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.

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.

Excimer Laser Assisted Angioplasty for Critical Limb Ischemia: Results of the LACI Belgium Study

BACKGROUND

The purpose of this study was to assess the safety and efficacy of translating into national practice methodology for infrainguinal excimer laser-assisted angioplasty, for the treatment of critical limb ischemia in poor surgical bypass candidates.

METHODS

A prospective five centre Belgian registry enrolled 48 patients, who presented with 51 chronic critically ischemic limbs (Rutherford category 4, 5 or 6) and were poor candidates for bypass surgery. Treatment included crossing the occlusion or stenosis by conventional guidewire followed by excimer laser angioplasty with, or without, adjunctive balloon angioplasty or stenting. A step-by-step technique was used in cases where the guidewire could not pass the occluded site. The primary endpoint was limb salvage, at 6 months, of the treated limb.

RESULTS

Initial treatment was successful in all 51 limbs. By 6 months there had been six deaths, six minor and four major amputations and further intervention was required in four patients. Among survivors, limb salvage rate at 6 month was 38/42 (90.5%), with freedom from critical limb ischemia in 86%.

CONCLUSIONS

This Belgian study of excimer laser assisted angioplasty, in high-risk patients who were poor candidates for surgical re-vascularisation, had a low incidence of surgical re-interventions and limb salvage rate in excess of 90%.

Aneurysm of the splenic artery

Splenic artery aneurysms, once considered rare entities are now being reported with increasing frequency. Due to a high incidence of fatal rupture, they are considered dangerous. Rupture is often the first and only symptom. With an increased index of suspicion and early aggressive treatment of asymptomatic splenic artery aneurysms, mortality has drastically decreased. We present a case of an unusually large asymptomatic aneurysm which was treated surgically, and discuss incidence, pathophysiology, clinical presentation, evaluation and treatment.

Pulmonary artery aneurysm: is surgery always indicated?

The authors present a seventy-eight year old woman with an aneurysm of the main pulmonary artery. Although a surgical approach is generally considered life-saving by preventing rupture of the aneurysm, literature is unclear about possible rupture in the specific situation of a pulmonary artery aneurysm without a causative cardiac lesion and/or pulmonary hypertension. In fact, some reports suggest a conservative treatment for this specific entity. Therefore we did not operate on our patient and she remains stable at 18 months follow-up.

Femoropopliteal endobypass: a feasibility study in 41 patients

The authors present a new technique for the treatment of atherosclerotic occlusive disease of the superficial femoral artery in highly symptomatic cases. The endovascular technique consists of recanalization, dilation and intraluminal positioning of a distally stented and dilated polytetrafluoroethylene (P.T.F.E.) graft. Until submission of this manuscript, 41 patients with total occlusion of the superficial femoral artery and collateral refill at the level of the proximal popliteal artery were treated with this technique with a very low morbidity. At 1 year follow-up, the life-table analysis shows a primary patency rate of 75.1% and an assisted primary patency of 79.1%. Amputation rate at 1 year was nil. The endovascular technique is depicted in detail and some important features are discussed.

Surgical treatment of benign tumours of the salivary glands

In this multicentre retrospective study 30 patients with benign salivary gland tumours are reviewed. Initial operation consisted of total parotidectomy in 6 patients, superficial lobectomy in 13 and tumour enucleation in 11. There were 5 recurrences, treated by enucleation in 1, superficial lobectomy in 2 and extensive total resection in 2 patients. In 18 cases a typical facial nerve dissection was performed. The resected specimens showed a pleiomorph adenoma in 24 cases and monomorph adenoma's in 6 cases. Complications were haematoma formation, Frey syndrome and facial nerve paresis. Recurrences were related to incomplete resection or fragmentation during operation. In this study benign tumours of the salivary glands proved to have a good prognosis, provided a total tumour excision with nerve dissection is performed; the excision should consist of a superficial lobectomy or total parotidectomy depending on the location of the tumour in the lateral or medial part of the gland.

