Isthmectomy: a conservative operation for solitary nodule of the thyroid isthmus.

PURPOSE: To assess the results obtained in patients with nontoxic uninodular goiter confined to the isthmus undergoing isthmectomy. METHODS: Between April 1994 and June 2006, 330 consecutive patients with nontoxic uninodular goiter underwent thyroidectomy at our institution. In 31 patients, lesions were limited to the thyroid isthmus with evidence of benign or undetermined pathology on ultrasound-guided fine-needle aspiration biopsy. Total isthmectomy was performed. RESULTS: Preoperatively, thyroid nodules on ultrasonography were solid in 26 patients and mixed with cystic and solid components in 2. The mean size of nodules was 2.43 (+/- 0.88) cm. No intraoperative or postoperative complications occurred. Histological examination showed nodular hyperplasia in 29 cases, follicular adenoma in 1 and papillary thyroid carcinoma in 1. The patient with papillary carcinoma underwent bilateral lobectomy 7 days later. A total of 24 patients (77.4%) attended clinical visits at follow-up (mean 70,57 months). Ultrasonographic scanning revealed thyroid nodules in 17 patients, in 16 of which nodules range from one to five (0.5 to 2 cm in size) and further surgery was not indicated. One patient with a 4-cm nodule and tracheal displacement found at ultrasonography 2 years after isthmectomy had inconclusive results of FNAB. This patient was re-operated for completion thyroidectomy, which was successfully performed without technical difficulties. The detection of recurrent nodules was independent of the time elapsed since thyroid isthmectomy. CONCLUSIONS: These findings document the feasibility and efficacy of isthmectomy in solitary thyroid nodules confined to the isthmus.

The effects of successful parathyroidectomy on clinical and biological manifestations of primary hyperparathyroidism.

PURPOSE: To assess changes of clinical manifestations, laboratory data, and bone mineral density after parathyroidectomy for primary hyperparathyroidism. METHODS: In 39 patients with symptomatic primary hyperparathyroidism undergoing parathyroidectomy, data of preoperative symptoms and bone densitometry were collected from the medical records. A telephone survey was used to collect information on postoperative symptoms and the patient's degree of satisfaction with the operation. Results of biochemical parameters before surgery, at the immediate postoperative period, and at late follow-up were compared. Differences of proportions were assessed with the chi-square test and differences in means with the one-way ANOVA and the Student's t test. RESULTS: A significant decrease was observed in the occurrence of renal colic and bone pain after parathyroidectomy. Calcium and PTH levels decreased and phosphorus levels increased significantly after the operation. 24-hour renal calcium excretion showed a statistically significant decrease in the immediate postoperative control and at follow-up in patients without renal colic, whereas in those with nephrolithiasis, significant differences were only observed at follow-up. Alkaline phosphatase decreased significantly in the immediate postoperative period, and bone densitometry improved in a 90% of the patients. Ninety-six percent of patients were satisfied with parathyroidectomy. CONCLUSIONS: In this clinical series, successful parathyroidectomy resulted in improvement of clinical manifestations, normalization of biochemical parameters, and a decrease in osteoporosis. Patients reported a high degree of satisfaction with parathyroidectomy.

[Hypokaliemic nephropathy as a form of presentation of Conn syndrome]. / Nefropatía hipokaliémica como presentación de un síndrome de Conn.

Hypokalemia is generally associated to neuromuscular symtoms, acid-base disorders and even to rhabdomyolysis. However, chronic hypokalemia can induce chronic renal failure through a characteristic tubulointerstitial damage consisting on vacuolization of epithelial tubular cells and interstitial fibrosis. This entity is called hypokalemic nephropathy, quite unusual and probably little know in our speciality. We present a clinical report of a patient admitted to our hospital with a severe hypokalemia secondary to an aldosterone producing adrenal adenoma that was diagnosed during admission. Besides hypokalemia the patient presented renal failure. Renal biopsy proved characteristic tubulointerstitial damage as described in hypokaliemic nephropathy. In summary, we report a Conn syndrome presenting as a hypokalemic nephropathy.

Strangulated small bowel evisceration after intraperitoneal drainage.

We report an exceptional case of strangulated small bowel evisceration through an intraperitoneal drainage after open cholecystectomy. It is a recognized but rare complication of surgical procedures. The drainage must be sited carefully and when necessary. If possible, drains of less than 10 mm external diameter should generally be used.

