Maximizing outcomes while minimizing exploration in hyperparathyroidism using localization tests.

HYPOTHESIS: Preoperative localization (ultrasonography and scintigraphy) can be used to limit operative exploration in primary hyperparathyroidism while providing a high rate of success. DESIGN: Prospective cohort analysis of 3 types of exploration (1-gland, unilateral, or 4-gland), as directed by localization. RESULTS: In 185 consecutive patients who underwent operations, the final diagnoses were solitary adenoma in 87% and multigland disease in 13%. Ultrasonography (75%) and scintigraphy (83%) demonstrated an enlarged parathyroid gland and, together with operative findings, resulted in 61 1-gland, 63 unilateral, and 61 4-gland explorations, with an initial success rate of 96% and an ultimate success rate of 99%. Limiting exploration resulted in a significant decrease in operative time and hospitalization. CONCLUSION: Localization can limit exploration with success.

Long-term biliary function after reconstruction of major bile duct injuries with hepaticoduodenostomy or hepaticojejunostomy.

HYPOTHESIS: Normal biliary function can be achieved after reconstruction for major bile duct injuries using either hepaticoduodenostomy (HD) or Roux-en-Y hepaticojejunostomy (HJ). DESIGN: Retrospective analysis of consecutive patients requiring biliary enteric reconstructions from February 1, 1993, through January 1, 2002, for bile duct injuries. SETTING: Academic multispecialty referral clinic. PATIENTS: Twenty-seven consecutive patients were evaluated who underwent biliary enteric reconstruction for bile duct injury caused during cholecystectomy. Patients were reconstructed either by HD (18 patients) or HJ (9 patients). INTERVENTIONS: Patients' medical records were reviewed and long-term evaluations were obtained via telephone questionnaire by 2 separate observers (R.J.M. and F.T.L.). Biliary function was evaluated in all using symptoms and liver function test results. Cholangiography was obtained, if indicated clinically. These were reviewed for stricture or dilatation. Any biliary interventions were recorded. MAIN OUTCOME MEASURES: Comparison of long-term biliary function after HD vs HJ reconstructions. RESULTS: All patients were contacted after a median postoperative time of 54 months. Excellent or good results were observed for biliary function in 25 (92%) of the 27 patients. These results were obtained regardless of the type of reconstruction-HD (18 patients) or HJ (9 patients). CONCLUSIONS: We found biliary function to be normal at more than 4 years after biliary-enteric reconstruction for bile duct injury. When surgically feasible, we prefer HD to HJ.

Surgical treatment of hyperparathyroidism improves health-related quality of life.

HYPOTHESIS: The surgical treatment of primary hyperparathyroidism results in an improved health-related quality of life. DESIGN: Prospective cohort analysis of consecutive patients with primary hyperparathyroidism analyzed preoperatively and 1 year postoperatively. SETTING: Academic multispecialty referral clinic. PATIENTS: We prospectively evaluated 74 consecutive patients who underwent parathyroid exploration for primary hyperparathyroidism during a 15-month period. INTERVENTIONS: The Medical Outcomes Study Short-Form Health Survey (SF-36) was administered before consultation with a surgeon. Patients were categorized based on reason for referral as either asymptomatic (group 1; n = 43) or symptomatic (group 2; n = 29). All patients underwent parathyroid exploration and normalization of calcium levels postoperatively. The SF-36 was then re-administered after 1 year. MAIN OUTCOME MEASURES: Statistical analysis of preoperative and postoperative SF-36 scores, and comparisons with national norms. RESULTS: The SF-36 was completed preoperatively and 1 year postoperatively by 72 (97%) of 74 patients. When the results were compared with published national norms, the preoperative population was significantly impaired in 5 of 8 domains, whereas the postoperative one had improved and was nearly indistinguishable from the norm. In 7 of 8 domains, the postoperative scores were significantly improved compared with preoperative scores. Group 1 patients showed significant preoperative impairment in 3 domains and significantly improved in 2, whereas group 2 patients showed significant impairment and improvement in 7 domains. CONCLUSION: The surgical treatment of primary hyperparathyroidism is associated with durable, statistically significant improvements in health-related quality of life.

Outcomes after resection of cholangiocellular carcinoma.

BACKGROUND: Cholangiocellular carcinoma (CCC) is a rare primary liver malignancy that arises from intrahepatic bile duct canaliculi and presents as a liver mass. Our purpose is to report operative morbidity and mortality and to determine long-term survival after resection for CCC. METHODS: Retrospective review of 31 consecutive patients who underwent resection during a 20-year period. RESULTS: Thirty-day hospital mortality was 3%, and postoperative morbidity was 38%. Kaplan-Meier 5-year survival was 35%; mean survival was 37 months; absolute 5-year survival was 33%. Mean survival in stages I, II, IIIA, and IIIC were 57, 33, 26, and 14 months, respectively (P = 0.03 comparing I to >I). Recurrence occurred in 18 patients; 89% were in the liver. Carbohydrate antigen 19-9 >100 U/mL was found to be an indicator of poor prognosis (P = 0.009). CONCLUSIONS: Resection for CCC can be performed with acceptable morbidity and mortality rates and results in good survival and cure. Hepatic recurrence is common. Carbohydrate antigen 19-9 may be useful in determining prognosis.