Prophylactic central neck dissection for papillary thyroid cancer

BACKGROUND

Prophylactic central neck dissection (CND) for papillary thyroid cancer (PTC) remains controversial. The aim of this study was to examine whether prophylactic CND for PTC affected long-term survival and locoregional control.

METHODS

This was a retrospective cohort study of patients who underwent total thyroidectomy (TT) with bilateral prophylactic CND. They were compared with patients who had TT without CND. Personalized adjuvant radioiodine treatment was used in both groups. Primary outcomes were overall and disease-specific survival, and locoregional control. Secondary outcomes were number of patients with negative serum thyroglobulin levels, and morbidity.

RESULTS

Of 640 patients with PTC included in this study, 282 (treated in 1993-1997) had TT without CND and 358 (treated in 1998-2002) underwent TT with CND. The 10-year disease-specific survival rate for patients who had TT without CND was 92·5 per cent compared with 98·0 per cent in patients with CND (P = 0·034), and the locoregional control rate was 87·6 and 94·5 per cent respectively (P = 0·003). In multivariable analysis, extrathyroidal extension was an independent predictive factor for locoregional recurrence (odds ratio 12·47, 95 per cent confidence interval 6·74 to 23·06; P < 0·001), whereas CND was an independent predictive factor for improved locoregional control at 10 years after surgery (odds ratio 0·21, 0·11 to 0·41; P < 0·001). No differences were seen in the rates of permanent hypoparathyroidism or recurrent laryngeal nerve injury between the groups.

CONCLUSION

Bilateral prophylactic CND for staging of the neck in PTC, followed by personalized adjuvant radioiodine treatment, improved both 10-year disease-specific survival and locoregional control, without increasing the risk of permanent morbidity.

REGISTRATION NUMBER

NCT01510002 (http://www.clinicaltrials.gov).

Randomized clinical trial of bilateral subtotal thyroidectomy versus total thyroidectomy for Graves' disease with a 5-year follow-up11

Background

The extent of thyroid resection in Graves' disease remains controversial. The aim of this study was to evaluate long-term results of bilateral subtotal thyroidectomy (BST) compared with total thyroidectomy (TT) in patients with Graves' disease and mild active ophthalmopathy.

Methods

Participants were assigned randomly to BST or TT, and followed for 5 years after surgery. The primary endpoints of the study were the prevalence of recurrent hyperthyroidism and changes in Graves' ophthalmopathy. Secondary endpoints were postoperative transient and permanent paresis of the recurrent laryngeal nerve, and postoperative hypocalcaemia and hypoparathyroidism.

Results

Two hundred patients were included, of whom 191 (BST 95, TT 96) completed the 5-year follow-up. Recurrent hyperthyroidism occurred in nine patients after BST and in none after TT (P = 0·002). Progression of Graves' ophthalmopathy was observed in nine patients after BST compared with seven following TT (P = 0·586). Transient hypoparathyroidism occurred in 13 and 24 patients respectively (P = 0·047). Permanent hypoparathyroidism was diagnosed in no patient after BST and in one after TT (P = 0·318). No differences were noted in transient or permanent recurrent laryngeal nerve injury.

Conclusion

TT for Graves' disease prevented recurrent hyperthyroidism but did not prevent the progression of ophthalmopathy compared with BST. Registration number: NCT01408368 (http://www.clinicaltrials.gov).

Randomized clinical trial of visualization versus neuromonitoring of recurrent laryngeal nerves during thyroidectomy

BACKGROUND

The aim of this study was to test the hypothesis that identification of the recurrent laryngeal nerve (RLN) during thyroid surgery reduces injury, and that intraoperative nerve monitoring may be of additional benefit.

METHODS

One thousand consenting patients scheduled to have bilateral thyroid surgery were randomized to standard protection or additional nerve monitoring. The primary outcome measure was prevalence of RLN injury.

RESULTS

Of 1000 nerves at risk in each group, transient and permanent RLN injuries were found respectively in 38 and 12 nerves without RLN monitoring (P = 0.011) and 19 and eight nerves with RLN monitoring (P = 0.368). The prevalence of transient RLN paresis was lower in patients who had RLN monitoring by 2.9 per cent in high-risk patients (P = 0.011) and 0.9 per cent in low-risk patients (P = 0.249). The negative and positive predictive values of RLN monitoring in predicting postoperative vocal cord function were 98.9 and 37.8 per cent respectively.

CONCLUSION

Nerve monitoring decreased the incidence of transient but not permanent RLN paresis compared with visualization alone, particularly in high-risk patients.

REGISTRATION NUMBER

NCT00661024 (http://www.clinicaltrials.gov).

Superiority of preemptive analgesia with intraperitoneal instillation of bupivacaine before rather than after the creation of pneumoperitoneum for laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled study

BACKGROUND

This study aimed to evaluate the optimal timing of preemptive analgesia with bupivacaine peritoneal instillation in a prospective, randomized, double-blind, placebo-controlled trial.

METHODS

In this study, 120 patients qualified for laparoscopic cholecystectomy were randomized to four groups. Group A received 2 mg/kg of bupivacaine in 200 ml of normal saline before creation of pneumoperitoneum. Group B received 2 mg/kg of bupivacaine in 200 ml of normal saline after creation of pneumoperitoneum. Group C received 200 ml of normal saline before creation of pneumoperitoneum. Group D received 200 ml of normal saline after creation of pneumoperitoneum. Local wound infiltration with bupivacaine was used before skin incisions. The primary end points of the study were postoperative pain intensity on a visual analog scale and incidence of shoulder tip pain. The secondary end points included the latency of nurse-controlled analgesia activation, the analgesia request rate, and analgesic consumption.

