Lipoadenoma of the parathyroid gland.

An unusual parathyroid adenoma containing abundant adipose tissue is described in four patients. In one patient, hyperparathyroidism was documented; in another, studies were incomplete but the adenoma was probably functioning. Prior reports of similar lesions have been called "parathyroid hamartoma or parathyroid adenoma with myxoid stroma," and some of these also have been shown to be functional. They may create diagnostic difficulties because of the presence of adipose tissue, a feature associated with normal parathyroid glands.

Results of emergency surgical management of hemorrhagic duodenal ulcer.

The results of emergency surgical operations carried out on 61 patients with massively beleding duodenal ulcers between the years 1960 and 1969 were reviewed. The most useful diagnostic tool was gastric roentgenography. However, celiac axis arteriography was not in use during this period. The basic procedure carried out was either gastric resection or vagotomy and pyloroplasty. The mortality between the two groups was similar. However, patients more than 60 years of age had a much greater morbidity after gastric resection. Complications were more likely to occur in patients who had a history of chronic ingestion of aspirin prior to the bleeding episode or in whom bleeding from their duodenal ulcer developed while they were recovering from some other surgical procedure.

Truncal vagotomy and resection in the treatment of duodenal ulcer.

A retrospective analysis was conducted of 466 patients who underwent elective truncal vagotomy with antrectomy or hemigastrectomy for chronic duodenal ulcer. The postoperative (30-day) mortality was 1.1%. In 412 of 466 patients (88.4%), follow-up was obtained, and in 290 patients alive at the writing of this paper, the mean follow-up was 17.1 years; the remaining 54 patients (11.6%) were lost to follow-up. The overall ulcer recurrence rate was 0.7%. Severe postoperative sequelae--postvagotomy diarrhea and postgastrectomy dumping--were uncommon--0.7% and 1.0% of patients, respectively. The combination of truncal vagotomy and gastric resection is a viable alternative in the surgical treatment of chronic duodenal ulcer disease and is the authors' operation of choice for most such patients.

Pheochromocytoma: current status and changing trends.

From 1971 through 1980, 106 patients underwent operations for pheochromocytoma. Twelve patients had a pheochromocytoma as a manifestation of the multiple endocrine neoplasia type 2 syndrome. Twenty patients were found to have extra-adrenal paragangliomas. Fifteen patients (14%) had malignant tumors; eight of these tumors were encountered in the group with extra-adrenal lesions. The cumulative survival probability at 5 years was 53%. Determination of urinary metanephrines and vanillylmandelic acid were the most sensitive diagnostic aids, with accuracy rates of 95% and 89%, respectively. In recent years, the measurement of fractionated urinary and plasma catecholamine levels has greatly increased the diagnostic accuracy. Preoperative localization of pheochromocytoma has improved during the last decade. Nephrotomography, selective angiography, and venous sampling have essentially been abandoned in favor of computed tomography. With an accuracy of more than 90%, computed tomography represents the major step forward in the overall management of pheochromocytoma during the past decade.

Further evaluation of total pancreatectomy.

The results of 64 total pancreatectomies performed at the Mayo Clinic between 1942 and 1973 have been reviewed. Improvement in recent results as compared to the previously reported series is probably related to improvements in operative techniques and in selection of patients with more favorable malignant lesions. The recent results are more favorable than those reported for a group of comparable patients undergoing standard Whipple procedures for malignant lesions at this institution. Diabetes was easily managed in 76% of patients. Hypoglycemia due to insulin sensitivity is the major problem, and ketoacidosis seldom occurs. Recognition of this has resulted in better management of diabetes with relatively small doses of insulin. The sequels of long-standing diabetes do not appear to be a problem. Gastrointestinal tract hemorrhage has been greatly decreased through the use of more extensive gastric resection.

Pseudocysts of the pancreas. Review of 71 cases.

During the period of 1962 to 1972, 71 patients underwent surgical treatment of pancreatic pseudocysts. Internal drainage was performed in 73% of these patients in comparison to only 20% in a series during the previous decade. From an analysis of results, it would appear that the treatment of choice is internal drainage via either cystogastrostomy or cystojejunostomy. Postoperative bleeding and sepsis were of negligible consequence. An unexpected finding was that the long-term results of these patients seemed to be better than those of patients with pancreatitis in whom pseudocysts did not develop.

Pancreatic cystadenoma. A clinicopathologic study of 45 cases.

Forty-five patients with pancreatic cystadenoma were treated surgically at the Mayo Clinic between 1939 and 1975. Each lesion was classified as mucous or serous. The most frequent lesion site was the tail of the pancreas. The typical patient was a middle-aged woman with upper abdominal pain and a palpable mass on initial examination. Total extirpation of the cystadenoma was the treatment of choice; internal drainage or external drainage of these cysts should not be done. Occasionally, the nearness of the tumors to the mesenteric vessels precluded excision. The mucous type had malignant potential whereas the serous does not. None of the cystadenomas subsequently underwent malignant degeneration. Because of the slow-growing characteristics of the tumor, undue operative risks should not be taken.

Annular pancreas: May Clinic experience from 1957 to 1976 with review of the literature.

