bluuebunny/crossref_metadata_2025 huggingface dataset:
Differentiated carcinoma of the thyroid gland
Authors: Ozaki Osamu , Notsu Takeshi , Hirai Keisuke , Mori Tohru
Published: May 2005

Local recurrence at the stump of resection was examined with regard to stage of disease and extent of resection in patients with papillary and follicular carcinoma of the thyroid treated during the 23‐year period from 1956 to 1979.

The overall recurrence rate was 8.3% in both papillary and follicular carcinoma. In papillary carcinoma, total lobectomy is indicated for tumors<2 cm in diameter and subtotal thyroidectomy for pT‐3 tumor stage, whereas total thyroidectomy should be performed for tumors ≧ 5 cm in diameter and for pT‐4 tumor stage. On the other hand, in follicular carcinoma, total lobectomy is performed for tumors<2 cm in diameter, but subtotal thyroidectomy is the treatment of choice for those ≧ 2 cm in diameter and for pT‐2 or more advanced tumor stage. Total thyroidectomy is not indicated for most patients with follicular carcinoma.
Hyperparathyroidism with hypercalciuria and urolithiasis: Long‐term effects of parathyroid surgery and postoperative thiazide therapy
Authors: Elomaa Inkeri , Sivula Arto , Kahri Arvi , Puutula‐Räsänen Liisa , Pelkonen Risto
Published: May 2005

Eleven hypercalciuric patients (10 women and 1 man) with hyperparathyroidism and recurrent renal stones are described. In 6 patients normal calcium metabolism was restored after the removal of a single adenoma. No new stones were passed during the follow‐up period of 5 years. In 2 patients with more than 1 abnormal parathyroid gland, the hypercalciuria continued for 8–12 months after the parathyroid surgery. New stones developed in both of them. Subsequent thiazide therapy abolished the hypercalciuria and no additional renal stones were seen during a follow‐up period of 4 years. In 3 patients hypercalcemia reappeared 2–12 years after parathyroid surgery. Treatment with thiazide decreased serum calcium and parathyroid hormone levels for at least 9–36 months. No new stones developed.

Hypercalciuria and recurrent hypercalcemia appearing after parathyroid surgery for hyperparathyroidism and the responses to thiazide therapy are thought to be evidence for renal hypercalciuria. Thiazides are recommended as therapy in such patients to prevent the formation of new renal stones, and probably also the recurrence of hyperparathyroidism.
Changes in thyroid surgery during iodine prophylaxis of endemic goiter
Authors: Riccabona G. , Ladurner D. , Steiner E.
Published: May 2005

The present report is based on 13,778 patients who had thyroid surgery between 1952 and 1980. Until 1971, western Austria was considered an endemic goiter area (school children goiter incidence 50% in 1963), but with the advent of iodized salt in 1963, the goiter incidence has decreased to 13% in preadolescents in recent years. This change in thyroid pathology was accompanied by a decrease in weight of removed thyroids (mean, 125 g→95 g) with a relative increase of hyperthyroid goiters (8.6%→43.6%) and of thyroid cancer in the surgical series (2.6%→6.8%), while the overall rate of interventions decreased only slightly. Surgery for recurrent goiters is rare now (6.2%) while it was considered a problem in previous years (16%). Histological patterns of thyroid cancer have shown a shift to more differentiated, and therefore more treatable, cancer types. The TNM classification has changed also, with 39.1% T2N1M0 cases now versus only 29% in this prognostically better group before 1971. In conclusion, this study indicates that during iodine prophylaxis for endemic goiter, thyroid surgery will retain its significance in the treatment of thyroid disease but that a different therapeutic approach becomes necessary as a result of significant changes in thyroid pathology. Nodular goiters developing under adequate iodine supply require a much more aggressive therapy than those observed in iodine deficient areas.
Unilateral versus bilateral adrenalectomy in multiple endocrine neoplasia IIA
Authors: Tibblin Sten , Dymling John ‐Fredrik , Ingemansson Stig , Telenius‐Berg Margareta
Published: May 2005

Factors influencing the result of various forms of surgical treatment for pheochromocytoma were studied in patients with multiple endocrine neoplasia IIA (MEN IIA) syndrome. The material consisted of 18 patients belonging to 4 non‐related families operated on during 1966–1981 with a mean follow‐up time of 7.4 years. Twenty‐seven adrenals were removed at 22 operations. In all adrenals, multiple pheochromocytomas and/or medullary hyperplasia were present. In 13 patients the first operation was a unilateral adrenalectomy. Four of these had to be reoperated on because of recurring or persisting symptoms. Five patients were operated on bilaterally at the first instance. In 4 of these, the reason was bilateral macroscopic tumor involvement. Various pre‐ and intraoperative findings were evaluated with respect to the surgical result. The maximum diameter of the largest tumor was the only factor relating positively to surgical success with unilateral operation. Of 9 patients who remained asymptomatic following unilateral adrenalectomy, 8 had tumors less than 5 cm in diameter. The 4 patients who had to be reoperated on with a contralateral adrenalectomy all had a maximum tumor diameter exceeding 5 cm. A pragmatic approach to the problem of timing and extent of adrenal surgery in MEN IIA is advocated. Clinical, biochemical, histopathological, genetic, and social dimensions of the disease should be taken into consideration when choosing the surgical procedure.
Adrenal radiography: Problems and pitfalls in adrenal localization
Authors: Geelhoed Glenn W. , Druy Edward M.
Published: May 2005

