Total Thyroidectomy for Amiodarone-induced Thyrotoxicosis in the Hyperthyroid State.

Amiodarone is a potent antiarrhythmic agent, indicated for the treatment of refractory arrhythmias, which may lead to thyrotoxicosis. In these patients, thyroidectomy is a valid therapeutic option. Antithyroid therapy in the immediate preoperative setting and the subsequently accepted minimal delay until thyroidectomy have not been clearly defined yet. The aim of the present study was to show, that total thyroidectomy under general anaesthesia in patients with amiodarone-induced thyrotoxicosis (AIT) is safe without necessarily obtaining an euthyroid state preoperatively.We conducted a retrospective cohort study of prospectively gathered data on 11 patients undergoing total thyroidectomy under general anaesthesia between January 2008 and December 2013 for AIT at our University Hospital.All patients were preoperatively treated with carbimazole, steroids and ß-receptor antagonists. Additionally, 3 patients received potassium perchlorate and in one patient carbimazole was changed to propylthiouracil. Plasmapheresis was performed in 3 patients. Only one patient was euthyroid at the time of operation. There were no significant intra- and postoperative complications, especially no signs of thyroid storm. One patient could postoperatively be removed from the cardiac transplant waiting list due to improved cardiac function.Improvements in the interdisciplinary surgical management for AIT between cardiologists, endocrinologists, anaesthetists and endocrine surgeons provide the basis of safe total thyroidectomy under general anaesthesia in hyperthyroid state. Early surgery without long delay for medical antithyroid treatment (with its potential negative side effects) is recommended.

[Treatment practice in patients with isolated blunt splenic injuries. A survey of Swiss traumatologists]. / Die Behandlungspraxis bei Patienten mit isolierter stumpfer Milzverletzung. Eine Befragung der Schweizer Traumatologen.

BACKGROUND: The non-operative management (NOM) of blunt splenic injuries has gained widespread acceptance. However, there are still many controversies regarding follow-up of these patients. The purpose of this study was to survey active members of the Swiss Society of General and Trauma Surgery (SGAUC) to determine their practices regarding the NOM of isolated splenic injuries. MATERIALS AND METHODS: A survey of active SGAUC members with a written questionnaire was carried out. The questionnaire was designed to elicit information about personal and facility demographics, diagnostic practices, in-hospital management, preferred follow-up imaging and return to activity. RESULTS: Out of 165 SGAUC members 52 (31.5%) completed the survey and 62.8% of all main trauma facilities in Switzerland were covered by the sample. Of the respondents 14 (26.9%) have a protocol in place for treating patients with splenic injuries. For initial imaging in hemodynamically stable patients 82.7% of respondents preferred ultrasonography (US). In cases of suspected splenic injury 19.2% of respondents would abstain from further imaging. In cases of contrast extravasation from the spleen half of the respondents would take no specific action. For low-grade injuries 86.5% chose to admit patients for an average of 1.6 days (range 0-4 days) with a continuously monitored bed. No differences in post-discharge activity restrictions between moderate and high-grade splenic injuries were found. CONCLUSION: The present survey showed considerable practice variation in several important aspects of the NOM of splenic injuries. Not performing further CT scans in patients with suspected splenic injuries and not intervening in cases of a contrast extravasation were the most important discrepancies to the current literature. Standardization of the NOM of splenic injuries may be of great benefit for both surgeons and patients.

[Acute "difficult" gastrointestinal bleeding]. / Die akute "schwierige" gastrointestinale Blutung.

Gastrointestinal bleeding with its point of origin outside the reach of conventional gastro- and colonoscopy represents an extraordinary diagnostic and therapeutic challenge. Bleeding may originate from the small bowel distal to the duodenojejunal junction (middle gastrointestinal bleeding) or from the biliary tree (haemobilia) or from the pancreatic ductal system (haemosuccus pancreaticus). This particular type of gastrointestinal bleeding is often intermittend and caused by a variety of different pathologies. Angiography is the diagnostic method of choice for further investigation. It allows precise localization of the bleeding site and simultaneous interventional therapy (embolization/coiling). The importance of further diagnostic modalities such as scintigraphy, capsule endoscopy, push-enteroscopy and double-balloon-enteroscopy is discussed.

Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection-long term results.

BACKGROUND: It is not known whether pylorus-preserving duodenopancreatectomy is as effective as the classical Whipple procedure in the resection of pancreatic and periampullary tumours. A prospective randomized trial was undertaken to compare the results of the two procedures. METHODS: Clinical data, histological findings, short-term results, survival and quality of life of all patients having surgery for suspected pancreatic or periampullary cancer between June 1996 and September 2001 were analysed. RESULTS: Two hundred and fourteen patients were randomized to undergo either a standard or a pylorus-preserving Whipple resection. After exclusion of 84 patients on the basis of intraoperative findings, 130 patients (66 standard Whipple operation and 64 pylorus-preserving resection) were entered into the trial. Of these, 110 patients with proven adenocarcinoma (57 standard Whipple and 53 pylorus-preserving resection) were analysed for long-term survival and quality of life. There was no difference in perioperative morbidity. Long-term survival, quality of life and weight gain were identical after a median follow-up of 63.1 (range 4-93) months. At 6 months, capacity to work was better after the pylorus-preserving procedure (77 versus 56 per cent; P = 0.019). CONCLUSION: Both procedures were equally effective for the treatment of pancreatic and periampullary cancer. Pylorus-preserving Whipple resection offers some minor advantages in the early postoperative period, but not in the long term.

Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma.

BACKGROUND: Mortality rates associated with pancreatic resection for cancer have steadily decreased with time, but improvements in long-term survival are less clear. This prospective study evaluated risk factors for survival after resection for pancreatic adenocarcinoma. METHODS: Data from 366 consecutive patients recorded prospectively between November 1993 and September 2001 were analysed using univariate and multivariate models. RESULTS: Fifty-eight patients (15.8 per cent) underwent surgical exploration only, 97 patients (26.5 per cent) underwent palliative bypass surgery and 211 patients (57.7 per cent) resection for pancreatic adenocarcinoma. Stage I disease was present in 9.0 per cent, stage II in 18.0 per cent, stage III in 68.7 per cent and stage IV in 4.3 per cent of patients who underwent resection. Resection was curative (R0) in 75.8 per cent of patients. Procedures included pylorus-preserving Whipple resection (41.2 per cent), classical Whipple resection (37.0 per cent), left pancreatic resection (13.7 per cent) and total pancreatectomy (8.1 per cent). The in-hospital mortality and cumulative morbidity rates were 2.8 and 44.1 per cent respectively. The overall actuarial 5-year survival rate was 19.8 per cent after resection. Survival was better after curative resection (R0) (24.2 per cent) and in lymph-node negative patients (31.6 per cent). A Cox proportional hazards survival analysis indicated that curative resection was the most powerful independent predictor of long-term survival. CONCLUSION: Resection for pancreatic adenocarcinoma can be performed safely. The overall survival rate is determined by the radicality of resection. Patients deemed fit for surgery who have no radiological signs of distant metastasis should undergo surgical exploration. Resection should follow if there is a reasonable likelihood that an R0 resection can be obtained.

[Stomata--surgical standards]. / Stomata--chirurgische Standards.

The placement of an intestinal stoma is still a common procedure despite the recent advantages in intestinal surgery. It is mandatory to apply meticulously sound surgical principles in order to achieve good results. Nevertheless, intestinal stomas are envisioned with a high perioperative morbidity which is mostly caused by surgical inadequacy. This can lead to considerable problems in management of the stoma in the long term and ultimately will affect quality of life of the patient. The cumulative morbidity can be given by 50% with prolaps, hernia, stenosis and necrosis as well as stoma retraction being the most relevant. In contrast, an adequate intestinal stoma will positively affect the quality of life of the patient. The availability of devices developed by the industry and the inauguration of a professional service in certain hospitals simplified the management of patients with a stoma. This significantly improved the standards of care especially regarding preoperative preparation and postoperative management. Thus, most patients are able to maintain an active and socially integrated life with minimal physical and psychical limitations.

