Anand Kumar Mishra

Adrenal Cysts: An Institutional Experience

Adrenal cysts are rare clinical entities. We report our institutional experience with adrenal cysts and also assess various management options. Over the past 15 years the Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, has had seven cases of adrenal cysts, of which two were functional: one patient had Cushing’s syndrome and the other patient had pheochromocytoma. The other five cases were incidentally detected. Ultrasound scan and computerized tomography (CT) scan were the imaging modalities. Four patients had a single cyst, two patients had two cysts, and one patient had multiple unilateral cysts. None of these cysts had foci of malignancy. Laparoscopic adrenalectomy was possible in three patients with no morbidity or mortality. The reported incidence in clinical series has been 5.4%. Pseudocysts, endothelial cysts, epithelial cysts, and hemorrhagic cysts have been commonly described. The management can be conservative or surgical. It is generally agreed that a hormonal work-up is necessary in all cases of adrenal cysts to rule out a sub-clinical disease. Adrenal neoplasms, including adrenocortical carcinomas, can be associated with cysts that are benign in appearance. Percutaneous aspiration has been suggested as an alternative treatment option if the cyst is not hormonally active and if there is no suspicion of malignancy. However, surgical excision provides a definite histopathological diagnosis and also removes the fear of future complications such as hemorrhage into the cyst and local pressure effects due to the tumor. Given that the adrenals are a vascular gland and taking into consideration the possibilities of bleeding and complications in the cyst, our treatment of choice is the elective excision of adrenal cysts.

High Incidence of Tracheomalacia in Longstanding Goiters: Experience from an Endemic Goiter Region

BackgroundOur institute caters to a large number of patients with large, longstanding multinodular goiters; tracheal deviation and resulting airway problems like tracheomalacia are relatively common. However, the literature is sparse on the criteria of early diagnosis and optimum management of tracheomalacia, which our study highlights.MethodsThis retrospective study analyzed 900 thyroidectomies carried out during 1990–2005 for which data from 28 patients treated for tracheomalacia after thyroidectomy were available for analysis. Criteria for making a diagnosis of tracheomalacia after thyroidectomy included one or more of the following: normal vocal cord mobility, absence of glottic or subglottic edema or hematoma, soft and floppy trachea on palpation, obstruction to spontaneous respiration on gradual withdrawal of the endotracheal tube.ResultsMean duration of thyroid enlargement was 13.75 years. Only 7 patients had a history of stridor. Tracheostomy was performed in 26 patients, and 2 patients were put on prolonged intubation. Tracheostomy was performed in 18 patients on the operating table, and 8 in the recovery room. The mean weight of the gland was 442 g and histopathology revealed that 11 cases were benign goiter. The tracheostomy tube was removed after an average of 8.5 days. There were no cases of tracheal stenosis on long-term follow-up.ConclusionsPatients with longstanding goiter, even when benign, are more prone to develop tracheomalacia. On the basis of our experience we strongly advocate tracheostomy intraoperatively if the trachea is soft and floppy and/or collapse of the trachea is observed following gradual withdrawal of the endotracheal tube.

Normotensive pheochromocytoma : Institutional experience

We report an audit of nine cases of subclinical or normotensive pheochromocytoma managed in our department. This is the first report from India of such a series. During the period 1990–2003 a total of 45 patients of pheochromocytoma were diagnosed and managed in the Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences. Among them, nine patients were diagnosed as having subclinical or normotensive pheochromocytoma. Inclusion criteria for normotensive pheochromocytoma were: no previous history of hypertension clinically and, in the previous treatment documents, any episode of symptoms suggesting high blood pressure. The demographic profile, clinical presentation, biochemical investigations, imaging results, surgical notes, and follow-up record were reviewed retrospectively. All patients had a primary complaint of flank/abdominal pain and were normotensive. Seven had elevated urinary metanephrine levels, and one patient had normal values. One patient did not undergo the urinary metanephrine assay. Imaging of the abdomen showed seven adrenal and two extra-adrenal masses (eight had computed tomography scans of the abdomen, and one underwent ultrasonography). After selective α-adrenergic blockade (prazosin), surgery was performed. Six patients required infusion of sodium nitroprusside intraoperatively. The final histopathology was pheochromocytoma in all patients. Metanephrine levels were normal during the follow-up. Normotensive pheochromocytomas are a distinct entity, and all adrenal incidentalomas should be investigated for catecholamine hypersecretion. We support the use of preoperative α-adrenergic blockade, and these patients should be treated along the same lines as hypertensive pheochromocytoma.

