Introduction of day care thyroid surgery in a Dutch non-academic hospital.

OBJECTIVE: Hemithyroidectomy is the most common endocrine surgical procedure and is performed with low complication rates. Multiple international reports indicate that thyroid surgery in the day care setting is feasible and safe. Despite these results, day care thyroid surgery has not yet been implemented in the Netherlands. The objective of this study is to assess the safety of thyroid surgery in our institution and, when deemed safe, implement day care thyroid surgery. METHODS: All patients who underwent hemithyroidectomy in our institution between January 2010 and December 2014 were included in the retrospective analysis. Hypothetical candidates for day care surgery were identified. All patients undergoing thyroid surgery in 2015 were included in a prospective cohort. Data regarding baseline characteristics, surgical procedures, complications and adherence to the day care schedule are presented. RESULTS: A total of 210 patients were included in the retrospective cohort; 149 patients complied with the day care criteria. No complications occurred that would prevent day care surgery, or make it unsafe. Day care thyroid surgery was implemented from January 2015. In one year 43 patients underwent hemithyroidectomy. Thirty-one patients were eligible for day care surgery of which 18 patients were treated in day care. Failure of the day care regimen was due to the patient's own choice (n = 5), large retrosternal goitre (n = 2) or failure of logistics (n = 6). Besides transient hoarseness, no complications occurred in this group. CONCLUSION: Based on a retrospective safety analysis we successfully introduced day care thyroid surgery in our clinic. Hemithyroidectomy can safely be conducted in day care setting. However, patient selection is of vital importance to minimise the risk of complications.

Intra-operative parathyroid hormone measurements - experience of a non-academic hospital.

BACKGROUND: Surgery is the treatment of choice for symptomatic primary hyperparathyroidism. The majority of research concerning intra-operative parathyroid hormone (ioPTH) measurements is conducted in university hospitals. Whether ioPTH measurements are feasible and useful in predicting the presence of remaining hyperfunctioning parathyroid tissue in a non-academic hospital remains uncertain. METHODS: Data were collected on all patients with biochemically proven and surgically treated primary hyperparathyroidism treated at the Reinier de Graaf Hospital from August 2002 to December 2007. RESULTS: Sixty-five patients were included. The mean pre-operative serum calcium level was 2.78 mmol/l (range 2.28 - 3.80 mmol/l, normal range 2.20 - 2.65 mmol/l) and the mean serum parathyroid hormone level 17.0 pmol/l (range 4.0 - 90.3 pmol/l, normal range 1.0 - 5.5 pmol/l). All patients were operated on for primary hyperparathyroidism, using ioPTH measurements during their first operation. Sensitivity and specificity rates of ioPTH measurements were 98% and 89%, respectively. The ioPTH test accurately indicated incomplete removal of all hyperfunctioning parathyroid tissue in 8 patients (12%). Five patients (8%) were re-explored immediately, of whom 4 were successfully treated in this single operative session. One patient was operated on successfully the next day. Two patients were operated on with a successful result during a second admission. In all the ioPTH measurements there was 1 false-positive result (1.5%) and 1 false-negative result (1.5%). The mean postoperative calcium value for the successfully treated patients was 2.34 mmol/l (range 2.14 - 2.71 mmol/l, normal range 2.20 - 2.65 mmol/l). The mean postoperative PTH level for the successfully treated patients was 3.76 pmol/l (range 0.40 - 7.1 pmol/l). CONCLUSION: Our data suggest that ioPTH measurements are feasible and useful in a non-academic hospital.

Surgeon-performed ultrasound as preoperative localization study in patients with primary hyperparathyroidism.

BACKGROUND: Minimally invasive parathyroidectomy is the treatment of choice for single-gland primary hyperparathyroidism. However, the exact location of the abnormal gland has to be established. Sestamibi scintigraphy, computed tomography and ultrasound (US) are commonly used modalities. We describe our experience in a non-academic center with surgeon-performed US (S-US) of the neck as preoperative localization study in patients with primary hyperparathyroidism (PHPT). METHODS: Patients with a biochemically proven diagnosis of PHPT and preoperative S-US were included. Data were recorded prospectively. Perioperative gland location was compared to the preoperative S-US to determine sensitivity, specificity and accuracy rates. RESULTS: Two of the 50 patients who underwent S-US were not subjected to surgery. In 85% of the patients analyzed by S-US, the appropriate abnormal gland(s) were identified. In 11%, no gland was identified, but abnormal glands were found during surgery. Sensitivity of S-US in our hospital is 85%, with a positive predictive value of 97%. CONCLUSIONS: We achieved a satisfactory sensitivity rate. S-US provides anatomic information to the surgeon which enables a more detailed operation planning, and it is a valuable diagnostic modality for patients with PHPT in our opinion. We hope that our data encourage other centers to implement this technique as well.

