Experience in a specialist thyroid surgery unit: a demographic study, surgical complications, and outcome.

OBJECTIVE: To present a demographic study of thyroid diseases and thyroid surgical activity, to analyse the results of one department that has specialised in thyroid surgery during an 11-year period, and to try to define those groups of patients at increased risk of complications and untoward sequelae. DESIGN: Retrospective study. SETTING: Danish regional university hospital. SUBJECTS: The total series comprised 1099 consecutive patients who were operated on for benign goitre during an 11-year period. The demographic series comprised a subgroup of 933 patients with goitres from the defined catchment area composed of five municipalities. MAIN OUTCOME MEASURES: Annual number of operations for goitre, waiting time to operation, incidence of complications, and sequelae. RESULTS: In the demographic study the number of patients operated on for benign thyroid diseases declined from about 50 cases to about 25 cases/100000 inhabitants during the study period. At the same time the average waiting time between consultation and operation increased from 5-33 weeks. In the total series (n = 1099) 18 patients developed temporary unilateral vocal cord paralysis (2%), and 8 developed permanent paralysis (0.7%). There were no bilateral vocal cord paralyses, 7 patients developed temporary postoperative hypocalcaemia (0.6%), and an additional 8 patients (0.7%) developed permanent hypocalcaemia. 5 patients developed wound haematomas (0.5%), and 3 had wound infections (0.3%). A total of 16 patients (1.5%) had a permanent complication in the form of nerve injury or damage to the parathyroid glands. The rates of postoperative complications were significantly higher among patients who had two or more operations on the neck (p = 0.0004), intrathoracic goitres (p = 0.0002), large goitres (p = 0.0002), and those having emergency operations (p = 0.0091). CONCLUSION: The decline in the number of operations for benign goitre at Odense University Hospital parallels the increase it waiting time before operation. This can be explained by loss of operating room capacity rather than introduction of some alternative cure for goitre or change of criteria for operation. Certain groups of patients are at higher risk of complications than others.

Influence of adjuvant irradiation on the development of late arm lymphedema and impaired shoulder mobility after mastectomy for carcinoma of the breast.

The influence of postoperative radiation therapy on development of late arm lymphedema and shoulder joint disability following mastectomy was evaluated from a series of 57 women with operable carcinoma of the breast. The patients were divided into three groups. Common for all three groups was mastectomy and partial axillary dissection. In addition one group received postoperative irradiation plus systemic therapy and another group systemic therapy alone. The incidence of late arm lymphedema/impaired shoulder mobility was 11%/4% in the group of patients undergoing surgery alone, 46%/38% in the group of patients receiving adjuvant irradiation and 6%/12% in the group of patients receiving adjuvant systemic therapy. It is concluded that adjuvant irradiation to the axilla in patients with metastatic lymph nodes highly increases the risk of late physical sequelae following modified radical mastectomy. Adjuvant systemic therapy can be administered to high risk patients without increasing the risk of late arm lymphedema and shoulder disability.

Profile of Danish women undergoing reversal of sterilization, 1978-1983.

To help identify those women who might regret undergoing sterilization, the Danish women refertilized from 1978 to 1983 were contacted by mailed questionnaire. Eighty-three percent (120/144) responded. These women were younger at the time of sterilization than Danish women sterilized in the same period (mean age 29 years versus 34 years). Furthermore, they had more children at the time of sterilization and had their first and last child at a younger age than Danish women generally, in the same age group. Their social and educational status was lower than the background population and fewer were in gainful employment. At sterilization, most of the women were in an emotionally stressful situation (e.g., marital disharmony (78% of the married women), single parenthood (28%), unwanted pregnancy (27%], or had chronic health problems in the family. Alternative contraceptive methods had not been fully explored. Thirty-eight percent complained of late secondary effects attributable to the sterilization, but the main reason for wanting reversal of sterilization was a new partner (75%). The study suggests that the psycho-social situation and contraceptive alternatives should be carefully evaluated in women requesting sterilization, especially in those below the age of 30.

PIP: Danish women who had been refertilized over the 1977-1983 period, inclusive, were contacted in an effort to characterize their demographic, educational, and social status and to identify measurable traits for probable subsequent regret of sterilization that would be useful in presterilization counseling. Over the study period, 147 women were sterilized and subsequently refertilized. A questionnaire was sent to each woman. Verification of sterilization and refertilization and descriptions of operative methods were obtained from the hospitals. The 147 sterilizations were performed at 52 different hospitals and the refertilizations at 33 hospitals. Data on the background population -- all Danish women in the same age group as the refertilized women -- were obtained from information published by the Danish National Board of Health and the Danish National Bureau of Statistics. 3 women were excluded from the study. At the time of sterilization, 61% of the women who later had reversal of sterilization were below age 30, compared with 22% of all Danish women sterilized during the same period. The mean number of living children/refertilized woman was 2.4 at the time of sterilization; the mean number of living children for each woman in the Danish general population in the same age group was 1.8. The mean number of elective abortions prior to sterilization was 0.6, identical with the mean number among all Danish women in the same age group. The educational level of the refertilized women was much lower compared with Danish women in the same age group. 77 women (64%) had paid work, which was fewer than anticipated for the age group. 61 women (51%) had tried at most 2 different contraceptive methods, and only 17 (14%) complained of lack of information about alternative contraceptive methods. Satisfaction with the numer of children was the primary reason for sterilization, but 20 women (17%) were dissatisfied with the number of children at the time of sterilization. Their reasons for choosing sterilization varied, including medical grounds or severe marital problems. 41% of the women were pregnant at the time they requested sterilization, and most of the pregnancies ended in elective abortion. The average age at reversal was 32 years, and the average time span from sterilization to reversal was 37 months. On average, the women regretted the sterilization 22 months following the operation. 103 women (87%) had experienced a change in marital status at reversal of sterilization. 90 of the women stated that their new partner was the reason for the reversal. 6 women had had a child die, and 7 women lost custody of their children. 45 of the women (38%) reported late secondary effects of the sterilization, but only 6 women were refertilized because of these secondary effects (hormone imbalance and pelvic pains). 10 women thought they had lost their "womanhood" after sterilization.