The traditional preoperative localization of adrenal tumors has employed one or more of the following radiographic techniques: plain abdominal films, intravenous urography, adrenal venography and venous sampling, arteriography, ultrasonography, computed tomographic scanning, and scintiscanning. These localization techniques may be divided into invasive or noninvasive types with each technique having different degrees of sensitivity and specificity for the establishment of adrenal disease. The diagnostic accuracy of these radiographic techniques is reviewed for a 5‐year series in a university hospital with special emphasis on false‐positive localization. The techniques employed in localization and their sequence vary and depend on whether adrenal medullary or adrenal cortical disease was suspected, and whether or not the patient was protected by pharmacologic preparation.
Analysis of preoperative combined bleomycin and radiation therapy for esophageal carcinoma
Authors: Soga Jun , Fujimaki Masao , Tanaka Otsuo , Sasaki Koichi , Kawaguchi Masaki , Muto Terukazu
Published: May 2005

Evaluation of the preoperative combined bleomycin (BLM) and radiation therapy for esophageal carcinoma was undertaken. Of 206 patients with esophageal carcinomas resected and histologically examined, 109 were treated with BLM and radiation (BR group) and compared with the other groups consisting of group R which was treated with radiation alone, group B with BLM alone, and group N with no preoperative treatment.

The combined BLM and radiation therapy in comparison particularly with simple radiation therapy was considered to have better histological effectiveness on carcinoma cells, particularly in remote lymph nodes, and better prognostic results represented by the 5‐year survival rates: 32.2% for the group treated with the former therapy and 16.3% for the group with the latter (average, 26.2%). The ideal total dosage of BLM may be 75 mg (intramuscular, 7.5 mg × 10 days) and that of radiation 3,000 rads (200 rads × 15 days), both in 3 weeks, and the operation may be performed 1 or 2 weeks after completion of this treatment. BLM may be replaced by other chemotherapeutic agents that are believed effective in squamous cell carcinomaf.
The incidence of gastric stump cancer
Authors: Clark Charles G. , Ward Michael W. N. , McDonald Alexander M. , Tovey Frank I.
Published: May 2005

A prospective study, consisting of annual interview, has been carried out on 225 patients who had a partial gastrectomy between 1955 and 1960, a follow‐up of between 22 and 27 years. Seventy‐seven patients have died during followup, with an accurate cause of death known in 71. One patient died of gastric stump cancer 17 years after a Polya gastrectomy for duodenal ulcer, representing the only stomach cancer in this series. This is an incidence of 0.44% as compared to an incidence of 0.1% for the general population of similar age.

We have reviewed the literature with regard to the incidence of gastric stump cancer. This review and our own data suggest that the incidence is sufficiently low to make annual endoscopy of asymptomatic post‐gastrectomy patients unjustified. This conclusion may well need qualification if it becomes possible to define premalignant changes in gastric mucosa from endoscopic biopsy, so that a high‐risk subpopulation can be identified.
Pancreatic endocrine function in patients with intrathoracic replacement after esophagectomy
Authors: Sudo Takaaki , Shiraha Sei , Ishiyama Kenji , Takemoto Masahiko , Kawamura Masao , Umemura Hiroya , Kuyama Takeshi
Published: May 2005

The majority of patients with esophageal carcinoma are elderly and have disturbances of carbohydrate metabolism to a greater or lesser extent. Surgery for esophageal carcinoma and change in the route of the digestive tract by reconstructive surgery are considered to have an effect on carbohydrate metabolism, especially on insulin and glucagon secretion.

Since the opening of Kinki University School of Medicine in 1976, the present authors have performed reconstructive surgery by the retrosternal route after total esophagectomy from the chest. In the present study, we carried out oral glucose (50 g) tolerance tests (O‐GTT) before and 1 month after esophageal reconstruction, gave intravenous glucose (0.5 g/kg) tolerance tests in controls and 1 month after esophageal surgery, and examined the influence of esophageal reconstruction on carbohydrate metabolism by determining blood sugar, insulin, and glucagon levels.

Consequently, the insulin response to O‐GTT was attenuated in the group of patients with esophageal carcinoma as compared with the control group. However, after esophageal operation, it was enhanced in the early phase and was weakened in the late phase. The glucagon secretion was significantly increased in the patients after esophagectomy. This suggested that hyperglucagonemia relates to disorders of carbohydrate metabolism after surgical treatment of esophageal carcinoma.

