Recurrence of hyperparathyroidism after total parathyroidectomy and autotransplantation in peritoneal dialysis patients.

OBJECTIVE: To evaluate the effectiveness of total parathyroidectomy (PTX) with autotransplantation in the treatment of secondary hyperparathyroidism (HPT), and to assess recurrence rate of HPT in this peritoneal dialysis (PD) population. DESIGN: A retrospective study in a single home PD unit. PATIENTS: Between 1994 and 1998, 19 of 574 patients on PD underwent PTX for treatment of secondary HPT. MAIN OUTCOME MEASURES: Clinical and biochemical improvement, recurrence of HPT, improvement in anemia post-PTX. RESULTS: Nineteen (3.3%) patients required PTX between 1994 and 1998. These 5 men and 14 women ranged in age from 22 to 66 years; they had been on maintenance PD pre-PTX for 47.5 +/- 38.1 months, and were followed for 26.1 +/- 15.5 months post-PTX. Sixteen patients had temporary hypocalcemia that was managed by oral (n = 10) or intravenous (n = 6) calcium supplements and calcitriol, while 3 patients had severe "hungry bone" syndrome postoperatively. One patient had recurrent laryngeal nerve palsy post-PTX. Bone pain disappeared in all 12 patients. Pruritus improved in 12/13 patients; fatigue improved in 15/16 patients. Comparison showed significant differences between hemoglobin and hematocrit values 1 month pre-PTX and 12 months post-PTX (p < 0.05). Parathyroid hormone (PTH) level in 15 (79%) patients returned to normal (< or = 7.6 pmol/L) during the first month post-PTX. In 5/12 (42%) patients, PTH level was < or = 7.6 pmol/L 2 years post-PTX, while in 2/12 (17%), PTH was > 22.8 pmol/L (three times normal) 2 years post-PTX, and 3/5 (60%) patients had a PTH > 22.8 pmol/L 3 years post-PTX. CONCLUSIONS: Total PTX with autotransplantation is associated with a tendency for recurrence of HPT. Our findings suggest that total PTX with autotransplantation may be an ineffective procedure in controlling HPT over the long term.

The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and long-term evaluation.

BACKGROUND: A variety of free flaps have been successfully used for mandible reconstruction. This study compared the short- and long-term results of using the free iliac crest and fibula flaps. METHODS: We conducted a retrospective analysis of 117 patients who underwent mandibular reconstruction, 59 patients with iliac crest and 58 with free fibula. Accurate long-term functional assessment was possible in 31 cases in the iliac crest group and in 48 patients with fibular reconstruction. Anterior or combined anterolateral defects formed 72% and 64% in the iliac crest and fibula groups, respectively. The remainder were pure lateral defects. In both series, a skin paddle was included to provide either lining, skin cover, or both in 77% of the cases, whereas in 23% bone only was used. RESULTS: Complications included two perioperative deaths and three flap losses in the iliac crest group and five flap losses in the fibula group. Long-term functional and cosmetic assessment showed no statistically significant differences in oral continence (p > 0.9), speech (p = 0.57), and contour results (p = 0.80) between the two groups. However, oral deglutition was statistically significantly better in the fibula free flap group (p = 0.009). CONCLUSION: Although the fibula free flap is the flap of choice, the iliac crest is an excellent and reliable complementary flap for mandibular reconstruction.

Adenovector-mediated gene delivery of interleukin-2 in metastatic breast cancer and melanoma: results of a phase 1 clinical trial.

