The rapid low-dose (1 microgram) cosyntropin test in the immediate postoperative period: results in elderly subjects after major abdominal surgery.

BACKGROUND: Recently the rapid low-dose (1 microgram) cosyntropin test has been found to be superior to the standard (250 micrograms) rapid cosyntropin test for evaluating the hypothalamic-pituitary-adrenal axis. Because the 1-microgram test has not been studied in postoperative patients, we evaluated the test after major abdominal surgery. METHODS: We performed rapid 1-microgram cosyntropin tests in 20 patients aged 65 years or older immediately and 24 hours after uncomplicated elective abdominal surgery (group A) and in 10 patients who were suspected of having adrenal insufficiency after abdominal surgery (group B). Subsequently, 250 micrograms of cosyntropin was infused over 8 hours on 2 successive days in group B patients. RESULTS: Ninety-five percent of group A patients had normal rapid 1-microgram cosyntropin test results immediately after surgery and 90% had normal test results 24 hours postoperatively. Six group B patients had abnormal rapid 1-microgram cosyntropin test results. Additional testing indicated primary adrenal insufficiency in 2 patients and central adrenal insufficiency in 1 patient; another patient probably had primary adrenal insufficiency and 2 patients appeared to be euadrenal. Four group B patients had normal rapid 1-microgram cosyntropin test results. After additional testing, 3 of these patients appeared to have normal adrenal function; 1 probably had primary adrenal insufficiency. CONCLUSION: The rapid 1-microgram cosyntropin test accurately evaluated adrenal gland function in selected patients after uncomplicated surgery. The test, however, was difficult to interpret in unselected seriously ill postoperative patients. Therefore we recommend that postoperative patients with unexplained hypotension or other features suggestive of adrenal insufficiency who have random plasma cortisol levels less than 20 micrograms/dL be treated with glucocorticoids and the hypothalamic-pituitary-adrenal axis be studied by standard tests after recovery.

A Muir-Torre syndrome family.

The Muir-Torre syndrome is a rare autosomal-dominant disease involving sebaceous neoplasms as markers for multiple internal malignancies. Diagnostic criteria include at least one sebaceous gland adenoma, epithelioma, or carcinoma and at least one internal malignancy. The world literature contains 162 cases with 316 internal malignancies. Colorectal and urogenital malignancies predominate, and nearly half the patients had two or more internal cancers. The discovery of a Muir-Torre syndrome-associated sebaceous lesion is rare and should prompt an evaluation for internal malignancies. We report a family over five generations displaying this syndrome. The proband is a 44-year-old man with two skin and two colon malignancies who presented to our clinic with the chief complaint of an infected sebaceous cyst. The world literature is reviewed, and an emphasis on the surgeon's role in evaluation and treatment is discussed.

Management of thyroid cancer of follicular cell origin: Gundersen/Lutheran Medical Center, 1969-1995.

BACKGROUND: Most reports regarding the treatment of thyroid cancer originate from university referral centers. In this article, we report our experience in managing thyroid cancer of follicular cell origin at a non-university institution over a 26-year period. STUDY DESIGN: We reviewed the medical records of all patients treated for thyroid cancer at the Gundersen/Lutheran Medical Center from 1969 to 1995. Histologic types, demographic and clinical characteristics, laboratory results, treatment, complications, and followup observations were tabulated. Risk was assigned according to the age, presence of distant metastasis, extent of the primary tumor, and site of the primary tumor (AMES) staging system. RESULTS: The histologic classification was as follows: papillary, 139; follicular, 24; Hürthle cell, 14; and anaplastic, 11. Low-risk lesions were identified in 96%, 79%, and 71% of the patients with papillary, follicular, and Hürthle cell (collectively designated differentiated) carcinoma, respectively. We treated 60% of our patients with differentiated thyroid cancer with near-total or total thyroidectomy. Clinically involved cervical lymph nodes were removed singly or by modified neck dissection. We frequently ablated thyroid remnants after operation with 29.9 mCi (1,110 MBq) of 131I, after which we treated the patient with suppressive doses of levothyroxine. Patients were evaluated yearly with thyroglobulin measurements and, in some high-risk patients, with total-body 131I scans. Cancer recurred in 13%, 8%, and 7% of our patients with papillary, follicular, and Hürthle cell carcinoma, respectively. Only three patients died of differentiated thyroid cancer; eight are alive with malignancy. In anaplastic thyroid cancer, cervical lymph node metastases, local invasion, and distant metastases were present in 18%, 64%, and 45% of patients at the time of initial evaluation. Total or near-total thyroidectomy was possible in only four of nine patients treated surgically. External radiation (11 patients) and chemotherapy (two patients) were used. Additional metastases developed in 45% of the patients, and nine patients died within a year. Permanent hypoparathyroidism or hoarseness complicated 2.7% of the thyroid operations. CONCLUSIONS: Although our followup was relatively short, the results of treating thyroid cancer by general surgeons at a nonuniversity hospital compare favorably with results obtained from university referral centers.

