Is FNAC (fine needle aspiration cytology) a useful tool in detection of malignancy in thyroid surgery? A single institution experience.

OBJECTIVE: To evaluate if FNAC (Fine Needle Aspiration Cytology) is a useful tool in the detection of malignancy in thyroid surgery. FNAC is used routinely as a preoperative diagnostic technique and surgical strategy is often adapted. But is FNAC such a good technique in defining surgical strategy? METHODS: We retrospectively reviewed all files of 703 patients operated from 1997 till today. We obtained the results of the FNAC, the final pathological diagnosis and these data were analyzed. RESULTS: There were 161 male and 542 female patients. 72 out 703 patients had a malignancy. 241 patients (34.3%) had a preoperative FNAC-procedure. Male patients had significantly more malignancies (p = 0.006). In 183 patients (75.9%) the FNAC was benign, 28 patients (11.6%) showed malignancy, in 15 patients (6.2%) only blood was found and 15 patients (6.2%) showed an inconclusive result. 70.1% of the patients were true negative, 5.8% were true positive, 5.8% false positive, 5.8% false negatives, 5.8% of inconclusive results were malignant on pathology. This gives a sensitivity of 50% and specificity of 92.4%. CONCLUSIONS: The specificity of FNAC in malignancy is high (92.4%) but a sensitivity of 50% is low. With these results adaptation of surgical strategy (hemithyroidectomy or total thyroidectomy) secondary to the results of the FNAC is not recommended. Free hand FNAC might be a reason for the relatively high percentage of inconclusive results. Ultrasound guided FNAC can improve the yield of the puncture. On top of that pathological interpretation of the cytology is not always straight forward.

Incarcerated vesico-inguinal hernia: a case report.

In this paper we report a rare case of an incarcerated inguinoscrotal hernia of the urinary bladder in a 64-year-old male patient. He presented with a giant inguinal hernia and pollakisuria. The bladder was surgically repositioned intra-abdominally and resection of part of the bladder fundus was performed through laparotomy. Closure of the inguinal defect was performed through an inguinal approach. The patient's further recovery was uneventful. Herniation of the bladder is a very infrequent finding in inguinal hernias. We searched the literature and only found a few case reports describing this rare pathology. The literature and treatment options are discussed.

Splenic abscess complicating infective endocarditis: three case reports.

We present three case-reports of splenic abscess in patients who were initially diagnosed with bacterial endocarditis. In all cases the diagnosis of splenic abscess was based on the findings of abdominal CT scan or MRI. All patients were treated by laparotomy and splenectomy. Two patients fully recovered and one patient, who suffered from splenic rupture and massive blood loss before surgery, died. Splenic abscess is a well-described but rare complication of infective endocarditis. Rapid diagnosis and treatment are essential as its course can prove fatal. Abdominal CT scan or MRI should be performed if there is clinical suspicion of splenic abscedation. Immediate splenectomy combined with appropriate antibiotics and valve replacement surgery is the treatment of choice. Splenic tissue is very fragile--especially if the abscess is located subcapsular--and a splenic rupture can result from minimal trauma. If the patient's general state allows it, it is best to perform splenectomy prior to valve replacement surgery to prevent re-infection of the valve prosthesis. A combined one-stage procedure is also an option.

Frozen section in thyroid surgery.

OBJECTIVE: We studied the use of frozen section in the detection of malignancy in thyroid surgery in a large teaching hospital. MATERIALS AND METHODS: We reviewed all case notes of patients operated on for thyroid disease between January 1st 1997 and December 31st 2004. We identified 420 operations in 408 patients. Data were available for 417 operations. RESULTS: In patients with a solitary thyroid nodule, a frozen section is sometimes performed. Frozen section was done in 128 of 417 operations. The specificity for malignancy was 98.16%. The positive predictive value was 81.81% and the negative predictive value 93.85%. However the sensitivity was 56.25%. Frozen section is a time-consuming investigation. With follicular lesions it is very difficult to distinguish between benign disease and malignancy since the diagnosis of malignancy depends on capsular and/or blood vessel invasion. Also it costs about 100 Euro (approximately 125 dollars). CONCLUSION: This study confirms that adequate histopathologic diagnosis of thyroid disease is based on extensive subsampling of the specimen which is not possible during a peroperatory frozen section procedure.

A defunctioning stoma in the treatment of lower third rectal carcinoma.

INTRODUCTION: Total mesorectal excision (TME) is the accepted standard for rectal cancer treatment. However, there is an increased risk of symptomatic anastomotic leakage associated with TME as TME potentially endangers the blood supply of the remaining rectum. On top of this, many patients will receive neo-adjuvant radio-chemotherapy. A defunctioning stoma helps in avoiding severe complications of anastomotic failure. MATERIAL AND METHODS: We prospectively collected data of all patients with a rectal carcinoma within reach of the palpating finger, operated on in our department between December 2000 and January 2005. There were 70 patients (42 men and 28 women, median age 70 (range 32-95)). RESULTS: In 40 patients (40/70 = 57%) a sphincter-saving procedure was performed. Eleven patients were diagnosed with anastomotic leakage or failure. Seven patients had neo-adjuvant radio-chemotherapy, 4 had no neo-adjuvant therapy. In 4 patients signs of anastomotic leakage were seen on the barium-enema that is routinely performed before closing the defunctioning stoma. Seven patients (7/40 = 17,5%) had clinical signs of anastomotic leakage. Three of them could be treated conservatively with antibiotics and parenteral nutrition. Two of these patients did not have a defunctioning stoma. Four patients needed re-intervention and were treated in intensive care for several days. Three of these patients did not have a defunctioning stoma. CONCLUSION: Neo-adjuvant radio-chemotherapy and TME resection are two factors in the treatment of rectal cancer that might interfere with anastomotic healing in the case of a sphincter-saving procedure. The construction of a defunctioning stoma helps in limiting the complications of anastomotic leakage or failure.