We conducted a phase 1 trial of direct injection of an E1, E3-deleted adenovirus encoding interleukin-2 (AdCAIL-2) into subcutaneous deposits of melanoma or breast cancer. Twenty-three patients were injected at seven dose levels (10(7)-10(10) p.f.u). Local inflammation was observed at the site of injection in 60% of patients, but side-effects were otherwise minor. Incomplete local tumor regression occurred at the site of injection in 24% of patients, but no conventional clinical responses were seen. Circulating CD4 and CD8 counts fell significantly 24 h after injection. Post-injection biopsies demonstrated tumor necrosis and lymphocytic infiltration with the predominant tumor-infiltrating cells both CD3- and CD8-positive. Vector-derived sequences were detected in 14 of 18 biopsies examined 7 days after injection and vector-derived hIL-2 mRNA was detected in 80% of 7-day biopsies processed after injection of 10(8) p.f.u. of AdCAIL-2 or higher. While IL-2 was detectable by ELISA in tumor biopsies at 48 h, no protein was detectable in injected tumors after 7 days and no circulating IL-2 was detectable at any time-point. No Ad5E1 sequences were detected either before or after injection indicating absence of replication-competent virus or endogenous E1-like sequence; furthermore, only rare vector shedding was detected. Anti-adenovirus and neutralizing antibody titers were elevated 1 month after injection in all patients. This trial therefore confirms the safety of use of adenoviral vectors for gene delivery in humans and demonstrates successful transgene expression even in the face of pre-existing immunity to adenovirus.

A retrospective comparison of the morbidity and cost of different reconstructive strategies in oral and oropharyngeal carcinoma.

PURPOSE: Evaluate and compare the morbidity and costs of different reconstructive strategies in oral and oropharyngeal carcinoma. STUDY DESIGN: Retrospective cross-sectional. PATIENTS AND METHODS: One hundred twenty-seven consecutive patients treated surgically for oral and oropharyngeal carcinoma between 1990 and 1996 were evaluated. Sixty-three patients had segmental mandibulectomies with 30 plate-soft tissue reconstructions and 33 bone-soft tissue flaps. Sixty-four patients had soft-tissue-only reconstructions. The following outcome parameters were analyzed: operative time, intraoperative blood loss, postoperative admission length, ICU and coronary care unit admission length, surgical interventions for complications, re-admissions, and prolonged (>6 mo) gastrostomy tube feeding, and all costs within the disease-free interval. Means and standard deviations were calculated for continuous parameters. Differences among the three groups were analyzed using one-way analysis of variance. For discontinuous parameters, the chi-square test was applied. RESULTS: Longer operative time (1.8 h) and more blood loss (150 mL) for bone-soft tissue flaps were the only statistically significant findings (P<.05) between the three groups. CONCLUSION: There is no rationale for allowing presumed factors of morbidity or cost select for type of reconstruction in patients with oral and oropharyngeal carcinoma.

Supraomohyoid neck dissection. Is it diagnostic or therapeutic?

BACKGROUND: The supraomohyoid neck dissection (SOHND) is often performed in patients with cancer of the oral cavity, where there is no clinical or radiologic evidence of regional metastases. When on pathologic examination positive neck nodes are found, however, some consider it a curative operation, whereas others regard it as a staging procedure only. METHODS: We retrospectively reviewed 43 patients with cancer of the oral cavity who had a SOHND during the period from 1991 to 1994. All patients were staged as having N0 disease and had a total of 48 SOHNDs (38 unilateral, 5 bilateral). The follow-up period was at least 2 years. RESULTS: Seven of 48 N0-staged necks showed occult metastasis (15%). Two of these patients received postoperative radiotherapy. One of 7 (14%) patients with pathologic node-positive disease on the SOHND side developed recurrent ipsilateral neck disease during the follow-up period, whereas 4 (10%) recurrences developed in 41 necks that were pathologically staged as N0. Survival was 88% for patients with pathologically N0 necks versus 86% for patients with pathologically N+; disease. CONCLUSION: Supraomohyoid neck dissection is an effective staging procedure; however, in this group of patients, neck recurrence and patient survival after SOHND appear not to be related to pathology N stage. Also, SOHND with or without adjuvant radiotherapy appears to control the neck in the majority of patients, attesting to therapeutic efficacy. A prospective study is needed, however, to see if a "wait and see" policy does not achieve similar long-term outcome.

