Ultrasound-guided unilateral neck exploration for sporadic primary hyperparathyroidism: is it worthwhile?

The role of preoperative localisation tests before initial neck exploration for primary hyperparathyroidism (PHP) remains controversial, as does the optimal surgical approach. We report our experience with preoperative ultrasound (US) and the operative management of sporadic PHP between 1990 and 1995. Preoperative US was carried out by an experienced radiologist. Three surgeons adopted a policy of 'selective' US-guided unilateral neck exploration (UNE); the fourth surgeon performed routine bilateral neck exploration (BNE). There were 72 patients: 26 men and 46 women, with a mean age of 57.4 +/- 12.5 years (range 21-80 years). All patients underwent initial neck exploration for 'sporadic' PHP, of whom 63 had preoperative US. This was positive in 52 patients; 27 of whom underwent a UNE, 23 had a BNE, and two patients had a UNE converted to a BNE. Patients with 'negative' US (n = 11), and those receiving no preoperative localisation test (n = 90) underwent a BNE. The sensitivity, specificity and accuracy of US were 80% (52/65), 100% (61/61), and 90% (113/126), respectively. Comparable success rates were achieved (BNE: 97% (33/34) vs UNE: 93% (27/29), P < 0.05), with very low morbidity. Failures with the scan-guided UNE were caused by missed contralateral adenomas. An experienced radiologist and a low incidence of multiglandular disease (MGD) are essential prerequisites for the scan-guided unilateral approach. An experienced surgeon, on the other hand, is the only prerequisite for the 'gold standard' bilateral approach.

A review of antibiotic prophylaxis for open fractures

A review of the literature strongly supports the use of antibiotic prophylaxis in open fracture management. Because of their broad spectrum of activity, cephalosporins are the drugs of choice in cases of orthopaedic trauma. The extent of the injury determines the appropriate agent and the length of time it should be given. Patients with Type 1 or Type 2 fractures require only brief treatment (one preoperative and two postoperative doses) with an agent that has good antistaphylococci activity. Cephalothin, cefazolin, cefamandole or cefuroxime are recommended. Type 3 fractures present a much greater problem because of the risk of gram-negative infection. The marked activity of cefuroxime, cefamandole, and cefotaxime against these organisms recommends their use in such cases. Combination regimens with aminoglycosides require further study to define added efficacy and to define appropriate dosing regimens. We advocate that antibiotic prophylaxis should be given as soon as possible to all patients with open fractures and Type 3 fractures, and that prophylaxis should continue until 48 hours after adequate soft tissue coverage is achieved.

Monocyte dysfunction in severe trauma: evidence for the role of C5a in deactivation

Consecutive severely traumatized patients (n = 16) requiring intensive care underwent serial monitoring of complement activation and monocyte migratory function with the chemoattractant activated serum (C5a) and formyl-methionyl-leucyl-phenylalanine (FMLP). Complement was found to be activated, and chemotaxis to C5a was correspondingly depressed maximally at a mean 5 to 7 days after injury (p = less than 0.01). The migratory response to FMLP was within the normal range throughout. Conversely, in a consecutive series of patients undergoing aortoiliac bypass grafting (n = 11), there was no evidence of complement activation, and monocyte migratory function remained normal for both C5a and FMLP. These data suggest that in patients with severe trauma, the activation of complement, particularly the fifth component (C5a), reduces the migratory responsiveness of circulating monocytes to C5a. This reduction in a host-response mechanism may explain the propensity to infection and poor wound healing seen in patients with severe trauma and also indicates that C5a, thought to be the major in vivo chemoattractant for leukocytes, has profound systemic actions.

