Citations

AbstractThe objective of this study was to determine the relation between the presence of a bullet (gunshot) after injury to the colon and the incidence of sepsis in its track and the soft tissue where it is retained. A retrospective review was carried out of the charts of consecutive patients admitted for abdominal gunshot wounds with proved colon injury during laparotomy where the bullet was either retained in the soft tissue or exited the body. The review covered a period of 4 years beginning January 1, 1990. Three groups were identified for analysis: (1) patients from whom the bullet was surgically removed, with additional cleansing and débridement of the area ( n= 21); (2) patients who did not undergo surgical removal of the bullet (n= 81); and (3) patients in whom the bullet exited spontaneously and in whom only débridement of the skin was carried out (n= 83). Similar risk factors were noted among the groups (age, ATI score, colostomy rate), except for a higher incidence of shock in group 3 (p= 0.003). The incidence of sepsis in soft tissue was least in group 1. It was five and seven times greater in groups 2 and 3, respectively. After an abdominal gunshot with colon injury, the missile should be removed if feasible and the local tissue débrided. If the bullet has exited spontaneously, its internal track must be débrided and lavaged extensively.

AbstractFunctioning extraadrenal paragangliomas represent more than 10% of all pheochromocytomas, occur at diverse anatomic locations, and are said to have a higher malignancy rate than intraadrenal pheochromocytomas. Sixty‐six patients had surgery for catecholamine‐producing paragangliomas between 1952 and 1992. Median follow‐up was 8.8 years. Median age was 40 years (11–67 years); the male/female ratio was 29:37. Familial disease occurred in 9 patients (13.6%), and 10 patients (15.2%) also developed adrenal pheochromocytoma. Solitary paragangliomas occurred in 52 patients: 46 abdominal, 4 thoracic, and 2 head and neck. Fifty‐three tumors developed in 14 patients with multiple paragangliomas: 38 abdominal and 15 thoracic. Of 28 patients with solitary tumors undergoing localization studies over the past 10 years accurate localization was achieved in 27. There was one operative death; 15 patients had persistent disease; and 50 were cured postoperatively. Of those cured, nine developed recurrence, disease‐free survival being 86%, 80%, and 80% at 5, 10, and 20 years. Metastatic disease was found in 14 patients (21%), 7 of whom have died. An additional 10 patients (15%) had locally invasive disease, of whom 4 have died. Cause‐specific survivals at 5, 10, and 20 years were 90%, 83%, and 72%. Risk factors for death from pheochromocytoma were tumor size > 5 cm (p= 0.0002), metastatic disease (p= 0.001), and tumor invasion (p= 0.0023). Cause‐specific survival for patients with tumors > 5 cm was 59% at 15 years compared to 100% among patients with tumors ≤ 5 cm (p= 0.0003). Functional paragangliomas are frequently malignant and are associated with a high incidence of persistent or recurrent disease. Tumor size > 5 cm and the occurrence of invasive or metastatic disease are strong predictors of outcome. Most tumors are abdominal, and imaging is highly successful for localization.

AbstractIslet cell carcinoma (ICC) of the pancreas is a rare, indolent malignancy associated with higher resectability rate and better survival than ductal carcinoma. This retrospective study presents results of surgical treatment from a single institution. From 1985 through 1993 a total of 64 patients (36 men, 28 women) were surgically treated for ICC. Ages ranged from 22 to 80 years (median 55 years) with a median postoperative follow‐up of 39 months (range 10–97 months). Of the 64 patients, 30 (47%) had functioning and 34 (53%) nonfunctioning tumors. Gastrinoma (n= 11) followed by glucagonoma (n= 6) and insulinoma (n= 4) were the most common functioning tumors. In the patients undergoing a laboratory study, 67% of the nonfunctioning tumors had elevated peptide hormone levels. Potentially curative resections were performed in 17 patients (26%), palliative procedures in 35 (55%), and exploratory laparotomy alone in 12 (19%). One patient (2%) died within 30 days after operation. Symptomatic improvement was achieved in 96% of patients with a mean duration of 22 months. Three‐ and five‐year survivals were 66% and 49%, respectively. In patients with curative resection, the disease‐free survival at 3 years was 53% (95% CI: 32–86%). The presence of diffuse hepatic metastases was a predictor of poor survival at 3 years (74% versus 58%;p= 0.05); there was no statistically significant difference in survival between functioning and nonfunctioning groups (p> 0.1). Although curative resection for ICC is rare, meaningful palliation can be achieved in most patients with rare mortality and acceptable morbidity.

