Small mammal populations and community under conditions of extremely high thallium contamination in the environment

BACKGROUND: The goal of this study was to evaluate the safety and efficacy of total thyroidectomy performed for benign thyroid disease. METHODS: A total of 106 consecutive patients undergoing total thyroidectomy for benign disease from October 1982 to July 1995 were reviewed. The 33 men and 73 women had an average age of 46 years (range, 16 to 82 years). Indications for total thyroidectomy were a thyroid nodule with the history of head and neck radiation in 36 patients, bilateral thyroid nodules in 35, needle biopsy of a follicular neoplasm or frozen section diagnosis of a possible malignancy in 18, and toxic goiter in 17. Total thyroidectomy was performed as the primary operation in 98 patients, and 8 patients had a completion reoperation for recurrent disease. RESULTS: Pathology findings revealed benign nodular goiter in 49 patients, follicular adenoma in 26, hyperplasia in 19, and Hashimoto's thyroiditis in 12. Postoperative hemorrhage requiring operative hemostasis occurred in two patients (1.9%). Two patients had unilateral recurrent laryngeal nerve (RLN) palsy before operation (1.9%). Three patients had unilateral postoperative RLN palsy (2.8%). Two cases resolved in 3 and 4 months. The only permanent RLN injury occurred in a patient reoperated for a compressive goiter. Early postoperative hypocalcemia (8.0 mg/dl or less) was found in nine patients (8.5%). No patient had permanent hypoparathyroidism at long-term follow-up evaluation. CONCLUSIONS: Total thyroidectomy for benign thyroid disease can avoid reoperation for nodular goiter and hyperthyroidism and eliminate any subsequent risk of malignant change in radiated thyroid glands. A low complication rate can be achieved with meticulous surgical technique. Total thyroidectomy can be performed safely for bilateral benign thyroid disease.     

Can total thyroidectomy be performed as safely by general surgeons in provincial centers as by surgeons in specialized endocrine surgical units? Making the case for surgical training

OBJECTIVE: To determine whether surgeons who had received appropriate training in the technique of total thyroidectomy could continue to perform the procedure with minimal morbidity after moving to a provincial surgical practice. DESIGN: Comparison of the complication rates from total thyroidectomy between a specialized endocrine surgical unit and provincial centers. SETTING AND PATIENTS: Six hundred fifty patients undergoing total thyroidectomy by two surgeons over a 5-year period in the endocrine surgical unit at Royal North Shore Hospital, St Leonards, Australia, were compared with 120 patients undergoing total thyroidectomy by seven provincial surgeons who were former trainees in the unit. MAIN OUTCOME MEASURES: Indications for surgery and specific complications of thyroidectomy including recurrent laryngeal nerve palsy, permanent hypoparathyroidism, and postoperative bleeding. RESULTS: Each of the seven surgeons in provincial practice performed only between two and 16 thyroidectomies annually. The percentage of total thyroidectomies for benign and malignant disease was identical for both the endocrine surgical unit and provincial center groups (44%). There was no difference in the incidence of recurrent laryngeal nerve palsy, permanent hypoparathyroidism, or postoperative bleeding between the two groups. CONCLUSION: Total thyroidectomy is an operation that always engenders controversy relating to the morbidity of recurrent laryngeal nerve and parathyroid injury. Surgeons who have completed a well-designed training program and who have become proficient at total thyroidectomy as trainees will remain proficient at the procedure despite practicing in a provincial center. Achieving a low morbidity rate demands meticulous attention to operative technique and anatomical detail.     

Recurrent laryngeal nerve paralysis after thyroid gland operations. Etiology and consequences]

