Evaluation of parathyroid autograft growth and function in hemodialysis patients

The aim of our study was to evaluate the function and growth of parathyroid tissue autografted into the forearm of hemodialysis patients using several presently available methods. In a dynamic study, the secretory function of autografted tissue was evaluated in seven patients using either zero calcium dialysate or calcium infusion. In an additional prospective study, seven patients had repeated determinations of plasma immunoreactive parathyroid hormone (iPTH) concentration on samples from both forearms, a radionuclide evaluation of autograft function using thallium-201 chloride, and real time ultrasonography. Light microscopy analysis was performed in two patients. The dynamic study demonstrated that induction of hypocalcemia was followed by an increase, and induction of hypercalcemia by a decrease, in circulating iPTH in both forearms using three different radioimmunoassays, similar to what has been reported for normal parathyroid tissue. A significant gradient (ie, greater than 2.0) of plasma iPTH concentration in samples from both forearms was observed in only three out of the seven patients of the prospective study. Two of these patients disclosed an increased uptake of 201TI chloride at the site of autografted tissue and had an echographically detectable mass. In both, hyperplastic parathyroid tissue was removed. At present, the remaining third patient does not have other features of recurrent hyperparathyroidism. In conclusion, autotransplanted parathyroid tissue of hemodialysis patients shows an adequate response to physiologic stimuli such as hypo- and hypercalcemia. Dynamic tests, therefore, appear to be a useful tool in the assessment of its function. In addition, radionuclide and echographic studies may be reliable adjuncts in the detection of marked parathyroid autograft hyperplasia.

[Peroperative circulatory arrest during excision of an unrecognized thoracic pheochromocytoma]

The authors present a case of thoracic phaeochromocytoma responsible for cardio-circulatory arrest during thoracotomy for mediastinal tumour. In such cases, hypertension must be controlled with phentolamine or sodium nitroprusside, cardiac arrhythmia with lignocaine, and collapse with volaemic expansion. The medical literature concerning thoracic phaeochromocytoma is briefly reviewed.

[Fibrovascular polyp of the esophagus]

A case of large intraluminal tumour located in the cervical portion of the oesophagus and removed by thoracotomy is presented. Detailed histological study was necessary, since hypervascularization and hypercellularity made it difficult to diagnose a fibrovascular polyp and to establish its histopathological prognosis. The patient has now been followed up for 7 years and remains cured. Intraluminal tumours are reviewed. Whether fibrovascular polyps should be removed surgically or endoscopically depends on their site and on their size.

[A parathyroid adenoma of uncommon localization in the middle mediastinum]

A case of parathyroid adenoma is reported which was of interest in two respects: the very atypical localization in the middle mediastinum and the clearly visible lesion on a straight thoracic film.

Blunt thorax oesophageal stripping: an emergency procedure for caustic ingestion

We report our experience with an original procedure which we have applied to the management of acute necrotic caustic burns of the upper gastro-intestinal tract. Blunt thorax oesophageal stripping is performed through a cervicotomy and a laparotomy, thus avoiding a wide pleural exposure and the frequent and often fatal respiratory complications of a thoracotomy. The stripping method permitted survival of 13 of 17 patients and is thus considered to be a safer and more successful technique than open thoracic oesophagectomy.

[Surgical treatment of primary hyperparathyroidism in patients over 70 years of age]

Hyperparathyroidism is a frequent, often fortuitous finding in elderly people. Our series includes 103 patients over 70 years of age, 90 of whom were operated upon. Elderly patients rarely are without any symptom, but it is difficult, prior to surgery, to associate their clinical disorders with hyperparathyroidism. Our results show that surgical treatment is virtually without danger and that most patients were distinctly improved. The innocuousness and effectiveness of surgery in these patients, as well as the absence of medical treatment are as many reasons to widen the indications of the surgical approach.