Peroperative measurement of PTH in the management of primary hyperparathyroidism.

UNLABELLED: This study was performed to prospectively evaluate the efficacy of a newly developed, non-expensive and non-commercial perioperative PTH-assay as indicator of successful surgery in minimally invasive adenomectomy (MIA) for primary hyperparathyroidism (pHPT). METHODS: A chemoluminescence-based PTH-assay was modified to significantly shorten the incubation time, producing results in a total of 45-60 minutes. Its reliability was tested in 19 patients undergoing MIA for pHPT. Patients were selected for MIA based on preoperative imaging including ultrasound and CT. After verification of its reliability, the PTH assay was incorporated into our treatment protocol and its results registered and correlated with serum calcium levels and surgical outcome. RESULTS: The PTH assay was found to fully correlate with the current gold standard, i.e. serum calcium levels on the first postoperative day after MIA. It was subsequently used in 55 patients selected for MIA, as well as in 26 patients undergoing conventional neck exploration (CNE). In all cases it correctly indicated surgical failure/success. The conventional re-exploration that was required in 3 patients after unsuccessful MIA, was also correctly interpreted on the basis of the PTH-assay. In 2 cases an unexpected delay was encountered in the decline of PTH-levels following adenomectomy. CONCLUSION: The perioperative PTH-assay described is a reliable, inexpensive, and relatively fast predictor of surgical outcome, and should be considered essential for minimally invasive surgery in patients with pHPT.

Direct, minimally invasive adenomectomy for primary hyperparathyroidism: An alternative to conventional neck exploration?

OBJECTIVE: To evaluate the feasibility and efficacy of a direct, minimally invasive adenomectomy (MIA) as an alternative to conventional neck exploration (CNE) in patients with primary hyperparathyroidism. SUMMARY BACKGROUND DATA: Because primary hyperparathyroidism is caused by a solitary adenoma in 85% to 90% of patients, a direct adenomectomy through a mini-incision would theoretically suffice whenever an adenoma is correctly localized on preoperative imaging. If effective, a less invasive method could spare the patient an unnecessary bilateral neck exploration, thus saving time and rendering future surgical procedures in the neck less problematic. METHODS: Between October 1994 and October 1998, 110 consecutive patients with biochemically proven primary hyperparathyroidism who were to undergo surgery were enrolled in this study. Ultrasound and spiral CT were routinely performed as standard preoperative imaging modalities in the first series of 65 patients. In the second series of 45 patients, ultrasound was performed as the sole initial modality; it was supplemented by CT only in case of inconclusive test results. If test results were unequivocal (one adenoma), the patient was offered MIA. CNE was performed if the results were equivocal or if multiglandular disease was suspected. RESULTS: Overall, 84 patients were selected for MIA and 26 for CNE. In the first series, 2 MIA procedures (2/51) were converted to CNE because of negative perioperative findings. All 65 procedures resulted in normocalcemia. In the second series, all but five (4/33 MIAs, 1/12 CNEs) resulted in normocalcemia. A reexploration (CNE) was performed in three patients, resulting in normocalcemia after resection of a second or third adenoma. Two patients are still awaiting reexploration. In both series together, 78 of the 110 patients were successfully treated with MIA and spared CNE. CONCLUSION: MIA is a safe and effective alternative to CNE that may replace CNE in approximately two thirds of all patients.

[Analysis and treatment of pancreatic cystic diseases]. / Analyse en behandeling van cysteuze aandoeningen van het pancreas.