Surgical treatment of acute, massive lung embolism. Results and follow-up

Between 1970 and 1984 the diagnosis of acute, massive lung embolism was made 30 times in our department. In 29 patients the clinical diagnosis was correct and a Trendelenburg operation under extra-corporeal circulation was performed. In 18 cases there was an operation in the immediate preoperative course. In 1 case there was a combination of operation and the use of contraceptives. 3 cases were immobilized by a plaster of Paris cast. In 4 cases the use of oral contraceptives and in 3 patients the history of chronic recurrent lung embolism were evident. The mean immobilisation time was 15 days. In 24 cases the diagnosis was made only on the base of the clinical anamnesis, and examination, E.C.G. and chest radiography. In 4 cases angiography and in 1 patient the scintigraphy confirmed the diagnosis. Preoperatively 28 patients were in severe shock. One patient was operated electively. 14 patients needed external cardiac massage. In all cases clots were found in the left pulmonary artery, 28 in the right pulmonary artery, in 3 cases clots in the right atrium, 3 in the right ventricle and three in the inferior caval vein. Nine De Weese caval vein clips were inserted and one Mobin-Uddin filter. Postoperatively 18 patients were alive and well without sequelae. Two patients developed a cerebro-vascular accident (CVA) with one complete recovery. Ten patients died. Postoperative treatment consisted of I.V. heparin administration immediately after surgery and 6 months of oral anticoagulants. Except for chronic recurrent lung embolism the pulmonary function tests were excellent postoperatively without recurrence of the disease.

Early and late postoperative sequelae after surgery for carcinoma of the breast

During a 4-year period, the authors performed 621 operations on 606 patients, suffering from carcinoma of the breast. The types of operations and their indications are described. Early postoperative complications of all kind appeared in only 6%, while lymphorrhoea and lymphocele were noted in 30% of the cases. Systematic measurements for early arm swelling indicate a fifty-fifty range. Follow-up study on 379 patients reveals the minor incidence of 8,9% of chronic lymphoedema. No statistic relationship between early swelling of the arm and chronic lymphoedema can be recognized.

Peritoneal lavage in acute pancreatitis. An experimental and clinical study

Experiments were performed to evaluate the use of peritoneal lavage in dogs, in which an acute non fatal necrotic-hemorrhagic pancreatitis was obtained by means of intraductal sodium-taurocholate injection. A single lavage of 2 liters of a balanced solution 6 hours after the pancreatitis onset produced a temporary biochemical improvement, as evidenced by the amylase, lipase and alcaline phosphatase values. Triple lavage with or without heparin, performed after 6, 18 and 24 hours, produced on the other hand clearcut reduction in mortality rates and long lasting improvement of the biochemical parameters. Two patients with operatively confirmed necrotic hemorrhagic pancreatitis were treated by the lavage method during three days. The treatment resulted in a significant improvement of the clinical condition and the biochemical parameters of both patients.

Nutritional assessment as a quality control of total parenteral nutrition

Because no single index can characterize a patient's nutritional status, a complete assessment requires a profile of different parameters. This profile incorporates various tests, measurements, and derived parameters, which have been established and adapted to clinical use for identifying the malnourished state, providing guidelines for nutritional support and evaluating the response to nutritional therapy. The quantitative value of anthropometric measurements (weight, triceps skinfold thickness, arm muscle circumference), biochemical determinations (creatinine-height index, serum albumin, serum transferrin total lymphocyte count). Immunological evaluations (skin antigen testing) and their importance in the classification of malnutrition are being discussed. Considerable attention is drawn on monitoring the nutritional assessment by serial measurements. So, a dynamic pattern of the patient's response to parenteral nutritional therapy can be evaluated and a more scientific base is found for determining the nutritional needs for any specific patient.

[Duplication of the colon in the adult (author's transl)]

The authors describe 2 cases of duplication of the colon. One was discovered by accident and not treated. The other occurred in a patient with a long story of abdominal pain and had been operated twice with signs of intestinal obstruction. A partial resection of the duplication with the adjoining bowel segment was performed and the digestive tract was reconstructed bij and end-to-end anastomosis. The different forms of duplication are described with their specific features and the current theories about their mode of formation. Finally a brief description of the symptoms and of the available surgical techniques is given.