Alkaline phosphatase predicts calcium requirements after total parathyroidectomy in patients receiving dialysis.

BACKGROUND: : It can be difficult to achieve a stable serum calcium level after parathyroidectomy for renal hyperparathyroidism. This study examined the impact of a calcium replacement protocol guided by predicted need in reducing hospital stay. METHODS: : This two-phase observational study included patients receiving dialysis who underwent parathyroidectomy. In the initial phase, a standard protocol was followed whereby oral calcium was gradually titrated upwards based on serum calcium levels. The protocol was revised in the second phase such that patients were 'loaded' with the predicted elemental calcium requirement immediately after surgery. RESULTS: : Forty-four patients were treated according to the standard protocol and 34 using the new protocol. There was a strong correlation between postoperative elemental calcium requirement and admission serum alkaline phosphatase level (ALP) (r(s) = 0.711, P < 0.001). Postoperative hospital stay was reduced from a median (range) of 5 (3-12) to 3 (2-7) days after introduction of the revised protocol as a result of better calcium balance (P < 0.001). Multivariable analysis confirmed that use of the revised protocol was the main predictor of length of stay. CONCLUSION: : ALP can predict postoperative calcium requirements and streamline hospital stay by guiding replacement therapy.

Total parathyroidectomy under local anaesthesia for renal hyperparathyroidism.

INTRODUCTION: Renal hyperparathyroidism with attendant osteodystrophy is a frequent and severe morbidity affecting the quality of life of end stage renal failure patients surviving on long-term renal replacement therapy. A small subgroup of these patients with severe cardiorespiratory dysfunction was deemed at very high risk for general anaesthesia (GA). We report on a series of total parathyroidectomy under local anaesthesia (LA) for these patients. METHODOLOGY: A total of 32 consecutive patients with severe cardiorespiratory dysfunction who underwent total parathyroidectomy under LA over a period of 7 years were prospectively accrued in this study. The patient characteristics, the operative outcome and the feasibility to surgery under LA were analysed. RESULTS: Sixteen of the patients (50%) had severe restrictive lung disease as a result of renal osteodystrophy and the other 16 patients had poor cardiac status. Histopathological examination confirmed 23 (71.9%) patients had four glands removed and seven (21.9%) patients had three glands removed. Two patients had only two glands removed and had recurrent hypercalcaemia. However, all patients reported symptomatic improvement. The post-operative complications were minimal; one patient had acute coronary syndrome and wound haematoma and another patient had wound haematoma which necessitated exploration under LA. A further patient developed congestive heart failure requiring treatment in the coronary care unit. CONCLUSION: Total parathyroidectomy can be performed safely and successfully under LA. We believe surgery under LA would be the most appropriate option for selected, high-risk patients to minimise the risk of GA.

Prebiopsy localisation of impalpable breast lesions.

Prebiopsy localization of impalpable breast lesions (IBL) assures removal of suspicious mammographically detected lesions. Specimen radiograph of the excised specimen is mandatory to confirm complete excision. The aim of this study was to audit our series of percutaneous hookwire localization and to determine the positive biopsy rate of the mammographically detected impalpable breast lesion in our center. Thirty-eight patients with suspicious IBL underwent excision biopsy under mammographic localization in our unit from late February 1998 to May 2003. The excised specimen is immobilized and compressed within the Transpec device. This device incorporates a reference grid visible in the specimen radiograph. Hence, the target lesion marked in the reference grid of the specimen radiograph will allow precise examination and exact localization of the suspicious lesion by the pathologist. The positive biopsy rate for malignant lesion was 26.3%, the majority fall in the range of 40-59 age group. Thirty-two (84.2%) of the patients had clustered micro-calcifications, 4 (10.5%) had impalpable mass lesions and in 2 (5.3%) spiculated lesions were seen on the preoperative mammogram. Mammographic feature of clustered micro-calcification accounts for all the malignant lesions in our series. Utilization of Transpec device has shown to be practical, reliable and cost effective in the management of IBL. Nonetheless, it should be emphasized that optimal specimen radiography and pathological correlation requires close cooperation between radiologist, surgeon and pathologist.

Large adrenocortical carcinoma extending into the inferior vena cava and right atrium.

