries in Europe,
North and South America (18-19).
Table 3: Largest Implanting Markets of CRT-P and CRT
- D Devices Per Million Population (2004-2006) (19).
Vol. 100 • Núm. 1 • Enero-Marzo 2008
41
Table 2: Total devices implanted per million population
(2000 - 2006)
* Population in millions
3- Demographics of Implanted Devices
Our pacemaker implant rate per million
population (18) has remained relatively stable
and has varied from 430 to 482 in 2000
and 2006, respectively. This information,
ranked Puerto Rico in 2006 as the third
largest implanting country in North and
South America, behind United States (950
per million) and Canada (591 per million) and
17th in the world among countries with the
largest implanting rates (19).
The rate of ICD implants has significantly
increased from 8 ICD per million in 2000 to
55 per million in 2006. Our implant rate in
2006 (55 per million) followed the United States
(396 per million) and Canada (56 per million)
and far exceeded the implant rates of larger
countries in Central and South America (19).
The CRT implant rate in 2006 (67 per million)
ranked second in North and South America
behind the United States (245 / million) and
11 th among the largest implanting countries in
the world (19) (Table 3). The dramatic changes
observed in implant patterns were due to
improved recognition of traditional indications
and more significantly, to the recent approval
of clinical indications with appropriate medical
coverage sponsored by governmental and
private insurance companies.

42
Figure 1 shows the gender differences in
recipients of permanent pacemakers, CRT’s
and ICD’s in Puerto Rico. Note that a significant
greater number of males received PP
than females (p < .05). 557 pacemakers per
million males were implanted in 2006 as
compared to 386 per million females (Figure
2), even though the population of females
in Puerto Rico has been greater than males
since 2000 (p < .05) (18). This gender difference
has remained relatively constant in
the last 7 years. Our data also shows that in
Puerto Rico four times as many men as
women received an ICD to prevent sudden
cardiac death (Figure 3). Almost twice as
many males as females received CRT to treat
heart failure in spite of the fact that women
account for the majority of deaths from heart
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
failure (20). This has occurred in spite of
significant efforts to increase female participants
in clinical studies which have shown similar
benefits in the female as compared to the male
gender (20). In the last 4 years, this gender disparity
has become more significant in our patient
population as newer indications have been
implemented in clinical practice (21).
The patients that received resynchronization
therapy, ICD or both appear to
be younger than the patients with PP implants.
Figure 4 shows that approximately
66% of PP recipients were > 70 years as
compared to 37% of CRT and ICD recipients
(p < .05). Only 17% of PP were implanted
in patients < 60 years as compared
to 32% for CRT and ICD recipients. In Puerto
Rico, similar to European and North Ameri-
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
can Countries, 32% of all PP implanted since
2000 were in patients > 80 years of age, a
characteristic of countries with a comprehensive
health care system (22).
4- Indications and Clinical Features of Device
Recipients
a- Permanent Pacemaker Recipients
The indications for initial PP implant were
clearly identified in 4,518 patients (Figure
5). Sick sinus syndrome (43%) and advanced
atrio-ventricular conduction disturbances
(48%), either complete A-V block or Mobitz
II A-V block, were the most frequent indications
for implant. These observations are very
similar to the data reported in the world survey
for calendar year 2001 (23). In 2001, a
permanent pacemaker was first implanted in
Puerto Rico for post ablation A-V block.
Since then, 14 other patients have received
PP implants for this complication of
radiofrequency ablation for supraventri-cular
tachycardia. None were reported in 2005
and 2006, a reflection of the local expertise
gained in the earlier years of ablation.
There has been a progressive and significant
increase in the use of dual chamber pacing
systems (DDD) as shown in Figure 6. This
trend became statistically significant in 2004
(p < .05). It increased from 50% in 2000 to
70% in 2006. Correspondingly the single chamber
pacing implants (VVI) decreased to 30% in
2006. It has been selected mostly for recipients
whose underling rhythm was atrial fibrilla-
Vol. 100 • Núm. 1 • Enero-Marzo 2008
43
tion with high grade A-V block.
b- CRT and ICD Recipients
The first ICD was implanted in Puerto Rico
in 1993 by Colón, Jiménez et a. (24). About 5
per year were implanted through 1998. Since
2000, there has been a significant increase in
ICD implants in Puerto Rico (30). Thirty (2% of
total cardiac devices) were implanted in 2000
as compared to 216 (9% of total cardiac devices)
in 2006 (Table 2). As new indications for
the device were approved for patients with congestive
heart failure, the potential target population
expanded as well (25-29).
Table 4 shows the total number of CRT and
ICD recipients in whom the indications for the devices
were identified (1,585 of 1,594 implants).
63% of the ICD devices were implanted in patients
with ischemic or non ischemic cardiomiopathy, EF
< 35%, congestive heart failure Class I – II – III
New York Heart Association and a QRS complex
less than 120 msec (25). This group included asymptomatic
survivors of an acute myocardial infarction
(>40 days) and a EF < 30%. It has been
shown that ICD implants in these groups of patients
decreased sudden death by 23% (25-30). The ICD’s
were implanted in the other group (37%) either
because they had spontaneous or induced, hemodynamically
unstable ventricular tachycardia or ventricular
fibrillation. When the QRS complex was over
120 msec, the patients met the criteria for cardiac
resynchroni-zation therapy (CRT), except
those that were asymptomatic (Class I) (26-29).
Table 4 also shows that all CRT – P devices

44
implanted in Puerto Rico since 2000 were implanted
in patients with EF < 35%, CHF, Class
II, III and IV and QRS duration > 120 msec. CRT
in addition to adequate medical therapy reduces
mortality, hospitalizations and improves cardiac
function, structure, symptoms and quality of life
(26-29). A defibrillator was added to CRT therapy
in 2002 after it was demonstrated that prophylactic
single lead ICD implantation in patients
with CHF II, III, who received CRT, decreased sudden
death by 30% (27). 274 CRT-D implants in
Puerto Rico were performed in this group of patients,
34% of them had spontaneous or induced
ventricular tachycardia or ventricular fibrillation.
An interesting observation was made in a subgroup
analysis of 2,123 patients with permanent
pacemakers and 232 with CRT and ICD devices
implanted in 2005. The implant procedures for PP
were evenly divided between private hospitals
throughout the island (49%) and primary academic
medical centers including the VA Hospital (51%).
On the other hand, most of the CRT / ICD implants
(88%) were performed in the academic centers
as compared to 12% implanted in private hospitals
(p < .05). Several factors were identified to
explain these differences; availability of trained implanting
electrophysiologists, appropriate medical
implant facilities and hospital reimbursement for the
procedure by private or government medical insurance
companies.
In the year 2006, the average hospital reimbursement
for implanting a CRT-D in the United
States was $44,000 as compared to $31,000 the
highest reimbursement to a medical school affiliated
hospital in Puerto Rico and $24,000.00 if the
procedure was performed in a private institution
(31). The lower reimbursement to private hospitals
is probably the most important factor that explains
the low number of CRT and ICD implanted in these
institutions (Figure 7).
DISCUSSION
This study conducted by clinical and
interventional electrophysiologists in Puerto Rico
together with the main manufacturers and distributors
of cardiac devices, included over 98% of all
devices implanted from 2000 – 2006. In the ab-
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Table 4: Clinical Indications for CRT and ICD
Implants in Puerto Rico 2000-2006
sence of an on going pacemaker and ICD registry
or a dedicated coordinator to conduct hospital surveys
of cardiac implants, using sales figures form
pacemakers and ICD manufacturers has been shown
to be a practical and reliable system to calculate
implant rates and delineate trends in the market
(32).
The major drawback of this method has been
the limited clinical information that is obtained from
sales figures (14). A specific example in our study,
has been the absence of data related to procedural
complications and outcomes of ICD implants in
survivors of sudden cardiac death. Nonetheless,
the committee believes that the numbers used to
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
calculate implants per year are very reliable and represent
current trends in Puerto Rico. Similar data
collection has been used to calculate annual implant
rates in the United States (14).
The classification of implantable cardiac devices
into devices for bradycardia therapy, devices for
tachycardia therapy (malignant ventricular
arrhythmias) and devices for heart failure (cardiac
resynchronization therapy) is useful specially for the
non implanting cardiologist and non cardio-vascular
physician since it allows them to identify specific
cardiac devices with specific clinical indications.
With increasing costs of sophisticated medical technology
and decreased reimbursement for specialized
hospital procedures, our findings should be of significant
interest to insurance companies, device manufactures,
health directors and medical providers. Our
rate of permanent pacemaker implants per million
population has remained relatively stable from 2000
through 2006 with a greater number implanted in
males than females even-though the number of females
has been greater than males through the 7 year period
(18). The rate of 482 pacemakers implanted per
million population in 2006, positions Puerto Rico as
the third largest implanting market in our hemisphere
and 17 th in the world among countries with the largest
implanting rates (19). It does not appear that this rate
will increase significantly over the next five years. Our
study was not designed to address this issue since we
expected that the data would have shown significant
yearly increases per million in PP implant rates.
Geographic and Regional Variations in Pacemakers
and ICD Implantation Rates
Geographic variations in annual implant rates have
been substantial within the United States and variations
have been reported among states and regions
(33, 34). Several factors interact with each other to
determine each country annual rate (14, 17, 22).
• Economic Indices
The Gross National Product and per capita
annual health expenditure are directly but
not always related to PP and ICD implant
rates (22-23). The correlation is modest
since some countries with similar economic
indices have different implant rates, (22)
which may be influenced by medical health
coverage, procedural reimbursement and
Vol. 100 • Núm. 1 • Enero-Marzo 2008
45
the age distribution of their population.
• Insurance Coverage and Procedure Reimbursement
Medical insurance coverage and procedural
reimbursement for hospitals is another determinant
factor. The DRG (Diagnosis Related
Group) may include cost of the device
and hospitalization, even if prolonged. The
type of institution where the device is implanted
also influences hospital reimbursement,
as a result hospital administrators scrutinize
each implant, specially if the procedure
is performed in a private institution. This
is clearly the situation in Puerto Rico as previously
discussed.
• Cost of the Device
The lower the cost of the device the higher
the implant rate. The goal of all payors and
administrators is to obtain the lowest price
for the best device available in the market
(33). Whether the device is imported or
manufactured locally is another influential
factor. The price of imported devices is usually
higher and depends on multiple factors
such as local taxation, reimbursement, medical
coverage and where is the device manufactured
or assembled (32-34).
• Implanting Physicians
Available trained implanting cardiologists or
electrophysiologists significantly increased
the CRT and ICD implants observed in our
study. The number of implanting physicians
increased in Puerto Rico after 2000 with the
arrival of several trained implanting electrophysiologists
that implemented very well the
emergent newly approved clinical indications.
• Aging Population
The age distribution of the population varies
significantly among different geographical areas
(22, 34). 82% of the pacemakers in Puerto Rico
were implanted in patients over 60 years old, 80%
were older than 65 years. Our data agrees with
the information reported in the literature (22).
Therefore the number of potential candidates for
permanent pacing is directly proportional to the %
of the population over 65 years. It is then reasonable
and more significant to compare rates among

46
different countries calculating the rate of implants
for each age group, specifically the rate per million
population over 65 years. Subgroup analysis of our
data shows the following pertinent observations;
In 2002, the implant rate in Puerto Rico per
million population over 65 years (3,308) was very
similar to the rate per million over 65 reported in
the United States (3,560)(22). Even though the
overall rate per million in the United States in 2002
(840 / million) was almost twice the overall implant
rate in Puerto Rico (475 / million) in the same year.
The rate in Puerto Rico per million over 65 was
significantly greater than any of the other larger
implanting countries in 2002 (22). We believe that
the explanation to this paradox is the availability of
medical insurance to all patients over 65 that qualify
to receive Medicare Parts A and B. This type of
medical coverage might not be available in many of
the other larger implanting countries.
This information (implant rate per million population
>65 years) is useful to all medical health providers
since it allows the plan administrator to estimate
the number of patients enrolled in their network
that may require implantable cardiac devices.
This will enable the health plan to identify and assign
the economic resources required to fund these
life saving clinical services.
World Wide Increases in CRT and ICD
Implants
Figure 8 summarizes the progressive yearly increases
in CRT and ICD implanted in Puerto Rico
since 2000 and the published studies that documented
the clinical indications and improved medical
outcomes after the devices were implanted.
Miracle study (28) published in 2001 was instrumental
in providing objective evidence which
lead the Food and Drug Administration to approve
the biventricular pacing system as definite therapy
for Class III – IV patients with congestive heart failure
in spite of optimal medical therapy. The same
investigators reported in 2003 (Miracle CRT-D) that
combined CRT with an implantable cardiovertor
defibrillation in advanced congestive heart failure,
diminished cardiac mortality (27). This report together
with the approval of prophylactic ICD implant
in patients with a previous myocardial infarc-
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
* 80% of PP were implanted in patients 65 years or older
tion (MADIT II) and an ejection fraction < 30% explains
the significant increases in ICD implants from
2002 through 2004 (30).
In the years 2003 and 2004 the reports published
in SCD – HeFT (25) and Companion Trials
(29) further expanded the indications for ICD implants.
SCD – HEFT (Sudden Cardiac Death in
Heart Failure) showed that in patients with NYHA
Class II, III CHF and an EF < 35%, a single lead
ICD implant reduced overall mortality by 23% irrespective
of the QRS duration. Companion Trial
demonstrated that in patients with CHF and optimal
medical therapy, the addition of an ICD to cardiac
resynchronization therapy decreased mortality
30% (29). As a result of these studies, CRT – D
implants in Puerto Rico increased 100% yearly from
2003 to 2005.
Although, all cause mortality with cardiac
resynchronization alone decreased as compared to
optimal medical therapy, it was not significant and
the results of CRT on the risks and complications
of the implanting procedure remained unclear. The
Care-Heart Failure Study published in 2005 (26)
clearly showed that in patients with echocardio-
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
graphic criteria of ventricular dyssynchrony, cardiac
resynchronization improved symptoms, quality of
life, reduced compli-cations and risk of death by
36% in addition to the benefits afforded by optimal
medical therapy. The addition of a defibrillator might
further reduce the risk of sudden death by 7% (29).
As of August, 2006, the following are the approved
clinical indications for an implantable
cardiovertor – defibrillator (ICD) and cardiac
resynchronization therapy (CRT) with or without a
defibrillator (25-30). The committee realizes that
individual assessment of each candidate and an explanation
of the risk and benefits of the procedure
are the clinical approaches to follow, however it
hopes that the following summary helps in the selection
and referral of candidates for implantation
of CRT and ICD devices.
Indications FOR ICD
A-Patients with Ischemic Cardiomiopathy
• EF < 30%
Previous myocardial infarction,
more than 40 days (30)
• EF < 35%
Previous myocardial infarction
more than 40 days
Spontaneous or induced sustained
ventricular tachycardia or ventricular
fibrillation, not related to an acute
infarction or reversible causes (29).
• EF < 35%
Congestive Heart Failure Class II –
III, after optimal medical therapy (25).
B-Patients with Non Ischemic Cardio-myopathy
• EF < 35%
Cardiomyopathy of more than 9
months duration
Congestive Heart Failure Class II or
III after adequate medical therapy (27).
If the duration of the QRS complex
is more than 120 msec seconds and
the patient presents CHF Class II -
IV, he / she meets the criteria for
cardiac resynchronization therapy.
Others
C-Patients with Genetic Cardiac, Hereditary
Vol. 100 • Núm. 1 • Enero-Marzo 2008
47
Diseases (6).
• Prolonged (congenital) QT syndrome
• Hypertrophic Cardiomyopathy
• Brugada Syndrome
• Idiopathic Ventricular Fibrillation or
Ventricular Tachycardia (hemodinamically
unstable)
As more clinical indications emerge and are
approved for patient selection, it is imperative that
each country performs on going evaluations of cardiac
rhythm management and device implant patterns
in order to determine the most cost effective
way to allocate the clinical and economic resources
that are available. The permanent data base developed
during this study provides the fundamental tool
to achieve this objective in Puerto Rico.
ACKNOWLEDGEMENT
We acknowledge the cooperation of Carlos
Girod, MD, FACC for the detailed revision of the
manuscript and Ms. Luz M. González for her expertise
in word processing used for the preparation
of this article.
RESUMEN
Evaluaciones de patrones de estimulación cardiaca
e implantes de cardiovertores – desfibriladores
se han reportado desde 1969 y 1993
respectivamente. Aumentos en costos de
tecnología médica, limitaciones presupuestarias y
nuevas indicaciones clínicas, motivó a nuestro grupo
de trabajo a llevar a cabo la primera recopilación y
evaluación de manejo de ritmo cardiaco y patrones
de implantes en Puerto Rico.
Información clínica y demográfica se obtuvo de
todos los dispositivos cardiacos vendidos e
implantados desde el año 2000 – 2006, a través
de acuerdos pre-establecidos con representantes de
las 2 compañías de distribución y manufactura de
marcapasos cardiacos y desfibriladores implantables
en Puerto Rico.
Se implantaron 13,854 dispositivos durante el
periodo de estudio (enero, 2000 – diciembre, 2006).
No hubo aumentos en el número de implantes de
marcapasos permanentes por millón de habitantes;
la tasa varió de 430 en el año 2000 a 482 en el
año 2006. Los marcapasos se implantaron

