[Radioguided surgery for primary hyperparathyroidism: 100 cases]. / Chirurgie radioguidée de l'hyperparathyroïdisme primaire.

One hundred patients with primary hyperparathyroidism underwent radioguided surgery within 90 to 180 minutes following IV injection of a diagnostic dose of MIBI and after parathyroid scanning with planar and oblique views. Exclusion criteria were thyroid pathology requiring surgery and suspicion of multiple endocrine neoplasia. A>20% step-up between the background noise and tissue uptake was the diagnostic threshold for parathyroid hyperfunctionning tissue, and this was observed in only 15% of cases overall all cured, but two. This method of detection is technically demanding and various angles of application of the probe can result in significant discrepancies of recorded uptake for the same spot. Our results demonstrate a physiological step-up between the ipsilateral unaffected upper and lower quadrants of the neck (range: - 34% to - 5%), seemingly because of the proximity of supra-aortic vessels (upper neck-upper mediastinal gradient: - 57% to - 21%). Therefore, significant ratios are meaningful only between either the symmetrical left and right controlateral quadrants, 8% of pre-operative scannings were non-contributory, and probe detection was contributory in 3/8 cases only. Benefit of the technique is limited in routine, but it can be helpful in redo cases if the offending gland is not located in close surroundings of tissues physiologically taking up the radio pharmaceutical (salivary glands, great vessels and heart).

Pilot study with air-automated sigmoid capnometry in abdominal aortic aneurysm surgery.

BACKGROUND: and objective Ischaemic colitis can be a serious complication after aortic surgery. The paucity of clinical symptoms makes its diagnosis particularly difficult and often delayed. Automated on-line tonometry is now proposed to monitor intestinal perfusion. This study was designed to assess the use of semi-continuous sigmoid-to-arterial [P(r-a)CO(2)] PCO(2) gap monitoring in aortic surgery to detect colonic ischaemia. METHODS: This prospective clinical study was realized at the University Hospital of Lille, France, including eight males scheduled for abdominal aortic aneurysm surgery. Intraoperative and postoperative P(r-a)CO(2) values were compared with conventional monitoring and colonic mucosa aspect performed by sigmoidoscopy 48 h after surgery. Haemodynamic variables, O(2) delivery (DO(2)), O(2) consumption (VO(2)), O(2) extraction (ERO(2)), lactate, P(v-a)CO(2), P(r-a)CO(2) were measured peroperatively and every 4 h during a 48-h postoperative period. RESULTS: Intraoperative P(r-a)CO(2) values increased significantly with the highest value (4.36 +/- 3.42 kPa) observed during aortic clamping when DO(2) was the most altered. P(r-a)CO(2) continued to deteriorate after surgery with the maximal values between 8 (4.79 +/- 3.85 kPa) and 12 (4.68 +/- 3.26 kPa) h after surgery. This peak was associated with a significant ERO(2) increase counterbalancing an increase of VO(2) whereas DO2 tended to decrease. P(r-a)CO(2) values began to decrease only at the end of the study. The highest values of P(r-a)CO(2) were registered in patients with the most altered haemodynamic variables, severe ischaemic colitis along with higher hospital lengths of stay. CONCLUSION: Taken together, these data suggest that regional and automated capnometry may be easily used non-invasively to detect peroperative intestinal ischaemia in aortic surgery.

[Radioguided surgery for primary hyperparathyroidism. Experience in 75 cases]. / Chirurgie radioguidée de l'hyperparathyroïdie primaire. Expérience de 75 observations.

STUDY AIM: To report feasibility and efficacy of radioguided mini invasive hyperparathyroidism surgery. PATIENTS AND METHOD: From November 1998 to August 2000, 75 patients with primary hyperparathyroidism have been operated on by radioguided surgery within 90 to 180 minutes following i.v. injection of a diagnostic dose of MIBI and after parathyroid scanning with planar and oblique views. Exclusion criteria were thyroid pathology requiring surgery and suspicion of multiple endocrine neoplasia. A 20% step-up between the background noise and tissue uptake was the diagnostic threshold for parathyroid hyperfunctioning tissue. RESULTS: A 20% step-up was observed in only 17% of cases overall; all cured, but two. Various angles of application of the probe can result in significant discrepancies of recorded uptake for the same spot. These results demonstrate a physiological step-up between the ipsilateral unaffected upper and lower quadrants of the neck (range: -17 to -8%), because of the proximity of supraortic vessels (upper neck-upper mediastinal gradient: -44 to -30%). Therefore, significant ratios are meaningful only between either the symmetrical left and right controlateral quadrants respectively, and not between the upper and the lower ipsilateral quadrants. Eleven per cent (8/75) of preoperative scannings were non-contributory, and probe detection was contributory in 3/8 cases only. CONCLUSION: Benefit of the technique is limited in routine, but it can be helpful in redo cases if the offending gland is not located in close surroundings of tissues physiologically taking up the radiopharmaceutical (salivary glands, great vessels and heart).

Intraoperative decay profile of intact (1-84) parathyroid hormone in surgery for renal hyperparathyroidism--a consecutive series of 80 patients.

