bluuebunny/crossref_metadata_2025 huggingface dataset:
Localization and surgical resection of metastatic parathyroid carcinoma
Authors: Fujimoto Yoshihide , Obara Takao , Ito Yukio , Kodama Takaya , Nobori Masakazu , Ebihara Satoshi
Published: May 2005

Six cases of recurrent parathyroid carcinoma were reviewed. Four patients presented with local recurrence, which followed a simple tumor resection more frequently than an en bloc initial operation. The fact that the mode of recurrence varied made preoperative localization difficult. In 3 earlier patients (1978–1980), careful palpation of the neck and venous sampling for parathyroid hormone concentrations were the means of localization. In 4 recent patients (1980–1985), including 1 of the former 3, thallium‐201 scan was the most useful method for detecting the local recurrence and the regional lymph node metastases, but the method failed to localize the lung metastases. Chest x‐rays and computed tomographic (CT) scan were useful in delineating metastatic pulmonary lesions. Wide excision of the local recurrent tumor, once or twice, was curative in 3 of the 4 patients. En bloc radical dissection of the neck and mediastinum in 1 patient resulted in normocalcemia for the past 2 years. Thoracotomies carried out in 2 patients with multiple pulmonary metastases were palliative in 1 case for 5 years and curative at least at the present time (3 months after the operation) in the other case. Thus, the results in our series justify aggressive surgical treatment for the recurrence of parathyroid carcinoma.
Serum thyroglobulin concentration in nontoxic goiter and response to surgery with special reference to risk of goiter relapse
Authors: Feldt‐Rasmussen Ulla , Blichert‐Toft Mogens , Date John , Haas Vagn
Published: May 2005

A consecutive series of 45 thyroglobulin antibody‐negative patients were operated on for nontoxic goiter and subsequently followed systematically for 3 years. Preoperative mean log serum thyroglobulin was elevated with a significantly positive correlation to the size of removed goiter tissue. No thyroid replacement was given postsurgically. Following operation, the thyroglobulin level decreased significantly reaching a minimum at 1 year. Thereafter, there was a continuous rise. Free thyroxine index and serum thyrotropin showed changes corresponding to transient hypothyroidism 1 month after surgery, being gradually normalized within 1 year. At 3 years, a thyrotropinreleasing hormone (TRH) test showed the highest thyroidstimulating hormone (TSH) response in patients with elevated baseline thyroglobulin. Clinical investigation at 3 years, however, revealed no goiter relapse. Therefore, the predictive value of thyroglobulin with reference to recurrence of goiter could not be established as yet. The hypothetical assumption that patients who postoperatively present an elevated serum thyroglobulin level are more likely to develop recurrence compared to those with low thyroglobulin levels is discussed and will be tested further by a prolonged follow‐up period.
Prospective comparison of radionuclide, computed tomographic, and sonographic localization of parathyroid tumors
Authors: Krubsack Arnold J. , Wilson Stuart D. , Lawson T. L. , David Collier B. , Hellman Robert S. , Isitman Ali T.
Published: May 2005

Controversy exists concerning the advantages and appropriateness of current imaging modalities of the localization of parathyroid tumors. We conducted a prospective, blinded study to compare the efficacy of 3 different imaging modalities in 40 patients with primary hyperparathyroidism (HPT). Patients with HPT were examined preoperatively by computer‐assisted thallium‐201/technetium‐99m scintigraphy (TTS), high‐resolution (GE 9800) computed tomography (CT), and high‐resolution (7.5 MHz) real‐time sonography (US). Each study was performed and interpreted independently. These patients then had a neck exploration and parathyroidectomy which allowed for clinical correlation of pathologic findings with the imaging results. Overall sensitivities of the 3 imaging modalities were TTS‐72%, CT‐72%, and US‐57%, with specificities of TTS‐93%, CT‐92%, and US‐96%. For lesions located below the thyroid (thymic tongue and mediastinum), sensitivities were TTS‐86%, CT‐29%, and US‐20%, all with specificities of 100%. In those HPT patients presenting with prior failed neck explorations, parathyroid tumors were detected with sensitivities of TTS‐88%, CT‐57%, and US‐67%, with specificities of 100%, 71%, and 100%, respectively. TTS with subsequent CT appears to be an optimal imaging strategy for HPT patients with prior failed neck explorations or suspected lesions below the thyroid. Since surgeons experienced in parathyroid surgery have a cure rate of 93% or greater in HPT patients without prior neck exploration, these imaging modalities may not be cost‐effective and thus not indicated for these patients.
Diazoxide in the management of patients with insulinoma
Authors: Goode Peter N. , Farndon John R. , Anderson John , Johnston Ivan D. A. , Morte Javier Abascal
Published: May 2005

The control of severe hypoglycemic symptoms in patients with insulin‐secreting islet tumors (insulinoma) of the pancreas is an important aspect of management. A series of 24 patients with insulinomas whose ages ranged from 5 months to 73 years seen at one center over a period of 17 years is described. The presenting symptoms and the effect of these on their lifestyles are discussed. Diazoxide has been used to control hypoglycemic symptoms in 18 of the 24 patients. Fourteen patients have received diazoxide for varying periods of time prior to successful surgery and 4 have received long‐term therapy. Three of these patients are highlighted to show various aspects of benefit and problems from the use of diazoxide. The mean dosage of diazoxide was 400 mg/day and the mean duration of therapy was 10 months. The control of symptoms was good in 8, fair in 6, and poor in 4. The main side effects observed were hirsutism (56%), ankle edema (50%), weight gain (38%), and nausea (11%). These side effects were well tolerated and the benefits of therapy were felt to outweigh disadvantages. Side effects only necessitated discontinuation of diazoxide in 1 patient who developed a severe hypersensitivity reaction. Our results show that diazoxide has a role to play in the management of patients with insulinoma during preoperative tumor localization and can also be used when surgery is contraindicated or when laparotomy is unsuccessful.
Plasma gut hormone levels in 37 patients with pheochromocytomas
Authors: Vinik Aaron I. , Shapiro Brahm , Thompson Norman W.
Published: May 2005

