Evaluation of preoperative localization of parathyroid adenoma using [99m]tc-sestamibi scintigraphy as a single diagnostic modality for patients with primary hyperparathyroidism

This- study was designed to evaluate the diagnostic yield of Technetium-99m hexakis methoxyisobutylisonitrile [Tc-99m-MIBI] scintigraphy in patients with primary hyperparathyroidism [PHPT] for identification of the site of parathyroid adenoma compared versus operative and histopathological findings. The study included 23 cases with PHPT; 5 nales and 8 females with mean age of 56.5 +/- 10.3; range: 39-69 years. Preoperative scanning using [99m]Tc-sestamibi was done. All patients underwent surgical exploration after methylene blue transfusion. Imaging data were compared with intraoperative finding. All identified and excised glands were sent for histopathological examination. Preoperative sestamibi scan defined a case with mediastinal parathyroid gland and another active cervical gland in 2 patients with persistent and recurrent hypercalcaemia, respectively. Preoperative sestamibi scan defined 6 cases with single parathyroid adenoma in each case, while surgical exploration defined 7 parathyroid adenomata; 5 cases had solitary adenoma and one case had adenoma in 2 parathyroid glands both stained blue after methylene blue infusion. Thus, sestamibi scan defined solitary parathyroid adenomas with an accuracy rate of 83.3%. However, sestamibi scan defined 3 cases with adenoma in 2 parathyroid glands and 2 cases had adenoma in 3 glands. Surgical exploration defined adenoma that confirmed histopathologically in 9 glands of the 12 identified by sestamibi scan; 4 cases had 2 adenomas and one case had one solitary adenoma, the other 3 glands showed only hyperplasia without adenoma formation. Thus, sestamibi scan defined multiple parathyroid adenomos with an accuracy rate of 75%. It could be concluded that preoperative localization of parathyroid gland depending on preoperative sestamibi scan could identify ectopic active glands with accuracy 100% and active cervical glands with an overall accuracy rate of 79.2% and concomitant intraoperative methylene blue localization allowed detection of active glands missed by preoperative sestamibi scan

Voice dysfunction following thyroidectomy

Voice dysfunction after thyroidectomy is not rare, and is generally reported in terms of recurrent laryngeal nerve [RLN] or superior laryngeal nerve [SLN] injuries. However, voice dysfunction can occur without laryngeal nerves injuries. Prompt recognition of causes of dysphonia is essential so that relevant therapeutic decision allows early management. The aim is to analyze voice change after thyroidectomy for patients with normal pre-operative voice. The study included 30 patients who had developed voice change within 6 months after thyroidectomy. They were subjected to voice evaluation, indirect laryngoscopy, videostroboscopy and electromyography [EMG]. It was found that dysphonia after thyroid surgery was caused by neurogenic causes [RLN and SLN injuries] in 23 patients [76.7%], non-neurogenic causes in 5 patients [16.7%] and combined causes in 2 patients [6.6%]. EMG studies revealed complete denervation in 6 patients [20] and incomplete denervation [paresis] in 19 patients [63.3%]. Post-thyroidectomy dysphonias are not rare. Injuries of the RLN constitute the main cause. Non-neurogenic injury is another contributing factor. Diagnosis is essential for early management through videostroboscopy and EMG which is specific to differentiate between neurogenic and traumatic injuries and to detect complete or incomplete denervation

Survival and recurrence after hepatic resection in cirrhotic patients

Although hepatic resection is one of the most effective treatments for hepatocellular carcinoma [HCC], the long term results of hepatic resection of this malignancy are far from satisfactory. The potential benefits of hepatectomy for patients with HCC have not been fully delineated. This study aimed to identify surgical outcomes of 18 consecutive cirrhotic patients with HCC undergoing hepatic resection. 18 patients with cirrhotic liver underwent hepatic resection between March 2002 and January 2007. We had 14 men and 4 women. The mean age was 55 years with a range between 42 and 67 years. The 30-day [operative] mortality rate was one case [5.5%] and there was one additional late death [5.5%]. Ten patients [62.5%] had recurrence after curative resection. Major hepatectomy was performed in 14 patients [77%] and the other 4 [22%] had minor hepatectomy In our study, the overall survival of patients after 3 years was 43.75% while the disease-free survival was 37.5%. The survival rate after operation remains unsatisfactory mainly because of the high recurrence rate. The improved care of cirrhotic patients, early detection and effective treatment of recurrent HCC may play an important role in achieving better prognosis and survival after operation

