Antimicrobial and osteoconductive properties of two different types of titanium silver coating.

In prosthetic joint surgery, Ag coating of implant areas in direct contact with bone has been met with hesitation for fear of compromising osseointegration. The physicochemical, antibacterial and osteoconductive properties of three different Ti samples were studied: Ti6Al4V alloy that was grit-blasted (GB), Ti6Al4V alloy with an experimental Ti-Ag-nitride layer (SN) applied by physical vapour deposition (PVD) and commercially available PVD-coated Ti6Al4V alloy with a base Ag layer and a surface Ti-Ag-nitride layer (SSN, clinically known as PorAg®). Ag content on the surface of experimental SN and SSN discs was 27.7 %wt and 68.5 % wt, respectively. At 28 d, Ag release was 4 ppm from SN and 26.9 ppm from SSN substrates. Colonisation of discs by Staphylococcus aureus was the highest on GB [944 (± 91) × 10 4 CFU/mL], distinctly lower on experimental SN discs [414 (± 117) × 104 CFU/mL] and the lowest on SSN discs [307 (± 126) × 10 4 CFU/mL]. Primary human osteoblasts were abundant 28 d after seeding on GB discs but their adhesion and differentiation, measured by alkaline-phosphatase production, was suppressed by 73 % on SN and by 96 % on SSN discs, in comparison to GB discs. Thus, the PVD-applied Ag coatings differed considerably in their antibacterial effects and osteoconductivity. The experimental SN coating had similar antibacterial effects to the commercially available SSN coating while providing slightly improved osteoconductivity. Balancing the Ag content of Ti implants will be vital for future developments of implants designed for cementless fixation into bone.

Outcome of hypocalcaemia after thyroidectomy treated only in symptomatic patients.

BACKGROUND: Calcium supplementation has been proposed after bilateral thyroid surgery, either to all patients or to those with biochemical hypocalcaemia. It has also been suggested that supplementation aids parathyroid recovery and prevents permanent hypoparathyroidism. This single-centre study investigated the feasibility of a restrictive management of post-thyroidectomy hypocalcaemia. METHODS: Serum calcium was checked before surgery, on postoperative day 1 (POD) 1, at a follow-up visit 6-8 weeks after surgery and after a minimum of 12 months in all patients. Regardless of serum calcium levels, patients with symptoms of hypocalcaemia were prescribed oral calcium supplementation (0·5-1·0 g twice daily) and asymptomatic patients were not. Asymptomatic patients were informed about hypocalcaemic symptoms and instructed to contact the surgical ward should symptoms appear. RESULTS: Some 640 patients underwent bilateral thyroid surgery without previous or intentional simultaneous parathyroidectomy. A subnormal serum calcium level (below 2·15 mmol/l) was observed in 412 patients (64·4 per cent) on POD 1. By comparison, only 63 patients (9·8 per cent) experienced symptoms of hypocalcaemia in the postoperative period, all but one with a corresponding biochemical hypocalcaemia on POD 1. Calcium levels in all patients with asymptomatic postoperative hypocalcaemia recovered to normal without supplementation. Serum calcium was also normalized during follow-up in all symptomatic patients, except 22 (3·4 per cent) who became permanently hypoparathyroid. No patient without early hypocalcaemic symptoms developed permanent hypoparathyroidism. CONCLUSION: The proposed restrictive management of postoperative hypocalcaemia after bilateral thyroid surgery avoids unnecessary supplementation for most patients.

Should asymptomatic retrosternal goitre be left untreated? A prospective single-centre study.

BACKGROUND AND AIMS: Retrosternal goiter may cause symptoms of airway obstruction and dysphagia, but often it is asymptomatic and is increasingly detected incidentally with imaging investigations. Consensus has been reached that sternotomy is not necessary in most cases, as a collar incision normally suffices. Yet, surgery for retrosternal goiter is associated with more complications than cervical goiter. There is controversy over whether patients with asymptomatic retrosternal goiter should be operated. Proponents argue that retrosternal goiter may be a risk for thyroid cancer and may progress to later cause symptoms, although clear evidence is missing. PATIENTS AND METHODS: Between 1984 and 2012, 132 patients underwent surgery for benign retrosternal goiter. Preoperatively, the benign nature was clinically apparent and confirmed by fine needle cytology in most cases. RESULTS: Sternotomy was required in only 4 of the 132 operations. Three patients died in the postoperative period. The risk of morbidity and mortality was 16.7% in 60 patients with compression symptoms and 13.9% in 72 patients without compression symptoms (P = 0.808). Histology revealed no case of unsuspected cancer. CONCLUSION: Surgery for retrosternal goiters involves a higher risk for complications than do cervical goiters, and the risk does not differ between patients with and without symptoms. This, and the fact that no patient in this study had unsuspected cancer, calls into question the rationale for surgery in patients with asymptomatic retrosternal goiter without suspected cancer.

