A hard thyroid mass due to plasma cell granuloma.

Plasma cell granuloma involving the thyroid is very rare. A 29-year-old man with type 1 diabetes mellitus presented with a one-week history of fever, sore throat, neck tenderness and dysphagia. Antibiotics were given but over the next two weeks a hard 8 cm mass in the left lobe of the thyroid developed. Fine needle aspiration was not diagnostic and surgical exploration revealed an inflammatory process arising from the left lobe of the thyroid involving the left sternothyroid muscle and parapharyngeal spaces. Histology of multiple biopsies showed plasma cell granuloma. Immunoperoxidase staining demonstrated the presence of IgG, IgM and IgA with predominance of IgG. The residual mass resolved and was impalpable after four weeks. Plasma cell granuloma should be suspected when there is a rapidly developing hard thyroid mass. Open biopsy/removal and histological confirmation are mandatory and residual disease may resolve within weeks.

Technical advantages of a ringed intra-luminal graft in the management of difficult aortic aneurysms.

The ringed intra-luminal graft has been designed for aortic repair with non-sutured anastomosis. The graft and technique of insertion are described. It is proposed that this type of prosthesis might have advantages over conventionally sutured grafts for the surgical management of thoraco-abdominal, suprarenal and dissecting aneurysms, and occasionally for infrarenal aneurysms when the neck is ectatic or excessively friable. This proposition is supported by reference to five patients with complex aneurysms which were repaired successfully with non-sutured grafts. The importance of appropriate patient selection and attention to technical detail is stressed.

Use of a ringed intraluminal graft in the operative management of abdominal aortic aneurysms.

The efficacy of a non-sutured technique of anastomosis has been assessed in 20 patients who had bifurcated grafts inserted for aneurysms of the infrarenal aorta. The grafts had rigid Dacron-covered metal rings incorporated at each end and the anastomoses were effected by securing these rings within the lumen of the vessel with a firmly tied Dacron tape. In order to allow access of the ring to the lumen of the aorta it was necessary to employ an intraluminal occlusion balloon catheter for proximal control. The patients included in the study formed a particularly high risk group. There were 12 emergency and 8 elective procedures. The mean duration of the operations was 134 +/- 34 min (+/- s.d.); the mean blood loss during surgery was 3498 +/- 2660 ml (+/- s.d.) and the mean length of inpatient stay after operation was 16 +/- 13 days (+/- s.d.). There were eight postoperative deaths and post-mortem examination, which was allowed in six cases, showed satisfactory appearances of the grafts and anastomoses. The surviving patients have remained free from complications for up to 18 months after operation. A non-sutured technique is possible for most aortic anastomoses but is of limited applicability for iliac and more distal anastomoses. With further technical refinements an intraluminal graft with a non-sutured aortic anastomosis may become a valuable alternative to the conventionally sutured prosthesis in the management of ruptured abdominal aneurysms.

The value of pre-operative ultrasound of the liver in colonic and gastric neoplasia.

In a series of 50 patients presenting with gastric or colonic neoplasms ultrasound scans of the liver were performed during the pre-operative assessment. The radiologist who performed the scan was informed that the patient had gastro-intestinal malignancy but was unaware of the clinical or biochemical findings that might suggest hepatic metastases. The ultrasound findings were then compared with the results of laparotomy, laparoscopy or the clinical course of the patient. The overall accuracy of ultrasound in this small series was 88%.

Transduodenal exploration of the common bile duct in a district general hospital.

In an 8 year period 214 transduodenal explorations were undertaken in a district general hospital. These were performed on 208 patients and in 40 instances a combined supraduodenal and transduodenal approach was employed. There were 23 deaths in 208 patients, a mortality of 11%. Twelve deaths occurred in 64 patients who underwent negative exploration. Postoperative pancreatitis was the most common cause of death and the occurrence resulted in a 53% mortality. We conclude that the transduodenal operation should only be performed by experienced surgeons with definite proof of common bile duct stone, and when the standard supraduodenal approach is unsatisfactory.

Penetrating laryngeal injuries.

Five cases of penetrating injury are described, together with the complications that ensued. Although usually obvious, the diagnosis, can be missed. Tracheostomy is usually but not always required. In some instances simple X-ray investigations are helpful. In all cases exploration should be performed. The operative management is discussed.