A case of large adrenocortical carcinoma extending into the inferior vena cava and right atrium is reported. Computed tomography showed a large mass displacing the left kidney inferiorly with an intravascular tumour thrombus extending into the inferior vena cava and right atrium. Radical surgery under hypothermia and cardiopulmonary bypass was performed and the tumour mass, together with the tumour thrombus, was successfully removed. The presence of intravascular tumour extension alone should not be a contraindication to radical surgical therapy, as it is the best hope for prolonged survival.

Core needle biopsy of palpable breast lump: the influence of needle size.

The diagnostic value of core needle biopsy is increasingly being preferred because of its better characterization of benign and malignant lesions and lower frequency of insufficient samples. The aim of this study was to determine the diagnostic accuracy and complication rates with 2 different gauges of core biopsy needle in the preoperative diagnosis of palpable breast lumps. A total of 150 consecutive core biopsies were included in this prospective non-randomised study of palpable breast lump from May 2000 to May 2001. The tissue diagnosis made from the core biopsy specimen was compared with the final histopathology reports from the excised specimen. However, if the lump is not excised, a presumptive diagnosis of benign lesion was made only after at least 6 months follow up with no change in the breast lump. The data were analysed for sensitivity, specificity, predictive values, diagnostic accuracy and complications. The results from the 2 different sizes of core needle biopsies were compared accordingly and a statistical analysis was performed using Chi-squared test. Ninety-six core specimens were acquired with 14 G needle while the other 54 with 16 G needle. There was no significant statistical difference between the accuracy of both needle sizes. However, 4 complications occurred with the larger size 14 G needle while none with the 16 G needle, but this was not statistically significant. In conclusion the size 16 G core biopsy needle provided an accurate diagnostic reliability that is comparable to the larger size 14 G needle in the preoperative diagnosis of palpable breast lump.

Post-thyroidectomy sore throat following endotracheal intubation.

BACKGROUND: Sore throat is not an uncommon complaint following general anaesthesia (GA) with endotracheal intubation. It has been a source of considerable discomfort particularly in those patients who had thyroid surgery. Driven by the increased number of patients with post-intubation sore throat following thyroid surgery, the aim of the present study was to evaluate the contributing factors of sore throat in patients who had thyroid surgery under general anaesthesia. METHODS: A total of 57 consecutive patients who had thyroid surgery from November 1998 to April 1999 was included in this prospective study. Factors such as intubation time, number of intubation attempts, size and type of endotracheal tube (ETT) used, gender and age were recorded. The nature and extent of the surgical procedures were also studied. Postoperative symptoms were assessed by questionnaire on the day after surgery and the different parameters were compared and analysed. RESULTS: The incidence of post-intubation sore throat following thyroid surgery was documented in 39 (68.4%) patients. Twenty-seven (47.4%) patients had a mild complaint of sore throat, which resolved after the third day. The data from the present study show that the size of ETT and extent of surgical procedure were significant contributing factors affecting the postoperative recovery. CONCLUSION: The outcome of the present study demonstrated a substantial increased incidence of sore throat after thyroid surgery under GA. Postoperative sore throat following thyroid surgery under GA may be caused by multiple contributing factors. Nonetheless effort and care should be taken during endotracheal intubation and surgery to reduce this unpleasant complaint arising mainly from pharyngeal irritation or trauma.

Total thyroidectomy: the procedure of choice for multinodular goitre.

OBJECTIVE: To review our experience of total thyroidectomy for bilateral multinodular goitre. DESIGN: Prospective open study. SETTING: Teaching hospital, Malaysia. SUBJECTS: 98 consecutive patients whose bilateral multinodular goitres were treated by total thyroidectomy, January 1998-November 1999. INTERVENTION: A revised technique of total thyroidectomy in which more attention than is customary was paid to the exposure and safety of the laryngeal nerves and the parathyroid glands. All patients had at least 1 parathyroid gland autotransplanted. MAIN OUTCOME MEASURES: Morbidity and mortality RESULTS: There were no injuries to the recurrent laryngeal nerves and no patient developed persistent hypocalcaemia; 27/98 developed transient hypocalcaemia, but this had settled by 6 months postoperatively. 59 patients had persistent symptoms of pressure preoperatively, and these all resolved by 3 months postoperatively. 6 patients had occult malignant disease discovered on histological examination, and 3 developed minor wound infections. CONCLUSIONS: Total thyroidectomy is the procedure of choice for bilateral multinodular goitres, provided that sufficient attention is paid to the preservation of the laryngeal nerves and the parathyroid glands.

External laryngeal nerve in thyroid surgery: recognition and surgical implications.