From a review of 266 cases reported in the literature and data on 15 other patients operated on a the Mayo Clinic for symptomatic, annular pancreas, the following three conclusions can be made. First, annular pancreas is an uncommon congenital anomaly, often not becoming symptomatic until late life. Second, complicating congenital and acquired disorders must be recognized it patients are to be properly prepared for surgery. Sometimes associated problems may be recognized, whereas the annular pancreas may be overlooked. The change of this happening is decreased by methodical inspection of the entire abdomen, especially all segments of the duodenum, because annuli can occur in any segment and can be partially or completely circumferential. Third, while there is no single operative procedure of choice, published experience militates against any direct attack on the offending annulus.

Primary hyperparathyroidism in patients with multiple endocrine neoplasia syndromes. Surgical experience.

Forty-five patients with biochemically documented primary hyperparathyroidism as part of multiple endocrine neoplasia syndrome types 1 or 2 were surgically treated from 1960 through 1980. Hyperplasia occurred in 69% of the patients, single adenoma in 27%, and double adenomas in 4%. All but two patients with hyperplasia underwent subtotal parathyroidectomy. In this group, the cure rate was 93% and the incidence of permanent postoperative hypoparathyroidism 23%. In the adenoma group, treatment included excision of the adenoma and biopsy of at least one other gland. The cure rate was 76%, with no postoperative hypoparathyroidism. Analysis of patients with persistent hyperparathyroidism suggested that failure to recognize multiple gland disease was the principal cause of postoperative hypercalcemia. In view of the high incidence of hypocalcemia after subtotal parathyroidectomy, approximately 500 mg of tissue should be cryopreserved to allow transplantation should hypocalcemia ensue postoperatively.

Cancer of the parathyroid glands.

Hyperfunctioning parathyroid carcinoma is a relatively rare endocrine tumor, accounting for approximately 1% of all cases of primary hyperparathyroidism. The diagnosis is suspected when the tumor is large, parathyroid hormone (iPTH) levels are high, and a palpable tumor is present in the neck. Patients who have recurrence of hyperparathyroidism several months after surgical treatment should be suspected of having a recurrent or persistent parathyroid carcinoma. At operation, a large invasive tumor is usually found. The fibrous, inflammatory-like reaction is the most characteristic indication of malignancy. Even in tumors with minimal invasiveness, the possibility of a carcinoma should be considered if the tumor has mitotic activity and a monotonous instead of a pleomorphic cellular population. If the surgeon can recognize the possibility of parathyroid malignancy and adequately treat the patient during the initial operation, more gratifying results should be obtained.

Staging laparotomy in Hodgkin's disease: Mayo Clinic experience.

Between 1967 and 1979, 316 patients with Hodgkin's disease underwent staging laparotomy. Histologic examination demonstrated lymphocyte predominance in 40 (12.7%) patients, nodular sclerosis in 178 (56.3%), mixed cellularity in 80 (25.3%), and lymphocyte depletion in seven (2.2%); results in 11 (3.5%) patients were considered unclassifiable. There were no deaths. Major complications occurred in 7.9% and required reoperation in 1.9%. Pathologic stage differed from clinical stage in 111 (35.1%) patients. In 90 (28.5%) patients, the stage advanced; in 21 (6.6%) patients, the stage was reduced; and in five (1.6%) patients, the histologic subtype was changed. Stage changes occurred in 40% of those with lymphocyte predominance, in 27.5% with nodular sclerosis, in 46.3% with mixed cellularity, and in 85.7% with lymphocyte depletion. The reliability of staging laparotomy for the determination of appropriate treatment favors its continued use.

Total pancreatectomy for ductal adenocarcinoma of the pancreas. Mayo Clinic experience.

This review reveals that, once again, surgical therapy of ductal adenocarcinoma of the pancreas has been thwarted, probably by the inherent biologic aggressiveness of this particular malignancy. The operative mortality rate (greater than 10 percent) coupled with the 5 year survival rate of 2.3 percent is eloquent testimony to this. Multicentric disease occurred in one third of the patients, whereas extrapancreatic spread was found in half of the resected specimens. At 1 year, the only statistically favorable determinants were multicentricity and female sex. The main bonus of total pancreatectomy appears to be the elimination of pancreatojejunal anastomosis with its lethal complications.

Adrenal surgery: trends during the seventies.

Surgical experience with adrenal disease from 1970 to 1979 was reviewed in 315 patients. The pathologic conditions that were encountered were hypercortisolism (74 patients), hyperaldosteronism (46 patients), adrenocortical carcinoma (35 patients), pheochromocytoma (77 patients), and nonfunctioning adenoma (47 patients). In addition, 5 patients with metastatic lesions, 14 with cysts, and 4 with myelolipoma were surgically treated. The accuracy of localizing adrenal lesions increased from about 50 percent to almost 100 percent during the decade studied. The increase was due mainly to the introduction of computerized tomography, the most important advance in the management of adrenal disease. The present study shows that adrenal surgery can be performed with low morbidity and mortality. Operative deaths were confined to patients with malignant disease or increased secretion of cortisol or catecholamines. Only patients with adrenocortical carcinoma (2 year survival probability, 34 percent) or hypercortisolism due to cortical hyperplasia (5 year survival probability, 76 percent) had significantly decreased survival.