A changing experience with primary hyperparathyroidism at Group Health Cooperative, Seattle.

BACKGROUND: Since 1996 new technologies have been brought to bear on the treatment of primary hyperparathyroidism. The Tc 99m sestamibi scan is useful in defining the location of a solitary adenoma, and used in combined with the gamma probe, it facilitates the removal of a solitary adenoma with a degree of accuracy and a cure rate previously not available. Intraoperative measurement of parathyroid hormone is also being used to judge immediately if the surgery has been successful. METHODS: This is a retrospective review of all cases of primary hyperparathyroidism treated surgically at Group Health Cooperative, Seattle, Washington, from April 1997 until June 2000. RESULTS: Of the 49 procedures in 47 patients, 44 had a sestamibi scan preoperatively. Fifteen patients had a combination of the sestamibi scan done on the day of surgery and the intraoperative use of the gamma probe. This has been labeled minimally invasive radioguided parathyroidectomy (MIRP). The procedures are divided into two groups. The 28 procedures before the advent of MIRP are labeled group A. The 22 procedures after the advent of MIRP are labeled group B. One patient with two procedures is represented in both groups. They are further differentiated into three groups in terms of surgical difficulty: routine, difficult, and complex. Eleven procedures are in the difficult category and 3 procedures are classified in the complex category. Since the start of MIRP on May 14, 1999, there have been 15 MIRPs and 7 procedures requiring a standard incision. Group A is compared with group B using a variety of parameters. CONCLUSIONS: The combination of the Tc 99m sestamibi scan on the day of surgery and the use of the gamma probe intraoperatively is a major advance in the treatment of primary hyperparathyroidism. A significant number of difficult and complex cases must still be treated with bilateral neck exploration, including patients with hyperplasia, double adenoma, carcinoma and patients with underlying thyroid pathology. There is a "surgery time" advantage to the surgeon who does more than 10 cases per year.

Outcome and sepsis after splenectomy in adults.

Of 277 splenectomies performed over 10 years, 24.2 percent were incidental. Operative mortality in this group was 14.9 percent, which is higher than that encountered after splenectomy for any other indication. A majority of the deaths were from septic causes, and infectious complications accounted for most of the morbidity as well. This finding is in marked contrast to the paucity of infectious morbidity and mortality in patients with all other splenectomies. Of the 251 patients who survived these operations, follow-up was available on 175. Twenty-six had received Pneumovax, and 4 of these patients died, none from infectious causes. There were 20 septic deaths among the 149 unvaccinated patients, including 3 cases of fulminant pneumococcal sepsis.

Regional hyperthermia for cancer.

The clinical use of regional hyperthermia combined with radiation therapy, chemotherapy, or both in 107 patients with advanced cancer is reported. Surgery was subsequently carried out in eight patients. The radiofrequency equipment used is capable of heating tumors at any depth with few adverse side effects. Complete responses to therapy occurred in 16 percent of patients, and partial responses in 52 percent. Striking pain relief was observed in both responders and nonresponders.

Adenocarcinoma of the pancreas. A ten-year experience.

The experience with proved pancreatic adenocarcinoma in Portland, Ore, for 1965 through 1975 is compared with the decade 1955 through 1965. Little difference is found in time of diagnosis, incidence of resection vs bypass or laparotomy, types of resection, and overall survival. However, operative mortality improved and survival after total pancreatectomy improved from seven to 23 months. Whipple resections leave residual pancreatic tumor in one third of patients. Combining fluorouracil and radiotherapy significantly increases survival after palliative bypass (15 months vs 7.4 months, P less than .02). Based on low operative mortality, improved survival, and avoidance or residual tumor, use of total pancreatectomy as the resection of choice is recommended.