Survival and prognostic factors in patients with small bowel carcinoid tumour.

BACKGROUND: Previous studies of small bowel carcinoid tumours usually presented overall or relative survival. This study, in addition, evaluated disease-specific survival in a cohort of patients in a geographically defined population. METHODS: Patients diagnosed with carcinoid of the jejunum or ileum in Jönköping County between 1960 and 2005 were eligible for inclusion. Available tumour specimens were re-examined to confirm the diagnosis. Medical records and pathology reports were reviewed in detail. RESULTS: A total of 145 patients were included in the study. One hundred and thirty-five patients underwent surgery in connection with the diagnosis. Resection was considered complete (R0) in 74 patients (54·8 per cent). Only two localized tumours recurred, whereas no patient with distant metastases was cured. Patients with regional metastases who underwent R0 resection had a better survival than patients with incomplete resection (P = 0·005), and a majority of patients remained recurrence-free. Median overall survival was 7·2 years and median disease-specific survival 12·3 years. In multivariable analysis, age 61-74 years (hazard ratio (HR) 3·78, 95 per cent confidence interval 1·86 to 7·68), age 75 years or more (HR 3·96, 1·79 to 8·74), distant metastases (HR 14·44, 1·59 to 131·36) and incomplete tumour resection (HR 2·71, 1·11 to 6·61) were associated with worse disease-specific survival. Later time period of diagnosis (HR 0·45, 0·24 to 0·84) was associated with better disease-specific survival. CONCLUSION: Age, disease stage and complete resection were identified as independent prognostic factors for survival in patients with small bowel carcinoid tumours. The importance of achieving R0 resection is therefore emphasized.

Long-term results of surgery for lithium-associated hyperparathyroidism.

BACKGROUND: Lithium therapy for affective bipolar disease is frequently associated with hyperparathyroidism (HPT), but the results of surgical treatment are virtually unknown. The aim of this retrospective review was to analyse the long-term outcome after surgery for lithium-induced HPT in a large series of patients. METHODS: Seventy-one patients on chronic lithium therapy who underwent surgery in three university and three district hospitals in Sweden were followed for a median of 6.3 years. Histopathology, complications of surgery and normocalcaemia at 6 months after surgery and last follow-up were analysed. RESULTS: The primary histopathological diagnoses were adenoma (45 per cent), double adenomas (3 per cent) and hyperplasia (52 per cent). No permanent paresis of the recurrent laryngeal nerve was recorded but 13 per cent of the patients suffered from permanent hypoparathyroidism. At follow-up, the rate of persistent and recurrent HPT was 42 per cent regardless of the histopathological diagnosis. CONCLUSION: The results of conventional surgery for lithium-associated HPT are poor. The surgical approach should be adjusted for the multiglandular disease that is usually the cause of HPT in patients on chronic lithium therapy.

To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial.

BACKGROUND: Major adverse cardiac events (MACEs) are a common cause of death after non-cardiac surgery. Despite evidence for the benefit of aspirin for secondary prevention, it is often discontinued in the perioperative period due to the risk of bleeding. METHODS: We conducted a randomized, double-blind, placebo-controlled trial in order to compare the effect of low-dose aspirin with that of placebo on myocardial damage, cardiovascular, and bleeding complications in high-risk patients undergoing non-cardiac surgery. Aspirin (75 mg) or placebo was given 7 days before surgery and continued until the third postoperative day. Patients were followed up for 30 days after surgery. RESULTS: A total of 220 patients were enrolled, 109 patients received aspirin and 111 received placebo. Four patients (3.7%) in the aspirin group and 10 patients (9.0%) in the placebo group had elevated troponin T levels in the postoperative period (P=0.10). Twelve patients (5.4%) had an MACE during the first 30 postoperative days. Two of these patients (1.8%) were in the aspirin group and 10 patients (9.0%) were in the placebo group (P=0.02). Treatment with aspirin resulted in a 7.2% absolute risk reduction [95% confidence interval (CI), 1.3-13%] for postoperative MACE. The relative risk reduction was 80% (95% CI, 9.2-95%). Numbers needed to treat were 14 (95% CI, 7.6-78). No significant differences in bleeding complications were seen between the two groups. CONCLUSIONS: In high-risk patients undergoing non-cardiac surgery, perioperative aspirin reduced the risk of MACE without increasing bleeding complications. However, the study was not powered to evaluate bleeding complications.