[Pro and contra lymphadenectomy in papillary and follicular thyroid gland carcinoma]. / Pro und Contra Lymphadenektomie beim papillären und follikulären Schilddrüsenkarzinom.

Patients with papillary and follicular thyroid carcinomas are said to have an excellent long-term prognosis. However, over 90% of papillary carcinomas have synchrone lymph node metastases. Based on clinical, histopathologic and molecular-biological factors, different patient groups can be defined with an increased recurrence rate and disease related mortality-rate of up to 50% in the long-term follow-up of 30 years. Therefore, not only the extent of the surgical resection of the thyroid cancer but also the lymph node dissection as an oncologic correct surgical procedure is of great importance. Although the position of surgical lymphadenectomy is still discussed controversially there are increasing reasons to support the concept of a radical initial operation following the rules of oncologic surgery. We consider total thyroidectomy and modified neck-dissection as the standard operation in well differentiated thyroid carcinoma. In unilateral carcinoma both the central and the ipsilateral cervico-lateral lymph node compartments are dissected. In multicentric bilateral carcinomas a bilateral cervico-central and cervico-lateral lymphadenectomy has to be performed.

Acute necrotizing pancreatitis: treatment strategy according to the status of infection.

OBJECTIVE: To determine benefits of conservative versus surgical treatment in patients with necrotizing pancreatitis. SUMMARY BACKGROUND DATA: Infection of pancreatic necrosis is the most important risk factor contributing to death in severe acute pancreatitis, and it is generally accepted that infected pancreatic necrosis should be managed surgically. In contrast, the management of sterile pancreatic necrosis accompanied by organ failure is controversial. Recent clinical experience has provided evidence that conservative management of sterile pancreatic necrosis including early antibiotic administration seems promising. METHODS: A prospective single-center trial evaluated the role of nonsurgical management including early antibiotic treatment in patients with necrotizing pancreatitis. Pancreatic infection, if confirmed by fine-needle aspiration, was considered an indication for surgery, whereas patients without signs of pancreatic infection were treated without surgery. RESULTS: Between January 1994 and June 1999, 204 consecutive patients with acute pancreatitis were recruited. Eighty-six (42%) had necrotizing disease, of whom 57 (66%) had sterile and 29 (34%) infected necrosis. Patients with infected necrosis had more organ failures and a greater extent of necrosis compared with those with sterile necrosis. When early antibiotic treatment was used in all patients with necrotizing pancreatitis (imipenem/cilastatin), the characteristics of pancreatic infection changed to predominantly gram-positive and fungal infections. Fine-needle aspiration showed a sensitivity of 96% for detecting pancreatic infection. The death rate was 1.8% (1/56) in patients with sterile necrosis managed without surgery versus 24% (7/29) in patients with infected necrosis (P <.01). Two patients whose infected necrosis could not be diagnosed in a timely fashion died while receiving nonsurgical treatment. Thus, an intent-to-treat analysis (nonsurgical vs. surgical treatment) revealed a death rate of 5% (3/58) with conservative management versus 21% (6/28) with surgery. CONCLUSIONS: These results support nonsurgical management, including early antibiotic treatment, in patients with sterile pancreatic necrosis. Patients with infected necrosis still represent a high-risk group in severe acute pancreatitis, and for them surgical treatment seems preferable.

Liver nodules resembling focal nodular hyperplasia after hepatic venous thrombosis.

We report the case of focal nodular hyperplasia-like nodular hepatic lesions, that developed in the liver of a 35-year-old Caucasian female who required orthotopic liver transplantation for Budd-Chiari syndrome. The rapid development of focal nodular hyperplasia-like lesions in a severe hepatic vascular disorder and in the absence of cirrhosis may represent an additional argument in favor of the vascular origin of focal nodular hyperplasia. The pathogenesis of the nodules is not clear, but pathological arterialization of the liver in hepatic vein thrombosis may be a candidate mechanism.