RESULTS

Significantly lower visual analog scores were observed in group A versus groups C and B versus group D during the initial 48 and 24 h, respectively. The patients in group A versus group B reported significantly lower pain at 4 h (p < 0.001) and 8 h (p = 0.003) postoperatively, but the difference was not significant after 12, 24, and 48 h. None of the group A patients reported shoulder tip pain, whereas it was reported by 3 patients in group B, 6 patients in group C, and 7 patients in group D (p < 0.01). The latency of nurse-controlled analgesia activation was 426.8 +/-57.2 min in group A, as compared with 307 +/- 39.8 min in group B, 109.3 +/- 51 min in group C, and 109 +/- 46.5 min in group D (p < 0.001). A significantly lower analgesia request rate was observed in group A versus C, as compared with group B versus D, throughout the entire study period (p < 0.05).

CONCLUSIONS

Preemptive analgesia with bupivacaine peritoneal instillation is much more effective for pain relief if used before creation of pneumoperitoneum. Although the effect of bupivacaine peritoneal instillation is also noticeable when used after creation of pneumoperitoneum, it confers significantly lower benefits.

Low-pressure pneumoperitoneum combined with intraperitoneal saline washout for reduction of pain after laparoscopic cholecystectomy: a prospective randomized study

BACKGROUND

We designed a prospective randomized clinical trial to investigate whether intraperitoneal saline washout combined with a low-pressure pneumoperitoneum (LPSW) was superior to low-pressure pneumoperitoneum (LP) alone as a means of reducing postoperative pain and analgesic consumption in the early recovery period after laparoscopic cholecystectomy (LC).

METHODS

A total of 124 consecutive patients undergoing LC due to uncomplicated symptomatic gallstones were randomized to the LP or LPSW group. In the LPSW group, normal saline at body temperature (25 ml/kg of body weight) was irrigated under the diaphragm. The fluid was evacuated via the passive-flow method through a 16-F closed drain left under the liver for 24 h. We then assessed the intensity of total abdominal postoperative pain using the Visual Analogue Scale (VAS), including the incidence of shoulder-tip pain (STP), total daily analgesia demand rate, analgesic consumption. Quality of life (QOL) within 7 days after the operation was assessed using the Medical Outcomes Study Short Form 36 Health Survey (SF-36). A p value of <0.05 was considered significant.

RESULTS

The mean postoperative pain score was lower by 2.64 +/- 0.86 in the LPSW; the difference equaled 9.64% (p < 0.05). The incidence of STP was lower in the LPSW group (LP 11.29% vs LPSW 1.6%; p = 0.028). The analgesia demand rate was remarkably lower in LPSW vs LP within 24 and 48 h postoperatively (70.96% vs 90.32%; p = 0.006 and 64.51% vs. 83.87%; p = 0.013, respectively). After LPSW vs LP, QOL was better in terms of physical functioning, role limitations due to physical problems, and bodily pain (90.32% vs 77.42%; p = 0.05, 90.32% vs 75.8%; p = 0.03, 91.93% vs 74.19%; p = 0.008, respectively).

CONCLUSION

In terms of lower postoperative pain and a better QOL within the early recovery period, LPSW is superior to LP alone. The saline washout procedure should be recommended during LC because it is a simple way to reduce pain intensity, even after LP operations.

A prospective randomized trial on comparison of low-pressure (LP) and standard-pressure (SP) pneumoperitoneum for laparoscopic cholecystectomy

AIM

This study aimed to investigate the advantages and disadvantages of LP (7 mmHg) in comparison to SP (12 mm Hg) pneumoperitoneum in a prospective randomized clinical trial.

MATERIALS AND METHODS

148 consecutive patients qualified for laparoscopic cholecystectomy (LC) due to uncomplicated symptomatic gallstones were randomized to either SPLC or LPLC. All the procedures were performed by the same experienced team of surgeons. The statistical analysis included sex, mean age, body mass index, ASA grade, operative time, complication rate, conversion rate, postoperative pain assessed by the Visual Analogue Scale of Pain (VAS) including the incidence of shoulder-tip pain, postoperative hospital stay, recovery time, and the quality of life (QOL) within 7 days following the operation. p <0.05 was considered as indicative of significance.

RESULTS

Neither conversion to an open procedure nor major complications occurred in either group. The operative time was similar in both groups (LP 55.7 +/- 8.6 min vs SP 51.9 +/- 8.3 min). The mean postoperative pain score was 6.18 +/- 3.48 lower after LP than SPLC and the difference amounted to 22.2% (p <0.005). The incidence of shoulder-tip pain was 2.1 times lower after LP than SPLC (p <0.05). QOL within 7 days following the operation was remarkably better after LPLC than after SPLC (p <0.01).

CONCLUSIONS

LP pneumoperitoneum is superior to SP pneumoperitoneum in terms of lower postoperative pain, a lower incidence of shoulder-tip pain, and a better QOL within 5 days following the operation. LP should be used for LC in cases of uncomplicated symptomatic gallstones as a recommended procedure as long as an adequate exposure is obtained with this technique.

[Medullary thyroid carcinoma--personal observations]

The paper presents the rules of surgical treatment in medullary carcinoma of the thyroid gland based on own experience and survey of literature. Changing trends in diagnostic and therapeutic approach were described. The results achieved encouraged authors to find some conclusions. Long term results of therapy depend mostly on stage of disease in time of initial surgery, radicality of primary operation and further supportive treatment. Systematic follow-up after surgery makes it possible to early detect the recurrence and has an influence on survival rate. In cases of poorly differentiated medullary thyroid cancer even radical surgical procedure followed by the appropriate supportive treatment results in a not satisfactory survival.

