Localization of abnormal parathyroid glands using thallium-201.

Ectopically located parathyroid adenomas may be difficult to find during initial neck exploration. They account for over 70 percent of missed adenomas found at reexploration. Preoperative localization of parathyroid adenomas would reduce unnecessary dissection and possibly reduce the number of negative results of initial neck exploration. Before reoperative parathyroid surgery is performed, some means of localization is mandatory to detect ectopic adenomas in the neck and mediastinum. Computed tomography and ultrasonography cannot effectively evaluate the mediastinum. Angiography and venous parathyroid hormone sampling are invasive, costly, and tedious to perform. We have shown that thallium-201 will accurately localize ectopic parathyroid adenomas. All 10 adenomas found in positions not immediately adjacent to the thyroid gland were detected by thallium-201 scintigraphy. One was a mediastinal adenoma resected with a median sternotomy. Our results suggest that thallium-201 scintigraphy should be the initial localization procedure of choice before all reexplorations. Its use before initial explorations, as well, will enable the surgeon to immediately direct attention to the area of the localized adenoma. If mediastinal uptake is found to be present, then median sternotomy may be performed during initial surgery provided a thorough neck exploration is performed first.

Cystic neoplasms of the pancreas.

Ten cystadenomas and cystadenocarcinomas of the pancreas are presented. We believe that the strong recommendations of the pathologists who feel that all cystic neoplasms of this type have malignant potential or contain malignant elements emphasizes the need for total excision if at all possible in these patients. It is conceivable that the reason for the high incidence of cystadenocarcinomas in our small series may be the meticulous searching of the cellular elements for evidence of malignancy. It strongly militates against anything less than total excision as treatment for these curable lesions. The correct preoperative diagnosis is mandatory for a logical plan for surgical intervention. All cysts, whether deemed benign or malignant, should be aggressively attacked surgically unless there is distant metastasis. The very high rate of malignant potential of benign cystadenomas coupled with the relatively indolent growth pattern of malignant cystadenocarcinomas combine to give a high rate of surgical cure.

The initial evaluation of the patient with multiple injuries.

The management of trauma patients requires organization and the cooperation of trained health personnel, beginning at the site of injury and continuing until the patient is discharged from the hospital. Treatment guidelines and priorities must be well outlined in advance to provide optimal care and minimize delay prior to definitive therapy. Resuscitation and treatment must begin immediately and simultaneously following well established principles. These guidelines and the general care of the patient with multiple trauma are discussed in this article.

Cystic neoplasms of the pancreas: new angiographic and ultrasonographic findings.

Cystic neoplasms of the pancreas (cystadenoma, cystadenocarcinoma) are rare tumors. Early diagnosis and differentiation from other pancreatic lesions are essential for appropriate management. Pancreatic angiography and gray scale ultrasonography facilitate rapid, accurate diagnosis and proper surgical therapy. In a 7 year period, eight patients were studied (one cystadenoma, seven cystadenocarcinoma); five had selective visceral angiography and six underwent abdominal ultrasonography. The ultrasonographic characteristics of these neoplasms and some new angiographic findings are presented. The sonographic findings for cystadenocarcinoma were similar to those of cystadenoma.

Adenocarcinoma in regional enteritis of the small intestine.

An increased risk for regional enteritis patients of small bowel adenocarcinoma to develop has been suspected but unproved. We have analyzed 49 cases reported since 1957 and two additional ones of our own. These have been compared with a current group of small bowel adenocarcinomas not associated with regional enteritis. The Crohn-associated cancers differed from adenocarcinomas not associated with Crohn disease in that (1) mean age at cancer discovery was less (46 vs 64 years), (2) more cancers arose in the ileum (76% vs 27%), (3) diagnosis and cure were less successful, and (4) they occurred more frequently. The 32 cases reported in the past five years were compared with the expected 0.1 to 5 cases. Regional enteritis patients were found to have an increased risk for the development not only of small bowel adenocarcinoma, but one that is more occult and lethal than that in individuals wihtout Crohn disease.

Duplication of the alimentary tract.

Duplications of the intestinal tract as can be seen from the embryologic and anatomic descriptions are varied and frequently complex. The great variety of presentation and pathology encountered requires almost individual treatment for each case. Certainly total surgical excision, or at the very least, good complete internal drainage should be carried out in these cases. Correct therapy should afford relief of the patients's symptoms and prevent future complications.