AbstractEighty‐two children and adolescents (18 males, 64 females; median age 14 years) surgically treated for Graves’ disease at a single institution between 1979 and 1993 were retrospectively reviewed. Most of the patients (74%) coming to thyroidectomy had been treated medically for a period ranging from 2 to 80 (median 15) months. Bilateral subtotal thyroid resection was the most frequently performed procedure (86%). Postoperatively, no permanent recurrent laryngeal nerve palsy or permanent hypocalcemia occurred. Operative mortality was zero. With a median follow‐up of 8.3 years, recurrent hyperthyroidism occurred in five patients (6%), one of whom required reoperation. Most children and adolescents with Graves’ disease can be rendered euthyroid by nonsurgical treatment options. However, prolonged and ineffective medical treatment should be avoided in these patients who are in the formative years of their lives. Surgical treatment, when indicated and employed, offers young patients with Graves’ disease a safe, rapid, definitive, cost‐effective treatment with a high success rate.

AbstractSurgical treatment for adrenal disease may be withheld from elderly patients because of concern about prohibitive operative morbidity and mortality. To obtain objective data in our practice, we analyzed the results of adrenalectomy for patients aged 65 years and older. From 1984 to 1993 there were 85 patients (41 men, 44 women) with ages ranging from 65 to 84 years (median 69 years) who underwent adrenalectomy for Cushing syndrome (n= 19), pheochromocytoma (n= 16), adrenocortical carcinoma (n= 7), benign adenoma (n= 26), or primary hyperaldosteronism (n= 17) at our institution. Median follow‐up was 26 months (range 1 month to 9.1 years). A retrospective review with respect to preoperative risks and postoperative morbidity and mortality was performed utilizing the American Society of Anesthesiologists (ASA) physical status classification and the modified Goldman multifactorial cardiac risk scheme. Survival was estimated by the Kaplan‐Meier methods. Operative mortality was 7% (six patients). No patients with pheochromocytoma or primary hyperaldosteronism died during the postoperative period. Patients undergoing adrenalectomy for adrenocortical carcinoma had a significantly higher operative mortality (43%) (p= 0.006). Postoperative complications developed in 19 patients (22%), and there was a reoperation rate of 6% (5 patients). Nineteen percent of patients required postoperative intensive care admission and had a median stay of 2 days (range, 1–38 days). Median hospital stay was 7 days (range 3–47 days). Seventy‐three patients (86%) remained alive at study completion. Two‐ and five‐year survivals were 86% and 84%, respectively. Goldman class II or greater was an excellent predictor of increased morbidity (p= 0.032) and mortality (p= 0.036). With the exception of adrenocortical carcinoma, adrenal surgery for elderly patients can be performed with acceptable morbidity and mortality. The Goldman multifactorial cardiac risk scheme reliably predicts postoperative outcome in this elderly group of patients.

AbstractMultiple endocrine neoplasia type I (MEN‐I) is an autosomal dominant disorder characterized by endocrinopathies involving the anterior pituitary gland, parathyroid glands, and pancreas. The long‐term prognosis for patients affected with this disorder is uncertain. To better characterize this prognosis, we performed a retrospective review of all patients with MEN‐I treated at a single institution during the period 1951–1997. A group of 233 patients served as the study population. Their records were analyzed for confirmation of diagnosis, treatments received, long‐term survival, and cause of death. Altogether, 108 eight male patients (46%) and 125 female patients (54%) were identified. At the conclusion of the study, 164 (70%) were alive and 69 (30%) were deceased, with a median follow‐up for patients alive at last contact of 13.4 years (range < 1 month to 54.3 years). The cause of death was reliably obtained in 60 patients. Of these patients, 17 (28%) died of causes related to MEN‐I, most commonly metastatic islet cell tumors (10 patients). The remaining patients died of causes unrelated to MEN‐I, most commonly coronary artery disease and nonendocrine malignancies (14% each). The overall 20‐year survival of MEN‐I patients was 64% (95% CI was 56–72%), and that of an age‐ and gender‐matched upper Midwest population was 81% (p < 0.001). Patients with MEN‐I appear to be at increased risk of premature death. Earlier diagnosis and treatment of potentially malignant pancreatic islet cell neoplasms may result in a decrease of this premature mortality.