48
significativa-mente mas en hombres que en mujeres
(p

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
26- Cleland J.G., Daubert J.C., Erdmann E. et al; The effect of cardiac resynchronization or morbity and mortality in heart failure N. Engl J.
Med. April 14, 2005. 352: 1539-1549.
27- Bristow M.R., Saxon L.A., Boehmer J., et al; Effect of Cardiac Resynchronization Therapy with and without an Implantable Defibrillator
in Morbity and Mortality in Advanced CHF. N. Eng. J. Med March, 2004 350: 1245-1256.
28- Abraham W., Fisher W, Smith A., et al, Cardiac Resynchronization in Chronic Heart Failure N Engl J. Med 2002, 364; - 1845-1853.
(Miracle CRT-P)
29- Young J.B., Abraham W.T., Smith A.L., et al, Combined Cardiac Resynchronization and Implantable Cardioversion Defibrillation in
advanced chronic heart failure: the Miracle ICD Trial JAMA 2003: 289: 2685-94 (Miracle CRT-D).
30- Moss A.J., Zareba W., Hall W.J., et al, Prophylactic Implantation of a Defibrillator in Patients with Myocardial Infarction and Reduced
Ejection Fraction N Engl J. Med 2002; 346: 877-883. (MADIT II).
31- Centers for Medicare and Medicaid Services, www.cms.hhs.gov. November 24, 2006.
32- Mond H.G.; The World Survey of Cardiac Pacing and Cardiovertor Defibrillator; Lesson Learnt J. Inter Card Electrophysiol (2006) 17:
211-214.
33- Ector H., Rickards A.F., Linde C., et al, Demographic data on First Pacemaker implantation in Europe. Europace 2001, 2: B 132.
34- Wennberg J.E., Understanding Geographic Variations in Health Care Delivery (editorial ) N Engl J Med. 1999; 340: 52-53.
Vol. 100 • Núm. 1 • Enero-Marzo 2008
49

50
Artículos de Repaso • Review Articles
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
HISTORY OF PARATHYROID SURGERY IN PUERTO RICO
By: Enrique Vázquez-Quintana, MD*
ABSTRACT
Review article that includes the worldwide history,
as a reference for the readers, and the local
history of hyperparathyroidism in Puerto Rico.
WORLDWIDE HISTORY
Few things in the history of medicine are more
fascinating than the history of parathyroid disease.
It is interesting to know how many medical students
have participated in endocrine surgery making significant
discoveries.
The oldest example of what is believed to be
the first case of hyperparathyroidism dates to the
Early Neolithic period, around 7000 years ago. The
examination of a skeleton revealed osteopenia, osteodystrophia
fibrosa cystica and salt-and-pepper
appearance of the cranium.
Sir Richard Owen, an anatomist of the Natural
History Museum of London, in 1850, was the first
to describe the parathyroid glands in a rhinoceros
autopsy, as a small compact yellow glandular body
attached to the thyroid gland. No credit was given
to his observations since he never performed a histological
confirmation.
Robert Remak, a microanatomist and embryologist,
in 1855, described a small gland in association
with the thymus, which was clearly not a
lymph node (1).
Rudolph Virchow, in 1862, also described in a
single specimen, a gland that was not an accessory
thyroid gland, lymph node or any other neck structure
familiar to him as pathologist.
In 1887, Ivar Victor Sandstrom, a Swedish
medical student, described the number, location,
color and blood supply of the parathyroids in animals
and 50 human autopsies. He wrote a manuscript
entitled “On a new gland in man and fellow
animals”. He suggested the name “glandulae
parathyroidae”. The manuscript was rejected by
German editors because of its length. Years later it
was published in the Uppsala Medical Journal. His
contribution was not recognized as deserved and
he committed suicide a few years later.
Eugene Cley, French physiologist, in 1891,
observed the relationship between tetany and the
parathyroid glands.
In 1891, Frederich von Recklinghausen, a pathology
professor at Strasbourg, described seven
patients with bone disease, multiple neurofibromas
and cafe au-lait spots.
The first attempt to transplant the parathyroid
glands was performed by Anton von Eiselberg, a
disciple of Theodor Billroth in 1892.
Neovascularization of the transplanted glands was
observed in experimental animals.
M. Askanazy, in 1903, described a patient
with bone disease associated with a large parathyroid
mass, speculating that it might be a parathyroid
tumor.
* From the Department of Surgery, Pavia Hospital, San Juan, PR. Address Reprints: E. Vazquez Quintana, MD - Pavía Street, Suite 301, San Juan,
P. R. 00909. E-mail evazquezmd@gmail.com Main Lecture of the 28 th Raffucci Surgical Forum given on February 21,2008 at Hotel La Concha,
San Juan, Puerto Rico
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Tetany, after total thyroidectomy, led to important
discoveries regarding parathyroid function.
Pathologist William J. MacCallum, at the John
Hopkins Hospital, in 1903, described tumors of the
parathyroid gland and the relief of tetany with parathyroid
extract in experimental animals. Both
MacCallum and Carl Voegtlin demonstrated that
tetany could be corrected by parathyroid extract or
by giving calcium intravenously.
Pfeiffer and Mayer, in 1907, were the first to
achieve clinical success with autotransplanted parathyroid
tissue.
In 1907, William Stewart Halsted, at John
Hopkins University used parathyroid transplantation
in dogs. He used calcium gluconate to treat
tetany in experimental animals and patients after
thyroidectomy. He emphasized the preservation of
the parathyroids during thyroid surgery.
Jacob Erdheim, a pathologist from the University
of Vienna, reported in 1907 the association of bone
disease with abnormalities of the parathyroid gland.
But he believed that the bone changes were primary
and not related to an excess of parathyroid hormone.
Freidrich Schkagenhaufer a physician from
Vienna was the first to suggest that parathyroid tumor
was the primary disease and the bone effects
as secondary. He recommended surgery to remove
the enlarged glands to cure the bone condition.
In 1907, William Halsted and Herbert M. Evans,
a medical student at Hopkins defined the blood supply
of the parathyroid glands using vascular cast injections.
They found that the inferior thyroid artery was the
principal blood supply to both inferior and superior
parathyroid glands in over 90% of the cases.
In 1923, Adolf M. Hanson, a medical student
working in the pharmacology laboratory at the
University of Minnesota, prepared a bovine parathyroid
extract that could be used to treat tetany in
dogs. He observed that the parathyroid extract
causes osteoporosis in animals if used for a long
period of time.
James P. Collip, a biochemist from the University
of Alberta, Canada, also independently developed
an extract identical to that of Hanson. He was
the first to induce experimental hypercalcemia and
to describe the effects of severe hypercalcemia.
Clinically, the three most famous patients with
Vol. 100 • Núm. 1 • Enero-Marzo 2008
51
hyperparathyroidism are Albert Gahne, Charles
Martell and Elva Dawkings (2).
In April 1925, O. Hirsch, a Viennese
otorhinolaryngologist, explored the neck of a patient
who had cystic lesions in both maxillae and mandible
in which he suspected Von Recklinghausen’s disease.
He was looking for a parathyroid tumor but the exploration
was negative.
Albert Gahne was a 34 year street car conductor
in Vienna. His symptoms started in 1919. For
five additional years he developed bony pains. Decalcification
of the bones was documented by x-rays
and cystic fibrosis of the pelvis and both femurs
observed. He was treated with parathyroid extract
and in July 2, 1995, four fresh human parathyroids
were transplanted. Because no improvement
was observed, Felix Mandl, chairman of surgery at
the University of Vienna, on July 30, 1925, explored
his neck. The operation was done under local
anesthesia. A large left lower parathyroid tumor
was identified close to the inferior thyroid artery.
The lesion was removed, and three other normal
parathyroids were identified and preserved. The
pathology revealed no rim of normal parathyroid
tissue to suggest an adenoma. The conclusion was
that it was an atypical adenoma which may have
malignant degeneration. He had an excellent recovery.
No symptoms of tetany occurred. He improved
and was discharged on August 7, 1925.
Bone healing and bone density improved.
He was readmitted in February 1926 because of
kidney stones and nephrocalcinosis. His renal problems
and bone pains continued to improve. By May of
1926 he was able to walk with canes. After six years
of clinical improvement, he was again readmitted on
March 23, 1933, with kidney stones and unable to
walk. On October 18, 1933, his neck was re-explored,
no recurrence or additional tumor was found. A portion
of the thyroid was removed, two additional parathyroids
were found, one inside the thyroid. He had
no improvement, continued with hypercalcemia and
died from uremia on February 26, 1936, almost eleven
years after his first operation.
The autopsy showed extensive cystic fibrosis of
the bones, brown tumors in both femurs and clavicle
and decalcification of the spinal column. He had bilateral
kidney stones with hydronephrosis and nephro-

52
Figure 1: Photo of Charles Martell before and
after his disease.
calcinosis. No abnormal parathyroid tissue was found
in the neck, mediastinum or retroperitoneum.
The histologic diagnosis of the tumor removed
from this patient is not clear. An ectopic tumor was
considered by Mandl but it was not proven at autopsy.
The possibility of parathyroid carcinoma has been
entertained by some authors, but again no proof of
recurrence or metastasis was detected postmortem.
The first parathyroid operation for a parathyroid
tumor in the United States was performed by
EJ Lewis at Cook County Hospital in Chicago, on
June 6, 1926. The patient was a 29 year old woman
with parathyroid carcinoma. The operation was
done six months after Felix Mandl’s operation in
Vienna and 4 months before the Charles Martell’s
first operation in Boston. Multiple nodes were found
in the neck. She developed recurrence of the tumor
requiring excision.
In July 20, 1927, two years after Mandl’s operation,
E. Gold, another Viennese surgeon explored
the neck of a 54 year old female with von
Recklinghausen’s disease. A bilateral neck exploration
was done assisted by his chief, A. Eiselsberg,
and under the supervision of Felix Mandl. He removed
a parathyroid adenoma from the right up-
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
per gland measuring 2.5 X 2.6 cm. Gold was the
first to use the term hyperparathyroidism for the
elevated parathyroid metabolism.
After analyzing 55 other cases, Mandl concluded
that surgery was the only way to cure hyperparathyroidism.
He advised bilateral neck exploration
to identify the normal and abnormal parathyroid
glands. He established the gold standard in the treatment
of hyperparathyroidism.
The most famous patient with hyperparathyroidism
is Charles Martell (see Figure 1). He is probably
the most extensively studied patient with this
disease in the annals of medicine. Charles Martell
was a healthy sea marine captain who was 30 years
old when the diagnosis of hyperparathyroidism was
made in January 1926 by Eugene F. Dubois at the
Belleveu Hospital in New York City. Extensive calcium
metabolism studies were done and he was
transferred to Massachusetts General Hospital on
April 1927. In May, 1927, he had two neck operations.
During the first, only the right neck was explored
and a normal parathyroid was removed. The
second operation was limited to the left side and
again only one normal parathyroid was removed.
In 1929 he underwent a third neck operation in
New York City by Russell Patterson with negative
results. In May, 1932, he was readmitted to MGH,
more studies were done under Fuller Albright and
Benjamin Castleman. Oliver Cope performed three
negative cervical explorations on this patient.
Martell himself insisted on a mediastinal exploration
for an elusive gland. The seventh and last operation
was done by Edward D. Churchill and Cope
and they removed a 3 X 3cm mediastinal parathyroid
adenoma. Although a remnant of tissue was
left in the sternal notch region, on the third postoperative
day he developed tetany. Six weeks later
while undergoing the removal of an obstructing ureteral
stone he developed laryngospasm and died.
The third of the most famous patients is Elva
Dawkings. She was a 56 year old woman who was
admitted to Barnes Hospital at Washington University.
She was complaining of muscle weakness, bone
fractures and bilateral renal stones. A fourth year medical
student, Henry A. Dixon, was intrigued by her symptoms.
He documented a serum calcium of 17 mgs/dl
and serum phosphorus of 1.4 mgs/dl. Isaac Y. Olch
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Figure 2: Photo of Dr. Manuel Paniagua
Cámara Courtesy of his daughter,
Dr. Carmen T. Paniagua
explored the neck of this patient on August 1, 1928,
and removed a left lower parathyroid adenoma measuring
3 X 3 cms. Her calcium dropped to 4.5 mgs/
dl and she was given the Collip’s parathyroid extract
and calcium intravenously and orally.
James Walton of London, in 1931, recommended
a wide exposure during surgery, not only
to explore all the parathyroid glands, but also to
search behind the trachea and the mediastinum.
G. Gordan is quoted as saying “The historical
diagnosis of hyperparathyroidism has gone from
bone to stone, to an epigastric moan to none”.
HISTORY IN PUERTO RICO
“In God we trust, all others must bring their
data” By Claude H. Organ, M.D.
The first three Puerto Rican endo-crinologists
trained in the United States were Doctors Manuel
Paniagua Cámara, Agustín Martínez de Andino and
Lillian Haddock Suárez.
Dr. Paniagua Cámara was the first endocrinologist
in Puerto Rico (see Figure 2). Was born in San
Juan, Puerto Rico in 1914 and died in 1983. He obtained
his medical degree in Madrid, Spain and completed
his internal medicine training at the Bayamón
District Hospital. Then obtained his endocrinology
subspecialty at the Thomas Jefferson University in
Philadelphia. He served as captain of the U.S. Army
Vol. 100 • Núm. 1 • Enero-Marzo 2008
53
Figure 3: Photo of Dr. Agustín Martínez de Andino
Courtesy of his son Dr. Richard de Andino
during the Second World War. In 1977, he was a founding
member of the Sociedad Puertorriqueña de
Endocrinología y Diabetes (SPED). He was the medical
director of the Rio Piedras Municipal Hospital as
well as Director of the Endocrinology and Diabetes
Section of the San Juan City Hospital in the Puerto
Rico Medical Center until his retirement in 1982. Dr.
Paniagua published 20 medical articles, none of them
on hyperparathyroidism.
Dr. Agustín Martínez de Andino completed his
medical education at the Jefferson Medical College in
Philadelphia in 1944 (see Figure 3). Then he did his
internship and residency in internal medicine and fellowship
in endocrinology at the same institution. He
returned to Puerto Rico in 1952. He was a founding
member and second president of the Sociedad
Puertorriqueña de Endocrinología y Diabetes. He was
chief of the Endocrine and Diabetes Section of the
Department of Medicine at the San Juan City Hospital
in Santurce since August, 1952, to June 30, 1968.
Dr. Martínez de Andino was attending in the Metabolic
Disease Ward at the San Patricio Veterans Administration
Hospital from 1952 to 1964. He published
29 articles, none of them about hyperparathyroidism.
Dr Juan E. Rizek was the first physician trained
in endocrinology in Puerto Rico at the San Juan City
Hospital from 1958-60. The Chairman of Medicine
was Dr. Rurico Díaz Rivera and the Director of Endocrinology
was Dr. Agustín Martínez de Andino.

