Preoperative detection of sporadic parathyroid adenomas using technetium-99m-sestamibi: what role in clinical practice?

Preoperative localization of pathologic parathyroid glands remains controversial. Because experienced parathyroid surgeons can identify and cure parathyroid pathology in sporadic primary hyperparathyroidism in better than 95 per cent of first-time explorations, few consider preoperative localization studies cost effective in this population. However, the primary reason for failure at the initial exploration is the inability of the surgeon to identify an adenoma in a normal anatomical location. Recent reports have indicated that operative time can be reduced and initial success improved with preoperative localization of adenomas using the highly sensitive technetium-99m (Tc)-sestamibi scan. We evaluated 16 consecutive patients with sporadic primary hyperparathyroidism using a double-phase Tc-sestamibi scan with delayed images, hypothesizing that 90 per cent of adenomas would be accurately detected, and furthermore that a negative scan would predict multigland disease. Of the 16 scans, 13 showed a focal delayed washout of the tracer, constituting a positive scan. Eleven of 13 were true positive (85%), with two false positive scans (15%), both of which also had nodular thyroid disease. The three negative scans were indeed hyperplastic multigland disease, determined at exploration. The mean operative time for a bilateral exploration for the true positive cases was 109 minutes, compared to 148 minutes for a small cohort group without imaging (not significant). In conclusion, 85 per cent of adenomas can be successfully localized with the Tc-sestamibi delayed-image technique, and may decrease operative time. Additionally, a negative scan is a likely predictor of multigland disease, which allows for improved preoperative patient education and preparation for cryopreservation. These data suggest that preoperative Tc-sestamibi scanning may improve the success rate for the occasional parathyroid surgeon, and that an extended prospective trial is warranted.

Aspiration pneumonia following surgically placed feeding tubes.

BACKGROUND: The enteral route is preferred in surgical patients requiring nutritional support; however, controversy surrounds the choice of location of feeding tube placement. Although jejunostomy has been commonly accepted as superior to gastrostomy for long-term nutritional support because of an assumed lower risk of aspiration pneumonia, recent studies suggest that reevaluation of common practices of surgical tube placement is warranted. PATIENTS AND METHODS: We conducted a retrospective chart review of gastrostomy and jejunostomy procedures from 1986 to 1993. Demographic information and complications related to the procedure were reviewed. Aspiration pneumonia was defined as respiratory symptoms, leukocytosis, and infiltrate on chest radiograph. RESULTS: Sixty-nine gastrostomies and 86 jejunostomies were performed during the study period. Six patients were diagnosed with aspiration pneumonia; 2 cases of which occurred with jejunostomy and 4 cases occurred with gastrostomy (P = not significant). CONCLUSIONS: There was no difference in rates of pulmonary aspiration or other complications between gastrostomy and jejunostomy. We suggest that when a surgically placed feeding tube is required, the determination of appropriate procedure be based on clinical factors such as the technical difficulty of the operation or long-term feeding goals.

Stereotactic fine-needle aspiration cytology of nonpalpable breast lesions: an analysis of 258 consecutive aspirates.

BACKGROUND: The role of stereotactic fine-needle aspiration cytology (SFNAC) in the diagnosis of nonpalpable breast lesions is poorly defined. PATIENTS AND METHODS: Data were prospectively collected from 225 consecutive patients with nonpalpable breast lesions who had aspiration cytology followed by immediate surgical excision. RESULTS: Between 1988 and 1993, 258 such procedures were performed. The results of 84 (33%) were interpreted as benign, 84 (33%) as atypical, 28 (11%) as suspicious for malignancy, and 49 (19%) as malignant. In all, 88 (34%) surgical specimens were malignant. SFNAC had an 80% sensitivity, a 96% specificity, a 91% positive predictive value, and an 89% negative predictive value. There were 18 false-negative and 7 false-positive aspirates. CONCLUSIONS: SFNAC for diagnosing nonpalpable breast lesions is moderately sensitive and highly specific, and has a high positive and negative predictive value. In conjunction with mammography and clinical assessment, the procedure is useful for determining which patients with nonpalpable breast lesions may require surgical biopsy.

Impact of adjunctive testing on the diagnosis and clinical course of patients with acute appendicitis.

The diagnosis of acute appendicitis is usually made from the history and physical examination. Recently, abdominal ultrasonography (US), laparoscopy, computerized tomography (CT), and barium enema (BE) have been used in the preoperative evaluation of patients with presumed appendicitis in order to improve the diagnostic accuracy. However, the usefulness of these tests in verifying the diagnosis of appendicitis has not been established. We reviewed the medical records of 203 patients who underwent appendectomy. One hundred patients were surgically treated before 1984 (group I) and 103 patients underwent surgery after 1988 (group II). Patients in group II were more likely to have preoperative US, laparoscopy, CT, or BE (24 in group II versus 3 in group I, p < 0.05). When groups I and II were compared, the rates of perforation (27% versus 20%), normal appendectomy (8% versus 11%), and the interval between admission and operation (12.2 hours versus 10.7 hours) and length of hospitalization (5.0 days versus 5.1 days) were not significantly different. We concluded that although adjunctive testing may be beneficial in selected patients, its routine use in patients suspected of having appendicitis cannot be advocated at present.