Prospective randomized trial of clips versus subcuticular polydioxanone for neck wound closure.
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Humans↗
Biomedical subjects
Z H Krukowski
Publications and source records attributed to Z H Krukowski.
Pancreatic tissue in a lateral cervical cyst attached to the thyroid gland--a presumed foregut remnant.
AIM: To report the previously undescribed occurrence of a lateral neck cyst, attached to the thyroid gland, containing pancreatic tissue. METHODS AND RESULTS: A 41-year-old man presented with a recurrent cystic lesion of the thyroid. At thyroidectomy cystic masses containing mucinous material were present in the neck, and there was a nodular lesion attached to the lower pole of the thyroid. Histological examination of the latter lesion revealed an epithelial lined cyst, with pancreatic tissue (exocrine and endocrine) in addition to fat, fibrous tissue, muscle and cartilage in the wall. CONCLUSIONS: The possible origin of this structure is discussed, with the conclusion being that it most likely represents a foregut remnant.
Adult↗
Theatre usage for emergency surgery--use or abuse?
A prospective study was performed to characterise the activity in the designated Emergency Operating Theatre of a fourteen hundred bed teaching hospital. The main conclusion was that a large group of non-emergency but non-elective patients undergo surgery in this facility. The study has shown that in this hospital, despite apparently adequate emergency facilities including a separate orthopaedic trauma theatre, additional theatre time equivalent to six designated theatre sessions would be required to optimise the management of these patients who are often elderly and require major surgery.
Adolescent↗
Risk of contamination from laparoscopic carbon dioxide insufflators.
Ten high flow laparoscopic carbon dioxides insufflators were examined to determine whether there was significant particulate or bacterial contamination of the gas delivered to patients. The gas delivery tubing and connections in the insufflators were also examined for the presence of bacterial colonization and for evidence of retrograde passage of body fluids to the insufflator. Metallic particulate debris was recovered from gas from all 10 insufflators. Staphylococci were recovered from the insufflated gas from one insufflator and from the internal tubing of three insufflators. Swabs from the internal tubing of two insufflators showed evidence of contamination by blood. The metallic particulate contamination of the insufflated gas may not be of clinical significance but the presence of bacteria and blood is a concern. Simple measures to minimize the risk of retrograde flow of gas and fluid to the insufflator should be followed and the provision of a filter between the patient and the insufflator is recommended.
Carbon Dioxide↗
Magnetic resonance imaging of thyroid swellings.
The preoperative diagnosis of some thyroid neoplasms remains difficult even with the routine use of fine-needle aspiration cytology. The potential of nuclear magnetic resonance imaging (MRI) to discriminate between different thyroid pathologies was explored prospectively and compared with the final pathology in a series of 37 patients. MRI yielded high-quality images of the thyroid swelling but did not provide additional information to differentiate benign from neoplastic lesions. MRI does not contribute to the routine management of thyroid swellings.
Carcinoma, Papillary↗
Laparoscopic trans-peritoneal adrenalectomy: a preliminary report of 14 adrenalectomies.
OBJECTIVES: Laparoscopic adrenalectomy offers the potential benefits of a smaller operation with more rapid hospital discharge, compared to open surgery. Only a few small series have been reported so far. We describe our preliminary experience of 14 adrenalectomies using this new technique. DESIGN: Review of all adrenalectomies (with the preoperative intention of laparoscopic removal) performed in an endocrine unit whose surgeon already had abdominal laparoscopic experience, particularly with cholecystectomy. PATIENTS AND MEASUREMENTS: Twelve patients (3 with Conn's syndrome, 3 Cushing's syndrome, 1 Cushing's disease, 2 phaeochromocytomas and 3 adrenal incidentalomas) were operated between September 1993 and February 1996. Operating times, operative technique, time from surgery to discharge, outcome and all complications were recorded prospectively. Comparative data were obtained from 14 consecutive open adrenalectomies performed by the same surgeon between February 1989 and February 1995. RESULTS: Fourteen glands were removed, two with a cholecystectomy, in 12 operations. Operating time (mean (range) 120 (60-225) min) was reduced with experience. Positioning the patient in the right lateral position facilitated left adrenalectomy. Time to discharge (mean (range)) was 5.3 (1-12) days. There were relatively minor complications in three patients, including two with Cushing's syndrome: a hernia at a port site, intra-peritoneal/wound haemorrhage and a pressure sore. Time to discharge for open adrenalectomy (mean (range)) was 6.5 (2-11) days and one case was complicated by wound infection. CONCLUSIONS: Laparoscopic adrenalectomy is a practical technique for appropriately trained surgeons who regularly undertake adrenalectomy. The smaller incisions offer potential advantages, particularly for patients with poor tissue quality due to Cushing's syndrome, but tissue haemorrhage may still be a problem in these patients. Time to hospital discharge was similar to that for open surgery.
Adenoma↗
Malignant obstruction of the left colon.