Pharyngocutaneous fistulae in laryngectomy patients: the Toronto Hospital experience.

OBJECTIVE: The purpose of this study was to determine the rate of post-laryngectomy pharyngocutaneous fistulae and its association with age, gender, preoperative radiation, TNM staging, patients comorbidity factors, choice of ablation, choice of reconstruction, modality of postoperative feeding, and whether or not a primary tracheoesophageal puncture was performed. DESIGN: Retrospective clinical study. SETTING: The Toronto Hospital/Princess Margaret Hospital, University of Toronto, Toronto, Ontario. METHOD: One hundred and twenty-five consecutive laryngectomy procedures performed between July 1, 1992, and October 1, 1996, were reviewed. RESULTS: There was an overall fistula rate of 22%. No association found was between fistula rates and age, gender, patient comorbidity factors, TNM stage, choice of ablation, choice of reconstruction, modality of postoperative feeding, or whether a primary tracheoesophageal puncture was performed or not. CONCLUSIONS: At this tertiary care head and neck oncology centre, pharyngocutaneous fistulae remain an unpredictable and serious complication with an estimated economic cost of Cdn $400,000 per year.

Reconstruction of partial laryngopharyngectomy defects.

As our contributors to this section have pointed out, there are at present two main methods of reconstructing defects of the pharynx and cervical esophagus: free jejunal transfer (FJT) and tubed radial forearm flap. The advantage of the FJT is that it is a tube, thus limiting the enteric suture lines to proximal and distal. The radial forearm flap requires not only the proximal and distal suture lines but a long longitudinal suture line to create the tube. This increase the possibility for fistula formation. The controversy surrounding this case concerns what to do with a remaining mucosal strip after a subtotal laryngectomy. Traditional reconstructive principles would dictate that normal tissue should not be sacrificed, but some would argue that the remaining mucosa should be sacrificed to allow for use of a FJT. The other alternative would be use of a radical forearm skin flap tubed to 270 degrees. At the University of Texas M. D. Anderson Cancer Center, we preferentially use the FJT for almost all defects and would probably have sacrificed the remaining mucosal strip in this particular case. We have used skin flaps to patch pharyngeal defects and prevent stricture in a number of cases. This is usually done however when the remaining pharyngeal mucosa approaches 50% or greater. Although we do not routinely use the tubed radial forearm flap because of the increased rate of fistula formation, there are some definite indications for its use. The first important indication is in patients in whom speech rehabilitation is desired or indicated. The skin flap provides a stiffer resonating chamber for the speech production and does not have the peristalsis or the mucus production associated with the jejunal flap. Another indication for use of radial forearm flap would be when there is a contraindication to celiotomy, ie, patients with hepatic cirrhosis and associated ascites or other abdominal conditions precluding abdominal exploration. In this situation, avoiding an intra-abdominal procedure would limit operative morbidity. In conclusion, one should use whichever procedure obtains a healed wound and re-establishes continuity of the upper gastrointestinal tract. In our hands, retention of the remaining mucosal segment would not be critical in this particular case and in fact would present a hindrance to use of the FJT.

Oromandibular reconstruction with the fibular free flap. Analysis of 50 consecutive flaps.