Fate of the non-operated, non-toxic goitre in a defined population.

BACKGROUND: There is lack of consensus in Europe regarding the management of patients with benign goitre. This study evaluated the long-term results of recommending no surgery for clinically and cytologically benign goitre. METHODS: Some 261 patients (median age 56 years) referred for surgical evaluation for goitre were followed prospectively for a median of 130 months. All hospital and primary care charts were reviewed and living patients interviewed by telephone. RESULTS: During follow-up, 36.4 per cent of patients were re-referred for a new surgical evaluation, mainly because of growth of the goitre and/or worsening of local symptoms. Fifty-seven (21.8 per cent) of the patients had surgery, and 13 developed thyrotoxicosis. Five patients (1.9 per cent) were diagnosed with thyroid carcinoma, three of whom (all elderly women) died from the disease. Some 95.0 per cent of patients were satisfied with the expectant policy, but 13.1 per cent had been worried about thyroid cancer despite the reassurance of a benign diagnosis. CONCLUSION: Patients with benign goitre can be treated conservatively with good results. However, there is a small risk that aggressive carcinoma will develop and about a quarter of patients may need surgery within 10 years of the decision to wait and see.

Graves' disease with moderate-severe endocrine ophthalmopathy-long term results of a prospective, randomized study of total or subtotal thyroid resection.

The optimal thyroid surgery to be performed in patients with Graves' disease and concomitant endocrine ophthalmopathy is a matter of debate. We randomly assigned 44 patients with moderate-severe eye signs in a trial of treatment with subtotal, leaving a small (approximately 2 g) thyroid remnant, or total thyroidectomy. At inclusion, the patients had been treated with antithyroid drugs, and corticosteroids been given to 12 (27%). All received postoperative thyroxine supplementation and were followed for 3 years at regular examinations. The eye disease improved in all cases, and throughout the study, the two groups did not differ with regard to subjective and objective eye symptoms and laboratory findings. At the study start, motility disturbances were present in 8 and 11 of the cases in the subtotal and total resection group and proptosis in 16 and 17, respectively. After 3 years, the corresponding data were 3 and 6 cases with motility defects and 16 and 15 cases with proptosis. Thyrotropin (TSH)-receptor antibody levels gradually fell and became nondetectable in 21 (49%). The surgical complication rate (permanent recurrent laryngeal nerve paresis and permanent hypoparathyroidism) was significantly higher in the total thyroidectomy group. The data indicate that in patients with Graves' disease and active endocrine ophthalmopathy, subtotal thyroidectomy, leaving a small thyroid remnant, will reduce the risk of surgical complications but not the beneficial effect of surgery.

Is preoperative evaluation of the biliary tree necessary in uncomplicated gallstone disease? Results of a randomized trial.

AIM: To analyse if preoperative radiology is of value in patients with uncomplicated gallstone disease. MATERIAL: 312 patients intended for laparoscopic cholecystectomy were randomly allocated to undergo preoperative radiology (intravenous cholangiography or magnetic resonance cholangiography) or to a control group. Intraoperative cholangiography was not used routinely in either group. RESULTS: There was no bile duct injury and no difference in complication frequency between the two groups. The incidence of common bile duct stones was 3.8% within the first postoperative year with no statistical difference between the two groups. CONCLUSIONS: Routine preoperative evaluation of the bile tree seems unnecessary before laparoscopic cholecystectomy in patients with uncomplicated gallstone disease.

Equal results with laparoscopic and Shouldice repairs of primary inguinal hernia in men. Report from a prospective randomised study.

AIM: To compare the laparoscopic and Shouldice techniques for repair of inguinal hernia. MATERIAL: 261 healthy men over 50 years with primary, unilateral inguinal hernia were randomly allocated to laparoscopic (total extraperitoneal approach, TEP) treatment (n = 131) or to a modified Shouldice technique (n = 130). RESULTS: Apart from a longer operative time in the laparoscopic group, there were no significant differences between the two methods with regard to perioperative complications, hospital stay, recurrencies or pain in the groin. CONCLUSIONS: Results following the total extraperitoneal laparoscopic and the Shouldice technique do not differ significantly 2 years after hernia repair.