[Acute appendicitis in Crakow population]

In spite of decreasing morbidity, acute appendicitis (AA) is still found the most frequent cause of so called acute abdomen. This study presents the retrospective estimation of 1515 patients treated surgically in ten years period, admitted to hospital with the initial diagnosis of AA. In 1339 patients the initial diagnosis was confirmed during surgery. This group was divided into three subgroups: 1. Without perforation, 2. With perforation or abscess presence, 3. With diffuse peritonitis. In our study 60% of patients were male, however in the group aged over 70 we found the majority were females. The mean age was 16.7 years and in half of the cases patients were under 20. The incidence for Cracow population was 61.6 new cases in group of 100,000 inhabitants per one year (74.7 for males and 49.7 for females). The risk of appendix perforation or diffuse peritonitis was higher in extreme age groups. Mortality rate we found as 0.9%, but the risk of death was significantly higher in patients with advanced AA, or in the group over 70. Percentage of missed diagnoses was found as 11.6, and there was an advantage of female (female 19.2%, male 5.7%). Wound infection was dominant with the frequency rising along with the progression of AA.

CONCLUSIONS

1. The morbidity of AA in Cracow population in years 1989-1998, was 61.6/100,000/year on average and showed decreasing trend. 2. General mortality in AA remains at a stable and does not exceed 1%. It is most frequent in patients over 70 irrespectively of the form of AA.

[Should we operate goiter in the elderly?]

The aim of this study was to compare the elderly patients group to the group of others undergoing surgical treatment due to goitre regarding type of goitre, extent of surgical procedures and postoperative follow-up (including early postoperative complications). 5872 patients with various type of goitre (between 1984 and 1998) were surgically treated, among them were 5244 (89.3%) females and 628 (10.7%) males (sex ratio as 8.1:1). The mean age was 46.1 (10 to 95 years). 278 (4.7%) patients were above 70 years of age (235-84.5% females and 43-15.5% males), their mean age was 73.7 years. The increase of malignant goitre was evident among the elderly patients (19.9% vs 5.5%). The dominant types were anaplastic cancers and malignant non-Hodgkin lymphomas. Much more frequently a giant goitre was diagnosed (20% vs 6.1%). It was localised substernally (39.6%) or intrathoracic (4.7%). The elderly prepared properly underwent surgical treatment quite well. Among early postoperative complications in the elderly dominant were surgical ones (6.8%), most frequently the injuries of the recurrent laryngeal nerve (4.67% vs 1.14%). Perioperative mortality regarded mostly the elderly with disseminated anaplastic cancer (3.6% vs. 0.2%). Surgical treatment of goitre in the elderly is a safe and justified method. High incidence of malignant tumours especially anaplastic cancers among the elderly should encourage to operation as early as possible.

Reversible autonomic dysfunction in hyperthyroid patients affects gastric myoelectrical activity and emptying

The autonomic nervous system (ANS) function in hyperthyroidism has been so far investigated mainly from the cardiovascular point of view. The aim of this study is to show that the ANS dysfunction in hyperthyroidism is also expressed in gastric myoelectrical activity disturbances and gastric emptying disorders and to search for a correlation between the severity of clinical manifestation and free thyroid hormone levels and the degree of the ANS dysfunction. The analyzed group included 50 recently diagnosed patients with hyperthyroidism who were examined twice: before and after 3 months of thyrostatic treatment. Results were compared with those of a sex-, age- and BMI-matched control group of 50 healthy volunteers. The study included: heart rate variability analysis in time and frequency domain, at rest and during a deep-breathing test, surface electrogastrography in preprandial and postprandial periods measured simultaneously with the ultrasound assessment of gastric emptying time by Bolondi method. In patients with hyperthyroidism in comparison with the control group, the following significant differences were observed: a sharp reduction of the high-frequency component and a decrease of heart rate variability, a high incidence of dysrhythmia with dominant bradyarrhythmia, and a delay of gastric emptying. The degree of disorders related to the degree of clinical manifestation of hyperthyroidism's symptoms and free triiodothyronine serum concentration both. All the disorders were functional and disappeared in a stable euthyroidism. To conclude, the ANS dysfunction in hyperthyroidism results not only in withdrawal of vagal inhibitory effect on sinoatrial node, but in impaired mutual neuro-hormonal regulation (decrease of vagal influence) of gastric myoelectrical activity followed by delay of gastric emptying.

[Is surgical treatment of hyperthyroidism in pregnancy reasonable?]

Hyperthyroidism is second to diabetes mellitus as the most common endocrinopathy in pregnancy. It is usually caused by Graves' disease. The appropriate treatment is the only way to prevent the incidence of dangerous complications both to mother and foetus, including thyrotoxic crisis. Most cases of hyperthyroidism during pregnancy can be successfully treated with thyrostatics (propylotiouracil, methylotiouracil in the lowest efficient doses). However, the surgical treatment (sub-total thyroidectomy within the second trimester of gestation, soon after the euthyroid state following short medication is reached) is still an elective approach in selected cases: 1) allergy to antithyroid drugs, 2) large compressive goitre, 3) suspicion of thyroid cancer, 4) patients who require large doses of antithyroid drugs to reach and sustain euthyroid state, 5) poor patient compliance, 6) extremely rare resistance to antithyroid drugs. The study included 24 cases of pregnant women, who underwent surgery due to hyperthyroidism. The analysis of indications to surgery and postoperative pregnancy, birth and puerperium course was performed. All the patients gave birth on time to healthy children. No negative influence of neither preoperative antithyroid treatment nor surgical procedure on pregnancy delivery, further psychomotoric children's development and health was found during 36 months (+/- 20 months) of postoperative follow up. It indicates on usefulness, efficacy and safety of surgical treatment in selected cases of hyperthyroidism during pregnancy.