54
Dr. Lillian Haddock Suárez finished her medical
degree at Temple University School of Medicine in
1954 (see Figure 4). She did her internship at the
Bayamón District Hospital and Residency in Internal
Medicine at the San Juan City Hospital in Santurce,
P. R. She then completed a fellowship in Endocrinology
and Metabolism at John Hopkins Hospital from
1957 to 1959. She was a member of the Endocrine
Section at the San Juan City Hospital from 1959-
1960. When the University of Puerto Rico School of
Medicine moved to the University Hospital at the
Puerto Rico Medical Center she was designated by Dr.
Mario R. García Palmieri as Director of the Endocrine
Section in 1960. She held that position until 1976.
In 1998 she made Professor Emeritus of the University
of Puerto Rico.
Dr. Elena Villavicencio obtained her medical degree
at the University of Puerto Rico School of Medicine in
1957 (see Figure 5). She completed her internship and
residency in Internal Medicine at the San Juan City
Hospital from 1957 to 1960. She was the first fellow
trained in endocrinology at the University Hospital from
1960-1961. She then obtained a Fellowship in Diabetes
at the University of Minnesota from 1961-1963.
She joined the faculty of the Department of Medicine at
the University Hospital in Rio Piedras in 1963, position
she held until 1967 when she moved to San Antonio,
Texas. In 1968, she started as Clinical Professor of Medicine
at the University of South Texas Medical School.
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Figure 4: Photo of Dr. Lillian Haddock Suárez Figure 5: Photo of Dr. Elena Villavicencio
(Courtesy of her daughter Francesca Cuello)
When I started my residency in General Surgery at
the University Hospital in Rio Piedras, the Chairman of
Surgery was Dr. Francisco L. Raffucci and the Program
Director in Surgery was Dr. Leo Cuello Mainardi (see
Figure 6). Dr. Cuello married Dr. Elena Villavicencio.
Dr. Francisco L. Raffucci was a pioneer in cardiovascular
surgery in Puerto Rico. He was also involved
in treating patients with portal hyper-tension, liver failure
and pancreatic diseases. At the end of this article
you will become aware of other areas in which he actively
participated.
Dr. Leo Cuello Mainardi was born in Santiago de
los Caballeros in the Dominican Republic. His parents
moved to Puerto Rico while he was an infant. He completed
his Bachelor in Biology at the Mayaguez College
of the University of Puerto Rico. Then he obtained
his medical degree at the University of Paris.
He completed his residency in General Surgery at the
University Hospital in Rio Piedras and a Master in
Science and subspecialty in Thoracic and Cardiovascular
Surgery at the University of Minnesota. From
1963 to 1967, he was an Associate Professor in Surgery
at the University Hospital. In 1967, he and Dr.
Villavicencio moved to San Antonio, Texas. He has
been professor of surgery at the University of Texas
Medical School since 1973.
My interest in parathyroid surgery started in
1964 when Dr. Cuello Mainardi assigned me to dis-
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Figure 6: Photos of Dr. Francisco L. Raffucci
and Dr. Leo Cuello Mainardi
cuss the topic of hypercalcemia. I prepared a seminar
on the differential diagnosis of hypercalcemia
that includes: sarcoidosis, milk-alkali syndrome,
multiple myeloma, hypernephroma, metastatic bone
disease and hyperparathyroidism.
G. Gordan in 1958 stated: “The historical diagnosis
of hyperparathyroidism has gone from bone
to stone, to an epigastric moan to none”.
The first article on hyperparathyroidism was
published in 1970. It was entitled, “The Clinical,
biochemical, operative and pathological analysis of
14 cases of primary hyperparathyroidism”, by Lillian
Haddock, Julián Vázquez Plard, Franciso Aguiló,
María del C. Vázquez, Francisco L. Raffucci and
Juan Velázquez (3). They reported 14 patients, 8
males and 6 females. Their age ranged from 16 to
67 years. The pathology revealed 12 adenomas,
one carcinoma and one mediastinal lesion. The latter
patient died from bilateral pneumothorax. For
such a small series it was rare to have one carcinoma
and one mediastinal lesion, both of which
have very low in incidence.
I did my first operation for hyperpara-thyroidism
in September 1970. The patient was a 41 year old
female with bone pains, repeated urinary infections,
burning sensation on the eyes and constipation. The
x-rays revealed nephrocalcinosis and a pelvic bone
cyst. The neck was explored on September 21,
1970. No neck lesions were found. A large lower
neck and mediastinal mass was found that required
Vol. 100 • Núm. 1 • Enero-Marzo 2008
Figure 7: Photo of the Lebsche sternal chisel
55
a median sternotomy for its removal. A large 12 x
5 x 3 mass, weighing 113.3 grams, was removed.
It is the second largest parathyroid adenoma ever
reported in the medical literature. The following
table shows the parathyroid adenomas weighing
over 50 grams reported in the medical literature.
This is the instrument used to do the sternotomy
on this patient (see Figure 7). At that time we
did not have the electric saw used nowadays for
median sternotomies.
The patient is alive after 36 years; she is now
77 years old. Her calcium is 10-10.3 mgs/dl, PTH
72.8 pg/ml. Her serum creatinine is elevated, 1.8
mgs/dl and her creatinine clearance is low, 24.93
ml/min. She has no kidney stones and continues
to work (see Figure 8).

56
More cases of hyperparathyroidism were diagnosed
following the determination of serum calcium
levels in the SMA23 test, now known as Comprehensive
Metabolic Profile, PTH measurements introduced
in the 1970’s and the utilization of localization
tests to aid the surgeon during the operative
procedure.
The localization tests utilized at different times
during the history of this disease are:
Toluidine blue
Thyroid lymphography
Seleno-methionine
PTH determination with massage
Barium swallow
Thallium-technetium substraction saca
Ultrasonography
CT scanning
Nuclear magnetic resonance
Arteriography
Selective cannulation of neck veins for
PTH levels
Sestamibi parathyroid scan
Parathyroid scan with SPECT
Some of these tests are no longer used.
Since the first article published in 1970, the
following articles have been published:
1. Localization of Parathyroid Lesions: Blind
study for Surgeons in 1989 (4). Fifteen
consecutive patients with hyperparathyroidism
were studied by the Endocrine Section
of the University Hospital in Rio
Piedras, P.R. The results were unknown
to the surgeon and the resident. The endocrinology
fellow was present at the operating
room with the localization studies
results. In all 15 patients an adenoma was
identified and removed. Only four parathyroid
adenomas were identified by CT scan.
The Thallium-technetium substraction scan
identified 7 of the 15 affected glands. It
was concluded that the utilization of those
two localizing tests were not indicated at
the initial parathyroid gland surgery.
2. Unusual Cases of Hyperparathyroidism (5)
published in September, 1995. This publication
describes patients with parathyroid
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Figure 8: Photo of AVC and her surgeon -
February 2008.
carcinoma, a large mediastinal adenoma,
reoperation for hyperplasia 20 years after
the first operation, advanced bone disease
and tertiary hyperparathyroidism secondary
to hypophosphatemic rickets.
3. Surgical Management of Hyperparathyroidism:
a 24 Year Experience, (6) published in
September, 1995. A total of 130 patients
from 1971-1994 were included. Females
predominated. The average age was 56.7
years ranging from 18-83 years. Renal lithiasis
and bone changes were seen in 66.6%
of the patients and 28.1% were asymptomatic.
Adenomas were seen in 93.1%, hyperplasia,
5.4%, one carcinoma and 9.2% had
associated thyroid lesions. No patient died
as the result of the operations.
4. Radiologic Manifestations of Hyperparathyroidism
(7) published in September, 1995.
5. Parathyroid Carcinoma: Diagnosis and Management
(8) published in November 1997.
The criteria for malignancy are: invasion of
surrounding tissues, capsular invasion, dense
fibrous septa, vascular or lymphatic metastasis,
presence of mitotic figures and visceral
metastasis (see Figure 9).
6. Clinical Profile of 128 Subjects Operated for
Primary Hyperparathyroidism (9) published
in 1998.
7. A total of 128 patients are included, females
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Figure 9: Slide of Barium swallow, gross pathology, microscopic examination.
predominate. Only 7% were asymptomatic.
Single adenomas were seen in 73.8%, 14.2
hyperplasia, four multiple adenomas, two carcinomas
and two mediastinal adenomas. The
cure rate was 93%. There were two deaths,
one from bilateral pneumothorax and one
from respiratory failure.
8. Parathyroid Surgery without Instant PTH or
Radioguided Sestamibi Scan (10) presented
at Poster Section of the Southeastern Surgical
Congress in February 2007. Fifty two
patients with primary hyperparathyroidism,
50 are normocalcemic and with normal PTH,
for a success rate of 96%. Eleven patients
had associated thyroid conditions, including
three papillary carcinomas.
9. Dr. William Méndez-Latalladi presented a paper
at the Western Surgical Association meeting
in 2007. The paper was entitled Long
Term Outcome of Patients with Elevated PTH
following Intraoperative Parathormone
Guided Parathyroidec-tomy (11). Five hundred
twenty two patients operated at the
University Of Miami School Of Medicine
were followed for 43 months. They had a
97% success rate and 505 patients remained
with normal calcium and PTH levels. Thirty
three percent (107) developed elevated PTH
levels and of these 7% had recurrent hyper-
Vol. 100 • Núm. 1 • Enero-Marzo 2008
57
parathyroidism warranting reoperation.
In Puerto Rico, no hospital has the
capability of doing instant PTH measurements
and in only two hospitals the Sestamibi
radioactive guided probe is utilized.
Since 1970 to early 2008, I have
operated 583 patients with hyperparathyroidism.
The following are some
Sestamibi Scans showing few mediastinal
lesions among this group of patients (see
next page, Figure 10).
The NIH Consensus Conference in 1990 established
the indications for surgery in hyperparathyroidism
as follows:
1. Serum calcium above 1-1.5 mgs/dl above
the normal values.
2. Urinary calcium above 400 mgs/24hours.
3. Creatinine Clearance reduced by 30%.
4. Bone density below 2 standard deviations
of normal.
5. Patients under 50 years of age.
6. Medical Surveillance not possible.
These indications were revised in another meeting
in April 2002 to include asymptomatic patients
and only minor changes were made.
The surgeon who performed the first parathyroid
operation in Puerto Rico was Dr. Francisco L.
Raffucci. This is the pathology report of the lesion

58
Figure 10: Sestamibi scans.
removed from a 65 year old female on May 17,
1960 (see Figure 11). The pathology was interpreted
by Dr. Enrique Koppisch.
The first of the initial group of patients operated
at the Puerto Rico Medical Center was a
60 year old male patient whose serum calcium
fluctuated between 12.9-15mgs/dl. A left lower
parathyroid adenoma was removed somewhere
after June 1960, measuring 4x3cm and weighing
12 grams. He developed tetany postoperatively
but was treated and recovered. The pathology
revealed a chief cell adenoma. He was also
operated by Dr. Raffucci.
Two of the authors of the first publication on
hyperparathyroidism suffered the disease and underwent
surgery in March and September 2004.
Hyperparathyroidism is an enigmatic or perplexing
disease. Generally, we have four parathyroid
glands, an unknown external stimulus makes
one of the glands to produce an excess parathyroid
hormone. Single adenoma is the most frequent
pathological finding, double adenomas are
very rare and recurrent disease is also rare.
Normocalcemic hyperparathyroidism has been
reported as well as patients with non-functioning
parathyroid adenomas. Why the external
stimulus does not repeat itself more frequently
in the remaining three glands to produce recurrent
hyperparathyroidism in a higher percent of
cases? What is the stimulus for hyperplasia when
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
all the four glands are affected? Is the stimulus
different from that producing an adenoma?
Humbleness:
We surgeons ought to have:
Intellectual and technical ability
Correct diagnosis
Surgical assistance
Peace of mind
Altruism
Empathy
Spirituality
And remember, there is always someone who
knows more than you do: another surgeon or…The
Chief of the Medical Staff (see Figure 12).
I leave you with a quotation by the late Dr.
Gumersindo Blanco: “In life there is only chance,
change and death”.
ACKNOWLEDGMENTS:
Dr. Sylvia Barceló, Director of the Outpatient
Clinics at the Puerto Rico Medical Center, and
Mrs. Lisandra Brenes Torres, Manager of the
Health Information Division of the Medical Center,
who devoted their time and effort in trying
to retrieve the old records of the first patients
who suffered this disease.
RESUMEN
Se presenta la historia del descu-brimiento
de las glándulas paratiroides y de la enfermedad
de hiperparatiroidismo a nivel mundial. Se
describen los síntomas, la operación y los
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Figure 11: Raffucci operative report.
Figure 12: Chief of medical staff.
Vol. 100 • Núm. 1 • Enero-Marzo 2008
59
hallazgos patológicos del primer paciente
operado de hiper-paratiroidismo en Viena, Austria
en el 1925. Luego se mencionan los otros
dos pacientes más famosos que tuvieron
hiperparatiroidismo en Estados Unidos. A lo
largo del artículo se indica la participación de
varios estudiantes de medicina que aportaron
grandes conocimientos a esta enfermedad.
Luego a nivel local se indica quién fue el cirujano
que operó el primer paciente con
hiperparatiroidismo primario en Puerto Rico en
el 1960. Se señalan las indicaciones para operar
a estos pacientes, al igual que las pruebas
utilizadas para identificar las glándulas afectadas.
Se discuten los síntomas del primer paciente
operado por el autor en el 1970. Se resumen
las publicaciones sobre este tema en Puerto Rico
y la experiencia del autor desde el 1970 tratando
pacientes con hiperparatiroidismo. Finalmente,
se plantean unas aseveraciones sobre lo
enigmático de esta enfermedad.