The insulin response to intravenous glucose suggests an impairment in the first phase of insulin secretion in the surgically treated group, demonstrating a role for the vagus in insulin secretion.
Treatment of retained common bile duct stones: A prospective controlled study comparing monooctanoin and heparin
Authors: Velasco Nicolás , Braghetto Italo , Csendes Attila
Published: May 2005

A prospective controlled trial comparing the efficacy of heparin and monooctanoin as solvents of retained common bile duct stones through the T‐tube is presented. The results were compared to those obtained by the saline washout technique which was used as a retrospective comparison group. After treatment, 33% and 65% of the patients treated with heparinized saline solution and monooctanoin, respectively, showed absence of stones on cholangiograms (p<0.01). In patients submitted to the washout technique, 20% of 54 patients who completed the treatment showed disappearance of stones. Side effects during infusion were more serious in the monooctanoin group and 1 patient developed sepsis in this group. The results of the present study strongly suggest that monooctanoin may be a reasonable alternative treatment for those patients who show residual common bile duct stones after surgery.
Radiological anatomy of the biliary tract: Variations and congenital abnormalities
Authors: Puente Sergio G. , Bannura Guillermo C.
Published: May 2005

A series of 3,845 operative cholangiograms performed at Hospital Paula Jaraquemada are analyzed. Normal cholangiograms were found in 57.6% of the cases. Anatomical variations were demonstrated in 24% and congenital abnormalities of the biliary tree in 18.4%.

The anatomic variations and congenital abnormalities are described and discussed. The importance of operative cholangiography and the valuable aid it provides the surgeon are emphasized.
Diagnosis of traumatic diaphragmatic hernia: Analysis of 63 cases
Authors: Christophi C.
Published: May 2005

Sixty‐three cases of traumatic diaphragmatic hernia due to blunt abdominal trauma are reviewed. Diagnosis based on clinical suspicion and plain chest x‐ray was achieved in only 39 cases (62%); 14 cases (22%) were diagnosed at laparotomy; and 4 cases (6%) were diagnosed at postmortem. Six cases (9%) were not initially diagnosed and re‐presented at varying intervals with symptoms of intermittent intestinal obstruction. Overall mortality rate was 14%. Possible methods of diagnosis are suggested.
Cancer of the male breast
Authors: Axelsson Jan , Andersson Åke
Published: May 2005

Thirty‐nine cases of male breast cancer were reported to the Swedish Cancer Registry in 1962–1963, and sufficient information was gained from 34 of them for inclusion in this study. Male breast cancer constitutes 0.7% of the total number of breast cancers. The average age at time of diagnosis was 65 years. Many of the patients had complicating diseases. The patient's delay in seeking medical attention was an average of 7.9 months. Fifty‐nine percent of the tumors were situated in the left breast. Four patients (12%) had gynecomastia. Fifteen percent of the cancers were clinical stage I, 38% stage II, 35% stage III, and 12% stage IV at the time of diagnosis. Twenty‐one percent had histologically proven nodal metastases. Twenty‐seven patients underwent a more or less radical operation. Most patients received radiotherapy after operative treatment. The overall corrected 5‐year survival is 54% and 10‐year survival 37%. A review of the literature is given.
Fournier's gangrene: A general surgery problem
Authors: Diettrich Nancy A. , Mason James H.
Published: May 2005

Fournier's gangrene is a specific form of synergistic gangrene involving the scrotum and perineum. The disease may follow a variety of clinical conditions or occur without an apparent precipitating cause. It is associated with severe systemic toxicity and a significant mortality rate, and it demands prompt recognition and urgent, aggressive surgical intervention. Its treatment calls on the full armamentarium of the general surgeon. Preoperative resuscitation is often required. Operative debridement can be extensive, involving the buttocks and on occasion the upper thighs and abdominal wall. Postoperative management consists of wound care with eventual grafting or flap rotations. Colostomy may be required. Three cases illustrating the salient features of this disease are presented, together with a review of the literature.
A simple method to prevent celestin tube regurgitation
Authors: Pimenta Amadeu P. A. , Cardoso Valdemar M. B. , Rodrigues Joaquim S. , Ramos Isabel
Published: May 2005

The incidence of esophageal carcinoma, the high mortality and morbidity rates, and the socioeconomic implications associated with the disease have stimulated a great deal of interest and controversy regarding the relative roles of surgical and palliative therapy. Intubation of the esophagus as a palliative for carcinoma is well established and is often useful in relieving symptoms of dysphagia. A simple technique is described which prevents regurgitation of the Celestin tube by use of a rubber “mushroom.” A case is presented in which this technique proved satisfactory in avoiding gastric laceration by the tube.
A fourteenth‐century description of rectal cancer
Authors: Swain C. P.
Published: May 2005

In 1376 John Arderne, an English surgeon with a special interest in proctology (Fig. 1), wrote this perceptive description of rectal cancer [1]. The stress that he places on the diagnostic value of digital examination, the clarity with which he differentiates the presentation of rectal cancer from that of inflammatory bowel disease, his simple and sensible recommendations for its palliation, his astute observations on its natural history, and the unequivocal recognition of its prognosis give his account the high quality of a classic description of disease.
Tissue oximetry: An interim report
Authors: Hunt Thomas K. , Rabkin John , Jensen J. Arthur , Jonsson Kent , von Smitten Karl , Goodson William H.
Published: May 2005

Tissue oximetry, already a practical reality in some centers, holds considerable promise for clinical use. It has the capacity to monitor the oxygen delivery system and estimate perfusion of tissues; and we suspect it can add considerably to prevention of surgical complications and treatment of surgical infections. Present instruments are relatively difficult to use, but their potential is not being utilized largely because of misconceptions about the transport of oxygen in tissue and the significance of peripheral perfusion. Oximetry measures perfusion, whereas currently popular indices such as urine output are indirect indicators and are often misleading.