The management of malignant obstruction of the colon distal to the splenic flexure is controversial. The 'traditional' three-stage procedure is marred by frequent failure to complete the planned sequence of operations and a resulting high permanent stoma rate. At each stage the mortality rate (7 per cent) and morbidity rate (30 per cent) are significant. The mortality rate following primary resection with delayed anastomosis (Hartmann's procedure) is 10 per cent. However, many patients experience complications and only 60 per cent have the stoma reversed. Primary anastomosis may be performed after subtotal or segmental colonic resection. The reported mortality rate is about 10 per cent with anastomotic leakage in 4-6 per cent, but cases are often carefully selected. It is difficult to suggest clear guidelines based on existing data. Although there are strong arguments in favour of a single-stage procedure, surgeons must decide whether available resources and local circumstances permit this. The alternative is Hartmann's procedure or referral to a surgeon with an interest in emergency colorectal surgery.
Anastomosis, Surgical↗
Radiological investigation in acute diverticulitis.
Optimal management of acute sigmoid diverticulitis depends on evaluation of the severity of the inflammatory process, in which radiological investigation is a useful but probably underutilized adjunct to clinical assessment. Plain abdominal radiography shows abnormalities in 30-50 per cent of patients but these tend to be non-specific and more accurate information is obtainable from a contrast enema. Although the quality of images produced by a water-soluble contrast agent is inferior to that with barium, the former is less hazardous in the presence of perforation and provides sufficient information to permit rational management decisions to be made. Ultrasonography and computed tomography (CT) are particularly useful in visualizing abscesses. They may be helpful in following the progression or resolution of suppuration and in guiding percutaneous aspiration when appropriate. Despite early reports to the contrary, CT is no more specific than a contrast enema in the diagnosis of acute diverticulitis. Radionuclide scans have little role in the routine assessment of acute diverticulitis and magnetic resonance imaging has not been adequately evaluated. Water-soluble contrast enema is safe, widely available and probably the most useful early supplementary investigation.
Barium Sulfate↗
Thyroid neoplasia coexistent with chronic lymphocytic thyroiditis.
During a 6-year period 115 patients presenting with thyroid enlargement had evidence of chronic lymphocytic thyroiditis on fine-needle aspiration cytology. Of 27 patients in whom histological analysis was carried out, 16 had neoplasms (follicular adenoma, four; follicular carcinoma, one; papillary carcinoma, four; lymphoma, seven). Assuming that neoplasia was not overlooked in the absence of histological examination, the overall incidence was 14 per cent and that of malignant disease 10 per cent. All patients with carcinoma had cytological features suspicious of neoplasia on the first or subsequent aspirates in addition to those of thyroiditis. Cytology was suspicious of lymphoma in only two of seven patients but increasing size of the thyroid swelling was a consistent feature. Evidence of chronic lymphocytic thyroiditis may lead to neoplasia being overlooked. Repeated cytological analysis is helpful in identifying coexistent carcinoma but unreliable in excluding lymphoma.
Adenocarcinoma, Follicular↗
Free intra-peritoneal gall-stones following laparoscopic cholecystectomy.
Laparoscopic cholecystectomy is now the operation of choice for symptomatic gall-bladder stones. Two cases of retained free intra-peritoneal gall-stones following this procedure are described; the first resulting in a peritoneal granuloma and causing initial confusion in diagnosis, and the second seen incidentally in a biloma. In the appropriate clinical setting free intra-peritoneal gall-stones must be added to the differential diagnosis of abdominal and pelvic calcification.
Aged↗
The role of intravenous cholangiography in pre-operative assessment for laparoscopic cholecystectomy.
With the advent of laparoscopic cholecystectomy, pre-operative identification of calculi in the common bile duct has become increasingly important. In patients without clinical or biochemical evidence of common bile duct calculi, debate continues as to the value of intravenous cholangiography (IVC) as a screening modality for the detection of unsuspected choledocholithiasis. In a prospective series of 180 patients, IVC was used to assess the common bile duct in 113 patients at low risk of choledocholithiasis, 51 patients at high risk underwent endoscopic retrograde cholangiography (ERC) and sphincterotomy if indicated, and in 16 patients, for a variety of reasons, no pre-operative cholangiography was performed. 31% of those who had ERC and two (1.8%) of those who had IVC had duct calculi. These data do not support the routine use of IVC in patients with no evidence of common bile duct calculi and its routine use has been discontinued.
Adolescent↗
Risk of neoplasia and malignancy in "dominant" thyroid swellings.
OBJECTIVE: To determine the risk of neoplasia and malignancy in "dominant" thyroid swellings. DESIGN: Prospective analysis during six years. SETTING: Thyroid clinic serving the Grampian region. PATIENTS: 574 consecutive patients presenting with a discrete thyroid swelling, of whom 179 (31%) were classified clinically as having a dominant area of enlargement within a multinodular gland. RESULTS: After clinical and cytological assessment 77 dominant swellings were excised. Of the excised swellings, 45 were non-neoplastic and 32 neoplastic, including 11 malignant lesions. The minimum incidence of neoplasia and malignancy in all 179 dominant swellings was therefore 18% and 6% respectively. CONCLUSION: Dominant thyroid swellings should be regarded with greater clinical suspicion than has been traditional.