[Modification of nephritic colic and 24-hour calcium excretion in urine in primary hyperthyroidism after parathyroidectomy]. / Modificación de los cólicos nefríticos y de la excreción de calcio en orina de 24 horas en el hiperparatiroidismo primario tras la paratiroidectomía.

We documented the frequency of nephritic colic in patients with primary hyperparathyroidism, and determined its modification after the parathyroidectomy; we also studied laboratory parameters such as calcium, phosphorus and parathyroid hormone in serum, and the excretion of Cao 24h, previous and later to the intervention. At sight of the results it is possible to be concluded that the parathyroidectomy is useful in the treatment of the kidney stone disease produced by the primary hyperparathyroidism.

[Venous microanastomoses by extraluminal cuff versus standard technique]. / Microanastomosi venosa diretta con cuff extraluminale versus sutura standard.

AIM: Venous microanastomoses are more difficult to carry out in comparison with the arterial ones, because of the characteristics of the vascular wall. The suture with loose stitches is the usual surgical technique, but it has 2 disadvantages: a long time of execution and the presence of foreign material in the anastomosis. To avoid these complications, we an extraluminal silicone cuff has been used. METHODS: We performed 70 microanastomoses on the internal jugular vein of Sprague-Dawley rats with these 2 techniques, estimating the immediate and late permeability and postoperative complications. Moreover, a histological study of all the anastomoses was carried out on the 15th day and after 1 mo from the intervention. RESULTS: The mean time requested to perform the microanastomosis is significatively shorter when using the extraluminal cuff. The late permeability with standard suture is 97% and 77% with the cuff. The number of complications with standard suture is significatively lower than with cuff, where rates of 20% of dehiscence and 14% of trombosis were observed. The histological study showed a poor alteration of the vascular wall, with important subendothelial hypertrophy on cuff microanastomosis and a great permanent histopatologic alteration if the standard technique had been used. CONCLUSIONS: The suture with loose stiches is a very good technique to use for this type of microanastomosis, even if the extraluminal cuff can be used in microanastomosis of a free graft or when it is necessary to perform more than 1 microanastomosis.

Subtotal thyroidectomy with transposition of the remnant gland to the subcutaneous space. A new alternative technique in benign thyroid disease.

BACKGROUND: Thyroidectomy is the preferred surgical option for the treatment of benign disease of the thyroid in a wide rage of indications. Controversy exists concerning the extent of the primary excision for optimal results. A subtotal thyroidectomy with transposition of the thyroid remnant to the subcutaneous space prevents thyroid hormone supplementation for life and laryngeal nerve damage during a re-operation. METHODS: We present the case of a 42-year-old female with nontoxic multinodular goitre who underwent subtotal thyroidectomy in which a thyroid remnant of the left upper pole was placed subcutaneously through a buttonhole incision at the junction of the left sternocleidomastoid and the pre-thyroidal muscles. The remnant of thyroid nourished by the vascular pedicle of the superior pole vessels was sutured to the pre-thyroidal muscles. RESULTS: One month after operation, the remnant was palpated as a small well-limited mass without signs of inflammation and thyroid function tests were normal. A contrast-enhanced computed tomography (CT) scan confirmed the subcutaneous position of the thyroid tissue without pathological signs. The scintigraphy showed uptake radioactivity by the transported thyroid remnant. One year after operation the patient was clinically euthyroid with TSH and T4 levels within normal limits. CONCLUSIONS: This report documents the feasibility and efficacy of subtotal thyroidectomy with transposition of the thyroid remnant to the subcutaneous space in multinodular goitre.

[Interferon-alpha2b recombinant improved the cognitive dysfunction in patients with relapsing remitting multiple sclerosis]. / El interferón-alpha2b recombinante mejora la disfunción cognitiva en pacientes con esclerosis múltiple.

