[How to prevent recurrent nerve palsy during thyroid surgery?]. / Comment prévenir la morbidité récurrentielle en chirurgie thyroïdienne?

Recurrent laryngeal nerve (RLN) injury and hypoparathyroidism can occur after thyroid surgery. The rate of RLN injury, mostly transient, ranges from 0.5% to 5% of patients. The risk is more important in patients who undergo reoperative thyroid surgery and in patients with thyroid cancer or hyperthyroidism. Rationales for technique of thyroidectomy are discussed. Meticulous and reproductive surgical technique can lower the postoperative morbidity. However, the potential for RLN injury still exists and must be explained to the patients who are candidate for thyroid surgery. The fact that this information has been delivered during the preoperative visit must be written by the surgeon in the patient's chart.

[Clear cell sarcoma (malignant melanoma of soft tissues) of the calf ]. / Sarcome à cellules claires (mélanome malin des tissus mous) du mollet.

Clear cell sarcoma (malignant melanoma of soft parts) is a rare malignancy that is found in the young adult, and is generally located in the extremities of the limbs. In this study, a new case has been reported in a 24-year old male with no previous history of cutaneous melanoma. The tumor consisted of fusiform or round cells with clear or granulocytic cytoplasm and vesicular nuclei. The patient was treated by surgical resection of the tumor and postoperative radiotherapy. Eight years later, metastatic nodes were detected in the inguinal region. The histogenesis of this tumor has not yet been determined, and it poses a diagnostic problem for pathologists as it can be mistaken for a malignant metastatic cutaneous melanoma.

[Thyroid metastases]. / Les métastases thyroïdiennes.

STUDY AIM: The aim of this retrospective study was to report a short series of thyroid metastases and to emphasize their unusual occurrence and their poor prognosis. PATIENTS AND METHOD: From January 1990 to December 1999, among 619 patients operated for a thyroid malignancy, 14 patients had a thyroid metastasis (2.2%). Mean age of the patients was 66 years (range: 35-81). The thyroid metastasis revealed the primitive tumor (n = 8) or occurred in the follow-up of a cancer already treated (n = 6). The primitive tumor was renal (n = 3), breast (n = 3), lung carcinoma (n = 4) and melanoma (n = 1). In the 3 other patients, the primitive tumor was not detected. The thyroid metastasis was apparently isolated in 13 patients. The surgical procedure was a total (n = 3) or partial (n = 7) thyroidectomy and a cervicotomy with biopsy (n = 4). RESULTS: Eleven patients died less than one year after the diagnosis of the metastasis. One patient survived 1 year, another 2 years. One patient only was alive 22 years after the diagnosis of his renal tumor and 10 years after total thyroidectomy. CONCLUSION: Thyroid metastases are clinically very rare and much more frequent at post-mortem examination. They may reveal the primitive cancer but are often detected during the follow-up after treatment of the primitive tumor. When thyroid metastasis is isolated, a total thyroidectomy is justified especially in renal carcinoma, as long-term survivals have been reported.

[Late rejection of Mersylene mesh used for promontory fixation with colonic obstruction]. / Intolérance des bandelettes de Mersylène dans les suites tardives d'une promontofixation responsable d'un syndrome occlusif colique.

We describe a case of colonic obstruction in a 48-year-old woman, 3. 5 years after surgery for genito-urinary prolapse. The causal agent was the Mersylene mesh used for promontory fixation. Late rejection of this kind of prosthesis has been described previously, but such a digestive complication is exceptional.

[Thyroid cancer in patients with hyperthyroidism]. / Cancer de la thyroïde chez les hyperthyroïdiens.

OBJECTIVE: The prevalence of thyroid carcinoma in hyperthyroidism remains controversial. The aim of this retrospective study was to evaluate prevalence. PATIENTS AND METHODS: The prevalence of thyroid carcinoma was studied in 861 patients operated for clinical or infraclinical hyperthyroidism between 1992 and 1999. One hundred and fifty patients had a hot nodule, 13 of them with an associated goiter. Four hundred five patients had Graves' disease and 306 had a multinodular goiter. Multiple sections were made in all surgical specimens for pathology study. RESULTS: Prevalence in solitary nodules was 1.45%. For Graves' disease patients, it was 4.1%. Prevalence among patients with multinodular goiter was 4.9%. Among the cancers, 83% were microcarcinoma. Parathyroid morbidity after subtotal and total thyroidectomy was 0.56% and recurrent hyperthyroidism occurred in 1.6%. CONCLUSIONS: These findings are grossly identical to those observed in simple, nontoxic diffuse multinodular goiter. It would therefore be difficult to incriminate hyperthyroidism as playing a causal role in the development of thyroid cancer. These results do however provide an argument favoring total or near total thyroidectomy when surgery is performed in patients with hyperthyroidism.

[Cholelithiasis in heart transplant patients]. / Lithiase biliaire chez le transplanté cardiaque.