Neoplasms in long-term Hartmann's pouches.

A Hartmann's pouch is a blind segment of the rectum created in conjunction with a colon resection in which primary bowel reanastomosis is judged unsafe. Often forgotten, this defunctionalized rectal pouch has a high potential of pathologic lesions, including disuse proctitis, ulcers, bleeding and occasionally neoplasm formation. What are the consequences of Hartmann's pouches left unattended? In this paper, we discuss three patients with neoplasms in a long-term Hartmann's pouch and the pathophysiology of the long-term defunctionalized rectum. We also question the possibility of increased incidences of neoplasms in long-term Hartmann's pouches. To monitor this we recommend close observation of the rectal pouch with proctoscopy and contrast studies.

Living related and unrelated donors for kidney transplantation. A 28-year experience.

OBJECTIVE: The objective of this study was to analyze a single center's 28-year experience with 1000 living donor transplants. SUMMARY BACKGROUND DATA: The number of potential renal transplant recipients far exceeds the number of cadaveric donors. For this reason, living related donors (LRDs) and, more recently, living unrelated donors (LURDs) have been used to decrease the cadaveric donor shortage. METHODS: From November 15, 1966, until August 5, 1994, 1000 living donor transplants were performed; 906 were living related and 94 were living unrelated transplants. Results were divided into precyclosporine (1966-1986, era I) and cyclosporine (1986-1994, era II) eras. Patient and graft survivals were compared between diabetic and nondiabetic recipients, between LRDs and LURDs, and according to human leukocyte antigen (HLA) matching. Donor mortality, morbidity, and postoperative renal function were also analyzed. RESULTS: The 5-, 10-, and 20-year graft survivals were 78.8%, 64.8%, and 43.4%, respectively. Patient and graft survival improved in era II (patient = 87.0% vs. 81.7%, p = 0.03; graft = 72.9% vs. 67.7%, p = 0.04). Nondiabetic patient and graft survivals were better than diabetic patient survivals in both eras. However, diabetic patient survival improved in era II (78.0% vs. 66.9%, p = 0.04). In era II, HLA-identical recipients had better graft survival than haploidentical or mismatched recipients (91.7% vs. 67.3% and 66.1%, p = 0.01). No difference between haploidentical LRDs and LURDs was seen. One donor death occurred in 1970, and 17% of donors developed postoperative complications. CONCLUSION: Living related and unrelated renal donation continues to be an important source of kidneys for patients with end-stage renal disease.

Postoperative acute adrenal failure caused by transient corticotropin deficiency.

BACKGROUND: Acute adrenal insufficiency after a surgical procedure or trauma is rarely reported. In recent years, however, we have treated seven patients with acute primary adrenal insufficiency and three patients with secondary adrenal insufficiency who presented with shock after a surgical procedure or trauma. The standard cosyntropin test was misleading for the diagnosis of corticotropin deficiency. METHODS: In this study we measured serum cortisol in patients older than 65 years who had unexplained hypotension after an abdominal surgical procedure. If the serum cortisol was less than 15 micrograms/dl, we performed 1 microgram and standard (250 micrograms) cosyntropin tests and measured thyroxine, thyrotropin, leutinizing hormone in all patients, and free testosterone in men. RESULTS: We identified five (5%) of 105 patients after an operation who displayed evidence of corticotropin deficiency (i.e., serum cortisol < 15 micrograms/dl during hypotension, prompt hemodynamic improvement with glucocorticoid therapy, and normal response to standard dose cosyntropin). In these patients 1 microgram cosyntropin produced abnormal peak cortisol levels. These patients also had thyrotropin or leutinizing hormone deficiency. After recovery the low hormone levels improved or became normal. CONCLUSIONS: Postoperative adrenal insufficiency, particularly that caused by transient corticotropin deficiency, is more common in patients than currently recognized. The 1 microgram cosyntropin test may be more sensitive than the standard test for identifying secondary adrenal insufficiency.