Pheochromocytomas are usually recognized by the effects of overproduction of catecholamines, but there are clinical features that cannot be ascribed to catecholamine excess that may be due to vasoactive peptides. We, therefore, measured blood levels of vasoactive intestinal peptides (VIP), substance P, somatostatin (SS), and motilin in 50 instances in 37 patients with pheochromocytomas‐21 malignant, 10 benign intra‐adrenal, and 6 ectopic (5 paracardial and 1 perirenal). Hormone levels were considered raised if the level was more than 3 S.D. above the mean value found in 52 healthy subjects. Of the 37 patients, 20 (54%) had an abnormality in 1 or more gut hormone levels. The most common abnormality was a raised SS in 9/37 (24%). In addition to these, however, 3 (8%) others had raised VIP, 5 (13.5%) raised motilin, and 3 (8%) raised substance P. Patients with benign adrenal adenomas had raised levels of SS and substance P. Ectopic pheochromocytomas produced only SS in addition to catecholamines, but malignant pheochromocytomas could secrete all 4 peptides, and more than 1 in the same patient. We conclude that pheochromocytomas may secrete multiple vasoactive peptides, and they are more likely to do so if malignant. Somatostatin is the most commonly secreted peptide and is found with benign adrenal and ectopic (paracardiac) tumors. If the level of more than 1 peptide is elevated, the likelihood of malignancy is significantly increased.
Evaluation of image‐diagnosing methods of enlarged parathyroid glands in chronic renal failure
Authors: Takagi Hiroshi , Tominaga Yoshihiro , Uchida Kazuharu , Yamada Nobuo , Kawai Machio , Kano Tadayuki , Funahashi Hiroomi , Mizuno Shigeru
Published: May 2005

Three noninvasive image‐diagnosing methods, computed tomography (CT), scintigraphy with201T1C1 and99mTcOh4−, and ultrasonography (US), were preoperatively performed on 50 patients with chronic renal failure and secondary hyperparathyroidism who underwent total parathyroidectomy and parathyroid autograft. The detection rates of the 3 methods on the 191 excised parathyroid glands were compared according to weight and location. CT detected 57.1% of all glands and 78.6% of 103 glands weighing over 500 mg. Scintigraphy detected 51.8% and 75.7%, and US detected 42.4% and 53.4%, respectively. The detection rate of upper glands was best with CT at 58.9% and 89.1%; that of lower glands was best with scintigraphy at 65.3% and 80.4%. Although the combination of the 3 methods diagnosed 69.6% and 89.5%, CT and scintigraphy, the best 2 combinations, visualized 67.5% and 88.3%.
Intraoperative ultrasound and reoperative parathyroid surgery: An initial evaluation
Authors: Norton Jeffrey A. , Shawker Thomas H. , Jones Bonnie L. , Spiegel Allen M. , Marx Stephen J. , Fitzpatrick Lorraine , Aurbach Gerald D. , Doppman John L.
Published: May 2005

We compared intraoperative ultrasound (IOUS) to preoperative high‐resolution real‐time ultrasound in 25 consecutive patients undergoing reoperations for primary hyperparathyroidism. Intraoperative neck scanning was performed after the platysma muscle flaps were raised, and one or both sides of the neck were opened along the medial border of the sternocleidomastoid muscle. Preoperative localization studies were used to determine which side of the neck to explore. Pathologic parathyroid glands appeared sonolucent on both pre‐ and intraoperative ultrasound. Glands were always imaged in 2 planes.

Neither preoperative nor intraoperative scans were able to image normal parathyroid glands. Preoperative scans were correct for abnormal tissue in 9 patients, and intraoperative scans were correct in 19 patients (p=0.01).Size of a pathologic parathyroid gland was not a factor in the ability of IOUS to detect it, but location was. Intrathyroidal and inferior glands were detected reliably, but superior glands were missed (33%). If IOUS imaged the pathologic parathyroid tissue, the length of the surgical procedure was significantly reduced [5.9 hours versus 3.1 hours (p= 0.005)].IOUS did not appear to impact on ultimate outcome as 5 of 6 patients in whom IOUS failed to image the pathologic gland had successful surgery without complication.
Primary hyperaldosteronism caused by adrenocortical carcinoma
Authors: Scott H. William , Sussman Craig R. , Page David L. , Thompson Norman W. , Gross Milton D. , Lloyd Ricardo
Published: May 2005

Since the syndrome of primary hyperaldosteronism was described by Jerome Conn in 1955, over 300 patients with this disorder have been identified in the medical centers of Vanderbilt University and the University of Michigan. The most frequent cause of this endocrinopathy has been a solitary adenoma of the adrenal cortex (72%); bilateral adrenocortical hyperplasia has been the cause of primary hyperaldosteronism in 27% of cases; less frequently, the cause has been multiple and/or bilateral adenomas (1%). During the last 4 years in these 2 medical centers, we have encountered 3 patients who have had biochemically proven primary hyperaldosteronism due to adrenocortical carcinoma. Each of these unusual cases is summarized with review of the recent literature.
Parathyroid surgery in the multiple endocrine neoplasia type I syndrome: Choice of surgical procedure
Authors: Malmaeus Jan , Benson Lars , Johansson Henry , Ljunghall Sverker , Rastad Jonas , Åkerström Göran , Öberg Kjell
Published: May 2005