OBJECTIVE: To evaluate the results and functional outcome associated with fibular free flap reconstruction of orofacial and mandibular defects. DESIGN: We conducted a retrospective analysis of 50 consecutive fibular free flaps during a 3-year period. Forty patients were available for follow-up, which ranged from 4 to 39 months. SETTING: Academic tertiary care referral medical center. PATIENTS: Fifty consecutive mandibular reconstructions using the fibular free flap were performed on 47 patients. Thirty-five patients (74%) underwent primary reconstruction. Sixty-six percent of the mandibular defects were anterior or combined anterolateral types; the remainder were pure lateral defects. In 38 patients (81%), a skin paddle was included with the flap to provide either a mucosal lining or skin cover, whereas in only 9 patients (19%), bone was used alone. MAIN OUTCOME MEASURES: Factors reflecting functional properties and processes as well as complications of the upper aerodigestive tract were evaluated clinically and radiographically. RESULTS: Four flaps required reexploration as emergencies, and none were successfully salvaged (8.5% failure). Three patients underwent further free vascularized fibula transfer with 1 failure. During follow-up, swallowing was normal in 25 patients (64%), oral continence was normal or almost normal in 26 patients (67%), and speech was normal or easily intelligible in 35 patients (90%). Aesthetic results were excellent or acceptable in 37 patients (95%). CONCLUSIONS: Our results reveal that the vascularized fibular free flap is very suitable with an excellent success rate for reconstructing both the composite or simple long-spanned mandibular defect. The overlying skin island is reliable and provides lining or coverage for intraoral and extraoral defects. Superior functional cosmetic results are expected in the majority of patients, while donor site morbidity is minimal.

Informed consent in head and neck surgery: how much do patients actually remember?

OBJECTIVE: This study was conducted to evaluate the effectiveness of informed consent in head and neck surgery by testing patient recall of potential complications from thyroidectomy, parathyroidectomy, and parotidectomy. DESIGN: A prospective design was used. SETTING: The setting was an academic tertiary care centre. METHODS: Fifty-four patients undergoing thyroidectomy, parathyroidectomy, or parotidectomy were consented by verbal contact by the operating surgeon with a specific preoperative checklist of complication and side effects. One week to 2 months after consent, the patients were surveyed for recall of potential complications. MAIN OUTCOME MEASURES: Rate of recall was related to various parameters including patient age, sex, level of education, occupation, and length of time from the consent interview to the recall interview. RESULTS: The overall recall rate for all procedures was 48%. Those patients who recalled over 50% of the complications were younger (p = .04) and better educated (p = .04). The gender of the patients did not appear to influence recall success (p = 1.00), even when facial scar or paralysis was considered. CONCLUSION: A significant relationship exists between education level and patient age and the rate of patient recall of potential complications of surgery.

Penetrating and blunt neck trauma: 10-year review of a Canadian experience.

OBJECTIVES: To determine if selective management of blunt and penetrating neck trauma is still appropriate in Canadian tertiary care centres because of differences in trauma demographics. A key secondary objective was a descriptive analysis of the Canadian head and neck trauma patient population and outcomes. DESIGN: A retrospective case series. SETTING: An academic tertiary care centre. PATIENTS: All 85 patients admitted between 1982 and 1992 with a diagnosis of blunt (19) or penetrating (66) neck trauma. INTERVENTIONS: Emergent neck explorations (29 patients), selective nonoperative management (20 patients) and elective neck exploration (17 patients). MAIN OUTCOME MEASURES: Hospital stay, complication rate, rate of negative exploration (elective management, emergent exploration) and rate of secondary exploration (selective management), and outcome and complication rate. The entire population was described demographically. RESULTS: In 66 patients the injuries were penetrating, with the majority being of low kinetic energy. The patients who underwent elective mandatory exploration were comparable to those who underwent selective nonoperative management. The length of stay in hospital for the selective group was significantly less (p = 0.0008), and no patient in this group required later operative management of a missed injury. However, 41% of patients who underwent elective mandatory neck exploration had no significant injury. The complication rate in the two groups was similar. CONCLUSIONS: The patients managed selectively had no difference in outcome from those who underwent mandatory elective exploration. In Canada, because of the lower incidence of high-morbidity zone I and zone III injuries and the high incidence of low kinetic energy trauma with a predilection to zone II, the surgeon may consider a selective approach where appropriate.

Regional versus systemic chemotherapy in the treatment of colorectal carcinoma metastatic to the liver. Is there a survival difference? Meta-analysis of the published literature.