The basic concepts of tissue oxygenation, the relevance of partial pressure of oxygen in tissue, the connection with perfusion, various technologies for measuring tissue oxygenation, and the currently available methods are discussed.
A new approach to physiology, monitoring, and therapy of shock states
Authors: Shoemaker William C.
Published: May 2005

Descriptions of the sequence of hemodynamic and oxygen transport patterns in the various types of shock syndromes have shown reduced oxygen consumption (VO2) as the earliest pathophysiologic event that precedes the initial hypotensive crisis. Inadequate VO2 may be produced by low flow, as in hemorrhagic and cardiogenic shock, by increased metabolic need, as in traumatic and septic shock, and/or by maldistribution of flow in all types of shock. These physiologic patterns are also related to the degree of the shock state and its outcome; the patterns of the survivors and nonsurvivors can be predicted from these patterns with a high degree of sensitivity and specificity by multivariate analysis.

Therapy directed toward optimizing the VO2 and its compensations to the range of survivors of life‐threatening shock was shown to improve outcome in prospective clinical trials. A branched chain decision tree was developed for fluid resuscitation of critically ill postoperative patients. The algorithm was developed from decision rules based on objective physiologic heuristic data from survivors as the criteria.

The improved mortality in prospective studies supports the hypothesis that compensatory responses of the survivors are major determinants of outcome. Therefore, therapy that supports these compensations and produces the survivor pattern will improve survival rates. These prospective studies confirm the validity of an organized, coherent physiologic approach in contrast to the traditional approach, the objectives of which are to restore hemodynamic and biochemical abnormalities to normal if and when they are discovered.

The use of a branched chain decision tree helps to achieve these therapeutic goals expeditiously by providing a coherent, organized patient management plan. It is not necessary to wait for patients to develop cardiorespiratory deficits before initiating therapy. Therapy should be started to optimize the important variables as soon as possible after the onset of accidental trauma or before, during, and immediately after surgery in the high‐risk patient.
Right ventricular function in the surgical patient
Authors: Raper R. , Sibbald W. J.
Published: May 2005

It has long been appreciated that the cardiovascular system plays a vital role in surgical illnesses. Although attention has, historically, been largely focused on the left ventricle, it has become apparent in recent years that the right ventricle may contribute significantly to an absolute or relative failure of cardiovascular adaptation to acute and chronic disease states. Many of the physiological principles governing left ventricular function also determine right ventricular function. Thus, the right ventricle is affected by changes in afterload, preload, and contractility. Since many surgically relevant disease states may potentially alter such determinants of right ventricular function, some consideration of right ventricular function and its effect on global cardiac function in the surgical patient is warranted. In this review, we have attempted to provide a brief overview of normal right ventricular physiology as well as the pathophysiology and therapy of right ventricular dysfunction that may be seen in the surgical patient.
Current concepts in the management of the adult respiratory distress syndrome
Authors: Weigelt John A.
Published: May 2005

The adult respiratory distress syndrome is the most severe pulmonary complication that can follow multiple trauma and critical illness. It is caused by an insult to the pulmonary circulation which results in an increased capillary permeability and subsequent interstitial edema. An increased venoarterial shunt occurs resulting in arterial hypoxemia. The mortality rate is at least 50% if treatment is not begun before profound hypoxemia occurs. Recognition of abnormal cardiopulmonary function before overt hypoxemia develops is important. This is best accomplished by attentive monitoring of arterial blood gases. Sequential arterial oxygen tensions obtained on 40% and 100% inspired oxygen concentration are the best guides to selecting patients who have a high probability of pulmonary deterioration. Aggressive cardiovascular monitoring and early treatment with low levels of positive‐end expiratory pressure offer this group of patients an improved change of survival.
High‐frequency ventilation
Authors: Enderson Blaine L. , Rice Charles L.
Published: May 2005

High‐frequency ventilators (HFV) use increased respiratory rates and decreased tidal volumes to achieve gas exchange similar to conventional mechanical ventilators (CMV). This reverses the relative importance of convection and diffusion to gas exchange. There are currently 3 major types of HFV. They differ from each other in how gas is delivered, how they work, and what physiological effects they have. Conclusions drawn using one type of HFV cannot necessarily be applied to the others. This review examines the different types of HFV as well as the studies that have been conducted using HFV. It stresses the role that HFV may play in the surgical intensive care unit. The one certain indication presently for HFV is in patients with a bronchopleural fistula. It may also be useful as an adjunct to endoscopy and in adult respiratory distress syndrome (ARDS). If the underlying lung disease cannot be reversed (i.e., end‐stage fibrotic ARDS), HFV has little to offer.
Physiology and metabolism in closed head injury
Authors: Deutschman Clifford Scott
Published: May 2005

