The impact of initial surgical management on outcome in young patients with differentiated thyroid cancer.

BACKGROUND/PURPOSE: It is generally believed that differentiated thyroid cancer (DTC) in young patients has an excellent prognosis. This calls into question the need for more extensive surgical ablation of the thyroid gland with attendant risks of surgical complications. The purpose of this report was to investigate both the incidence of surgical morbidity and the impact of surgery on locoregional recurrence of disease. METHODS: The authors reviewed the clinical course of patients under 22 years of age treated for DTC within Department of Defense hospitals since 1950. Data were available for determination of surgical morbidity in 126 and for outcome in 105. RESULTS: The incidence of postoperative hypocalcemia was 17% and of recurrent laryngeal nerve injury 3%. Factors predictive of morbidity were (1) more extensive thyroid surgery (P = .023), and (2) the presence of gross tumor invasion (P = .022). The incidence of neck recurrence was analyzed among a cohort of 90 patients. A total of 19 (21%) patients had a local recurrence. The median time to recurrence was 24 months. The factor predictive of recurrence was the presence of gross invasion (P = .0001). A strong trend toward locoregional recurrence was found among patients with metastatic disease to more than five cervical nodes (P < .08). The primary operations on the thyroid and regional nodes were not significant predictors of neck recurrence. Among these 19 patients there have been no deaths, but 25% had persistent disease at a mean follow-up of 12.6 years. CONCLUSIONS: The incidence of surgical morbidity does increase with more extensive surgery. Outcome is predicted primarily by the initial extent of disease.

Clinical features associated with metastasis and recurrence of differentiated thyroid cancer in children, adolescents and young adults.

OBJECTIVE: Differentiated thyroid cancer (DTC), including papillary (PTC) and follicular (FTC) variants, is unusual in children and accounts for only 10% of all cases. For that reason, knowledge of the clinical features which predict recurrence is limited. We reviewed 170 cases of childhood DTC to determine if specific clinical or pathological findings were associated with increased risk of recurrence. DESIGN: This was a retrospective study of children and adolescents with DTC registered in the Department of Defense Automated Centralized Tumor Registry. PATIENTS: We reviewed 137 cases of PTC and 33 cases of FTC diagnosed between 1953 and 1996 at < or = 21 years of age. RESULTS: In the PTC group (median follow-up 6.6 years, range 2 month-39.5 years), only one patient died, but 21 developed local and 6 developed distant recurrence. By univariate analysis, recurrence was more common in patients with multifocal (odds ratio 7.5) or large tumours (odds ratio 4.1), and in those with palpable cervical lymphadenopathy (odds ratio 3.0) or metastasis at diagnosis (odds ratio 2.8). By multivariate analysis focality was the best predictor of recurrence (P = 0.0019). In the FTC group (median follow-up 5 years, range 6 month-38.1 years), no patient died of disease, but 5 developed recurrence. As with PTC, recurrence was more likely in patients with multifocal tumours (odds ratio 22.0). CONCLUSIONS: Differentiated thyroid cancer in children and adolescents has low mortality, but a high risk of recurrence. Young patients with large, multifocal tumours that are already metastatic at diagnosis have the greatest risk of recurrence.

Urgent proctocolectomy in ulcerative colitis.

UC being a typical medical disease is encountered by the surgeon only in the stage of toxic megacolon or in case of severe complication during conservative treatment such as perforation, haemorrhage, obstruction or malignity. The authors operated urgently 6 young women with all these complications performing total proctocolectomy, constructing ileal pouch with complete stapling technique. In spite of high rate of complications the results are promising. The best prevention of malignant change and complication is the earlier indication for operative treatment which offers the ideal treatment for patients with UC.

[Long-term results of anti-reflux surgery of the popliteal vein]. / Dlhodobé výsledky antirefluxnej operácie na popliteálnej véne.

The pathophysiological cause of chronic venous insufficiency with trophic dermal changes is a valvular lesion in the deep and perforating venous system which develops in as many as 72% during recanalization of thrombi. The reduction of reflux by valvuloplasty in the popliteal section with discontinuation of the insufficient perforating vessels (sclerotization) leads promptly not only to marked subjective relief, but on a long-term basis it improves the trophic state of the skin and healing of refractory ulcerations. The technique of valvuloplasty by invagination of the venous wall after its prolongation by the axillary vein with a functional valve rules out venotomy and the use of alien material for suture which would damage the intima, and thus reduces to a minimum the possibility of postoperative thrombosis.

[Comprehensive prevention of postoperative thrombosis]. / Komplexná prevencia pooperacnej trombózy.