Thirty‐nine patients with hyperparathyroidism (HPT) in association with the multiple endocrine neoplasia type I (MEN‐I) syndrome underwent parathyroid surgery from 1961 to 1985. Twenty‐one patients underwent resection of 1–21/2 glands, 6 had 3–31/2 glands removed, and 18 (9 of whom had previously been subjected to parathyroid surgery) underwent total parathyroidectomy with autotransplantation to the forearm. Resection of 1–21/2 glands resulted in persistent or recurrent HPT in 18 (88%) of the 21 cases. Two (33%) of the 6 patients who underwent 3–31/2‐gland resection had recurrent disease. After total parathyroidectomy with autotransplantation to the forearm, no patient had persistent or recurrent HPT. Five (26%) of 18 patients had permanent hypocalcemia requiring supplemental therapy. After a change in the operative technique, however, only 1 of 10 was permanently hypocalcemic. It is concluded that primary HPT in the MEN‐I syndrome always should be treated with radical surgery. Total parathyroidectomy with autotransplantation seems more favorable than 3–31/2‐gland resection owing to the absence of recurrent HPT in this material and the limited number of patients with long‐standing postoperative hypocalcemia, provided that an optimal technique for autotransplantation was performed.
A computer‐assisted thyroid follow‐up system
Authors: Davies Peter D. O. , Lazarus John H. , Wheeler Malcolm H.
Published: May 2005

Three hundred and fifty‐five patients treated for hyperthyroidism by subtotal thyroidectomy have been followed for up to 11 years (mean 5 yr) by a computer‐assisted follow‐up register (WAFUR). The system is based on a central hospital clinic with patients being reviewed regularly by their general practitioners over a wide geographic area and blood samples being mailed to the hospital. After allowing for 50 patients who were lost to follow‐up and 48 recalled because of hypothyroidism, 1,379 thyroid function tests were evaluated in the remaining 257 patients. Forty‐three of 132 surgically treated patients and 81 of 125 surgically treated patients on replacement T4 therapy had normal TSH levels throughout the follow‐up period. The other patients all had at least 1 elevated TSH level. In patients not receiving T4 therapy, 47% of tests with a normal serum T4 had elevation of TSH. In patients receiving thyroxine, 46% of tests with normal TSH showed a rise in T4. It is concluded that this computer‐assisted thyroid follow‐up system is reliable and cost‐effective. Further modification is required to identify patients lost to follow‐up, to improve the diagnostic accuracy of the thyroid function tests, and to define the pathophysiological significance of minor abnormalities in T4 and TSH in otherwise euthyroid patients.
Mediastinal parathyroid exploration: A clinical and pathologic study of 47 cases
Authors: Wang Chiu‐an , Gaz Randall D. , Moncure Ashby C.
Published: May 2005

Of the 1,200 patients with hyperparathyroidism surgically treated at the Massachusetts General Hospital (MGH) from 1926 to 1984, there were 47 who underwent mediastinal exploration. Of these, 30 patients (64%) had hyperfunctioning parathyroid glands successfully excised by median sternotomy. Twelve of these underwent their initial neck operation at the MGH, and 18 were referred to us having undergone 1 or more previous unsuccessful neck explorations. There were 17 females and 13 males. The ages of these patients ranged from 17 to 75 years. Twenty‐four patients had nephrolithiasis or nephrocalcinosis; 15, osteitis fibrosa cystica; 14, renal and bone disease; 6, peptic ulcer disease; 2, hypertension; and 1, gouty arthritis. Two patients were asymptomatic with hypercalcemia detected by routine simultaneous multichannel analyzer. The serum calcium level ranged from 11.4 to 18.4 mg/100 ml with a mean of 13.8 mg/100 ml, and phosphorus from 1.4 to 3.3 mg/100 ml with a mean of 2.0 mg/100 ml. Of the 11 patients who had plasma parathyroid hormone determinations, the values ranged from 1 to 11 times normal. In 24 patients, the mediastinal tumor was intrathymic in location and the remaining 6 were parathymic, either adjacent to the great vessels or the pleura. The tumors varied greatly in size, ranging from 0.7 to 5.0 cm in greatest dimension, weighing 0.3 to 18.0 g. Five of these patients had hyperfunctioning supernumerary glands. Pathologic evaluation revealed 26 parathyroid adenomas and 4 primary hyperplastic glands. In 17 patients (36%) mediastinal exploration was unsuccessful. Four of the patients successfully explored developed permanent hypocalcemia. The complications included 1 recurrent laryngeal nerve injury, 1 phrenic nerve injury, 1 pneumothorax, and 1 spontaneously resolving postoperative pleural effusion. There were no deaths or other significant complications. We believe hyperfunctioning mediastinal tumors are rare and mediastinal exploration should be undertaken only when careful selective criteria are met.
Relation between changes in clinical and histopathological features of primary hyperparathyroidism
Authors: Åkerström Göran , Bergström Reinhold , Grimelius Lars , Johansson Henry , Ljunghall Sverker , Lundström Bertil , Palmér Mats , Rastad Jonas , Rudberg Claes
Published: May 2005