UNLABELLED: The incidence of cholelithiasis is increased in heart transplant recipients. STUDY AIM: The aim of this retrospective study was to report a series of 27 heart transplant recipients operated for cholelithiasis and to assess the indications and safety of cholecystectomy in this population. PATIENTS AND METHODS: Over a 9-year period, from January 1991 to December 1999, 27 heart transplant recipients (21 men and 6 women; mean age: 54.6 years, mainly transplanted for ischemic or dilated cardiomyopathy) underwent cholecystectomy. All patients received immunosuppressive therapy with a combination of corticosteroids and cyclosporin and 10 also received azathioprine. Five patients admitted urgently with calculous acute cholecystitis and one patient with previous gastrectomy underwent laparotomy, while the other 21 patients were operated by laparoscopy. RESULTS: There were no postoperative deaths. In patients operated by laparoscopy, there was no conversion to laparotomy and oral immunosuppressive drugs were continued without interruption. There was one postoperative hemoperitoneum related to liver biopsy performed concomitantly. In patients operated by laparotomy, intravenous cyclosporin was necessary until return to bowel function and the only complication was a wound abscess. Mean length of hospital stay was 3.1 days after laparoscopy and 8.8 days after laparotomy. CONCLUSION: Systematic ultrasound screening of cholelithiasis after heart transplantation is necessary because cholelithiasis carries a risk of septic complications in these patients. Laparoscopic cholecystectomy, associated with a low morbidity, is justified even in asymptomatic cases. In patients with acute cholecystitis, "open" cholecystectomy must be preferred in order to minimize the risk of biliary complications which would be very serious in these immunosuppressed patients.

[Theodor Emil Kocher, modern surgery pioneer]. / Theodor Emil Kocher, pionnier de la chirurgie moderne.

Theodore Kocher was awarded the Nobel Prize in 1909 for his work on the physiology, pathology and surgery of the thyroid gland. He was the first Swiss citizen and the first surgeon to ever receive such a distinction. He was a pioneer and a world leader in the surgical revolution of the end of the nineteenth century. After graduation in 1865, he traveled in Germany, England, France and Austria to observe the work of Langenbeck, Paget, Wells, Nelaton, Billroth.... In 1866, he returned to Bern and was appointed assistant in the surgical clinic of Lücke. In 1872 he applied for the succession of Lücke. After a lively debate, he was appointed by the Board of Regents against the recommendation of the faculty who wished to nominate a German surgeon, König. It proved to be a good choice, as, over a period of 45 years, Kocher developed a considerable activity in various fields of surgery leading to world-wide acclaim and renown. Kocher's most significant contribution to medicine concerned the thyroid gland. He considerably improved thyroid surgery. His anatomical knowledge, precise operating technic and respect of the aseptic principles defined by Lister, whom he had met in Glasgow, contributed to a reduction of mortality from 13% to 0.18%. He described postoperative hypothyroidism, which he called cachexia strumipriva and concluded that total thyroidectomy was not indicated in benign diseases. When he died, more than 7,000 thyroidectomies had been performed in his clinic. Kocher was also interested in orthopedics, abdominal and genitourinary surgery, surgical oncology, neurosurgery (Cushing conducted experimental research with him). He developed or modified many surgical instruments. He conducted a large number of experimental studies and published 249 articles and books.

Secondary thyroidectomy in patients with prior thyroid surgery for benign disease: a study of 203 cases.

BACKGROUND: The goal of this study was to evaluate the complication rate of secondary thyroidectomy in patients with prior thyroid surgery for benign disease. METHODS: Over an 8-year period, 203 thyroid reoperations were performed on 202 patients. All information relating to operative procedures, pathology, and complications was recorded prospectively. RESULTS: There were 24 men and 178 women with a mean age of 52 years. Prior surgery was unilateral in 136 cases (67%) and bilateral in 67 cases (33%), and 14 patients (6.9%) had more than 1 previous thyroid operation. For euthyroid or pretoxic recurrent nodular goiter, 190 reoperations were performed and 13 reoperations were performed for recurrent thyrotoxicosis. Twenty-three cancers were found in a specimen (11.4%). Completion thyroidectomy was done in 143 patients. Postoperative complications occurred in 21 patients (10.4%): recurrent laryngeal nerve palsy (7 patients), hypocalcemia (8 patients), hematoma requiring surgical evacuation (5 patients), and wound infection (1 patient). Complications remained permanent in 4 patients (2%). CONCLUSIONS: The permanent complication rate is higher in thyroid reoperations than in primary thyroid operations. However, we believe that this 2% rate is low enough to allow reoperation whenever it is necessary, provided precise operative rules are respected.

Isolated retroperitoneal intradiaphragmatic bronchogenic cyst. A case report.

Isolated retroperitoneal bronchogenic cysts are extremely rare. We report a case which was intradiaphragmatic intimately associated with the musculature of the left crus diaphragmatic and unconnected with any other structures. Ultrasound and computed tomography findings were consistent with a pancreatic or an adrenal mass. Pathology confirmed a bronchogenic cyst. The outcome is favourable and the overall prognosis is good.

[What is the contribution of imaging?]. / Que faut-il attendre de l'imagerie?