Owing to the spectacular progress in imaging techniques, cystic lesions of the pancreas are detected more often than previously, and this leads to therapeutic dilemmas. Of the cystic lesions of the pancreas, 80% are found to be pseudocysts and 10-15%, neoplastic cysts. The definition of a pseudocyst is: 'an accumulation of pancreatic juice surrounded by a wall of connective tissue or granulation tissue, developed as the result of acute pancreatitis, pancreatic injury or chronic pancreatitis'. In cases of asymptomatic pseudocyst, an expectative policy suffices; growth and symptomatic pseudocysts justify intervention. In addition to surgical internal drainage (cystojejunostomy) there are new therapeutic techniques: external drainage guided by ultrasonography or CT, and internal drainage guided by endoscopy. Endoscopic drainage is the treatment of choice, but it requires experienced hands. The cystic tumours are subdivided into two groups: serous and mucinous cystadenomas. The group of mucinous tumours is subdivided into mucinous cystadenomas and intraductal papillary mucinous tumours. The mucinous or macrocystic adenoma is potentially malignant and should be treated as a malignancy.

[Peroperative parathyroid hormone assay: assurance of successful surgical treatment of primary hyperparathyroidism]. / Peroperatieve parathormoonbepaling: zekerstelling van geslaagde chirurgische behandeling van primaire hyperparathyreoïdie.

OBJECTIVE: To study the reliability and applicability of a rapid parathormone (PTH) test as predictor of successful surgical treatment of primary hyperparathyroidism. DESIGN: Prospective. METHOD: All 35 consecutive patients undergoing surgery for primary hyperparathyroidism in the University Hospital Utrecht, the Netherlands, in august 1997-august 1998, were tested just prior to surgery, and immediately following adenomectomy. The rapid PTH test consisted of a modification of the computerized immunometric detection by chemoluminescence. The decrease of serum PTH as estimated with the rapid test was correlated with surgical findings as well as postoperative serum calcium levels. In the first 25 patients (group A) the reliability of the test was investigated. In the next 10 patients (group B) the PTH test results were allowed to have implications for surgical management, i.e. an insufficient (< 50%) decrease of serum PTH following adenomectomy resulted in immediate re-exploration. RESULTS: The 35 patients, 22 women and 13 men, had a median age of 58 years (range: 22-80). The results obtained with our rapid PTH test correlated fully with both conventional PTH measurement techniques and postoperative serum calcium levels. In group A 21/25 patients showed adequate (> 50%) decrease of their serum PTH levels; the 4 patients without such decrease were the ones displaying persistent postoperative hypercalcaemia. In group B 9/10 patients had adequate PTH decrease immediately following adenomectomy, while in one patient this was only attained after further exploration and excision of a second adenoma. No false-positive or false-negative measurements were encountered. CONCLUSION: The rapid PTH test used is a reliable predictor of successful adenomectomy for primary hyperparathyroidism, also in minimally invasive surgery.

Protection of computerized medical data--a problem?

The rules of South African and international law and practice in respect of the medical practitioner's duty to preserve confidential information are briefly analysed and the consequences of breaches of this duty discussed. The impact of computer technology on medical practice and the attendant risks of 'information leaks' from medical data banks are reviewed. A call is made for a multidisciplinary approach to the problem of computerization and confidentiality involving the medical, legal and data-processing professions.

[A professional duty to heal!]. / 'n Beroepsplig om te genees!

The rules of South African law are analysed, especially any possible rules which may impose a duty upon a medical practitioner to heal in cases where the patient refuses treatment. The conclusion is reached that a refusal of medical treatment expressed on behalf of a minor child or an unconscious patient might safely be ignored by a medical practitioner, but that an express refusal by a major patient of full legal capacity should be heeded. It is also concluded that, according to South African law, there rests no legal duty upon a medical practitioner to treat a patient where such treatment--even if necessary to save the patient's life--is refused by the patient himself. Therefore, where the conditions imposed by a Jehovah's Witness preclude a medical practitioner from practising good medicine, he should refuse the case.

Clinical trials, children and the law.

Clinical trials are necessary for the advancement of medical science. The law is reasonably tolerant as far as experiments on adults are concerned. The legal limits within which experiments on children, especially children of tender years, may take place are, however, far more strict. The medical researcher who goes beyond these limits is liable to be attacked for legal indecorum. This article deals with these legal limits and with guidelines for the researcher.