Studies on metabolism in head injury have indicated the presence of some degree of elevation in metabolic rate associated with extensive nitrogen wasting. Cardiodynamics are consistent with an adaptive increase in substrate delivery in an effort to meet the increased tissue demands. Most studies suffer from lack of longitudinal data and an inability to separate the effects of the injury from the effects imposed by some frequently utilized treatment modalities. In this article, the existing literature on metabolism and cardiodynamics is reviewed and contrasted with the findings of a study intended to focus on changes over time as well as to eliminate as many of the contaminating modalities as possible.
Nutritional support in the management of critically ill patients in surgical intensive care
Authors: Streat Stephen J. , Hill Graham L.
Published: May 2005

Nutritional support is given to many patients in surgical intensive care after major trauma and serious sepsis but rarely after major elective surgery. We have quantified the changes in body composition that occur in these patients and have found that serious losses of body protein still occur after trauma and sepsis despite nutritional support. Correct nutritional management of critically ill patients in surgical intensive care depends on an understanding of the underlying physiology, drainage of sepsis, a high standard of general intensive care measures, and appreciation of sound principles of administration of intravenous nutrition.
Adequacy and support of physiological functions in the acutely ill cirrhotic patient
Authors: Giovannini Ivo , Boldrini Giuseppe , Chiarla Carlo , Castagneto Marco , Sganga Gabriele , Tramutola Giuseppe , Caracciolo Francesco , Castiglioni Giancarlo
Published: May 2005

The cirrhotic condition is characterized by a series of changes in physiological functions and of subclinical alterations that imply an abnormal and fragile adaptive pattern with reduced resistance to superimposed distress. In the care of the critically ill cirrhotic patient, the supportive measures aimed at maintaining physiological stability through the control of such debilitating factors have a key role and are not secondary in importance to the more obvious measures needed to treat clinically evident and specific alterations or complications. The relationship between hepatic malfunction and the development of these physiological abnormalities is not fully understood. Our knowledge of the problem, however, has been recently improved and the need for supportive measures motivated by a series of notions on cardiorespiratory and metabolic abnormalities and interactions in hepatic decompensation.
Pharmacokinetics and pharmacodynamics in critically ill patients
Authors: Mann Henry J. , Fuhs David W. , Cerra Frank B.
Published: May 2005

The rapidly changing physiology of critically ill patients causes variations in the absorption, distribution, metabolism, excretion, and pharmacodynamic effect of drugs used to treat these patients. Alterations in fluid status, cardiac, renal and hepatic function, and circulating serum proteins necessitate increased attention to drug selection and dosage modification. Cardiac failure results in decreased absorption, metabolism, and excretion of drugs while renal failure results in parent drug and metabolite accumulation, increases in unbound drug, and changes in distribution volume. The changes in hepatic blood flow and protein binding, and decreases in hepatocellular mass and enzyme function that occur in hepatic failure may alter the clearance of several drugs. Serum drug concentrations are helpful in defining the pharmacokinetics and ultimately the pharmacodynamic effect of the drugs used in critically ill patients. The serum drug concentrations must be interpreted in association with their pharmacodynamic effect and the clinical situation. Adjusting drug therapy based on pharmacokinetic principles is discussed in detail with specific suggestions for dosage modifications in renal and hepatic failure.
Reintervention in abdominal surgery
Authors: Krause Rudolph
Published: May 2005

The literature on reinterventional abdominal surgery is confusing. The incidence and mortality rates are greatly affected by the type of surgery reported. There is also a difference between recent and older studies with regard to definitions and indications for relaparotomy, rendering comparison of these studies rather useless.

Reinterventional laparotomy is reported to occur in 0.5–15% of all laparotomies. The highest incidence is seen in gastrointestinal surgery and the lowest in vascular surgery. The indications are infection and disruption of anastomoses, wound dehiscence, hemorrhage, obstruction, ischemia and necrosis, multiple system failure, and miscellaneous indications. The overall mortality rate after reinterventional laparotomy is over 40%, ranging from 24 to 71%. Factors that appear to correlate with mortality are age over 50, peritonitis at initial procedure, and multiple system failure. Criteria leading to relaparotomy are usually clinical (tenderness, fever, and absence of bowel sounds) and, to a minor extent, depend on radiological procedures of which computed tomographic scanning has the highest accuracy (97%).

Multiple system failure carries the highest mortality rate (80% if treated, 100% if untreated) and presents the greatest number of negative laparotomies. Arguments for accepting this criterion are discussed. Mortality rates apparently will not be lowered limiting technical failures. A better yield could be gained by improving perioperative management and inducing a shift toward second‐look or elective procedures within a fully developed protocol.
Immunotherapeutic advances in the treatment of gram‐negative bacterial sepsis
Authors: Dunn David L.
Published: May 2005