A material consisting of 609 patients with primary hyperparathyroidism (HPT) operated on from 1955 to 1984 was examined retrospectively. The number of patients operated on for HPT increased until 1970 but remained fairly constant thereafter. The increase was due to HPT being diagnosed and treated more often in older women without symptoms or with vague neuromuscular or psychiatric impairment. A renal stone disorder was mainly found in young males and, to a gradually decreasing extent, in females. During the last years, when the number of operations remained constant, approximately 25% of the females had either neuromuscular or psychiatric symptoms, renal stones, or were asymptomatic. Among the male patients, 65% had renal stones while 10% had either neuromuscular or psychiatric symptoms or were asymptomatic. Patients with parathyroid chief cell hyperplasia had lower serum calcium values than patients with adenomas. Before 1979, mostly younger patients with renal stones were subjected to operation in spite of low serum calcium values, and parathyroid chief cell hyperplasia was then mainly found in these individuals. After this date, a more liberal attitude toward surgery was also adopted in older patients with vague symptoms and a slight hypercalcemia and then the proportion of chief cell hyperplasia increased also among these patients. A recurrent parathyroid disease was encountered among patients previously operated on for hyperplasia but was also observed in a few adenoma cases, but only after a long postoperative period of time. The findings seem to indicate that parathyroid chief cell hyperplasia may represent an early form of primary HPT not related to any specific symptoms, but mainly seen in patients with a mild hypercalcemia. A recommendation that parathyroid surgery should be undertaken more generally in patients with low serum calcium values should take into account the greater difficulties associated with this type of surgery. The glands are often small and sometimes asymmetrically enlarged due to a nodular chief cell hyperplasia, which makes the extent of the necessary surgical resection difficult to decide.
Current approach to the management of tumoral process in patients with gastrinoma
Authors: Mignon M. , Ruszniewski P. , Haffar S. , Rigaud D. , Rene E. , Bonfils S.
Published: May 2005

One hundred forty‐four consecutive patients with Zollinger‐Ellison syndrome (ZES) were reviewed at Bichat Hospital in 1985. The population included 117 patients with a demonstrated tumoral process, 10 with islet‐cell hyperplasia, and 17 in whom no anatomical findings had yet been demonstrated. Patients in the 2 latter categories had clinical and biological features of ZES. Thirty‐five patients had multiple endocrine neoplasia type I (MEN I). Hyperparathyroidism was the most frequently associated endocrine disorder and required neck surgery in 65% of the patients. Pancreatic surgery failed in 61% of these individuals. Preoperative imaging techniques allowed a correct topographic diagnosis in only 1 out of every 2 patients. In 27 patients with negative preoperative imagery, pathological findings were revealed at surgery.

Since 1974, major gastric antisecretory agents were used systematically in practically every patient which recommended either no surgical intervention (18 patients) or in most cases elective abdominal surgery. H2‐blockers have, in this series, clearly induced a reduction of the classical surgery combining total gastrectomy with gastrinoma removal and fostered gastrinoma surgery alone. The best chance of getting an apparently complete cure is offered to patients with ectopic gastrinomas, particularly those with duodenal wall tumors, and to a lesser degree, removable pancreatic tumors.

Malignancy is frequent: 36 patients had hepatic metastases, which adversely and considerably influenced the probability of survival in ZES patients. Chemotherapy was used in 14 individuals with encouraging results.
Intraoperative scintigraphy in surgical treatment of thyroid carcinoma: Evaluation of a new technique
Authors: Lennquist Sten , Persliden Jan , Smeds Staffan
Published: May 2005

Even when thyroidectomy with lymphadenectomy for thyroid carcinoma is macroscopic‐ally radical, postoperative scintigraphy sometimes reveals iodine uptake in residual or ectopic thyroid tissue or lymph nodes, necessitating radioiodine ablation. In order to detect such tissue during the operation, a technique for intraoperative scintigraphy was devised. It was tested in 20 patients undergoing total thyroidectomy for highly differentiated thyroid carcinoma. The patients received 20 mBq125I intravenously 24 hours before the operation. After removal of all macroscopically visible thyroid tissue and metastatic growth, the operative field was examined with a cadmium‐telluride detector placed in a sterile tube of stainless steel. By using this technique, iodine uptake was found in 16 of the 20 patients. All of this tissue was removed in 11 patients, leading to a negative postoperative scintiscan in 9 patients. In 2 patients, the perioperative scanning identified minimal residual uptake in a minute remnant of thyroid tissue adjoining the nerve entrance and not requiring postoperative radioiodine ablation. Scintigraphy was repeated in all patients 6 weeks after thyroidectomy. Recordings over different‐sized tissue fragments showed the detector to have a very high sensitivity, with capacity to detect tissue fragments weighing less than 2 mg. The results indicate that intraoperative scintigraphy, according to this technique, increases the possibilities to perform a complete removal of thyroid and tumor tissue and significantly reduces the need of postoperative radioiodine ablation.
Decrease in serum uric acid level following parathyroidectomy in patients with primary hyperparathyroidism
Authors: Duh Quan ‐Yang , Morris R. Curtis , Arnaud Claude D. , Clark Orlo H.
Published: May 2005

Serum uric acid levels in 101 patients with surgically treated hyperparathyroidism were studied retrospectively. Twenty‐five patients had preoperative hyperuricemia and 8 patients had a history of gout. Preoperatively the serum uric acid level correlated positively with the blood urea nitrogen and serum creatinine levels, but not with serum immunoreactive parathyroid hormone or calcium levels. Following parathyroidectomy the serum uric acid level decreased from a preoperative level of 6.55±0.18 mg/100 ml (mean±S.E.) to 6.05±0.21 mg/100 ml at 1 week to 1 month postoperatively, and the uric acid level remained decreased at 6–18 months postoperatively (5.22±0.31 mg/100 ml). Patients with the highest serum uric acid level seemed to improve most.
Microsurgical free fibular bone transfer: A technique for reconstruction of large skeletal defects following resection of high‐grade malignant tumors
Authors: Schuind F. , Burny F. , Lejeune F. J.
Published: May 2005