In the period of 1 January 1990 to 31 December 1996 the thyroidectomy cases we performed were immediately followed by vocal cord evaluation using a flexible bronchoscope while the patient was still on the operating table. If an obvious cord paralysis was discovered, an exploration of the recurrent laryngeal nerve, to the level of the larynx, was performed. If the nerve was found to be intact, no further measures were taken. A severed nerve underwent suture repair. If an otolaryngologist diagnosed a vocal cord paralysis 1-5 days after surgery, a reoperation was recommended except in the cases where postoperative bronchoscopy had shown an easily mobile cord or the recurrent nerve was completely dissected during the operation. Within this 7-year period, we performed 3492 thyroidectomy operations. The diagnosis of subsequent unilateral postoperative vocal cord paralysis occurred in 48 cases. In 33 of these cases the status of the nerve in the surgical field was known: 4 patients had an intact nerve proved by complete dissection during thyroidectomy, in two patients the lesions of the nerve were detected intraoperatively (1 transsection, 1 partial resection), and 27 cases were followed by reoperation. Of the 33 patients mentioned above, in 19 instances the recurrent laryngeal nerve was found to be intact; 3 displayed signs of local trauma, and 11 were found to be severed with total discontinuity. Those patients with an intact nerve, or local nerve trauma only, went on to develop normal function within 6 months in 20 (91%) of 22 cases. Of the 11 with a severed nerve, 8 showed "autoparalysis" with good voice within 4-8 months, after suture repair in 10 cases. The patient with partial resection had no repair of the nerve. If immediate postoperative evaluation showed mobility of the vocal cords but a paralysis was detected later by an otolaryngologist and repeat intervention was not done, vocal cord function was spontaneously restored in 9 of 11 patients. Four patients refused reoperation. From 1990 to 1991, the recurrent laryngeal nerve was not always dissected during our thyroidectomy operations. However, this was done routinely from 1991 to 1996. Routine intraoperative dissection of the vocal cord nerve reduced the rate of postoperative cord paralysis from 2.0% to 1.2%. It also reduced the frequency of intraoperative nerve injury with total discontinuity from 0.58% to 0.23%.     

Thyroid surgery in children and teenagers

From 1961 to 1976 62 patients under age 20 underwent thyroidectomy for various thyroid disorders. Twenty-four thyroid lobectomies and eight subtotal or near-total thyroidectomies were performed for benign nodular goiter. Eight near-total thyroidectomies and two thyroid lobectomies were performed for carcinoma. Two patients also had a radical neck dissection. Twenty patients with hyperthyroidism underwent near-total thyroidectomy. Postoperative complications occurred in six patients-all with hyperthyroidism. Operative mortality was zero. Two indications for thyroidectomy in our series were nodular goiter (to rule out carcinoma), and hyperthyroidism (that was not well-controlled medically or where surgery was chosen as primary therapy). In patients with nodular goiters that required surgery, a minimal complication rate occurred. By contrast, surgery for hyperthyroidism was associated with a high postoperative complication rate, six of 20 patients or 30%, which must be anticipated by the surgeon.     

The relationship between serum and saliva erythropoietin concentrations in adults, full-term and premature infants

Not only thyroid adenomas and carcinomas, but also the majority of single and well delimited goiter nodules, even if morphologically heterogeneous, are of clonal origin. However, it is still unknown whether the nodules of rapidly growing, recurrent goiters are clonal or polyclonal. We investigated by PCR-based analysis of exon 1 of the human androgen receptor gene clonality of nodules grown in recurrent multinodular goiters (MNG) of 14 female patients. The total goiter volume varied widely between 15 ml and 170 ml. The mean age of patients undergoing surgery for recurrent goiter at the time of their first operation was significantly lower with 34.6 +/- 10.9 yr in comparison to 50 consecutive patients who were operated for MNG for the first time (53.7 +/- 13.5 yr). The interval between first and recurrent operation was 18 +/- 8.5 yr. The mean volume of well circumscribed nodules selected for the present investigation was 3.8 +/- 1.4 ml. Assessment of clonality in at least 2 samples of each lesion revealed a polyclonal pattern in 10 out of 14 nodules, whereas only 3 nodules were clonal and in one case the result remained unclear. The unexpected finding that most nodules within MNG, that had re-grown after a first subtotal thyroidectomy, were of polyclonal rather than clonal composition, suggests that these lesions are generated by de novo-proliferation of cohorts of differing thyrocytes sharing the common trait of an exceedingly high intrinsic growth rate or alternatively, by unknown growth stimulating molecular events acting focally on clusters of cells derived from different ancestors. In addition, the relatively young age of patients with recurrent MNG at the time of their first surgery and the comparatively short interval between first and second operation point to a genetic element in the occurrence of growth-prone thyrocytes.     

