Central neck dissection in the management of sporadic medullary thyroid microcarcinoma.

AIM: Treatment of medullary thyroid carcinoma (MTC) includes total thyroidectomy with at least bilateral central neck dissection. Systematic measurement of thyrocalcitonin (CT) levels in thyroid nodules allows for early diagnosis of MTC. As central neck dissection (CND) is associated with high morbidity, the aim of this study was to investigate the necessity of this procedure in the treatment of sporadic medullary thyroid microcarcinoma (S-mMTC). METHODS: Prospective multicentric study including 43 patients with sporadic micro-MTC who underwent CND between January 1991 and August 2001. RESULTS: 26 women and 17 men with sporadic micro-MTC, aged 28-87 (mean age was 58 years), without family history of multiple endocrine neoplasia, underwent surgery. Total thyroidectomy was performed in all patients and combined with 'picking' (n=7) or CND (n=36). Size of tumours ranged from 0.2 to 9mm (mean size was 4.1mm). Solitary (32/43 patients) and multiple S-mMTC lesions (11/43 patients) were seen. 601 lymph nodes from the 41 subclinical patients were analysed. Mean follow-up period for these patients was 32 months. No mutations in the RET oncogene were seen. CONCLUSION: As lymph node involvement is uncommon in S-mMTC, systematic CND is of questionable value.

Multicentre study of thyroid nodules in patients with Graves' disease.

BACKGROUND: The association of Graves' disease with thyroid nodules and thyroid carcinoma is rarely reported. The incidence seems to be increasing according to recent literature. The aim of this multicentre study was to review patients who had surgery for Graves' disease associated with thyroid nodules, and to evaluate the risk of thyroid carcinoma. METHODS: A retrospective study was made of 557 consecutive patients who underwent operation for Graves' disease between 1991 and 1997 in five endocrine surgery departments. Each patient underwent clinical, biochemical, ultrasonographic and scintigraphic evaluation. None of the patients had had previous radioactive iodine therapy or external irradiation. Surgery consisted of either a subtotal or total thyroidectomy. RESULTS: Nodules were observed before operation in 140 patients (25.1 per cent). Thyroid carcinoma was diagnosed in 21 patients (15.0 per cent), always inside a nodule. The incidence of thyroid carcinoma associated with Graves' disease was 3.8 per cent (21 of 557 patients): 20 papillary and one follicular carcinoma. The carcinoma was multifocal in two patients. Tumour diameter ranged from 2 to 25 mm. A nodule was palpable in four patients. CONCLUSION: This multicentre study of patients having thyroidectomy for Graves' disease showed that 3.8 per cent had a carcinoma; the rate of carcinoma in cold nodules was 15.0 per cent. Surgery should be advised in any patient with Graves' disease and a thyroid nodule; the operation should be total thyroidectomy.

[Diagnosis of parathyroid cysts: value of parathyroid hormone level in puncture fluid]. / Diagnostic des kystes parathyroïdiens: intérêt du dosage de la parathormone dans le liquide de ponction.

OBJECTIVE: Determine a means of establishing the diagnosis of parathyroid cysts preoperatively. PATIENTS AND METHODS: Classically, crystal-clear watery fluid removed by fine-needle aspiration of a suspected thyroid mass raises the suspicion of a parathyroid cyst. Immunoradiometric assay of parathyroid hormone level in the fluid may give the diagnosis sparing unnecessary surgery. RESULTS: Over the last 5 years, among the 12 patients presenting a suspected thyroid cyst containing a crystal-clear fluid, we were able to diagnose 3 cases of parathyroid cysts due to the considerable elevation of parathyroid hormone in the puncture fluid. None of these patients had hyperparathyroidism. In patients with a thyroid cyst, parathyroid hormone level in the puncture fluid was nil. CONCLUSION: The parathyroid nature of cervical cysts containing crystal-clear fluid can be established by assaying parathyroid hormone in the puncture fluid. Non-functional parathyroid cysts may be treated by repeated aspiration. Serum calcium level must be checked regularly to detect potential hyperparathryoidism.

[The role of hyperbaric oxygen therapy in radiation-induced digestive disorders. 36 cases]. / Intérêt de l'oxygènothérapie hyperbare dans la pathologie digestive post-radique. 36 observations.