Thyroid imaging has an essentially diagnostic value, but is also plays a role in definition of indications and operative techniques. Ultrasound is the most useful examination. Scintigraphy has become less useful, but remains indicated in hyperthyroidism and in certain retrosternal goitres inaccessible to ultrasound. The other examinations only have a limited value.

Diffuse peritonitis in steroid-treated patients.

Patients on systemic steroid therapy are at increased risk of diffuse peritonitis, specially from gastrointestinal perforation. We performed a retrospective study of 37 patients on systemic steroid therapy who underwent surgery for diffuse peritonitis. Clinical presentation of peritonitis was usually aspecific, making the diagnosis difficult. The median interval between onset of symptoms and surgery was 3.3 days, reduced to 2.0 days between hospitalization and surgery. The mortality rate was 46% (17 of 37 patients). We emphasize aggressive diagnostic efforts and early abdominal exploration in front of any persisting abdominal pain in patients on systemic steroid therapy.

[Comparative study between laparoscopic and conventional adrenalectomy for pheochromocytomas]. / Etude comparative entre la surrénalectomie laparoscopique et conventionnelle dans les phéochromocytomes.

This prospective study compares the outcome of 2 groups of patients with pheochromocytoma undergoing adrenalectomy via a transabdominal approach or a laparoscopie approach. Mean operating time was exactly the same in both groups (122 and 125 minutes). Postoperative stay in the intensive care unit and in hospital was significantly shorter in the laparoscopic group as previously demonstrated fo other adrenal tumors. More important, no differences in haemodynamic changes were observed during surgery. In both groups, the increase of cathecholamine levels was identical, with a peak occuring during manipulation of tumors. Pneumoperitoneum was not responsible for any cardiovascular instability. Laparosopic adrenalectomy should therefore be preferred to open procedures in pheochromocytomas unless tumors are too large or potentially malignant.

Differential transferrin receptor density in human colorectal cancer: A potential probe for diagnosis and therapy.

Transferrin receptor density was investigated in human colorectal surgical specimens. Crude membranes were prepared from 23 cancer tumors (adenocarcinoma or malignant villous tumor) and 3 non-cancer tumors (polyadenoma or villous tumor) and 26 adjacent control mucosa. Contrary to non-cancer tumors, Scatchard analysis of 125I-transferrin binding data evidenced higher maximal transferrin binding capacity and lower dissociation constant in cancer tissues (Bmax cancer 1.828+/-0.320 nmol/g, Kd 24.1+/-4.7 nM), as compared to paired control colonic mucosa (Bmax contol 0.851+/-0.182 nmol/g, Kd 30.7+/-7.3 nM), paired t-tests: Bmax p<0.001, Kd p<0.05). As the cancer/control Bmax ratio was 2.6+/-0.4,transferrin carrier constructs should be proposed for cancer imaging or therapy.

Biliary surgery after heart transplantation.

BACKGROUND: Biliary tract diseases are frequent in heart transplant recipients, with significant morbidity and mortality. Since the first presentation of gallstones in this population is often acute cholecystitis, asymptomatic cholelithiasis should not be considered benign. PATIENTS AND METHODS: We retrospectively reviewed 18 heart transplant recipients who underwent cholecystectomy from January 1991 to June 1997. We intentionally chose to perform a straightforward open procedure when acute cholecystitis was suspected (3 patients). A laparoscopic cholecystectomy was performed in all the other cases (15 patients) without conversion to open procedure. CONCLUSION: Since no significant complications were observed in our patients, we believe that transplant recipients with cholelithiasis should undergo laparoscopic cholecystectomy in their posttransplantation course regardless of the symptomatic status of their biliary tract.

[Therapeutic approach of differentiated and nondifferentiated cancer of the thyroid]. / Stratégie thérapeutique dans les cancers différenciés et indifférenciés de la thyroïde.

Outcome after treatment for differentiated thyroid carcinoma is good: 10-year survival rate is 80%. The surgical procedures should however be adapted to prognostic factors of the carcinoma and limited to selected cases with good prognosis in order to prevent unwarranted postoperative sequellae in cases of highly advanced disease. The most important prognostic factor is local extension. Rate of recurrence increases 4-to 6-fold in case of local invasion. The diameter of the tumor (under or over 4 centimeters) and the degree of vascular invasion are also very important in determining prognosis. The independent role of lymph node invasion is debated. Total thyroidectomy is the indicated surgical procedure; the rate of postoperative complications is about 4%. Systematic node dissection is not indicated but should be reserved for cases with poor prognosis. Picking nodes is recommended in cases with good prognostic factors. Radiotherapy should always be performed in case of poor prognosis but its efficacy is not as good as surgical resection of residual tumoral tissue. Hormonal therapy should also be adapted to prognostic factors. Follow-up is based on clinical, ultrasonographic and scintigraphic findings. Outcome after treatment for undifferentiated thyroid carcinoma is poor. Surgery, radiotherapy and chemotherapy must be associated. Surgery is performed before or after chemotherapy depending on the degree of local invasion.