Risk factors and follow-up of recurrent laryngeal nerve paralysis after first surgeries of benign thyroid diseases. Results of a retrospective analysis of 1,556 patients

PATIENTS AND METHODS: risk factors of recurrent laryngeal nerve (RLN) palsy after thyroid gland surgery were evaluated retrospectively in 1556 patients who were submitted to an operation because of a benign thyroid disease. Recurrences were also excluded. RESULTS: RLN palsy occurred in 6.6%. In relation to the nerves at risk the incidence of primary postoperative nerve damages was 4.3%. After a long-term follow-up of in total 18 months the incidence of permanent nerve palsy was 1.6% (related to the nerves at risk: 1.1%) as 75.5% of the paralyses were transient in an average of 6.2 months. Substernal goitres especially when sternotomy became necessary, the ligature of the inferior laryngeal artery, serious perioperative complications and total lobectomy in comparison to subtotal resection were important risk factors for primary postoperative RLN palsy (p < 0.05 resp. p < 0.01). The ligature of the inferior laryngeal artery and the extension of resection were indeed significant risk factors also for permanent nerve damages, but the other factors had no influence on the risk of permanent RLN palsy. However, the non-exposure of RLN in subtotal lobectomy was significantly associated (p < 0.01) with permanent, but not with transient nerve palsy. CONCLUSION: The exposure of the RLN is one of the most important procedures during thyroid surgery and particular also during subtotal lobectomy to reduce the rate of permanent RLN damages.     

Thyroidectomy without drainage

Recent randomized series did not support routine prophylactic drainage after thyroidectomy. We undertook a prospective study in order to evaluate the effectiveness and the morbidity of a non drainage strategy after thyroidectomy. Between april 1993 and may 1995, one hundred fifty consecutive patients underwent thyroidectomy without drainage. During this period, two thyroid cancers were treated by total thyroidectomy with a modified radical neck dissection and drainage; they are not included in the study. Age range was 16 to 72 years. Sex ratio was 126F/124M. Indication for surgery was: solitary nodule (16), multinodular goiter (56), Graves' disease (21), toxic nodular goiter (34), cancer (8), retrosternal goiter (13), thyroiditis (2). The surgery done was: total lobectomy + isthmusectomy (15), total lobectomy + subtotal controlateral thyroidectomy (42), bilateral subtotal thyroidectomy (84), total thyroidectomy (9). Surgical technique was identical to that used previously by the author when drainage was installed routinely. Patients left the hospital on the first or second postoperative day and were reexamined on day 7 and day 30. There was no mortality, no suffocating hematoma, no reoperation and no laryngeal nerve paralysis. One patient developed a transient hypocalcemia that regressed one month later. Two patients developed a minor hematoma of which one disappeared after two weeks and the other drained spontaneously through the surgical incision on the seventh postoperative day. We conclude that drainage after thyroidectomy has no adverse effects and can be avoided if meticulous surgery is done. Absence of drainage simplifies the early postoperative course, improves the comfort of the patient, decreases hospital stay and reduces hospital cost. However, drainage may be of value in case of hemostatic problems or associated cervical neck dissection.     

High incidence of adeno- and polyomavirus-induced hemorrhagic cystitis in bone marrow allotransplantation for hematological malignancy following T cell depletion and cyclosporine

Retrosternal goiter is defined as any goiter in which at least 50 per cent of the thyroid resides below the level of the thoracic inlet. The incidence of retrosternal goiter varies from 3 to 20 per cent with respect to thyroidectomy patients. A retrospective chart review from June 1991 to December 1997 found 232 thyroidectomies performed at our institution. Sixteen patients were found to have retrosternal goiters (6.9%). The mean age was 57.8 years (range, 34-92). All were of benign pathology. Symptoms included shortness of breath (68.8%), hoarseness (37.5%), dysphagia (31.3%), and superior vena cava obstruction (6.25%). Thirteen patients were female (81.3%). Fifteen patients had surgical intervention (93.8%). Total thyroidectomy was performed in nine cases (60%), whereas lobectomy was performed in six cases (40%). All treated patients had complete resolution of symptoms. A cervical incision alone was used in 13 cases (86.7%). Complications consisted of one postoperative pleural effusion and in one case a traumatic C5 nerve root compression occurred. There were no instances of long-term vocal cord paralysis or hypoparathyroidism. There was no perioperative mortality. In the majority of patients with retrosternal goiter, surgery can be done expeditiously through a cervical incision with minimal morbidity and mortality.     