Hürthle cell neoplasms of the thyroid gland: reassessment of functional capacity.

We treated a hyperthyroid man and a euthyroid woman who had autonomously functioning Hürthle cell adenomas and demonstrated uptake of radioactive 131I in a woman with recurrent Hürthle cell carcinoma. Since these tumors are thought to be inactive, we reassessed the functional capacity of Hürthle cell neoplasms by reviewing the medical records of all patients operated upon for these tumors at our medical center from 1950 through November, 1993. We also reviewed series of Hürthle cell neoplasms identified from a MEDLINE search of papers published from 1960 to November, 1993. We identified 92 patients with Hürthle cell neoplasms. Thyroid scintigraphy was performed in 28 of 72 patients with benign adenomas and six of 20 patients with Hürthle cell carcinomas. In addition to the two index cases, four euthyroid patients had hot nodules that partially suppressed the extranodular tissue; seven patients had warm nodules. Thyroid scans performed in patients with Hürthle cell carcinomas revealed five cold nodules and one warm nodule. Our index patient with carcinoma displayed elevated serum thyroglobulin levels when the cancer recurred. This patient and another had uptake of 131I by recurrent or metastatic cancer that allowed for treatment with this nuclide. Of 539 patients identified in a literature survey, 489 had benign Hürthle cell adenomas and 50 had Hürthle cell carcinoma. Thyroid scans performed in 282 patients revealed 247 cold nodules, 20 warm nodules, and 8 hot nodules. Our results, added to those published in case series of Hürthle cell neoplasms, indicated that 4.4% of thyroid scans were hot and 8.9% were warm.(ABSTRACT TRUNCATED AT 250 WORDS)

Implant metastasis of gallbladder carcinoma in situ in a cholecystectomy scar: a case report.

A subcutaneous mass within the scar left by cholecystectomy with common bile duct exploration and T-tube drainage developed 6 years after surgery. Pathologic examination of this mass showed features of atypical villous hyperplasia, similar to that identified within the previously removed gallbladder, but with additional foci of carcinoma in situ. Since excision of the mass, the patient has had persistent fluid collections requiring frequent aspiration. Cytologic analysis of the fluid has revealed tumor cells. The cause of this spread has been unclear. Few literature reports have identified biliary drainage techniques as a source for metastatic seeding. The malignant or metastatic potential of severe dysplasia or carcinoma in situ of the gallbladder associated with T-tube drainage and implantation in the drainage tract is previously unreported.

Delayed recovery from post-thyroidectomy hypoparathyroidism: a case report.

Thirteen hours after a subtotal thyroidectomy was performed for hyperthyroidism, a patient developed carpopedal spasms, parathesias and hypocalcemia to 6.9 mg/dL. After initial stabilization with intravenous calcium administration, oral calcium carbonate and calcitriol were required. Ten months postoperatively serum calcium levels rose and supplementation was gradually discontinued. The serum parathyroid hormone (PTH) level was 1.0 pg/mL on the second postoperative day and levels were undetectable despite sensitive testing 3 months later (normal 10-65 pg/mL). Two years after surgery, the PTH level has increased to 36 pg/mL, but remains relatively low considering the patient's continued mild hypocalcemia. To our knowledge, there has been no previously reported case of long-term post-thyroidectomy hypocalcemia documenting undetectable parathyroid function and subsequent spontaneous improvement. This case suggests that delayed recovery of parathyroid function and discontinuation of vitamin D and calcium supplementation may be possible in some post-thyroidectomy patients with hypocalcemia due to severe hypoparathyroidism.

Incidentally discovered adrenal masses.

