Clinical Characteristics of ESRD Patients with Severe Hyperparathyroidism Who Undertook Surgical Parathyroidectomy / 대한신장학회잡지

BACKGROUND: Medical treatments such as restriction of phosphate, phosphate binder use, and active vitamine D therapy have been widely used for hyperparathyroidism in ESRD patients, and surgical parathyroidectomy should be considered in patients with uncontrolled hyperparathyroidism. METHODS: A retrospective study was performed in 24 ESRD patients with severe and uncontrolled hyperparathyroidism despite of medical treatment who undertook surgical parathyroidectomy in Severance hospital from 1990 to 1999. RESULTS: Sixteen patients had total parathyroidectomy with immediate autotransplant, 7 patients had subtotal parathyroidectomy and only 1 patient had minimally invasive parathyroidectomy. An excellent short-term control of hyperparathyroidism was achieved in all patients after parathyroidectomy. Preoperative bone and joint pain improved in 16 of 19 patients. Muscle weakness and pain improved in 11 of 17 patiens, malaise improved in 8 of 10 patients and pruritus improved in 10 of 13 patients. In addition, clinical laboratory finding improved after parathyroidectomy. No clinical differences were seen between 16 patients who undertook total parathyroidectomy with immediate autotransplant and 7 patients who undertook subtotal parathyroidectomy. Recurrence of hyperparathyroidism ocurred in 5 of 24 patients with 4 nodular hyperplasia and 1 diffuse hyperplasia in pathologic finding. The less degree of attenuated response of intact PTH levels immediately after operation was observed in 5 recurrent cases. CONCLUSION: Good results were obtained after parathyroidectomy. We believe that histologic subtype and the attenuated response of intact PTH after surgical parathyroidectomy could be possible predictors of the recurrent hyperparathyroidism.

The Patterns of Lateral Neck Node Involvement in Papillary Thyroid Carcinoma / 대한암학회지

PURPOSE: We performed this study to identify the patterns of lateral neck node involvement and to define the appropriate method of neck node dissection in papillary thyroid carcinoma. MATERIAL AND METHODS: One hundred seventy one patients who had undergone radical neck dissection for lateral cervical lymph node metastasis of papillary thyroid cancer from January 1986 to December 1995 were analyzed retrospectively. Total operations were 178 cases and total radical neck dissections were 206 cases (bilateral in 28 cases, unilateral in 150 cases). Of these 206 cases, group I (170 cases, 82.5%) who had undergone comprehensive radical neck dissection or modified radical neck dissection and group II (36 cases, 17.5%) who had undergone jugular neck dissection were studied. RESULTS: In group I, the most prevalent site of lymph node metastases was level III, followed by level II, IV, V and I. The 158 cases of group I in which nodes in the posterior triangle of the neck were not palpable preoperatively, were divided into five groups, 0, 1, 2, 3 and 4 or more, according to the number of clinically positive internal jugular nodes. The incidence of microscopically positive nodes in level V was significantly lower in the groups of one or less palpable internal jugular nodes (p=0.0007). In the 60 of 158 cases with the evaluable CT scans of the neck, the incidence of microscopically positive nodes in level V was significantly lower in the groups of two or less positive nodes on CT scan (p=0.0001). And, there were no significant differences in the incidence of recurrence, sites of recurrence, distant metastases, mortality between Group I and Group II. CONCLUSION: The modified radical neck dissection might be justified in most papillary thyroid cancer patients with clinically positive lateral neck nodes. However, in patients with only one or less palpable node and two or less positive nodes on CT scan along the jugular lymphatic chains but negative in level V, it appears to be beneficial to perform a jugular neck dissection in reducing cosmetic disfigurement and preserving function.

Insulinoma of the Pancreas

Insulinoma is the most common functioning tumor of pancreas even though its prevalence is rare. The diagnosis and the treatment of insulinoma is very important because the tumor can induce critical and permanent neurologic deficit. We experienced ten patients with insulinoma and treated by surgical interventions at the Department of Surgery, Yonsei university college of medicine from 1983 to 1996. All the data were analysed retrospectively. The mean age of patient was 45 years (range: 17 to 69) and the sex ratio of male to female was 1:2.3. The most common clinical manifestation was weakness. The preoperative mean levels of fasting blood sugar, plasma insulin, C-peptide, insulin to glucose ratio were 41(mg/dl), 40.07(U/ml), 4.03(ng/ml), 1.51, respectively. The detection rates of localizing tools on our cases were showed as follows: THPVS(100% in 5 cases), EUS(67% in 3 cases), MRI(33% in 3 cases), CT scan(33% in 9 cases), angiography(33% in 6 cases) and US (20% in 10 cases). The intraoperative ultrasound(IOUS) was performed in the last three cases to try to find occult insulinoma and the relationship with main duct of pancreas in operative field. The types of surgical interventions were enucleation in 5 patients, distal pancreatectomy in 4 patients, pancreatoduodenectomy in 1 patient. The tumors were located in nearly equal frequencies over the entire pancreas: head(30%), neck & body (30%), tail(40%). All of the tumors were single and 90% of them were solid and benign. The mean diameter of the tumors was 1.5cm. Symptoms of hypoglycemia and laboratory values such as fasting blood sugar, plasma insulin, C-peptide, insulin glucose ratio were improved in all the patient after operation. We suggest that the THPVS is the most sensitive preoperative test for localizing insulinomas and recommend the IOUS as a tool for detecting occult or multiple insulinoma and identifing the relationship with main duct of pancreas in operative field.

A Successful Treatment of Ileal Atresia in A 1200 g Premature Neonate

The ileal atresia has been commonly accepted to be caused by a vascular accident during early intrauterine period. Thanks to the development of anesthesia, surgical techniques, postoperative supportive treatment and the hyperalimentation technique, the motality rate of this disease has been decreased. In spite of these developments, premature and very low birth weight babies should be given more attention because they still have a high motality rate. The authors report a successful treatment of ileal atresia in a 1,200g premature female infant. The proximal distended and hypertrophied intestine was resected. The distal small bowel was transected using a oblique line to create a fish-mouth. An end to end anastomosis was performed. We gave postoperative care, such as incubator care, fluid therapy, gastric decomprssion and total parenteral nutrition(TPN). TPN was initiated on postoperative one day. Calories were increased from 60cal/kg to 90cal/kg. TPN was stopped on the postoperative 24 day when the patient tolerated full strength milk feeding. Eighteen months postoperatively, she is healthy and her weight is 9.0kg(9 percentile).