PREVELENCE OF PRIMARY ALDOSTERONISM IN AN URBAN HYPERTENSIVE POPULATION.

OBJECTIVE: To determine the prevalence of primary aldosteronism (PA) in hypertensive patients presenting to the primary care clinic at The Mount Sinai Hospital, regardless of the degree of hypertension and to identify clinical criteria that should prompt screening for PA. METHODS: An aldosterone:renin ratio (ARR, cutoff ≥20, with plasma aldosterone concentration [PAC] ≥10 and suppressed renin) was used to prospectively screen 296 hypertensive patients (blood pressure [BP] ≥140/90) over the age of 18 from August 2012 through May 2013. Subjects who screened positive then underwent confirmatory oral salt load testing (OSLT). RESULTS: Of the 296 patients, 14 screened positive for PA, an overall prevalence of 4.7%. Six of the 14 cases underwent confirmatory OSLT, upon which 2 were confirmed positive, for a prevalence of 0.7%. Overall, patients with confirmed PA were more likely to have resistant hypertension (42.9% vs. 18.1% (P = .0334)) and require more antihypertensive agents (2.8 ± 1.2 agents vs. 2.1 ± 1.1 agents, P = .0213). There was a trend toward lower potassium values in the cases. CONCLUSION: The prevalence of PA in our clinic is much lower than in reports from certain "at-risk" populations. PA screening is indicated in patients with resistant hypertension, regardless of serum potassium levels. ABBREVIATIONS: ARR = aldosterone:renin ratio ACTH = adrenocorticotropic hormone AVS = adrenal venous sampling BP = blood pressure MRA = mineralocorticoid receptor antagonist OSLT = oral salt load confirmatory test PA = primary aldosteronism PAC = plasma aldosterone concentration PCP = primary care provider PRA = plasma renin activity.

Esophageal dilation after laparoscopic adjustable gastric banding.

BACKGROUND: Esophageal dilation can occur after laparoscopic adjustable gastric banding (LAGB). There are few studies in the literature that describe the outcomes of patients with esophageal dilation. The aim of this article is to evaluate weight loss and symptomatic outcome in patients with esophageal dilation after LAGB. METHODS: We performed a retrospective chart review of all LAGBs performed at Columbia University Medical Center from March 2001 to December 2006. Patients with barium swallow (BaSw) at 1 year after surgery were evaluated for esophageal diameter. A diameter of 35 mm or greater was considered to be dilated. Data collected before surgery and at 6 months and 1, 2 and 3 years after surgery were weight, body mass index (BMI), status of co-morbidities, eating parameters, and esophageal dilation as evaluated by BaSw. RESULTS: Of 440 patients, 121 had follow-up with a clinic visit and BaSw performed at 1 year. Seventeen patients (10 women and 7 men) (14%) were found to have esophageal dilation with an average diameter of 40.9 +/- 4.6 mm. There were no significant differences in percent of excess weight lost at any time point; however, GERD symptoms and emesis were more frequent in patients with dilated esophagus than in those without dilation. Intolerance of bread, rice, meat, and pasta was not different at any time during the study. CONCLUSIONS: In our experience the incidence of esophageal dilation at 1 year after LAGB was 14%. The presence of dilation did not affect percent excess weight loss (%EWL). GERD symptoms and emesis are more frequent in patients who develop esophageal dilation.

[Early improvement in Type 2 diabetes in obese patients following gastric bypass and bilio-pancreatic diversion: the role of the entero-insular axis]. / Traitement précoce du diabète de type 2 chez l'obèse après gastric bypass et diversion bilio-pancréatique: rôle de l'axe entéro-insulinique.

Improvement in Type 2 diabetes is seen in 80-98% of obese diabetic patients who undergo gastric bypass or bilio-pancreatic diversion. This improvement is evident early after the operation before significant weight loss has occurred. Although numerous teams have extensively studied the physiology of this early post-bypass amelioration of type 2 diabetes, the exact mechanism of diabetes remission remains unclear. Studies have focused on changes in the entero-insular axis, which is mediated in part by the interaction of insulinotropic hormones GIP and GIP 1 on the beta islet cells of the pancreas. Other mechanisms which have been postulated focus on the adipo-insular axis; the actions of adiponectin and leptin seem to have an important role in insulin resistance but their action is weight-loss dependent. Post-operative caloric restriction may also contribute to the early resolution of type 2 diabetes observed after gastric bypass and bilio- pancreatic diversion.