Inoperable oesophageal and cardia cancer. Benefits from Celestin intubation.

During a 12-year period, 77 consecutive patients with unresectable malignant stricture of the oesophagus or cardia were treated with a Celestin tube for relief of dysphagia of varying degree. Pull-through technique and gastrotomy were used for insertion of the tube in 72 patients, and endoscopy in five. One-third of the patients benefited from the operation, i.e. experienced good palliation and no serious complications. The mortality rate was 27%. The authors conclude that all patients with difficulty in swallowing saliva should be intubated, as good palliation was achieved in all such patients. When there is dysphagia for liquid food, insertion of a Celestin tube may be considered, but intubation should not be done when dysphagia is confined to solid foods.

Results of reversal of sterilization performed in Danish women 1978-1983.

To follow up the outcome of refertilization after female sterilization, the Danish women refertilized from 1978 through 1983 were contacted by questionnaires, and the operative reports from sterilization and refertilization were obtained. Ninety percent (132/147) responded. The median follow up time was 39 months (range 18-83). Forty-four percent of the women became pregnant, 26% gave live birth, 7% had a miscarriage only, and 11% had a tubal pregnancy. The results of reversal of sterilization by means of conventional surgery (n = 101) and microsurgery with microscope or magnifying glasses (n = 31) did not differ in terms of number of live births. Refertilization after sterilization by laparoscopic methods was more successful: 34% of these women gave live birth, whereas 19% gave live birth after reversal of sterilization performed by resection of the tubes. The predictive value of peroperative tubal patency for subsequent pregnancy was 32%, whereas the prediction of no pregnancy in cases of no patency was found to be 60% correct. Postoperative hysterosalpingography (HSG) showing tubal patency was of predictive value for later pregnancy in 45%, whereas no patency by HSG gave a correct prediction for no pregnancy in 94% of the cases. In order to improve the skill of the surgeons, and thus, apply the microsurgical technique to full advantage, it would seem necessary to concentrate reversal of female sterilization on a small number of departments especially interested in this technique.

Retention of urine in genital herpetic infection. Survey and case report.

During the last years several cases of acute urinary retention, due to genital herpetic infection, have been described, especially in youngsters. The condition is caused by neurogenic dysfunction due to a sacral meningomyelitis. The clinical picture before the acute attack is characterized by painful genital eruptions; fever and malaise; tender inguinal lymph nodes; paresthesia in the perineum and on the inside of the thigh, and obstipation. Skin and mucous membrane manifestations are often sparse or located so that they are easily overlooked. The treatment is bladder drainage until the patient is able to void spontaneously. Most of the patients regain normal bladder function within 10 days, but bladder dysfunction for 5 weeks has been described. We present a typical case of acute urinary retention due to genital herpetic infection.

Acetate versus lactate in peritoneal dialysis solutions.

The acid-base characteristics of two peritoneal dialysis solutions containing either lactate or acetate are compared and the time course of changes in intraperitoneal pH following instillation into the abdominal cavity is measured. The concentration of titratable acid (cTA) is 5.58 mmol/l or 7 times as high in solutions containing acetate as in those containing lactate (0.79 mmol/l). The buffer capacity, -dcTA/dpH, is 11.43 and 1.82 mmol/l, respectively. Following intraperitoneal instillation of 1.5 liter of the solutions, the time course is 2-3 times as long before intraperitoneal pH reaches 7 using acetate (18 min) as when using lactate (7 min). The above mentioned difference in acid-base characteristics as well as an individual acetate intolerance is supposed to be the cause for the development of abdominal pains and peritoneal irritation observed in some patients using acetate-containing solutions. 123 mmol/l of sodium bicarbonate is to be added to the acetate solution to raise the pH value from 5.6 to 7.4. Neutralization using sodium bicarbonate will thus result in sodium intoxication of the patient. The use of lactate instead of acetate for peritoneal solutions is advocated.

Influence of adjuvant irradiation on shoulder joint function after mastectomy for breast carcinoma.

The influence of postoperative radiation therapy on ipsilateral shoulder function following mastectomy was evaluated from a series of 52 women with primarily operable carcinoma of the breast. Mastectomy and partial axillary dissection were carried out in all patients. In addition, 29 of the patients received postoperative irradiation with 36.6 Gy applied mid-axillarily in 12 fractions with irradiation twice a week. A significant impairment of the active shoulder mobility was found in the irradiated group (p less than 0.01). The passive mobility did not differ significantly between the two groups. The impairment of active shoulder mobility is suggested to be caused by radiation induced subcutaneous fibrosis.

Burkitt's lymphoma mimicking prostatitis.

We report on a 24-year-old man who had symptoms suggestive of acute pancreatitis but the diagnosis was Burkitt's lymphoma infiltrating the prostate. He was treated with cytotoxic drugs with a good initial response. Voiding improved and the tumor had disappeared completely on rectal palpation. However, the patient suffered a relapse and, despite intensive chemotherapy, he died a few months later with disseminated tumor infiltration.

Necrosis of ureter as a complication to chemical lumbar sympathectomy. Report of a case.

After right-sided chemical lumbar sympathectomy with alcohol, necrosis of the right ureter developed, necessitating nephrectomy. X-ray control ad been used to control the correct placement of the needle at the time the injection was made.