In selected patients with localized malignant bone tumors, radical en bloc resection with adjuvant chemotherapy is now performed. Vascularized bone autografts can be used for secondary reconstruction of the bone defect. These grafts have the advantages of the nonvascularized ones, as well as the advantages of preserved viability. The fibula is usually the most suitable donor bone. Our surgical technique and the advantages and limitations of vascularized bone grafts are discussed.
Limb salvage in sarcomas in children
Authors: van der Eijken Jan W.
Published: May 2005

Limb‐saving surgery plays an increasingly important role in the treatment of malignant tumors of the extremities. This type of surgery may pose special problems in children when one or two epiphyses have to be sacrificed. An unacceptable leg‐length discrepancy may occur, especially in the very young child, at the end of growth after reconstructive procedures. The different possibilities of reconstruction after a tumor resection and their repercussions in growth are discussed. The role of reconstruction by means of a rotation plasty versus other methods of reconstruction is especially considered.
Upper and lower limb disarticulation in soft tissue and bone sarcomas
Authors: Lienard D. , Lejeune F. J.
Published: May 2005

The authors have reviewed 23 patients with proximal disarticulations with the aim of assessing the therapeutic value in sarcoma, taking into account previous radio‐ and chemotherapy. The following criteria were especially examined: recurrences, survival, and quality of life. There were 14 soft tissue sarcomas, and 9 bone sarcomas. In 11 cases, the tumor was primary and treated for the first time while, in 12 cases, it was recurrent. Eighteen patients had been previously treated by nonradical surgery, 11 by radiotherapy, and 10 by chemotherapy. For upper limb tumors, 6 patients underwent an interscapulothoracic disarticulation, and 3 an interscapulothoracic resection according to Tikhoff‐Linberg. For lower limb tumors, 8 patients were submitted to interilioabdominal disarticulation, 3 to coxofemoral disarticulation, and 1 to internal hemipelvectomy according to Eilber. The mean disease‐free interval has been 34 months, and the mean survival, 38.5 months. Three (15%) of 20 evaluable patients recurred locally, although most of them benefited from second surgery. Quality of life has been excellent, in general, despite the fact that only 8 patients accepted to wear a prosthesis. The Karnofsky index ranged from 60 to 100%. No significant difference was seen, whether or not previous radio‐ and/or chemotherapy had been administered.
Hyperthermic isolation perfusion of the limbs with cytostatics after surgical excision of sarcomas
Authors: Lejeune F. J. , Lienard D. , Ewalenko P.
Published: May 2005

In order to prevent recurrence, isolation perfusion was applied in 15 patients after resection of sarcomas of the limbs. There were 6 liposarcomas, 4 synoviosarcomas, 2 malignant fibrohistiocytomas, 1 malignant mesenchynoma, 1 Kaposi, and 1 osteosarcoma (the only bone sarcoma). Eight sarcomas were recurrent after narrow surgery and/or radiotherapy.

The treatment schedule was conducted in 2 steps: (a) removal of the tumor with safety margins at least outside the tumor capsule, followed 3–8 weeks later by (b) isolation perfusion with melphalan with or without actinomycin D under moderate hyperthermia at 39–41°C for 1 hour.

Median follow‐up time has been 30 months. Four of the 8 recurrent sarcomas recurred again and developed distal metastases. In contrast, none of the previously untreated patients recurred and 1 disseminated in the form of multicentric liposarcoma. Eleven are still alive with survival ranging from 8 to 103 months.

It is concluded that isolation perfusion with melphalan with or without actinomycin D may be considered as an adjunct to surgery.
Two cases of gastric carcinoids: Diagnostic and therapeutic aspects
Authors: Ahlman Håkan , Dahlström Annica , Enerbäck Lennart , Granérus Göran , Nilsson Ola , Persson Stellan , Tisell Lars ‐Erik
Published: May 2005

Two cases of gastric carcinoid tumors with the foregut carcinoid syndrome are presented. Due to elevated urinary levels of 5‐hydroxyindoleacetic acid (5‐HIAA), primary tumors of midgut origin were suspected. Provocation with pentagastrin (PG) elicited atypical flushing and severe bronchoconstriction, most probably caused by the release of histamine. Excessive excretion of the main histamine metabolite, tele‐methylimidazole acetic acid (MeImAA), in urine of both patients was demonstrated. Both patients had good symptomatic relief with prednisolone and blockade of histamine receptors. One of the patients had excessive secretion of serotonin (5‐HT) as well as of histamine. Peripheral blockade of 5‐HT2receptors was therefore added to the medical treatment. This patient had a subjective and biochemical response to cytotoxic treatment with streptozotocin and later responded well to a somatostatin analogue.