Quality of life in chronic inflammatory bowel diseases. Validation of a questionnaire and first French data]

One hundred and seventy patients with Graves' disease underwent thyroidectomy between 1987 and 1994 (10.5% of all thyroidectomies performed in the same period). Female/male ratio was 9/1; mean age 55.2 years and average period between diagnosis and surgical treatment 5.3 years. The average thyroid weight was 230 g (range 90-950 g). Thyroidectomy was subtotal in 110 and total in 60 patients, 5 of which had been previously treated elsewhere from 5 to 33 years before. Malignancy was incidentally found in 2.35% of patients. The complication rate resulted higher in total thyroidectomies than in subtotal procedures (bleeding 0.9% vs 5.4%, transient hypoparathyroidism 4.5% vs 12.7%, recurrent nerve lesion 0.45% vs 2.72%) however the differences were not statistically significant; this probably because both the procedures were carried out with the same technique for parathyroid gland and recurrent nerve safety. The need of repeated surgery increased the risk. In opposition to total thyroidectomy, subtotal thyroidectomy does not doom to complete and permanent replacement therapy (96.4% of hypothyroidism at 2 months, 72.6% at 4 years), but in this series it failed to achieve remission in 2 patients who maintained a mild hyperthyroidism and in one more patient who developed a relapse 4 years later. Serum TSI meaning is not clear, but preoperative positivity suggests a wider resection and postoperative persistence a closer follow-up by functional assessment. In conclusion surgical procedures for Graves' disease range from subtotal to total thyroidectomy but for a safe outcome the choice depends more on the intraoperative troubles of each single case than on theoretic advantages.     

Thyroid gland surgery at the 1st Surgical Clinic of the 1st Medical School of Charles University and General Medical School Hospital in Prague--review of problems

The authors analyze a group of 100 patients indicated for goitrectomy during the period from 1995-1996. The most frequent indication for surgery was an eufunctional polynodular goitre. The group comprised 86 women and 14 men. Their mean age was 47 years, bilateral affections predominated. The most frequent type of operation was total thyroidectomy. Carcinoma was found in three of the operated patients. The mean period of hospitalisation was 6 days. Postoperative complications were more frequent after total goitrectomies, and with the extent of the operation the number of possible complications increased. The most serious complication in the authors opinion was a lesion of the parathyroid glands, observed in 5% of the patients. Permanent unilateral lesions of the recurrent nerve were recorded in 2% of the operated patients. There was no lethal postoperative complication. The largest operated goitre weighed 625 g (photograph 1). The authors conclude that it cannot be stated that the operation of larger goitres is associated with the highest incidence of postoperative complications. The opposite is rather the case.     

Primary hyperthyroidism 1996

55 prospectively documented patients aged 20-84 (median 67) years (47 women, 8 males) underwent surgery for primary hyperparathyroidism (pHPT). The most frequent symptoms and associated conditions were nephrolithiasis (42%) and neuropsychiatric symptoms (39%). Only one case of asymptomatic and one case of "normocalcemic" pHPT were found in this series. 47 patients (89%) were cured following initial neck exploration, and 3 further patients (6%) were cured by a second operation. Reoperation also led to cure in 2 patients operated on elsewhere in the first instance. 6 patients (11%) had double adenoma (bilaterally) and 36% of the adenomas had an ectopic location, with an intrathyroidal adenoma in 2 cases. In 2 patients sternotomy was carried out. Persistent pHPT was observed in 3 patients (following initial exploration in 2 cases and reoperation in one). These patients had a supernumerary adenomatous gland with ectopic location in 2 cases and a double adenoma with ectopic position of one adenoma in a further case. One 80-year-old patient died post-operatively from intestinal ischemia. 2 patients had permanent postoperative hypoparathyroidism; in no case was a permanent recurrent laryngeal nerve palsy observed. Bilateral parathyroid exploration with thyroid mobilization by capsular dissection is the procedure of choice for pHPT. In 2 patients with the MEN 2A-syndrome and with medullary thyroid carcinoma thyroidectomy, lymphadenectomy and autotransplantation of normal parathyroids to the arm was performed, with normal parathyroid function in both cases.     