Persistence of severe iodine-deficiency disorders despite universal salt iodization in an iodine-deficient area in northern India

OBJECTIVE The aim of the present study was to determine the impact of universal salt iodization (USI) on the prevalence of iodine deficiency in the population of an area previously known to have severe iodine deficiency in India. DESIGN In a cross-sectional survey, a total of 2860 subjects residing in fifty-three villages of four sub-districts of Gonda District were examined for goitre and urinary iodine concentration. Free thyroxine and thyroid-stimulating hormone levels were also measured. Salt samples from households were collected for estimation of iodine content. RESULTS A reduction in goitre prevalence was observed from 69 % reported in 1982 to 27.7 % assessed in 2007. However, 34 % of villages still had very high endemicity of goitre (goitre prevalence >30 %). Twenty-three per cent of households consumed a negligible amount (<5 ppm) and 56 % of households consumed an insufficient amount (5-15 ppm) of iodine from salt. CONCLUSIONS Although there was an overall improvement in iodine nutrition as revealed by decreased goitre prevalence and increased median urinary iodine levels, there were several pockets of severe deficiency that require a more targeted approach. Poor coverage, the use of unpackaged crystal salt with inadequate iodine and the washing of salt before use by 90 % of rural households are the major causes of persisting iodine-deficiency disorders. This demonstrates lapses in USI implementation, lack of monitoring and the need to identify hot spots. We advocate strengthening the USI programme with a mass education component, the supply of adequately iodized salt and the implementation of complementary strategies for vulnerable groups, particularly neonates and lactating mothers.

Association of unilocular thymic cyst and myasthenia gravis.

Neurology India | Jan-Feb 2012 | Vol 60 | Issue 1 103 (1) ingestion of the raw or undercooked flesh of snakes, frogs or freshwater fish infected with the Sparganum; (2) drinking untreated water containing infected copepods; and (3) using the raw flesh of an infected intermediate host in traditional poultices.[3] In our patient, the possible route was drinking untreated water, since she denied the other causes. Sparganosis usually presents with migratory subcutaneous nodules. [7] Acute angioedema or chronic skin rash may also play an important role in parasitic infection.[8] Sparganosis related to skin rash has not been reported prior to this case. The mechanism of the skin rash is unknown. Preoperative diagnosis of spinal sparganosis remains a challenge. It is difficult to differentiate this condition from other inflammatory or neoplastic disorders.[2-4] Diagnosis has usually been made after surgery based on the histological identification of the worm. The enzyme-linked immunosorbent assay (ELISA) measurement for the diagnosis of sparganosis is highly sensitive and specific.[2,3] As it turned out, our preoperative impression was wrong, and we did not think about using the preoperative ELISA test. The optimal treatment of spinal sparganosis is the surgical removal of the worms and the granulation tissues.[3] In conclusion, although spinal sparganosis is a rare clinical condition, it should be included in the differential diagnosis of patients with a spinal lesion.

A Survey on Breast Cancer Awareness Among Medical, Paramedical, and General Population in North India Using Self-Designed Questionnaire: a Prospective Study

Breast cancer (BC) has become the most common cancer in urban women. Unfortunately, most women are not aware of BC symptoms/signs, prevention, and management. In resource-limited countries like India where we do not have structured screening/awareness programs, a majority of women present with locally advanced BC. The aim of our study is to identify the present status of awareness about BC prevention, early detection, symptoms, and management in urban and rural Indian women (medical, paramedical, and nonmedical) and to assess whether education and socioeconomic strata have any role in better awareness about BC or not. We did a prospective cross-sectional observation study among the medical, paramedical, and nonmedical women in the northern part of India. We designed a questionnaire keeping in mind the three domains about BC—knowledge (questions 1–25 include risk factors, genetics, lifestyle changes, hormones, associated cancers, and modes of presentation like lump, nipple/skin changes), breast self-examination (questions 25–37), and attitude to prevention and early detection (questions 38–44). We also asked how many do breast self-examination (BSE) and what they think are the three main factors responsible for late presentation and the three main ways to increase BC awareness. The Likert scale was used for objective assessment. We analyzed the whole data using SPSS software version 15. A total of 220 women out of 270 completed the questionnaire. Out of 220 women, 26.4% were medical, 20.9% paramedical, and 52.7% nonmedical. Most women were educated (82.7%) and married (65%). 59.5% women resided in urban areas and the rest (40.5%) were from rural areas. We found that there was relatively more knowledge in the medical group; however, the skills of BSE and attitude to prevention and early detection in all the three subgroups and among rural and urban women were suboptimal and not different significantly. The three main factors responsible for delayed presentation were shyness and not knowing BSE, ignorance about BC symptoms, and social stigma of cancer along with financial constraints. The three main ways to improve BC awareness suggested were to have more advertisements on television and social media, roadside campaigns and in colleges along with group discussions and debates, and at grassroots level to involve Anganwadi workers and nurses to create more awareness in villages. There was less breast cancer knowledge and awareness among the nonmedical women compared to those among the medical and paramedical, the skills of BSE and attitude to prevention and early detection were suboptimal in all the three groups. Rural or urban dwellings did not make much difference in BC knowledge, skills of BSE, and attitude to prevention. More awareness regarding breast cancer symptoms with early detection and BSE need to be addressed with more information dissemination via social media, campaigns, and involvement of paramedics and social workers.