OBJECTIVES: Study the effect of hyperbaric oxygen on chronic irradiation induced digestive disorders. PATIENTS AND METHODS: A retrospective study was conducted in 36 patients (mean age 66 +/- 11 years) with chronic digestive tract necrosis which had developed a mean 42 months after irradiation therapy. Hyperbaric oxygen therapy was given a mean 17 months after symptom onset: failing healing (n = 9), rectal bleeding (n = 19), profuse diarrhea (n = 9), recurrent anal abscess (n = 1). The severity of the digestive tract radionecrosis was quantified using the Soma-Lent scale. Hyperbaric oxygen therapy was grade 1 (n = 1), grade 2 (n = 11), grade 3 (n = 16), grade 4 (n = 8). RESULTS: Thirty-six patients underwent a mean 67 hyperbaric sessions (100% O2, 2.5 atm, 90 min). Three patients died within one month of the first session due to radiation enteritis, a neoplastic process or another concomitant cause. Immediate outcome after hyperbaric oxygen therapy was cure (n = 3) or improvement (n = 16) in 19 patients (53%) and failure in 17 (47%). Long-term results evaluated in 32 subjects with a mean 52 months follow-up were: cure (n = 9) or improvement (n = 12) in 21 patients (66%) and failure in 11 (34%). Nine patients died within a mean 25 months after the end of the hyperbaric sessions. Death was related to digestive tract radionecrosis in 1 case and neoplasia in 5. CONCLUSION: Hyperbaric oxygen therapy provides clinical relief in 2 out of 3 patients and can be a useful alternative to conventional treatment in patients with chronic radiation-induced necrosis of the digestive tract.

[Internal hernia: a rare cause of intestinal obstruction. Apropos of 14 cases]. / Hernie interne: une cause rare d'occlusion intestinale. A propos de 14 cas.

AIM OF THE STUDY: Internal hernia is an uncommon cause of acute intestinal obstruction. The aim of this study was to retrospectively evaluate the diagnosis, the management, and the follow-up of the internal hernias operated over a 10-year period in our department of visceral surgery. METHODS: 14 spontaneous internal hernias were observed. The patients were evaluated with respect to symptoms, radiological findings, time elapsed between the onset of symptoms and surgery, type of operation performed, postoperative morbidity and mortality, postoperative stay, and follow-up. RESULTS: There were 8 men and 6 women. The preoperative diagnosis was evoked in only one case. The mean time elapsed between the onset of the symptoms and surgery was 31.1 hours (range 6 to 72 hours). Two intestinal resection were performed. Mean postoperative hospital stay was 11.3 days (range 6 to 22 days). The morbidity was 21.4% with no mortality. Mean follow-up was 7 months (range 3 to 15 months); one patient developed an incisional hernia. CONCLUSION: Since preoperative diagnosis of an internal hernia is difficult because of the lack of specific signs, morbidity and mortality can be decreased with early surgical intervention. Operative risks include vascular accidents, especially to hernia neck vessels.

Early gastric cancer: univariate and multivariate analysis for survival.

BACKGROUND/AIMS: The aim of this retrospective study was to analyse the characteristics, treatment and prognosis of early gastric carcinoma, based on an analysis of our surgical results. METHODOLOGY: Between 1973 and 1994, 102 patients (68 males, 34 females) with a mean age of 65 years, were operated on for an early gastric carcinoma. Mean follow-up was 7 years. Survival was calculated using the Kaplan-Meier method. Prognosis was determined with univariate and multivariate analysis according to the Cox model. RESULTS: The carcinoma was limited to the mucosa in 57 patients (56%) and extended to the submucosa in 45 (44%). There was a lymph node invasion in 17 patients (16.5%). The post-operative mortality rate was 5.8% (n = 6). Secondary deaths occurred in relation with the gastric cancer in 10.4% (n = 10). The 5- and 10-year survival rates were 84% and 68.6%, respectively. Univariate analysis of prognosis factors showed a significant survival difference according to the age (p = 0.001); submucosal extension (p = 0.03), lymph node invasion (p = 0.0005) and type of gastric resection performed (p = 0.03). With multivariate analysis of prognostic factors, advanced patient age and lymph node metastases were the only independent factors for survival (p = 0.0002 and p = 0.002, respectively). CONCLUSIONS: Prognosis of early gastric cancer is usually excellent. Patients with high risk of recurrence may be identified in relation to lymph node invasion. We propose that lymph node dissection is necessary in addition to gastric resection, at least in patients with high risk of lymph node metastasis.

[Superficial stomach cancers: surgical experience and study of prognostic factors in 102 patients]. / Les cancers superficiels de l'estomac: expérience chirurgicale et étude des facteurs de pronostic chez 102 patients.

