Relative risk of cancer in sonographically detected thyroid nodules with calcifications.

PURPOSE: The aim of this prospective study was to evaluate the significance of sonographically detected thyroid calcifications in the diagnosis of thyroid cancer. METHODS: One hundred eighty-eight patients with thyroid disease, including 37 with thyroid cancer, were included in the study. Each patient underwent preoperative, high-resolution sonography to evaluate the thyroid gland for the presence of calcifications. RESULTS: The highest incidence of calcification was found in thyroid cancer (54%), followed by multinodular goiter (40%), solitary nodular goiter (14%), and follicular adenomas (12%). The incidence of cancer was significantly higher in calcified nodules (29%) than in noncalcified nodules in the entire group (14%) (p = 0.019), with a relative risk of 2.5. In the group of solitary thyroid nodules, the incidence of cancer in the calcified nodules (55%) was higher than in the nodules without calcification (23%) (p = 0.016). Multiple noncalcified thyroid nodules harbored cancer in only 5% of cases. Compared with multiple noncalcified thyroid nodules, the solitary calcified nodules demonstrated a relative risk of 22.8. In both the solitary and multiple nodules, the relative risk in the presence of calcification was about the same, around 4. Patients younger than 40 years with calcified nodules constituted a high-risk group, with a relative risk of 3.8 versus 2.5 in patients older than 40 years with calcified nodules. CONCLUSIONS: The detection of thyroid calcifications by sonography is diagnostically valuable, especially in cases involving a solitary nodule or a young person. The presence of calcifications in these cases should raise the suspicion of malignancy. The low incidence of cancer in patients with multiple noncalcified thyroid nodules suggests that a more conservative approach may be appropriate in such cases.

Aortocaval fistula in ruptured aneurysms.

OBJECTIVES: to study incidence, clinical presentation and problems in management of aortocaval fistula in our series. DESIGN: retrospective study. MATERIALS: during a seven-year period, 112 patients operated on for abdominal aortic aneurysm, including four patients with aortocaval fistula. METHODS: standard repair of aortocaval fistula from inside the aneurysmal sac was the preferred operative technique. RESULTS: the incidence of aortocaval fistula was 3.6%. Three cases were found incidentally during emergency surgery for ruptured aneurysms; the fourth case was an isolated aortocaval fistula associated with inferior vena cava thrombosis, diagnosed preoperatively by angiography. In this case, inferior vena cava ligation instead of standard aortocaval repair was performed. CONCLUSIONS: Aortocaval fistulas, although rare, should be kept in mind, because clinical diagnosis is often difficult. Furthermore, unsuspected problems during repair may necessitate appropriate change in operative technique.

Treatment of patients with severe acute necrotizing pancreatitis based on prospective evaluation.

BACKGROUND/AIMS: To examine the impact of a prospectively applied diagnostic and treatment protocol in patients with severe acute necrotizing pancreatitis. METHODOLOGY: During a 4-year period (1993-1996), 26 patients were treated for necrotizing pancreatitis, as documented by contrast-enhanced computed tomography (CE-CT). All patients were prospectively treated by medical means. Patients with persistent systemic inflammatory response syndrome underwent fine-needle aspiration for bacterial cultures. In case of positive results operative intervention was followed, while in negative results the conservative management was continued. Fine-needle aspiration was repeated every 5-7 days if systemic inflammatory response syndrome persisted or worsened. Sixty-five patients hospitalized during the preceding 11 years (1982-1992), when such a treatment was not constantly applied, served as controls. RESULTS: Infected pancreatic necrosis was demonstrated in 7 of the 26 patients (27%) and was treated by open drainage and/or post-operative lavage with a mortality rate of 14.2%. Thirteen patients in whom fine-needle aspiration was not necessary and 6 with negative cultures after fine-needle aspiration (73%) followed conservative treatment and the mortality rate was 5.2%. The total mortality rate of 7.7% was significantly lower than the mortality rate of 26.2% observed in the control group (p = 0.05). CONCLUSIONS: Recent evolution made in the management of severe necrotizing acute pancreatitis can lead to better results in the context of a strictly applied treatment protocol. Such protocols may improve mortality and serve as controls in future study.

Ductectatic mucinous cystadenocarcinoma of the pancreas: a rare variant.

A rare case of the ductectatic variant of mucinous pancreatic cystadenocarcinoma in a 64 year-old man, presenting with painless obstructive jaundice, is reported. CT scan revealed a multicystic lesion of the pancreatic head, which caused biliary obstruction. Endoscopic retrograde pancreatography (ERP) revealed the characteristic grapelike cluster pattern of pancreatic ductectatic neoplasms. Pancreaticoduodenectomy was then successfully performed. Pancreatic ductectatic mucinous cystadenocarcinoma is a rare entity, presenting, usually, with obstructive pancreatitis, and is histologically indistinguishable from the classic malignant mucinous cystic neoplasm. ERP is the diagnostic method of choice and should be performed in any case of susceptible pancreatic lesions.