60
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REFERENCES
1. DuBose J., Ragsdale T., Morvant J. “Bodies So Tiny”: The History of Parathyroid Surgery, Current Surgery Vol 62/Number 1 January/
February 2005 Pag. 91-95
2. Organ, C.H. The History of Parathyroid Surgery J Am Coll Surg 191:284-299
3. Haddock L., Vázquez Plard J., Aguiló F., Vázquez María del C., Raffucci FJ., Velázquez J. The Clinical, Biochemical, Operative and
Pathological Análisis of 14 Cases with Primary Hyperparathyroidism Bol. Asoc. Med PR Vol 62 Number 3, Pages 76085, March 1970.
4. Vázquez-Quintana, E., Quintana, C., Aguiló F., Pagán Sáez H., Silva F., Localization of Parathyroid Lesions: Blind Study for Surgeons
Bol. Asoc. Med PR Vol. 81:343-344 Sept. 1989
5. Vázquez-Quintana, E., Haddock, L., Aguiló, F., Sotomayor, R., Ramírez, M., Vázquez-Plard, J., Rabell, V., Pagán-Sáez, H. Unusual
Cases of Hyperparathyroidism Puerto Rico Health Sciences Journal Vol. 14, No.3, September 1995
6. Vázquez-Quintana, E. Surgical Management of Hyperparathyroidism: a 24 Year Experience Bol Asoc. Med PR Vol. 87, No. 7-8-9 July-
September 1995
7. Vázquez-Quintana, E., Pagán Sáez, H.,Bayrón Vélez, F., de Jesús, M. Radiologic Manifestations of Hyperparathyroidism Bol. Asoc. Med.
PR Vol. 87 July- Sept. 1995
8. Vázquez-Quintana, D. Parathyroid Carcinoma: Diagnosis and Management- The American Surgeon Vol. 63, No.11. Pag .954-957,
November 1996.
9. Haddock, L., Aguiló, F., Vázquez-Quintana, E., Vázquez, María del C., Rabell, V., Allende, M. Clinical Profile of 128 Subjects Operated
for Primary Hyperparathyroidism Puerto Rico Health Sciences Journal Vol.17, No. 4, Pag. 309-316 Dec. 1998
10. Vázquez-Quintana, E., Vázquez-Torres, DE., Parathyroid Surgery Without Instant PTH or Radioguided Sestamici Scan Submitted for publication
11. Méndez-Latalladi, W., et al. Long Term Outcome of Patients with Elevated PTH following Intraoperative Parathyroid Hormone Guided
Parathyroidectomy Submitted for publication.
Vol. 100 • Núm. 1 • Enero-Marzo 2008

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Vol. 100 • Núm. 1 • Enero-Marzo 2008
61
Artículos de Repaso • Review Articles
28 TH F.L. RAFFUCCI RESEARCH FORUM ABSTRACTS
February 21, 2008, La Concha Hotel, San Juan, Puerto Rico
1. Results of the Malpractice Survey in
San Juan
By: Norma I. Cruz, M.D., Puerto Rico College of Physicians
and Surgeons, District of San Juan
Introduction: The current medical liability insurance
crisis has changed the way medicine and
surgery are practiced. To evaluate the extent of
these changes and the frequency of malpractice
claims in our community, the District of San Juan
of the Puerto Rico College of Physicians and Surgeons
performed a survey.
Method: A questionnaire, consisting of 15
items which evaluated medical liability, was mailed
to all physicians in the San Juan District. The questionnaire
requested information on basic demographics,
medical specialty, insurance company
used, annual premium paid, umbrella coverage,
changes made in their medical practices to decrease
medical liability risk, malpractice claims received
during the last ten years, and if awards exceeding
insurance coverage were paid. Physicians were
requested to return the completed questionnaires
by FAX or mail to the main office of the Puerto
Rico College of Physicians and Surgeons. The questionnaires
were mailed in October 2006 and replies
were received up to the end of January 2007 (a three
month period). All information received was analyzed
using the computerized statistical program SPSS (Statistical
Package for the Social Sciences).
Results: A total of 432 completed questionnaires
were returned. Since the region has 3,558
physicians on the mailing list, 12% of the group
participated in the survey. The mean age of the
responders was 51± 13 and 72% were males. The
mean time in practice was 21 years and 86% were
specialists. The main professional liability insurance
carrier was SIMED (82%) followed by Triple S
(12%). Umbrella coverage, in addition to basic liability
insurance, was carried by only 11% of the
responders. Changes in their medical practices to
decrease medical liability risk had been made by
76% of the physicians. Currently, 59% of physicians
do not accept emergency cases and 72% do
not accept high risk patients. If we add the responders
that indicated that they plan to “close their
office”, “leave Puerto Rico”, or “retire” it appears
that Puerto Rico would lose 63% of its medical
manpower. Malpractice claims were received at
least once in the previous ten years by 44% of the
physicians. The awards requested by these claims exceeded
the insurance coverage 79% of the time. However,
after the final court decision was reached, only 28%
of the payments exceeded the insurance coverage.
Conclusion: The medical liability crisis has
affected the majority of physicians in San Juan, leading
76% of them to make changes in their practices
to decrease the risk. As a result of these
changes, the number of physicians willing to care
for high risk and emergency patients has decreased
significantly. The problem is compounded by malpractice
awards that exceed a physician’s insurance
coverage 28% of the time.

62
2. Role of Surgeon-Performed Ultrasound
in Predicting Malignancy in Patients with
Indeterminate Thyroid Nodules
By: William Méndez-Latalladi, M.D., John I. Lew, M.D.,
Steven Rodgers, M.D., George I. Irvin, M.D. and Carmen C.
Solorzano, M.D., Dept of Surgery, Med. School, UPR, Div. of
Endocrine Surgery, Dept. of Surgery, Univ. of Miami-Miller
School of Medicine, Miami, Fl
Introduction: Certain ultrasound features can
predict malignancy in patients with thyroid nodules.
The purpose of this study was to determine the value
of office based surgeon-performed ultrasound (SUS)
in predicting thyroid nodule malignancy in patients with
indeterminate fine needle aspiration (FNA) cytology.
Method: From 2002 to 2007, 477 consecutive
patients underwent FNA of dominant thyroid nodules.
Of these patients 180/477 (38%) were judged to have
indeterminate FNA: follicular neoplasm (FN, n=108),
Hurthle cell neoplasm (HN, n=29) and “suspicious
papillary thyroid cancer” (SPTC, n=43). SUS-characteristics
for thyroid nodules were recorded prior to thyroidectomy
and entered into a prospective database.
Data points analyzed included patient’s age and sex,
nodule size, shape, echogenicity, consistency (solid/
cystic), borders, multiplicity/multi-centricity and presence
of microcalcifications. Features of thyroid nodules
were compared to final pathology. Univariate and
multivariate analyses were performed. The accuracy
of individual SUS features as well as the presence of 2
or more adverse features in predicting malignancy was
also examined.
Results: There were 144 females and 36
males. The mean age was 52 years (17-87). The
mean tumor size was 2.7cm (0.65-6.6). Overall,
final pathology revealed cancer in 91/180 (50%)
patients. Malignancy was present in 40/108 (37%)
FN, 11/29 (38%) HN, and 40/43 (93%) SPTC.
On univariate analysis, the presence of
microcalcifications correlated highly with malignancy
with a specificity, positive predictive value
(PPV), and accuracy of 81%, 75%, and 70%, respectively.
On multivariate analysis, solid nodules,
shape (taller>wider), hypoechogenicity and presence
of microcalcifications were significantly associated
with malignancy (p

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
cancer in this population. When compared by HI,
diabetes increases the occurrence of breast cancer
5.7 times in the public compared to 2.9 in the private
HI. These findings suggest that diabetes is associated
with breast cancer, especially in the public
HI population.
Conclusion: Diabetes increases the occurrence
of breast cancer 4.5 times in the Puerto Rican population
evaluated. Further studies will analyze clinical
and economic factors that might contribute to
this difference.
4. The Role of Non-Invasive Imaging
Studies in the Diagnosis of Right Blunt
Diaphragmatic Rupture: A Case Series and
Review of Literature
By: Suhein D. Galloza, M.D., Pablo Rodriguez, M.D., Quirico
Canario, M.D., Emmanuel Agosto, B.SE, Gori Ballester, M.D.,
Wilma Rodríguez, M.D. and Fernando Joglar, M.D., Puerto
Rico Trauma Center and Dept. of Surgery, UPR
Introduction: Diaphragmatic injuries represent
approximately 0.8-5% of blunt chest and abdominal
trauma. The diagnosis is frequently missed or
delayed in the acute phase because they present
with variable clinical and radiological signs. A misdiagnosis
represents a risk for complications (e.g.
organ herniation), consequently increasing morbidity
and mortality. A high index of suspicion and
an aggressive search should continue in patients
at risk, especially those that have failed to
progress clinically.
Objective: To evaluate current diagnostic modalities
for the diagnosis of right diaphragmatic rupture
in blunt trauma patients in an effort to improve
early identification of this injury.
Method: A retrospective chart review of all the
cases of right traumatic diaphragmatic rupture admitted
to the Puerto Rico Trauma Center between
November 2006 and July 2007 was performed. In
this study a retrospective analysis of the chest radiograph
(CXR), ultrasound, and computed tomography
(CT scan) were performed to evaluate the
possibility of unnoticed injuries, and to note any sign
that might be helpful in the assessment of future
cases. The images were reviewed by a trauma attending
and a senior level radiology resident for signs
that were suggestive of right diaphragmatic rupture.
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63
Results: During the study period a total of
1,185 patients were admitted to the Puerto Rico
Trauma Center. From this population of patients
873 (73.9%) were admitted due to blunt injuries,
and 252 (21.3%) due to penetrating injuries. Blunt
diaphragmatic rupture was diagnosed in 8 patients
(0.92%). Right traumatic diaphragmatic rupture
secondary to severe blunt trauma resulting from
motor vehicle accidents was identified in two females
and one male ranging in age from 46-62,
representing 0.3 % of the admissions during the
study period.
Retrospective review of the initial CXRs and
CT scans failed to demonstrate signs suggestive
of diaphragmatic rupture. The right upper quadrant
view of the Focused Abdominal Sonography
for Trauma (FAST) showed a diaphragmatic discontinuity
that was suggestive of a rupture of the
right hemidiaphragm during the initial assessment
of one case. All of the cases presented with refractory
hemothorax and pleural effusions despite
chest tube drainage. Initial studies did not identify
the diaphragmatic injuries and a video-assisted
thoracoscopy failed to identify the injury
in one of the cases. In terms of follow-up imaging
studies after the admission, the CXR of case
1 showed elevation of the right hemidiaphragm;
the CT scan of case 3 demonstrated the liver
herniating into the right thoracic cavity, and an
ultrasound confirmed discontinuity of the right
hemidiaphragm. Fluoroscopy was used for case
2 preoperatively, demonstrating abnormal diaphragmatic
motion.
Conclusion: The use of the ultrasound can be
a valuable tool for the evaluation of the diaphragm
in addition to the CXR and CT scan. The diaphragmatic
discontinuity observed by ultrasound was the
key sign that raised the suspicion of a right diaphragmatic
rupture. Neither the CXR nor the CT
scans were suggestive of a right diaphragmatic rupture
at the initial evaluation. The fluoroscopy was
a helpful alternative that suggested a diaphragmatic
rupture; however, this is not always a feasible test.
Sequential films and additional studies were needed
in order to diagnose the diaphragmatic rupture.
Further prospective studies are needed to provide
a concrete conclusion.

64
5. Carotid Endarterectomy Under Regional
Anesthesia: Our Experience at the Puerto
Rico Veterans’ Administration Hospital
By: Luis Rodriguez-Escolá, M.D., Gustavo De Jesús-Gómez, M.D.,
Carlos Calimano-Guardiola, M.D., Norma Santiago-Rivera, M.D.
and Ernesto Rivé-Mora, M.D., Vascular Surgery, VA.
Introduction: Endarterectomy is the standard
treatment for symptomatic and critical carotid artery
stenotic lesions. Controversies persist on many technical
issues, one of which is general versus regional
anesthesia. We present our experience with Carotid
Endarterectomy (CAE) under regional anesthesia.
Method: This is a descriptive study on a retrospective
analysis of all patients who underwent CAE
in the Puerto Rico Veterans’ Administration Medical
Center from 2005-2007. All pertinent data was recovered
from the Computerized Patient Record System
(CPRS electronic patient record system).
Results: The patient population for the study
period consists of a total of 50 subjects. Demographic
information did not vary significantly among studied
individuals. A significant amount of comorbid conditions
were encountered, among which hypertension
and diabetes were most common. The mean age for
our study population was 70 years with an age range
between 65 and 95 years. The indication for endarterectomy
was evenly distributed among symptomatic
and asymptomatic lesions. All procedures were completed
under regional / local anesthesia. All procedures
were performed by the same Vascular Surgeon
and a General Surgery senior resident. Average operative
time was 135 minutes, ranging from 75 min
to 150 min. Mean length of stay was 2 days. All
patients were followed-up at clinics for a minimum of
2 weeks post surgery. So far, during this time period,
we have not encountered any complications.
Conclusions: We hope to provide additional evidence
that Carotid Endarterectomy under Regional
Anesthesia is safe and appealing. This investigation is
ongoing, final results are not yet available.
6. Pediatric Brain Tumors in Puerto Rico
By: Manuel F Saavedra M.D., Juan Vigo Prieto, M.D., Iván
Sosa, M.D., Lincoln Jiménez, M.D. and Indira De Jesús Alvelo,
M.D., Division of Neurosurgery, Pediatric Hospital PRMC, UPR
Introduction: Brain tumors are the second
most common malignancy among children and
the most common form of solid tumor. We have
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
studied the incidence and important characteristics
of pediatric brain tumors in our population.
Data was collected from the Pediatric Hospital
at the Puerto Rico Medical Center which is the
only full time Neurosurgical Pediatric Center in
the Island and provides this service for our current
population.
Method: We collected data retrospectively,
during 5 and _ year period from January 2002 to
July 2007. The information was reviewed from the
Neurosurgical Procedures Data Base and the Medical
Records of the University Pediatric Hospital of
Puerto Rico Medical Center. We included all pediatric
neurosurgical procedures for brain tumors and
excluded recurrent tumors, spinal tumors and other
scalp and skull tumors. Data was analyzed and compared
with current literature.
Results: The incidence rate for pediatric brain
tumors was 1.99/100,000 child per year. Patients
most commonly involved were between the ages of
9 to 19 years old, male more affected than female
and the Supratentorial region the most common
affected area. By far the most common single tumor
was the Pilocytic Astrocytoma WHO I representing
30% of the total cases.
Conclusion: The incidence rates for pediatric
brain tumors in Puerto Rico are somehow different
from current literature, supratentorial tumors were
more common in this population. The variable of
Hispanic Population may have a role on this issue.
Further studies need to be conducted.
7. Surgical Incidence of Central Nervous
System Tumors in Puerto Rico
By: Gisela Murray, M.D. Lincoln Jimenez, M.D., Frankie Báez,
M.D., Liliam Colón, M.D, and Ricardo H. Brau, M.D., Section
of Neurosurgery and Dept. of Pathology, Med. School, UPR
Introduction: Published studies regarding the
incidence of central nervous system (CNS) tumors in
Puerto Rico are exceedingly rare. The general understanding
is that the incidence of these tumors in Puerto
Rico is similar to the one found in the United States.
The objective of this study is to describe the specific
profile of all the CNS tumors that are surgically intervened
in Puerto Rico. To the best of our knowledge,
this is the first study of its kind in Puerto Rico.
Method: A retrospective analysis of all the surgical
procedures from January 1, 2002 to May 31, 2006
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
for adult CNS tumors in Puerto Rico was performed.
Each case was evaluated for demographic information,
operative procedure, lesion description and official
pathological report. Recurrent lesions were excluded.
The information was organized to form a database
of all the CNS neoplasms.
Results: A total of 1,018 procedures for CNS
tumors were performed on 1,005 patients. The
incidence rate of CNS tumors in Puerto Rico is 6.7
per 100,000 people. The most common histological
type found was Meningioma WHO I (24%), followed
by pituitary adenomas (16%), and Glioblastoma
Multiforme (14%). Among the spinal cord tumors,
Schwannomas were the most frequent (20%).
Conclusion: Our results reflect a unique histopathological
distribution of CNS tumors in Puerto Rico.
In our series, primary tumors are more common than
metastatic tumors. Benign histological tumors were
more frequent than more malignant variants. Although
this study reflects only the histologically diagnosed tumors,
it is headway towards diagnosing the exact incidence
of CNS tumors in Puerto Rico.
8. Distal Fragmented Port Catheter: Case
Report and Review of Literature
By: Norman E. Colón-Casasnovas, MS3 and Humberto Lugo-
Vicente, M.D., Section of Pediatric Surgery, Dept. of Surgery,
Med. School, UPR
Introduction: Insertion of long-term central
venous catheters (CVC) plays a vital role in providing
continuous venous access for therapy in children.
CVC line fractures are most commonly seen
after long-term periods of therapy during removal.
Usual place of rupture is proximal, at the point of
entrance of the catheter into the vein, when the
subclavian approach is utilized. We discuss a case
that shows that CVC can also fracture in places
different than the most common location and is
possible not to detect that a fracture has occurred
if a substantial portion of catheter is removed.
Method: We report a two-year-old child that
was incidentally found to have a distal fragmented
piece of CVC left after previous “successful” removal
on simple chest films. At time of removal the catheter
length was deemed properly. A CT Scan confirmed
the suspected diagnosis. Fragment of catheter
was successfully removed via femoral percutaneous
endovascular technique.
Vol. 100 • Núm. 1 • Enero-Marzo 2008
65
Results: CVC fractures can be suspected when
there is resistance during removal or the length retrieved
is too short. In this case the ease of retrieval
and unusual site of rupture was the cause of not
noticing that a part of catheter remained fixed to
the vessel wall. Different potential mechanisms of
CVC rupture include mechanical trauma, manufacturing
defect or material degradation. Ruptures
should be detected early to prevent complications
such as sepsis, endocarditis, thrombosis, embolization,
vessel stenosis and dysrhythmia. Best method
to remove the fragmented catheter is via percutaneous
endovascular retrieval method. After catheter
removal a hyperdensity silhouette on a CXR
can mimic the fragmented portion of a catheter
known as a calcified cast or “ghost”. To differentiate
a “ghost” from an actual fragmented portion of
catheter a CT Scan is needed.
Conclusion: Most important single step in preventing
such complication is to keep record of the
patient length of catheter that was inserted to be able
to measure it after removal confirming it still has the
same length. Fragmented CVC should be removed
using percutaneous endovascular techniques.
9. Tracheostomy Decannulation: A
Retrospective Chart Review
By: Fernando Joglar, M.D., Pablo Rodríguez, M.D., Quirico
Canario, M.D., Guillermo Rivera, MS4, Laura Santos, M.D.,
Marian Báez, M.D., Suhein D. Galloza, M.D. and Ada Lebron,
M.S., Trauma Section, Dept. of Surgery, Med. School, UPR
Introduction: The benefits of tracheostomy in
patients on prolonged mechanical ventilation have
been well described. Studies have shown that early
tracheostomy decreases the length of stay in the
trauma intensive care unit, vocal cord ulceration and
subglottic inflammation. Of notice is that the majority
of these studies have focused on the timing of
tracheostomy placement, but little has been written
about the decannulation process and the outcomes
of patients after decannulation. We evaluated
the long-term outcomes of tracheostomized
trauma patients after in-hospital decannulation.
Method: A retrospective descriptive chart review
of 160 patients admitted to the Trauma Intensive
Care Unit at the Puerto Rico Trauma Hospital
over a 28 month period (September 2003-December
2005) who underwent tracheostomy was con-