relationship between breastfeeding position ans level of postpartum fatigue

A quasi-experimental study was conducted at Postpartum Unit of King Fahd University Hospital in Al-Khobar, Kingdome of Saudi Arabia to investigate the relationship between breastfeeding position and level of postpartum fatigue. The study sample consisted of 100 postpartum women who accepted to participate in the study. Level of fatigue was initially assessed before breastfeeding the baby using the Iowa fatigue scale, then the study subjects were randomly divided into two groups, group [n =50] began breastfeeding their newborns for 10 minutes in high Fowler's position on the bed with back supported and a pillow under the arm to support the newborn and to reduce the tension on the muscle and a pillow under the newborn to raise him to sufficient height to reach the breast easily. After the 10 minutes, they were assisted to reposition themselves to side lying position with the arm raised on the head, comfortably supported, and the newborn lying supported on side so can grasp the breast easily, and the mother feeding the newborn for another 10 minutes. Group II [n =50] started breastfeeding their newborn in side lying position for 10 minutes and then shifted to high Fowler's position and breastfed for another 10 minutes. Each subject was instructed to mark the Iowa fatigue scale after breastfeeding in each position to determine the level of fatigue. Side lying position, for those during breastfeeding was the most comfortable position for the whole studied women aged less than 25 years old, were pregnant for less than three times, had less than three living children, received antenatal care, and who did not receive any information about breastfeeding. Increased emphasis on the advantages of the side lying position for breastfeeding can easily be included in routine postpartum nursing practice with minimal risk and cost

Non-operative managementof blunt hepatic trauma :results of a prospective trial

Background: It has been shown that bleeding from injured liver cancease spontaneously, in the majority of blunt hepatic trauma. The aim ofthe study was to evaluate the criteria of non-operative management forpatients with blunt hepatic injury

Study design:Thirty five patients with blunt hepatic trauma were selected for non-operative management from January 2003 to October2005. All patients were hemodynamically stable and admitted to the Intensive Care Unit [ICU] for the first 24-72 hours. They were subjected toresuscitation, close observation, serial laboratory investigations and scanning assessment

Results: Thirty five patients with liver injuries were classified according to CT findings into grade I in 2 patients [6%], grade II in 11 patients[31%], grade III in 12 patients [34%] and grade IV in 10 patients [29%]. CTscan revealed minor hemoperitoneum in 8 patients [22.8%], moderate he-moperitoneum in 10 patients [28.6%] and major hemoperitoneum in 10 patients [28.6%]. Liver enzymes ALT and AST levels at admission weresignificantly correlated to the grade of the hepatic injury. Non-operativemanagement succeeded in 28 patients [80%] of patients with blunt hepatic trauma while 3 patients [8.6%] required laparotomy after initial successof non-operative management. Percutaneous guided drainage was required for 4 patients [11.4%] with localized collection. The mortality ratewas 2.8%

Conclusion: Minimal intervention is the policy of treating blunt hepaticinjuries in hemodynamically stable patients. It requires strict clinical,hemdynamic, and scanning monitoring, in a centre with intensive care facilities and immediate access to the operating room

Haemorrhoidectomy for advanced haemorrhoidal disease, comparative study between the conventional and modern techniques

Surgical excision is considered the ideal treatment for the third and fourth degree haemorrhoids. Inspite of being safe, surgical excision is liable to some complications as postoperative bleeding, pain, discharge, stenosis and recurrence So, a wide variety of techniques had been developed to avoid these complications. This study was performed for two hundred patients complaining of third or fourth degree haemorrhoidal disease. Their ages ranged between 18 and 66 years, [mean 40.28 +/- 11.84 years]. The patients were divided into four groups. Group I, [50 patients], for whom stapler haemorrhoidectomy was done. Group II, [50 patients], for whom rubber band ligation was performed. Group III, [50 patients], for whom Good-Sall's stitch technique was done. Group IV [50 patients], for whom conventional haemorrhodectomy was performed. The aim of this study was evaluation of the four techniques regarding, the operative time, hospital slay, time off work, postoperative pain, bleeding and post operative complications: For each technique the study concluded that: The shortest mean operative time was in group II, [5.7 +/- 2.14 mins.]. The shortest hospital slay and shortest time-off work was in group II, [1.60 +/- 0.91 days] and [3.12 +/- 1.39 days] respectively. Minimal post operative pain was in group I. The highest incidence of postoperative minor bleeding pruritis and wound discharge was recorded in group IV. The highest incidence of recurrence was recorded in group II. The results seen with stapler haembrrhoidectomy are very promising and actually superior to that of conventional haemorrhoidectomy in treatment of third and fourth degrees haemorrhoidal disease. Cost which remains high, seems to be balanced by the superior results obtained and the significant rapid return to normal activities and patient satisfaction

Evaluation of splenectomy and devascularization operation on portal hemodynamics using Doppler ultrasonography