On clinical suspicion of a foregut carcinoid tumor, or in patients with carcinoid tumors without anatomical localization, PG provocation should not be used until the excretion of MeImAA has been determined.
Cefotaxime i.v. versus oral neomycin‐erythromycin for prophylaxis of infections after colorectal operations
Authors: Raahave Dennis , Hesselfeldt Peter , Pedersen Torben B.
Published: May 2005

One hundred patients undergoing colorectal operations were randomly assigned to a parenteral prophylactic regimen with 2 g cefotaxime i.v. (3 doses) or to our present oral prophylaxis with neomycin‐erythromycin. Wound infection occurred in 2 patients who received cefotaxime (4%) compared with 6 patients (12%) who received neomycin‐erythromycin, a nonsignificant difference. Nor was there any significant difference between the anastomotic leakage rates, 12.5% and 6.1%. Predominant pathogens wereEscherichia coli andBacteroides fragilis. The results show that a 12‐hour cover with cefotaxime has a low rate of infectious complications and is as effective a prophylaxis as neomycin‐erythromycin orally.
Results of gastric resection for carcinoma of the stomach: The European experience
Authors: Heberer G. , Teichmann R. K. , Krämling H. ‐J. , Günther B.
Published: May 2005

A European state of the art in the treatment of gastric cancer is presented from the results of a questionnaire. Data were obtained from 62 centers, 60% of which were from abroad and 40% of which were from Germany, reporting a total of 16,594 patients. A feature was a low portion (8.8%) of early cancer. The operation preferred was total gastrectomy. Only in the case of antral carcinoma of the intestinal type, according to Laurén, would the majority perform subtotal gastrectomy. Staging of lymph nodes was performed by 84% of these centers; however, systematic radical dissection was carried out only by 27%. The preferred type of reconstruction after total gastrectomy was Roux‐en‐Y esophagojejunostomy; 16% of the European centers used some type of pouch in addition. Splenectomy was carried out depending on location of the tumor.

The median in‐hospital mortality for early cancer was 0; for carcinoma of the antrum, 6.7%; corpus, 9.6%; and gastroesophageal junction, 11.7%. The median 5‐year survival rate in patients with early cancer was 82.5%; for advanced cancer of the antrum, 30.7%; corpus, 24%; and gastroesophageal junction, 15.5%. Ten‐year survival was 6–10% less.

It is concluded that in Europe there is a high rate of advanced gastric cancer affecting the results. Improved results may be expected if gastric cancer can be detected earlier and if there is radical lymph node dissection. Generally, prospective randomized studies presented by standardized documentation and statistics are urgently needed.
Effect of proximal gastric vagotomy on human gastric blood flow evaluated by endoscopic laser doppler flowmetry
Authors: Lunde Ole ‐Christian , Kvernebo Knut , Liavåg Ivar
Published: May 2005

The effect of proximal gastric vagotomy (PGV) on gastric blood flow has been evaluated endoscopically by laser Doppler flowmetry (LDF) in 12 patients with duodenal ulcer. The gastric wall circulation was examined at 7 defined positions in all subjects prior to surgery, 1 week postoperatively, and after 3 months. For comparison, 21 healthy volunteers were also examined by LDF.

In all the investigated areas of the stomach, the blood flow values were lower in the unoperated duodenal ulcer patients than in the controls. In both groups, the blood circulation was significantly lower at the lesser curvature than at the greater curvature.

Seven days after PGV, the blood flow was reduced 30% in the devascularized part of the lesser curvature. After 3 months, the flow values were similar to the preoperative ones. The gastric acid secretion was significantly reduced at 3 months.

Postoperatively, one patient developed a gastric ulcer in the dissected area of the lesser curvature. This patient had lower flow values along the lesser curvature than the other patients after 7 days.

The results of this study show that PGV leads to a temporary reduction of blood flow at the lesser curvature. This regional decrease in blood flow is probably not an important factor for the reduced acid secretion measured after PGV.
Effect of pancreatitis on moxalactam excretion in pancreatic fluids of dogs and man
Authors: Rubinstein Ethan , Meissel Doron , Klein Ehud , Samra Yehezkel , Schwartzkopf Renata , Ben‐Ari Gur
Published: May 2005

Pancreatic excretion of moxalactam was evaluated in a patient with mild pancreatitis and pancreatic fistula, in normal dogs, and in dogs with induced pancreatitis. In the patient, moxalactam was not excreted in the pancreatic fluid, despite adequate blood levels. Similarly, no moxalactam activity was present in the pancreatic fluids of normal animals and animals with experimentally induced pancreatitis. The data suggest that moxalactam does not penetrate into pancreatic fluid in detectable concentrations in the presence or absence of pancreatic inflammation.

These results suggest the need for further study of the use of moxalactam in the treatment of bacterial infections of the pancreas.
Surgical management of large paraesophageal hernia with complete intrathoracic stomach
Authors: Menguy René
Published: May 2005

Between 1971 and 1986, the author operated on 30 patients, 23 women and 7 men, with large paraesophageal (PE) hernias and complete intrathoracic stomach. The average age of the patients was 70 years. Thirteen patients required urgent repair because of incarceration causing complete obstruction, bleeding, and, in one instance, perforation. Only 2 patients had a prior history of esophageal reflux. Surgery, always transabdominal, included excision of the sac, closure of the defect with pledgetted sutures, and anterior gastropexy. Four extremely poor‐risk patients underwent anterior gastropexy alone under local anesthesia. Two other patients underwent anterior gastropexy alone for different reasons. There were no deaths or major complications and no recurrences. The author's experience suggests that: (a) an abdominal approach is preferable to a transthoracic repair; (b) ancillary antireflux surgery, such as fundoplication, should be used only when indicated on the basis of a prior history of reflux esophagitis, which was the case in only 2 of our patients; (c) because the symptoms and complications of PE hernias result from the gastric volvulus rather than from the hernia per se, formal repair of the defect is not always necessary. Thus, patients whose general condition does not permit a major abdominal operation under general anesthesia can be completely relieved of their symptoms by an anterior gastropexy done under local anesthesia; (d) a PE hernia is a life‐threatening condition and elective repair should be recommended once the diagnosis is made.
Training for laparoscopic surgery
Authors: Zucker Karl A. , Bailey Robert W. , Graham Scott M. , Scovil William , Imbembo Anthony L.
Published: May 2005