Early U.S. outcomes of laparoscopic gastric bypass versus laparoscopic adjustable silicone gastric banding for morbid obesity.

Laparoscopic gastric bypass (LGBP) is the gold standard operation for long-term weight control in the United States. Laparoscopic adjustable silicone gastric banding (LASGB) is the preferred operative method for morbid obesity worldwide. Limited data are available comparing the two procedure in the United States. This study compares weight loss, complications, and early outcome of comorbidity resolution in patients who underwent LGBP versus LASGB. A review of prospectively collected data was performed on 392 patients undergoing primary LGBP (n = 232) and LASGB (n = 160) procedures between February 2001 and July 2004. Differences in percentage excess weight lost (%EWL) at 3, 6, 12, 18, and 24 months postop, improvement or resolution of comorbidities, and complications across procedure types were evaluated. Mean initial body mass index between groups was not significantly different (LGBP 47.2 vs LASGB 47.1, p < 0.53). There were significant differences in age, gender, and self-reported sweet-eating behavior between operative groups. There was a significantly greater %EWL in patients who underwent LGBP compared to patients of the LASGB groups 3, 6, 12, and 18 months after surgery. There were no significant differences in resolution or improvement of comorbidities between the groups. Although LGBP patients experienced more complications compared to LASGB patients (5.6 vs 4.3%, respectively; p < 0.56), this did not reach statistical significance. Early after surgery, LGBP patients lose more weight than LASGB patients but have similar improvements in comorbidities. Further follow-up is needed to determine the relative long-term efficacy of these procedures.

Symptomatic internal hernias after laparoscopic bariatric surgery.

BACKGROUND: The aim of this study was to describe the occurrence and clinical characteristics of symptomatic internal hernias (IH) after laparoscopic bariatric procedures. METHODS: We conducted a retrospective review of cases of IH after 1,064 laparoscopic gastric bypasses (LGB) and biliopancreatic diversions with duodenal switch (LBPD-DS) performed from September 1998 to August 2002. RESULTS: We documented 35 cases of IH (overall incidence of 3.3%). The IH occurred in 6.0% of patients with retrocolic procedures and 3.3% of patients with antecolic procedures. Most were in the Petersen defect (55.9%) and at the enteroenterostomy site (35.3%). A bimodal presentation was observed, with 22.9% of patients with IH diagnosed in the early postoperative period (2-58 days) and 77.1% in a delayed fashion (187-1,109 days). A laparoscopic approach to the repair of IH was possible in 60.0% of patients. Complications occurred in 18.8% of patients, including one death (2.9%). CONCLUSION: Complete closure of all mesenteric defects is strongly recommended during laparoscopic bariatric procedures to avoid IH and their associated complications.

Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient.

BACKGROUND: Surgical management of the supersuper obese patient (BMI >60 kg/m2) has been a challenging problem associated with higher morbidity, mortality, and long-term weight loss failure. Current limited experience exists with a two-stage biliopancreatic diversion and duodenal switch in the supersuper obese patient, and we now present our early experience with a two-stage gastric bypass for these patients. METHODS: We completed a retrospective bariatric database and chart review of super-super obese patients who underwent laparoscopic sleeve gastrectomy as a first-stage procedure followed by laparoscopic Roux-en-Y gastric bypass as a second-stage for more definitive treatment of obesity. RESULTS: During a two-year period, 7 patients with BMI 58-71 kg/m2 underwent a two-stage laparoscopic Roux-en-Y gastric bypass by two surgeons at the Mount Sinai Medical Center. 3 patients were female, 4 patients were male, and the average age was 43. Prior to the sleeve gastrectomy, the mean weight was 181 kg with a BMI of 63. Average time between procedures was 11 months. Prior to the second-stage procedure, the mean weight was 145 kg with a BMI of 50 and average excess weight loss of 37 kg (33% EWL). Six patients have had follow-up after the second-stage procedure with an average of 2.5 months. At follow-up the mean weight was 126 kg with a BMI of 44 and average excess weight loss of 51 kg (46% EWL). The mean operative times for the two procedures were 124 and 158 minutes respectively. The average length of stay for all procedures was 2.7 days. 4 patients had 5 complications, which included splenic injury, proximal anastomotic stricture, left arm nerve praxia, trocar site hernia, and urinary tract infection. There were no mortalities in the series. CONCLUSIONS: Laparoscopic sleeve gastrectomy with second-stage Roux-en-Y gastric bypass are feasible and effective procedures based on short-term results. This two-stage approach is a reasonable alternative for surgical treatment of the high-risk supersuper obese patient.