STUDY AIM: The aim of this retrospective study was to analyze the characteristics, treatment and prognosis of early gastric carcinoma in a series of 102 patients. METHODS: Between 1973 and 1994, 102 patients (68 males, 34 females) with a mean age of 65 years, were operated on for an early gastric carcinoma. Mean follow-up was 7 years. Survival was calculated using the Kaplan-Meier method. Prognosis was determined with univariate and multivariate analysis according to Cox model. RESULTS: The carcinoma was limited to the mucosa in 57 patients (56%) and extended to the submucosa in 45 (44%). There was a lymph node invasion in 17 patients (16.5%). The postoperative mortality rate was 5.8% (n = 6). Secondary deaths occurred in relation with the gastric cancer in 10.4% (n = 10). The 5- and 10-year actuarial crude survival rates were 84% and 68.6%, respectively. Univariate analysis of prognosis factors showed a significant survival difference according to the age (P = 0.001), submucosal extension (P = 0.03), lymph node invasion (P = 0.0005) and type of gastric resection performed (P = 0.03). With multivariate analysis of prognostic factors, advanced patient age and lymph node metastases were the only statistically significant independent prognostic factors, advanced patient age and lymph node metastases were the only statistically significant independent prognostic factors (P = 0.0002 and P = 0.002, respectively). CONCLUSIONS: Prognosis of early gastric cancer is usually excellent. Patients with high risk of recurrence may be identified in relation with prognostic factors and mainly with lymph node invasion.

Morbidity of thyroid surgery.

BACKGROUND: Morbidity is today's concern in thyroid surgery. The purpose of this paper was to quantify risk factors' contribution to morbidity rates. METHODS: During 50 months, 1,163 patients undergoing 1,192 thyroidectomies at one hospital were reviewed at follow-up of 8 to 58 months. RESULTS: There was 1 death (0.08%). Wound morbidity included 19 hematomas (1.6%), 3 chyle leaks (0.2%), and 6 abscesses (0.5%). Mean hospital stay was 4.3 days after surgery without drain and 5.3 days with drain (P < 0.01). Temporary and permanent hypoparathyroidism (TH; PH) rates were 20% and 4%. Parathyroid autografting and excision rates were 19% and 9%. TH rates were higher after parathyroid autografting or accidental excision (P < 0.01). There was no correlation between the severity of TH and the number of lymph nodes at neck dissection nor between postoperative serum calcium levels and the number of parathyroids identified at bilateral surgery. Temporary and permanent recurrent laryngeal nerve (RLN) palsy (TRLNP; PRLNP) rates were 2.9% and 0.5% (0.3% of 2,010 RLNs at risk). PH and TRLNP (not PRLNP) rates were higher after completion or total thyroidectomy with node dissection (P < 0.01). TRLNP and PRLNP rates after RLN exposure and after nonexposure were not statistically different. Surgical volume had no bearing on hematoma, abscess, TH, PH, TRLNP, and PRLNP rates. CONCLUSIONS: High surgical volume, identifying parathyroids and RLNs, failed to reduce morbidity. Completion and total thyroidectomy with node dissection increased PH and TRLNP (not PRLNP) rates.

[Pancreatojejunal or pancreatogastric anastomosis after cephalic duodenopancreatectomy. A comparative retrospective study]. / Anastomose pancréatojéjunale ou pancréatogastrique après duodénopancréatectomie céphalique. Etude comparative rétrospective.

AIM OF THE STUDY: The aim of this retrospective study was to compare pancreatico-jejunostomy vs pancreatico-gastrostomy with regard to safety of pancreatic anastomosis after pancreatico-duodenectomy. PATIENTS AND METHODS: From January 1980 to June 1995, 171 patients underwent pancreatico-duodenectomy, 136 for pancreas, ampulla, distal bile duct or duodenum cancers, and 36 for chronic pancreatitis. Pancreatic anastomosis was realised by pancreatico-jejunostomy in 91 cases and by pancreatico-gastrostomy in 80 cases. There was no significant difference between the two groups (age, gender and primary disease). Comparison between the two groups concerned mainly postoperative mortality and morbidity. RESULTS: The overall postoperative mortality rate was significantly higher in the pancreatico-jejunostomy group (12%) than in the pancreatico-gastrostomy group (3.7%) (P = 0.05); death was directly related to necrosis of the remnant pancreas in four cases among the 14 postoperative deaths. The postoperative morbidity rate was respectively 23% after pancreatico-jejunostomy and 12.5% after pancreatico-gastrostomy; the pancreatic leakage and/or necrosis rate was higher in the pancreatico-jejunostomy group (13%) than in the pancreatico-gastrostomy group (3.75%) (P = 0.029). CONCLUSION: This study seems to demonstrate the superiority of the pancreatico-gastric anastomosis, but these results have to be confirmed or invalidated by a prospective multicentric randomised trial.