Laparoscopic cholecystectomy has rapidly become the procedure of choice for most patients with symptomatic gallbladder disease. Laparoscopic surgery, however, has not been a required component of most general surgery training programs. The demonstrated efficacy of laparoscopic surgery dictates that this discipline be rapidly incorporated into residency programs. Laparoscopic cholecystectomy and other surgical endoscopic procedures have been an integral part of the training program at the University of Maryland since 1989. Currently, residents who are completing their training have performed on average 50 to 75 laparoscopic procedures as the primary surgeon and 25 to 30 as the first assistant. In addition to training future community and academic physicians, those surgeons currently in practice must receive appropriate instruction in laparoscopic surgery. Most practicing surgeons attend a 2‐ to 3‐day intensive course offering both didactic and hands‐on experience. Additional exposure to clinical cases is achieved by working with other surgeons with laparoscopic expertise. Full credentialing in laparoscopic cholecystectomy generally requires proctoring by a surgeon from the local community. Since 1990 faculty from the University of Maryland have been active in the local community serving as proctors to surgeons in 14 hospitals.
Elective and emergent laparoscopy
Authors: Berci George
Published: May 2005

Although laparoscopy has been received enthusiastically by gastroenterologists, mainly in Europe, over the past four decades, its usefulness in surgery has been ill‐defined or neglected. Gynecologists recognized the value and included laparoscopy as one of the most important diagnostic and therapeutic tools for pelvic pathology. After the introduction of laparoscopic cholecystectomy, several thousand surgeons were trained in laparoscopic techniques. Laparoscopy allows direct visualization of abdominal organs and the parietal peritoneum. It permits a safe target biopsy under precise visual control. The practical value of laparoscopy is the observation of lesions that would not be discovered by other investigations and the ability to assess the dissemination of malignant disease and its operability. Hence many unnecessary explorations are avoided. Diagnostic laparoscopy has a high overall diagnostic yield, has an excellent safety record in the hands of a well trained operator, and is cost‐effective. Minilaparoscopy in the emergent (blunt abdominal) trauma case gives the surgeon a much larger latitude for decision making than does diagnostic peritoneal lavage. Emergency minilaparoscopy has been performed in 150 trauma patients and has accurately predicted the need for laparotomy in all but one patient (0.7%). No major complications have occurred as a result of minilaparoscopy in this setting. A large number of emergency laparotomies in the multiorgan‐injured or high‐risk case can be avoided. Minilaparoscopy may be useful also in the elderly patient with an equivocal abdominal examination but suspicion of visceral injury.
Laparoscopic appendectomy
Authors: Pier Arnold , Götz Friedrich , Bacher Christoph , Ibald Rudolf
Published: May 2005

Appendectomy was performed using a laparoscopic approach in 915 patients. The collected data show that the technique is as feasible, rapid, and safe as open surgery. Few wound infections, minimal pain, and rapid postoperative mobilization are the main arguments in favor of laparoscopic appendectomy. The most important potential benefit, a lower incidence of long‐term complications such as adhesive intestinal obstruction, remains to be confirmed by prolonged follow‐up of our patients.
Laparoscopic vagotomy for chronic duodenal ulcer disease
Authors: Mouiel J. , Katkhouda N.
Published: May 2005

Two laparoscopic procedures for treatment of chronic duodenal ulcer are described: bilateral truncal vagotomy with balloon pyloric dilatation and posterior truncal vagotomy with anterior lesser curve seromyotomy. The first procedure is simple to perform and easily reproducible, but the latter is preferred because it respects the physiology of the stomach. Thirty‐six patients were operated on over a period of 18 months with good results comparable to those with open surgery. The indications for surgery were intractable chronic duodenal ulcers resistant to optimal medical therapy. There was no perioperative morbidity or mortality, and recurrent ulcers have not been demonstrated during early postoperative follow‐up. The proper role of laparoscopic surgery in the arsenal of treatment of duodenal ulcers is unclear. The method of laparoscopic vagotomy requires rigorous experimental evaluation in specialized centers before widespread clinical application. Future multicentric prospective studies with long‐term follow‐up are necessary to assess the results of this innovative therapy of acid‐peptic disease.
Laparoscopic antireflux surgery and repair of hiatal hernia
Authors: Cuschieri A.
Published: May 2005

Laparoscopic mobilization of the esophagus and esophagogastric (O‐G) junction enables the safe and effective performance of endoscopic antireflux surgery for intractable reflux esophagitis. The two antireflux procedures that we have evaluated in clinical practice at this institution are the ligamentum teres cardiopexy (n=9) and partial posterior fundoplication (n=5). More recently, laparoscopic repair of large symptomatic hiatal hernia (sliding, paraesophageal, and mixed) has also been introduced (n=4). The procedure entails reduction of the hernia, mobilization of the O‐G junction with crural repair by a continuous suture technique employing a special preformed jamming loop knot, followed by total fundoplication, which is fixed proximal to the anterior margin of the diaphragmatic hiatus and distal to the O‐G junction. The early results (maximum follow‐up 18 months) of this experience have been favorable, with minimal morbidity, early hospital discharge, and effective control of reflux symptoms without adverse sequelae. Laparoscopic antireflux surgery is an alternative to long‐term medication in patients with intractable esophagitis, and laparoscopic repair of large hiatal hernias offers significant advantage over the conventional open surgical approach in terms of rapid convalescence.
Laparoscopic urology: Past, present, and future
Authors: Clayman Ralph V. , Kavoussi Louis R.
Published: May 2005