Thromboembolic disease with its high mortality and morbidity is currently one of the most serious postoperative complications. Its occurrence in high-risk patients in surgical wards is 25-50%. Since 1979, the authors have examined 160 risk patients in whom no prevention had been performed. In this group of patients they detected the occurrence of profound venous thrombosis by means of the accumulation fibrinogen test, targeted phlebography under skiascopic control. At the same time the clinical symptomatology was followed in detail. Since the thrombosis is a multifactorial process, the effective preventive measure must affect and normalize as many disturbed homeostatic processes as possible. Into the group of 176 high-risk patients, the authors introduced a complex prevention into surgical routine residing in classical low-dose heparinization by 5000 u.s.c. with the first dose administered 1 hours prior to surgery, preoperational haemodilution with the administration of minimally 500 ml of Dextran and in preoperation administration of antiaggregants (Acylpyrin). by means of this tactic, the greatest antithrombotic effect is brought about preoperatively and in the first postoperative hours while the patient is protected minimally 5 to 7 postoperative days. Both preoperative and postoperative procedures are monitored by means of a complex haemocoagulation examination of the basic 10 haemocoagulation factors. The occurrence of thrombosis in patients without prevention with minimally 5 thrombogenetic risk factors during the control by means of the accumulation fibrinogen test was 32.4% and during the control by means of targeted phlebography is 24%. The differences are not statistically significant. In the group of patients with prevention the occurrence is 5.6%. In this group the screening is represented by the accumulation fibrinogen test and its positivity is verified by its localization by means of selective phlebography. The occurrence of deep vein thrombosis in the group with prevention and in the control groups statistically highly significant p > 0.0005. Haemocoagulation examination is aimed at the determination of the normalization impact of prevention on the state of hypercoagulation ability associated with the depression of spontaneous fibrinolysis in patients without prevention. The thrombi detected in patients with prevention are localized in short segments of crural veins. Clinically more significant bleeding in the group of patients with prevention occurred only in 2 patients, i.e. in 1%. Complex multifactorial prevention is not only simple and safe for patients, but also highly effective in the group of patients with high risk of postoperative thrombosis. The clinical diagnosis is unreliable and misleading with low sensitivity and specificity. (Tab. 2, Fig. 2, Ref. 28.).

[Vulvar varices]. / K problematike vulválnych varixov.

The authors treated in 1983-1993 72 patients with vulvar varicosities who suffered particularly during pregnancy. Typical symptoms are pruritus, pain caused by pressure in the vulvar area and the sensation of prolapse. According to the authors surgical treatment is unnecessary and involves risk. They recommend compressive sclerotherapy as described by Fegan, using sodium tetradecyl sulphate S.T.D. Hegefort England not only in case of a marked clinical symptomatology but also as prevention of dangerous haemorrhage during delivery.

[Advantages of continuous resorbable mattress sutures in closing extensive laparotomies]. / Výhody pokracujúceho rezorbovatel'ného sl'uckového stehu pri uzatváraní vel'kých laparotómií.

In a group of 170 patients the mean time taken to close the abdominal cavity was 10 minutes, suppuration and fistulation resp. was observed in 2% of patients after 6 weeks. In 1.1% dehiscence occurred and in 3.5% hernia in the scar. All this applies to patients with severe malignity and hypoproteinaemia. Smead Jones technique of a continuous absorbable suture without knots is not only quick, safe, effective, cheap but also reliable in risk patients and obese patients with impaired healing, but only when its basic principles are respected: reliable anchoring and termination in fasciae, regularly alternating distances of stitches.

[Mechanical anastomoses in gastrointestinal surgery]. / Mechanická anastomóza v gastrointestinálnej chirurgii.

The authors present an account of possibilities to use a mechanical anastomosis by means of staplers in gastrointestinal surgery and the advantages of this procedure. It is a rapid, simple, and above all, reliable technique with a minimal percentage of postoperative complications. Despite the relatively high cost its importance is invaluable in particular in surgery of the oesophagus, cardia and in low resections of the rectum where it is possible to fix a reliable anastomosis up to 2 cm from the linea dentata. The authors evaluate 95 mechanical anastomoses, incl. three where during the postoperative period dehiscence occurred.

[Surgical treatment of ulcerous colitis]. / Chirurgická liecba ulceróznej kolitídy.

Ulcerative colitis, being a typical medical disease, is encountered by the surgeon only in the stage of toxic megacolon or in case of sever complications during conservative treatment such as perforation, haemorrhage or obstruction. The authors operated six young women where they performed as the only choice total proctocolectomy with formation of an ileal reservoir which was sutured to the rectum stripped of the mucosa. Despite the serious condition at the time of operation, the patients survive the operation, although the percentage of postoperative complications is high, with the exception of one patient who died on the 126th day after operation. The remainder survive in a fair condition with complete and continence.

[Detection of leukosis on brown Leghorn chicken farms]. / Detekcia leukózý v chove sliepok plemena Brown Leghorn.

Samples taken on the Brown Leghorn hen farms were tested for the leucosis virus. Out of 21 samples the leucosis virus was present in five cases (24%). Viruses are detectable in chicken embryonic cells, accompanied by transformation and focus formation. Viruses are not transformed by the guniea pig and quail embryonic cells. The results were achieved by fusion but not by co-cultivation of the tested cells with permanent line 16 Q. These viruses appear to belong to the sub-group B, it is less probable that they belong to the sub-group C. The isolated viruses document spontaneous infection of the originally leucosis-free hen farm during five years when leucosis-free conditions were not secured.