Reversible dilated cardiomyopathy associated with post-partum thyrotoxic storm.

The following case of a young mother presenting with post-partum pulmonary oedema, highlights a singular and life-threatening complication of a common condition (thyrotoxicosis). While thyrotoxic heart disease is well described, thyrotoxic storm in the post-partum period associated with dilated cardiomyopathy, congestive cardiac failure and ventricular fibrillation is exceptional.

Laparoscopic adrenalectomy versus open adrenalectomy: results from a retrospective comparative study.

The relatively new operation of laparoscopic adrenalectomy has now become the procedure of choice for the management of most benign adrenal tumours. We have reviewed the data relating to the first 25 patients on whom we performed laparoscopic adrenalectomy and have made comparison with a group of 25 diagnosis-matched individuals on whom we had previously carried out open adrenalectomy. The patients who underwent laparoscopic adrenalectomy had a significantly shorter hospital stay and experienced significantly less postoperative morbidity than those who had an open operation, but the operation time was significantly longer for the laparoscopic group of patients. There is now good potential and sound evidence base for extending the indications for laparoscopic adrenalectomy.

Randomized clinical trial comparing scan-directed unilateral versus bilateral cervical exploration for primary hyperparathyroidism due to solitary adenoma.

BACKGROUND: It was shown in a previous retrospective study that scan-directed unilateral cervical exploration for primary hyperparathyroidism (HPT) can be carried out without an increase in the incidence of persistent or recurrent hypercalcaemia. This randomized clinical trial was conducted to test the hypothesis that focused unilateral operation leaves the patient no more vulnerable to persistent HPT than standard bilateral neck exploration. METHODS: Patients with HPT routinely underwent preoperative dual-isotope subtraction scintigraphy in an attempt to localize the presumed solitary parathyroid adenoma. Individuals with a positive scan (one residual focus of activity following subtraction) were deemed suitable for focused unilateral cervical exploration. At operation, if a single tumour was identified at the site suggested by the scan, the patient was randomized to unilateral or bilateral neck exploration. RESULTS: Between April 1998 and December 2003, 190 patients underwent first-time cervical exploration for HPT. Of these, 100 qualified for randomization. Fifty-four patients were randomized to unilateral neck exploration and 46 to bilateral operation. All 100 patients were cured following operation, as assessed by return of the serum calcium level to normal. Two patients randomized to bilateral exploration were found to have an unsuspected additional enlarged parathyroid on the contralateral side. CONCLUSION: Scan-directed unilateral cervical exploration for HPT does not significantly increase the incidence of persistent hypercalcaemia compared with standard bilateral operation.

Minimally invasive parathyroidectomy: 50 consecutive cases.

OBJECTIVE: To determine the effectiveness and outcomes of minimally invasive parathyroidectomy. DESIGN: Prospective, non-randomised, non-blinded trial. SETTING: Affiliated university teaching hospitals of the Northern Clinical School, University of Sydney, New South Wales, May 1998 to October 1999. PATIENTS: 50 consecutive patients who underwent minimally invasive parathyroidectomy for primary hyperparathyroidism, and 150 consecutive patients undergoing open parathyroidectomy over the same period. RESULTS: Minimally invasive parathyroidectomy was successfully completed and resulted in cure (normocalcaemia) in 42 of 50 patients (84%). Seven patients (14%) required conversion to an open procedure, all of which also resulted in normocalcaemia, giving an overall cure rate of 98%. One patient had persistent hyperparathyroidism after minimally invasive parathyroidectomy which was cured at subsequent open reoperation. Three patients had a temporary recurrent laryngeal nerve palsy. Open parathyroidectomy was successful in 147 of 150 patients (98%) at initial operation; one patient had a temporary recurrent laryngeal nerve palsy. Intraoperative measurement of parathyroid hormone levels by a quick technique in 23 of the patients (13 having minimally invasive and 10 open procedures) correctly identified the presence of multiple-gland disease. CONCLUSION: Minimally invasive parathyroidectomy is a feasible procedure, although there are concerns about the complication rate.

Medullary thyroid carcinoma in Northern Ireland, 1967-1997.

BACKGROUND: The experience of managing medullary thyroid carcinoma (MTC) in a specialist endocrine surgery unit was reviewed. METHODS: The case records of 38 patients (19 male, 19 female) treated over a 30 year period were studied. RESULTS: There were 23 (60.5%) patients with sporadic MTC while the remainder had familial MTC--12 multiple endocrine neoplasia (MEN) type 2A, two MEN type 2B, one non-MEN familial medullary thyroid carcinoma (FMTC). Sporadic MTC patients were significantly older at presentation (median 56 years, interquartile range 41.5-61.3 years) compared to MEN 2A patients (median 26 years interquartile range 17.5-34 years) and had more advanced stage of disease. Survival of MTC patients was significantly worse in sporadic disease than in those with MEN 2A (P < 0.0001). All familial cases had bilateral multifocal tumour whereas in sporadic patients only unilateral disease was seen. The availability of genetic testing now allows early identification of affected members of familial MTC kindreds. This has led to total thyroidectomy being performed on the basis of positive genetic screening alone in three patients (two MEN 2A, one FMTC), in all of whom widespread C-cell hyperplasia and microscopic multifocal invasive MTC were identified histologically. CONCLUSIONS: The management of MTC has changed during the study period with total thyroidectomy recommended as the primary procedure of choice for all patients. In the familial setting, positive genetic testing now allows thyroidectomy to be performed at an early pre-clinical stage, with the hope of permanent cure.

Median sternotomy for parathyroid adenoma.

Most mediastinal parathyroid tumours lie within the thymus gland and may be retrieved when cervical thymectomy is carried out in the course of neck exploration for primary hyperparathyroidism (HPT). We report 4 patients, each of whom required sternotomy for removal of a true mediastinal parathyroid adenoma. Subtraction isotope scintigraphy suggested the presence of a mediastinal tumour prior to cervical exploration in 2 individuals and prior to re-exploration in a third. When localisation before initial exploration for HPT suggests a parathyroid tumour within the chest, consideration should be given to proceeding to sternotomy, at first operation if a comprehensive neck exploration, including cervical thymectomy, fails to uncover the adenoma. Uniquely, one of our patients underwent sternotomy for HPT when 23 weeks pregnant.