Skeletal muscle metastasis from a conventional renal cell carcinoma, two years after nephrectomy: a case report.

In this paper, we describe a case of skeletal muscle metastasis from a conventional (clear cell) renal cell carcinoma, two years after nephrectomy. Our first clinical tentative diagnosis was soft tissue tumour, showing the mimicking capacity of renal cell carcinoma. A review of literature shows that skeletal muscle metastases from renal cell carcinoma are extremely rare: only 16 cases have been described. In 5/16, the muscle mass was the initial manifestation of the renal tumour. In the other 11/16, the muscle masses were metachronous (10 months-16 years). We conclude that, when confronted with a patient with a muscle mass and a history of renal cell carcinoma, one should always keep in mind the possibility of a (late) renal cell carcinoma metastasis.

Osteomyelitis pubis versus osteitis pubis: a case presentation and review of the literature.

An athletic 23 year old man presented with suprapubic tenderness, fever, and raised inflammatory blood variables. A diagnostic laparoscopy was performed, with a presumed diagnosis of retrocaecal appendicitis, but no abnormalities were found, apart from free fluid in the pouch of Douglas. Imaging of the pubic area suggested bony infection and inflammation. Biopsy and culture confirmed the presence of Staphylococcus aureus, a very common pathogen. The final diagnosis was osteomyelitis pubis, an infectious disease, and osteitis pubis, an inflammatory disease.

Laparoscopic management of acute small bowel obstruction.

Laparosopy is now a well established tool in abdominal surgery. More often it is used in acute abominal situations. We present our experience with laparoscopy and laparoscopic treatment in patients with acute small bowel obstruction. Although it is technically challenging, in carefully selected patients laparoscopy and laparoscopic treatment is feasible and a valid option for treatment.

Hemobilia: a rare complication of cholecystitis and cholecystolithiasis. Case report.

Hemobilia, although not uncommon, is usually inconsequential and most of the times not even diagnosed. It is known that hemobilia is a rare complication of cholecystitis and cholecystolithiasis. We report the case of a patient who presented with a life-threatening upper gastro-intestinal bleeding due to erosion of the cystic artery by cholecystolithiasis and cholecystitis.

Chondrosarcoma of the thoracic wall.

Eight cases of chondrosarcoma of the thoracic wall were treated during a 13-year period. The radicality of tumor resection was positively correlated with patient survival. Wide primary resection without preceding biopsy is advocated for thoracic lesions suspected from computed tomography and magnetic resonance imaging to be chondrosarcoma.

Prophylactic use of a single dose of tobramycin in elective colorectal surgery.

The aim of this prospective study is to acquire clinical experience with a single high dose of tobramycin in prophylactic use. Sixty three patients undergoing elective colorectal surgery, were assigned to receive antibiotic prophylaxis (24 hours perioperatively) in the form of a single high dose of tobramycin and a classically recommended thrice-a-day (TID) administration of clindamycin. The planned dose for tobramycin was 3.3 mg/kg/day. Adjustment was made in case of impaired renal function. Serum levels of the drug were monitored. The results showed well predictable levels. Six out of fifty five evaluable patients (10.9%) presented postoperative infectious complications within the follow up period. No renal nor otovestibular toxicity was recorded.

Choledochotomy: primary closure versus T-tube. A prospective trial.

From January 1986 until December 1988 twenty two patients entered a prospective trial comparing primary closure versus T-tube drainage after exploratory choledochotomy for lithiasis, giving 11 primary closures (P) and 11 on T-tube (T). Both groups were well matched for age and risk factors. Preoperative values of alkaline phosphatase on day 2 and 7 were significantly lower in case of primary closure (p less than .025). In case of primary closure there was 1 bile leakage without peritonitis. In 9 T-tube biles additional micro-organisms appeared without clinical importance. In each group 1 infectious complication occurred. Post-operative hospital stay was 12 days (P) versus 14 (T) (p less than .05). There was 1 residual lithiasis (P), without detrimental effect on the healing of the primary closure. Endoscopic sphincterotomy and stone extraction was performed. Within the given exclusion criteria closing a choledochotomy primarily is a safe and attractive procedure.

Herniation of the small intestine through an incised rectal prolapse. Case report.

Spontaneous rupture of protruding rectal wall with evisceration is a rare complication of rectal prolapse. We hereby present the case of a woman with a large prolapse of the rectum into which small intestine descended and strangulated. The evisceration became clear after incision of the prolapse taken for a large anal haematoma.

Simulation of vaccination and resistance in leprosy using an epidemiometric model.

Epidemiometric models are useful in studying disease dynamics in populations. Such a model was developed for leprosy and proved useful, but did not take into account age- and sex-specific incidence rates. This paper presents a new version of the model which makes provisions for age and sex differential rates according to the type of leprosy and which includes more realistic parameters for death rates, population variations, and natural growth rates. This new version of the epidemiometric model was used to stimulate the effects of various vaccines and drug resistance on the incidence of leprosy in a population.