Dilemma of bilateral versus unilateral neck exploration in management of primary hyperparathyroidism

There is still a considerable discussion about whether focal unilateral or bilateral neck exploration should be used in patients with primary sporadic hyperparathyroidism because of improved preoperative localization tests and intraoperative parathyroid hormone assay. Making sense of applying these new technologies is difficult and poses the question. Is limited parathyroid surgery better surgery?. Most clinicians deduce that limited surgery is better only if the success rate is equivalent to bilateral exploration. The aim of this study was to find out if there is an advantage in unilateral neck exploration over the standard bilateral neck exploration for parathyroid surgery. This is a prospective non-randomized clinical study which had been conducted in the period between October 1996 and January 2004 on 29 patients with a diagnosis of primary hyperparathyroidism divide into two groups. Group I: Fourteen patients [4M and 10F] that had bilateral neck exploration. Group II: Fifteen patients [5M and 10F] that underwent unilateral neck exploration. All patients had preoperative clinical and biochemical assessment, ultrasound, CT of the neck and sestamibi scanning [for those patients considered candidates for unilateral neck exploration]. All patients were seen on follow-up visits after 1 week, 1 month, 3 months, 6 months and then yearly. There was no statistically significant difference in preoperative serum calcium level or serum parathyroid hormone level between the two groups [p>0.5]. Median operative time was 105 minutes [range 95-180 minutes] in group I compared to 90 minutes [range 80-155 minutes] in group II [p value<0.5; significant]. Only one patient [7.2%] had postoperative hypocalcaemia in group 1. One patient [7.2%] had recurrence in group! compared with two patients [13%] in group II [p value>0.5, non-significant]. No patient had recurrent laryngeal nerve paralysis or permanent hypocalcaemia in either group. There was no statistically significant difference between group I and II patients in postoperative histopathological findings. In group II three patients [20%] required conversion to bilateral neck exploration; one patient had [7%] multiple adenomas and two patients bad hyperplasia [13%]. Bilateral neck exploration for surgery for primary hyperparathyroidism is as safe as unilateral neck exploration and has higher cure rates. It also avoids the costs of preoperative and intra-operative localization scans and techniques. In hospitals where intra-operative localization methods are not available; the conventional neck exploration for primary hyperparathyroidism should be considered the method of choice

Experience with vascular delay in unipedicled transverse rectus abdominis myocutaneous flap breast reconstruction

The transverse rectus abdominis myocutaneous flap [TRAM] is a popular method of autologous breast reconstruction that results in a soft, natural looking ptotic breast and does not need addition prosthetic volume replacement giving an excellent cosmetic result, however, ischaemic related complications including partial-or total flap loss and fat necrosis continue to occur. In this report we describe our experience in TRAM flap breast reconstruction using vascular delay in high-risk patients in an effort to decrease ischaemic related flap complications. Nineteen patients underwent unilateral breast reconstruction using a unipedicled vascular delay TRAM flap between March, 1997 and May, 2000. All patients had one or more risk factors including obesity, previous irradiation, chronic cigarette smoking,diabetes or abdominal scars. Eleven cases had mastectomy with vascular delay then reconstruction while 8 had reconstruction done- after completion of their.adjuvant therapy There. Were nmo cases with total flap loss. We had one case with partial flap loss needing debridment and secondary sutures and one with a patch of epidermal sloughing which responded to conservative measures. Minimal fat necrosis was seen in one case. There was no mortality in our cases and the cosmetic results and patient satisfaction ranged from satisfactory to excellent. We believe that vascular delay and unipedicled TRAM flap reconstruction of the breast in high-risk patients is a simple, reliable procedure with a predictable outcome and satisfactory results. Its only drawback is the need for 2 surgical procedures which is a small price to pay especially in high-risk patients who have a very high flap complication rate using other methods of reconstruction

Effect of tension free inguinal hernia repair with mesh on testicular perfusion

Tension-free inguinal hernia repair with mesh was reported to have the best results as regards postoperative pain, patient's comfort and hospital stay, with the lowest recurrence rates ever reported. Few reports were concerned with the local effects of the mesh shrinkage and the resulting fibrosis on the adherent cord structures including testicular vessels. Seventy-eight males with unilateral uncomplicated primary inguinal hernia were included in this prospective study, underwent tension-free repair with polypropylene mesh. Operative and postoperative data were recorded. Pre- and postoperative testicular ultrasound and colored duplex study were performed to all patients to compare testicular volume and perfusion before, three months and every 6 months after the repair and with the contralateral non-operated side. The mean operative time was 42 +/- 12 minutes, hospital stay was 1.3 +/- 0.5 days and pain score 1.9 +/- 0.4. There was no recurrence. There was no significant difference as regards testicular volume and perfusion before and after tension-free repair of inguinal hernia. Tension-free inguinal hernia repair with mesh is confirmed to be a simple, effective and safe technique. With no to date proved effect on testicular perfusion in spite of the proposed hypothesis of mesh shrinkage, fibrosis and adherence of the cord structures to the mesh