66
ducted. Information about demographics, admission,
diagnoses, duration of mechanical ventilation,
cannulation times, complications, and outcomes was
gathered. Follow-up information was obtained from
the speech pathology decannulation protocol registry
of our Trauma Hospital. Chi-square and student
t-test analyses were used to compare and describe
the groups that developed complications as
well as the groups that were decannulated early (25 days).
Results: Of the 160 charts reviewed, 26 patients
died and 29 patients were lost to followup.
There were 105 patients included in the
analysis, 92 males and 13 females, with a mean
age of 37 ± 17 years. The mean cannulation time
was 42 ± 61 days (median = 25 days). The majority
of patients were successfully decannulated
during the first 50 days after tracheostomy (82%).
The complications identified were swallowing
difficulties (10.5%), hoarseness (9.5%), tracheal
stenosis (1.9%) and granulomas (1.9%). Patients
who developed swallowing problems had significantly
longer cannulation times compared to the
group that had no complications (p

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
ing. In the United States the estimated age of retirement
for general surgeons is currently higher
than in the past and the number of residents that
enter into the general surgery workforce has remained
constant. The potential effect of this trend
might result in a future crisis in the general surgery
workforce. To project the number of general surgeons
that will be active for the next five, ten and
fifteen years and to analyze the potential impact on
the general surgery workforce in Puerto Rico.
Method: A survey formulary was distributed
among the general surgeons in Puerto Rico. They
were asked to provide information such as their
expected age of retirement, years in practice, location
of practice, membership in surgical associations,
and availability for emergency department
calls. They were also asked to classify the types of
surgical procedures done as endocrine,
hepatobiliary, trauma, hernia, transplant,
laparoscopic procedures, vascular, bariatric, burns,
colorectal and oncologic. Statistical analysis was
done on the projected number of general surgeons
that will be active in five, ten and fifteen years. In
addition, the listing of graduates from the University
of Puerto Rico School of Medicine General
Surgery Residency program for the last eleven years
was reviewed.
Results: A total of 85 surgeons completed and
returned the survey formulary. Seventy-eight (91.8
Vol. 100 • Núm. 1 • Enero-Marzo 2008
67
%) out of these surgeons have an active practice
status, seven (8.2%) are currently retired. The mean
age of active surgeons is 52.5 (range: 33- 78) years
old. Thirty-four out of the 76 surgeons range from
51- 60 years old, representing 44.7% of the work
force. The average years of practice of active surgeons
is 21.2 (2- 54) years and the average expected
age of retirement is at 64.9 (50- 80) years
old. In five years 10.5% of surgeons will be retired.
Similarly, projections suggest that 31.6% and
56.6% of active surgeons will be retired in 10 and
15 years respectively. Conversely, only 40.4 % (19)
of the 47 general surgeons who graduated from the
University of Puerto Rico General Surgery Residency
during the last 11 years are actively practicing as general
surgeons, while 51.1 % (24) continued training in
a surgical subspecialty. In addition, 8.5 % (4) of general
surgery graduates have relocated to practice general
surgery in the United States.
Conclusion: The diversion of general surgeons
into subspecialties is creating a potential deficit on the
general surgery workforce in Puerto Rico. The patient
population is growing and the number of new general
surgeons is decreasing. Although the mean age of retirement
has increased for general surgeons, indicating
that surgeons remain in practice longer, this is only
a short term answer to a long term problem. If these
trends continue we will face a worsening crisis of access
to general surgical care.

68
QUESTIONS
1- The best localizing test for patients with hyperparathyroidism
consist of:
a) MRI
b) CT-Scan
c) barium swallow
d) Sestamibi Scan
e) thallium-technetium substraction scans
2- The accuracy of the Sestamibi scan depends on:
a) the concentration of iodine in the thyroid gland
b) the amount of radioactive material injected
c) number of oxyphil cells of the adenoma
d) number of follicular cells of the adenoma
e) none of the above
3- Hyperparathyroidism causes:
a) hypocalcemia and hyperphospathemia
b) hypernatremia and hypochloremia
c) hypercalcemia and hyperphosphatemia
d) hypercalcemia and hypophosphatemia
e) hyperkalemia and hyponatremia
4- Recommendation for surgery in hyperparathyroidism
includes all of the above,
EXCEPT:
a) bone, renal, gastrointestinal, or neuromuscular
symptom
b) calcium level > 11.2-12.0 mg/dL
CME Credits
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Instructions: Answer the questions below, fill in your personal information, cut and send with a check
for $20.00 payable to: Asociacion Medica de Puerto Rico.
To obtain CME four (4) credits AMA 1, you should read the three articles on Parathyroid surgery and be
able to answer four of six questions correctly.
Fill in the following information:
c) renal stones with urine calcium level > 400 mg/d
d) Bone Mass Density T score < 2.5 at any sites
e) normal creatinine clearance
5- The most common pathological hystology
found in hyperparathyroidism is:
a) adenoma
b) hyperplasia
c) carcinoma
d) follicular
e) papillary
6) The surgeon that performed the first parathyroid
operation in Puerto Rico was:
a) Enrique Vázquez Quintana
b) Gumersindo Blanco
c) Enrique Márquez
d) Francisco Raffucci
e) Fernando Noya
ANSWERS
1- (A) (B) (C) (D) (E)
2- (A) (B) (C) (D) (E)
3- (A) (B) (C) (D) (E)
4- (A) (B) (C) (D) (E)
5- (A) (B) (C) (D) (E)
6- (A) (B) (C) (D) (E)
Name _________________________________ License No. ________________
Postal Address ____________________________________________________
Telephone _______________________ Fax ______________________________
Cut along the dotted line and send answers with check to:
Asociación Médica de Puerto Rico
PO Box 9387
San Juan, PR 00908-9387
Vol. 100 • Núm. 1 • Enero-Marzo 2008

70
Informe de Casos • Case Reports
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
DISTAL FRAGMENTED PORT CATHETER:
CASE REPORT AND REVIEW OF LITERATURE
By: Norman E. Colón-Casasnovas* and Humberto Lugo-Vicente**
ABSTRACT
Background: Insertion of long-term central
venous catheters (CVC) plays a vital role in providing
continuous venous access for therapy in children.
CVC line fractures are most commonly seen
after long-term periods of therapy during removal.
Usual place of rupture is proximal, at the point of
entrance of the catheter into the vein, when the
subclavian approach is utilized. We discuss a case
that shows that CVC can also fracture in places
different than the most common location and is
possible not to detect that a fracture has occurred
if a substantial portion of catheter is removed.
Method: We report a two-year-old child that
was incidentally found to have a distal fragmented
piece of CVC left after previous “successful” removal
on simple chest films. At time of removal the catheter
length was deemed properly. A CT Scan confirmed
the suspected diagnosis. Fragment of catheter
was successfully removed via femoral percutaneous
endovascular technique.
Results: CVC fractures can be suspected when
there is resistance during removal or the length retrieved
is too short. In this case the ease of retrieval
and unusual site of rupture was the cause of not
noticing that a part of catheter remained fixed to
the vessel wall. Different potential mechanisms of
CVC rupture include mechanical trauma, manufac-
turing defect or material degradation. Ruptures
should be detected early to prevent complications
such as sepsis, endocarditis, thrombosis, embolization,
vessel stenosis and dysrhythmia. Best method
to remove the fragmented catheter is via percutaneous
endovascular retrieval method. After catheter
removal a hyperdensity silhouette on a CXR
can mimic the fragmented portion of a catheter
known as a calcified cast or “ghost”. To differentiate
a “ghost” from an actual fragmented portion of
catheter a CT Scan or echocardiogram is needed.
Conclusion: Most important single step in preventing
such complication is to keep record of the
patient length of catheter that was inserted to be able
to measure it after removal confirming it still has the
same length. Fragmented CVC should be removed
using percutaneous endovascular techniques.
Key words: hemoport, fragmentation,
chemotherapy, complication, distal
INTRODUCTION
Insertion of long-term central venous catheters
plays a vital role in providing continuous venous
access for such therapy as parenteral nutrition, longterm
antibiotics, dialysis and cancer chemo-therapy
in children and adults. 1 Central venous catheter
From the * U.P.R. School of Medicine, and ** Section of Pediatric Surgery, Department of Surgery, U.P.R. School of Medicine. Address reprints:
Humberto Lugo-Vicente MD, PO Box 10426, Caparra Heights Station, San Juan, PR 00922 . Poster presented at the 28 th
Annual Meeting Raffucci Surgical Forum, February 21, 2008, La Concha Hotel, San Juan, Puerto Rico.
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
(CVC) line fractures are most commonly seen after
long-term periods of therapy during removal of the
indwelling catheter. The usual place of rupture is
proximal, at the point of entrance of the catheter
into the vein, when the subclavian approach is utilized.
This is a well known complication recognized
as the pinch-off syndrome, which is a mechanical
occlusion of the catheter due to a narrowing of the
catheter that occurs as the catheter is compressed
between the first rib and the clavicle. 2 We present a
unique case since the site of fragmentation and rupture
of the catheter occurred at a significantly distal
site making less obvious that a fracture has occurred
since a substantial part of the catheter was properly
removed. The purpose of this case report is to
share our experience and suggest a comprehensive
step by step management plan on how to properly
detect and prevent such situation.
CASE HISTORY
A two-year-old male child with previously diagnosed
acute lymphoblastic leukemia since one year
prior to admission comes to the emergency room
of our institution with fever of one day duration.
Since the patient had been receiving peripheral
Vol. 100 • Núm. 1 • Enero-Marzo 2008
71
chemotherapy with his last dose applied three days
before the onset of fever, it raised suspicion of a
pneumonic process related to immune suppression.
A simple chest film (CXR) was ordered and it showed
a hyperdensity silhouette on superior vena cava and
right atrium suggesting the presence of a fragment
of a previously removed MedPort catheter four
months ago (Figure 1). At that time the catheter,
placed through the left external jugular vein, was
removed because the port had rotated and upon
flushing to see if the lumen was patent no blood
came out. The patient tolerated the procedure well
and the catheter length removed with the port was
deemed properly. Patient had this catheter for one
year when chemotherapy was started upon discovery
of his leukemic condition.
In addition, to rule out systemic infections a
urinalysis and blood tests were also ordered (WBC
= 6.30 [N 5.0-13.5], HGB = 11.8 [N 10.5-14.5
g/dL], MCV = 77.3 [N 80-96], NEU% = 82.2 [N
16.0-70 %], LYM% = 10.6 [N 20.0-70.0 %]). Urinalysis
showed no evidence of urinary tract infection
or blood in urine.
After evaluating the CXR the suspicion of a fragment
of a catheter or calcified cast (“ghost”) inside
the superior vena cava and right atrium lead us to
order further imaging tests. A CT scan of the thorax
without contrast (see Figure 2) showed that the
catheter tip was within the most superior aspect of
the right atrium inside a calcified cast, minimal cardiomegaly,
clear lung fields, normal anatomy within

72
the pulmonary, hilar, mediastinal and thoracic wall
components. No mass or gross lymphadenopathy
was found. Lung perfusion scan showed no evidence
or probability of emboli. A cardiac report was ordered
and it showed that the heart had normal segmental
anatomy, normal dimensions, a trivial tricuspid
regurgitation but otherwise normal flows,
normal function, no vegetations and a catheter-like
structure with definite lumen seen from innominate
vein into superior vena cava with tip in right atrium.
Blood cultures did not show growth after 24h, 2
days and 3 days.
Patient was started on broad spectrum antibiotics
and was transferred to the Cardiovascular
Hospital for further examination and removal of the
catheter fragment via femoral percutaneous
endovascular technique. The catheter fragmented
further during the retrieval procedure embolizing
each fragment to the right and left pulmonary artery
but both segments with a total length of two
centimeters were able to be removed satisfactorily
without complications. The child was discharged
from the hospital two days later.
DISCUSSION
As previously mentioned, insertion of long-term
central line catheters plays a vital role in providing
continuous central venous access for therapy such
as parenteral nutrition, long-term antibiotics and
cancer chemotherapy in children and adults. Even
though many complications with long-term application
of indwelling catheters have been previously
reported, to our knowledge, no report exists showing
the probability of a distal fracture in a central
line on the pediatric child and a plan of management
on how to prevent it. To correctly position a
CVC the tip of the hemoport catheter should lie
within the superior vena cava or right atrial junction.
Placement can be done through the external
or internal jugular vein or using the subclavian vein
approach with the port usually lying infraclavicularly
in the anterior chest area. Very rarely (incidence of
0-2.1%) proximal fragmentation with or without
embolization of the port catheter can occur spe-
3, 4
cially during removal of the port.
A distal fracture of a CVC can be suspected if
the catheter offers resistance to removal and/or the
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
length removed is too short. In our case the catheter
fracture occurred without resistance and at an
unusually distal site, when a substantial part of the
catheter was properly removed. Since the external
jugular approach was utilized the catheter length
was longer than a similar subclavian site approach.
The ease of retrieval, deceiving length and unusual
site of rupture was the cause of not noticing that the
distal part of the catheter was fixed to the vessel wall.
There are several types of catheters currently
on the market. The most commonly used materials
for long term therapy are polyurethane and silicone.
Different potential mechanisms of rupture of a catheter
include manufacturing defect, mechanical
trauma, the angle formed at the point of entry of
the catheter into the vein (the catheter being a rigid
structure), excessive hydrostatic pressure when flushing
or infusing (Polyurethane catheters ruptured at
flow rates between 4 and 15.4 mL/sec, with one
catheter not rupturing at the maximal flow rate [17
mL/sec], while silicone catheters ruptured at flow
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
rates between 0.5 to 3.5 mL/sec) 5 , material degradation,
stress due to constant motion (the constant
movement of the vein as the adjacent artery
moves as the heart beats, movement during pulmonary
inspiration/expiration, external manipulation
of the catheter), deposition of fibrin, clot or
calcium within the catheter, or the pinch-off sign
effect (a narrowing of the catheter that occurs as
the catheter is compressed between the first rib and
the clavicle).
There is much controversy in the literature regarding
which material is better in preventing complications.
For example, Gieneva et al, reported that
in 200 cases of catheter fixation to the vessel wall
194 were made of polyurethane and concluded that
silicone catheters do not become as adherent to their
fibrous sheet and vessel wall as with catheters made
of polyurethane. 6 Hla Thei et al, reported a case in
Vol. 100 • Núm. 1 • Enero-Marzo 2008
73
which a catheter made of silicon was extensively
adhered to the vessel wall. 7 Overall, catheter rupture
is probably a combination between its material
and ongoing situations to which this specific material
is susceptible to fracture. Further specific studies
remains to be performed to be able to determine
which of both materials is best in preventing
complications.
It is important to detect catheter fractures as
early as possible to provide prompt treatment and
prevent complications that are associated with intravascular
catheter remnants after removal. These
complications are well documented in the literature
and include: sepsis, endocarditis, thrombosis with
catheter fixation to the vessel wall, pulmonary abscess
from catheter embolization, vessel stenosis and
dysrhythmia with or without sudden death.
There are different possible approaches to remove
the remaining portion of a fractured catheter. Thoracotomy
and sternotomy have been used with great success
in removal but the morbidity associated with these
procedures is high in the pediatric population. We
preferred the percutaneous endovascular retrieval
method by an invasive cardiologist or radiologist due
to decreased morbidity and high success rate if per-
8, 9
formed by a skilled physician.
Sometimes the physician may think that a portion
of a catheter remains inside the patient after
removal because of hyperdensity or hyperechoic
silhouette found on a CXR or sonogram that mimics
a catheter portion. 10 This shadows is caused by
a fibrin sheath or thrombosis that forms around the
catheter and then calcifies (it is called a calcified
cast or “ghost”). 11 They suggest that the best way
of differentiating a calcified cast or ghost from a
portion of fractured catheter, if still uncertain after
extensive sonographic evaluation, is to perform a
CT scan. 10 Basically the difference is established
looking closely at the margins of the silhouette, if it
has uniform margins and a definite lumen it is a
catheter fragment, if not it is probably a “ghost”.
We prefer a CT over a sonogram since it is not
operator dependent. Also the ribs and clavicles can
make sonographic examination difficult.
The best way to diagnose a distal catheter rupture
is having a previous measurement of the length
of the catheter before it is inserted so the physician