BACKGROUND: Injury to the external laryngeal branch of the superior laryngeal nerve during thyroid surgery is not uncommon. Most surgeons tend to avoid rather than expose and identify the external laryngeal nerve (ELN). The aim of the present study was to analyse the frequency and types of ELN crossing the avascular space in relationship to the structures to the upper pole of the thyroid and related thyroid pathology. METHODS: One hundred and fifty-one consecutive patients who had thyroid surgery from February 1998 to February 1999 and who met the required preoperative criteria were included into this prospective study. The frequency and type of ELN was documented as it crossed the potential avascular space. RESULTS: A total of 202 ELN (92.7%) nerves were identified during thyroid surgery. The frequency of the ELN documented crossing the avascular space were: type 1 nerve, 35 (17.3%); type 2a, 113 (56%); and type 2b, 54 (26.7%). Sixteen (7.3%) ELN were not seen despite an extensive search; seven (3.2%) were cases of secondary thyroid surgery and six (2.8%) were cases of malignant related pathology. In 78 cases the goitres weighed more than 100 g and the frequencies of ELN distribution seen were: type 1, six (7.7%); type 2a, 32 (41%); and type 2b, 40 (51.3%). There was a considerably higher frequency of type 2b ELN (51.3%) in large goitres of more than 100 g. CONCLUSIONS: The various technical problems in preserving the ELN need to be considered. Recognition of the potential avascular space aids the exposure and preservation of ELN. As such every attempt should be made to ensure safe dissection in order to reduce morbidity related to thyroid surgery.

Non-recurrent laryngeal nerve in thyroid surgery.

A case of non-recurrent laryngeal nerve is reported. The non-recurrent laryngeal nerve was found on the right side and was not associated with any vascular abnormalities. The anatomy and surgical implication of this rare condition is discussed

Histoplasmosis presenting with progressively worsening backache--a case report.

INTRODUCTION: Bilateral adrenal enlargement is often the result of disseminated malignant disease, and this diagnosis is particularly likely in a patient with severe weight loss. We describe a case with bilateral adrenal enlargement presenting with progressively worsening backache as a prominent symptom. CLINICAL PICTURE: A 55-year-old man presented with intermittent low back pain which was progressively worsening, fever, anorexia, low back pain and a 10-kg weight loss. He had underlying diabetes mellitus and ischaemic heart disease. He gave a history of travel to caves for worship. Clinically, the most significant findings included nodular lesions in the anterior fauces and left palatoglossal region. Computed tomographic scan revealed bilateral adrenal masses. Biopsies were taken from the palatal nodules, which revealed histiocytes with numerous histoplasma organisms. TREATMENT: He was commenced on itraconazole 200 mg daily for a period of 9 months. There was a dramatic initial response with settling of his fever and this was followed by subjective improvement in his well-being. OUTCOME: He is presently on follow-up and has completed 9 months of itraconazole therapy with resolution of all his symptoms and has gained about 10 kg of weight.

External laryngeal nerve in thyroid surgery: is the nerve stimulator necessary?

OBJECTIVE: To find out the incidence and type of external laryngeal nerves during operations on the thyroid, and to assess the role of a nerve stimulator in detecting them. DESIGN: Prospective, non-randomised study. SETTING: Teaching hospital, Malaysia. SUBJECTS: 317 patients who had 447 dissections between early January 1998 and late November 1999. MAIN OUTCOME MEASURES: Number and type of nerves crossing the cricothyroid space, and the usefulness of the nerve stimulator in finding them. RESULTS: The nerve stimulator was used in 206/447 dissections (46%). 392 external laryngeal nerves were seen (88%), of which 196/206 (95%) were detected with the stimulator. However, without the stimulator 196 nerves were detected out of 241 dissections (81%). The stimulator detected 47 (23%) Type I nerves (nerve > 1 cm from the upper edge of superior pole); 86 (42%) Type IIa nerves (nerve < 1 cm from the upper edge of superior pole); and 63 (31%) Type IIb nerves (nerve below upper edge of superior pole). 10 nerves were not detected. When the stimulator was not used the corresponding figures were 32 (13%), 113 (47%), and 51 (21%), and 45 nerves were not seen. If the nerve cannot be found we recommend dissection of capsule close to the medial border of the upper pole of the thyroid to avoid injury to the nerve. CONCLUSION: Although the use of the nerve stimulator seems desirable, it confers no added advantage in finding the nerve. In the event of uncertainty about whether a structure is the nerve, the stimulator may help to confirm it. However, exposure of the cricothyroid space is most important for good exposure in searching for the external laryngeal nerve.