[Triple valve replacement. Evaluation of 90 surgically treated patients]

Ninety patients, aged 17 to 59 years (average 39.8 yrs) underwent triple valve replacement from January 1967 to December 1979. The aetiology was rheumatic carditis in 84% of cases. There had been previous surgery in 29 cases (19 mitral commissurotomies). All patients were severely symptomatic: 68 (76%) had atrial fibrillation and the cardiothoracic ratio was 0.70 +/- 0.085. In 24 cases, triple valve stenosis (aortic, mitral and tricuspid) was observed; 13 patients had triple regurgitation and 53 patients had mixed lesions (stenosis and regurgitation). Triple mechanical valve prostheses were implanted in 35 cases (Björk or Starr), triple bioprostheses were implanted in 12 cases, and 43 patients received a combination of mechanical and bioprostheses (tricuspid bioprostheses in all 43 cases). The patients were divided into two groups according to the type of valve replacement; Group I: 57 patients, subdivided into Group IA (35 cases, 39%) with triple mechanical prosthesis, and Group IB (22 cases, 25%) with mechanical aortic and mitral valve prostheses and tricuspid bioprostheses; Group II, 33 patients, subdivided into Group IIA (12 patients, 13%) with triple bioprostheses, and Group IIB (21 patients, 23%) with mitral and tricuspid bioprostheses and a mechanical aortic valve prosthesis. Techniques of myocardial protection have have improved since the beginning of this series and at present comprise cardioplegia associated with general hypothermia to 25 degrees C and pericardial irrigation with ice cold saline. The overall operative mortality was 37% (34/90) but in 1979 alone it was only 10%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Thyroid metastasis of a kidney cancer]

The authors report a case of multiple thyroid metastases in a patient who had undergone excision of a renal adenocarcinoma eight years previously. At the first operation, there had been no sign of any metastases. A benign thyroid adenoma was also found.

[Cystic teratoma of the diaphragm. Apropos of a case, review of the literature]

Benign tumors of the diaphragm are rare lesions. The cystic teratoma of this muscle is an internal axial tumor, a benign dysembryoma, and only 4 cases could be found in the published literature. The cystic teratoma reported was discovered fortuitously during investigation of hypertension. It was located in the diaphragm above the psoas arch.

[Tricuspid reoperation in the surgery of rheumatic valve diseases. Apropos of 24 cases]

Twenty four patients were reoperated on the tricuspid valve alone between 1967 and 1981. The first operation had been performed for mitral valve disease and consisted of 23 mitral valve replacements and one commissurotomy associated with two aortic valve replacements. The surgical decision with regard to the tricuspid valve at the initial operation had been abstention (10 cases), tricuspid valvuloplasty (10 cases) and tricuspid valve replacement (4 cases). Reoperation on the tricuspid valve is rare (0,2 p. 100 of mitral valve operations, 1 p. 100 of mitro-tricuspid valve operations). The 24 cases were divided into 2 groups: --Group I, in which reoperation was indicated for curable tricuspid lesions: .4 reoperations for prosthetic valve dysfunction (4 mechanical prostheses were responsible for 3 thromboses and 1 perivalvular leak); .3 reoperations for failed valvuloplasty (2 Kay valvuloplasties and 1 Carpentier annuloplasty); .2 reoperations for aggravation of neglected functional lesions at the first operation and which were reoperated after 3,5 and 4,5 years, because of increased dilatation of the annulus; .5 reoperations for aggravation of organic lesions which had been neglected in 3 cases and treated by valvuloplasty in 2 cases. Five prosthetic valve replacements were carried out, on average 17 months after the first operation. --Group II, in which reoperation was unable to improve congestive heart failure; dilatation of the tricuspid annulus was only a consequence of the cardiac failure. The secondary tricuspid valve surgery (5 valvuloplasties, 5 annuloplasties) did not alter the extremely poor prognosis of these patients (5 hospital deaths, 3 postoperative deaths within 2 years).(ABSTRACT TRUNCATED AT 250 WORDS)

[Giant fibroma of the pleura. Apropos of 2 cases]

Two cases are reported of giant pleural fibroma (2.9 and 4.2 kg), of slow growth (both had been present for 17 years), developing in the parietal pleura in a 56-year-old woman and in the triangular ligament of a 35-year-old man respectively, and treated by surgical excision. Findings in these cases and data on those reported in the literature indicate the principal pathologic and clinical characteristics of these very rare benign tumors of the pleura: onset in the absent of any history of exposure to dust (asbestos); usually fortuitous discovery; suggestive radiological appearances (calcification in some cases) that are not pathognomonic however; differentiation from fibrous mesothelioma by the microscopic or particularly gross pathologic appearance; treatment exclusively surgical and of variable difficulty according to the size of and especially the structures related to the tumor, with the need for careful preoperative screening.