74
is able to measure it after removal. Since distal fracture
of a catheter is a rare event, not many perform
this crucial step in detecting catheter rupture
complications. As in our case, sometimes this is an
incidental finding on a CXR film that was done looking
for respiratory infections, but it can also be an
incidental finding using sonography for other reasons.
In these situations a physician should suspect the possibility
of a remaining fragment of a fractured catheter
and should rule out the possibility of a calcified cast by
performing a CT scan or doing an extensive
sonographic analysis of the margins of the silhouette.
In terms of insertion and removal of central lines
we propose two algorithms. On algorithm 1 our
preference in selecting the insertion site of the catheter
is based primarily on accessibility, risk of complications
and caliber of the vein. The pediatric
population has a smaller vessel caliber compared
to the adult population. The prevention of future
complications caused by possible stenosis in the
present pediatric population and risks during the
procedure are forces that guided us in choosing this
particular order. It has been well established in the
literature that in as fast as two weeks a central line
catheter causes stenosis of the subclavian vein. 12
The external jugular vein is our first choice because
it’s the most accessible compared to internal jugular
vein and the subclavian vein and has the lowest
risk of complications. Our second choice is the internal
jugular vein which is deeper and has more
risk of complications compared to the external jugular.
13 Compared to the subclavian vein it has a larger
caliber and a lowest risk of complications. Our third
choice would be the subclavian vein because compared
to the other two has a higher risk of complications
such as pneumothorax, hemothorax, arrhythmia
and stenosis. There is no need for performing
chest films after successful insertion of catheter
if it is done under fluoroscopy. 14
As depicted in algorithm 2, during catheter removal
the most important step is to measure the
length of the catheter after each successful removal.
If the catheter measures less than during insertion
a distal fracture has occurred during retrieval and a
chest film should be taken. With a retained fragment
we suggest to place the patient in broad spectrum
antibiotics to prevent infections, order a chest
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
CT scan without contrast for exact localization of
fragment and surgery procedure planning, and consult
interventional radiology or cardiology for
15, 16
endovascular percutaneous retrieval.
RESUMEN
La inserción de catéteres venosos centrales
(CVC) juega un rol vital en proveer terapia de acceso
venoso a niños. Fractura de estos catéteres suele
verse luego de su uso prolongado al tratar de
removerlos. El sitio usual de ruptura es proximal
donde el catéter entra en la vena cuando se usa el
abordaje de la subclavia. En este reporte discutimos
un caso donde el CVC se fracturó en su parte mas
distal y no se detectó que una fractura había ocurrido
cuando se removió el catéter.
Este es un niño de dos años que se encontró
incidentalmente que tenía un pedazo de CVC distal
fragmentado en una placa de pecho. Cuando el catéter
se removió se daba por hecho que había salido
completo. Un CT-Scan confirmó el diagnostico y el
catéter se removió satisfactoriamente usando la técnica
percutanea endovascular.
Fracturas de CVC se deben sospechar cuando
hay resistencia al removerlo o si el largo que se
remueve es muy corto. Existen diferentes
mecanismos potenciales para la ruptura de estos
CVC que incluyen trauma mecánico, defecto de
manufactura o degradación del material de que están
hechos. La ruptura se debe detectar temprano parta
evitar complicaciones como sepsis, endocarditis,
trombosis, embolización, estenosis del vaso
sanguíneo o arritmias. El mejor método para remover
el catéter fragmentado es usando la técnica
endoscópica percutanea. Luego de remover un
catéter una silueta hiperdensa que se ve en placa
sencilla de pecho puede representar un tracto
calcificado o ‘fantasma’. Para diferenciar este tracto
o ‘fantasma’ de un pedazo de catéter se debe hacer
un CT-Scan o ecocardiograma.
El paso mas importante en prevenir tal
complicación descrita es mantener en el expediente
medico del paciente el largo del catéter que se puso
originalmente y medir el largo al removerlo para
determinar si el catéter salió completo o no.
Catéteres fragmentados se deben remover usando
la técnica percutanea endovascular.
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
REFERENCES
1- Courtney M. Townsend Jr., et al: (2004) Sabiston Textbook of Surgery. 17th Ed. Philadelphia: Elsevier Inc pp. 2081
2- DA Andris, EA Krzywda, et al: Pinch-off syndrome: a rare etiology for central venous catheter occlusion. J Parenter Enteral Nutr. 18(6):531-
3. 1994
3- Klotz HP, Schopke W, et al: Catheter fracture: a rare complication of totally implantable subclavian venous access devices. J Surg Oncol.
62(3):222-5, 1996
4- Jones SA, Giacomantonio M: A complication associated with central line removal in the pediatric population. J Pediatr Surg. 38(4):594-
6, 2003
5- Salis AI, Eclavea A, et al: Maximal flow rates possible during power injection through currently available PICCs: an in vitro study. J Vasc
Interv Radiol. 15(3):275-81, 2004
6- Wilson GJ, van Noesel MM, et al: The catheter is stuck: complications experienced during removal of a totally implantable venous access
device. A single-center study in 200 children. J Pediatr Surg. 41(10):1694-8, 2006
7- Thein H, Ratanjee SK: Tethered hemodialysis catheter with retained portions in central vein and right atrium on attempted removal. Am J
Kidney Dis. 46(3):e35-9, 2005
8- Roye GD, Breazeale EE, et al: Management of catheter emboli. South Med J. 89(7):714-7, 1996
9- Chen CC, Liang CD, et al: Percutaneous removal of a peripherally inserted central catheter remnant using cardiac catheterization. Pediatr
Int. 48(4):430-2, 2006
10- Konen O, Daneman A, et al: Intravascular linear thrombus after catheter removal: sonographic appearance mimicking retained catheter
fragment. Pediatr Radiol. 34(2):125-9, 2004
11- Hughes DB, Ullery BW, Spigland N: Formation of a calcified “cast” in a long-term indwelling central venous catheter: a case report. J
Pediatr Surg. 41(11):1927-9, 2006
12- Courtney M. Townsend Jr., et al: (2004) Sabiston Textbook of Surgery. 17th Ed. Philadelphia: Elsevier Inc pp. 2082
13- Belani KG, Buckley JJ, et al: Percutaneous cervical central venous line placement: a comparison of the internal and external jugular vein
routes. Anesth Analg. 59(1):40-4 1980
14- Janik JE, Cothren CC, et al: Is a routine chest x-ray necessary for children after fluoroscopically assisted central venous access? J Pediatr
Surg. 38(8):1199-202, 2003
15- Fuenfer MM, Georgeson KE, Cain WS, Colvin EV, Johnson WH Jr, Pearce FB, McMahon WS: Etiology and retrieval of retained central
venous catheter fragments within the heart and great vessels of infants and children. J Pediatr Surg. 33(3):454-6, 1998
16- Giretti R, Caruselli M, Zannini R, de Vivo E, Piattellini G, Bechi P, Catani F, Amici M, Santelli F, Pagni R: Dislocation of central venous
catheters in paediatric patients. J Vasc Access. 7(3):132-5, 2006
Vol. 100 • Núm. 1 • Enero-Marzo 2008
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76
Informe de Casos • Case Reports
HERMANSKY PUDLAK SYNDROME:
AN UNUSUAL FORM OF PROCTO-COLITIS
By: Ignacio Echenique MD.*, José M. García González MD.**, Ignacio A. Echenique MS. §,
Natalio J. Izquierdo MD.**, Juan R. Mella MA.£, Eligio Barasorda MD.*, Maria T. Mella MS. §
and Siegfried Figueroa-Boilo MD. ¥
ABSTRACT
Hermansky-Pudlak syndrome (HPS) is a rare autosomal
recessive disorder consisting of oculocutaneous
albinism, platelet dysfunction and systemic complications
associated with lipofuscin deposition in the reticuloendothelial
system. HPS has been associated with a
granulomatous enterocolitis with pathologic features
suggestive of Crohn’s disease. It remains uncertain if
HPS represents a truly distinct form of granulomatous
enterocolitis. We report a series of two patients with
HPS treated in Puerto Rico, and the results from medical
and surgical intervention for gastrointestinal disease.
Our experience with HPS patients has shown
the difficult management of perineal disease similar
in the management of Crohn’s. However, complications
from the bleeding diathesis necessitate
caution during surgery and potential anesthesia
complications. Furthermore, avoidance of a perineal
wound is preferred, and when possible, ileostomies
have fewer complications than colostomies as they
do not involve the small bowel.
Key words: Hermansky Pudlak, syndrome,
proctocolitis
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
The first description by Hermansky Pudlak syndrome
(HPS) was made in Prague in 1959. They described
two unrelated patients with oculocutaneous
albinism who had pseudohemophilia, peculiar pigmented
reticular cells in the bone marrow and pulmonary
fibrosis. HPS is also frequently associated with
pulmonary fibrosis and granulomatous colitis (1). In
the northwestern coast of Puerto Rico (PR) there is a
prevalence of 1 in 1800 while 1 in 22 are carriers,
making the island one of the places with the highest
incidence of HPS in the world. In PR, 5 out of 6 albinos
have the HPS gene (2). The first description of
an HPS patient with perineal disease presentation
was in 1989 (3). Since then until 2006 more cases
have been described (4, 5). Several genes have been
associated with the syndrome; (6, 7); however, only
HPS type 1 and HPS type 3 have been reported in
Puerto Rico (8).
In this study we present two patients with HPS
who had complicated perineal disease and granulomatous
colitis as part of the syndrome. The severe
perineal disease and recto-vaginal fistulas were the
cause for their referral to surgery.
From the *Department of Surgery, Auxilio Mutuo Hospital, Rio Piedras, P.R., § Jefferson’s Medical School Philadelphia, PA, ** Department of
Ophthalmology, UPR School of Medicine, £ Boston University, Medical School, Boston, MA, and ¥ Department of Surgery, Hospital HIMA-San
Pablo, Bayamon, PR. Address reprints to: Ignacio Echenique, MD - Office 218, Torre Auxilio Mutuo, 715 Ave. Ponce de Leon, Rio Piedras, PR,
00918. E-mail . Poster presented at the 58 th Annual Meeting American College of Surgeons, Puerto Rico Chapter, February
22, 2008, La Concha Hotel, San Juan, PR.
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Figure 1: Ceroid deposits; mucosal sparing;
skip lesions; predominately submucosal
inflammation and ulceration; and noncaseating
granulomas
CASE HISTORY 1
In 1991, we treated an 11 year-old girl from
the central region of PR with a history of HPS who
had severe rectal stricture, rectovaginal & perineal
fistulas, and severe distal colitis with lower gastrointestinal
bleeding. She failed aggressive medical
therapy and was referred for a diverting stoma.
In this operation she had significant bleeding. She
developed Pyoderma-Gangrenosa at the colostomy
site and required extensive enterostomal therapy and
wound care. A year after her fecal diversion, with
failure to improve her perineal symptoms after the
colostomy, she underwent a total proctocolectomy
with intersphincteric resection and end ileostomy.
She developed a persistent perineal wound sinus.
Her multiple fistulas continue to drain and eventually,
improved but still remained with a perineal sinus.
Histopathology showed: ceroid deposits; mucosal
sparing; skip lesions; predominately submucosal inflammation
and ulceration with non-caseating granulomas
(Figure 1). She had no pulmonary fibrosis.
CASE HISTORY 2
In 1983, a 15 year-old girl from Puerto Rico
presented HPS and severe perianal and perineal
fistulas, recto-vaginal fistula and diffused colonic
disease. After failure of treatment of her perineal
disease she underwent a total proctocolectomy and
terminal ileostomy. Postoperatively she developed
a persistent perineal sinus needing a gracilis flap,
but the perineal fistulas recurred months later. She
Vol. 100 • Núm. 1 • Enero-Marzo 2008
77
had multiple re-admissions and required multiple
interventions for small bowel obstructions and ileostomy
complications. She also developed very symptomatic
fistulization at the ileostomy site and required
resection of more than 40 cm of small bowel.
A white-grayish, wax-like material was found retroperitoneally
associated with a severe inflammatory
tissue reaction and causing obstructive uropathy.
She eventually died from complications of her disease.
She had no pulmonary fibrosis.
DISCUSSION
Shinella and co-workers first described a patient
with HPS who had granulomatous colitis and a patient
with the syndrome who had small bowel involvement.
They described a patient who had gastrointestinal
complications and presented an acute abdomen
(9). Witkop and co-workers described in their study
that ceroid lesions in HPS are associated with pulmonary
fibrosis and granulomatous gastrointestinal disease
and are the most frequent accounting for the
majority cause of deaths (2). Gastrointestinal complications
occurred in 10.6% of patients and a mortality
rate of 9% among deceased patients with the syndrome
(10). The accumulation of ceroid-like pigment in the
macrophages lysosomes is believed to cause their rupture
with release of lysosomal hydrolases, causing tissue
damage in lungs and colon. (2, 10) Patients with
HP syndrome may have a confusing clinical presentation
that may mimic Crohn’s disease. In our cases,
both patients had severe perineal disease and a very
symptomatic recto-vaginal fistula as part of the initial
presentation. They both required a total
proctocolectomy with end Ileostomy. They both had
persistent perineal sinus, one partially resolved with
gracilis flap. One patient developed terminal ileum disease
that required several surgical interventions. This
ileal involvement has been described in the literature
(13). This presentation could be easily confused with
Crohn’s Disease. The GI complications of HPS are
not the development of classical Crohn’s as has been
suggested in the literature (5). The histological difference
between Crohn’s and HPS granulomatous colitis
are the tissue ceroid deposits in HPS (10). These ceroid
deposits are not present in the granulomas of Crohn’s
Disease. It is very important to distinguish both conditions,
as the treatment for the bleeding disorder in HPS

