Malcolm H. Wheeler

Intraoperative identification of parathyroid glands: Appraisal of methylene blue staining

Methylene blue administered intravenously in a dose of 5 mg/kg of body weight was employed as an aid to the intraoperative identification of parathyroid glands in 90 patients undergoing surgery for hyperparathyroidism. Staining occurred in 95 percent of adenomas and 86 percent of hyperplastic glands. Normal and suppressed glands stained in 71 and 70 percent of cases, respectively. There were no adverse side effects from the technique. We conclude that preoperative intravenous infusion of methylene blue is a valuable technique that facilitates identification of parathyroid tissue at operation.

Collagenase inhibition in the healing colon.

A randomized controlled trial was performed to assess the effect of intravenous aprotinin (Trasylol) on the healing of experimental colonic anastomoses in the rabbit following a standard left colonic resection anastomosis. Assessment of tensile strength was by means of both bursting pressure and breaking strength. Those animals subjected to bursting pressure assessment received intravenous aprotinin 80 000 KIU (kallikrein inhibitory units) at the time of anaesthesia, and postoperatively 160000 KIU per day given in divided doses for three days. Control animals received saline placebo. A further group of animals received a lower loading and maintenance aprotinin dose (40 000 KIU and 60000 KIU per day respectively) with control animals receiving saline. Breaking strength was employed as the means of assessment. The mean bursting pressures were 47.7 ∓ 2.9 mmHg and 37.5 ∓ 3.4 mmHg for aprotinin and controls respectively (P≤0.05). The mean difference in collagen content of the anastomosis compared to the resected specimen was +1.25 ∓0.50 μg/mg and −1.02 ∓ 0.47 ug/mg for aprotinin and placebo groups (P ≤ 0.005). The mean breaking strength in the aprotinin group was 169.6 ∓74.5 g and 110.0 ∓65.9 g for the saline group (P≤0.02). The mean difference in collagen content of the anastomosis compared to the resected specimen was +0.95 ∓0.69 ug/mg and −1.5 ∓0.78 ug/mg for the aprotinin and saline groups respectively (P≤0.05). The significant elevation of both bursting pressure and breaking strength assessments, with a significant improvement in the collagen content of the anastomoses, may be the result of collagenase inhibition following the use of intravenous aprotinin in the experimental model.

THE TECHNIQUE OF THYROIDECTOMY

The earliest account of thyroidectomy is probably that given by Roger Frugardi of Salerno in 11701. Thyroidectomy remained a rarely performed procedure, William Halsted2 finding accounts of only eight operations in which the scalpel had been used on the thyroid between 1596 and 1800, and of only 69 more cases between 1800 and 1848. The morbidity and mortality, usually from uncontrolled bleeding and sepsis, were prohibitive but advances in general anaesthesia, antisepsis and haemostasis paved the way for surgeons at the turn of the century to make thyroidectomy a safe and acceptable operation. At the forefront of these developments was Theodor Kocher of Berne3 who performed thousands of thyroidectomies bringing the mortality down to under 1%. Today, thyroidectomy should be an extremely safe and uneventful procedure when performed by a trained endocrine surgeon. The term thyroidectomy embraces a variety of surgical procedures on the thyroid, the precise operation being tailored according to the existing pathology (Table 1). Thyroid nodules are a common disorder occurring in 4% of the population and many of these patients, especially when the lesion is solitary or fine needle aspiration (FNA) has raised the possibility of malignancy, are treated by surgery. Unilateral total lobectomy including the isthmus and pyramidal lobe is the minimum procedure necessary to treat such disease and obtain an adequate histological diagnosis. This operation will therefore be described in detail.

Results of a prospective randomized double-blind trial of aprotinin in colonic surgery.