A rapid method for monocyte isolation and chemotaxis

A rapid method for isolating human peripheral blood monocytes and studying chemotaxis is described. The cells are isolated at a mean purity of 60% (+/- 10%) using Dextran. T500 sedimentation of whole blood, followed by centrifugation of the leucocyte-rich plasma obtained on a discontinuous Percoll gradient (density 1.067 g/ml). Chemotaxis was performed using a 48-well chamber and the chemoattractants activated serum (C5a) and FMLP and was proven by checkerboard analysis. Using this technique pooled serum was found to be activated by the PVP-coated polycarbonate filter in use, producing the attractant C5a. At high concentrations this produced a chemotactic response identical to zymosan-activated serum (ZAS). This technique requires small volumes of blood (15 ml) and enables monocyte isolation and chemotaxis to be completed in approximately 4 hr using leucocyte preparations in which the monocyte is the predominant cell. It therefore facilitates the sequential investigation of monocyte function in patients.

Suppressed neutrophil oxidative activity in sepsis: a receptor-mediated regulatory response

We have reported that neutrophils from patients with intraabdominal sepsis show suppressed superoxide production in response to soluble chemoattractants. To determine whether this could be a result of altered receptor function, neutrophil function studies and characterization of receptors were performed upon 22 patients recently operated upon for intraabdominal sepsis. Patient cells showed an absence of subagarose migratory response to activation serum (C5) but intact FMLP response. Superoxide production to FMLP was 5.3 +/- 0.1 nmole FcC compared to 11.2 +/- 0.1 nmole for laboratory normals. Addition of cytochalasin B reversed this. Scatchard analyses of patients' cells showed affinity of 55.5 +/- 0.6 as compared to 36.5 +/- 1.8 for controls. The number of receptors of cell was approximately 55,000 for both controls and patients. Internalization studies revealed significant increase in tritiated-FMLP uptake at room temperature. These results support the hypothesis that superoxide suppression is due to enhanced clearance of stimulant by enhanced internalization of the receptor-ligand complex.

Regulation of monocyte function by complement activation products

Normal human monocytes, obtained at a mean purity of 60% by Percoll density gradient centrifugation, were found to be chemotactically deactivated to C5a by exposure to low, and biologically significant, concentrations of zymosan-activated serum (ZAS), while retaining their full response to FMLP. C5a was found to be 40X more potent than its metabolite C5adesArg in reducing chemotaxis to activated pooled serum. Conversely, exposure of monocytes to varying concentrations of N-formyl-methionyl-leucyl-phenylalanine (FMLP) decreased chemotaxis to that attractant, though had no effect on chemotaxis to activated serum. Monocytes were also found to actively absorb C5a from solutions of ZAS, rich in C5a. Our data support the concept that monocytes are specifically regulated by C5a and C5adesArg.

Morbidity of simple cholecystectomy and cholecystectomy with transduodenal sphincteroplasty

Exploration of the common bile duct via transduodenal sphincteroplasty is thorough and provides an opportunity for the natural passage of retained calculi. However, this procedure destroys both the sphincter ampulla and sphincter choledochus, the sequelae of which are unknown. Fifty patients who had a transduodenal sphincteroplasty performed between 1970 and 1980 were randomly selected and compared with 50 patients who only had cholecystectomy. They were all seen in the outpatient department, assessed on a modified Visick scale and had liver function tests performed. There was no statistical difference in the subjective quality of result or in the liver function of the sphincteroplasty group when compared with the cholecystectomy patients, which suggests that destruction of the sphincters does not appear to be harmful to the patient.

Transduodenal sphincteroplasty: an analysis of 118 consecutive cases

The results of 118 consecutive common bile duct explorations via transduodenal sphincteroplasty are presented and analysed. The operations were performed for suspected choledocholithiasis by one surgeon over a 10-year period. Choledocholithiasis was proved in 22 per cent of the cholecystectomies carried out during this period and tended to present significantly earlier in females, 14.5 per cent presenting before 35 years of age. One hundred and four survivors were traced and 93.5 per cent had achieved a good result at a mean 5-year follow-up.

Radical excision of the nailfold for ingrowing toenail

A simple method of treatment for ingrowing toenail by radical excision of the affected nailfold is described. The results in a prospective series of 50 patients are presented. This procedure, first described in 1872, does not destroy the nail, which heals to give an excellent cosmetic result. The recurrence rate after 18 months was 20 per cent, which compares favourably with procedures in which the nailbed is ablated. This method is proposed as an alternative to more complex procedures, especially when a cosmetic result is desired.