Gram‐negative bacterial sepsis with the frequent sequelae of shock, multi‐system organ failure, and death represents one of the most severe infections that can occur in the surgical patient. Fatality in most series has paralleled the presence and severity of underlying host disease processes, polymicrobial bacteremia, shock, and lack of early appropriate antimicrobial therapy. Even patients with no underlying disease state have a significant mortality (10–20%). Therapy of gram‐negative bacterial sepsis and shock at present consists of antimicrobial agents, hemodynamic monitoring, aggressive fluid resuscitation, and metabolic support. The use of these treatment modalities in concert has reduced, but not eliminated, the severe consequences that may ensue. Administration of antibody directed against the comon core lipopolysaccharide antigen of gramnegative microorganisms to patients with gram‐negative sepsis represents a means by which the morbidity and mortality of this disease process may be further reduced. This is supported by a large body of experimental evidence, as well as several preliminary clinical studies. It is necessary to determine how the clinical efficacy of such antibody preparations can be maximized. This will entail rigorously controlled studies in which the timing of antibody administration and dose utilized can be correlated with clinical efficacy. Should such antibody preparations continue to prove efficacious as an additive form of therapy, it may be possible to identify high‐risk groups of patients who would benefit from antibody prophylaxis.
Cost‐effective use of the surgical intensive care unit
Authors: Eyer Steven D. , Cerra Frank B.
Published: May 2005

The intensive care unit (ICU) continues to be a large user of resources. There is a continued need for a balance of cost‐effective utilization and quality patient care. A data base of information currently exists that defines those groups of patients in whom reasonable success in resource allocation can be anticipated. In other cases, attempts are being made to define variables that adequately predict survival so they can be used to effect care decisions. Although some progress has been made, considerable work is needed to achieve both of these.

For surgeons, the ICU has become an essential “part of the knife.” It is a necessity in modern high‐technology care and has become an essential element in surgical training programs. The use of the ICU for currently conceived high‐risk patients is now commonplace. A growing database supports this preoperative use of ICU resources. Techniques are now available to make ICU care more cost‐effective. Tools such as not having routine orders, daily rewriting of all orders, review of drug orders, and the utilization of the laboratory and radiographic resources have already reduced significantly the real cost of using these life‐saving facilities.
Prognostic index: prediction of operative mortality in geriatric patients by use of stepwise logistic regression analysis
Authors: Reiss R. , Haddad M. , Deutsch A. , Lilos P. , Fuchs C.
Published: May 2005

The decision‐making process with regard to surgery in geriatric patients is of great importance, requiring consideration of ethical, medicolegal, and economic factors in addition to the purely medical ones. An important component in the decision‐making process is the precise knowledge of the expected mortality. Clearly, such knowledge helps the surgeon as well as the patient and family to make the final decision whether to operate.

Twelve hundred major laparotomies in elderly patients were used as a data base. Thirty‐six preoperative variants were noted for each patient as well as the occurrence of postoperative mortality or morbidity. All data were loaded into a 6,000 CDC computer and subjected to Multifactorial Stepwise Logistic Regression Analysis (MSLRA). The method allowed a choice of the 5 most significant factors in the prediction of mortality, as well as calculation of a numerical coefficient for every factor. A formula (MIX Formula) was devised to calculate the mortality in percentile terms using the factor coefficient. The results of this study show that the use of statistical multifactorial analysis permits an accurate preoperative prediction of postoperative mortality in geriatric candidates for major abdominal surgery. The accuracy of the prediction was confirmed by both retrospective and prospective analysis.
Serum gastrin, calcitonin, and prolactin as markers of multiple endocrine neoplasia syndromes in patients with primary hyperparathyroidism
Authors: Farndon John R. , Geraghty John M. , Dilley William G. , Handwerger Stuart , Leight George S.
Published: May 2005

Since primary hyperparathyroidism (PHPT) is a component of the multiple endocrine neoplasia syndromes types I and II (MEN I and MEN II), patients presenting with PHPT might represent a population at increased risk for either of the 2 syndromes. To test this hypothesis, serum gastrin, prolactin, and calcitonin concentrations were measured pre‐ and postoperatively in 100 consecutive patients undergoing surgery for PHPT. Mean preoperative serum gastrin concentrations were within the normal range and did not decrease postoperatively, and there was no correlation between serum gastrin and calcium preoperatively. A high proportion of females (16%) had abnormally high serum gastrin concentrations but no evidence of MEN I. Six females had abnormal secretin stimulation of gastrin release but had achlorhydria or hypochlorhydria with other features suggestive of type A atrophic gastritis. No abnormal calcitonin concentrations were detected. Two elderly females had insignificant elevations of serum prolactin concentrations. These results suggest that serum gastrin, prolactin, and calcitonin are needless determinations in patients who are undergoing surgery for PHPT and who have no clinical indication of MEN syndromes. The interpretation of secretin‐stimulated gastrin concentrations in the diagnosis of a gastrinoma may need to be reevaluated. It would appear that a high proportion of females with PHPT have atrophic gastritis and secondary hypergastrinemia.
Acute volvulus of the sigmoid colon
Authors: Welch G. H. , Anderson J. R.
Published: May 2005