Randomized prospective trial of pylorus-preserving vs. Classic duodenopancreatectomy (Whipple procedure): initial clinical results.

During the past decades, the classic Whipple resection (cWhipple) and the pylorus-preserving Whipple (ppWhipple) operation have been advanced for the resection of cancer of the pancreatic head. However, no definitive answer exists as to whether the more conservative ppWhipple operation indeed equalizes the short- and long-term results of the cWhipple procedure. Therefore we conducted a randomized prospective trial in a nonselected series of consecutive patients. Demographics, diagnostic, intraoperative, and histologic findings (tumor type and tumor stage of these patients) as well as postoperative mortality, morbidity, and follow-up after discharge were analyzed. For statistical evaluation Kruskal-Wallis and chi-square tests were used where appropriate. Survival was analyzed according to Kaplan-Meier curves, and differences were examined using the log-rank test. From June 1996 to April 1999, a total of 114 patients with suspected pancreatic or periampullary tumors were prospectively randomized to undergo either a cWhipple or a ppWhipple (intention to treat) operation. Based on the inclusion and exclusion criteria, 77 of these patients were included in the final analysis. Forty had a cWhipple and 37 had a ppWhipple resection. There were no differences with regard to age, sex distribution, ASA classification, histologic classification, UICC stage, length of stay in the intensive care unit, and length of hospital stay. The ppWhipple group had a significantly shorter operative time, reduced blood loss, and fewer blood transfusions. There was no difference in mortality, but the cWhipple group showed a significantly higher total morbidity. The incidence of delayed gastric emptying was identical in both groups. For long-term follow-up, a total of 61 patients with histologically proven pancreatic or periampullary carcinoma were analyzed. There were no differences in tumor recurrence or in long-term survival at a median follow-up of 1.1 years (range 0.1 to 2.9 years). Our initial results demonstrate that the cWhipple and ppWhipple operation are equally radical. However, ppWhipple may be the procedure of choice for the treatment of pancreatic and periampullary cancer.

[Surgery of pancreatic carcinoma]. / Chirurgie des Pankreaskarzinoms.

Pancreatic cancer is the third leading neoplasm of the gastrointestinal system and has a dismal prognosis. The majority of patients are no more suitable for resection at time of diagnosis due to early development of distant metastases or major infiltration of adjacent structures. However, due to the resistance of pancreatic cancer against radiation and chemotherapy, radical resection represents the only therapy with a potential for cure. For the surgical treatment of pancreatic head cancer, the classical Whipple operation is still the standard procedure but during the last two decades, pylorus-preserving pancreatoduodenectomy has been evolved as a more conservative procedure in order to omit the consequences of partial gastrectomy. For cancer of the pancreatic body and tail, distal pancreatectomy or total pancreatectomy represent the current standard treatment. More radical methods like regional pancreatectomy and resection with extended lymph node dissection have failed so far to demonstrate any improvements in long-term survival compared to the standard types of resection. To further improve the treatment of pancreatic cancer, prospectively randomized trials are needed to compare extended surgical procedures with the standard types of resection and the efficiency of various adjuvant therapies.

[Pylorus preserving or classical Whipple operation in tumors. Initial clinical results of a prospective randomized study]. / Pylorus-erhaltender oder klassischer Whipple bei Tumoren. Erste klinische Resultate einer prospektiv randomisierten Studie.