Pheochromocytoma: inherited associations, bilaterality, and cortex preservation.

BACKGROUND: Hereditary pheochromocytoma (HP) is characterized by early onset, bilateral adrenal involvement, low malignancy rate, and genetic linkage with certain familial syndromes. This retrospective review is intended to show the high yield of surveillance, predictable bilaterality, and the challenge of cortex-sparing adrenalectomy. METHODS: From 1964 to 1999, 32 patients with HP were treated at a single institution and followed for a mean of 7 years. There were 15 cases of multiple endocrine neoplasia type 2A (MEN 2A), 12 cases of von Hippel-Lindau (VHL) disease, 3 cases of von Recklinghausen's disease (VRD), and 2 cases of familial pheochromocytoma. Twenty-four of 32 patients underwent bilateral adrenalectomy (9 metachronous). Subtotal resection with orthotopic cortex preservation was performed in 5 patients, and heterotopic autografting was performed in 14 patients. RESULTS: Pheochromocytoma was the first manifestation in 50% of patients with VHL disease and in 27% of patients with MEN 2A. Surveillance uncovered medullary thyroid cancer in 5 of 15 patients with MEN 2A and hemangioblastomas, renal cell carcinoma, and islet cell tumors in 7 of 15 patients with VHL disease and VRD. HP was bilateral in 24 of 32 patients (14/15 in patients with MEN 2A, 7/12 in patients with VHL disease, 2/3 in patients with VRD, and 1/2 in patients with familial pheochromocytoma). In 9 cases of metachronous adrenalectomy, the mean interval was 67 months (range, 9-156 months). Three of 5 patients who underwent orthotopic preservation of the adrenal cortex experienced recurrence compared with 0 of 14 patients with heterotopic autotransplantation of cortical tissue. CONCLUSIONS: Pheochromocytoma frequently heralds coexisting silent VHL disease or MEN-2, mandating surveillance for inherited associations. The long interval of metachronous pheochromocytoma argues against prophylactic removal of the contralateral "normal" adrenal gland. Total adrenalectomy and heterotopic autotransplantation of medulla-free cortex may diminish the need for lifelong steroid substitution and eliminates recurrence.

Hyperparathyroidism and pancreatitis during pregnancy.

Although the simultaneous occurrence of hyperparathyroidism and pancreatitis during pregnancy is rare, several points should be emphasized. Early recognition and treatment are essential. Pancreatitis should be kept in the differential diagnosis of unexplained nausea, vomiting, and abdominal pain during pregnancy. Hyperparathyroidism should always be included in the differential diagnosis of pancreatitis. Finally, the second trimester is the optimal period for surgical intervention.

Endoscopic endocrine neck surgery with carbon dioxide insufflation: the effect on intracranial pressure in a large animal model.

BACKGROUND: Endoscopic endocrine neck surgery requires insufflation with carbon dioxide (CO(2)) at 10 to 15 mm Hg, which may decrease the cerebral venous return and increase intracranial pressure. This study evaluated the effect of CO(2) neck insufflation on intracranial pressure (ICP) and hemodynamic parameters. METHODS: Fifteen pigs underwent endoscopic thyroid dissection. Insufflation was performed with CO(2) at 0 (sham), 10, 15, and 20 mm Hg and with helium at 20 mm Hg with 3 pigs in each group. ICP, mean arterial pressure, central venous pressure (CVP), cardiac output, and blood gas were measured at baseline, 30, 60, and 120 minutes. RESULTS: There were no differences in mean ICP between the sham group and CO(2) insufflation at 10 mm Hg. Mean ICP increased significantly with CO(2) at 15 and 20 mm Hg and with helium at 20 mm Hg. A significant increase in CVP occurred in pigs operated with CO(2) at 20 mm Hg. We observed jugular vein collapse under all insufflation pressures; however, pigs operated at 10 mm Hg were able to maintain an intermittent blood flow. CONCLUSIONS: A severe increase in ICP occurs with insufflation pressures higher than 15 mm Hg, possibly as a result of decreased cervical venous blood flow. Carbon dioxide insufflation up to 10 mm Hg does not alter ICP and is recommended for clinical application in endoscopic neck surgery.

