Stapled haemorrhoidopexy versus Ferguson haemorrhoidectomy: a prospective study with 2-year postoperative follow-up.

Patients with grade III or IV haemorrhoids underwent stapled haemorrhoidopexy or Ferguson haemorrhoidectomy (50 patients in each group) between June 2000 and April 2003. Six patients (12.0%) receiving stapled haemorrhoidopexy experienced complications: bleeding (2.0%) and haematoma (4.0%); late complications were anal fissure (4.0%) and recurrence of haemorrhoidal disease (2.0%). Bleeding was treated during the operation by suture ligation and fissures by sphincterotomy; haematomas resolved spontaneously with conservative medical treatment. Of those undergoing Ferguson haemorrhoidectomy, no bleeding occurred postoperatively, however urinary retention was seen in three patients (6.0%) We conclude that Ferguson haemorrhoidectomy was safer than stapled haemorrhoidopexy for bleeding complications, but stapled haemorrhoidopexy was superior to the Ferguson technique in terms of postoperative pain (4.2 versus 7.4 on day 1 after operation, decreasing to 2.2 versus 4.2 at 1 week for stapled haemorrhoidopexy compared with Ferguson haemorrhoidectomy, respectively), duration of hospital stay (92% undergoing stapled haemorrhoidopexy discharged on postoperative day 1) and time to return to normal activities (10.0+/-1 versus 28.0+/-2 days, respectively).

Reliability of fine-needle aspiration in patients with familial nonmedullary thyroid cancer.

In this case-control study we describe how often thyroid cancers and occult cancers are diagnosed or not diagnosed by fine-needle aspiration (FNA) in patients with thyroid nodules and a family history of nonmedullary thyroid cancers (FNMTC). Our hypothesis is that patients with thyroid nodules and a family history of FNMTC seem to be similar to patients with thyroid nodules and a history of exposure to low-dose therapeutic radiation. Both have been reported to have multifocal thyroid neoplasms and malignant tumors are common. Cytological examination may therefore be less accurate. From 1979 to 1996, 27 patients from 24 families with FNMTC were examined histologically after a preoperative cytological examination in all of them. A positive cytology examination was defined when biopsy documented thyroid cancer. It was interpreted as a false-negative study when a benign diagnosis was made and thyroid cancer was present anywhere within the thyroid, including in areas sampled or not sampled by FNA and not palpable preoperatively. A randomized control group, matched for age and gender, contained 27 patients with papillary thyroid cancer without familial disease. In our study group, 25 patients were treated with total thyroidectomy, including 7 with neck dissection, and 2 by thyroid lobectomy. At final histological examination 17 of 27 patients (63%) in this study group had multiple nodules and 25 of 27 (92.6%) had thyroid cancer. Thyroid cancer was diagnosed by FNA in 22 of 25 patients (88%), with 3 (12%) false-negative biopsies due to sampling errors (thyroid cancer not in the index nodule), versus 1 (3.7%) false-negative biopsy in the control group. Two patients in the study group with benign nodules were accurately diagnosed. In patients with false-negative biopsies and a history of FNMTC, the cancer was situated in one or more small nodules. Only one cancer was occult (< 1.0 cm). One-third of the patients in our study group (33%) had a history of radiation; 44% of the irradiated group had a single nodule; 56% had multiple nodules. In the control group, 9 of 27 patients (33%) also had a history of radiation; 33% of the irradiated group had a single nodule, 67% had multiple nodules. In conclusion, the reliability of FNA in patients with FNMTC appears to be less accurate than it is for other patients because of the high incidence of multifocal thyroid cancer and coexistence of benign nodules. Patients with thyroid nodules and a family history of thyroid cancer are more likely to have thyroid cancer and because they also have more coexistent benign nodules, they must be followed closely or treated with total or near-total thyroidectomy.

Management of thyroid carcinosarcoma.

BACKGROUND: Thyroid carcinosarcoma is a rare and aggressive malignant thyroid tumor that has been described pathologically, but there is little clinical information regarding tumor behavior. METHODS: We retrospectively analyzed the course of our patient and 16 others reported in the literature to determine optimal management. We review the case history of our patient and the literature concerning patients with carcinosarcoma of the thyroid. RESULTS: Seventeen patients, 52 to 80 years of age (mean, 60 years), have had a thyroid carcinosarcoma of the thyroid. Five of seven patients for whom the information is available were treated by partial thyroidectomy and two by total thyroidectomy. Among these patients five (71%) died within the first 3 months and two (29%) survived more than 6 months. The mean survival was 5 months. At autopsy in seven patients, six had lymph node or distant metastases. CONCLUSIONS: Carcinosarcoma of the thyroid is a very aggressive tumor with a clinical course similar to anaplastic thyroid carcinoma. Like patients with anaplastic thyroid carcinoma, few survive more than 6 months despite aggressive multimodal treatment. Our patient's exposure to raw phosphorus, radiation, and 1,3-bis-(2-chloroethyl)-1-nitrosourea may have predisposed her to this aggressive tumor.

Sestamibi scanning is inadequate for directing unilateral neck exploration for first-time parathyroidectomy.

OBJECTIVE: To determine whether technetium Tc 99m sestamibi scanning is accurate enough to allow surgeons to perform unilateral neck exploration for first-time parathyroidectomy in patients with primary hyperparathyroidism. DESIGN: Retrospective review. SETTING: University tertiary care center. PATIENTS: Forty patients with primary hyperparathyroidism who underwent sestamibi scanning before first-time parathyroidectomy, of whom 28 had single adenomas, 9 had multiple adenomas, and 3 had hyperplasia. INTERVENTIONS: All 40 patients underwent bilateral neck exploration with identification of 4 parathyroid glands. MAIN OUTCOME MEASURES: We compared the results of preoperative sestamibi scanning with operative and histologic findings. We then used these data to calculate the projected success rates of parathyroidectomy if unilateral neck explorations had been performed based on the results of sestamibi scanning, instead of bilateral explorations. RESULTS: Sestamibi scanning was correct in 20 (71%) of 28 patients with single adenomas, 4 (44%) of 9 patients with multiple adenomas, and 0 (0%) of 3 patients with hyperplasia. If unilateral neck explorations had been performed on the basis of localization by sestamibi scanning, parathyroidectomy would have failed in 4 (10%) of 40 patients. CONCLUSIONS: Sestamibi scanning, although helpful, is inadequate for directing unilateral neck exploration for first-time parathyroidectomy. Surgeons who perform unilateral neck exploration based on the results of sestamibi scanning will record a higher failure rate and incur higher costs than those who perform bilateral neck exploration for first-time parathyroidectomy.