UNLABELLED: During the last decades, the classical Whipple resection (cWhipple) and pylorus-preserving Whipple (ppWhipple) operation have been evolved for the resection of cancer of the pancreatic head. However no definitive answer exists whether the more conservative ppWhipple indeed equalizes the short and long term results of the cWhipple procedure. METHODS: Therefore we conducted a randomized prospective trial in a non-selected, consecutive patient series. All relevant data concerning patient's demographics, intraoperative and histological findings as well as postoperative mortality morbidity and follow-up after discharge were analyzed. RESULTS: From 6/96 to 10/99 139 patients with suspicion of pancreatic or periampullary tumor were prospectively randomized to undergo either a cWhipple or a ppWhipple (intention to treat). Based on the inclusion and exclusion criteria, 93 of these patients were finally analyzed in the study. There were 51 cWhipple and 42 ppWhipple resections. There were no differences concerning age, sex, ASA classification, tumor type and stage, length of ICU- and in-hospital stay. However, the ppWhipple group had a significant shorter operation time. There was no difference in mortality and morbidity. The incidence of delayed gastric emptying was identical in both groups. For long-term follow-up, a total of 76 patients with histological proven pancreatic or periampullary carcinoma were analyzed. There was no difference in tumor recurrence and in long-term survival after a median follow-up of 1.5 years (0.1-3.5). CONCLUSION: Our intermediate results demonstrate that cWhipple and ppWhipple are equally radical. However, ppWhipple may be the procedure of choice for the treatment of pancreatic and periampullary cancer.

[Stent or surgical bypass as palliative therapy in obstructive jaundice]. / Stent oder chirurgischer Bypass als palliative Therapie beim Verschlussikterus.

UNLABELLED: During the last decades, the mortality following pancreatic resections has decreased tremendously due to advances in operative technique and perioperative management. In order to examine if similar improvements have been achieved for surgical palliation of obstructive jaundice, we conducted an analysis of our series of surgical bypass procedures. METHODS: Data from all patients undergoing surgical palliation after exploration for pancreatic carcinoma, were prospectively recorded. RESULTS: Between 1.11.93 to 1.11.99 a total of 348 patients were treated with a tumor of the pancreas. 74 of these patients received a bypass procedure: there were 40 double bypass, 20 biliary and 14 gastric bypass procedures. Overall morbidity and mortality was 35% and 1.2% respectively. Median in-hospital stay was 12 days (range 6-37). Median survival time was 5 months (range 1-25). Neither the type of surgical palliation, age nor perioperative risk assessment according to the ASA classification affected perioperative mortality. In contrast, jaundiced patients had significantly more postoperative complications than non-jaundiced patients (58% versus 18%; p = 0.001). CONCLUSIONS: Surgical palliation can nowadays be performed with great safety. A double bypass procedure consisting of a hepatojejunostomy combined with a gastrojejunostomy seems to be the procedure of choice for patients with unresectable pancreatic carcinoma.

[Liver resection for liver metastases--1998 Bern Symposium]. / Leberresektion für Lebermetastasen--Berner Symposium 1998.

The increasing knowledge of the anatomy and function of the liver made the surgical resection of liver metastases currently to the therapy of choice. Although liver metastasis is an advanced stage in tumor-progression, surgery achieves the best long-term results due to a better understanding of the carcinogenesis (i.e. micrometastases) and the prognostic risk factors. This study summarizes the results of 109 resections of colorectal and non-colorectal liver metastases during a period of 59 months at our department. Four different surgical techniques (extended hepatectomy vs. segmental resection vs. atypical resection vs. biopsy) were investigated. For resections a tumour-free resection margin of at least 10 mm was always attempted to achieve. The accumulated morbidity of all techniques together was 23%. Although the morbidity was higher for extended resections (Encephalopathy 16% vs. 2.3% for segmental resections, Liver insufficiency 23% vs. 4.7%), compared to the limited resection procedures, the long-term survival improved. The overall mortality was 2.7%. Survival was higher in patients with resection of colorectal than non colorectal metastases. Our results indicate that liver resection, under observance of the anatomical and functional margins (i.e. an adequate resection margin), is the only potentially curative therapy for liver metastases. An extensive formal resection, although inducing a higher perioperative morbidity, is superior to the limited resection techniques and results in an increased long-term survival. One reason is the increased probability of co-resection of preoperatively undetected local micrometastases.

Use of accurate diagnostic criteria may increase incidence of stercoral perforation of the colon.

