Intraoperative PTH Assay during Minimally Invasive Parathyroidectomy May Be Helpful in the Detection of Double Adenomas and May Minimise the Risk of Recurrent Surgery.

Background. Minimally invasive parathyroidectomy (MIP) is increasingly replacing the traditional bilateral neck exploration in the treatment of primary hyperparathyroidism (PHP). Intraoperative PTH (IOPTH) measurement has recently been introduced as a useful adjunct in confirming successful excision of abnormal parathyroid gland. Aims. We evaluate the safety, efficacy, and clinical usefulness of IOPTH measurement during MIP in a district general hospital. Methods. Retrospective review of eleven consecutive patients with PHP who underwent MIP with IOPTH, following preoperative assessment with ultrasound and sestamibi scans. Results. All patients had successful removal of the abnormal parathyroid gland. The concordance rate between ultrasound and sestamibi scan in localising the parathyroid adenoma was 82%. IOPTH measurement confirmed the removal of adenoma in all cases and, in one case, led to identification of a second adenoma, not localised preoperatively. The median hospital stay was 2 days (range 1-7 days). All patients remained normocalcaemic after a median of 6 months (range 1-10 months). Conclusions. Minimally invasive parathyroidectomy is a feasible, safe, and effective method for treatment of PHP. The use of IOPTH monitoring potentially offers increased sensitivity in detecting multiglandular disease, can minimise the need and risk associated with recurrent operations, and may facilitate cost-effective minimally invasive surgery.

Neoadjuvant chemotherapy in breast cancer.

BACKGROUND: Neoadjuvant chemotherapy for breast cancer was originally used in locally advanced inoperable disease in order to achieve surgical resection. It was then extended to operable breast cancer with a view to downstaging tumours to facilitate breast-conserving surgery. Increasingly, it is being considered as a treatment for earlier-stage disease. METHODS: A Medline literature search was performed to identify articles relating to neoadjuvant chemotherapy in breast cancer published in the English language between 1960 and 2004. Secondary references were obtained from key articles. Search words included 'neoadjuvant chemotherapy', 'breast cancer', 'tumour biology', 'tumour markers' and 'sentinel lymph node biopsy'. RESULTS: Long-term results from randomized studies have shown no difference in disease-free or overall survival between neoadjuvant and adjuvant chemotherapy. The main benefit of neoadjuvant chemotherapy is its ability to downstage large tumours with a view to treatment by breast-conserving surgery, although there is a non-significant increase in the local recurrence rate. Initial results of neoadjuvant chemotherapy trials using newer agents such as taxanes have demonstrated a greater pathological complete response. Whether this will translate into better long-term survival remains to be seen.

Selective cholangiography in 600 patients undergoing cholecystectomy with 5-year follow-up for residual bile duct stones.

BACKGROUND: The need for cholangiography to identify possible bile duct stones in all patients undergoing cholecystectomy is controversial. AIMS: To assess the results of a policy for selective pre-operative endoscopic retrograde cholangiography (ERC) in patients undergoing laparoscopic cholecystectomy and to determine the incidence of postoperative symptomatic bile duct stones. PATIENTS AND METHODS: Between 1993 and 1998, 600 patients underwent laparoscopic cholecystectomy under one consultant surgeon. Patients were selected for pre-operative or postoperative ERC based on symptoms, liver function tests and/or abnormalities on ultrasonography. A general practitioner questionnaire was used to assess follow-up of patients with postoperative stones. RESULTS: Of 600 patients, 107 (18%) with a median age of 57 years and male:female ratio of 1:2.1 were selected to undergo pre-operative ERC; of these, 41 patients (38%) had bile duct stones. Postoperative ERC was performed in 30 patients (5%) and stones were identified in seven (23.3%). Three patients (0.5%) had stones removed within 15 days of operation and four (0.7%) between 2.6 months and 1.8 years. Median follow-up was 5.0 years (range, 2.5-7.5 years). The overall incidence of bile duct stones was 48 cases (8%). The stone rate was 11% in males and 7.3% in females. Stones were successfully extracted at ERC in 43 patients (89.6%). CONCLUSIONS: A policy of selective pre-operative ERC is the most effective technique for identifying and removing bile duct stones and the incidence of symptomatic gallstones following laparoscopic cholecystectomy is very low. With an overall stone rate of 8%, routine peroperative cholangiography is unnecessary and, in a surgical unit providing an ERC service, laparoscopic exploration of the bile duct is not a technique required for the management of bile duct stones.

Laparoscopic excision of the urachus.

Embryologically, the urachus represents the obliterated alantois in the form of a fibrous cord extending from the dome of the bladder to the umbilicus. Incomplete obliteration can result in the formation of an umbilical sinus, fistula, cyst, or abscess in the infraumbilical area. The traditional treatment of a residual urachus is surgical resection of the entire tract from the dome of the bladder to the umbilicus through a lower midline incision. We report the case of a 14-year-old girl who presented with an abscess below the umbilicus. After initial drainage, she developed a sinus that communicated with the navel. Surgical resection of the underlying urachus was carried out laparoscopically. The peritoneum was incised at the umbilicus, and the whole tract along with the skin sinus was excised using diathermy scissors. The lower end was ligated and the specimen retrieved. The patient was discharged the following day. One week later, her wounds had healed. Histology confirmed an epithelial-lined urachus. We believe that laparoscopic excision of a patent urachus is feasible and safe. This technique gives the surgeon good access to the area and has a cosmetically better result.