[The role of the autonomic nervous system on malfunction of gastric motor and myoelectric activity in patients with hyperthyroidism]

The aim of this study was to determine both the type of gastric mioelectric and emptying disorders in correlation to degree of severity of hyperthyroidism (clinical and thyroid hormones' blood levels) and ANS function estimated in HRV analysis. The study was performed on a group of 50 patients (35 with multinodular toxic goitre and 15 with Graves' disease, 45 females and 5 males, mean age 39.6 years, mean BMI 23.72) with newly diagnosed and so far untreated hyperthyroidism. The control group were 50 healthy volunteers age-, sex-, and BMI-matched to the studied group. Patients were studied twice, within newly diagnosed thyreotoxicosis and after treatment (Metizol) and reaching stable euthyroid state. The study consisted of: a) percutaneous EGG analysis (Synectics): 30 minutes before and after a test meal (ENRICH Liquid 250 ml), b) HRV analysis (ECG POSTER 2002): 10 minutes at rest and during deep breathing test, c) ultrasound measurement of gastric emptying by Bolondi method. Statistical analysis of collected data was performed. In hyperthyroid patients significant both preprandial and postprandial dysrhythmia (33.01% of bradygastria and 16.49% of tachygastria) was found. In some patients decrease of amplitude of EGG signal was marked as a result of antral hypomotility with coexisting significantly prolonged gastric emptying (110 min). Among severe hyperthyroid patients both the antral food distribution (antrum 35% bigger than in a control group) and impaired proximal stomach relaxation were evident. The degree of gastric mioelectric activity and emptying disorders was proportional to the degree of both severity of clinical manifestation of hyperthyroidism in Zgliczynski scale (from I degree to III degrees) and free thyroid hormones' blood levels (positive correlation). In HRV analysis at rest in hyperthyroid patients comparing to a control group the decrease of both the heart rate variability and a total power was found particularly in HF component resulting in relative sympathetic activation. In HRV analysis during deep breathing test the decrease of heart rate variability was present mostly in LF component. It indicates on reduction of vagal regulation (and vagal excitability) of sinus node and gastric pacemaker function. Coexistence of the increase and decrease of a gastric basic electrical rhythm with delay of gastric emptying indicates on a complex mechanism of their formation. Both neurogenic regulation dysfunction and primary miogenic autoregulation disorders as a result of tyreotoxicosis seem to be the possible causes. All the found changes were functional and disappeared after reaching the stable euthyroid state within 3 months of pharmacological treatment.

Current management of thyroid cancer--a change of therapeutic strategy over the last 20 years

A radical change of epidemiological structure of thyroid cancer incidence in Poland has been reported for few years. The total incidence of thyroid cancer is successively increasing, mostly in form of well differentiated thyroid cancer, especially papillary cancer. The diagnostic and therapeutic approach to thyroid cancer have also changed. Ultrasound guided fine needle aspiration has become the first choice procedure in diagnostics of thyroid cancer. Careful assessment of prognostic factors is no longer helpful in choice of selective surgical procedure in thyroid cancer as elective total thyroidectomy is widely recommended. In well differentiated thyroid cancer a complementary treatment with radioiodine is mandatory in most cases. Own experience in treatment of thyroid cancer presented in the paper is based on over 520 consecutive patients with thyroid cancer treated in a single department specialised in endocrine surgery during last 20 years. Successive changes in epidemiological structure of thyroid cancer incidence as well as the evolution of diagnostic and therapeutic algorithm in thyroid cancer are presented in details. Radical surgical treatment of thyroid cancer is still a fundamental part of a complex treatment of thyroid cancer.

[Diagnosis, treatment and prognosis in cases of renal clear cell carcinoma metastases into the thyroid gland]

The most common metastatic tumour of the thyroid gland which is clinically revealed is renal clear cell carcinoma (RCCC). Our clinical experience in cases of RCCC metastases into thyroid gland is reviewed in terms of the history of the disease, obligatory diagnostic procedures, surgical management and outcome prognosis. We believe that all the patients with even a remote RCCC history require systematic follow-up including thyroid gland as metachronic metastatic disease can occur many years after primary surgery. Clinical diagnosis and ultrasound of the thyroid gland is essential in selection for surgical treatment. Confirmation of malignancy in FNA (fine needle aspiration) in often difficult regarding concomitant multinodular goitre. Enlargement of a single thyroid nodule except L-thyroxin therapy for 3-6 months is a sufficient indication for surgical treatment, not depending on FNA result, particularly when a suspected nodule becomes bigger than 30 mm in diameter.

[Parathyroid neoplasm--diagnostic challenge and therapeutic difficulty]

The paper presents current diagnostic and therapeutic approach in parathyroid cancer. The suspicion of parathyroid cancer should be taken into account in patients with primary hyperparathyroidism symptoms (and elevated total and ionised calcium blood level and PTH blood level), present palpable cervical mass and enlarged cervical lymph nodes. Further diagnosis should be based on ultrasound of the neck (including power-Doppler ultrasound), subtraction 99mTc-MIBI and 123J scintigraphy, ultrasound-guided fine needle aspiration, and CT or MRI if necessary to assess the stage of the process. The elective surgical procedure should be primary 'en block' excision of the tumour with the unilateral thyroid lobe and the following loco-regional adjuvant radiotherapy. Patients who underwent surgical treatment due to parathyroid cancer require long-term follow-up as the risk of local recurrence or distant metastases (mostly into lungs or bones) remains high even many years after initial operation. Patients with dissemination usually suffer from severe hypercalcemia leading to death if untreated correctly. Thus, so crucial is effective treatment of hypercalcemia (diuresis, biphosphonates, calcitonine, oktreotide).