The effect of the primary operation on reoperations on the thyroid gland

The authors analyze the possibility to reduce the number of reoperations of the thyroid gland, based on a group of thyroid operations performed at the Surgical Clinic of the Second Medical Faculty Charles University and Faculty Hospital Motol during the 22-year period from 1975-1997. 507 reoperations from a total number of 4501 thyroid operations amount to 11.3%. In the authors opinion correct indication of the operation is most important as well as the correct extent and technique of the primary operation. The achieved results are except for unilateral temporary lesions of the NLR comparable with primary operations.     

Dural tears secondary to operations on the lumbar spine. Management and results after a two-year-minimum follow-up of eighty-eight patients

We reviewed the results of acute management of patients who had sustained a dural tear during an operation on the lumbar spine, and we attempted to determine the long-term sequelae of this complication. In the five years from July 1989 to July 1994, 641 consecutive patients had a decompression of the lumbar spine, performed by the senior one of us; of these patients, eighty-eight (14 percent) sustained a dural tear, which was repaired during the operation. The duration of follow-up ranged from two to eight years (average, 4.3 years). Postoperative management consisted of closed suction wound drainage for an average of 2.1 days and bed rest for an average of 2.9 days. Of the eighty-eight procedures that resulted in a dural tear, forty-five were revisions; these revisions were performed after an average of 2.2 previous operations on the lumbar spine, all of which resulted in a scar adherent to the dura. Only eight patients had headaches related to the spinal procedure and photophobia in the postoperative period; these symptoms resolved in all but two patients, both of whom had had a revision operation. Each of the two patients had symptoms of a persistent leak of spinal fluid and needed a reoperation for repair. Overall, seventy-six patients had a good or excellent result and twelve had a poor or satisfactory result with some residual back pain. One patient had arachnoiditis, and another had symptoms of viral meningitis one month postoperatively. A dural tear that occurs during an operation on the lumbar spine can be treated successfully with primary repair followed by bed rest. Such a tear does not appear to have any long-term deleterious effects or to increase the risk of postoperative infection, neural damage, or arachnoiditis. Closed suction wound drainage does not seem to aggravate the leak and can be used safely in the presence of a dural repair.     

Surgical treatment of thyroid diseases in geriatric patients

Thyroid diseases have a characteristic evolution in geriatric age, whether for the symptomatology frequently mingled with typical manifestations of again, or for glandular involution. Moreover, in the aged patient, the particular aspect of the epidemiology, physiopathology, clinic and therapy are to know and interpret. In most cases, the presence of a uni- or multi-nodular goiter does not cause compression problems or cancerization risk. In the presence of these problems and in multi-nodular goiter, we prefer total thyroidectomy because, at the present time, it is possible to put at zero the risks of this operation, neither we fear hypothyroidism which all the same also appears in less extensive operations. Between thyroid diseases, cancer has a typical biological behaviour and prognosis in geriatric patients. While most tumors have a better curability in geriatric age, these have a worse prognosis. So therapeutic indications very as a function of age. About this the authors present preliminary data of a prospective trial started in 1992.     

Five-year follow-up of a prospective randomised multi-centre trial of weekly chemotherapy (CAPOMEt) versus cyclical chemotherapy (CHOP-Mtx) in the treatment of aggressive non-Hodgkin''s lymphoma. Central Lymphoma Group