Seasonal variation of the abdominal aortic aneurysm rupture in southwestern Greece.

OBJECTIVE: To examine the hypothesis of seasonal variation in the rupture of abdominal aortic aneurysm in our region. DESIGN: Retrospective open study. SETTING: University Hospital, Greece. PATIENTS: Forty-six patients with abdominal aortic aneurysm admitted between 1991-1995. INTERVENTION: The month of admission was registered. MAIN OUTCOME MEASURES: The seasonal variation in the abdominal aortic aneurysm rupture. RESULTS: The majority of ruptures (78%) occurred during the months October and April, a phenomenon proven to be periodical (p<0.05). CONCLUSIONS: The abdominal aortic aneurysm rupture clearly showed seasonal variation.

Peritoneal echinococcosis.

Peritoneal echinococcosis is rare, even in areas where hydatid disease is endemic. Although the liver and lungs are the organs most commonly involved, peritoneal echinococcosis, either primary or secondary, represents an uncommon but significant manifestation of the disease. We reviewed the medical records of 121 patients with abdominal echinococcosis operated on in our department over the past 12 years. Peritoneal echinococcosis was found in 17 patients, usually combined with liver disease. The presenting symptoms were mostly atypical, and a few cases were discovered accidentally during routine follow-up after operations for hepatic echinococcosis. Surgery remains the best curative or palliative treatment for peritoneal echinococcosis, although anthelmintics can be an effective alternative for the treatment of small and asymptomatic cysts.

Conservative surgery in the treatment of hepatic hydatidosis.

OBJECTIVE: To examine the morbidity, mortality and recurrence rate after a modified conservative operation in the treatment of hepatic hydatidosis. DESIGN: Prospective open study. SETTING: University hospital, Greece. SUBJECTS: 67 Consecutive patients with hepatic hydatidosis, operated on between 1985 and 1990. INTERVENTION: The liver was mobilised and abdominal cavity isolated with pads soaked in 15% saline solution. Hydatid fluid was aspirated from the cysts which were widely deroofed, sterilised with 15% saline, and then oversewn with a braided absorbable suture. Drains were left in place and a third of patients also had omentoplasty (n = 22). MAIN OUTCOME MEASURES: Morbidity, mortality and recurrence rate. RESULTS: One patient died (1%), 4 developed complications (6%), and there were 3 recurrences (6%). It made no difference whether an omentoplasty was added or not. CONCLUSION: Conservative surgery achieves satisfactory results in the treatment of hepatic hydatidosis.

Embryologic and anatomic basis of inguinal herniorrhaphy.

The embryology and surgical anatomy of the inguinal area is presented with emphasis on embryologic and anatomic entities related to surgery. We have presented the factors, such as patent processus vaginalis and defective posterior wall of the inguinal canal, that may be responsible for the genesis of congenital inguinofemoral herniation. These, together with impaired collagen synthesis and trauma, are responsible for the formation of the acquired inguinofemoral hernia. Still, we do not have all the answers for an ideal repair. Despite the latest successes in repair, we, to paraphrase Ritsos, are awaiting the triumphant return of Theseus.

Total parenteral nutrition in severe acute pancreatitis.

The influence of total parenteral nutrition (TPN) was studied in 67 patients with severe acute pancreatitis having three or more criteria according to Ranson (mean +/- SD = 3.8 +/- 0.21). Although TPN has been reported to not be of benefit in the progress and severity of the disease, we have found that the time TPN is started is important in influencing the course of the disease and in the development of local complications, as well as in the mortality rate. Patients whose TPN was started within the first 72 hours of the disease had a 23.6% complication rate and 13% mortality, in comparison with patients whose TPN was started later in the course of the disease, who had a 95.6% complication rate (p less than 0.01) and a mortality rate of 38% (p less than 0.03). The nutritional status of the patients during TPN administration of 28.4 days was maintained either steady or was improved, as assessed by nitrogen balance, serum levels of transferrin (p less than 0.05), and albumin (p less than 0.05). The administration of fat solution, either to prevent essential fatty acid deficiency or to provide part of the caloric requirements, was found to cause neither clinical nor laboratory worsening of the disease. All pancreatic fistulae that developed during the course of the disease spontaneously closed in patients receiving TPN without operation in a mean period of 33.3 days, and all pseudocysts subsided in an average of 18.3 days. Those who died (overall mortality rate 24%) had had uncontrollable sepsis, which resulted in hypercatabolism and multiple system organ failure.(ABSTRACT TRUNCATED AT 250 WORDS)