[Retrosternal parathyroid gland cystic neoplasm as a cause of primary hyperparathyroidism]

Parathyroid carcinoma is a rare cause of primary hyperparathyroidism (1-2%). In this paper a case of parathyroid cancer of the right inferior parathyroid gland cyst (5 cm in diameter) localised mostly retrosternally is presented in a patient suffering from severe hypercalcaemia (Ca--3.7 mmol/l, Ca(++)--1.8 mmol/l), severe bone pains and weakness, huge osteoporosis with following L5 compression fracture and recurrent nephrolithiasis. PTH blood level before surgical treatment was 1243 pg/ml (Norm: 10-60 pg/ml). In the preoperative ultrasonography of the neck, a lesion was found, but it was considered to be a cyst in the inferior pole of the right thyroid lobe. In a fine-needle biopsy from the lesion-colloid mass without any cells was found. In a 99mTc-MIBI scintigraphy of the neck a suspicion of focus lesion in the right superior parathyroid gland was made, which was not confirmed intra-operatively. Parathyroid carcinoma was diagnosed intraoperatively in histological examination. 'En block' resection of the retrosternal parathyroid tumor and right thyroid lobe was performed from the jugular incision. Any enlarged jugular lymph nodes were not found. In a postoperative period a transient hypocalcaemia was present, which disappeared after pharmacological treatment. During 32 months of follow-up neither no features of local recurrence nor distant metastases were found. Calcium level in blood was normal, PTH 216.0 pg/ml, severity of bone pains and weakness lessened, osteoporosis in a course of pharmacological treatment--with no further progress.

[H"urthle cell thyroid neoplasms]

The paper presents up to date knowledge about oncocytic neoplasms (Hürtle cell tumor). The following paper is based on the biggest study group in Poland. Most of these tumors were benign. The histopathological diagnosis was usually very difficult. The authors pointed out that the most important problem in the treatment process was the histopathological examination. Even intraoperative pathological diagnosis is not discriminative for the diagnosis. All diagnoses were based on paraffin-embedded samples examination. In the authors' opinion treatment process should be individualised according to all clinical and histopathological results.

[Evaluation of autonomic nervous system function with heart rate variability analysis in patients with hyperthyroidism and during euthyroidism after pharmacologic and surgical treatment]

The aim of the present study was both to estimate autonomic nervous system (ANS) function in patients with hyperthyroidism by the heart rate variability (HRV) analysis and to evaluate the impact of pharmacological and surgical treatment on the ANS function. Analysis of the HRV underwent 10 female patients in course of thyreotoxicosis and after reaching full clinical and biochemical euthyroidism, after pharmacological therapy and in month after surgical treatment. The 10 minutes records at rest, in horizontal position were evaluated. The HRV parameters like mean of the heart rate, mean of RR intervals, standard deviation of all normal RR intervals (SDNN), range of the heart rate variability, low frequency (LF), high frequency (HF) components of the heart rate power spectral density and LF/HF ratio were assessed. The results were compared to those obtained from 10 age-, sex-, and body mass index-matched control subjects. The statistical significance (p < 0.05) was found in reduction of range of RR intervals, in increase of LF/HF ratio and in decrease of SDNN in hyperthyroidism in comparison to the control group (151.6/346.8 ms; 2.4/0.74; 24.4/57.2 ms2). In course of pharmacological euthyroidism there were statistically significant (p < 0.05) increase of range of RR intervals, reduction of LF/HF ratio and increase of SDNN in comparison to hyperthyroidism (270/151.6 ms; 0.995/2.4; 39/24.4 ms2). In euthyroidism after surgical treatment all the above parameters kept the similar levels as in pharmacological euthyroidism (no statistical significance for p < 0.05). On the base of the outcomes it was considered that in hyperthyroid patients there is advantage of sympathetic part of ANS over parasympathetic one which is due to sharp reduction of parasympathetic system activity. Pharmacological therapy with thyreostatics normalises balance of ANS to the level of the control group and after surgical treatment the balance keeps the same. Moreover, in the estimation of ANS as important as LF/HF ratio is the mean range of RR intervals.

[Perioperative mortality for perforated duodenal and gastric ulcer--analysis of 226 patients]

Between 1988 and 1997 in 226 patients (169 males--75.2% and 57 females--24.8%) surgical treatment was performed due to duodenal ulcer perforation (205 cases--90.7%) or gastric ulcer perforation (21 cases--9.3%, including 3 cases of perforated gastric cancer). Mean age was 51.5 years (19-94 years). In perforated duodenal ulcer the main procedure was truncal vagotomy with pyloroplasty performed in 95.6%, and simple ulcer suture in 4.4%. In perforated gastric ulcer the main procedure was Billroth I (Rydygier) stomach resection performed in 76.18%, and simple ulcer suture in 23.82%. A group of patients who died in perioperative period (29 cases--12.8%) was selected and compared to a group of others regarding age, sex, smoking, alcohol abuse, time elapsing between first symptoms and surgical treatment, use of NSAIDs, location and size of perforation hole, type of surgical procedures. On that basis 4 risk factors of disease in perioperative period due to perforated ulcer surgery were appointed: 1. Age--mean age of patients who died was 67 years (vs. 48.9 years among successfully treated), perioperative mortality in patients over 60 years old was 35.4%, and in patients over 70 years old was 50%). 2. Presence of three or more coexisting diseases--54.54% risk of disease (vs. 2.5% in patients with less than three or without coexisting diseases). 3. Delay in surgical treatment over 24 hours--48.15% of diseases vs. 7.04% in patients undergoing surgery within the first 24 hours following perforation. 4. Septic shock--80% of diseases.