Total parathyroidectomy and delayed parathyroid autotransplantation using a simplified cryopreservation technique: human and animal studies

Following earlier studies using a simplified cryopreservation method in rats, we report the successful use of this technique in a hemodialysis patient who had previously undergone total parathyroidectomy. In additional studies, parathyroid glands from rats were conserved by this rapid freezing procedure after total parathyroidectomy. Six weeks after parathyroid autotransplantation the animals were submitted to a low-calcium diet and their parathyroid gland function compared to that of rats that had previously undergone sham operation, immediate autotransplantation, or delayed autotransplantation using the classical cryopreservation method. With both cryopreservation techniques, plasma calcium, phosphorus, and 1,25 (OH)2 vitamin D concentrations after low-calcium diet were similar although results were less satisfactory than with immediate autotransplantation or after sham operation. We suggest that this simplified cryopreservation technique, developed in rats, yields functioning parathyroid gland tissue and can be successfully used in the human.

[Mitral insufficiency complicating idiopathic subvalvular aneurysm of the left ventricle. Apropos of 5 surgical cases]

The surgical team of Pr Ch. Dubost operated 5 cases of idiopathic subvalvular left ventricular aneurysm with associated mitral incompetence over a 6 year period (from 1976 to 1981). These 5 cases closely resemble Abraham's et al's classical description of "annular subvalvular left ventricular aneurysms". They occur in black Africans, often young adults (mean age of our five cases 31,8 years) in the absence of coronary artery disease. The common feature is the peculiar anatomical localisation of the aneurysm on the posterior or lateral wall of the left ventricle, which explains the common finding of mitral regurgitation. They are often calcified and thrombosed, the thrombosis tending to extend into the left heart chambers. This was the case in 3 of the reported cases. Mitral regurgitation was controlled in one case by closure of a fistula into the left atrium with a very good result, and in 2 cases by simple section-suture of the neck of the aneurysm with good results and a small residual mitral leak. In a fourth case (Case n degree 1) the mitral valve was normal, regurgitation being the result of an extensive thrombosis. The valve was replaced but, in the light of the following cases, it is possible that the valve might have been unnecessarily sacrificed. Despite their sometime vast size and the association with mitral regurgitation, these subvalvular idiopathic left ventricular aneurysms are reasonable surgical indications for the following three reasons: the neck is often narrow, enabling closure under satisfactory surgical conditions; the structure of the valve is normal which, in the majority of cases, means that it can be respected at surgery; the absence of coronary artery disease.

[Exudative enteropathy and residual tricuspid insufficiency following repair of tetralogy of Fallot. Regression following tricuspid valvuloplasty]

Chronic right ventricular failure was observed in a young female operated at 25 years of age for Fallot's tetralogy despite surgical refixation of the patch closing the ventricular septal defect which had previously worked loose. The signs of right ventricular failure were due to severe tricuspid incompetence, confirmed at catheterisation and selective right ventricular angiography. They were associated with major hypoproteinaemia which was not due to urinary loss nor hepatic dysfunction, but which was attributed to an exudative enteropathy. The correction of the valvular defect by valvuloplasty was followed by rapid correction of the biological abnormality. The authors review the relationship between serum proteins and cardiac disease, discuss those cardiac affections with known associations with exudative enteropathy, and also the possibilities of reversing the biological abnormality after surgical cure of the causal cardiac lesion.

[Severe tracheobronchial complications of the ingestion of caustics in adults. A case of perforation healed with a pulmonary patch]

Since 1969, in a study of 100 patients hospitalized for severe caustic ingestion meeding intensive surgery, the authors have found 9 cases of critical tracheo-bronchic burns characterized by necrotic lesions. Those lesions constitute a severe complication (6 deaths amongst 9 patients) thus the obsolute necessity of precocius and repeated tracheobronchic fiber endoscopies. In case of an ulcerating or pre-splitting aspect appearing in localised necrotic lesions, the authors preconise in emergency a tracheobronchic plasty using a lung patch. Other treatments are discussed.

[Ruptured angular pregnancy in the 16th week. Apropos of a case]

Angular pregnancies which result from implantation of the fertilised oocyte in the mucosa of a uterine horn are very rare. They are usually demonstrated by a picture of rupture which is associated with severe abdominal pain, the syndrome of internal haemorrhage, often a state of shock and all occurring usually between the 6th and the 12th week of pregnancy. Although many authors have shown that there is congenital abnormality of the uterus in these cases this does not always happen and the aetiology of "idiopathic angular pregnancies" is ill understood. The treatment is carried out according to the clinical state: endometrial curettage under laparoscopic control, removal of the uterine horn together with the tube on the same side or even hysterectomy.