Unilateral neck exploration under local anesthesia: the approach of choice for asymptomatic primary hyperparathyroidism.

BACKGROUND: Conventional parathyroidectomy involves a bilateral neck exploration with the patient under general anesthesia with a thorough search for all parathyroid tissue. The purpose of this study was to assess the efficacy and safety of unilateral neck exploration under local anesthesia in patients with asymptomatic primary hyperparathyroidism (first-degree hyperparathyroidism). METHODS: Of 679 patients who underwent parathyroidectomy for first-degree hyperparathyroidism from July 1989 to June 1997, 230 asymptomatic patients underwent unilateral neck exploration under local anesthesia. Selection criteria for this approach included the successful identification of a solitary parathyroid adenoma on preoperative imaging, no thyroid disease, and no family history of multiple endocrine neoplasia. Intact parathyroid hormone levels were monitored during the operation. RESULTS: Total serum calcium levels were normal in 220 patients (96%) 3 to 6 months after surgery. Ten patients (4%) experienced persistent hypercalcemia, 8 of whom had multiple gland disease and 2 of whom had false-positive imaging. Two of these patients underwent bilateral neck exploration under general anesthesia and were cured, although 8 patients remained asymptomatic and were followed up non-operatively. The mean operating time was 30 minutes (range, 12-65 minutes). There were two complications (0.87%) including one wound hematoma and one transient recurrent laryngeal nerve palsy. CONCLUSIONS: Unilateral neck exploration under local anesthesia is an efficacious and safe approach to the treatment of first-degree hyperparathyroidism and should be considered in all patients with asymptomatic disease.

Laparoscopic pancreatic resection: single-institution experience of 19 patients.

BACKGROUND: The number of laparoscopic pancreatic resections reported in the surgical literature has been remarkably low. Few substantive data are available concerning current indications and outcomes after laparoscopic pancreatectomy. The purpose of this article is to review the recent indications, complications, and outcomes after laparoscopic pancreatic resection. STUDY DESIGN: A retrospective analysis of the Mount Sinai hospital records was performed for all patients who underwent laparoscopic distal pancreatectomy or enucleation between the time of the first resection in November 1993 until the time of this study in March 2000. RESULTS: In the 19 patients (6 men) the mean age was 53 years (range 22 to 83 years). In 16 patients (84%) the entire procedure was done by laparoscopy; one operation was converted to a hand-assisted technique; and two cases were converted to open. Median operating time was 4.4 hours (range 1.6 to 6.6 hours), and median intraoperative blood loss was 200 mL. Postoperative complications included three pancreatic leaks (16%), one case of superficial phlebitis, and one prolonged ileus for 7 days (total morbidity of 26%). There were no deaths. The median length of postoperative hospital stay was 6 days (range 1 to 26 days). CONCLUSIONS: This represents the largest single-institution experience with laparoscopic pancreatic resection. The considerable morbidity rate is comparable to recently published open series, and is likely inherent in pancreatic surgery, rather than the technical approach. Laparoscopic pancreatic surgery resulted in shorter hospital stays and appears to be safe for benign diseases.

Endoscopic thyroidectomy for solitary thyroid nodules.