[Nerve damage after thyroid-parathyroid surgery. Recurrent nerve paralysis significantly impair quality of life in many patients]. / Nervskador efter tyreoidea-paratyreoideakirurgi. Recurrens-pares kan ge kraftigt sänkt livskvalitet hos många patienter.

Forty-seven cases of permanent vocal cord paralysis after neck surgery are investigated. Very few operations were described as technically problematical. The recurrent laryngeal nerve was identified in 77% of the procedures. Patients in particular need of an excellent voice in their work or leisure activities described a definite decrease in quality of life after surgery. Straightforward information concerning this complication should always be given to the patient preoperatively.

[Endoscopic ultrasound in the investigation of gastric tumors]. / Endoskopiskt ultraljud vid utredning av magsäckstumörer.

Preoperative staging has been considered to be of importance in gastric cancer. Recently, 133 patients were examined preoperatively using endoscopic ultrasound, and 77 of these had gastric cancer. Preoperative staging (T + M) using endoscopic ultrasound coincided with findings at surgery in 84% of the cases. The depth of penetration was accurate in 92% of the cases. It is concluded that endoscopic ultrasound is more reliable for preoperative staging than conventional ultrasound, computer tomography or magnetic resonance imaging for gastric cancer. Whether or not improved preoperative staging has a bearing on the treatment of patients with gastric cancer, depends largely on whether or not cytostatic therapy is used. We believe that centralizing diagnosis and treatment of gastric cancer is beneficial.

Laparoscopic treatment of recurrent inguinal hernias: experience from 281 operations.

The results of laparoscopic repair of 281 recurrent inguinal hernias in 260 patients are presented. One hundred sixty-eight totally extraperitoneal (TEP) and 113 transabdominal preperitoneal (TAPP) procedures were performed. Four major complications occurred in the early postoperative period, three of them in the TAPP group. After 2-4 years, the results were controlled by questionnaires and clinical reexaminations, if necessary. Eleven percent of the TAPP patients and 2% of the TEP patients experienced a recurrence. About 20% of the patients reported occasional discomfort and pain in the operated groin. We conclude that laparoscopic herniorrhaphy provides acceptable results in reoperative hernia surgery.

Minilaparotomy approach to tumors of the right colon.

OBJECTIVE: The study contained herein was undertaken to describe the minilaparotomy approach to tumors of the right colon. METHOD: Clinical data were prospectively registered from 47 patients who were undergoing resection of the right colon via minilaparotomy. RESULTS: Bowel function returned after two days and passage of stools after four days. Pain medication was necessary only during the first three postoperative days. Major complications were few, and no postoperative deaths occurred. Tumors 10 cm or smaller could be handled by minilaparotomy, and the technique allowed a relevant number of lymph nodes to be removed. No local recurrences were detected during the early postoperative period. CONCLUSION: The minilaparotomy approach to tumors of the right colon seems to be an attractive alternative to conventional colon surgery.

[Minilaparotomy is a careful method in right colon tumor surgery]. / Minilaparotomin skonsam vid tumörkirurgi på högerkolon.

In a series of 47 patients, right colon tumours were treated surgically with a minilaparotomy approach, entailing a skin incision of less than 10 centimetres. The procedure allows appropriate oncological management of the tumour, and is associated with a mild postoperative course and a rapid recovery and resumption of normal life. The short-term outcome in this series has been promising, and the minilaparotomy approach would thus appear to be an attractive alternative to traditional open surgery of the right colon.

Multiple endocrine neoplasia type 1 and the search for the genetic trigger.

Multiple endocrine neoplasia type 1 (MEN-1) is characterized by primary hyperparathyroidism, endocrine pancreatic-duodenal and anterior pituitary tumors. The diagnosis is challenging and involves the exclusion of other endocrine neoplasia syndromes with overlapping features. The predisposing genetic defect was assigned to chromosomal region 11q13 based on linkage analysis. Combined tumor and pedigree genotype analysis showed that allele losses in pancreatic, parathyroid and pituitary tumors eliminated the wild-type allele at the 11q13 loci, suggesting inactivation of a tumor suppressor gene in this region. A 5-Mb integrated map of the region has been established by the European consortium on MEN-1. Based on this mapping the critical interval was restricted to 2 Mb, a region within which eight candidate genes are located.