The present prospective study was designed to evaluate the effects of splenectomy and devascularization operation on the hemodynamics of portal circulation and the reliability of color Doppler ultrasonography as a non-invasive tool in the assessment of portal hemodynamics before and after the operation. Thirty patients [19 males and 11 females] with clinical diagnosis of portal hypertension and endoscopic evidence of oesophageal and/or gastric varices who underwent splenectomy and devascularization were included in this study. The mean age of the whole group was 32.12 +/- 1.8 years [range: 17-52 years]. Doppler scanning of the portal vein before and after the operation revealed a sign reduction in the maximum blood velocity postoperatively [mean 10.59 +/- 2.66 cm/sec. versus 12.51 +/- 3.16 cm/sec preoperatively], and a sign reduction in the volume blood flow postoperatively [mean 884.3 +/- 233.9 ml/mm. versus 1073.8 +/- 422.4 ml/mm., preoperatively], and insignificant change in the diameter. Also, the direction of blood flow was hepatopetal in all patients after operation, while it was bidirectional in. one patient and hepatopetal in 29 patients before operation. The study revealed a sign positive correlation between the size of the spleen and the decrease in the blood velocity and volume blood flow of the portal vein after operation. Also, there was a positively sign correlation between the presence of a history of injection sclerotherapy and the diameter and volume blood flow of the portal vein before the operation. From the present study, it was concluded that splenectomy and devascularization could be performed with extremely low mortality in selected elective patients, particularly the non alcoholic, with virtually no postoperative encephalopathy. This is in addition to the preservation of the vascular anatomy of the right upper quad rant for future use in potential liver transplant. The operation did not lead to complete disappearance of oesophageal varices, but sign reduction in their grades and injection sclerotherapy is recommended for variceal remenants. Based on the fact that there is a sign positive correlation between the size of the spleen and the decrease in the blood velocity and volume blood flow of portal vein after the operation, it is suggested that this splenic venous flow contributes, in part, to portal hypertension. The Doppler scanning is an ideal investigation for portal circulation, as it is noninvasive, cheap and provides accurate data about the velocity, volume flow, direction of blood flow and patency of portal circulation

Laparoscopic management of patients with acute biliary symptoms. Factors predictive of Failure of a laparoscopic technique

Laparoscopic cholecystectomy has become the standard elective management of cholelithiasis. Little information exists, however, regarding the appropriateness of this procedure in the setting of acute symptomatology. We reviewed our results with 26 patients with acute biliary symptoms managed laparoscopically. There were 18 females and 8 males with their ages ranging from 22 to 70 years with an average of 46 years. Laparoscopic cholecystectomy was attempted in all patients, and was successful in 22 of 26 patients, four procedures were converted to open cholecystectomy because of difficulty in dissection precluding laparoscopic cholecystectomy. Patients requiring open cholecystectomy were older, more likely to be febrile [mean temperature of 37.9 +/- 0.6 versus 37 +/- 0.7] and were more likely to have a significant leukocytosis [mean white cell Count 12.8 +/- 5.2 +/- 10[3] cells/mm[3] versus 9.2 +/- 2.8 +/- 10[3] cells/mm[3]] than were those undergoing successful laparoscopic cholecystectomy. Laparaoscopic cholecystectomy can be performed safely in the majority of patients presenting with acute biliary symptoms. Patients presenting with a triad of right upper quadrant pain, fever and elevated white cell count who are especially males, elderly and morbidly obese are more likely to require conversion to a standard cholecystectomy and should be informed accordingly

Does bacterial infection have a role in primary gastritis and duodenal ulcer?

We investigated the presence of Campylobacter pylori colonization of gastroduodenal mucosa and of histologic evidence of gastritis in a prospective study of 84 consecutive patients undergoing upper gastrointestinal endoscopy because of gastrointestinal symptoms. Chronic gastritis was evident endoscopically in 52 cases and chronic duodenal ulcer was found in 12 patients. Tissue samples were obtained from the gastric antrum and from the edges of duodenal ulcers. Samples were evaluated for evidence of gastritis and stained with silver to detect Campylobacter pylori organisms. Antral gastritis was diagnosed histologically in 20 of the 52 patients with endoscopically evident gastritis. Campylobacter pylori was identified in 9 of 12 patients with primary gastritis but none in patients with secondary gastritis [gastritis associated with an identifiable underlying cause]. Campylobacter pylori was not identified in any of the 32 cases with normal histologic features. 10 of the 12 duodenal ulcer cases had histologically proven antral gastritis with Campylobacter pylori identified in 8 of them. Campylobacter pylori was identified also in the edges of duodenal ulcers in 7 cases out of the 12. We conclude that the presence of Campylobacteral pylori on the antral mucosa is specifically associated with primary antral gastritis and may also be associated with duodenal ulceration