Benign tumors of the pancreatic head are normally treated by a partial duodenopancreatectomy. This operation has been developed for the treatment of malignant alterations in the pancreatic head and includes resection of the gastric bowel, duodenum and common bile duct. The aim of this study was to evaluate whether the less radical duodenum-preserving pancreatic head resection is a suitable surgical procedure in the treatment of benign pancreatic head tumors. From May 1982 to December 1996, seven patients underwent surgical treatment for benign pancreatic head tumors. Two patients suffered from gastrinoma of the pancreatic head, four exhibited a serous or mucinous cystadenoma, and one patient suffered from an intraductal papillary-mucinous tumor in this region. All patients were treated by duodenum-preserving pancreatic head resection. The operation was easily performed with little blood loss and a low rate of complications. None of the patients had to be reoperated upon due to postoperative surgical complications. After a follow-up period of a median 3 years, six of seven patients were had no recurrence of the disease and were symptom-free. One patient who had initially been operated on for gastrinoma still exhibited high gastrin values postoperatively. The endocrine and exocrine pancreatic function was not impaired in the early and late postoperative phase as compared to the preoperative assessment. From our results, it is concluded that duodenum-preserving pancreatic head resection is an adequately radical, yet organ-preserving procedure for the treatment of benign tumors of the pancreatic head without compromising endocrine and exocrine function.     

Primary experiences with laparoscopic appendectomy

The material comprises 77 patients with suspected appendicitis seen in a district community hospital. In the presence of a surgeon with laparoscopic experience laparoscopy was performed in 23 patients. In two patients the laparoscopy was only diagnostic, and in two patients adhesions or friable gangrenous appendicitis necessitated conversion to conventional appendicectomy. Nineteen patients thus had a laparoscopic appendicectomy performed with a median operation time of 63 minutes and a median hospital stay of two days. One patient with gangrenous appendicitis and a periappendicular abscess was readmitted after three weeks because of deep infection, which resolved after antibiotic treatment. The remaining 54 patients had a conventional appendicectomy performed, with a median operation time of 40 minutes and a median hospital stay of three days. There were six complications in this group. We conclude that laparoscopic appendicectomy is a safe alternative to open operation with benefits for the patient in form of lesser pain, shorter hospital stay, fewer complications, better cosmetic outcome, and shorter time to normal activity.     

Choledochoduodenostomy, choledochojejunostomy or sphincteroplasty for biliary and pancreatic disease

Choledochoduodenostomy, choledochojejunostomy, or sphincteroplasty are used in the treatment of selected patients with retained, recurrent, and impacted bile duct stones; strictures of the bile ducts; stenosis of the sphincter of Oddi; pancreatitis associated with biliary disease; choledochal cysts; fistulas of the bile duct; and biliary obstruction, either benign or malignant. From a group of approximately 1600 patients operated on for biliary and pancreatic disease during the 17-year period, 1962 to 1979, 153 patients who had choledochoduodenostomy, choledochojejunostomy or sphincteroplasty were identified. Follow-up information was available for 146 patients (95%). Overall, 84% of the patients had good results, 10% had fair results, and 3% had poor results. A 3% postoperative mortality rate was found, all in patients with unresectable malignancies. Treatment of bile duct obstruction, benign or malignant, was equally effective by choledochoduodenostomy or choledochojejunostomy. Jaundice resolved in all patients; three patients with benign strictures required reoperations for recurrent stricture formation, two after choledochoduodenostomy, and one after choledochojejunostomy. Recurrent cholangitis heralded the development of another stricture. Both choledochoduodenostomy and sphincteroplasty were used for patients with retained, recurrent or impacted duct stones. Pancreatitis did not occur in any patient after sphincteroplasty; the sump syndrome was not seen after choledochoduodenostomy. This review supports the view that choledochoduodenostomy is a safe and effective procedure. All three operative procedures were effective for the problems for which they were used; each procedure has a place in the treatment of recurrent or complicated biliary and pancreatic diseases. The procedures are complementary, not competitive. For certain problems, the operation performed depends upon the surgeon's preference and experience. The indications for and results of these operative procedures are discussed.     