[Diagnosis and treatment approach in anaplastic thyroid carcinoma]

The paper presents diagnosis and treatment of anaplastic thyroid cancer based on the own experience and literature review. There were presented up to date diagnosis and treatment which included radical thyroidectomy and radio-, chemio-, and hormonotherapy. The results of radical thyroidectomy and teleradiotherapy in anaplastic thyroid carcinoma are not satisfactory.

[Treatment approach for substernal and intrathoracic goiter. Personal experience]

The retrospective analysis of 489 cases of substernal and intrathoracic goiters among 4122 patients undergoing surgical treatment between 1984 and 1996 due to various thyroid gland diseases including clinical data, surgical technics and early postoperative complications was performed. The surgical procedures of substernal and intrathoracic goiter amounted to 11.9% of all thyroid gland surgery. In 468 (95.5%) patients goiter was situated substernally, in 22 (4.5%) intrathoracicaly. The mean age and time of goiter growth in that location exceeded over 10 years the location of goiter within the neck. In preoperative examination the X-ray of chest and trachea were essential. Routine ultrasonography and thyroid gland scyntigraphy were scarcely helpful as the retrosternal and mediastinal region were often omitted. The jugular access was dominant (98.6%), sternotomy was performed in 1.4% of cases due to big disproportion between size of the goiter and size of the upper inlet into the chest. The surgical complications, similarly as in goiter within the neck (no cases of pneumothorax were observed), included the single-side paresis of recurrent laryngeal nerve in 3.7% of patients, in 0.2% hypoparathyroidism, in 1% bleeding requiring reoperation and in 0.2% esophageal fistula (self-healed). The surgical treatment of retrosternal and intramediastineal goiter was safe and a total number of complications was comparable to that one in a group of patients under-going surgery due to goiter within the neck. Most of surgical procedures was possible to perform using the jugular access. In a small number of cases because of difficulties related to the anatomical conditions the access was reached through the oblong sternotomy.

[Postoperative wound infections. IV. Flora and clinical course of postoperative wound infection]

Each wound infection may be coursed in few clinical manifestations and may concern either skin with subcutaneous tissue (superficial infection) or deeper layers-fascias, muscles (deep infection). The aim of this study was to evaluate the form of infection and its clinical course, and moreover, to find the specific flora of infected wounds. The material was 1527 surgically treated patients in the 3rd Surgical Department of the Collegium Medicum of the Jagiellonian University during one year. 66 patients with wounds of the head and 7 patients who died within first three days after surgery without wound infection signs were excluded from the study population. The healing of each wound was observed during the patient's hospitalisation and 30 days after discharge from hospital, and in orthopedic patients 6 months after discharge. The total number of 132 infected wounds was identified. The population of 1352 wounds healed without any complications was a control group. All the data were recorded in a Wound Infection Register Card and were collected in the computer database. The data were statistically analysed. Relationships between single factors and postoperative wound infection were evaluated using chi-square statistics and in the small number Fisher's exact probability test. Analysis of variance was used for continuous variables. Odds ratios and corresponding 95% confidence intervals were computed for all variables. Postoperative wound infection was found in 132 (8.9%) cases, including 76 (57.6%) in males and 56 (42.4%) in females. The average age was 50.9 years. The period of hospitalisation ranged from 3 to 119 days, with the mean of 31.9 days in comparison to 16.3 days in the control group.

[Postoperative wound infections. III. Patient related risk factors]

A nosocomial infection is determined by plenty of factors, such as a kind of flora and its virulence, hygiene standard, efficacy of material and instruments sterilisation, technical terms of work organisation in hospital, and other staff and patient related factors. The aim of this study was to establish the risk factors of postoperative wound infection related to patient. The material was 1527 surgically treated patients in the 3rd Surgical Department of the Collegium Medicum of the Jagiellonian University during one year. 66 patients with wounds of the head and 7 patients who died within three days after surgery without any wound infection signs were excluded from the study population. The healing of each wound was observed during the patient's hospitalisation and 30 days after his discharge from hospital, and in orthopedic patients 6 months after discharge. The total number of 132 infected wounds was identified. The population of 1352 wounds healed without any complications was a control group. All the data were recorded in a Wound Infection Register Card and were collected in the computer database. The data were statistically analysed. Relationships between single factor and postoperative wound infection were evaluated using chi-square statistics and in the small group Fisher's exact probability test. Odds ratios and corresponding 95% confidence intervals were computed for all variables. The overall wound infection rate was 8.9%. The significant factors (p < 0.05) were radiotherapy prior to operation, malnutrition, renal failure, respirator treatment, colostomy, tracheostomy in contaminated wounds and neoplastic disease in dirty wounds. Antibiotic therapy and the presence of remote active infection at the time of operation were found also risk factors.

CONCLUSION

Statistically significant risk factors of the postoperative wound infection related to patient's condition appeared malnutrition, radiotherapy prior to surgery, renal failure, artificial ventilation, presence of colostomy and coexisting another nosocomial infection at the operation.

