Microscopic papillary thyroid cancer as an incidental finding in patients treated surgically for presumably benign thyroid disease.

BACKGROUND: Papillary thyroid microcarcinoma (PTMC) is a relatively common entity in the general population. AIM: To present our experience with papillary thyroid microcarcinoma of the thyroid as an incidental finding in patients treated surgically for presumably benign thyroid disease. SETTINGS AND DESIGN: Histology reports of patients treated surgically with a preoperative diagnosis of benign thyroid disease were reviewed to identify patients with PTMC. Patients with a preoperative diagnosis of thyroid cancer were excluded from this study. MATERIALS AND METHODS: The files of 380 patients who underwent surgery for presumably benign thyroid disease in our hospital from 1990 to 2002 were reviewed. Data regarding patient's demographics, pathology findings, management and outcomes, were retrieved. STATISTICAL ANALYSIS USED: The findings are expressed as absolute numbers and as percentages (with reference to the total number of patients of this study). RESULTS: Twenty-seven patients with PTMC diagnosed incidentally following thyroid surgery for presumably benign thyroid disease (27/380 or 7.1%) (multinodular goiter = 20 patients, follicular adenoma = 6 patients, diffuse hyperplasia of the thyroid = 1 patient) are presented. Mean diameter of PTMC was 4.4 mm. In 11 patients (40.7%) the tumor was multifocal and in about half of them tumor foci were found in both thyroid lobes. In two patients the tumor infiltrated the thyroid capsule. Total/near-total thyroidectomy was performed in all these patients (in three as completion thyroidectomy). All patients received suppression therapy and 20 of them underwent adjuvant radioiodine therapy. Follow-up (mean 4.56 years, range 1-12 years) was completed in 25 patients; all these patients were alive and disease-free. CONCLUSIONS: PTMC is not an uncommon incidental finding after surgery for presumably benign thyroid disease (7.1% in our series). The possibility of an underlying PTMC should be taken into account in the management of patients with nodular thyroid disease; total/near total thyroidectomy should be considered, at least in selected patients with presumably benign nodular thyroid disease.

A case of gallstone ileus with an unusual impaction site and spontaneous evacuation.

Gallstone ileus is an unusual cause of colonic obstruction. The formation of a fistula between the gall bladder and the bowel wall may allow a gallstone to enter the intestinal tract. Plain abdominal films, abdominal ultrasound and abdominal computed tomography aid in the diagnosis. Although surgery is the treatment of choice in cases of colonic gallstone ileus, colonoscopic removal of the impacted stone should be attempted. We describe the case of an 85-year-old man who presented with symptoms and signs of large bowel obstruction. Diagnostic evaluation revealed a large gallstone impacted in the sigmoid colon, which is a rather unusual impaction site. Despite our efforts we could not extract the stone endoscopically, mainly due to its large size. Yet, despite its large size, the stone was spontaneously evacuated a few hours later.

Open tension free repair of inguinal hernias; the Lichtenstein technique.

BACKGROUND: Recurrences have been a significant problem following hernia repair. Prosthetic materials have been increasingly used in hernia repair to prevent recurrences. Their use has been associated with several advantages, such as less postoperative pain, rapid recovery, low recurrence rates. METHODS: In this retrospective study, 540 tension-free inguinal hernia repairs were performed between August 1994 and December 1999 in 510 patients, using a polypropylene mesh (Lichtenstein technique). The main outcome measure was early and late morbidity and especially recurrence. RESULTS: Inguinal hernia was indirect in 55 % of cases (297 patients), direct in 30 % (162 patients) and of the pantaloon (mixed) type in 15 % (81 patients). Mean patient age was 53.7 years (range, 18 - 85). Follow-up was completed in 407 patients (80 %) by clinical examination or phone call. The median follow-up period was 3.8 years (range, 1 - 6 years). Seroma and hematoma formation requiring drainage was observed in 6 and 2 patients, respectively, while transient testicular swelling occurred in 5 patients. We have not observed acute infection or abscess formation related to the presence of the foreign body (mesh). In two patients, however, a delayed rejection of the mesh occurred 10 months and 4 years following surgery. There was one recurrence of the hernia (in one of these patients with late mesh rejection) (recurrence rate = 0.2 %). Postoperative neuralgia was observed in 5 patients (1 %). CONCLUSION: Lichtenstein tension-free mesh inguinal hernia repair is a simple, safe, comfortable, effective method, with extremely low early and late morbidity and remarkably low recurrence rate and therefore it is our preferred method for hernia repair since 1994.