Adrenal Teratoma: Unusual Tumor with Typical Imaging Characteristics

Teratomas per se are rare and retroperitoneal teratomas are a still rarer entity. We report the image of a patient who presented with a large adrenal teratoma which was nonfunctional biochemically and who underwent surgical excision. The imaging characteristics are suggestive of teratoma and must be kept in mind while managing large adrenal tumors.

Surgical Techniques for Dealing with Intraluminal Thrombus of Great Vessels in Advanced Differentiated Thyroid Carcinoma

Aim: We aim to define and refine the surgical technique for dealing with intraluminal thrombus of great vessels in advanced differentiated thyroid carcinoma (DTC) to reduce the morbidity. Background: Venous tumor thrombus from DTC is a rare occurrence with sequelae that cause increased morbidity and early mortality. Management of such patients poses a challenge to surgeons. Materials and methods: We define the surgical planning and road map for surgical management of advanced DTC with tumor thrombus involving the internal jugular vein (IJV) and superior vena cava (SVC) by sacrificing one IJV and retrieving the thrombus from the SVC by Fogarty catheter. This technique has minimal morbidity with good outcome. Conclusion: By appropriate planning and meticulous surgical techniques, we can aggressively manage patients of advanced DTC with venous tumor thrombus and reduce the morbidity. Clinical significance: By surgical techniques leading to complete surgical resections and saving native vital structures, we can aim for successful aggressive surgical management of advanced DTC with venous tumor thrombus.

Serum phosphorus values for early prediction of hypocalcemia in total thyroidectomy

I read with interest article by Inversini et al. (1) in October issue. Hypocalcaemia is most dreaded complication after thyroidectomy and we agree with authors. There is also ample evidence in literature for postoperative parathyroid hormone (PTH) use to predict the risk of hypocalcaemia after thyroidectomy. However it is not possible to have PTH estimation in all patients in third world hospitals where either the facility is not available or all patients cannot afford. In India, almost all government medical college hospitals provide treatment free or at minimum cost which includes admission, bed, operation and bed charges, including meals. Thyroid surgery is practised by specialists as a day care surgery but we keep the patient in hospital for at least two days for hypocalcaemia monitoring. Here day care means that these patients are off fluid and orally allowed with eight hours. Thyroidectomy patient is kept in the hospital for two post-operative days as there is no bed charge. We always want to discharge our patients earlier not because of cost factor but because of patient load and waiting. PTH estimation is not available in all government hospital but calcium and phosphorus is available free of cost.

Surgical Techniques for operating on Large Adherent Cervical Nodal Metastases from Thyroid Cancer causing Severe Neck Pain and Compression Effects and encasing Major Vessels

Aim: We aim to refine and define surgical techniques for doing difficult adherent bulky cervical nodal metastases from thyroid cancer to help surgeons do dissections with better curability and lesser morbidity. Background: Patients with thyroid cancer with large nodal metastases presenting with severe neck pain due to compression effects and encasing carotid artery and other major vessels pose a challenge to surgeons to do complete resections while preserving important structures in the neck. Materials and methods: We define surgical planning and road map to dissect difficult bulky adherent cervical nodes encasing carotid artery and jugular vein by splaying the plane over carotid sheath by doing adventitial level dissection and dissecting medial and lateral to carotid sheath the large nodal mass adherent to adjacent structures preserving the major vessels and nerve plexus. Conclusion: By appropriate surgical planning and meticulous dissection techniques, we can do major neck dissections with complete resections and same time preserving important structures in the neck minimizing morbidity. Clinical significance: By doing neck dissections with complete oncological resections and saving vital structures in the neck, we aim to offer best possible chance of cure to the patient along with reduced morbidity at same time.