BACKGROUND: The utility of intraoperative parathyroid hormone (PTH) monitoring is unclear in the surgical management of renal hyperparathyroidism. Our goal was to define the normal pattern of decay during operation for renal hyperparathyroidism by using the rapid intact (1-84) parathyroid hormone (PTH) assay. METHODS: Eighty consecutive patients underwent neck exploration for renal hyperparathyroidism. Intact PTH levels were monitored with a rapid immunochemiluminometric assay. Samples were assayed at the induction of anesthesia, after dissection before resection, and 20 and 40 minutes after resection. Follow-up ranged from 3 to 24 months. RESULTS: Twenty minutes after resection, PTH levels remained many-fold supranormal. Seventy-seven patients (96%) were cured. Of these, 75 patients (94%) had PTH decay of more than 50% from the preoperative level; 74 (99%) were cured. Only 1 of 3 patients (33%) in whom the PTH level decreased less than 40% from the preoperative level was cured. Two patients had intermediate values and both were cured. CONCLUSIONS: The intraoperative decay of PTH during operation for renal hyperparathyroidism is slower than for patients with normal renal function. However, 20 minutes after resection, a decline to less than 50% of the preoperative level predicts cure, while a level greater than 60% predicts failure.

Outcomes in the management of vascular prosthetic graft infections confined to the groin: a reappraisal.

The management of vascular prosthetic graft infections confined to the groin continues to be controversial. To critically evaluate this problem, we reviewed the records of our vascular registry from December 1992 through February 1995 and found 17 incidences of groin sepsis involving a vascular prosthesis in 10 patients. These included a proximal prosthetic femoropopliteal bypass (n = 6), an aortobifemoral graft limb (n = 5), an ileofemoral bypass (n = 3), a prosthetic femoral patch (n = 2), and an aortofemoral/femorofemoral bypass (n = 1). The mean age of these patients was 65 years. Six patients were diabetic, four were on systemic steroids, and two were diabetic and on steroids. All infections were Szilagyi grade III including three in which the patients presented with local hemorrhage. Treatment consisted of irrigation, radical debridement with or without in situ graft replacement, and local rotational muscle flap coverage in nine cases, graft excision with extra-anatomic (obturator ileofemoral bypass) graft replacement in six cases, and excision alone in two cases. Of the 17 infections treated operatively and followed from 1 week to 18 months (median 5 months), eight (47%) showed no evidence of recurrence, six (35%) recurred, two (12%) caused early death, and one resulted in a thrombosed graft requiring extra-anatomic reconstruction. Of the nine infected grafted treated locally with muscle flaps, six showed recurrent infection from 3 weeks to 15 months and one thrombosed for a total local treatment failure rate of 78%. Only two grafts are free of infection at 4 and 5 months, respectively. Of the six incidences of infection treated with obturator bypass, four (66%) are free of infection and two resulted in patient death; both infections treated with excision alone were eradicated but resulted in a major lower extremity amputation. These data question the growing acceptance of debridement and local muscle flap coverage for the treatment of all prosthetic vascular graft infections confined to the groin, especially in patients who are diabetic or on systemic steroids.

A controlled trial of the effect of 4-hydroxypyrazolopyrimidine (allopurinol) on the toxicity of a single bolus dose of 5-fluorouracil.

We have evaluated, in a controlled study, the modification of the toxicity of a single bolus dose of 5-fluorouracil (5-FU) by allopurinol. Patients first received a single dose of 5-FU and were monitored for toxicity. If a measurable nadir in WBC or platelet count occurred, then the same dose of 5-FU was repeated with concurrent allopurinol, given for four consecutive days at an initial dose of 300 mg twice daily, starting the day before the administration of 5-FU. With this schedule, each evaluable patient received courses of 5-FU with and without allopurinol that could be compared for toxicity. Twenty patients received initial 5-FU doses of either 1,200 mg/m2 or 1,500 mg/m2 and later had the same dose repeated with allopurinol. Nineteen of these patients had a higher WBC count with allopurinol than without it. In several patients who received a further course of 5-FU with 900-mg/d allopurinol, the WBC count was yet higher than with 600-mg/d allopurinol. The myelosuppression produced by 5-FU was characterized by a decrease in granulocyte levels that was much greater than the decrease in lymphocyte levels, and the result of allopurinol treatment was to attenuate this effort on granulocytes. In a second part of the trial, the goal was to establish the maximum tolerated dose of 5-FU given with concurrent allopurinol. In this part of the study, all patients entered were given 5-FU, usually 1,200 mg/m2, with allopurinol, usually 600 mg/d for four days. Escalations of one or the other drugs were made on subsequent treatments. The data for 22 patients showed that 1,800 mg/m2 of 5-FU was well tolerated if given with 600 to 1,200 mg of allopurinol per day, and that the WBC count nadirs were no more severe than those of 1,200-mg/m2 5-FU without allopurinol. Neurotoxicity became limiting in some patients treated at these higher doses. We conclude that allopurinol given in the proper dose and schedule can diminish the granulocytopenia produced by bolus doses of 5-FU, thereby allowing a 50% increase in the maximal tolerated dose of 5-FU.