Fifty patients presenting with acute volvulus of the sigmoid colon have been analyzed. The diagnosis was made in 39 patients from the presenting features and abdominal radiographs. Deflation by sigmoidoscopy and flatus tube was performed in 19 patients with initial success in 15. Recurrent volvulus occurred in 6 of these patients. Laparotomy was carried out in 36 patients and colonie gangrene was present in 6 patients. The operative mortality rate was 42%. Mortality was related to a combination of age, intercurrent medical illness, and sepsis. Simple operative reduction was associated with a lower mortality when compared to resection but had a higher incidence of recurrent volvulus. This study supports the use of sigmoidoscopic reduction as the primary treatment of acute sigmoid volvulus. Laparotomy and colonic resection should be reserved for those patients who are medically fit and should ideally be performed on an elective basis after preliminary decompression. In unfit patients in whom sigmoidoscopic reduction fails, detorsion and colopexy is advocated.
Surgery of thyroid cancer
Authors: Cady Blake
Published: May 2005

Occult and microscopic differentiated carcinoma of the thyroid is a clinically benign lesion, even when accompanied by lymph node metastases, and should be treated surgically by conservative procedures. Clinically detectable thyroid carcinomas may be of low‐risk types in younger patients or high‐risk types in older patients. Age is the primary determinant of risk. Low‐risk patients should be treated conservatively since the risk of death is currently no higher than 1.5%. High‐risk patients should be treated more aggressively since recurrence rates may be high and risk of death from disease may reach 15% to 20%. In all patients, total thyroidectomy should be avoided since it does not improve local control rates or cure rates and exposes the patient to considerable risk of iatrogenic hypoparathyroidism and recurrent nerve injury. This recommendation is particularly true for occult and microscopic disease as well as for low‐risk disease, because risk of death from disease is so low.
Medullary carcinoma of the thyroid
Authors: Lynn John , Gamvros Orestis I. , Taylor Selwyn
Published: May 2005

Medullary carcinoma of the thyroid (MCT) is a rare tumor which, since its identification by Hazard et al. [2] in 1959, has attracted interest for 2 reasons. First, the secretion of the tumor marker, thyrocalcitonin, provides a means of making the diagnosis of MCT before the tumor is clinically evident. Second, MCT may be associated with pheochromocytoma and parathyroid hyperplasia as the autosomal dominant familial syndrome of multiple endocrine neoplasia, type II (MEN II). MCT may occur sporadically. When MCT is encountered in the familial form the natural history varies from family to family and also in individuals within a specific kindred. This variation creates difficulties in management and in reaching the decision for an aggressive approach to surgical treatment.
Primary lymphoma of the thyroid: A review of the mayo clinic experience through 1978
Authors: Devine Richard M. , Edis Anthony J. , Banks Peter M.
Published: May 2005

At the Mayo Clinic, 103 patients with primary malignant lymphoma of the thyroid have been diagnosed and treated through 1978. This study examines the clinical findings in the 57 new cases seen since the last review in 1966; pathology and survival are evaluated for the series as a whole, including the 46 patients reported previously. Age and sex patterns were unchanged since the earlier review; thyroid lymphoma tended to occur in middle‐ to older‐aged women, and patients typically presented with a fairly rapidly enlarging, painless, and firm thyroid mass. The most common histologic subtype of lymphoma encountered was diffuse large cell (diffuse histiocytic). Hashimoto's disease was found in 36% of the pathologic specimens available for review. Follow‐up was completed for all patients up to 1979. Age, sex, and histologic subtype of tumor did not appear to be significant determinants of prognosis. Patients in whom the lymphoma was confined to the thyroid (intrathyroidal type) had a better overall 5‐year survival rate (86%) than those in whom tumor invaded soft tissues surrounding the hyroid or involved regional cervical nodes (38% for the extrathyroidal type). Almost all of the patients who had intrathyroidal tumors underwent surgical resection before irradiation. However, 3 of the 5 patients in this group who were treated by radiotherapy alone survived more than 5 years. There were approximately equal numbers of patients with the extrathyroidal type of lymphoma who were treated either by radiotherapy combined with surgical resection or by radiotherapy alone. The one form of therapy was just as effective as the other.
Methods of investigation in the diagnosis and management of thyroid carcinoma
Authors: Maisey M. N.
Published: May 2005

Preoperative investigation of thyroid nodules is discussed with emphasis on the use of radionuclide scanning, ultrasound examination, and x‐ray fluorescence to decrease the need for unnecessary surgical excision. A follow‐up program is described involving the use of131I imaging techniques and serial thyroglobulin measurements in patients postoperatively for evaluation of response to treatment and detection of recurrence.
Aspiration biopsy cytology in diagnosis of thyroid cancer
Authors: Löwhagen Torsten , Willems Jan‐Silvester , Lundell Göran , Sundblad Rolf , Granberg Per‐Ola
Published: May 2005

Aspiration biopsy cytology (ABC) is a diagnostic method that has been used extensively in Sweden for a quarter of a century. The technical steps involved in this biopsy procedure are described, and the differences from large needle biopsy techniques are pointed out. An overview is given of the different pathologic conditions that present as thyroid nodules and are recognizable by ABC. The accuracy of the method as a preoperative diagnostic tool has been shown to be superior to other clinical methods. ABC enables the surgeon not only to better select patients with thyroid nodules for surgery, but also to plan a definite operative strategy in papillary, medullary, and anaplastic neoplasms. In follicular neoplasms, however, the method cannot distinguish with certainty between adenoma and carcinoma. ABC has drastically reduced the number of diagnostic surgical operations for benign lesions. It requires no anesthesia. It has no complications and there is good patient acceptance, even in children.
External radiotherapy and radioiodine in the treatment of thyroid cancer
Authors: Tubiana Maurice
Published: May 2005

