Surgical treatment of hyperparathyroidism : with an analysis of 267 cases

It is generally accepted that for autonomous hyperparathyroidism, whether primary or tertiary, surgery is still the only suitable method of treatment available. Analysis of a series of cases treated in t his way over the past twenty years has shown that there are certain problems associated with the treatment of this disease that have not yet been solved. Even experienced surgeons may have difficulty in finding the parathyroid glands when the localization or number is abnormal. The histological differentiation between nodular hyperplastic, and adenomatous parathyroid tissue may be extremely difficult, sometimes even impossible. It is just this difference that might determine the amount of resection and the postoperative course. Furthermore, in some cases it is exceedingly difficult for the surgeon to judge whether a parathyroid is of normal size and has a normal appearance. Lastly, the etiology of primary hyperparathyroidism is still unknown. In the present work the findings in 267 patients treated surgically between 1950 and 1970 are discussed and evaluated in relation to the data in the literature. Special attention is paid to the etiology of the disease, the histological picture, and the surgical technique. The symptomatology, diagnosis, and biochemical changes will only be mentioned briefly, since the problems associated with them are so numerous that they deserve separate treatment. A thesis on these subjects is in preparation in Leiden. Because the prognosis of associated disease, especially the renal, is the more favourable the earlier the diagnosis is made, some principles are given to promote earlier consideration of the diagnosis hyperparathyroidism in cases with few symptoms. The data of 267 patients who underwent an operation between 1950 and 1970 under the probability diagnosis hyperparathyroidism are discussed. These patients were treated in the Leiden University Hospital, the Leiden Diaconess Hospital, or the Rotterdam University Hospital. In 255 of t hese cases the diagnosis was confirmed at surgery and histologically

Regional ischemia in hypertrophic Langendorff-perfused rat hearts

Myocardial hypertrophy decreases the muscle mass-to-vascularization ratio, thereby changing myocardial perfusion. The effect of these changes on myocardial oxygenation in hypertrophic Langendorff-perfused rat hearts was measured using epimyocardial NADH videofluorimetry, whereby ischemic myocardium displays a high fluorescence intensity. Hypertrophic hearts, in contrast to control hearts, developed ischemic areas during oxygen-saturated Langendorff perfusion. Reoxygenation of control hearts after a hypoxic episode resulted in a swift decrease of fluorescence in a heterogeneous pattern of small, evenly dispersed, highly fluorescent patches. Identical patterns could be evoked by occluding capillaries with microspheres 5.9 micrometer in diameter. Ten seconds after reoxygenation there were no more dysoxic areas, whereas reoxygenation in hypertrophic hearts showed larger ischemic areas that took significantly longer to return to normoxic fluorescence intensities. Hypothesizing that the larger areas originate at a vascular level proximal to the capillary network, we induced hypoxic patterns by embolizing control hearts with microspheres 9.8 and 15 micrometer in diameter. The frequency distribution histograms of these dysoxic surface areas matched those of hypertrophic hearts and differed significantly from those of hearts embolized with 5.9-micrometer microspheres. These results suggest the existence of areas in hypertrophic Langendorff-perfused hearts with suboptimal vascularization originating at the arteriolar and/or arterial level

Imminent ischemia in normal and hypertrophic Langendorff rat hearts; effects of fatty acids and superoxyde dismutase monitored by NADH surface fluorescence

Hypertrophic hearts contain areas of hypoperfusion which can be visualized by increased NADH surface fluorescence during in vitro perfusion without oxygen-carrying particles under constant pressure and pacing. By contrast, fluorescence remained low when non-hypertrophic hearts were used instead. When during perfusion of normal hearts the pH of the medium was lowered from 7.5 to 7.0, areas of high fluorescence appeared in a few minutes. The high fluorescent areas under conditions of cardiac hypertrophy or pH 7.0 perfusion could be reduced by addtion of superoxide dismutase. It indicates that oxygen free radicals interfere with proper flow regulation in areas of low pH. Fluorescence in hypertrophic hearts also diminished during addition of albumin-bound oleate to the standard, glucose-containing, medium. This is in agreement with our earlier findin of fatty acid protection from acidosis-initiated loss of capillary flow (Biochim. Biophys. Acta, 1033 (1990) 214–218). In contrast to low concentrations of free fatty acids, high concentrations interfere with tissue oxygenation. This has been illustrated by the use of 1 mM octanoate, which after a few min caused the appearance of high fluorescent areas. We conclude that decompensation of flow in hypoperfused areas of heart, as occurs in hypertrophy, may be stimulated by acidosis and oxygen free radicals

Tonometry to assess the adequacy of splanchnic oxygenation in the critically ill patient

Tonometry, a relatively non-invasive technique for indirectly measuring the intramucosal pH (pHi) of the gastrointestinal tract, has recently been developed for use in critically ill patients. Reports in the literature suggest that the technique is of greatest benefit to patients at risk of developing reductions in splanchnic oxygenation (decreased O2 delivery) in whom early detection of the ischemic episode could possibly guide treatment. Tonometry, although still at a relatively early stage in its clinical development, could be of value for selected patient groups although further evaluation of the technique is necessary

Radiographic features of oral cholecystograms of 448 symptomatic gallstone patients: Implications for nonsurgical therapy

Since radiographic findings on oral cholecystography (OCG) have implications for the eligibility for nonsurgical therapy of elderly patients, we investigated the OCGs of 448 symptomatic gallstone patients (109 male, 339 female; mean age, 49.8 ± 14 (range, 21–88)). Opacification of the gallbladder was found in 323 cases (72.1%). Calcifications of gallstones were found in 85 opacified gallbladders (26.3%). Solitary and multiple stones were calcified in 35.3% and 18.2%, respectively (P 40 years), there was a significant increase in calcifications (P < 0.02) and a non-significant increase in opacification with increasing age. It is concluded that age is a determinant for calcification of gallstones and not opacification of the gallbladder. Since multiple stones are proportionately observed more in clinical studies than in epidemiologic studies, it is suggested that multiplicity of stones predisposes to biliary complaints. That solitary stones are more likely to be calcified than multiple stones, adds to the hypothesis that solitary and multiple stones have a different pathogenesis. Elderly patients, in whom nonsurgical therapy is most likely to be indicated and cost-effective, are less likely to be suitable for this form of treatment, since age is a determinant for stone calcification

Role of extracorporeal shock wave lithotripsy in hepato-biliary-pancreatic surgery

Since the early 1980s extracorporeal shock wave lithotripsy (ESWL) has partially replaced major operative procedures in various fields of surgery. In the interest of the patient, it is important to determine the exact role of ESWL in surgery. Comparing our own prospectively followed patients with other patient series, we have tried to assess this role. We treated 133 patients with cholecystolithiasis, 80 patients with choledocholithiasis, and 17 patients with pancreatic stones using a second- generation lithotriptor, the Siemens Lithostar (Siemens, Erlangen, Germany). The results suggest a limited role of ESWL for cholecystolithiasis, in which it is reserved for patients with high operative risk and patients who reject an operation. For choledocholithiasis ESWL seems to become an integral part of the treatment in the elderly patient in whom endoscopic stone removal proved impossible. Finally, ESWL could become a first option for the treatment of intractable pain in patients with chronic calcifying pancreatitis