This report describes a retrospective study of 23 patients with incidentally discovered adrenal masses. Two patients with subclinical cortisol secretion developed adrenal insufficiency after removal of benign adenomas. Another patient, who probably harbors an asymptomatic pheochromocytoma, developed a hypertensive crisis when a mass was palpated during aortic vascular surgery. Twelve patients underwent surgery. Seven benign adenomas, an angiomyolipoma, and a cyst were removed. Three patients had malignant masses that include an angiosarcoma, an adrenal adenocarcinoma, and a congenital neuroblastoma. We conclude that hormones, especially cortisol, may be secreted in subclinical amounts by incidentally discovered masses. We recommend a concise laboratory evaluation that includes an overnight dexamethasone suppression test. Based on our interpretation of the literature, we believe masses greater than 3 cm in size should be removed. Patients who do not undergo surgery should have computed tomographic scans repeated for one year and should be reassessed periodically for the development of hormone secretion.

Fine-needle aspiration biopsy of thyroid nodules. A cost-effective diagnostic plan.

Fine-needle aspiration biopsy is a safe and accurate method for diagnosing thyroid nodules. Personnel who have experience with the aspiration technique and with the cytologic classification of specimens are crucial to accurate results. One important advantage of using fine-needle biopsy to initially screen patients with nodules is that it can save substantially on healthcare resources.

Fine needle aspiration biopsy of thyroid nodules.

Between April 1982 and December 1988, we performed 611 fine needle aspiration (FNA) biopsies in 502 patients with solitary thyroid nodules. The biopsy results were classified as follows: unsatisfactory, 19%; benign, 53%; suspicious, 23%; and malignant, 5%. Malignant lesions were found at surgery in 24 of 25 patients with malignant cytology and 31 of 68 patients with suspicious cytology. Autonomous nodules, obviating the need for surgery, were detected in 5 of 36 (14%) patients with cytology suspicious for follicular neoplasm. We conclude that FNA biopsy of the thyroid nodule is a safe and accurate diagnostic test. Thyroid scintigraphy remains useful in patients with cytologic results suspicious for follicular neoplasm. A cost-effective strategy for managing thyroid nodules is presented.

Consent problems and the Southeast Asian refugee.

More than 24,000 refugees of Southeast Asian descent live in Wisconsin. These people, of a different cultural background with different methods of treating the sick, on occasion seek medical aid. It is incumbent on the treating physicians to understand the cultural differences and the avenues open to them to render treatment to these people. This paper reviews these concerns.

Thrombolytic therapy of axillary-subclavian venous thrombosis.

Patients with axillary-subclavian vein thrombosis often have a poor outcome when treated with intravenous heparin sodium and oral warfarin sodium. Four patients were therefore treated with thrombolytic therapy. Good initial and excellent long-term results were achieved. In follow-up that has ranged up to four years, these patients do not have the common complaints of edema, fatigue, cramping, or weakness seen after traditional anticoagulation. Patients have returned to their previous occupations and have normal arm function. Noninvasive Doppler vascular laboratory studies suggest continued patency of axillary veins. Thrombolytic therapy should be considered in the treatment of spontaneous axillary-subclavian vein thrombosis.

Mesenteric ischemia in chronic dialysis patients.

6 chronic dialysis patients with acute mesenteric ischemia are described. 3 had nonocclusive infarctions, and 3 had occlusive disease. 5 of the patients had episodes of severe hypotension or hypovolemia immediately before the onset of abdominal symptoms. All patients had leukocyte counts of greater than 12,000 on admission, and 4 had stools positive for occult blood. The characteristic features of dialysis-induced hypotension followed by nonspecific abdominal symptoms and leukocytosis are emphasized.

Hürthle cell tumors of the thyroid gland. A clinicopathologic review and long-term follow-up.

We reviewed the pathology and clinical follow-up of 26 patients with H urthle cell adenomas and three patients harboring H urthle cell carcinomas, who were treated at our medical center from 1950 to 1979. Although benign lesions could not be distinguished from malignant tumors by cytologic features alone, other pathologic features allowed differentiation. A total thyroidectomy was performed in only one patient; the remaining patients were treated by less extensive operations. None of the patients with benign adenomas, including those with tumors greater than 2 cm in diameter, experienced recurrent or metastatic disease. The period of observation varied from two to 22 years (mean, 8.5 +/- 7.7 years). We conclude that lobectomy is a satisfactory operation for removal of benign H urthle cell tumors, and reserve total or near-total thyroidectomy for cases displaying pathologic evidence of malignancy.