Laparoscopy has begun to have a significant impact on the management of urologic problems. Although initially limited to diagnostic pediatric problems, it has more recently been used to resolve myriad adult urologic conditions. Indeed, during the past year laparoscopic urology has moved well beyond the diagnosis of the undescended testicle and has been successfully used for pelvic lymphadenectomy, varicocelectomy, ureterolysis, drainage of a pelvic lymphocele, bladder suspension, and nephrectomy. Future applications of laparoscopy in urology may well include nephroureterectomy, cystectomy, and creation of an ileal conduit.
Advances in gynecologic laparoscopic procedures
Authors: Levine Ronald L. , Reich Harry
Published: May 2005

Most gynecologic procedures can be accomplished using laparoscopic surgical techniques. Gynecologic laparoscopic procedures are described that involve the reproductive system, lymph node sampling, bowel and urinary tract repair, and abscess therapy. Laparoscopic surgery enhances the outcome of most current gynecologic procedures.
Aberrant left hepatic artery arising from the left gastric artery and liver function after radical gastrectomy for gastric cancer
Authors: Okano Shinji , Sawai Kiyoshi , Taniguchi Hiroki , Takahashi Toshio
Published: May 2005

An aberrant left hepatic artery, arising from the left gastric artery (LHLG), either as an accessory or replacing the left hepatic artery, is occasionally seen in patients with gastric cancer. Resection of LHLG, as part of the gastrectomy procedure, may cause liver dysfunction. The surgical records of a group of 141 patients who had undergone gastrectomy for gastric cancer following preoperative angiography were reviewed. Twenty‐eight of the patients had an LHLG preoperatively; in 15 the artery was severed during surgery and in the remainder it was preserved. Postoperative liver function was assessed by measuring changes in lactate dehydrogenase, glutamic oxaloacetic transaminase, and glutamic pyruvic transaminase activities. The greatest changes in liver function were observed in patients in whom the LHLG had been severed; the changes in liver function among patients whose LHLGs were preserved were similar to those in patients who had no LHLG. Notably, the wider the area fed by the LHLG, the greater was the change in liver function. The observed liver dysfunctions were transient, however, and normal function resumed within 7 days after operation.
Gastroplasty for obesity: Long‐term weight loss improved by vagotomy
Authors: Kral John G. , Görtz Lars , Hermansson Gert , Wallin Göran S.
Published: May 2005

Sixty‐nine (13M, 56F), severely obese patients (body mass index 47 kg/m2) have had vertical banded gastroplasty (GP) with 5‐cm polypropylene mesh (n=39) or fascia (n=30) bands since 1981. Of these 69 patients, 30 also had truncal vagotomy (TVG) without drainage. Total office follow‐up rate is 94%. During follow‐up of 1 year or more (mean 60 months), 25 patients with vagotomy plus gastroplasty lost 33±3 kg, corresponding to 51% of excess weight, compared to 21±3 kg (34% Excess weight) in the 34 patients having gastroplasty alone (p<0.01). In patients followed ≥ 5 years (mean 83 months) 10 patients with TVG lost 40±5 kg (61% of excess) compared to 17±4 kg (28% of excess) in 22 patients with GP alone (p<0.001). Frequency and severity of complications were similar in both groups, but there were seven reoperations after GP and three after TVG (p<0.05). Studies of gastric emptying of a solid meal in 14 of the patients with GP and 14 with TVG demonstrated greater weight loss in those with prolonged emptying and gastroesophageal pooling, though the emptying rates of patients with GP and those with TVG showed no statistically significant difference. Our earlier studies, which showed reduced liquid consumption after vagotomy, imply that this mechanism (rather than delayed emptying) explains why vagotomy potentiates weight loss after gastroplasty.
Resting energy expenditure and nitrogen loss after surgery in chronically undernourished patients
Authors: Fernandez Ivo S. , Kurpad Anura V. , Kilpadi Arun B. , Shetty Prakash S.
Published: May 2005

Chronically undernourished patients (n=10) undergoing elective abdominal surgery were assessed with regard to their energy expenditure and urinary nitrogen loss. These measurements were made for 1 week after the surgery, and stress factors for each parameter were computed. The responses of the chronically undernourished patients were compared to those of relatively well nourished patients (n=10) undergoing comparable surgeries. It was found that the postoperative resting energy expenditure (REE) of the chronically undernourished patients was not significantly elevated when compared to their preoperative values (mean±SEM): 1210.66±88.13, 1354.91±86.61, 1215.09±89.68, and 1188.23±86.61 kcal/day preoperatively and on postoperative days 1, 4, and 8, respectively. On the other hand, the postoperative REE of the controls was significantly elevated (p<0.05) over their baseline values: 1357.18±70.81, 1574.66±100.35, 1502.89±109.44, and 1477.23±83.52; kcal/day, respectively, for the same days. The stress factors for the controls were higher than those for the undernourished (1.16 versus 1.12, 1.11 versus 1.00, and 1.09 versus 0.98 on postoperative days 1, 4, and 8, respectively). The urinary nitrogen excretion in both groups (for the 4 days) was not significantly elevated over baseline (6.23±0.87, 7.72±0.71, 8.36±0.87, and 8.04±1.56 grams/day in the undernourished; and 7.59±1.03, 9.57±1.33, 9.49±1.03, and 8.67±0.76 grams/day in the controls. The stress factors for nitrogen excretion were slightly higher in the undernourished group. The data from this study show that the postoperative REE of chronically undernourished subjects is lower than that of well nourished controls. The nitrogen loss, however, is similar in the two groups.