Incidence of contralateral vesicoureteral reflux following unilateral extravesical detrusorrhaphy (ureteroneocystostomy)

PURPOSE: The development of contralateral vesicoureteral reflux following different types of unilateral antireflux surgery has been reported to be as high as 22%. We review our recent experience with unilateral extravesical detrusorrhaphy in regard to the incidence of postoperative contralateral vesicoureteral reflux. MATERIALS AND METHODS: Between 1990 and 1995, 72 children underwent unilateral extravesical detrusorrhaphy. Of 73 refluxing renal moieties (1 patient had reflux in both moieties of a completely duplicated kidney) reflux grade was II in 35 (48%), III in 25 (34%), IV in 11 (15%) and V in 2 (3%). Common sheath reimplantation for complete ipsilateral duplication was performed in 16 patients. RESULTS: One patient had grade I postoperative ipsilateral vesicoureteral reflux resulting in a success rate of 98.6%. In 4 patients (5.6%) contralateral vesicoureteral reflux developed, and was grade II in 3 and grade I in 1. In all patients contralateral reflux resolved at 16, 17, 18 and 31 months of followup. No additional surgery was required in any patient. There was no association between the incidence of contralateral vesicoureteral reflux, and patient age, gender, preoperative ipsilateral reflux grade and presence of ipsilateral duplication. CONCLUSIONS: Unilateral extravesical detrusorrhaphy is a highly successful procedure with a low incidence of postoperative contralateral vesicoureteral reflux. Should reflux develop, it is of low grade with a significant rate of spontaneous resolution.     

Organization and results of ambulatory surgery for inguinal hernia]

The results of a reorganization of surgery for inguinal hernias within a department of surgical gastroenterology were assessed concerning staff simplifications, feasibility, patient satisfaction, safety, complications and resources. Five hundred consecutive, elective, open operations for unilateral reducible inguinal hernias were performed in 466 patients under local anaesthesia in an ambulatory setup. One hundred and fourteen of the operations were for a recurrent hernia. The median age was 60 years (44-74 years as 25% and 75% quartiles). Two of the operations were converted to general anaesthesia. The patients were discharged 85 min (median) post-operatively, but 12 patients were not discharged on the same day. Bleeding or wound infections in need of treatment were seen postoperatively in 1.6% and 1.6%, respectively. All patients were given a postoperative questionnaires with a response rate of 95%, 89% of the respondents were satisfied with the whole procedure, 11% were dissatisfied. A reorganization of surgery for inguinal hernias to a standardized ambulatory setup induced staff simplifications and saved resources with a preserved high patient satisfaction, safety and a low complication rate.     

Contrast-associated nephropathy--old clinical problem and new therapeutic perspectives

BACKGROUND: Most complications after lung lobectomy are related to pain, narcotic analgesia, and inactivity. When the operation is performed with the goal of minimizing postoperative pain, and when rapid restoration of activity and patient independence can be achieved, most postoperative complications can be obviated and early discharge can be attained. METHODS: Since March 1996, we have performed 10 consecutive elective major lung resections (8 lobectomies and 2 bilobectomies) for neoplastic (n = 8) and benign inflammatory (n = 2) lesions. Of the 10 patients, 4 were men and 6 were women ranging in age from 58 to 77 years (mean age, 66 years). Extensive preoperative patient and family education was provided in the surgeon's office. Same-day admission was followed by an oblique muscle-sparing minithoracotomy to access the chest cavity. A meticulous operation, with special attention to minimizing air leak and postoperative discomfort, was performed. Intercostal nerve cryolysis was used as the main method of analgesia. RESULTS: All patients underwent the planned operation through a minithoracotomy and were extubated in the operating room. All patients exhibited normal ipsilateral shoulder girdle mobility in the recovery room and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation. The chest tube was removed the night of the operation in 2 patients, the morning after the operation in 6 patients, and on the second postoperative day in 1 patient. One patient who was discharged with a Heimlich valve had this device removed in the office 4 days after the operation. After the chest tubes were removed, there were no instances of pneumothorax. All 10 patients were able to ambulate independently on the first postoperative day. Eight patients were discharged home the morning after the operation and 2 on the second postoperative day. None of the patients have required readmission related to their operation or have exhibited evidence of postthoracotomy pain syndrome. CONCLUSIONS: We have developed a clinical pathway based on patient education, meticulous minimally invasive operation, cryoanalgesia, and quick resumption of physical activity. Our preliminary experience with this approach has shown minimal morbidity, rapid restoration to preoperative status, and, for most patients, a 1-day hospital stay after major lung resection.