[Metastasis of kidney clear cell carcinoma to the thyroid cell in patients on renal replacement therapy]

The paper presents 2 cases of metastases of clear cell carcinoma of kidney into thyroid gland in patients on renal replacement therapy. In one patient after bilateral nephrectomy due to renal clear cell carcinoma (in 15 years time interval) and in second patient after left-side nephrectomy performed 16 years earlier and terminal right kidney insufficiency due to nephropathy with nephrotic syndrome for a year. In diagnosis essentials were: physical signs--palpable single node within the thyroid gland, earlier neoplastic anamnesis, cold node in scintigraphy, hypoechogenic node in ultrasonography of the thyroid gland, particularly with a rich vascular net within the node in power-doppler examination and, at last cytology of material from ultrasound-guided fine needle biopsy of the node. The diagnosis had been confirmed in intraoperative histopathological examination before the total thyroidectomy was performed.

[Intrathoracic goiter as a cause of superior vena cava syndrome]

Between 1984 and 1997 year 4985 patients underwent surgical treatment due to various thyroid gland diseases, among them were 28 (0.6%) patients with intrathoracic goitre, but only in one case (0.002%) the signs of superior vena cava syndrome (SVCS) were observed: oedema and lividity of the face, enlargement of jugular veins and superior limbs' veins. In addition the patient manifested subsequently growing dyspnoea, dysphagia and hoarseness. In diagnose essential were X-ray examination of the chest (widening of mediastinal shadow), X-ray examination of the trachea (dislocation and compression of the trachea), X-ray of esophagus with contrast (compression from the outside), ultrasonography of thyroid gland. Intraoperatively, after it was confirmed that the SVCS was caused by compression of the intrathoracic right lobe of thyroid gland, the oblong sternotomy was performed to provide the proper surgical access for subtotal thyroidectomy. The weight of resected tissues of thyroid gland was 1036 g. In histopathological examination the diagnosis of multinodular toxic goitre was confirmed.

[Hodgkin's disease in the thyroid gland]

The paper presents one case with diagnosed the primary extra-nodular Hodgkin's disease in the thyroid gland. Patient was operated on. Hodgkin's disease was diagnosed postoperatively in the paraffin-embedded tissues. In authors' opinion progress in the imaging technics with fine-needle aspiration biopsy allows to formulate diagnosis, and treatment which includes chemo- and radiotherapy, improves survival.

[Postoperative wound infections. I. Population data and risk factors]

Postoperative wound infection is one of the most essential problems in surgical department related to surgery. The occurrence of infection depends on different factors related to both, the patient and his disease, and treatment organisation as well. The aim of this study was to establish the postoperative wound infection rate and to assess the correlations between age, sex, wound contamination, time and mode of operation, type of anaesthesia, duration of preoperative hospitalisation, wound drainage and the season of the year and development of postoperative wound infections. Patients undergoing surgery in the 3rd Surgical Department of the Collegium Medicum of the Jagiellonian University during one year were prospectively investigated. From the study population, 66 patients with, wounds of the head and 7 patients who died within three days after surgery without wound infection signs were excluded. The healing of each wound was observed during the patient's hospitalisation and 30 days after discharge from hospital, and in orthopedic patients 6 months after discharge. The total number of 132 infected wounds was identified. The population of 1352 wounds healed without any complications was a control group. All the data were recorded in a Wound Infection Register Card and were collected in the computer database. The data were statistically analysed. Relations between single factor and postoperative wound infection were evaluated using chi2 statistics and in the small number Fisher's exact probability test. Analysis of variance for continuous variables was used. Odds ratios and corresponding 95% confidence intervals were computed for all variables. The overall wound infection rate was 8.9%. The mean hospitalisation time was 18 days and was doubled in the group with wound infection (p < 0.001). The mean age of the whole population was 48.1.77 (5.2%) patients died after surgery. The relationship between sex, duration and mode of operation, duration of preoperative stay in hospital, wound contamination, kind of wound drainage and postoperative wound infection rate was significant.

CONCLUSIONS

1. The time of hospitalisation was twice longer in the infected group of patients with infected wounds in comparison to the control group. 2. Male sex, longer preoperative stay in hospital, duration of operation longer than one hour, emergency mode of operation, contaminated and dirty infected operation in traditional wound classification system and open (passive) drainage were statistically significant factors which influenced occurrence of postoperative wound infection.

[Neurilemmoma in the thyroid region]

In the paper we present the group of 3 patients with neurilemmoma. Patients were operated on because of simple nodular goiter transformed into the thyroid carcinoma. In all cases final diagnosis was based on postoperative paraffin-embedded tissues. In the authors' opinion modern imaging technics strictly allows to formulate the preoperative diagnosis. Total resection with special attention paid to the postoperative examination including ultrasound diagnostics improve survival.

[Surgical treatment of secondary hyperparathyroidism in patients treated with renal replacement]

Between January 1990 and July 1997, in 15 maintenance dialyzed patients and in 3 patients after renal transplantation manifesting hyperparathyroidisms surgical treatment was performed. The diagnosis was based both on the estimation of serum PTH level, total and ionised calcium, phosphates, alkaline phosphatase and imaging procedures: ultrasonography and 99-mTc subtraction scintigraphy. Indications to surgical treatment included ailments like generalized prurigo, bone and joint pains and muscular weakness with no response to pharmacological treatment. The commonly used procedure was subtotal parathyroidectomy (94%), its extent, however, was in each case determined during surgery, depending on the quantity and size of parathyroid glands found. In all cases the immediate intraoperative histopathological examination of the resected tissues was performed. In 10 patients resection of the thyroid gland tissues was carried out because of goiter (56%), among them in 1 case occult papillar carcinoma was found in histopathological examination. In the postoperative period 4 patients (22%) manifested transient hypocalcemia with good response to pharmacological treatment. Good results of surgical treatment reflected by both ailment relief and normalization of serum PTH and phosphates were obtained in 16 patients (89%). In 2 patients (11%) the ailments subsided but did not completely disappear. Surgical treatment of secondary hyperparathyroidism by subtotal parathyroidectomy is efficacious and entails a low risk of complications.