PURPOSE: Stercoral perforation of the colon is reported to be a rare disease with poor prognosis. The aim of this study was to determine the frequency of stercoral perforation of the colon, to define diagnostic criteria for stercoral perforation of the colon, and to analyze the patient outcome in a university hospital gastrointestinal surgery unit. METHODS: From November 1993 until November 1998 all surgically treated patients with a colorectal disease were prospectively recorded in a computerized database. Diagnosis of stercoral perforation of the colon was made if 1) the colonic perforation was round or ovoid, exceeded 1 cm in diameter, and lay antimesenteric; 2) fecalomas were present within the colon, protruding through the perforation site or lying within the abdominal cavity; and 3) pressure necrosis or ulcer and chronic inflammatory reaction around the perforation site were present microscopically. Any additional colon pathology led to exclusion from the diagnosis of stercoral perforation of the colon. Using the same criteria, 81 cases in the literature were found to qualify and were further analyzed. RESULTS: In a five-year period 1,295 patients underwent colorectal interventions through laparotomy. A total of 566 (44 percent) cases were emergencies, 220 (17 percent) of these caused by colonic perforation. Seven patients had stercoral perforation of the colon. The incidence of stercoral perforation of the colon was 0.5 percent of all surgical colorectal procedures through laparotomy, 1.2 percent of all emergency colorectal procedures, and 3.2 percent of all colonic perforations. The mean age of the patients was 59 (median, 64; range, 22-85) years. All perforations were situated in the left hemicolon or upper rectum. The round or ovoid perforation had a mean diameter of 3.6 cm. Fecalomas were present in all patients and protruded from the perforation site or were found within the free abdominal cavity in three of them. Generalized stercoral peritonitis was a constant finding. Using a colonic resection without immediate restoration of continuity, an extensive intraoperative lavage, and antibiotics, there was no in-hospital mortality. Analysis of the reports in the literature revealed additionally that 28 percent of patients with stercoral perforation of the colon have multiple stercoral ulcers in the colon and that substantial mortality is encountered if only minor surgical procedures of treatment are used. CONCLUSIONS: The incidence of stercoral perforation of the colon seemed to have been underestimated. The reason for this might be the lack of defined diagnostic criteria for this disease. Low mortality is obtained by early surgical eradication of the affected part of the colon, including all stercoral ulcers, and by aggressive therapy for peritonitis.

Conservative surgical treatment of diffuse peritonitis.

BACKGROUND: Peritonitis is, even today, a significant source of death and complications. The objective of this study was to determine the morbidity and mortality rates, the incidence of reoperations, and the need for additional treatment strategies (on demand) in patients with diffuse peritonitis. METHODS: Prospective analysis including all patients (n = 258) with diffuse peritonitis admitted to our surgical service between November 1993 and April 1998 who underwent a uniform surgical treatment concept of peritonitis including early intervention, source control, and extensive intraoperative lavage. RESULTS: The 258 patients with diffuse peritonitis averaged a mean Mannheim Peritonitis Index of 27.1 points (range, 11-43 points). Source control at the initial operation was possible in 230 of the patients (89%), of those, 21 patients (9%) needed reintervention. In 28 patients (11%), source control was not possible at the initial operation. Twenty of these patients (71%) had to undergo additional treatment strategies (on demand) such as continuous lavage and/or laparostomy. Overall 228 of the 258 patients (88%) needed just 1 initial surgical intervention. The overall morbidity rate was 41%; the rate of reoperation was 12%, and the hospital mortality rate was 14%. CONCLUSIONS: A conservative surgical treatment concept supplemented with "extensive" intraoperative lavage reduces the reoperation rate compared with other treatment standards of peritonitis and achieves a low mortality rate in patients with diffuse peritonitis.

Primary liver disease as a determinant for acute rejection after liver transplantation.