INTRODUCTION: Some experimental, Phase II clinical trials and the preliminary reports of the Cuban Phase III clinical trial indicate that alpha-IFN (IFN) may be useful in relapsing remitting (RR) multiple sclerosis (MS). The reports in Cuba showed that 70% of the MS patients have cognitive dysfunction. OBJECTIVE: To assess the efficacy of IFN-alpha2b recombinant in the cognitive dysfunction of RR MS. PATIENTS AND METHODS: 57 RR-MS clinical definite patients from the randomised, double blind, placebo controlled study of 225 patients with RR-MS and brain MRI confirmed. Patients were randomly assigned to receive intramuscular IFN-alpha2b (Heberon R) 10 million IU (high dose), 3 million IU (low dose) or placebo twice week for 2 years. Outcome results were blinding evaluated considering changes in the following tests: Luria, WAIS, Benton and PASAT-3. Adverse events and side effects were not evaluated to maintain physician blinding. RESULTS: The initial comparison of the groups did not show any differences among the placebo (n=20), low dose (n=18) and high dose (n=19) considering age (p=0.234), gender, ethnic group (p=0.012), years ill (p=0.787), EDSS (p=0.203) and rate of relapses (p=0.432). The Luria's Test showed an improved in the low dose group from 2.50 +/- 1.34 to 1.39 +/- 1.85 (p=0.029) and in the high dose group from 3.22 +/- 1.89 to 2.17 +/- 1.50 (p=0.006) vs placebo 2.85 +/- 1.66 to 2.90 +/- 1.97 (p=0.723). The results of the Benton's test demonstrated that the low dose group had an improved from 5.50 +/- 1.10 to 6.22 +/- 1.31 (p=0.047), in the high dose group from 4.87 +/- 1.85 to 5.78 +/- 1.35 (p=0.005) where as in the placebo group worse from 5.15 +/- 1.76 to 5.05 +/- 2.11 (p=0.893). The WAIS test showed the same results, the low dose group increased from 5.17 +/- 1.34 to 6.06 +/- 1.21 (p=0.022), the high dose group from 4.56 +/- 1.38 to 5.39 +/- 1.29 (p=0.007) and the placebo group worse from 5.25 +/- 1.25 to 5.05 +/- 1.57 (p=0.354). Finally, the PASAT-3 test increased in the IFNs groups: from 45.72 +/- 10.61 to 49.94 +/- 11.68 (p=0.015) in the low dose group, from 42.67 +/- 11.04 to 48.72 +/- 8.84 (p=0.03) in the high dose group, but in the placebo group worse from 44.55 +/- 10.86 to 41.95 +/- 13.74 (p=0.655). CONCLUSION: IFN-alpha improved the cognitive dysfunction in RR-MS patients. The higher dose is more beneficial.

[Venous microanastomoses by fibrin glue versus standard technique]. / Microanastomosi venosa diretta con colla di fibrina versus sutura standard.

BACKGROUND: The goal of this study is to compare the usual surgical technique with the use of fibrin glue, which is faster to perform and has few histological alterations in the anastomosis. METHODS: We performed 70 microanastomoses on the internal jugular vein of the Sprague-Dawley rats, and we estimated: immediate and late permeability and postoperative complication. Besides, we made a histological study of all the anastomoses on the 15th day and after one month of the intervention. RESULTS: The middletime request to practise the microanastomosis is significantly shorter when using the fibrin glue. The late permeability rate with standard suture is 97 and 77% with fibrin glue. The number of complications is similar, even if we found a 14.7% rate of aneurysms in the anastomosis with fibrin glue. The histological study showed few alterations to the vascular wall in the fibrin seal group and a great permanent histopathological alteration in the standard technique. CONCLUSIONS: The use of fibrin glue is a very good technique for this kind of microanastomosis. It is fast to perform, has few histological alterations and a similar permeability rate although careful approximation of the vascular edges is necessary to get a good anastomosis.

[Verneuil's disease or perianal hydradenitis suppurativa]. / La malattia di Verneuil o idrosiadenite suppurativa perianale.

Verneuil's disease or perianal hidradenitis suppurativa is a chronic suppurative disease with a tendency to fistulization and sclerosis, developing on the subcutaneous tissue, on apocrine glands. The perianal location is the most frequent, and the elective therapy in such case is surgery. A case of perianal Verneuil's disease of great size, invalidating for the patient, in which medical therapy failed, making necessary an aggressive surgical treatment is reported. The therapeutical possibilities of this disease and its possible complications, are discussed.

[A spontaneous hematoma of the rectus abdominis sheath]. / Hematoma espontáneo de la vaina de los rectos.