Surgery remains the most effective treatment for thyroid cancer. The indications for radiotherapy and radioiodine treatment should take into account the nature and extent of the surgical excision. There is not yet convincing evidence of the effectiveness of prophylactic postoperative radiotherapy. For patients under 45 years of age, the results obtained by complete surgical excision are excellent, and the degree of improvement that may be obtained from radiotherapy is not sufficient to justify the sequelae associated with beam therapy and the long‐term hazards induced by radioiodine. On the other hand, for patients over 45 years of age and, in particular, when the cancer is of the moderately differentiated follicular type, the prognosis is clearly much less favorable and there is an indication for additional treatment. Furthermore thyroid ablation by radioiodine facilitates the early detection of local recurrence or metastases by whole body scintiscans or serum thyroglobulin immunoassay. After grossly incomplete surgery, the efficacy of high dose (over 5000 rads) beam therapy has been demonstrated by a low incidence of local recurrence. Combination of external radiation therapy and radioiodine is indicated and well tolerated. For inoperable tumors the results of radiotherapy are limited; although complete remissions are sometimes obtained the incidence of local recurrence is high. However, the palliative effect of radiotherapy should not be overlooked. Patients with lung metastases that take up radioiodine have a high survival rate; about 50% of them survive for 15 years after the first administration of radioiodine. Cure is probably achieved in a large proportion of these patients. The survival of patients without significant radioiodine uptake after thyroid ablation is much shorter. The results obtained in treatment of bone metastases are less satisfactory. Combination of radioiodine and external therapy is advocated. External radiotherapy is effective in medullary carcinoma despite the slow shrinkage of the tumor after irradiation. Calcitonin assay can help to select those patients who need postoperative irradiation. In undifferentiated carcinoma, radiotherapy is recommended even after complete surgical excision although the results are generally poor.
Results of operative treatment of 615 patients with primary hyperparathyroidism
Authors: Bruining Hajo A. , van Houten Herman , Juttmann Jacob R. , Lamberts Steven W. J. , Birkenhäger Jan C.
Published: May 2005

This is a report of 615 patients who were operated on for primary hyperparathyroidism during the 20 years from 1950 to 1979. There were twice as many females in the series as males, mainly because of a sharp rise in the incidence in females over the age of 45 years. Identification of all parathyroid glands and confirmation by frozen section was always attempted. Only macroscopically enlarged glands were removed, regardless of histologic findings. Enlargement of 1 gland was found in 433 patients, of 2 glands in 106, and of 3 glands in 43. In 33 patients all glands were enlarged. Bilateral exploration of the neck is mandatory in order to prevent persistent hyperparathyroidism. An abnormal location of parathyroid glands was found in 263 patients; location within the thymus was the most frequent. Most ectopically located parathyroids can be removed through the neck. Sternotomy gave disappointing results; in only 3 of 9 patients was an enlarged parathyroid found. Persistent hyperparathyroidism necessitating reoperation occurred in 25 patients. The results of reoperation were not as favorable as those of primary operations and gave rise to more complications, especially inadvertent removal of all parathyroid tissue. The mean follow‐up time was 5.6 years. During this period no patient developed true recurrent hyperparathyroidism arising in a previously identified normal appearing gland. Therefore, we advise removal of only those glands that are macroscopically enlarged.
The localization of parathyroid tissue by ultrasound scanning prior to surgery in patients with hyperparathyroidism
Authors: Barraclough Bruce H. , Reeve Thomas S. , Duffy Peter J. , Picker Richard H.
Published: May 2005

Ultrasonic localization of parathyroid tissue has been attempted in 24 patients with hyperparathyroidism prior to surgical exploration of the neck. All 24 patients had biochemically proven hyperparathyroidism. Standard contact diagnostic ultrasound equipment fitted with a 5 MHz transducer was used, and transverse and longitudinal scans of the region of the thyroid gland were performed at 5 mm intervals. The normal anatomical structures identified were the lobes of the thyroid gland, trachea, common carotid arteries, and jugular veins. The longus colli muscle on each side was used as a major landmark. These structures define the site where most parathyroid glands are found in the neck. In 18 of the 24 patients the suspected parathyroid tumor was visualized preoperatively and confirmed at operation. The abnormal glands ranged in size from 5 to 12 mm in transverse diameter. In 3 patients false‐positive diagnoses were made by ultrasound; at operation the abnormalities proved to be thyroid nodules protruding from the posterior surface of the thyroid gland. Ultrasonography is of little value in the presence of multinodular goiter. Three adenomas and 3 hyperplastic parathyroid glands greater than 5 mm in diameter were not identified. Localization of enlarged parathyroid glands by echography may be difficult when normal anatomical landmarks are altered by the presence of multinodular goiter or because of previous surgery. The sensitivity of this technique for identifying in the neck parathyroid glands larger than 5 mm in diameter was found to be 79.3% with 11.5% false‐positive and 8.6% falsenegative results.