BACKGROUND: A number of articles have appeared in the medical literature regarding regional infusion chemotherapy for the treatment of metastatic colorectal carcinoma confined to the liver. The results and conclusions have been varied. A meta-analysis of the literature was undertaken to determine if regional infusion chemotherapy using either 5-fluorouracil or floxuridine (FUDR) confers a survival advantage over systemic chemotherapy for the treatment of this disease. METHODS: A MEDLINE search was conducted encompassing the period from January 1976 to May 1995. The search was narrowed to include only articles that referenced prospective randomized clinical trials. A total of 149 articles or abstracts were reviewed for potential eligibility in this meta-analysis. Six articles met the current study inclusion criteria. One and 2-year survival rates for each treatment modality were directly retrieved from each study or calculated from the Kaplan-Meier survival curves that were presented. Prior to pooling the estimates of the treatment survival differences, a test was conducted for homogeneity of the treatment effect using the test statistic proposed by DerSimonian and Laird 1986. The fixed effect model was then used to obtain summary estimates of the survival differences from the group of studies. RESULTS: Regional infusion chemotherapy with FUDR produced a 10% (P = 0.041) and 6% (P = 0.124) increased survival at 1 and 2 years, respectively. CONCLUSIONS: Based on this meta-analysis, it appears that hepatic artery infusion chemotherapy confers a modest survival benefit over systemic chemotherapy. Whether this is clinically relevant depends on the quality rather than just the duration of survival.

Concurrent papillary and squamous carcinoma in a thyroglossal duct cyst: a case report.

Carcinomas of thyroglossal duct cysts are rare. Most are papillary carcinomas; only about 5% are squamous cell carcinomas. Only one case of mixed papillary and squamous cell carcinoma of a thyroglossal duct cyst has been reported so far. The authors present a second case, that of a 38-year-old man who was first seen with a midline neck lump. It was diagnosed clinically as a thyroglossal duct cyst and was locally excised. Pathological examination showed both a concurrent papillary carcinoma and a squamous cell carcinoma. Treatment consisted of a near-total thyroidectomy, ablative radioactive iodine and adjuvant external radiation therapy. The authors review the literature and explain the rationale behind their choice of treatment.

The free flap and plate in oromandibular reconstruction: long-term review and indications.

The purpose of this study was to define the role of reconstruction plates as bone replacement in oromandibular reconstruction. From 1987 through 1991, 71 consecutive oral cancer patients underwent composite resection and reconstruction and were entered into one of two studies. In the first study of 31 patients, 15 underwent oromandibular reconstruction using a radial forearm osteocutaneous flap, while the remainder (16) received a radial forearm fasciocutaneous flap together with a mandibular reconstruction plate. The second study involved 40 subsequent patients, all receiving the latter form of reconstruction. Twenty-one of the plates were stainless steel, and the remaining 19 were of the titanium hollow screw (THORP) type. We followed the patients prospectively. We defined success as a reconstruction that we did not have to remove. Additionally, since the patients had limited life expectancy, we developed the idea of days of life lost and incorporated it into our definition of a successful outcome. Vascularized autogenous bone proved to be more successful than metallic plates used alone in terms both of reconstruction survival and of minimizing days of life lost. The overall success rate of mandibular plate reconstruction was 78.9 percent, but analysis by defect type revealed a failure rate of 35 percent when the defects were anterior and only 5 percent when they were lateral. THORP plates demonstrated a trend towards more durability. We would now recommend plate reconstruction only in lateral defects in patients with a poor prognosis.

Intraoral pyogenic granuloma after allogeneic bone marrow transplant. Report of three cases.

Allogeneic bone marrow transplant patients commonly have oral complications related to their disease or its treatment. Those reported include: xerostomia, mucositis, caries, infection, gingival hyperplasia, periodontitis, and graft-versus-host disease. These complications may be responsible for significant morbidity. This article reviews commonly reported oral complications of bone marrow transplantation and presents three cases in which intraoral pyogenic granuloma occurred. The cause of these lesions in post-bone marrow transplant patients is discussed.