[Isolated thyroid nodule. Comparative value of cyto-puncture and scintigraphy]. / Nodule thyroïdien isolé. Intérêt comparé de la cytoponction et de la scintigraphie.

OBJECTIVES: Nodular thyroid disease, indicated by the presence of single or multiple nodules within the thyroid gland is a common clinical problem, the main question remains the malignancy. Radionuclide scanning, ultrasonography and fine needle aspiration biopsy have been helpful to distinguish benign from malignant nodules and to select patients for surgery. METHODS: We performed a prospective study to assess the comparative value of fine needle nonaspiration biopsy and thyroid scinti scan in the management of 412 patients operated for solitary thyroid nodule. RESULTS: Sensitivity and negative predictive values were the same for both methods, but specificity of cytology was greater than that of thyroid scinti scan (80.53% vs. 10.47%, p < 0.001). DISCUSSION: Thyroid radionuclide scanning remains valuable in the evaluation of a cytological benign solitary thyroid nodule when TSH value is low, in order to distinguish toxic adenoma from cold nodule in Graves' disease.

[Value of fine-needle aspiration and extemporaneous examination in thyroid surgery. A prospective study of 1235 fine-needle aspirations and extemporaneous examinations in 846 patients]. / Intérêt de la cytoponction et de l'examen extemporané en chirurgie thyroïdienne. Etude prospective à propos de 1,235 cytoponctions et examens extemporanés réalisés chez 846 patients.

We report a prospective study conducted from 1993 through 1995 in 846 patients (mainly women) consulting for a thyroid nodule. There were 465 multinodular goiters and 373 single nodules. The clinical diagnosis was obvious in 8 patients who were excluded. Pre-operative fine-needle aspiration was performed in 1235 patients and per-operative extemporaneous examinations in 569. These two simple reliable examinations, with few significant complications in skillful hands, are complementary. Fine-needle aspiration gives reliable histology data for thyroid nodules and should always be included in the pre-operative workup. Extemporaneous pathology examination of the surgical specimen provides information for adapted surgery and avoids morbidity due to reoperation.

[Cancer of the gallbladder. A surgical experience. A propos of 143 cases]. / Le cancer de la vésicule biliaire. Une expérience chirurgicale. A propos de 143 cas.

The records of 143 patients with gallbladder carcinoma operatively treated between 1975 and 1995 were retrospectively reviewed. Abdominal pain was the most common symptom and was present in 103 patients (72%). Jaundice was present in 83 patients (58%) and weight loss in 68 (47.5%). Pre-operative diagnosis was made in 40.5% of the patients. Surgical procedures included cholecystectomy alone (16.8%), cholecystectomy with resection of the hepatic bed and lymphadenectomy (11%), cholecystectomy with biliary drainage (57.3%), and exploration with biopsy (14%). Surgery was considered as curative in 21.5% of the patients. Overall five-year survival rate was 11%. Actuarial 5-year survival rate was 100%, 29% and 23% in patients with T1, T2 and T3 tumors. The five-year survival rate was nil in patients with T4 and T5 cancers.

[Value of thyroidectomy in amiodarone-induced hyperthyroidism. Apropos of 3 cases]. / Intérêt de la thyroïdectomie dans les hyperthyroïdies induites par l'amiodarone. A propos de 3 cas.

Amiodarone-induced hyperthyroidism in a relatively rare complication of long-term treatment with this molecule. It usually carries a good prognosis with regression being the rule after withdrawal of the drug although lethal forms have been reported. Conventional medical therapy (synthetic antithyroid drugs, steroids, betablockers) used in severe forms, is not always effective. In addition, amiodarone may be essential for the treatment of life-threatening, poorly tolerated arrhythmias, refractory to other forms of treatment. The authors report the cases of three patients treated with amiodarone for malignant arrhythmias who developed severe hyperthyroidism resistant to medical therapy and who were treated by total thyroidectomy. Surgery was followed by rapid resolution of the thyrotoxicosis without significant complications and immediate represcription of amiodarone. Thyroidectomy therefore seems a simple solution for amiodarone-induced hyperthyroidism allowing very rapid resolution of the hyperthyroidism and the possibility of immediate represcription of amiodarone.

Primary carcinoma of the gallbladder--review of 143 cases.

