Patrick F. Sheedy

Cavernous hemangiomas of the liver: Resect or observe?

Surgical decisions regarding cavernous hemangioma of the liver require consideration of the natural history of the lesion. To provide background, we retrospectively evaluated 49 cases of such hemangiomas exceeding 4 cm in diameter. There were 36 female patients (including 4 infants) and 13 males. Their ages ranged from 1 month to 68 years and averaged 44 years. Surgical procedures that ranged from simple excision to hepatic lobectomy were performed on 13 patients. Four had postoperative complications. There were no surgical deaths or any late deaths attributable to hemangioma. The other 36 patients have been observed for up to 15 years (mean 5.5 years) without the need for surgery. None of the patients in this group died, and none has experienced intraperitoneal hemorrhage or intensification of symptoms, although the size of four lesions increased. The benign course should be considered when deciding on management of lesions that are asymptomatic or so large as to pose significant operative risk.

Mediastinal parathyroid tumors: experience with 38 tumors requiring mediastinotomy for removal.

Most hyperfunctioning parathyroid tumors situated in the mediastinum can be removed by means of a cervical approach. However, a few tumors, because of their location deep in the chest, require mediastinotomy for removal. These tumors are probably derived from parathyroid glands that have developed from the third branchial pouch. Between 1942 and 1980, 38 such tumors were removed at the Mayo Clinic, using a sternum-splitting procedure. With one exception, the patients had undergone previous parathyroid exploration. Almost all of the patients had significant complications of primary hyperparathyroidism (HPT). Thirty-seven patients (97%) were cured after removal of their mediastinal parathyroid tumors, but postoperative chest complications were encountered in eight patients (21%), and eight have permanent hypoparathyroidism. Six patients had selective arteriography, two had selective thyroid venous sampling and parathyroid hormone assay, and 13 had mediastinal computed tomography in an attempt to localize tumors before operation. The anatomic locations of the tumors at operation were variable, but the vast majority (68%) were in or near the thymus.

Adrenal Insufficiency From Bilateral Adrenal Hemorrhage

Bilateral adrenal hemorrhage is a rare cause of adrenal insufficiency in adults. Because of the nonspecific manifestations of adrenal insufficiency, antemortem diagnosis is difficult. Serial computed tomographic scans of the abdomen are a valuable adjunct in confirming the diagnosis of bilateral adrenal hemorrhage, which manifests as round or oval adrenal masses of high density that subsequently decrease in both size and density. The diagnosis should be suspected in any complex highly stressful illness, in the postoperative period, or in the presence of a coagulopathy in conjunction with hypotension, fever, or electrolyte disturbances. Herein we describe five patients in whom the computed tomographic scans suggested or confirmed the presence of bilateral adrenal hemorrhage. In three of the five patients, the presence of a circulating lupus anticoagulant was demonstrated. Once the diagnosis of adrenal hemorrhage is suspected, steroid replacement therapy should be initiated promptly.

Computed tomographic scanning versus radioisotope imaging in adrenocortical diagnosis

Referral patterns from internists to departments of nuclear medicine or radiology are important determinants of whether adrenal glands are imaged by computed tomography (CT) or by radioisotope scintigraphy. To assist clinicians in making an informed choice, computed tomographic scans were compared with isotope scintigrams using 131I-19-iodocholesterol (19-IC) and 131I-6 beta-iodomethyl-19-norcholesterol (NP-59). In general, imaging techniques serve to localize diseases that are diagnosed on the basis of biochemical tests of adrenal function. Computed tomographic scanning and NP-59 scanning are of comparable diagnostic accuracy. Both are superior to 19-IC scanning in the diagnosis of Cushings syndrome and primary aldosteronism. Computed tomographic scanning is faster and less expensive, and involves lower radiation doses to the patient than scintigraphy. Adrenocortical isotope scanning as a routine procedure has been superseded by computed tomographic scanning at the Mayo Clinic.

Detection of intrapericardial hematoma after open heart surgery: The roles of echocardiography and computed tomography

Two patients who had right atrial compression caused by intrapericardial hematomas after coronary artery bypass grafting and aortic valve replacement are described. During the course of postoperative evaluation, each patient underwent an echocardiographic examination followed by computed tomography of the chest. Two-dimensional echocardiography visualized the hematomas in both cases. Computed tomography played a useful adjunctive role by further clarifying their nature, location and extent.

Intraoperative real-time ultrasonographic localization of pancreatic insulinoma: initial experience.

Intraoperative localization of pancreatic insulinomas in four patients using a commercially available real‐time scanner is described. Four tumors that were suspected preoperatively were confirmed and another that had not been suspected was identified.

Adrenal surgery: Trends during the seventies

Surgical experience with adrenal disease from 1970 to 1979 was reviewed in 315 patients. The pathologic conditions that were encountered were hypercortisolism (74 patients), hyperaldosteronism (46 patients), adrenocortical carcinoma (35 patients), pheochromocytoma (77 patients), and nonfunctioning adenoma (47 patients). In addition, 5 patients with metastatic lesions, 14 with cysts, and 4 with myelolipoma were surgically treated. The accuracy of localizing adrenal lesions increased from about 50 percent to almost 100 percent during the decade studied. The increase was due mainly to the introduction of computerized tomography, the most important advance in the management of adrenal disease. The present study shows that adrenal surgery can be performed with low morbidity and mortality. Operative deaths were confined to patients with malignant disease or increased secretion of cortisol or catecholamines. Only patients with adrenocortical carcinoma (2 year survival probability, 34 percent) or hypercortisolism due to cortical hyperplasia (5 year survival probability, 76 percent) had significantly decreased survival.

COMPUTED TOMOGRAPHIC SCANNING VERSUS RADIOISOTOPE IMAGING IN ADRENOCORTICAL DIAGNOSIS

Referral patterns from internists to departments of nuclear medicine or radiology are important determinants of whether adrenal glands are imaged by computed tomography (CT) or by radioisotope scintigraphy. To assist clinicians in making an informed choice, computed tomographic scans were compared with isotope scintigrams using 131I-19-iodocholesterol (19-IC) and 131I-6 beta-iodomethyl-19-norcholesterol (NP-59). In general, imaging techniques serve to localize diseases that are diagnosed on the basis of biochemical tests of adrenal function. Computed tomographic scanning and NP-59 scanning are of comparable diagnostic accuracy. Both are superior to 19-IC scanning in the diagnosis of Cushings syndrome and primary aldosteronism. Computed tomographic scanning is faster and less expensive, and involves lower radiation doses to the patient than scintigraphy. Adrenocortical isotope scanning as a routine procedure has been superseded by computed tomographic scanning at the Mayo Clinic.