78
requires specialized care. Patients with HPS, as part
of the syndrome, also have a bleeding diathesis due to
absence or decreased number of platelets dense bodies
(9, 10). This absence leads to abnormal platelet function,
despite the normal number of platelets. For this
reason up to 75% of patients with the syndrome have
abnormal bleeding times. Recently, Infliximab has been
reported to obtain some remission in HPS patients as in
Crohn’s and presents a possible therapy for treatment
of HPS granulomatous proctocolitis (11, 12).
Surgical management for perineal disease in
patients with the syndrome should be similar to the
one recommended for patients from the general
population with Crohn’s disease. If possible, a
perineal wound should be avoided. Ileostomies do
better than colostomies but rarely small bowel involvement
has been described without colitis (13).
Due to bleeding diathesis and potential anesthesia
complications, elective surgery or tissue biopsies
should be done with caution in patients with
the syndrome.
Patients with oculocutaneous albinism, or relatives
of a patient with the condition who are either
Puerto Ricans or Puerto Rican descendants living
in the continental U.S., must be screened to rule
out HPS. Genetic linkage analysis is available for
this purpose (8). Pre and postoperative management
between surgeon, hematologist and
pneumologist is advisable in patients with HPS, or
patients with OCA who are Puerto Rican or Puerto
Rican descendants living in continental U.S. (4, 14).
Hermansky Pudlak syndrome presents a well known
hereditary condition that shares many characteristics
with Crohn’s disease and presents a medicosurgical
challenge that requires both diseases to be
evaluated for similarities that may help in future
management of both.
A study is been conducted (2007) evaluating medical
treatments in colitis sponsored by the National Institute
of Allergy and Infectious Diseases (15). Recommendations
from this study are included in Table 1.
RESUMEN
El Síndrome Hermansky-Pudlak (SHP) es una
condición rara autosómica recesiva que consiste de
albinismo oculocutáneo, disfunción plaquetaria y
complicaciones sistémicas asociadas con el depósito
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Table 1: Recommendations for Medical
Treatment of Colitis
• Complete History and physical exam
• Hematology consultation
• Watch for partial oculocutaneous
albinism if positive family history of
albinism in a patient of Hispanic
origin, particularly from Puerto Rico
• Endoscopic biopsies may not reveal the
ceroid pigment
• Skin Biopsies
• Imaging studies
• Pulmonary evaluation
• Genetic counseling
• Avoid drugs affecting platelet function
• Avoid elective surgery or tissue biopsies
• Same management for perineal
disease as in Crohn’s
• High rate of bleeding of dysfunctional bowel
• Low Hartman’s pouch – avoid
perineal wound if possible
Ileostomies better than colostomies
de lipofusina en el sistema reticuloendoteliar. SHP
ha sido asociado con enterocolitis granulomatosa
con características patológicas sugestivas de la
enfermadad de Crohns. Sin embargo, algunos
autores aún no están seguros de que SHP represente
realmente una forma distinta de en-terocolitis
granulomatosa. El síndrome es casi exclusivamente
encontrado en pacientes de descendencia
puertorriqueña, particularmente en las regiones
central y nor-oeste de la isla.
Se reporta una serie de dos pacientes con SHP
tratados en San Juan, Puerto Rico, y los resultados
de los tratamientos médicos y quirúrgicos de las
manifestaciones gastrointestinales.
Nuestra experiencia con pacientes con SHP
nos ha demostrado la dificultad en el manejo cuando
la presentación es perineal y similar a las
presentaciones de Crohns. Sin embargo,
complicaciones por los desordenes de coagulación
nos obliga a tener cautela en operaciones y posibles
complicaciones durante anestesia. Aún más, es
preferible el tratar de evitar una herida en el perineo
y cuando sea necesario una ostomía, la ileostomías
si el íleo no esta afectado, pues tienen menos
complica-ciones que las colostomías.
Vol. 100 • Núm. 1 • Enero-Marzo 2008

BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
REFERENCES
1. Hermansky F, Pudlak P: Albinism associated with hemorrhagic diathesis and unusual pigmented reticular cells in
the bone marrow: report of two cases with histochemical studies. Blood 1959, 14: 162-169
2. Witkop CJ, Nuñez BM, Rao GH, Gaudier F, Summers CG, Shanahan F, Harmon KR, Townsend D, Sedano HO, King
RA: Albinism and Hermansky-Pudlak Syndrome in Puerto Rico. Bol Asoc. Med PR 1990, 82: 333-339.
3. Sherman A, Genuth L, Hazzi CG, Balthazar EJ, Schinella RA., Perirectal abscess in the Hermansky-Pudlak
syndrome. [Am J Gastroenterol. 1989
4 Echenique I, Hermansky Pudlack Syndrome, An Unusual form of Colitis, Eastern Colorectal Surgical Congress, Podium
Presentation, Palm Beach, Fl. 2001
5 Hazzan D, Seward S, Stock H, Zisman S, Gabriel K, Harpaz N, et al., Crohn’s-like colitis, enterocolitis and perianal
disease in Hermansky-Pudlak syndrome. Colorectal Dis. †Sep†2006; 8(7): 539-43
6 Spritz RA. Molecular Genetics of the Hermansky-Pudlak and Chediak-Higashi syndromes. Platelets. 1998, 9(1): 21-9.
7 Spritz RA. Molecular genetics of oculocutaneous albinism. Semin Dermatol. 1993 Sep; 12(3): 167-72.
8 Santiago Borrero PJ, Rodriguez-Perez Y, Renta JY, Izquierdo NJ, Del Fiero L, Muñoz D, Molina NL, Ramírez S, Pagan-
Mercado G, Ortiz I, Rivera-Caragol E, Spritz RA, Cadilla CL., Genetic Testing for oculocutaneous albinism type 1 and 2
and Hermansky-Pudlack syndrome type 1 and 3 mutations in Puerto Rico, J Invest Dermatol.2006 Jan;126(1):85-90
9 Schinella RA, Greco MA, Cobert BL, Denmark LW, Cox RP. Hermansky-Pudlak Syndrome with granulomatous colitis.
Ann Intern Med 1980, 92: 20-3.
10 Witkop CJ, Townsed D, Bitterman PB, Harmon K. The role of cerunoid in lung and gastrointestinal disease in Hermansky-
Pudlak syndrome. Adv Exp Med Biol 1989, 266: 283-296.
11 Grucela, Patel, Goldstein, Ron Palmon, Sachar, DR. Steinhagen, Granulomatous enterocolitis Associated with Hermansky-
Pudlack Syndrome. AMJ Gastroenterology 2006; 101:2090-2095
12 Erzin Y, Cosgun S, Dobrucali A, Tasyurekli M, Erdamar S, Tuncer M. Complicated granulomatous colitis in a
patient with Hermansky-Pudlak Syndrome successfully treated with Infliximab. Acta Gastroenterol Belg. 2006
Apr-Jun; 69(2): 213-6.
13 De Leusse A, Dupuy E, Huizing M, Danel C, Jian R Marteau P. Ileal Crohns Disease in a women with Hermansky
Pudlack Syndrome, Gastroenrol Clin Biol 2006,Apr;30(4):621-4
14 Izquierdo NJ, Townsend W, Hussels IE. Ocular findings in the Hermansky-Pudlak Syndrome.Trans Am Ophthalmol
Soc. 1995; 93:191-200; discussion 200-2.
15 National Institute of Allergy and Infectious Diseases (NIAID) Medical Treatment of Colitis in Patients With Hermansky-
Pudlak Syndrome http://clinicaltrials.gov/ct2/show/NCT00514982?cond=%22Hermanski-Pudlak+
Syndrome%22&rank=1.
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Vol. 100 • Núm. 1 • Enero-Marzo 2008
81
Informe de Casos • Case Reports
LAPAROSCOPIC NEPHRECTOMY WITH
LAPAROSCOPICALLY ASSISTED TRANSVAGINAL
EXTRACTION OF INTACT KIDNEY
ABSTRACT
Purpose: Describe the first laparoscopic
transperitoneal nephroureterectomy followed by
laparoscopically assisted transvaginal extraction of
the intact kidney performed in Puerto Rico.
Case History/Results: A 39 year-old female
patient consulted her urologist regarding chronic
urinary tract infection. A diagnosis of a non-functioning
left kidney was made, secondary to long
standing obstruction due to a distal ureteral stone.
Laparoscopic nephroureterectomy procedure was
performed and the intact specimen was removed
through a transverse posterior colpotomy. Patient
was discharged home the next day without intraoperative
or post-operative complications.
Conclusions: Laparoscopic nephrec-tomy with
transvaginal extraction of the intact specimen provides
a surgical option as a minimally invasive technique
with very few functional and cosmetic compromises
and with low post-operative morbidity
when performed in appropriate female patients.
Key words: laparoscopy, nephrectomy,
transvaginal
INTRODUCTION
The combination of laparoscopic nephrectomy
with vaginal delivery of the intact kidney has been
By: Alfonso Serrano-Ysern MD.*, Alvin Lopez MD.**, Freddie Mendez MD.**,
Lianette Perez MD.* and Jaime Acosta MD.
previously described in the urologic literature (1-4).
Many abdominal procedures which once required
large skin incisions can now be performed
through smaller incisions with the associated advantages
of less morbidity and improved cosmesis.
Usually, to remove the intact specimen after
laparoscopic nephrectomy a 4–8 centimeters incision
is needed (5).
The laparoscopic nephrectomy is a procedure
which uses minimally invasive surgical techniques,
with low post-operative morbidity. This procedure
can be done transperitoneally or retroperitoneally
and used for both, benign and malignant diseases
(6-11).
Controversy exists between intact extractions
of the specimen versus morcellation. With the morcellation
technique for extraction of renal tumors,
the specimen can be evaluated for histology but not
for pathological staging (5,12).
Colpotomy is an old technique with minimal
morbidity, used by the gynecologist for diagnostic
and therapeutic purposes in selected patients (13).
This technique provides an excellent route for cases
where a voluminous specimen extraction is needed.
In addition it has the advantage of leaving a small
hidden scar from an esthetic point of view.
* From the Department of Obstetrics and Gynecology, and ** Department of Urology, Hospital Interamericano de Medicina Avanzada (HIMA),
Caguas, Puerto Rico. Address reprints: Alfonso Serrano-Ysern MD, P.O. Box 4980, Caguas, Puerto Rico 00726-4980. E-mail:
. Poster presented at the 58 th Annual Meeting of the American College of Surgeons, Puerto Rico Chapter, February 22, 2008,
La Concha Hotel, San Juan, Puerto Rico.

82
Figure 1: KUB, left kidney with multiple calculi
(see arrows) and left distal ureteral calculi.
Figure 3: Renal diuretic scan using 99mTc-MAG3 with
non-visualization of the left kidney throughout the
study which suggested a non-functioning left renal unit.
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Figure 2: (CT) scan showed left renal atrophy,
multiple calculi (see arrow),
hydroureteronephrosis secondary to a left distal
ureteral calculi and perinephric fatty stranding
We describe the first laparoscopic transperitoneal
nephroureterectomy followed by laparoscopically assisted
transvaginal extraction of the intact kidney performed
in Puerto Rico (March, 2005).
CASE HISTORY
A 39 year-old woman was seen in a urologic
consult for evaluation due to chronic urinary tract
infections. Workup included a computed tomography
(CT) scan which showed left renal atrophy with
multiple calculi including hydroureterone-phrosis
secondary to a left distal ureteral calculi and perinephric
fatty stranding. A renal diuretic scan using
99mTc-MAG3 revealed non- visualization of the left
kidney throughout the study which suggested a nonfunctioning
left renal unit. (Fig. 1,2,3)
A gynecologic consultation was obtained in this
patient (gravida 3, para 3, abort 0) with 3 previous
cesarean sections. She was asymptomatic, the
physical examination including the gynecologic examination
was unremarkable (weight: 68 Kgs.,
height: 152 Cms.). Informed consent was obtained
for laparoscopic nephroureterectomy and transvaginal
extraction of the specimen.
During surgery, the patient was placed in the
modified lateral decubitus position, left side up with
legs in stirrups. The urology team performed a
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
laparoscopic transperitoneal nephroureterectomy
using 4 ports. Operative time was 250 minutes.
After completion of the primary laparoscopic procedure
the specimen was placed into a retrieval bag.
(LapSac® 8x10” / Cook®)*
The operating table was positioned to the side so
that the patient rested in the lithotomy and
Trendelenburg positions. There was no need to place
a new port and only previous trocars were used. The
pelvis was visualized and adhesions were lysed. The
laparoscope was pushed behind the uterus into the
cul-de-sac so that the surgeon making the vaginal incision
could use the light through the vagina.
A transverse posterior colpotomy (13) was
done. The index finger was used to displace the
rectum and the peritoneum was opened without
danger of injury to the bowel. The vaginal incision
was extended sharply by stretching to approximately
5-6 centimeters. The retrieval bag (LapSac®) drawstring
was pushed through the vaginal incision; and
while exerting a downward pressure the surgeon
pulled the drawstring and removed the intact kidney
in the retrieval bag.
The posterior colpotomy incision was repaired
with interrupted mattress absorbable sutures, including
all layers. Operative time for the vaginal extraction
procedure was 45 minutes. Blood loss was
minimal and the specimen weighed 238 grams. No
intra-operative complications occurred.
The postoperative course was uneventful.
There was no vaginal spotting and the patient was
discharged home the next day.
The pathologic examination revealed a left kidney
surrounded by perirenal fat. Also attached to
the kidney was the ureter, and at the distal margin
of the resection the obstructing calculus was identified.
Pathologic diagnosis was: Ureterolithiasis,
hydronephrosis, chronic pyelonephritis and chronic
glomerulonephritis consistent with the clinical diagnosis
of non-functional kidney. (Fig.4)
DISCUSSION
The first laparoscopy on a human was performed
in 1910 by the Swedish Doctor H.C.
Jacobeus (14). In 1911, Doctor Bertram M.
Bernheim (15) of Johns Hopkins University was the
first to perform laparoscopic surgery in the United
Vol. 100 • Núm. 1 • Enero-Marzo 2008
83
Figure 4: Specimen weighed 238 grams. Kidney
surrounded by perirenal fat, attached was the ureter,
and at the distal margin of the resection the
obstructing calculus was identified (see arrow).
States. The technique of posterior colpotomy was
described by Bradbury (13) in 1952.
Laparoscopy and colpotomy have long been used
by gynecologists for diagnosis and treatment of pelvic
pathology. In the early 1970s, therapeutic laparoscopy
was introduced by gynecologists. Rapid technical advances
in miniaturized surgical tools, fiber optics, and
video systems enabled new developments in minimally
invasive surgical techniques and the substitution of laparotomy.
These methods greatly reduced post-operative
complications (15).
The first laparoscopic nephrectomy was described
by Clayman et al (16) in 1991. The laparoscopic nephrectomy
procedure is now well established with considerable
advantages such as decreased post-operative
morbidity, decreased analgesic requirements, improved
cosmesis with a shorter hospital stay and convalescence
(6-9,12,11,17).
The combination of laparoscopic nephrectomy
and vaginal extraction of the intact specimen was