One hundred patients undergoing colorectal surgery were entered into a prospective, randomized, double-blind trial of the collagenase inhibitor aprotinin (Trasylol®). Postoperative assessment of the integrity of the anastomoses was performed and the overall radiological leakage rate was 22% for the aprotinin group and 35% for the placebo group. The overall clinical leakage rate was 8% and 15% for aprotinin and placebo, respectively. This reduction in the leakage rates may be of clinical importance and further studies are therefore warranted. Cent malades qui ont subi une intervention chirurgicale colorectale ont été soumis à une étude prospective en double aveugle pour définir laction éventuelle de laprotinine (Trasylol) en tant quinhibiteur de la collagénase. Létude postopératoire de la qualité de lanastomose à laide de lexploration radiologique a permis de constater que le taux de la déhiscence de la suture a été de 22 pour cent chez les sujets traités par le Trasylol et de 35 pour cent dans le groupe de contrôle. Sur le plan clinique la déhiscence sest manifestée dans 8 pour cent des cas traités par laprotinine et dans 15 pour cent des cas du groupe placebo. La réduction de la déhiscence des anastomoses portant sur le colon et le rectum peut avoir une grande importance pratique; elle mérite dêtre confirmée par des études plus poussées. El escape de contenido intestinal en las anastomosis de colon ha sido causa de considerable morbilidad y mortalidad desde los primeros días de la cirugía colónica. Recientemente se ha tratado de identificar aquellos factores específicos que puedan lograr reducir la incidencia del escape. Un concepto básico de cicatrización de heridas establece que en el curso del proceso de reestructuración hay una fase inicial de lisis destinada a la remoción de los tejidos lesionados. Experimentalmente se ha demostrado que en las etapas tempranas de la cicatrización este proceso lítico ocurre en exceso sobre la síntesis de colágeno; más tarde la síntesis predomina, pero el tiempo necesario para que la herida retorne a la fortaleza original del tejido es considerable y está relacionado con la maduración del colágeno. Involucradas en la fase lítica se hallan enzimas vagamente denominadas colagenasas, las cuales han sido identificadas en una variedad de tejidos incluyendo el colon y el estómago. Estudios de laboratorio han mostrado que las colagenasas pueden ser inhibidas por la aprotinina (Trasylol, Bayer UK Ltd.), que es una droga inhibidora de la proteinasa. Cien pacientes sometidos a cirugía colo-rectal fueron ingresados a un estudio prospectivo doble ciego y aleatorizado sobre la aprotinina, agente inhibidor de las colagenasas. La valoración postoperatoria de la integridad de las anastomosis reveló que la tasa de escape radiológico fue del 22% para el grupo que recibió aprotinina y del 35% para el grupo que recibió placebo. La tasa global de escape clínico fue del 8% y 15% respectivamente. Esta reducción en las tasas de escape puede ser de importancia clínica y justifica la realización de estudios adicionales.One hundred patients undergoing colorectal surgery were entered into a prospective, randomized, double-blind trial of the collagenase inhibitor aprotinin (Trasylol®). Postoperative assessment of the integrity of the anastomoses was performed and the overall radiological leakage rate was 22% for the aprotinin group and 35% for the placebo group. The overall clinical leakage rate was 8% and 15% for aprotinin and placebo, respectively. This reduction in the leakage rates may be of clinical importance and further studies are therefore warranted.RésuméCent malades qui ont subi une intervention chirurgicale colorectale ont été soumis à une étude prospective en double aveugle pour définir laction éventuelle de laprotinine (Trasylol) en tant quinhibiteur de la collagénase. Létude postopératoire de la qualité de lanastomose à laide de lexploration radiologique a permis de constater que le taux de la déhiscence de la suture a été de 22 pour cent chez les sujets traités par le Trasylol et de 35 pour cent dans le groupe de contrôle. Sur le plan clinique la déhiscence sest manifestée dans 8 pour cent des cas traités par laprotinine et dans 15 pour cent des cas du groupe placebo.La réduction de la déhiscence des anastomoses portant sur le colon et le rectum peut avoir une grande importance pratique; elle mérite dêtre confirmée par des études plus poussées.ResumenEl escape de contenido intestinal en las anastomosis de colon ha sido causa de considerable morbilidad y mortalidad desde los primeros días de la cirugía colónica.Recientemente se ha tratado de identificar aquellos factores específicos que puedan lograr reducir la incidencia del escape. Un concepto básico de cicatrización de heridas establece que en el curso del proceso de reestructuración hay una fase inicial de lisis destinada a la remoción de los tejidos lesionados. Experimentalmente se ha demostrado que en las etapas tempranas de la cicatrización este proceso lítico ocurre en exceso sobre la síntesis de colágeno; más tarde la síntesis predomina, pero el tiempo necesario para que la herida retorne a la fortaleza original del tejido es considerable y está relacionado con la maduración del colágeno. Involucradas en la fase lítica se hallan enzimas vagamente denominadas colagenasas, las cuales han sido identificadas en una variedad de tejidos incluyendo el colon y el estómago. Estudios de laboratorio han mostrado que las colagenasas pueden ser inhibidas por la aprotinina (Trasylol, Bayer UK Ltd.), que es una droga inhibidora de la proteinasa.Cien pacientes sometidos a cirugía colo-rectal fueron ingresados a un estudio prospectivo doble ciego y aleatorizado sobre la aprotinina, agente inhibidor de las colagenasas.La valoración postoperatoria de la integridad de las anastomosis reveló que la tasa de escape radiológico fue del 22% para el grupo que recibió aprotinina y del 35% para el grupo que recibió placebo. La tasa global de escape clínico fue del 8% y 15% respectivamente. Esta reducción en las tasas de escape puede ser de importancia clínica y justifica la realización de estudios adicionales.