AbstractTo evaluate long‐term survival of patients with gastrointestinal carcinoid tumors and to assess factors that may influence prognosis, 154 patients (49% females, 51% males), median age 62 years (range 12–84 years) treated at our institution during 1972–1982 have been followed long term. Tumor location included the foregut (7%), midgut (62%), and hindgut (30%). Ninety‐five percent of the patients underwent surgical or endoscopic excision of the primary tumor, with overall operative mortality and postoperative morbidity rates of 2.6% and 11%, respectively. At follow‐up, 60 patients (39%) were alive (median follow‐up 18 years; range 1–26 years). The main causes of death included carcinoid tumor burden (32%), unrelated causes (45%), other malignancy (19%), and unknown causes (4%). Observed overall 5‐ and 10‐year survivals were 69% and 53%, respectively. Survival was not related to gender or symptoms at presentation. However, age, embryologic origin, tumor size, depth of invasion, nodal status, and stage of disease proved to be of statistical significance (log‐rank). In a multivariate Cox' model, only older age (> 62 years) [P =0.001, odds ratio (OR) = 3.4) and embryologic origin (midgut versus foregut) (P = 0.045, OR = 0.45) provided independent prognostic power when death from any cause was taken as the end‐point. This study confirms that patient's age and the site of the primary tumor have prognostic significance. Carcinoid tumors are neuroendocrine tumors with a relatively good prognosis, and long‐term survival is possible despite advanced stages of disease.

AbstractMedical management of congenital adrenal hyperplasia (CAH) patients has led to suboptimal results in most cases. High glucocorticoid doses, often needed to suppress adrenal androgen production, may lead to signs of Cushing syndrome. Incompletely suppressed androgen levels commonly lead to premature closure of growth centers, acne, virilization, precocious puberty, irregular or absent menses, and decreased fertility in female CAH patients. A newly proposed therapy for CAH patients is bilateral adrenalectomy. Three Caucasian female patients with 21‐hydroxylase deficiency were treated with bilateral adrenalectomy. Two of the three procedures were accomplished laparoscopically. In each patient, medical management alone was unsuccessful. Two patients had salt‐losing 21‐hydroxylase deficiency. The third patient had uncontrolled hyperandrogenism complicated by obesity and glucose intolerance. All patients had low height percentiles with respect to their normalized percentiles for weight. Bone age was advanced in one patient. Androgen and renin levels were well controlled in two patients, whereas the third patient had persistent hyperandrogenism. Bilateral adrenalectomy was performed at the ages of 14, 19, and 30 years with follow‐up, to date, of 25 months, 10 months, and 26 months, respectively. Postoperatively, all patients were free from hyperandrogenism. One patient experienced one episode of urosepsis precipitating an addisonian crisis. Bilateral adrenalectomy may successfully address the problems of increasing steroid requirements and hyperandrogenism in patients with severe CAH. The ability to perform this operation laparoscopically coupled with the overall metabolic benefits make bilateral adrenalectomy a reasonable alternative to lifelong androgen suppression in select patients.

AbstractWhat is the future of thyroid surgery in the new millennium? How can surgeons keep abreast of advances in thyroid endocrinology, genetics, surgical therapy, and other aspects of thyroid disease management? How should surgeons be trained to become highly competent in thyroid disease and to perform safe, effective thyroid operative procedures? Nine internationally recognized endocrine surgeons were asked to express their views on these and related subjects. They noted that advances in molecular biology, pathology, and genetics of thyroid disease should allow more tailored surgical approaches during the twenty‐first century. Current training of general surgical residents in thyroid and other types of endocrine surgery is highly variable, which may contribute to increased complication rates and number of second operations. The leadership for addressing these deficiencies and promoting a more organized approach to thyroid disease management should come from national endocrine surgery associations and their leaders. It is incumbent upon endocrine surgeons to maintain their central role in the management of many aspects of thyroid disease. Organizing teams of specialists into thyroid centers (centers of excellence) can (1) increase efficiency; (2) increase quality of care; (3) decrease costs; (4) encourage a more individualized approach to surgery; (5) lower complication rates; and (6) foster innovation in technology and disease management. Two years of additional fellowship training in thyroid and endocrine surgery is now being advocated by increasing numbers of national endocrine surgical associations as the best way to prepare surgeons for society's needs for highly skilled, competent thyroid surgeons of the future.

AbstractAn early colorectal carcinoma is TNM stage T1NxMx. Most early carcinomas of the colon and rectum can be treated by adequate local excision, such as colonoscopic polypectomy and per‐anal excision. If there are adverse risk factors, especially poorly differentiated carcinoma, lymphovascular invasion, or incomplete excision, a radical resection is indicated if there is no contraindication. In the case of a low rectal carcinoma, adjuvant chemoradiation should be considered. Recently a new classification has been developed: sm1 is invasion to the upper one‐third of the submucosa, sm2 is invasion to the middle one‐third, and sm3 is invasion to the lower one‐third. Lesions of sm1 and sm2 have a low risk of local recurrence and lymph node metastasis; local excision is adequate. The sm3 lesions and sm2 flat and depressed types have a high risk of local recurrence and lymph node metastasis; further treatment is indicated.