[Postoperative wound infections. II. Risk factors related to surgery]

Postoperative wound infection is the most frequent complication of surgical treatment. The occurrence of infection depends on many factors, but the most important is bacterial contamination of wound according to the site of operation. The aim of this study was to establish wound infection rate and to determine the relationship between site of operation, wound contamination and the other surgery related factors and postoperative wound infection risk. The material was 1527 surgically treated patients in the 3rd Surgical Department of the Collegium Medicum of the Jagiellonian University during one year. From the study population were excluded 66 patients with wounds of the head and 7 patients who died within three days after surgery without wound infection signs. The healing of each wound was observed during the patient's hospitalisation and 30 days after discharge from hospital, and in orthopedic patients 6 months after discharge. The total number of 132 infected wounds was identified. The population of 1352 wounds healed without any complications was a control group. Data were recorded in a Wound Infection Register Card and were collected in the computer database. The data were statistically analysed. Relations between single factor and postoperative wound infection were evaluated using chi2 statistics and in the small group Fisher's exact probability test. Odds ratios and corresponding 95% confidence intervals were computed for all variables. The overall wound infection rate was 8.9%. The significant factors (p < 0.05) were gastrointestinal operation, reoperation, intraoperative X-ray examination, haematoma of the wound after operation, skeletal traction prior to surgery and implantation of prosthetic material in clean wounds.

CONCLUSIONS

1. Wound contamination, site of operation (GI tract), open drainage, reoperation, intraoperative X-ray examination and postoperative haematoma of the wound are statistically significant risk factors which influence postoperative wound infection rate. 2. Postoperative haematoma of wound is the most important local risk factor of wound infection after surgery.

[Chromosome aberrations in patients with papillary thyroid cancer and other neoplasms]

Cancer is essentially a genetic disease resulting from congenital or acquired alterations in some cells of the patient. Such changes may occur in particular oncogens and are responsible for the tumour phenotype of the affected population of cells. In contrast, unaltered tumour-suppressor genes are responsible for suppressing the neoplastic phenotype, and their inactivation by deletion or mutation permits cancerous development in the affected cells. The genetic model of carcinogenesis is based on the idea mutations at the DNA level, what creates a functional imbalance between the oncogenes and the tumour-suppressor genes, resulting in uncontrolled clonal proliferation. The ret/PTC oncogene is unique to papillary thyroid cancer. The paper presents a correlation analysis between chromosomal changes in papillary thyroid cancer and abnormalities of chromosomes in patients with breast cancer and chronic lymphocytic leukemia.

[Metastasis of clear cell carcinoma of the kidney to the thyroid gland]

We preset three patients operated on at our hospital with diagnosed metastasis clear cell carcinoma of the kidney to the thyroid gland 5, 6, and 9 years after nefrectomy. Patients were operated on because of nodular goiter and metastases were diagnosed intraoperatively (frozen section) at two cases and postoperatively in the remaining care (diagnosis made by pathologist-microscopic examination). A radical thyroidectomy was employed without chemio- or radiotherapy which is now recommended as a method of treatment of clear cell carcinoma metastasis.

[Primary malignant lymphoma of the thyroid gland--diagnosis and treatment tactics]

The paper presents clinical signs, diagnosis, treatment and therapeutic results in the group of 10 patients with at primary malignant lymphoma of the thyroid gland. There were presented up to date methods of diagnosis and treatment with includes chemio- and radiotherapy. In authors opinion progress in imaging technics cyto- and histopathology, and potentiality of complex treatment allows us to avoid from surgery in most cases of malignant lymphoma of the thyroid.

[Modern possibilities of preventing postoperative goiter recurrence]

The authors present an analysis of the material of 84 patients operated on in the years 1979-1992 for non-malignant recurrent goitre. The method of management and treatment results are presented. The schema of management is also described in prevention of goitre recurrences, involving correctly performed operation, periodical control examination, and routine postoperative administration of thyroid preparations. The use of hormonal prophylaxis (L-Thyroxin) in suppressive doses, under TSH control seems to have a significant influence on the reduction of the number of recurrences.

[Mortality in acute appendicitis. (Risk yesterday and today)]

An analysis is presented of deaths of patients operated on in the III Department of Surgery, Medical Academy in Cracow, for acute appendicitis (AA). In the years 1980-1988 962 patients were operated on with preliminary diagnosis of AA which was confirmed intraoperatively in 749 cases. In the group of patients with AA confirmed intraoperatively 14 patients died (1.9%). The most frequent postoperative complications and, at the same time, the most important cause of death were purulent complications. In the paper a detailed analysis is presented of all cases of AA leading to death. It is stressed that advanced age and extensiveness of inflammatory changes are significant factors of high risk of death.

[Ectopic pancreas treated surgically as a suspected gastric polyp]

A very rare case is described in which the preoperative diagnosis was: gastric polyp, and the histological examination done intraoperatively demonstrated accessory pancreas.