BACKGROUND/AIMS: We reviewed a consecutive series of patients with primary cancer of the gallbladder and looked for specific symptoms, signs, laboratory tests, radiological examinations, operative procedures, operative findings and survival. MATERIAL AND METHODS: The records of 143 patients with gallbladder carcinoma operatively treated between 1975 and 1990 were retrospectively reviewed. RESULTS: Abdominal pain was the most common symptom and present in 72% of our patients. Jaundice was present in 83 patients (58%) and weight loss in 68 (47.5%). The pre-operative diagnosis was made in only 28.7 per cent of the cases. Surgical procedures included cholecystectomy alone (24 patients), cholecystectomy and resection of the hepatic bed (17 patients), and exploration with biopsy or bypass (20 patients). Only 21.5% of patients underwent curative surgery. Overall five year survival rate was 11%. For patients whose tumor was limited to the gallbladder wall (T1, T2, T3), the acturial 5-year survival rate was respectively 100%, 29% and 23%. For patients with T4 and T5 tumor, the 5 year survival rate was nil.

[Intraoperative colonic irrigation in the emergency treatment of occlusive lesions of the left colon]. / L'irrigation colique per-opératoire dans le traitement en urgence des lésions occlusives du côlon gauche.

This study reports the use of an intraoperative antegrade colonic irrigation in the management of left-sided large bowel obstruction requiring emergency surgery. 35 consecutive patients had primary bowel resection with immediate anastomosis (without colostomy) after intraoperative antegrade colonic irrigation. The cause of the obstruction was large bowel carcinoma in 26, diverticulitis in seven and volvulus in two cases. There were two post-operative deaths (5.7%). No digestive fistula was observed. The results of this study suggest that intraoperative colonic irrigation is an effective method, enabling the surgeon to perform a primary anastomosis with reasonable safety after emergency resection of selected distal colonic lesions.

[Neurosarcoma of the Treitz fossa. Apropos of a case]. / Neurosarcome de l'angle de Treitz. A propos d'une observation.

A unique neurosarcoma was observed located in the Treitz' fossa. Such tumours are usually occur in Rechlinghausent's disease and are exception in isolated situations. Diagnosis is difficult and requires a small bowel study. Surgical exeresis is the only treatment.

[Hypersecreting villous rectosigmoid tumors. Apropos of 14 cases]. / Tumeurs villeuses recto-sigmoïdiennes hypersécrétantes. A propos de 14 cas.

Villous recto-sigmoidal tumors with severe fluid and electrolyte loss are rare. We report here fourteen new cases with severe electrolyte imbalance (hypokalemia, hyponatremia, renal failure). We analysed too electrolyte loss in stools and we researched electrocardiographic disorders. Finally, we reported a long-term evolution of these patients.

[Mesocaval anastomosis in the treatment of recurring hemorrhage caused by portal hypertension]. / L'anastomose mésentérico-cave dans le traitement des récidives hémorragiques par hypertension portale.

The ideal therapy for variceal hemorrhage would permanently eliminate this life-threatening complication of portal hypertension and have no adverse effects on hepatic physiology. Mesocaval interposition shunts preserve a hepato-pedal blood flow. 35 shunts were performed as an elective procedure from 1982 to 1992 in patients with hemorrhagic liver cirrhosis. There were 24 men and 11 women, with a median age of 51.7 years. The underlying etiology of the varices was alcoholic cirrhosis in 31 patients. The criteria of Child-Pugh were utilised to evaluate + all patients; 21 were in class A and 14 were in class B. All patients presented before the operation, two or several histories of acute variceal hemorrhage. The mean diameter of the graft was 14 mm (range 10 to 16 mm). Intra-operative portal pressure measurements showed satisfactory pressure reduction (18.7 mmHg to 11.2 mmHg). There was no death in the postoperative period. Eight patients had postoperative complications, for an overall morbidity rate of 22.8%: 2 ascites, 4 episodes of temporary encephalopathies and 2 recurrent bleeding. At the third month, angiographic (5 cases), sonographic (6 cases) or scanographic (17 cases) studies evaluated shunt patency. In one case, We observed an occluded graft. The actuarial survival rate was 82% at 2 years, 66% at 5 years. It is concluded that the interposition mesocaval shunt appears to be an effective technique for the control of variceal hemorrhage, has important hemodynamic advantages and can be applied to most patients for the control of variceal hemorrhage due to portal hypertension. Moreover, the procedure can be considered as a solution before the hepatic transplantation.

[Correction of substance losses in the abdominal wall by an aponeurotic graft]. / Cure des pertes de substance de la paroi abdominale par un procédé de plastie aponévrotique.

A series of 123 patients presenting with abdominal eventrations were treated by an aponeurotic graft. Operative mortality was 0.8%. Recurrent eventration was observed in eventrations with a diameter superior to 4 cm (38% at 55 months). The authors recommended this technique only in case of small eventrations or for the parietal reparation following closure colostomies.