Adolescent↗
DNA aneuploidy in follicular thyroid neoplasia.
The potential value of DNA aneuploidy, in distinguishing benign from malignant follicular thyroid neoplasms, was studied. The nuclear DNA content of 65 follicular thyroid neoplasms (52 adenomas and 13 carcinomas) was determined by flow cytometric analysis of paraffin embedded material; in 58 cases preparations were technically satisfactory. In 22 follicular neoplasms DNA analysis was also performed on fresh material obtained by fine needle aspiration of surgical specimens. Cell cycle analysis was performed on both fresh and fixed specimens. An aneuploid DNA profile was found on analysis of fixed tissue in eight of 45 (18 per cent) follicular adenomas and four of 13 (31 per cent) follicular carcinomas. DNA aneuploidy was also found in six of the 22 (27 per cent) fresh preparations from follicular adenomas. The frequency of DNA aneuploidy in apparently benign and malignant follicular neoplasms was similar. Follicular thyroid neoplasia are best regarded as a single entity with a low incidence of local and distant spread. All follicular neoplasia are therefore best excised.
Adenocarcinoma↗
Management of isolated thyroid swellings: a prospective six year study of fine needle aspiration cytology in diagnosis.
OBJECTIVE: To audit the accuracy and impact on the frequency of operation of fine needle aspiration cytology of isolated thyroid swellings. DESIGN: Prospective analysis over six years of cytological predictions compared with histological findings. SETTING: Thyroid clinic serving the Grampian region. PATIENTS: 395 Consecutive patients presenting with an isolated thyroid swelling, 307 of whom underwent surgical excision. Analysis was confined to a subgroup of 283 patients with satisfactory aspirates who were operated on. RESULTS: The positive predictive value of aspiration cytology for detecting malignant disease was 100% and the sensitivity 83%. The sensitivity for the detection of neoplasia (frank malignancy together with follicular adenomas) was 76%. The specificity was 58% and the overall accuracy 69%. Recalculation of data in previous papers with strict criteria showed the accuracy of aspiration cytology to be variable and lower than is widely accepted. Since the introduction of aspiration cytology 21% fewer operations for isolated thyroid swellings have been performed. CONCLUSIONS: As a basis of selection for surgical excision of isolated thyroid swellings according to prediction of neoplasia fine needle aspiration cytology is less reliable than is widely accepted. It is an adjunct to management rather than a definitive test, and negative cytological results do not exclude neoplastic disease. Further study should take account of the implications of repeated clinic attendances for review and aspiration as these may culminate in delayed surgical treatment.
Biopsy, Needle↗
Single layer anastomosis in the upper gastrointestinal tract.
A total of 466 single layer upper gastrointestinal anastomoses were made in 349 patients during an 11-year period. Six (1.3 per cent) anastomoses leaked. Radiological leakage was seen in one of 24 (4.2 per cent) oesophagogastric/jejunal anastomoses. There were no leaks after 66 gastrojejunal anastomoses; one of 84 (1.2 per cent) gastroduodenal anastomoses leaked and was converted to a gastrojejunal anastomosis. Two of 121 (1.7 per cent) biliary-enteric anastomoses leaked and both were successfully managed without reoperation. Two of 171 (1.2 per cent) enteroenteric anastomoses leaked, both in patients with established intraperitoneal sepsis which proved fatal. Of the 349 patients, 13 (3.7 per cent) died in hospital or within 30 days of operation but in only two was anastomotic leakage implicated. Single layer appositional upper gastrointestinal anastomoses are simple, safe and economic.
Anastomosis, Surgical↗
Comparison of flow cytometry with static densitometry in papillary thyroid carcinoma.
The prognostic accuracy of flow cytometric and static densitometric DNA analysis was compared in 31 patients who had undergone surgery for papillary thyroid carcinoma between 1959 and 1978 (median follow-up 18 years). There were five deaths from papillary thyroid carcinoma. Three of six patients with DNA aneuploid tumours on flow cytometry died (P greater than 0.05, Fisher's exact test) compared with four of eight patients whose tumours were found to be aneuploid by static densitometry (P less than 0.02). When quantitative analysis was applied to the static densitometry data, all five patients who died from papillary carcinoma were distinguished, with no false positives (P less than 0.002). The prognostic accuracy of flow cytometric DNA analysis is less than that of static densitometry in which morphological selection of malignant cells permits quantitative measurements. DNA analysis may add refinement to existing scoring systems in predicting the risk of death from papillary thyroid carcinoma. Such information could provide the basis for controlled prospective evaluation of bilateral resection as opposed to lobectomy in defined high risk patients. At present there is insufficient evidence upon which aneuploidy should be used as a determinant of the extent of operation for papillary thyroid carcinoma.
Adult↗
Percutaneous gastrostomy; a simpler technique.
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Endoscopy, Gastrointestinal↗
Definitive one-stage emergency large bowel surgery.
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Anastomosis, Surgical↗