BACKGROUND: Graft rejection and infection remain major problems following liver transplantation; both are heavily influenced by the immunosuppressive regimen. Despite the disparity in the primary disease leading to transplantation, all patients receive the same posttransplant immunosuppressive treatment in a given center. The aim of this study is to detect a possible effect of the underlying disease on the incidence of early acute rejection episodes after orthotopic liver transplantation (OLT). PATIENTS AND METHODS: Retrospective analysis on all 101 consecutive liver transplants performed in 95 patients between 1983 and March 1998; five of these patients, surviving less than 30 days, were not included. The immunosuppressive regimen was based on conventional triple therapy during the whole study period. The diagnosis and treatment of acute rejection within the first 30 days post-OLT was uniform throughout the whole study period. RESULTS: Though there were no differences with respect to patients' characteristics [age, child classification, number of HLA-mismatches or cytomegalovirus (CMV)-serocompatibility], patients with primary biliary cirrhosis (PBC) showed a significant increase of acute rejection after OLT compared with the other patients transplanted for other liver diseases (P = 0.024). The incidence of infection was not elevated in patients transplanted for PBC when compared with other diagnoses. CONCLUSION: Our results indicate that primary liver disease may be a determinant for acute graft rejection in PBC. Furthermore, these results suggest that immunosuppressive regimens based on the underlying disease should be considered.

[Surgery of the goiter]. / Chirurgie der Struma.

Surgery of the goiter has been greatly influenced by Theodor Kocher all over the world. Dedicated to his understanding of goiterogenesis he is considered the father of the prevention and elimination of the wide spread iodine deficiency goiter disease in Switzerland by introducing the iodinesation of salt. Therefore Switzerland is the only country in Europe, which is no longer an iodine deficiency region but remains an endemic goiter region. The traditional conservative Kocher type of surgical resection of the multinodular goiter showed to harbour the problem of a high recurrence rate. The analysis of our Bernese data (3193 thyroid operations with 4395 nerves at risk) brought us to the point to question this traditional surgical strategy. In order to lower the recurrence rate and in addition to lower surgical morbidity we started from 1990 to resect much more thyroid tissue in order to resect all pathologic thyroid tissue. This meant as a minimal surgical procedure, a thyroidectomy on one side followed by a subtotal resection on the contralateral side in case of bilateral disease. The surgical concept in parallel was supported by the novel molecular biological concept of goiterogenesis presented by our Bernese research team, which could demonstrate that the potential for goiterogenesis and clonal growth of functional and morphological independent cluster is distributed all over the whole thyroid gland. Therefore a more radical resection at the first operation will resect much more potential clones at risk to become recurrent goiters than the 'old' conservative resection type. With the more radical initial resection combined with a routine demonstration of the recurrent laryngeal nerve and the parathyroid glands we could reduce the recurrent laryngeal nerve palsy from 2.7% (nerves at risk) in the early period (1972-1990) to 0.7% with the more radical resection (1991-1996, p < 0.05). In parallel the postoperative hypoparathyroidism of the early period of 3.6% could be lowered to 1% in the actual series (p < 0.05). Theodor Kocher's conservative thyroid gland surgical concept has now one century later found a correction by a Bernese team again, which could significantly reduce the morbidity of thyroid gland surgery and as well, will greatly reduce the incidence of recurrent goiter disease after initial surgery in our endemic region.

Early acute cellular rejection: no effect on late hepatic allograft function in man.

Whereas early acute cellular rejection, even if successfully treated, seems to have an impact on late function and survival of kidney and heart transplants, little quantitative data are available on its effect(s) on liver transplants. Routine liver function tests, the functioning liver cell mass (galactose elimination capacity) and microsomal metabolic capacity (aminopyrine breath test) were determined prospectively in 37 consecutive patients 1 year after liver transplantation. Of these, 19 (7 females and 12 males, 32-69 years of age) had previously required treatment for at least one biopsy proven acute cellular rejection episode occuring a median 7 days after grafting, while 18 (6 females and 12 males, 30-67 years of age) had not. The functioning liver cell mass and microsomal metabolic capacity were both within normal limits for the majority of patients and did not differ significantly between patients with and without previous acute cellular rejection episodes. In contrast to other solid organ transplants, early acute cellular rejection episodes do not affect late function of liver allografts in man.