The spontaneous hematoma of rectus abdominis sheath is a rare condition which usually presents as acute abdomen. We report our experience with 19 patients, most of them on treatment with oral anticoagulants. The most common symptoms were abdominal pain and palpable tumor. Twenty-six percent required blood transfusion. Echography and computerized tomography, were useful for diagnosis. Treatment was mainly conservative and was the mode of choice; surgery was left only for those patients who had hemodynamic changes or infection of the hematoma.

New technique of parathyroidectomy to prevent parathyromatosis and hypoparathyroidism.

A 54-year-old woman with end-stage renal disease and on haemodialysis for 4 years developed severe secondary hyperparathyroidism and was operated upon. The two upper and the largest lower parathyroid glands were resected. The right lower gland was dissected from the lower pole of the thyroid and, by gently pulling upwards, the lateral walls were dissected using electrocautery. The lower aspect of the gland maintained the blood supply through small mediastinal and thymic vessels of the neopedicle, which allowed its mobilization to a more superficial plane. Because of the large size of the gland, the part opposite to the neopedicle was resected and the cutting surface was sealed with fibrin adhesive. Pre-thyroidal muscles were reapproximated and the remnant of the parathyroid gland was pulled out through a small hole in the inferior part of the midline and sutured with fine silk to the muscle. The gland was therefore placed in a subcutaneous position in the lowest part of the operative field just above the sternal border. The postoperative course was uneventful and, 8 months after surgery, the patient maintains a normal parathyroid function.

[Prognostic significance of postoperative septic complications in surgery of rectal carcinoma]. / Significato prognostico delle complicanze settiche postoperatorie nella chirurgia del carcinoma rettale.

AIM: To assess whether there is a correlation between the onset of postoperative sepsis and the 5-years survival rate in patients undergoing surgery for rectal cancer. EXPERIMENTAL DESIGN: A retrospective study of all patients, undergoing rectal cancer surgery during the period January 1981-December 1987. PLACE: General Surgery Unit, Hospital Arnau de Vilanova. PATIENTS: All patients operated with Duke's stage B and C colorectal neoplasms, excluding cases with postoperative complications not directly correlated to surgery: pneumonia, thromboblebitis, urinary infection or fever of unknown origin. FINDINGS: Postsurgical complications distinguished as minor (wall abscess) or major (anastomotic dehiscence, peritoneal abscess). 5-year survival rate. RESULTS: The actuarial 5-year survival rate of patients with major septic complications was significantly lower (p < 0.05) than that in noncomplicated cases. No difference was observed in the survival of patients with and without minor septic complications. CONCLUSION: Major septic complications secondary to colorectal surgery are still a threat in spite of improved techniques and antibiotic prophylaxis, and negatively influence the long-term survival rate.

[Biliary tract cancer following bilioenteric anastomosis]. / Cáncer de vía biliar después de anastomosis biliodigestivas.

Two cases of carcinoma of bile ducts after bilioenteric anastomosis are presented. The first one arose in the gallbladder eleven years after cholecystojejunostomy; the second, in the common bile duct three years after cholecystectomy and choledocoduodenostomy. The reflux into the bile duct and recurrent infections can be risk factors in tumor development. Although palliative resection was feasible in one case, the early tumor spread and the invasion of the enteric structure, resulted in a poor outcome in the second case.

[A double aorto-enteric fistula secondary to an aortic pseudoaneurysm. Its anatomical correction]. / Doble fístula aorto-entérica secundaria a pseudoaneurisma aórtico. Corrección anatómica.

A very rare case of double fistula aorto-enteric jejunal and ileal, draining to an aortic pseudoaneurysm, is presented. There were not evidence of sepsis, and by this reason pseudoaneurysm and prosthesis were removed, a new prosthesis was inserted by reconstruction "in situ", and intestinal fistulas were closed. The short- and large-term postoperatory was satisfactory. A review about possible mechanisms implicated in a fistula, diagnosis and therapeutic alternatives was made.

[Results of the treatment of diabetic patients who required emergency surgery for infection or ischemia]. / Resultados del tratamiento en pacientes diabéticos que precisaron cirugía urgente por infección o isquemia.

An extensive summary on the results of treatment of diabetic patients with necessity of urgent treatment for ischemic or infectious complications is presented. Such frequent events often need an active treatment for infection, followed in some cases by a large debridement or minor amputations. Adequate treatment may avoid a major amputation. Revascularization surgery may play a opportune role and it depends on clinical criterion.