Classification of mandibular defects.

A classification of mandibular defects based on functional as well as aesthetic factors is presented. By taking into account the difficulties in restoring form and function and not simply relying on traditional anatomic landmarks, it is hoped that this method will allow different types of reconstructions to be fairly evaluated. It also should help surgeons to tailor individual reconstructive techniques to specific clinical situations. Major difficulties in mandibular reconstruction arise when a condyle requires replacement, when there is a mucosal and/or skin component to the defect, and when the area to be reconstructed involves the anterior arch. The classification is based on three upper-case and three lower-case characters: H, C, L and o, m, s. H defects are lateral defects of any length, including the condyle but not significantly crossing the midline; L defects are the same only without the condyle; C defects consist of the entire central segment containing the four incisors and the two canines. Combinations of these letters are possible (an angle-to-angle defect, for example, is represented as LCL). Thus H and L defects may reach or even extend slightly beyond the midline but are not referred to as LC or HC unless they contain the entire central segment. The letters o (neither a skin nor a mucosal component), s (skin), m (mucosa), and sm (skin plus mucosa) are added to denote the epithelial requirement.

Consensus conference on well-differentiated thyroid cancer: a summary.

OBJECTIVE: To update recommendations for the surgical treatment of well-differentiated thyroid cancer. DATA SOURCES: Literature reviews and personal files. STUDY SELECTION: Panelists selected relevant articles to make arguments for and against current recommendations for the surgical treatment of well-differentiated thyroid cancer. OUTCOMES: Four aspects of surgical treatment were considered: (a) the extent of surgical resection, (b) the definition and utilization of high- and low-risk patient groups, (c) who should perform thyroid surgery and (d) the use of radioactive iodine. RECOMMENDATIONS: Total thyroidectomy is not the treatment of choice for all well-differentiated thyroid cancers. The use of risk factors help select those patients in whom a total thyroidectomy would be of benefit. High-risk patients are those who are considered at high risk according to the AGES and AMES classifications or who have lymph-node metastases, aggressive variants of their disease, multifocal cancer or disease in the contralateral thyroid lobe and a history of radiation to the neck. Those at low-risk are those previously described as being at low risk according to the AGES and AMES classifications. General surgery training programs across Canada need to ensure that their residents obtain enough experience in thyroid surgery that as general surgeons they can perform this type of surgery with low morbidity. CONCLUSIONS: The findings of this consensus conference were supported by those of several review articles and by the arguments put forward by the panelists. These findings are only guidelines as to the surgical approach to well-differentiated thyroid cancer.

A phase I dose escalation trial of yttrium-90 microspheres in the treatment of primary hepatocellular carcinoma.

METHODS: Ten patients with primary hepatocellular carcinoma were treated with intraarterial instillation of yttrium-90 (Y-90) microspheres, including eight men and two women (median age, 52 years; range, 29-69 years). Four patients were treated at a targeted hepatic dose of 50 Gy, two at 75 Gy, and four at 100 Gy. RESULTS: In 8 of the 10 patients, there was a significant concentration of Y-90 in localized tumor masses with tumor-to-liver perfusion ratios from 1.0:1-10.0:1. No patient had a complete or partial response, but 10 patients had stable disease (median duration, 10 weeks; range, 5-64 weeks). The median survival was 18 weeks (range, 2-150 weeks), and three patients lived longer than 1 year. Significant bone marrow or hepatic toxicity was not seen. One patient had a radiation-induced duodenal ulcer that required surgical management. CONCLUSIONS: Intraarterial instillation of Y-90 microspheres appears to be safe and deserves additional evaluation to determine whether there is meaningful activity in patients with primary hepatocellular carcinoma.