Conventional thyroidectomy often leaves an undesirable scar on the anterior neck. The aim of this study was to assess the feasibility and efficacy of endoscopic thyroidectomy, a new minimally invasive technique for thyroid surgery. Between September 1998 and February 2000, 18 patients with a solitary thyroid nodule underwent endoscopic thyroidectomy utilizing CO2 insufflation. There were 16 females and 2 males with a mean age of 43 years (range 17-66 years). Indications for surgery included indeterminate cytology (n = 8), follicular neoplasm (n = 8), Hürthle cell neoplasm (n = 1), and toxic thyroid nodule (n = 1). The mean nodule diameter was 2.7 cm (0.6-7 cm). Analgesic requirement, return to normal activity, and cosmetic results were compared to 18 consecutive patients who had conventional thyroidectomy. Sixteen of 18 cases were successfully completed endoscopically with a mean operating time of 220 minutes (range, 120-330 minutes). There were no major complications, but 3 patients developed mild hypercarbia and 1 patient had an incidental parathyroidectomy. When compared to conventional thyroidectomy, patients undergoing endoscopic thyroidectomy had a significantly superior cosmetic result (p < 0.005) and a quicker return to normal activity (p < 0.05), but there was no difference in analgesic requirement. Endoscopic thyroidectomy is a technically feasible and safe procedure that leads to an improved cosmetic result and a quicker recovery. Open completion thyroidectomy is recommended for thyroid carcinoma until more data are available.

Multimedia article. Laparoscopic enucleation of a pancreatic insulinoma.

Insulinoma is the most common functional neuroendocrine tumor of the pancreas. In most cases the lesions are benign, solitary, and located within the pancreatic parenchyma. Because of these characteristics, the majority of these lesions can be treated with simple enucleation. Advances in laparoscopic techniques have recently enabled the safe resection of pancreatic islet cell tumors and may provide patients with the benefits of minimally invasive surgery. This video demonstrates the technique of laparoscopic enucleation of a pancreatic insulinoma. The case presentation is that of a 40-year-old man who had symptoms of neuroglycopenia and was found to have elevated proinsulin levels during a 72-hour fast. Further evaluation included a CT scan, which revealed a 1.5 cm lesion on the posterior surface of the midbody of the pancreas. The video shows the operative technique of enucleation of the lesion, including positioning and trocar placement, performance of intraoperative ultrasound for tumor localization, and the use of specialized instruments (laparoscopic freer-elevator with a spatulated tip) that allowed enucleation of the lesion without excess handling of the tumor itself. The operation was performed in 105 minutes with minimal blood loss. The patient was fed clear liquid diet on the day after surgery and was discharged home on the third postoperative day. He had an uneventful recovery and has experienced no further symptoms.

Transcervical endoscopic-assisted mediastinal parathyroidectomy with intraoperative parathyroid hormone monitoring.

Ectopic mediastinal parathyroid adenomas are rare lesions that typically necessitate either median sternotomy or thoracotomy. More recently, video-assisted thoracoscopy has been used to excise mediastinal parathyroid adenomas. Herein we describe a novel technique in which we used a minimally invasive transcervical endoscopic-assisted approach to excise an anterior mediastinal parathyroid adenoma in a young man with a history of spontaneous pneumothorax. Intraoperative parathormone monitoring confirmed the excision of all hypersecreting parathyroid tissue, thereby obviating the need for a conventional neck exploration.

Minimally invasive endoscopic thyroidectomy by a cervical approach.

BACKGROUND: The technique of thyroidectomy mandates adequate visualization of the operative field to identify pertinent anatomical structures. The purpose of this prospective review was to assess the feasibility and safety of endoscopic thyroidectomy by a cervical approach. METHODS: All patients who underwent endoscopic thyroidectomy were assessed by retrospective review of a prospective database. RESULTS: Thirty-eight patients underwent endoscopic thyroidectomy by a cervical approach. Thirty-five of 38 cases were successfully completed endoscopically with a mean OR time of 190 min. One patient experienced a permanent recurrent laryngeal palsy. CONCLUSION: Endoscopic thyroidectomy by a cervical approach is a feasible procedure. As in conventional thyroid surgery, great care should be exercised when dissecting the recurrent laryngeal nerve.

Endoscopic approach for carotid artery surgery.

