Combined off-pump coronary artery bypass grafting and thyroidectomy.

A 70-year-old Indian woman presented with an acute anterior wall myocardial infarction and a large multinodular goiter causing tracheal compression and dyspnea. Coronary artery angiography revealed severe triple-vessel disease, with an 80% occlusion of the left main stem, necessitating early coronary artery bypass grafting combined with total thyroidectomy. The procedure was performed successfully. At the 1-year follow-up, the patient remains euthyroid and in New York Heart Association functional class I. This case provides further evidence that combined coronary artery bypass grafting and total thyroidectomy is both feasible and safe.

Thyrotoxicosis--surgical management in the era of evidence-based medicine: experience in western India with 752 cases.

The three modalities of treatment of thyrotoxicosis, antithyroid therapy (ATT), radio-iodine (I131) therapy and surgery are not cause-specific. In this paper, we describe our evolving experience with 752 thyrotoxic patients who underwent surgery during the last 40 years and discuss the current scenario with evidence-based data and observations wherever possible. Thyroidectomy was performed in 428 patients with Grave's disease (GD), 299 patients with toxic multinodular goitre, and 25 with toxic solitary nodules (TSN). Whereas 289 patients with GD had surgery for failed ATT, the other 139 had primary surgery for controversial or debatable indications such as poor socio-economic status, desire for early pregnancy, poor drug compliance and severe ophthalmopathy. Preoperatively, all patients were administered carbimazole or propylthiouracil. Non-selective b-blocker propranolol and Lugol's iodine were routinely given. In the 25 patients with TSN, hemithyroidectomy was performed. In all others, subtotal thyroidectomy (STT), was performed leaving behind 4 to 8 g of thyroid tissue: a larger amount was left behind in those with higher antithyroid antibody titres. During the last decade, 80 patients received near total thyroidectomy (NTT), mainly to minimize recurrence of thyrotoxicosis and to ameliorate severe eye signs. Because of our increasing experience, no significant increase in postoperative morbidity was encountered with NTT compared to STT. Transient hoarseness was observed in 53 patients with STT and only in two patients with NTT. Three patients with STT and one with NTT developed permanent hoarseness due to recurrent laryngeal nerve palsy; voice in these four was normalized by intraglottic injection of Teflon paste 6 months after the operation. In patients undergoing STT, transient hypoparathyroidism was encountered in 63, and permanent hypoparathyroidism in five. The corresponding figures for NTT were 12 and one, respectively. Of the 500 patients monitored for 1 year or more, hypothyroidism was observed in 135 and recurrent thyrotoxicosis in nine. In the same group of 500, exophthalmos was ameliorated in 130 of the 265 with positive eye signs. Nineteen glands exhibited features of severe Hashitoxicosis with marked destruction of acini and considerable lymphoid aggregates and follicles. Carcinoma was observed in three other thyroid glands.

A solid variant of aneurysmal bone cyst of maxilla.

A solid variant of Aneurysmal Bone cyst is very rare tumour of maxilla. Histopathologically it is very much similar to giant cell granuloma but the radiographic features can influence the pathologic interpretation.A solid variant of anenurysmal bone cyst has been reported in facial bones and it can involve several adjacent bone synchronously (3). Both giant cell granuloma and aneurysmal bone cyst have a propensity for recurrence variably in the 15%-26% range (5).

Preoperative complications of gallstones and their relevance to treatment and prognosis: experience with 451 cases.

Of 451 patients with cholelithiasis, 273 suffered from 396 preoperative complications; the common ones were acute cholecystitis (n = 120), jaundice (n = 135), and acute pancreatitis (n = 52). Of the 195 patients under the age of 50 years 48% had complications, compared with 70% of the 256 above the age of 50 years. For acute cholecystitis and acute pancreatitis, an interval cholecystectomy was carried out 3-6 wk after initial conservative treatment. Except in the 33 cases with obstructive jaundice of indeterminate etiology (n = 15) or jaundice associated with uncontrollable cholangitis (n = 18), surgery in icteric patients was deferred until serum bilirubin became normal or reached a plateau. Routine intraoperative radiology detected unsuspected stones in common bile ducts in 11 cases. In all, 139 choledochotomies were carried out; the frequency of ductal exploration rose after the age 50 years. Operative elimination of sphincter of Oddi (by sphincteroplasty or by choledochoduodenostomy) was required in 82 cases. Bile culture was positive in only 17 of 178 cases without preoperative complications but in 97 of 273 with preoperative complications. Of the 21 cases who died, 19 had preoperative complications and 66% had positive bile culture. Nine of 139 requiring choledochotomy died. Mortality after 60 years was 15 of 119.

Abdominal tuberculosis. Experiences with 300 cases.

Problems in the management of abdominal tuberculosis are discussed with reference to 300 surgically verified cases. The protean clinical manifestations depend on the site and extent of the disease, and its complications. Operation was resorted to for complications when diagnosis was in doubt and when intrinsic intestinal disease was proved. Surgery was preceded by antituberculous drugs whenever possible. At operation, the disease was found to involve the alimentary canal in 196 cases; in the remaining 104, only the lymph nodes and/or the peritoneum were affected. Intestinal resection was carried out in 100 cases. Emergency surgery carries a high mortality (18/76) because of toxemia, hypoproteinemia, anemia, etc. Positive histology was obtained in 229 cases. One hundred and seventy-nine cases showed evidence of caseation. Caseation and peritoneal tubercles (103 cases) differentiate intestinal tuberculosis from Crohn's disease. Despite considerable progress made in therapy and prophylaxis during the last quarter of the century, tuberculosis of various sites continues to be a major health hazard in India. The precise prevalence of Koch's disease of the abdomen has not been determined due to lack of a survey in random samples of population. This common malady, however, with its protean profiles and varied complications continues to challenge the diagnostic acumen and therapeutic skill of clinicians practicing various discplines of medicine.