Recognition and management of hungry bone syndrome--a case report.

Hungry bone syndrome (HBS) following successful parathyroid surgery is a well described phenomenon. However, few studies have clearly addressed this syndrome or looked at the outcome of perioperative management. We report a case of HBS following successful parathyroid surgery. The perioperative management is discussed and literature pertaining to this interesting case is reviewed.

Zuckerkandl's tubercle of the thyroid gland in association with pressure symptoms: a coincidence or consequence?

BACKGROUND: The Zuckerkandl's tubercle (ZT) of the thyroid gland is a well-described anatomical landmark, but few studies have clearly defined its association with pressure symptoms. METHODS: Sixty-six consecutive patients who had primary thyroid surgery were prospectively included in the present study between late January and early August 1998. RESULTS: A total of 96 capsular dissections were performed at thyroid surgery. Grades two and three ZT were recognized in 77 (80.2%) dissections. In general 49 (63.6%) of them were associated with significant pressure symptoms. In 43 (87.8%) of the dissections with pressure symptoms, grade 3 ZT was observed (mean weight of goitre: 154.8 g). Interestingly in this group, 16 (37.2%) patients with pressure symptoms had a goitre that was < 100 g and in one patient it was only 21 g. CONCLUSIONS: The pressure symptom of the thyroid gland does not always appear to be due to the large size of the goitre. In a relatively small-size goitre the ZT may cause significant pressure symptoms. Observations in the present study supported a strong association of enlarged ZT with pressure symptoms. We believe this is unlikely to be simply a coincidence but rather a consequence of the enlarged tubercle. Nonetheless a prospective randomized study is called for to allow meaningful and objective evidence to be drawn.

Huge adrenal haemangioma.

Adrenal tumours are either functioning or non-functioning. Non-functioning adrenal tumours are generally asymptomatic and usually of enormous proportions at the time of presentation. A case is presented here of a patient with a huge right adrenal haemangioma which was successfully treated surgically. This unusual tumour was 25 cm in diameter, was well encapsulated and weighed 4 kg. The literature pertaining to this interesting case is reviewed.

The surgical treatment of adrenal diseases.

Between January 1978 to December 1993, 130 cases of adrenal diseases were diagnosed and surgically treated at the National University of Malaysia. They were 58 cases (44.6%) of Conn's syndrome, 40 cases (30.7%) of Cushing's syndrome, 20 cases (15.3%) of phaeochromocytoma and 12 cases (9.2%) of adrenocortical carcinoma (ACC). The commonest cause of Conn's syndrome was an adenoma (96.5%) which affected the left gland four times more than the right gland. Cushing's syndrome was caused by adrenocortical adenoma (32.5%), diffuse bilateral adrenal hyperplasia (40.0%), pigmented macronodular hyperplasia (20.0%) and adrenal carcinoma (7.5%). Twenty-five percent of the phaeochromocytomas were extraadrenal in origin arising mainly from the abdominal sympathetic chain. More than 50% of ACCs were non-functioning tumours. Fifty percent of the patients with ACC had inoperable tumours. The prognosis was poor even with adjuvant chemoradiotherapy. The main surgical approach was the anterior transabdominal route. There was no operative mortality or morbidity in all operated cases.

Polycystic liver disease treated by fenestration and segmental liver resection.

A case of symptomatic polycystic liver disease treated by fenestration and segmental liver resection is reported. The intraoperative use of ultrasound to define the plane of liver resection is emphasised. No significant post-operative complication was encountered. The clinical presentation, management and treatment are discussed.

Fracture of the penis.

Fracture of the penis is not an uncommon urological emergency. Six patients with this injury, treated at the Institute of Urology, General Hospital, Kuala Lumpur, since 1988, were reviewed. Their ages ranged from 21 to 30 years old (mean 25). Four cases were self-inflicted by abnormal bending and 2 cases occurred during sexual intercourse. A sudden "cracking sound", violent pain, rapid flaccidity and deformity of the penis were documented. Duration of injury at presentation ranged from 12 to 90 hours (mean 35 hours). Primary repair of the tunica albuginea with absorbable suture was performed in all cases. The results of surgery was excellent, with restoration of normal function in 4 patients (2 patients defaulted follow-up). We advocate immediate surgical repair for this injury.