A G Krudy

Selective Venous Sampling for Gastrin to Localize Gastrinomas: A Prospective Assessment

In 27 consecutive patients with Zollinger-Ellison syndrome, we prospectively evaluated the ability of selective venous sampling for gastrin to localize gastrinomas, then compared the results with those from imaging studies and with findings at surgery. All patients had a gastrin gradient, but in only 20 patients was it significant. Neither the magnitude of the gastrin gradient nor its presence or absence correlated with the frequency with which gastrinoma was found at surgery. A gastrinoma was found at surgery in 15 patients, of whom 12 had positive imaging studies, 11 had a significant gastrin gradient, 14 had both tests positive, and 1 had both tests negative. A gastrinoma was not found at surgery in 12 patients, of whom 8 had a significant gradient and none had a positive imaging study. Gastrin sampling has equal sensitivity with imaging studies in localizing gastrinoma, but imaging studies have higher positive and negative predictive values and higher specificity. Thus, selective venous sampling for gastrin is much less useful in localizing gastrinoma than has been suggested and should not be routinely done preoperatively in patients with Zollinger-Ellison syndrome.

Transvaginal fluoroscopic recanalization of a proximally occluded oviduct

A hysterosalpingogram performed on a patient with infertility showed bilateral interstitial obstruction with partial intramural patency of the right tube and complete intramural obstruction of the left. Recanalization of the tube under fluoroscopy resulted in unilateral tubal patency and an intrauterine pregnancy followed. 7 references, 3 figures.

Results of reoperation for persistent and recurrent hyperparathyroidism.

Between August 1975 and January 1981, 106 patients thought to have persistent or recurrent hyperparathyroidism underwent a total of 108 parathyroid re-explorations at the National Institutes of Health. These 106 patients had a total of 175 previous operations for hyperparathyroidism (156 cervical and 19 mediastinal). Nephrolithiasis (54% of patients) and bone disease (24% o patients) were the predominant symptoms. Arteriographic examination and selective venous sampling provided highly accurate localizing results in 33% of the patients, and were of some help in 64%. The final diagnoses after reoperation and re-evaluation were: single-gland disease in 58 patients, primary nonfamilial hyperplasia in 19 patients, familial hyperplasia in three patients, multiple endocrine neoplasia (MEN) Type I in ten patients, MEN Type II in two, parathyroid carcinoma in four patients, secondary hyperplasia in three patients, and familial hypocalciuric hypercalcemia (FHH) in two patients. The diagnosis was in doubt in five patients. In the 95 patients with unequivocal hyperparathyroidism, not due to parathyroid carcinoma, surgery eliminated hypercalcemia in 91 (96%). Two patients died after operation, one of disseminated candidiasis, and one patient, with an immunodeficiency, of sepsis. Five patients developed temporary, and one permanent, recurrent nerve damage; 41% of the patients were hypocalcemic, at the time of discharge from the hospital.

Removal of gastrinomas for control of Zollinger-Ellison syndrome.

There are two distinct problems in patients with Zollinger-Ellison Syndrome (ZES): peptic ulcer diathesis and malignant tumors. Antisecretory drugs have allowed us to control the ulcer symptoms and acid output in 45 patients with ZES. We report here the initial seven patients selected for surgical exploration with the goal of removing their gastrinomas. Prior to surgery, an extensive and rigorous protocol to localize the gastrinoma was carried out, including hypotonic duodenography, abdominal ultrasonography, selective arteriography, portal vein sampling for gastrin, and computerized tomography. With this protocol of radiographic localization, gastrinomas were found in two of the seven cases and the syndrome was “cured” in three of the seven patients. The results also demonstrate that preoperative localization is not a substitute for careful surgical exploration as tumors were found in two patients in whom localization failed.

Intraoperative urinary cyclic adenosine monophosphate as a guide to successful reoperative parathyroidectomy.

Sixty patients with persistent or recurrent primary hyperparathyroidism underwent reexploration during which urinary cyclic adenosine monophosphate (UcAMP) levels were determined at half-hour intervals by radioimmunoassay. Retrospective analysis of the data allowed us to develop UcAMP criteria for surgical success. Following removal of parathyroid tissue, if an individual UcAMP level dropped 50% from the median baseline level, or if elevated levels dropped to less than 4.0 nmol/dl glomerular filtrate, surgery was predicted to be successful. Eight unsuccessful procedures in seven patients produced no decline in UcAMP, and the intraoperative results accurately predicted surgical failure. Fifty-three patients underwent successful procedures and in every case UcAMP fell. Ninety-eight per cent of these successful procedures were predicted by our criteria. Levels of UcAMP fell 1.5 +/- 0.5 hours (means +/- SD) following abnormal parathyroidectomy. In 19 of 36 successful cases diagnosed before surgery as adenoma, the operative procedure was terminated before a significant drop in UcAMP. In 16 of 17 successful cases diagnosed before surgery as hyperplasia or uncertain histology, UcAMP fell during the operation. Intraoperative determination of UcAMP is helpful in reoperative parathyroid surgery. The criteria established allow intraoperative prediction of success with remarkable accuracy. Urinary cyclic AMP is especially helpful in reoperation for multigland disease; when enough pathologic tissue has been removed, the criteria will be met and the procedure may be terminated with confidence.

Ct Appearance of Enlarged Parathyroid Glands in the Posterior Superior Mediastinum

Enlarged ectopic parathyroid glands in the posterior superior mediastinum appear as rounded dense masses in the tracheoesophageal groove. Five of six surgically proven adenomas in the posterosuperior mediastinum were demonstrated by computed tomography.

Gastric manifestations of North American Burkitt's lymphoma

Stomach involvement is rare in American Burkitts lymphoma. Three cases were noted in 66 patients, and all were associated with large left upper quadrant masses. The appearance of Burkitts lymphoma of the stomach is similar to other lymphomas and consists of diffuse infiltration of the wall, mucosal thickening, ulcerations, and intra- and extragastric masses. Extension into the oesophagus was noted twice, and small bowel masses were associated with two cases. CT scanning and ultrasound are useful for defining extragastric extent of tumour. Rapid reversion to a more normal appearance is noted following chemotherapy.

Ultrasonic parathyroid localisation in previously operated patients

Sixty-two patients with hyperparathyroidism and failed prior neck surgery were examined by ultrasound before reoperation to localise abnormally enlarged glands. If mediastinal lesions are excluded, a total of 57 glands greater than 5 mm in size were removed from 48 patients. Ultrasound demonstrated only 18 of these for a true positive rate of 32%. There were 39/57 (68%) false negatives. In addition, there were 16 false positives. In our experience, the detection rate of ultrasound for enlarged parathyroid glands in patients with failed surgery is significantly less than that reported in previously unoperated patients (73%), or in the limited number of reported cases of patients with previous operations (75%). Our high false negative rate is probably partially due to the large number of posteriorly located small glands which cannot be adequately visualised by ultrasound. Nevertheless, because of its non-invasive nature, low cost and ready availability, ultrasound should be utilised as an initial screening procedure in patients with failed previous surgery.

Use of a microcomputer to store information on radiology cases

A microcomputer program for storage of qualitative patient data has been applied to CT and special procedures case data. Different vocabularies have been established and utilised for these two case categories. Experience over two years involving more than 10,000 cases is discussed. Utility for statistical, research, and patient care purposes is demonstrated.