BACKGROUND: Although recent advances in the treatment of carotid artery stenosis have included endovascular angioplasty and stent placement, carotid endarterectomy is still the approach of choice for carotid disease and is one of the most commonly performed operations today. Minimally invasive surgeries involving the neck have recently been performed for thyroid and parathyroid diseases. The purpose of this study was to evaluate the feasibility of an endoscopic approach for carotid artery surgery in a large animal model. METHODS: Eight 25- to 30-kg pigs were used. Animals underwent endoscopic carotid dissection with carbon dioxide insufflation at 10 mmHg. A 1.5- to 2-cm arteriotomy was made in the common carotid artery. Four animals underwent direct arteriotomy closure, and four animals underwent synthetic patch graft placement using intracorporeal suturing techniques. Open examination of the operative site and carotid angiograms were performed at the end of the procedure. Operative time was recorded in the last four cases. RESULTS: All animals tolerated the procedure well and carotid artery repair was successfully performed in all cases using a four-trocar technique. The entire extent of the cervical common and internal carotid arteries was exposed up to the cranial base. Cranial nerves and cervical structures were clearly visualized and preserved. No bleeding occurred at the end of the procedure. Carotid angiograms confirmed patent, nonstenotic vessels in all cases. CONCLUSION: Endoscopic approach for carotid surgery is technically feasible in the porcine model. This approach may represent a valuable option for surgery of the carotid artery since it offers the advantages of minimally invasive techniques while maintaining the benefits of surgical arterial repair.

Effect of standard vs extended Roux limb length on weight loss outcomes after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Increasing the length of the Roux limb in open Roux-en-Y gastric bypass (RYGB) effectively increases excess weight loss in superobese patients with a body mass index (BMI) >50 kg/m2. Extending the RYGB limb length for obese patients with a BMI < 50 could produce similar results. The purpose of this study was to compare the outcomes of superobese patients undergoing laparoscopic RYGB with standard (< or =100-cm) with those undergoing the procedure with an extended (150-cm) Roux limb length over 1-year period of follow-up. METHODS: Retrospective data over 2.5 years were reviewed to identify patients with a BMI < 50 who underwent primary laparoscopic RYGB with 1-year follow-up ( n = 58). Forty-five patients (sRYGB group) received limb lengths < or = 100 cm, including 45 cm ( n = 1), 50 cm ( n = 2), 60 cm ( n = 6), 65 cm ( n = 1), 70 cm ( n = 1), 75 cm ( n = 3), and 100 cm ( n = 31). Thirteen patients (eRYGB group) received 150-cm limbs. Postoperative weight loss was compared at 3 weeks, 3 months, 6 months, and 1 year. RESULTS: Comparing the sRYGB vs the eRYGB group (average +/- SD), respectively: There were no significant differences in age (41.5 +/- 11.0 vs 38.0 +/- 11.9 years), preoperative weight (119.2 +/- 11.9 vs 127.8 +/- 12.5 kg), BMI (43.7 +/- 3.0 vs 45.2 +/- 3.5 kg/m2), operative time (167.1 +/- 72.7 vs 156.5 +/- 62.4 min), estimated blood loss (129.9 +/- 101.1 vs 166.8 +/- 127.3 cc), or length of stay (median, 3 vs 3 days; range, 2-18 vs 3-19). Body weight decreased over time in both groups, except in the sRYGB group between 3 and 6 months and 6 and 12 months after surgery and in the eRYGB group between 6 and 12 months. BMI also decreased over time, except in the eRYGB group between 6 and 12 months. Absolute weight loss leveled out between 6 and 12 months in both groups, with no increase after 6 months. Percent of excess weight loss did not increase in the eRYGB group after 6 months. An extended Roux limb did not significantly affect body weight, BMI, absolute weight loss, or precent of excess weight loss at any time point when the two groups were compared. A trend toward an increased proportion of patients with >50% excess weight loss ( p = 0.07) was observed in the extended Roux limb group. CONCLUSIONS: In this series, no difference in weight loss outcome variables were observed up to 1 year after laparoscopic RYGB. Thus, extending Roux limb length from < or =100 cm to 150 cm did not significantly improve weight loss outcome in patients with a BMI < 50 kg/m2.

Surgical management of thyroid cancer.