Parasympathomimetics in Ogilvie's syndrome

by the balloon of the catheter on the bleeding site can be easily modulated and controlled by adjusting the quantity of water in it. As a matter of fact, as in bleeding esophageal varices, excellent results are achieved by the employment of balloon tamponade. 3 On discharge, we routinely instruct our patients on how to use the Foley ~ catheter should bleeding occur. We, therefore, recommend the Foley ~ catheter technique as the first option to treat delayed postoperative hemorrhage following surgical hemorrhoidectomy.

Effect of intravenous amino acids on the canine gastric mucosa

A mixture of synthetic L-amino acids (Aminoplex 14) was infused intravenously over 4 hours in five dogs each prepared with a gastric fistula and a denervated fundic pouch. Acid and pepsin outputs from the innervated fundic pouch. Acid and pepsin outputs from the innervated gastric mucosa (gastric fistula) increased significantly after 90 minutes infusion of amino acid. Acid output from the denervated fundic mucosa (Heidenhain pouch) was estimated by a method of intragastric titration and increased significantly only in response to intravenous amino acid infusion when the pouch was subjected to distention with 100 ml of perfusate. Blood glucose, serum gastrin, hematocrit and serum osmolality levels did not change throughout the experiments. Bolus intravenous injection of either atropine (0.15 mg/kg) or cimetidine (10 mg/kg) blocked the acid secretory response to intravenous amino acids. It is concluded that intravenous amino acids stimulate the innervated gastric mucosa to secrete both acid and pepsin. The secretory response from denervated mucosa in only obtained in the presence of fundic pouch distention. The gastric secretory response is susceptible to both atropine and histamine H2 antagonist blockade.

Treatment of Zollinger-Ellison syndrome.

I take issue with Dr Colvin and coauthors (January 1998 JRSM pp26-29) on some statements in their article. A cervical collar does not immobilize the neck and will not prevent secondary spinal cord injury. It restricts access to the patient, is uncomfortable, and can cause pressure sores. It certainly should not be necessary for an intensive care unit patient to wear such a collar for several days. If the neck is at risk, light skull traction is the simplest and most effective means of controlling it. If it is not at significant risk, simple sandbags and routine postural nursing are all that is required. All patients should be examined neurologically, not simply the awake patient. Treating lower limb fractures by traction makes nursing difficult only because these nursing skills are being lost through changes in nursing training and career structure. Nursing lower limb fractures in traction is not difficult in the hands of trained and experienced orthopaedic nurses. Treating lower limb fractures by traction does not (cause unnecessary pain but rather relieves pain, and it does not increase bleeding at the fracture site. Open surgery on the fracture results in much greater blood loss than does conservative treatment. The reference they cite does not support those statements. In my experience the nursing care of locomotor injuries is of much higher standard on an orthopaedic ward than in an intensive care unit, and the sooner such patients are transferred to the ward, the lower the incidence of complications of their locomotor injuries.

Results of a Prospective Randomized Double-Blind Trial of Aprotinin (Trasylol) in Colonic Surgery

100 patients undergoing colorectal surgery were entered into a prospective randomised double-blind trial of the collagenase inhibitor aprotinin (Trasylol). Post-operative assessment of the integrity of the anastomoses was performed and the overall radiological leakage rate was 22% for the aprotinin group and 35% for the placebo group. The overall clinical leakage rate was 8 and 15 % for aprotinin and placebo, respectively. This reduction in the leakage rates may be of clinical importance and further studies are therefore warranted.