84
reported in 1993. Breda et al (1) reported the extraction
of a non cancerous kidney and Dauleh (2)
reported the extraction of two kidneys, one using a
retrieval bag and the other removed intact but not
protected by a bag. Gill et al (3) described in 2002
ten cases of vaginal extraction of kidney after
laparoscopic nephrectomy using a retrieval bag and
Sunoo et al (4) reported one case of laparoscopic
radical nephrectomy with vaginal delivery and retrieval
bag in 2005.
Contraindication for this type of surgical intervention
includes such systemic conditions as chronic obstructive
pulmonary disease with hypercarbia, ascites,
bleeding diatheses, bowel obstruction and acute or
chronic vaginal pathology. Previous history of renal,
abdominal or pelvic surgery is a relative contraindication.
This procedure should be individualized, based
on the surgeons experience (8,13).
Hand assisted laparoscopic donor nephrectomy
has gained acceptance. This technique is likely to become
the “gold standard” in the near future (18). In
this particular setting it is necessary to obtain the intact
specimen with minimal trauma and the posterior
colpotomy would need further investigation to consider
it a surgical option in donor females.
CONCLUSION
This report describes the first transperitoneal
nephroureterectomy for benign disease with transvaginal
extraction of the intact kidney, using
laparoscopically assisted posterior colpotomy, performed
in Puerto Rico.
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
Transvaginal extraction of the intact specimen
provides a surgical option for both benign and malignant
disease processes, as a minimally invasive
technique with very few functional and cosmetic
compromises and with low morbidity when performed
in appropriate female patients.
RESUMEN
Propósito: Describir la primera Nefroureterectomia
Transperitoneal Laparoscopica seguida por extracción
del riñón intacto, por vía transvaginal con ayuda del
laparoscopio, realizada en Puerto Rico.
Caso / Resultados: Paciente femenina de 39
años de edad, que consulto a su urólogo por
infecciones crónicas del tracto urinario. Se realizó
un diagnóstico de un riñón izquierdo no funcionante,
secundario a una obstrucción crónica, por un cálculo
distal del uréter izquierdo.
Se realizó una Nefroureterectomia
Transperitoneal Laparoscopica, luego el espécimen
intacto, fue removido através de una colpotomía
posterior transversa. La paciente fue egresada al
día siguiente, sin complicaciones intra-operatorias
o post-operatorias.
Conclusiones: La Nefroureterectomia
Transperitoneal Laparoscopica con extracción del
espécimen intacto, provee una opción quirúrgica,
con una técnica mínimamente invasiva, poco
compromiso funcional y cosmético, con una baja
morbilidad post-operatoria, cuando se realiza en los
pacientes femeninos apropiados.
REFERENCES
1.- Breda, G. Silvestre, P. Giunta, A. et al. Laparoscopic nephrectomy with vaginal delivery of the intact kidney. Eur Urol 24(1): 116-7,
1993.
2.- Dauleh, MI. Townell, NH. Laparoscopic nephroureterectomy for malignancy: vaginal route for retrieval of intact specimen. Br J Urol
72(5 Pt 1): 667-8, Nov. 1993.
3.- Gill, I.S. Cherullo EE. Meraney, AM. et al. Vaginal extraction of the intact specimen following laparoscopic radical nephrectomy. J Urol
167(1): 238-41, Jan. 2002
4.- Sunoo, Ch. Aaberg, RA. Nakamura, J.K. Laparoscopically assisted vaginal extraction of the kidney after laparoscopic radical nephrectomy.
The permanente J. 9(1): 1-5, 2005
5.- Varkarakis, I. Rha, K. Hernandez, F. Kavoussi, LR. Jarret, TW. Laparoscopic specimen extraction: Morcellation. BJU International.
95(2):27. 2005
6.- Rassweiler, J. Frede, T. Henkel, TO. et al. Nephrectomy: A comparative study between the transperitoneal and retroperitoneal
laparoscopic versus the open approach. Eur Urol 33:489-496, 1998
7.- Kerbl, K. Clayman, RV. McDougall, EM. Gill, IS. Et al. Transperitoneal nephrectomy for benign disease of the kidney: Comparison of
laparoscopic and open surgical techniques. J Urol 43(5):607-13. 1994
8.- Harmon, WJ. Bishoff, JT. Transperitoneal laparoscopic radical nephrectomy. (emedicine® web site) July 25, 2001. Available at: http:/
/www.emedicine.com Accessed March 12, 2005
9.- Rassweiler, JJ. Stock, C. Frede, T. et al. Transperitoneal and retroperitoneal laparoscopic nephrectomy in comparison with conventional
nephrectomy. Urologe A. 35(3):215-22. 1996
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BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
10.- Rassweiler, JJ. Henkel, TO. Potempa, DM. et al. Transperitoneal laparoscopic neprectomy: Training , technique,and results. J Urol.
7(6):505-15. 1993
11.- Eraky, I. Kappany, H. Shamaa, MA. Laparoscopic nephrectomy: an established routine procedure. J Endourol. 8(4):275-8. 1994
12.- Kaouk, JH. Gill, IS. Laparoscopic radical nephrectomy: Morcellate or leave intact? Leave intact. Rev Urol 4(1): 38-42. 2002
13.- Bradbury, WC. West J Surg Obstet Gynecol. 60(8): 377–86, Aug. 1952.
14.- Jacobaeus, HC. Ueber die möglich keit die zystoskopie bei untersuchung seröser höhlungen anzuweden. Munch Med Wochenschr. 57:
2090-2, 1910.
15.- Stellato, TA. History of laparoscopic surgery. Surgical Clinics of North America. Vol. 72: 5, Oct. 1992.
16.- Clayman, RV. Kavoussi, LR. Soper, NJ. et al. Laparoscopic nephrectomy : initial case report. J Urol 146(2) : 278-82, Aug. 1991.
17.- Gill, IS. Kavousi, LR. Clayman RV. et al. Complications of laparoscopic nephrectomy in185 patients: A multi-institutional review. J
Urol 154(2):479-483. 1995
18.- Handchin, AE. Weber, M. Demartines, N. Clavien, PA. Laparoscopic donor nephrectomy. Br. J Surg. 90(11):1323-32. 2003.
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Pueblo: ZIP Code: Teléfono Residencial:
Dirección Oficina:
Teléfono Oficina: Fax: No. Beeper:
Número Seguro Social: Estado Civil:
Fecha de Nacimiento: Ciudad y País: Ciudadanía:
Nornibre dél Padre: Nombre de la Madre: Nombre del Cónyuge:
Escuela de Medicina: Número de Licencia:
Especialidad: Año de Graduación:
INTERNO RESIDENTE (Llenar):
Fecha de Comienzo: • Término de Entrenamiento
AFILIADO (Llenar):
Fecha- Cominzo • Término de Entrenamiento
ESTUDIANTE (Llenar):
— SOLICITUD PRELIMINAR DE INGRESO COMO SOCIO—
Fecha de Graduación: • Escuela de Medicina
Certifico que la información arriba brindada es cierta y completa.
Firma del Solicitante: Fecha:
Vol. 100 • Núm. 1 • Enero-Marzo 2008
NOTA: ES REQUISITO INDISPENSABLE PARA LA.APROBACION DE
LA SOLICITUD EL QUE SE LLENEN TODOS LOS ENCASILLADOS
87

BOLETÍN
88
BOLETÍN • ASOCIACIÓN MÉDICA DE PUERTO RICO
ASOCIACIÓN MÉDICA DE PUERTO RICO
• Instrucciones para los Autores*
El “Boletín” acepta para su publicación artículos relativos a medicina y cirugía
y las ciencias afines. ¡Igualmente acepta artículos especiales y correspondencia que
pudiera ser de interés general para la profesión médica. Se urge a los autores se
esfuercen en perseguir claridad, brevedad, e ir a lo pertinente en sus manuscritos,
no importa el tema o formato del manuscrito.
El artículo, si se aceptara, será con la condición de que se publicara únicamente
en la revista. Para facilitar la labor de revisión de la junta Editora y la del impresor,
se requiere de los autores que sigan las siguientes instrucciones:
• Manuscrito
El manuscrito completo, incluyendo las leyendas y referencias deberán estar escritos
en maquinilla a doble espacio; por un sólo lado de cada página, en TRIPLICADO y con
amplio margen (ARTÍCULO DEBERÁ SER ACOMPAÑADO POR UN “CD”). En
página separada deberá incluirse lo siguiente: título, nombre de autor(es) y su grado (ej.:
MD, FACP), ciudad donde se hizo el trabajo, el hospital o institución académica,
patrocinadores del estudio, y si un artículo ha sido leído en alguna reunión o congreso, así
debe hacerse constar como una nota al calce.
El manuscrito debe comenzar con una breve introducción en la cual se especifique
el propósito del mismo. Las secciones principales (como por ejemplo: materiales y métodos)
deben identificarse con un encabezamiento en letras mayúsculas.
Artículos referentes a resultados de estudios clínicos o investigaciones de laboratorio
deben organizarse bajo los siguientes encabezamientos: introducción, Materiales y Métodos,
Resultados, Discusión, Resumen (en español e inglés), Reconocimiento y Referencias.
Artículos referentes a estudios de casos aislados deben organizarse en la siguiente
forma: Introducción, Materiales y Métodos si es aplicable, Observaciones del Caso,
Discusión, Resumen (en español e inglés), Reconocimientos y Referencias.
• Nomenclatura
Deben usarse los nombres genéricos de los medicamentos. Podrán usarse también
los nombres comerciales, entre paréntesis, si así se desea se usará con preferencia el
sistema métrico de pesos y medidas.
• Tablas
Las tablas deben aparecer en hojas separadas. Estas deben incluir el título, y el
número de la tabla debe estar en romano. Los símbolos de unidades deben limitarse al
encabezamiento de las columnas. Se deben omitir líneas verticales en la tabla. Se usará en
las tablas el mismo idioma en el cual está escrito el artículo. Deben limitarse las tablas a
solo aquellas que contribuyan al mejor entendimiento del manuscrito.
• Ilustraciones
Las fotografías y microfotografías se someterán como copias en papel de lustre,
sin montar o en transparencias. En el reverso de la figura debe aparecer el número de la
figura (arábigo) y el autor. Debe indicarse la parte superior de la ilustración.
• Resumen
Un abstracto no mayor de 150 palabras debe acompañar los manuscritos. Debe
incluir los puntos principales que ilustren la substancia del artículo y la exposición del
problema, métodos, resultados y conclusiones.
• Referencias
Las referencias deben ir numeradas sucesivamente de acuerdo a su aparición en el
texto. Los números deben aparecer en paréntesis al nivel de la línea u oración. Al final de
cada artículo las referencias deben aparecer en el orden numérico en que se citan en el
texto. Deben utilizarse solamente las abreviaturas para títulos de revistas científicas según
indicadas en el “Cumulative Index Medicus" que publica la Asociación Médica Americana.
Las referencias deben seguir el patrón que se describe a continuación.
1. Para artículos de revistas: Apellido(s) e iniciales del nombre del autor(es), título del
artículo, nombre de la revista, año, volumen, páginas. Por ejemplo: Villavicencio R:
Soplos inocentes en pediatría, Bol Asoc Méd P Rico 198 1; 73: 479-87. Si hay más
de 7 autores, incluir los primeros 3 y añadir et al.
2. Para citación de libros donde el autor(es) del capítulo citado es a su vez el (los) editor(es):
Apellido(s) e iniciales del autor(es), título del libro, número de edición, ciudad, casa
editora, año y página. Por ejemplo: Keith JD, Rowe RD, Vlad P: Heart disease in
infancy and childhood, 3d. Ed., New York, MacMillan, 1978: 789
3. Para citación de libros donde el editor(es) no es el autor(es) del capítulo citado se
añade el autor(es) del capítulo y el título del mismo. Por ejemplo: Olley PM: Cardiac
arrythmias; In: Keith ID, Rowe RD, Vlad P Eds. Heart disease in infancy and childhood,
3d Ed., New York, MacMillan, 1978: 275-301
• Cartas al Editor
Se publicarán a discreción de la Junta Editora. Deben estar escritas en maquinilla a
doble espacio, no deben ser mayores de 500 palabras, ni incluir más de cinco referencias.
(ARTÍCULO DEBERÁ SER ACOMPAÑADO POR UN “CD”)* Estas
“Instrucciones para los Autores` son de acuerdo a las normas establecidas por el
Comité Internacional de Editores de Revistas Médicas en sus `Requisitos Uniformes
para Manuscritos Sometidos a Revistas Bio-Médicas".
• Instructions to Authors*
The “Buletín” will accept for publication contributions relating to the
various areas of medicine, surgery and allied medical sciences. Special articles
and correspondence on subjects of general interest to physicians will also be
accepted. All material is accepted with the understanding that is to be published
solely in this journal.
All authors are urged to seek clarity, brevity, and pertinence in the manuscripts
regardless of subject or format.
In order to facilitate review of the article by the Editorial Board and the work of the
printer, the authors must conform with the following instructions:
• Manuscripts
The entire manuscript, including legends and references should be
typewritten double spaced in TRIPLICATE with ample margins (ARTICLES
SHOULD BE ACCOMPANIED WITH A ”CD”). A separate title page should
include the following: title, authors and their degrees (e.g. MD, FACP), city
where the work was done, hospital or academic institutions, acknowledgments
of financial sponsors, and if the paper has been at a meeting the place and date
should be given.
The manuscripts should start with a brief introductory paragraph or
paragraphs which should state its purpose. The main sections (for example,
Materials and Methods) should be identified by heading in capital letters.
Articles reporting the results of clinical studies or laboratory investigation
should be organized under the following headings: Introduction, Materials and
Methods, Result if indicated, Discussion, Summary in English and Spanish,
Acknowledgments if any, and References.
• Nomenclature
Generic names of drugs should be used; trade names my also be given in parenthesis,
if desired, metric units of measurement should be used preferentially.
• Tables
These should be typed on separate sheets with the title and table number (Roman)
centered. Symbol for units should be confined lo the column headings. Vertical lines should
be omitted. The language used in the tables must be the same as that of the article. Include
only those tables which will enhance the understanding of the article. They should
supplement, not duplicate the text.
• Illustrations
Photographs and photomicrographs should be submitted as glossy prints
(unmounted) or slides. They should be labeled in the back with the name of the authors
and figure number (Arabic) and the top should be indicated. Legend to the figures should
be typed on a separate sheet.
• Summary
An abstract not longer than 150 words should accompany all articles. It must include
the main points that present the core of the article and the exposition of the problem,
method, results, and conclusions.
• References
These should be numbered serially as they appear in the text. The number should
be enclosed in parenthesis on the line or writing and not as superscript, numbers. At the
end of the article references should be listed in the numerical order in which they are first
cited in the text. The titles of journals should be abbreviated according to the style used in
the "Cumulative Index Medicus" published by the American Medical Association. The
correct forms of references are as given below:
1. For periodicals: Surname and initials of author(s), title of article, name of journal,
year, volume, pages. For example: Villavicencio R.: Soplos inocentes en pediatría.
Bol Asoc Med P Rico 198 1; 73: 479 87. If there are more than 7 authors list only
3 and add et al.
2. For books when the authors of the cited chapter is at the same time the editor:
Surname and initials of author(s), title, edition, city, publishing house, ~ear and page.
For example: Keith JD, Rowe RD, Vlad P: Heart disease in infancy and childhood,
3d Ed., New York, MacMillan, 1978: 789
3. For chapter in book when the author of the chapter is not one of the Olley PM:
Cardiac arrythmias: In: Keith JD, Rowe RD, Vlad P. Eds. Heart disease in infancy and
childhood, 3d Ed. New York, MacMillan, 1978, 275-301
• Letters to the Editor
Will be published at the discretion of the Editorial Board. They should be typewritten
double-spaced, should not exceed 500 words nor more than five references.
ARTICLES SHOULD BE ACCOMPANIED WITH A "CD" *The above
'Instructions to Authors" are according to the format required by the international
Committee of Medical Journal Editors in its “Uniform Requirements for Manuscripts
Submitted to Biomedical Journals”.
Vol. 100 • Núm. 1 • Enero-Marzo 2008