OBJECTIVE: To present an overview of surgical management of differentiated thyroid cancer. METHODS: Evaluation of the thyroid nodule, assessment of indications for surgical treatment, analysis of the extent of surgical excision, and recommendations for lymph node dissection are addressed. RESULTS: In a patient with a thyroid nodule, certain historical information (such as prior irradiation to the head and neck or a family history of thyroid carcinoma) and physical findings (for example, a nonfunctioning, solitary thyroid nodule) increase the likelihood of a thyroid malignant lesion. Some indications for surgical intervention are a diagnosis of cancer on fine-needle aspiration biopsy, the presence of a cold nodule, or the presence of a large thyroid lesion, especially one that causes symptoms such as hoarseness or dysphagia. Although the extent of surgical excision is controversial, the presence of metastatic lesions, extrathyroidal extension, and multicentricity all are indications for total thyroidectomy. Grossly enlarged lymph nodes should be surgically excised. Probe-guided surgical resection is a promising advance in the management of persistent or recurrent thyroid carcinoma. CONCLUSION: Most patients with differentiated thyroid cancer have an excellent prognosis. Appropriate management is the key to minimizing morbidity and recurrences.

Laparoscopic liver biopsy in patients with coagulopathy, portal hypertension, and ascites.

The safety, reliability, and technique of laparoscopic liver biopsy were evaluated in 22 consecutive patients with coagulation abnormalities who were considered high risk for standard percutaneous liver biopsy. Fifty-eight biopsies were performed in 15 men and seven women. All patients had a prolonged prothrombin time (> 13.5 seconds), bleeding time (> 9 minutes), or thrombocytopenia (< 100,000 TH/UL). Ten patients (45%) had more pronounced coagulation abnormalities defined as a prolonged PT > 2.5 seconds or < or = 30% control, platelet count < 50,000 TH/UL, or bleeding time twice normal. Thirteen patients (59%) had both thrombocytopenia and a prolonged PT. Ascites was present in 19 patients (86%) and portal hypertension in 16 (73%). Laparoscopic liver biopsy was performed under general anesthesia, most commonly using two trocar sites and an open laparoscopic technique. Hemostasis was most effectively obtained by application of direct pressure and topical gelfoam and thrombin. A postoperative drop in hemoglobin of > or = 1 gm per cent occurred in four patients. One patient required laparotomy for postoperative bleeding and was the only patient requiring transfusion of red blood cells. Other complications included two minor ascitic leaks, one small subcapsular hematoma, and one wound infection. In conclusion, laparoscopic liver biopsy can be performed safely and reliably in patients with conditions contraindicating percutaneous biopsy.

A normal variant on Tl-201 and Tc-99m MIBI whole-body imaging: the superior right atrial wall (auricle) and superoanterior right ventricular wall are often seen as mediastinal lesions.

PURPOSE: The authors have often observed on Tl-201 and Tc-99m sestamibi (MIBI) scans in patients with thyroid cancer a small focus of increased uptake in the right midparasternal region (focus A) or sometimes in the lower mid chest at the level of the lower sternum (focus B) just inferomedial to focus A. The objective of this study was to assess the frequency of this finding on Tl-201 MIBI studies, to assess the incidence of true pathologic lesions corresponding to these foci, and to identify their nature. MATERIALS AND METHODS: One hundred ten whole body Tl-201 studies using 4 mCi (148 MBq) and 84 MIBI studies using 20 mCi (740 MBq: first-pass, planar, and SPECT images) were reviewed. The appearance of either focus A or focus B on three orthogonal SPECT images was correlated with an atlas of cross-sectional anatomy and computed tomography. If focus A was seen on the immediate static image (obtained at the end of the first-pass acquisition without moving the patient), this image was coregistered with a selected image from the first-pass study showing the superior vena cava and also with another selected image showing the ascending aorta. RESULTS: Focus A was seen in 40% of Tl-201 scans and in 49% of MIBI scans, whereas focus B was seen in 20% of Tl-201 scans and 39% of MIBI scans. On correlation of the SPECT images with a cross-sectional anatomy atlas, focus A and focus B invariably corresponded to the superior portion of the right auricle and basal superoanterior right ventricular wall, respectively. These myocardial regions are prominent and sometimes appear as discrete foci because they are considerably thicker than other parts of the right atrial and right ventricular muscle, respectively, and because they are seen partly end-on in the anterior projection. CONCLUSIONS: The superior portion of the right auricle and basal superoanterior right ventricular myocardium often appear as isolated foci on whole-body Tl-201 and MIBl scans. Neither focus should be interpreted as a metastatic lesion in patients with possible cancer or as an ectopic parathyroid adenoma in patients with hyperparathyroid disease.